School Feeding Reduces Anemia Prevalence in Adolescent Girls and Other Vulnerable Household Members in a Cluster Randomized Controlled Trial in Uganda

Sarah Adelman, Daniel O Gilligan, Joseph Konde-Lule, Harold Alderman, Sarah Adelman, Daniel O Gilligan, Joseph Konde-Lule, Harold Alderman

Abstract

Background: Food for education (FFE) programs that include school meals are widely used to improve school participation and performance, but evidence on nutritional benefits is limited.

Objective: This study tested whether food fortified with multiple micronutrients provided in FFE programs reduced anemia prevalence of primary-school-age adolescent girls, adult women, and preschool children.

Methods: Through the use of a cluster randomized controlled trial with individual-level repeated cross-sectional data, we measured impacts on anemia prevalence from 2 FFE programs, a school feeding program (SFP) providing multiple-micronutrient-fortified meals and a nutritionally equivalent take-home ration (THR). Camps for internally displaced people (IDP) (n = 31) in Northern Uganda were randomly assigned to SFP, THR, or a control group with no FFE. Rations were provided for 15 mo at SFP and THR schools. A survey of households (n = 627) with children aged 6-17 y was conducted (baseline and 18 mo later). Analyses used difference-in-differences by intent to treat.

Results: Adolescent girls aged 10-13 y in FFE schools experienced a significant (P < 0.05) 25.7 percentage point reduction (95% CI: -0.43, -0.08) in prevalence of any anemia [hemoglobin (Hb) <11.5 g/dL, age 10-11 y; Hb <12 g/dL, age 12-13 y] and a significant 19.5 percentage point reduction (95% CI: -0.35, -0.04) in moderate-to-severe anemia (Hb <11 g/dL) relative to the control group, with no difference in impact between SFP and THR. The THR reduced moderate-to-severe anemia prevalence (Hb <11g/dL) of adult women aged ≥18 y (12.8 percentage points, 95% CI: -0.24, -0.02). All IDP camps initially received micronutrient-fortified rations through a separate humanitarian program; in one district where most households stopped receiving these rations, SFP reduced moderate-to-severe anemia of children aged 6-59 mo by 22.1 percentage points (95% CI: -0.42, -0.02).

Conclusions: FFE programs reduced any anemia and moderate-to-severe anemia in primary-school-age adolescent girls and reduced moderate-to-severe anemia for adult women and preschool children. This study was registered with clinicaltrials.gov as NCT01261182.

Keywords: adolescents; anemia; internally displaced people's camps; school feeding programs; take-home rations.

Copyright © American Society for Nutrition 2019.

Figures

FIGURE 1
FIGURE 1
Study and sample design for cluster randomized controlled trial of impact of FFE programs on anemia. FFE, food for education.
FIGURE 2
FIGURE 2
Age progression of prevalence of anemia (Hb n = 999) and males (n = 994). The sample includes all children aged <17 y in the baseline sample with nonmissing anemia status.
FIGURE 3
FIGURE 3
Impact of FFE programs on prevalence of moderate-to-severe anemia among females aged 10–13 y (n = 486) (A), females aged ≥18 y (n = 1076) (B), and children aged 6–59 mo in Lira district (n = 464) (C). Prevalence of anemia is shown by treatment group and round. “Pooled FFE Programs” refers to a model in which the THR and SFP samples are pooled for analysis of impact from either program relative to control. D represents the single difference in moderate-to-severe anemia prevalence (Hb <11 g/dL for age 10–13 y, ≥18 y; Hb <10g/dL for age 6–59 mo) within treatment group from baseline to endline. DD represents the difference-in-difference estimates of program impacts from unadjusted models (significantly different from 0, P < 0.05). Error bars represent 95% CIs, based on standard errors that are robust to clustering at baseline IDP camp level and district stratification. Impact estimates were not significantly different between SFP and THR in (A), (B), or (C). FFE, food for education; IDP, internally displaced people; SFP, school feeding program; THR, take-home ration.

References

    1. Bundy D, Burbano C, Grosh M, Gelli A, Jukes M, Drake L. Rethinking school feeding: social safety nets, child development and the education sector. Washington (DC): The World Bank; 2009.
    1. World Food Program. State of school feeding 2013. Rome: World Food Program; 2013.
    1. Adelman S, Gilligan D, Lehrer K. How effective are food for education programs? A critical assessment of the evidence from developing countries. Food Policy Review No. 8. Washington (DC): International Food Policy Research Institute; 2008.
    1. Alderman H, Bundy D. School feeding programs and development: are we framing the question correctly?. World Bank Res Obser. 2012;27:204–21.
    1. Bundy DAP, Schultz L, Sarr B, Banham L, Colenso P, Tang KC. The school as a platform for addressing health in middle childhood and adolescence. In: Bundy DAP, de Silva N, Horton S, Jamison DT, Patton GC, editors. Disease control priorities, Vol. 8: Child and adolescent health and development. 3rd ed. Washington (DC): World Bank; 2017. pp. 269–86.
    1. Drake L, Fernandes M, Aurino E, Kiamba J, Giyose B, Burbano C, Alderman H, Mai L, Mitchell A, Gelli A. School feeding programs in middle childhood and adolescence. In: Bundy DAP, de Silva N, Horton S, Jamison DT, Patton GC, editors. Disease control priorities, Vol. 8: Child and adolescent health and development. 3rd ed. Washington (DC: ): World Bank; 2017. pp. 147–64.
    1. de Regli LM, Harding KB, Roche ML. Preconceptional nutrition interventions for adolescent girls and adult women: global guidelines and gaps in evidence and policy with emphasis on micronutrients. J Nutr. 2016;146(7):1S–10S.
    1. World Bank. Repositioning nutrition as central to development: a strategy for large-scale action. Washington (DC): The World Bank; 2006.
    1. Balarajan Y, Ramakrishnan U, Özaltin E, Shankar AH, Subramanian SV. Anemia in low-income and middle-income countries. Lancet. 2011;378:2123–35.
    1. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, Ezzati M, Grantham-McGregor S, Katz J, Martorell Rthe Maternal and Child Nutrition Study Group; et al. .; the Maternal and Child Nutrition Study Group Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382:427–51.
    1. WHO/UNICEF/UNU. Iron deficiency anemia assessment, prevention and control. Geneva: WHO; 2001.
    1. Kurz KM, Galloway R. Improving adolescent iron status before childbearing. J Nutr. 2000;130:437S–9S.
    1. Fernández-Gaxiola AC, de-Regil LM. Intermittent iron supplementation for reducing anaemia and its associated impairments in menstruating women. Cochrane Database Syst Rev. 2011;(12):CD009218.
    1. Stoltzfus RJ. Iron interventions for women and children in low-income countries. J Nutr. 2011;141(4):756S–62S.
    1. Zhang L, Kleiman-Weiner M, Luo R, Shi Y, Martorell R, Medina A, Rozelle S. Multiple micronutrient supplementation reduces anemia and anxiety in rural China's elementary school children. J Nutr. 2013;143(5):640–7.
    1. Renfu L, Shi Y, Zhang L, Liu C, Rozelle S, Sharbono B, Yue A, Zhao Q, Martorell R. Nutrition and educational performance in rural China's elementary schools: results of a randomized control trial in Shaanxi province. Econ Dev Cult Change. 2012;60:735–72.
    1. Kruger M, Badenhorst CJ, Mansvelt EPG, Laubscher JA, Spinnler Benadé AJ. Effects of iron fortification in a school feeding scheme and anthelmintic therapy on the iron status and growth of six- to eight-year-old schoolchildren. Food Nutr Bull. 1996;17:11–21.
    1. Van Stuijvenberg ME, Kvalsvig JD, Faber M, Kruger M, Kenoyer DG, Spinnler Benadé AJ. Effect of iron-, iodine-, and β-carotene-fortified biscuits on the micronutrient status of primary school children: a randomized controlled trial. Am J Clin Nutr. 1999;69:497–503.
    1. Siekmann JH, Allen LH, Bwibo NO, Demment MW, Murphy SP, Neumann CG. Kenyan school children have multiple micronutrient deficiencies, but increased plasma vitamin B-12 is the only detectable micronutrient response to meat or milk supplementation. J Nutr. 2003;133:3972S–80S.
    1. Walter T, Hertrampf E, Pizzaro F, Olivares M, Llaguno S, Letelier A, Vega V, Stekel A. Effect of bovine-hemoglobin–fortified cookies on iron status of schoolchildren: a nationwide program in Chile. Am J Clin Nutr. 1993;57:190–4.
    1. Osei A, Rosenberg IH, Houser RF, Bulusu S, Mathews M, Hamer DH. Community-level micronutrient fortification of school lunch meals improved vitamin A, folate, and iron status of schoolchildren in Himalayan villages of India. J Nutr. 2010;140:1146–54.
    1. Beard JL. Iron requirements in adolescent females. J Nutr. 2000;130:440S–2S.
    1. Beaton GH, Ghassemi H. Supplementary feeding programs for young children in developing countries. Am J Clin Nutr. 1982;35:864–916.
    1. World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. 2011. Geneva: WHO; 2011.
    1. World Health Organization and Centers for Disease Control and Prevention. Assessing the iron status of populations: including literature reviews: report of a Joint World Health Organization/Centers for Disease Control and Prevention technical consultation on the assessment of iron status at the population level. 2nd ed. Geneva: WHO; 2004.
    1. Jacoby HG. Is there an intrahousehold “flypaper effect”? Evidence from a school feeding programme. Econ J. 2002;112:196–221.
    1. Neema S, Ahmed FH, Kibombo R, Bankole A. Adolescent sexual and reproductive health in Uganda: results from the 2004 Uganda National Survey of Adolescents. Occasional Report No 25. New York: Guttmacher Institute; 2006.
    1. Uganda Bureau of Statistics (UBOS) and Macro International Inc. Uganda Demographic and Health Survey 2006. Calverton (MD): UBOS and Macro International Inc; 2007.
    1. Christian P, Khatry S, Katz J, Pardhan D, LeClerq S, Shrestha S, Adhikari R, Sommer A, West K. Effects of alternative maternal micronutrient supplements on low birth weight in rural Nepal: double blind randomised community trial. Br Med J. 2003;326:571.
    1. Alderman H, Gilligan DO, Lehrer K. The impact of food for education programs on school participation in Northern Uganda. Econ Dev Cult Change. 2012;61:187–218.
    1. Bobonis G, Miguel E, Puri-Sharma C. Anemia and school participation. J Human Resources. 2009;41:692–721.
    1. Biesalski H-K, Erhardt JG. Diagnosis of nutritional anemia—laboratory assessment of iron status. In: Klaus Kraemer K, Zimmerman Meditors. Nutritional anemia. Zurich: Sight & Life Press; 2007, pp. 37–44.
    1. World Health Organization and Centers for Disease Control and Prevention. Assessing the iron status of populations. Geneva: WHO; 2007.
    1. UNHCR. UNHCR global trends 2010. Geneva: United Nations High Commissioner for Refugees; 2011.

Source: PubMed

Sponzoři a spolupracovníci

Zdravotní podmínky

Drogové intervence

3
Předplatit