Ghana: Sustained growth effects of early lipid-based nutrient supplements
This is a summary of the following paper: Bentil H, Adu-Afarwuah S, Prado E et al. (2023) Sustained effects of small-quantity lipid-based nutrient supplements provided during the first 1000 days on child growth at 9–11 y in a randomized controlled trial in Ghana. The American Journal of Clinical Nutrition, 119, 2, 425–432. https://doi.org/10.1016/j.ajcnut.2023.10.033
Nutritional supplementation during the first 1,000 days has proven effective in preventing child undernutrition. In 2009–2014, a trial in Ghana enrolled 1,320 pregnant women ≤20 weeks of gestation and randomly assigned them to three groups. The first group received Iron-folic acid (IFA) during pregnancy and a placebo at six months postpartum. The second, multiple micronutrient supplements (MMS) during pregnancy and six months postpartum. The third, small-quantity lipid-based nutrient supplements (SQ-LNS) during pregnancy and six months postpartum, with SQ-LNS for their children (aged from 6–18 months).
In this article, surviving children were followed up and re-enrolled from the original trial, at ages 9–11 years. This study analysed findings in two groups: SQ-LNS vs a control group (comprised of the original IFA and MMS groups). Height-for-age z-score (HAZ), systolic blood pressure (SBP), and diastolic blood pressure (DBP) were primarily assessed. Secondary outcomes included body mass index-for-age z-score, mid-upper arm circumference (MUAC), triceps skinfold, waist-to-height ratio, blood pressure, and overweight, obesity, and stunting prevalence.
At follow-up, measurements were obtained from 966 children (331 SQ-LNS, 635 control). Baseline characteristics, except household asset score (higher in controls, p=0.02), were similar. Mean HAZ did not differ significantly (p=0.06) between SQ-LNS (-0.04, SD=0.96) and control groups (-0.16, SD=0.99). No group differences were found in other outcomes. Both groups approximated the WHO median for HAZ, with a 2% prevalence of stunted children. Overweight and obesity prevalence in the SQ-LNS group was 10.9% and 3.9%, respectively, with few having high blood pressure (0% systolic, 1% diastolic). There were near identical results in the controls.
However, the authors found an interaction of the intervention with child sex (p-interaction = 0.075) and maternal pre-pregnancy body mass index (BMI) (p-interaction = 0.007). In girls, the SQ-LNS group had a higher HAZ than controls (0.08 vs. -0.16; P = 0.01). There was no difference in boys. Among mothers with pre-pregnancy BMI<25 kg/m2, the SQ-LNS group had a higher HAZ (-0.04 vs. -0.29; P = 0.004). For BMI ≥25 kg/m2, no significant differences were observed.
The study's strengths were a randomised design and large sample size. Limitations arise from children lost to follow-up, whose mothers differed in parity – which may affect our interpretation. The study population (from a specific region in Ghana) also prevents us from extrapolating these findings. Nonetheless, the semiurban areas observed encompass characteristics of both rural and urban settings – enhancing relevance to both contexts. Overall, the findings reveal that providing SQ-LNS during the 1,000-day window promotes long-term linear growth in girls and those with non-overweight/obese mothers. Further investigation is warranted to understand the differential response between girls and boys to SQ-LNS in terms of growth.
Comments from the editors
These are intriguing results showing increased linear growth in girls and children born to mothers with a lower pre-pregnancy BMI. This paper features an excellent original trial design and a rare opportunity to follow up longer-term linear growth (ages 9–11 years) for the children involved. At this stage, the mechanisms are unclear and warrant further investigation. Over time, as the evidence builds, we look forward to learning the public health significance of the effect sizes and their programming implications.