Assessment of dietary intake and nutrient gaps, and development of food-based recommendations, among pregnant and lactating women in Zinder, Niger: An optifood linear programming analysis

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Study Justification:
– Pregnant and lactating women in rural Niger are at high risk for inadequate intakes of multiple micronutrients.
– This study aims to assess the dietary intake and nutrient gaps among this population.
– The findings will help identify the micronutrient deficiencies and develop food-based recommendations to improve dietary adequacy.
Highlights:
– Energy intakes were below estimated requirements, and most women had inadequate intakes of multiple micronutrients.
– Linear programming analyses showed that it would be difficult to achieve recommended dietary allowances for most micronutrients.
– Consumption of additional meals and adherence to specific food-based recommendations could improve dietary adequacy for several micronutrients.
– Multiple micronutrient supplementation or provision of nutrient-dense foods should be prioritized to ensure adequate intake of all modeled micronutrients.
Recommendations:
– Promote realistic food-based recommendations, including daily consumption of dark green leafy vegetables, fermented milk, millet, pulses, and vitamin A fortified oil.
– Encourage the consumption of one additional meal per day.
– Prioritize the provision of multiple micronutrient supplementation or nutrient-dense foods to address the remaining nutrient gaps.
Key Role Players:
– Ministry of Public Health in Niger
– NiMaNu Project team
– Trained fieldworkers (government certified midwives and medical doctor)
– National Ethical Committee in Niamey, Niger
– Institutional Review Board of the University of California, Davis, USA
Cost Items for Planning Recommendations:
– Cost of promoting and implementing food-based recommendations
– Cost of providing multiple micronutrient supplementation or nutrient-dense foods
– Cost of training and employing fieldworkers
– Cost of conducting surveys and data collection
– Cost of monitoring and evaluating the effectiveness of interventions

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a cross-sectional study with a sample size of 202 pregnant and lactating women in rural Niger. The study used 24-hour dietary recalls and linear programming analyses to assess dietary intakes and nutrient gaps. The findings suggest that most women in the population are at risk of inadequate intakes of multiple micronutrients. The study proposes food-based recommendations and supplementation strategies to improve dietary adequacy. While the study provides valuable insights, there are a few limitations. First, the study design is cross-sectional, which limits the ability to establish causality. Second, the sample size is relatively small, which may affect the generalizability of the findings. To improve the strength of the evidence, future research could consider conducting a longitudinal study with a larger sample size to establish causal relationships and enhance generalizability.

Pregnant and lactating women in rural Niger are at high risk for inadequate intakes of multiple micronutrients. Thus, 24 h dietary recalls were conducted and analyzed for dietary intakes in this population (n = 202). Using linear programming analyses, micronutrient gaps in women’s diets were identified, food-based recommendations (FBR) to improve dietary micronutrient adequacy were developed, and various supplementation strategies were modelled. Energy intakes were below estimated requirements, and, for most micronutrients, >50% of women were at risk of inadequate intakes. Linear programming analyses indicated it would be difficult to select a diet that achieved recommended dietary allowances for all but three (vitamin B 6 , iron and zinc) of 11 modeled micronutrients. Consumption of one additional meal per day, and adherence to the selected FBR (daily consumption of dark green leafy vegetables, fermented milk, millet, pulses, and vitamin A fortified oil), would result in a low percentage of women at risk of inadequate intakes for eight modeled micronutrients (vitamin A, riboflavin, thiamin, B 6 folate, iron, zinc, and calcium). Because the promotion of realistic FBRs likely will not ensure that a low percentage of women are at risk of inadequate intakes for all modeled micronutrients, multiple micronutrient supplementation or provision of nutrient-dense foods should be prioritized.

The present assessment of dietary intake and daily nutrient intakes among pregnant and lactating women is a cross-sectional study embedded into the Niger Maternal Nutrition (NiMaNu) Project. The NiMaNu project was a program-based effectiveness trial in the Zinder region of Niger, designed to assist the Nigerien Ministry of Public Health in its efforts to improve the nutritional and health status of pregnant women through multiple strategies to increase antenatal care attendance and adherence to iron folic acid (IFA) supplementation. The overall NiMaNu programmatic intervention, study design and data collection methods have been reported in detail elsewhere [6,20,21]. Briefly, 18 governmental integrated health centers located in two districts (Zinder and Mirriah) of the Zinder Region of Niger were randomly assigned to time of enrollment in the NiMaNu project from March 2014 – September 2015, and 2307 pregnant women in surrounding rural villages participated in the study. The present dietary intake assessment survey was implemented from May – October 2015, exclusive of the month of Ramadan and included women from nine villages within the catchment areas of three integrated health centers enrolled in the baseline NiMaNu survey during that time frame. Pregnant and lactating women were identified using the random walk method [22] and were eligible to participate in the dietary intake assessment survey if they lived in the catchment area of the NiMaNu project, were in their second or third trimester of pregnancy or breastfeeding an infant or young child 19 years of age, and provided written informed consent. Women were ineligible to participate if they were unable to provide consent due to impaired decision-making ability, or if they (or their breastfeeding child) had an illness warranting immediate hospital referral or a chronic or congenital illness interfering with dietary intake, as assessed via a structured questionnaire and the professional judgement of the fieldworkers and study coordinator (government certified midwives and medical doctor, respectively). The NiMaNu Project was approved by the National Ethical Committee in Niamey (Niger) (005/2013/CCNE; 007/MSP/CCNE/2015) and the Institutional Review Board of the University of California, Davis (USA) (447971). Consent materials were presented in both written and oral format, in the presence of a neutral witness. Informed consent was documented with a written signature or a fingerprint prior to enrollment in the study. The study was registered at www.clinicaltrials.gov as {“type”:”clinical-trial”,”attrs”:{“text”:”NCT01832688″,”term_id”:”NCT01832688″}}NCT01832688. Information on socio-economic and demographic characteristics of the woman and her household, pregnancy and health status, food security, and knowledge, attitudes and practices pertaining to antenatal care and nutrition were collected via structured interviews by trained female fieldworkers [6,20,21]. The survey on knowledge, attitudes and practices included questions of knowledge (e.g., benefits of IFA and recommended foods to consume during pregnancy and lactation), attitudes (e.g., perceived importance of IFA, reasons for compliance or non-compliance with IFA supplementation, and identification of foods they would like to consume in greater quantity during pregnancy and lactation), and practices (e.g., IFA consumption, changes to physical labor and dietary intakes during pregnancy and lactation). Household food insecurity was assessed using the Household Food Insecurity Access Scale (HFIAS) of the Food and Nutrition Technical Assistance/USAID [23]. Height, weight, mid-upper arm circumference (MUAC) and symphysis-fundal height were measured by trained and standardized anthropometrists. Lightly clothed women were weighed to 50 g precision (SECA 874, Seca, Hamburg, Germany) in duplicate. Women’s height (SECA 213, Seca, Hamburg, Germany), MUAC (ShorrTape© Measuring Tape, Weigh and Measure, Olney, MD, USA) and, among pregnant women, symphysis-fundal height (ShorrTape© Measuring Tape, Weigh and Measure, Olney, MD, USA) were measured in duplicate to 0.1 cm precision. If the two measurements were >0.2 kg (weight) or >0.5 cm apart (height, MUAC, and symphysis-fundal height), a third measurement was taken and the mean of the two closest measurements was calculated. Undernutrition was defined as a MUAC < 23 cm among pregnant women or a BMI 6 months post-partum among lactating women) and physical activity level (PAL; assumed active PAL 1.27). The acceptable macronutrient distribution ranges (AMDR) of dietary protein and fat were considered to be 10–35% and 20–35% of energy, respectively. Nutritional adequacy of eleven micronutrients was assessed (thiamin, riboflavin, niacin, folate, vitamins B6, B12, A and C and iron, zinc and calcium). The estimated average requirement (EAR) and recommended dietary allowance (RDA) for micronutrients were IOM DRI recommendations, with the exception of the iron bioavailability among lactating women and the calcium recommendations. Specifically, for lactating women, the fractional absorption of iron was assumed to be 10%, due to lower bioavailability which may be encountered in predominantly vegetarian diets with limited diversity; thus increasing recommendations above those set by the IOM, yet still in line with recommendations from the WHO [3,41]. DRI for pregnant women were not adjusted, due to increases in iron absorption during later pregnancy [42]. In addition, models were run using both the calcium recommendations set by the IOM, as well as those recommended by WHO/FAO for settings where animal source foods provide less than 20–40 g/day of protein [41]. Data were entered using EpiData version 3.1 (EpiData Association, Odense, Denmark). Dietary data were prepared in RedCap and SAS System software for Windows release 9.4 (SAS Institute, Cary, NC, USA). Statistical analyses were completed with SAS System software for Windows release 9.4 (SAS Institute, Cary, NC, USA). Descriptive statistics were calculated for all variables. The distribution of usual micronutrient intakes and daily per capita reported cost of foods consumed was estimated using the National Cancer Institute (NCI) method to adjust for intra-individual variation in dietary intake; the EAR cut-point method was applied to estimate the prevalence of inadequate intake [43,44]. Differences in market availability and median prices of specific foods by season were analyzed using logistic regression with Firth’s adjustment and the Kruskal Wallis test on ranked data, respectively. Data are presented as mean ± SD for normally distributed variables (Shapiro-Wilk statistic, W > 0.97), and the median and IQR for non-normal values. The alpha value is 0.05. Summary statistics from the dietary intake assessment survey (24 h recalls), including a list of foods consumed, food serving sizes and food patterns, were used to define the linear programming model parameters. The list of foods consumed included those consumed by > 5% of each target group and nutrient-dense foods consumed by 65% of the RDA. A worst-case-scenario level ≥ 65% indicates, if women achieve the FBR, then a low percentage of the population would be at risk of inadequate intakes for that nutrient. Sample size estimates for the collection of dietary data among pregnant and lactating women were based on sample sizes previously reported in the literature [15,47,48]. Based on this information, and including an attrition rate of 10%, it was planned to enroll 110 pregnant women concurrent to their participation in the NiMaNu study and 110 lactating women residing in the same catchment areas. Duplicate non-consecutive day 24 h recalls were attempted in 20% of enrolled women within seven days, in order to examine intra-individual variation in nutrient intake. Due to study resources and logistics, it was not always possible to implement the NiMaNu study and dietary intake assessment survey simultaneously as planned. Thus, only 56 pregnant women participating in the NiMaNu study were also enrolled in the present dietary assessment survey; an additional 48 pregnant women were enrolled in the dietary intake assessment survey only or subsequent to their completion of the NiMaNu study. In all cases, recruitment procedures were the same and data for the dietary intake assessment survey were collected using identical protocols and fieldworkers. In addition, an oversampling of lactating women occurred in the first village due to a miscommunication with fieldworkers. Thus, a post-hoc random sample of enrolled lactating women from the first village who completed the 24 h dietary recall was included in the analyses (n = 20 of 41).

The recommendation to improve access to maternal health in rural Niger is to develop food-based recommendations (FBR) to improve dietary micronutrient adequacy among pregnant and lactating women. This recommendation is based on a study that assessed dietary intake and nutrient gaps among this population. The study found that pregnant and lactating women in rural Niger are at high risk for inadequate intakes of multiple micronutrients. Using linear programming analyses, micronutrient gaps in women’s diets were identified, and FBRs were developed to address these gaps. The FBR includes daily consumption of dark green leafy vegetables, fermented milk, millet, pulses, and vitamin A fortified oil. The study also suggests that multiple micronutrient supplementation or provision of nutrient-dense foods should be prioritized to ensure adequate nutrient intake. This recommendation aims to improve the nutritional status of pregnant and lactating women in rural Niger and ultimately improve maternal health outcomes. The findings and recommendations of this study were published in the journal Nutrients in 2019.
AI Innovations Description
The recommendation to improve access to maternal health in rural Niger is to develop food-based recommendations (FBR) to improve dietary micronutrient adequacy among pregnant and lactating women. This recommendation is based on a study that assessed dietary intake and nutrient gaps among this population. The study found that pregnant and lactating women in rural Niger are at high risk for inadequate intakes of multiple micronutrients. Using linear programming analyses, micronutrient gaps in women’s diets were identified, and FBRs were developed to address these gaps. The FBR includes daily consumption of dark green leafy vegetables, fermented milk, millet, pulses, and vitamin A fortified oil. The study also suggests that multiple micronutrient supplementation or provision of nutrient-dense foods should be prioritized to ensure adequate nutrient intake. This recommendation aims to improve the nutritional status of pregnant and lactating women in rural Niger and ultimately improve maternal health outcomes. The findings and recommendations of this study were published in the journal Nutrients in 2019.
AI Innovations Methodology
The methodology used to simulate the impact of the main recommendations on improving access to maternal health in rural Niger involved the following steps:

1. Cross-sectional Study: The study was embedded into the Niger Maternal Nutrition (NiMaNu) Project, which was a program-based effectiveness trial in the Zinder region of Niger. The study collected data on socio-economic and demographic characteristics, pregnancy and health status, food security, and knowledge, attitudes, and practices related to antenatal care and nutrition.

2. Dietary Intake Assessment: The study conducted 24-hour dietary recalls among pregnant and lactating women in rural Niger (n = 202). The recalls were conducted using the multi-pass approach, which is designed for use in low-income countries with low rates of literacy. The dietary data collected included information on food consumption, portion sizes, and frequency of consumption.

3. Nutrient Analysis: The dietary data were analyzed to assess the dietary intake and nutrient gaps among pregnant and lactating women. The distribution of usual micronutrient intakes and the prevalence of inadequate intake were estimated using statistical methods. The study used the Dietary Reference Intakes (DRI) of the Institute of Medicine (IOM) as the reference for assessing nutrient adequacy.

4. Linear Programming Analysis: Linear programming analyses were conducted using the Optifood software tool. The analyses identified micronutrient gaps in women’s diets and developed food-based recommendations (FBR) to address these gaps. The FBR included specific foods to be consumed daily, such as dark green leafy vegetables, fermented milk, millet, pulses, and vitamin A fortified oil.

5. Simulation of Intervention Strategies: The study simulated the impact of the FBR on improving access to maternal health by modeling different intervention strategies. The models included scenarios with the reported diet, as well as scenarios with an added meal to increase energy intake. The models also tested the impact of different intervention products, such as corn soy blend plus (CSB+), iron and folic acid supplements (IFA), and small-quantity lipid-based nutrient supplements (SQ-LNS).

6. Assessment of Nutritional Adequacy and Cost: The linear programming models assessed the nutritional adequacy and cost of the different intervention strategies. The models compared the achievement of nutrient requirements and the cost of the diets under different scenarios.

7. Identification of Problem Nutrients: The models identified “problem” nutrients, which are nutrients that are likely to remain inadequate in the population even if women follow the FBR. These problem nutrients were defined as nutrients that did not achieve 100% of the recommended dietary allowance (RDA) in the maximized best-case scenario.

8. Recommendations: Based on the findings of the linear programming analyses, the study recommended the implementation of the FBR, along with multiple micronutrient supplementation or provision of nutrient-dense foods, to ensure adequate nutrient intake among pregnant and lactating women in rural Niger.

The findings and recommendations of this study were published in the journal Nutrients in 2019.

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