Effects of lipid-based nutrient supplements and infant and young child feeding counseling with or without improved water, sanitation, and hygiene (WASH) on anemia and micronutrient status: results from 2 cluster-randomized trials in Kenya and Bangladesh

Christine P Stewart, Kathryn G Dewey, Audrie Lin, Amy J Pickering, Kendra A Byrd, Kaniz Jannat, Shahjahan Ali, Gouthami Rao, Holly N Dentz, Marion Kiprotich, Charles D Arnold, Benjamin F Arnold, Lindsay H Allen, Setareh Shahab-Ferdows, Ayse Ercumen, Jessica A Grembi, Abu Mohd Naser, Mahbubur Rahman, Leanne Unicomb, John M Colford Jr, Stephen P Luby, Clair Null, Christine P Stewart, Kathryn G Dewey, Audrie Lin, Amy J Pickering, Kendra A Byrd, Kaniz Jannat, Shahjahan Ali, Gouthami Rao, Holly N Dentz, Marion Kiprotich, Charles D Arnold, Benjamin F Arnold, Lindsay H Allen, Setareh Shahab-Ferdows, Ayse Ercumen, Jessica A Grembi, Abu Mohd Naser, Mahbubur Rahman, Leanne Unicomb, John M Colford Jr, Stephen P Luby, Clair Null

Abstract

Background: Anemia in young children is a global health problem. Risk factors include poor nutrient intake and poor water quality, sanitation, or hygiene.

Objective: We evaluated the effects of water quality, sanitation, handwashing, and nutrition interventions on micronutrient status and anemia among children in rural Kenya and Bangladesh.

Design: We nested substudies within 2 cluster-randomized controlled trials enrolling pregnant women and following their children for 2 y. These substudies included 4 groups: water, sanitation, and handwashing (WSH); nutrition (N), including lipid-based nutrient supplements (LNSs; ages 6-24 mo) and infant and young child feeding (IYCF) counseling; WSH+N; and control. Hemoglobin and micronutrient biomarkers were measured after 2 y of intervention and compared between groups using generalized linear models with robust SEs.

Results: In Kenya, 699 children were assessed at a mean ± SD age of 22.1 ± 1.8 mo, and in Bangladesh 1470 participants were measured at a mean ± SD age of 28.0 ± 1.9 mo. The control group anemia prevalences were 48.8% in Kenya and 17.4% in Bangladesh. There was a lower prevalence of anemia in the 2 N intervention groups in both Kenya [N: 36.2%; prevalence ratio (PR): 0.74; 95% CI: 0.58, 0.94; WSH+N: 27.3%; PR: 0.56; 95% CI: 0.42, 0.75] and Bangladesh (N: 8.7%; PR: 0.50; 95% CI: 0.32, 0.78; WSH+N: 7.9%, PR: 0.46; 95% CI: 0.29, 0.73). In both trials, the 2 N groups also had significantly lower prevalences of iron deficiency, iron deficiency anemia, and low vitamin B-12 and, in Kenya, a lower prevalence of folate and vitamin A deficiencies. In Bangladesh, the WSH group had a lower prevalence of anemia (12.8%; PR: 0.74; 95% CI: 0.54, 1.00) than the control group, whereas in Kenya, the WSH+N group had a lower prevalence of anemia than did the N group (PR: 0.75; 95% CI: 0.53, 1.07), but this was not significant (P = 0.102).

Conclusions: IYCF counseling with LNSs reduced the risks of anemia, iron deficiency, and low vitamin B-12. Effects on folate and vitamin A varied between studies. Improvements in WSH also reduced the risk of anemia in Bangladesh but did not provide added benefit over the nutrition-specific intervention. These trials were registered at clinicaltrials.gov as NCT01590095 (Bangladesh) and NCT01704105 (Kenya).

Figures

FIGURE 1
FIGURE 1
Summary of participant enrollment, random assignment, retention, and analysis in the WASH Benefits Kenya Study. WASH, water, sanitation, and hygiene.
FIGURE 2
FIGURE 2
Summary of participant enrollment, random assignment, retention, and analysis in the WASH Benefits Bangladesh Study. WASH, water, sanitation, and hygiene.
FIGURE 3
FIGURE 3
Prevalence (95% CI) of anemia in each intervention group in the WASH Benefits Kenya (A) and Bangladesh (B) Trials. Prevalence ratios and 95% CIs were derived from generalized linear models using a binomial distribution and log link with robust SEs controlling for clustering at the block level. N, nutrition; Ref, reference; WASH, water, sanitation, and hygiene; WSH, water, sanitation, and handwashing.

References

    1. WHO. The global prevalence of anaemia in 2011. Geneva (Switzerland): World Health Organization; 2015.
    1. Engle-Stone R, Aaron GJ, Huang J, Wirth JP, Namaste SM, Williams AM, Peerson JM, Rohner F, Varadhan R, Addo OY et al. .. Predictors of anemia in preschool children: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project. Am J Clin Nutr. 2017;106(Suppl 1):402S–15S.
    1. Fishman SM, Christian P, West KP. The role of vitamins in the prevention and control of anaemia. Public Health Nutr. 2000;3(2):125–50.
    1. Campbell SJ, Nery SV, Doi SA, Gray DJ, Soares Magalhães RJ, McCarthy JS, Traub RJ, Andrews RM, Clements AC. Complexities and perplexities: a critical appraisal of the evidence for soil-transmitted helminth infection-related morbidity. PLoS Negl Trop Dis. 2016;10(5):e0004566.
    1. Drakesmith H, Prentice AM. Hepcidin and the iron-infection axis. Science. 2012;338(6108):768–72.
    1. Prendergast A, Kelly P. Enteropathies in the developing world: neglected effects on global health. Am J Trop Med Hyg. 2012;86(5):756–63.
    1. WHO. Guideline: use of multiple micronutrient powders for point-of-use fortification of foods consumed by infants and young children aged 6–23 months and children aged 2–12 years. Geneva: (Switzerland): World Health Organization; 2016.
    1. Larsen DA, Grisham T, Slawsky E, Narine L. An individual-level meta-analysis assessing the impact of community-level sanitation access on child stunting, anemia, and diarrhea: evidence from DHS and MICS surveys. PLoS Negl Trop Dis. 2017;11(6):e0005591.
    1. Luby SP, Rahman M, Arnold BF, Unicomb L, Ashraf S, Winch PJ, Stewart CP, Begum F, Hussain F, Benjamin-Chung J et al. .. Effects of water quality, sanitation, handwashing and nutritional interventions on diarrhoea and child growth in rural Bangladesh: a cluster randomized trial. Lancet Global Health. 2018;6(3):e302–e15.
    1. Null C, Stewart CP, Pickering AJ, Dentz HN, Arnold BF, Arnold CD, Benjamin-Chung J, Clasen T, Dewey KG, Fernald LCH et al. .. Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Kenya: a cluster-randomised controlled trial. Lancet Global Health. 2018;6(3):e316–e29.
    1. Arnold BF, Null C, Luby SP, Unicomb L, Stewart CP, Dewey KG, Ahmed T, Ashraf S, Christensen G, Clasen T et al. .. Cluster-randomised controlled trials of individual and combined water, sanitation, hygiene and nutritional interventions in rural Bangladesh and Kenya: the WASH Benefits study design and rationale. BMJ Open. 2013;3(8):e003476.
    1. Parvez SM, Azad R, Rahman M, Unicomb L, Ram PK, Naser AM, Stewart CP, Jannat K, Rahman MJ, Leontsini E et al. .. Achieving optimal technology and behavioral uptake of single and combined interventions of water, sanitation hygiene and nutrition, in an efficacy trial (WASH benefits) in rural Bangladesh. Trials. 2018;19(1):358.
    1. Rahman M, Ashraf S, Unicomb L, Mainuddin AKM, Parvez SM, Begum F, Das KK, Naser AM, Hussain F, Clasen T et al. .. WASH Benefits Bangladesh trial: system for monitoring coverage and quality in an efficacy trial. Trials. 2018;19(1):360.
    1. Christensen G, Dentz HN, Pickering AJ, Bourdier T, Arnold BF, Colford JM Jr, Null C. Pilot cluster randomized controlled trials to evaluate adoption of water, sanitation, and hygiene interventions and their combination in rural western Kenya. Am J Trop Med Hyg. 2015;92(2):437–47.
    1. Byrd KA, Dentz, Williams, Kiprotich M, Omondi R, Kwena O, Rao G, Arnold CD, Arnold BF, Dewey KG et al. .. A behavior change intervention with lipid-based nutrient supplements had little impact on young child feeding indicators in rural Kenya. Matern Child Nutr. 2018:e12660, doi:10.1111/mcn.12660.
    1. DPHE/BGS/DFID. Bangladesh: DPHE/BGS National Hydrochemical Survey[Internet]. [cited 2017 Feb 1]. Available from: .
    1. Naser AM, Higgins EM, Arman S, Ercumen A, Ashraf S, Das KK, Rahman M, Luby SP, Unicomb L. Effect of groundwater iron on residual chlorine in water treated with sodium dichloroisocyanurate tablets in rural Bangladesh. Am J Trop Med Hyg. 2018;98(4):977–83.
    1. Menon P, Nguyen PH, Saha KK, Khaled A, Sanghvi T, Baker J, Afsana K, Haque R, Frongillo EA, Ruel MT et al. .. Combining intensive counseling by frontline workers with a nationwide mass media campaign has large differential impacts on complementary feeding practices but not on child growth: results of a cluster-randomized program evaluation in Bangladesh. J Nutr. 2016;146(10):2075–84.
    1. Jannat K, Luby SP, Unicomb L, Rahman M, Das KK, Parvez SM, Winch PJ, Leonstini E, Ram PK, Stewart CP. Complementary feeding practices among rural Bangladeshi mothers: results from WASH Benefits, a randomized controlled trial of water, sanitation, handwashing and nutrition interventions. Matern Child Nutr 2018:e12654 doi:10.1111/mcn.12654.
    1. Coates J, Swindale A, Bilinsky P. Household Food Insecurity Access Scale (HFIAS) for measurement of food access: indicator guide. Washington (DC): Academy for Educational Development, Food and Nutrition Technical Assistance Project (FANTA); 2007.
    1. Ballard T, Coates J, Swindale A, Deitchler M. Household Hunger Scale: indicator definition and measurement guide. Washington (DC): Food and Nutrition Technical Assistance (FANTA-II) Project, FHI 360; 2011.
    1. Erhardt JG, Estes JE, Pfeiffer CM, Biesalski HK, Craft NE. Combined measurement of ferritin, soluble transferrin receptor, retinol binding protein, and C-reactive protein by an inexpensive, sensitive, and simple sandwich enzyme-linked immunosorbent assay technique. J Nutr. 2004;134(11):3127–32.
    1. Chong SS, Boehm CD, Higgs DR, Cutting GR. Single-tube multiplex-PCR screen for common deletional determinants of alpha-thalassemia. Blood. 2000;95(1):360–2.
    1. Waterfall CM, Cobb BD. Single tube genotyping of sickle cell anaemia using PCR-based SNP analysis. Nucleic Acids Res. 2001;29(23):E119.
    1. Suchdev PS, Ruth LJ, Woodruff BA, Mbakaya C, Mandava U, Flores-Ayala R, Jefferds ME, Quick R. Selling Sprinkles micronutrient powder reduces anemia, iron deficiency, and vitamin A deficiency in young children in western Kenya: a cluster-randomized controlled trial. Am J Clin Nutr. 2012;95(5):1223–30.
    1. Chang S, El Arifeen S, Bari S, Wahed MA, Rahman KM, Rahman MT, Mahmud AB, Begum N, Zaman K, Baqui AH et al. .. Supplementing iron and zinc: double blind, randomized evaluation of separate or combined delivery. Eur J Clin Nutr. 2010;64(2):153–60.
    1. Cameron L, Shah M, Olivia S. Impact evaluation of a large-scale rural sanitation project in Indonesia. Impact Evaluation Series No. 83. Policy Research Working Paper 6360. Washington (DC): The World Bank Sustainable Development Network, Water and Sanitation Program; 2013.
    1. Chase C, Do Q. Handwashing behavior change at scale: evidence from a randomized evaluation in Vietnam. Policy Research Working Paper 6207. Washington (DC): The World Bank Sustainable Development Network, Water and Sanitation Program; 2012.
    1. Salvatore A, Patil SR. Scaling up rural sanitation: findings from the impact evaluation baseline survey in Madhya Pradesh, India. Washington (DC): The Water and Sanitation Program; 2011.
    1. WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Geneva (Switzerland: ): World Health Organization; 2011.
    1. Engle-Stone R, Haskell MJ, Ndjebayi AO, Nankap M, Erhardt JG, Gimou MM, Brown KH. Plasma retinol-binding protein predicts plasma retinol concentration in both infected and uninfected Cameroonian women and children. J Nutr. 2011;141(12):2233–41.
    1. Bailey LB, Stover PJ, McNulty H, Fenech MF, Gregory JF 3rd, Mills JL, Pfeiffer CM, Fazili Z, Zhang M, Ueland PM et al. .. Biomarkers of Nutrition for Development—folate review. J Nutr. 2015;145(7):1636S–80S.
    1. de Benoist B. Conclusions of a WHO Technical Consultation on folate and vitamin B12 deficiencies. Food Nutr Bull. 2008;29(2 Suppl):S238–44.
    1. Allen LH. How common is vitamin B-12 deficiency?. Am J Clin Nutr. 2009;89(2):693S–6S.
    1. Pasricha SR, Atkinson SH, Armitage AE, Khandwala S, Veenemans J, Cox SE, Eddowes LA, Hayes T, Doherty CP, Demir AY et al. .. Expression of the iron hormone hepcidin distinguishes different types of anemia in African children. Sci Transl Med. 2014;6(235):235re3.
    1. Pfeiffer CM, Caudill SP, Gunter EW, Osterloh J, Sampson EJ. Biochemical indicators of B vitamin status in the US population after folic acid fortification: results from the National Health and Nutrition Examination Survey 1999–2000. Am J Clin Nutr. 2005;82(2):442–50.
    1. Thurnham DI, McCabe LD, Haldar S, Wieringa FT, Northrop-Clewes CA, McCabe GP. Adjusting plasma ferritin concentrations to remove the effects of subclinical inflammation in the assessment of iron deficiency: a meta-analysis. Am J Clin Nutr. 2010;92(3):546–55.
    1. Engle-Stone R, Nankap M, Ndjebayi AO, Erhardt JG, Brown KH. Plasma ferritin and soluble transferrin receptor concentrations and body iron stores identify similar risk factors for iron deficiency but result in different estimates of the national prevalence of iron deficiency and iron-deficiency anemia among women and children in Cameroon. J Nutr. 2013;143(3):369–77.
    1. Larson LM, Namaste SM, Williams AM, Engle-Stone R, Addo OY, Suchdev PS, Wirth JP, Temple V, Serdula M, Northrop-Clewes CA. Adjusting retinol-binding protein concentrations for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project. Am J Clin Nutr. 2017;106(Suppl 1):390S–401S.
    1. Namaste SM, Rohner F, Huang J, Bhushan NL, Flores-Ayala R, Kupka R, Mei Z, Rawat R, Williams AM, Raiten DJ et al. .. Adjusting ferritin concentrations for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project. Am J Clin Nutr. 2017;106(Suppl 1):359S–71S.
    1. Rohner F, Namaste SM, Larson LM, Addo OY, Mei Z, Suchdev PS, Williams AM, Sakr Ashour FA, Rawat R, Raiten DJ et al. .. Adjusting soluble transferrin receptor concentrations for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project. Am J Clin Nutr. 2017;106(Suppl 1):372S–82S.
    1. Hernan MA, Hernandez-Diaz S, Robins JM. A structural approach to selection bias. Epidemiology. 2004;15(5):615–25.
    1. Gruber S, Van der Laan MJ. TMLE: an R package for targeted maximum likelihood estimation. J Stat Softw. 2012;51(13):1–35.
    1. icddr,b, UNICEF, GAIN, Institute of Public Health and Nutrition. National Micronutrient Status Survey. Dhaka (Bangladesh): Center for Nutrition and Food Security, icddr,b; 2013.
    1. Hinnouho GM, Barffour MA, Wessells KR, Brown KH, Kounnavong S, Chanhthavong B, Ratsavong K, Kewcharoenwong C, Hess SY. Comparison of haemoglobin assessments by HemoCue and two automated haematology analysers in young Laotian children. J Clin Pathol. 2018;71(6):532–8.
    1. Merrill RD, Shamim AA, Ali H, Jahan N, Labrique AB, Schulze K, Christian P, West KP Jr.. Iron status of women is associated with the iron concentration of potable groundwater in rural Bangladesh. J Nutr. 2011;141(5):944–9.
    1. Tanumihardjo SA, Russell RM, Stephensen CB, Gannon BM, Craft NE, Haskell MJ, Lietz G, Schulze K, Raiten DJ. Biomarkers of Nutrition for Development (BOND)—vitamin A review. J Nutr. 2016;146(9):1816S–48S.
    1. Green R. Indicators for assessing folate and vitamin B-12 status and for monitoring the efficacy of intervention strategies. Am J Clin Nutr. 2011;94(2):666S–72S.
    1. Palmer AC, West KP Jr., Dalmiya N, Schultink W. The use and interpretation of serum retinol distributions in evaluating the public health impact of vitamin A programmes. Public Health Nutr. 2012;15(7):1201–15.
    1. Smith JL, Brooker S. Impact of hookworm infection and deworming on anaemia in non-pregnant populations: a systematic review. Trop Med Int Health. 2010;15(7):776–95.
    1. Abbeddou S, Yakes Jimenez E, Some JW, Ouedraogo JB, Brown KH, Hess SY. Small-quantity lipid-based nutrient supplements containing different amounts of zinc along with diarrhea and malaria treatment increase iron and vitamin A status and reduce anemia prevalence, but do not affect zinc status in young Burkinabe children: a cluster-randomized trial. BMC Pediatr. 2017;17(1):46.
    1. Siega-Riz AM, Estrada Del Campo Y, Kinlaw A, Reinhart GA, Allen LH, Shahab-Ferdows S, Heck J, Suchindran CM, Bentley ME. Effect of supplementation with a lipid-based nutrient supplement on the micronutrient status of children aged 6–18 months living in the rural region of Intibuca, Honduras. Paediatr Perinat Epidemiol. 2014;28(3):245–54.
    1. Bauserman M, Lokangaka A, Gado J, Close K, Wallace D, Kodondi KK, Tshefu A, Bose C. A cluster-randomized trial determining the efficacy of caterpillar cereal as a locally available and sustainable complementary food to prevent stunting and anaemia. Public Health Nutr. 2015;18(10):1785–92.
    1. Dewey KG, Adu-Afarwuah S. Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries. Matern Child Nutr. 2008;4(Suppl 1):24–85.
    1. Verhoef H, Veenemans J, Mwangi MN, Prentice AM. Safety and benefits of interventions to increase folate status in malaria-endemic areas. Br J Haematol. 2017;177(6):905–18.
    1. Kenya National Bureau of Statistics, Ministry of Health Kenya, National AIDS Control Council, Kenya Medical Research Institute, National Council for Population and Development, The DHS Program, ICF International. Kenya Demographic and Health Survey 2014. Rockville (MD): ICF International; 2015.
    1. Nzila A, Okombo J, Hyde J. Malaria in the era of food fortification with folic acid. Food Nutr Bull. 2016;37(2):153–63.
    1. Domellof M, Braegger C, Campoy C, Colomb V, Decsi T, Fewtrell M, Hojsak I, Mihatsch W, Molgaard C, Shamir R et al. .. Iron requirements of infants and toddlers. J Pediatr Gastroenterol Nutr. 2014;58(1):119–29.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe