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 two cluster randomized

Authors: STEWART, CHRISTINE - University Of California, Davis; DEWEY, KATHRYN - University Of California, Davis; LIN, AUDRIE - University Of California; PICKERING, AMY - University Of Stanford; BYRD, KENDRA - University Of California, Davis; JANNAT, KANIZ - Dhaka University; ALI, SHAHJAHAN - Dhaka University; RAO, GOUTHAMI - University Of Nairobi; DENTZ, HOLLY - University Of California, Davis; KIPROTICH, MARION - University Of Nairobi; ARNOLD, CHARLES - University Of California, Davis; ARNOLD, BENJAMIN - University Of California; Allen, Lindsay - A; Shahab-Ferdows, Setti; ERCUMEN, AYSE - University Of California; GREMBI, JESSICA - Stanford University; NASER, ABU - Dhaka University; RAHMAN, MAHBUBUR - Dhaka University; UNICOMB, LEANNA - Dhaka University; COLFORD, JOHN JR - University Of California; LUBY, STEPHEN - Stanford University; NULL, CLAIR - University Of Nairobi

Submitted to: The American Journal of Clinical Nutrition
Publication Type: Peer Reviewed Journal
Publication Acceptance Date: 8/14/2018
Publication Date: 1/9/2019
Citation: Stewart, C.P., Dewey, K.G., Lin, A., Pickering, A.J., Byrd, K.A., Jannat, K., Ali, S., Rao, G., Dentz, H.N., Kiprotich, M., Arnold, C.D., Arnold, B.F., Allen, L.H., Shahab-Ferdows, S., Ercumen, A., Grembi, J.A., Naser, A.M., Rahman, M., Unicomb, L., Colford, J.M., Luby, S.P., Null, C. 2019. 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 two cluster randomized trials in Kenya and Bangladesh. American Journal of Clinical Nutrition. 109(1):148-164. https://doi.org/10.1093/ajcn/nqy239.
DOI: https://doi.org/10.1093/ajcn/nqy239

Interpretive Summary: 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: There were 4 groups (substudies) nested within 2 cluster-randomized controlled trials that enrolled pregnant women and followed their children for 2 y. The substudies were: 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. 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’s anemia prevalences were 48.8% in Kenya and 17.4% in Bangladesh. There was less anemia in the two N intervention groups in both Kenya [N: 36.2%; prevalence ratio (PR): 0.74; WSH+N: 27.3%; PR: 0.56); and Bangladesh (N: 8.7%; PR: 0.50; WSH+N: 7.9%, PR: 0.46). In both trials, the 2 N groups also had significantly less iron deficiency, iron deficiency anemia, and low vitamin B-12 and, in Kenya, a lower prevalence of folate and vitamin A deficiency. In Bangladesh, the WSH group had a lower prevalence of anemia (12.8%; PR: 0.74) than the control group, whereas in Kenya, the WSH+N group had less anemia than did the N group (PR: 0.75) but this was not significant. 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.

Technical 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).