Micronutrient malnutrition affects more than 20 million children and women (at least 50% of this population) in Bangladesh. The diets of more than 85% of women and children in Bangladesh are inadequate in essential micronutrients such as vitamin A, largely because adequate amounts of foods containing these micronutrients are not available, or the household purchasing power for these foods is inadequate. In Bangladesh and many other developing countries, large-scale programmes are needed to make a significant impact on this overwhelming malnutrition problem. There has been limited experience and success in expanding small-scale pilot programmes into large-scale, community-based programmes. This paper describes the development and expansion of the Bangladesh homestead gardening programme, which has successfully increased the availability and consumption of vitamin A-rich foods. The programme, implemented by Helen Keller International through partnerships with local non-governmental organizations, encourages improvements in existing gardening practices, such as promotion of year-round gardening and increased varieties of fruits and vegetables. We present our experience with the targeted programme beneficiaries, but we have observed that neighbouring households also benefit from the programme. Although this spillover effect amplifies the benefit, it also makes an evaluation of the impact more difficult. The lessons learned during the development and expansion of this community-based programme are presented. There is a need for an innovative pilot programme, strong collaborative partnerships with local organizations, and continuous monitoring and evaluation of programme experiences. The expansion has occurred with a high degree

Objective: To examine sex differences in height-for-age z-scores and the percentage stunting among Bangladeshi children estimated using three growth references. Design, setting and subjects: Data collected between 1990 and 1999 by Helen Keller International's nutritional surveillance system in rural Bangladesh were analyzed for 504 358 children aged 6-59 months. Height-for-age z-scores were estimated using the 1977 NCHS, 2000 CDC and 1990 British growth references. Results: The shape of the growth curves for Bangladeshi boys and girls, and their positions relative to one another, depend on which of the three growth references is used. At 6 months of age the British reference showed no sex difference whereas the NCHS and CDC showed girls to have higher average z-scores than boys by 0.14 and 0.28 s.d., respectively. While all references showed a faster deterioration of girls' z-scores from 6 to 24 months, the magnitude and direction of the sex differences, and how they changed with age, were different. There was greater disagreement about girls' z-scores than boys. Discontinuities at 24 months in the NCHS and CDC produced jagged curves whereas the British curves were smooth. Conclusions: The assessment of sex differences in linear growth depends on the growth reference used. Reasons for the different results need to be determined and may aid the final development of the new WHO international growth reference and the guidelines for its use. The findings suggest that anthropometry as a tool to explore the effects of societal gender inequality must be used with caution.

During the last decade, growth monitoring has been promoted us an important intervention for child survival, but questions have been raised about its electiveness and feasibility in less-developed countries. A growth-monitoring programme was carried out by the Bangladesh Rural Advancement Committee for over four years, covering about 20,000 children under two years of age. The programme was equally accessible to all socioeconomic groups and both sexes. Children were weighed monthly in village centres, and their mothers were given health and nutrition education. A recent evaluation found modest coverage (43 %) of the target children. Accuracy in determining ages of the target children was reasonably good, with more than 90% within 30 days of actual age. Eighty-seven per cent of the Salter round scales used gave accurate results, compared with only 17% of the Salter cylinder scales. Local volunteers, mostly women, participated in growth-monitoring sessions by weighing, recording, and demonstrating how to prepare supplementary diets. Growth monitoring was associated with increased use of selected child-survival interventions such as immunization. The nutrition status of participating children was not significantly better than that of a comparable group of children who did not participate (p =.051).

Local market prices in rural Bangladesh were used to compute the costs of filling the nutrient gaps between actual intakes and safe nutrient requirements, and the costs of compliance with nutrition messages, for 78 lactating mothers and 61 weaning-age breastfed children. (The gap is the difference between the requirement and the amount of nutrient consumed.) To fill the mother's energy gap of approximately 1050 kcal (4393 kJ) would cost an additional 21% of the daily wage, or almost double the value of food she was presently eating. Given social reality, these costs would probably be much greater, as the mother would also need to increase the allocation of food to other household members. The weaning-age children's energy gap could theoretically be closed for less than one-third of the cost of improving the mothers' diets, or about 8% of the daily wage. The increase in food intake equivalent to 2% of the daily wage actually achieved through nutrition education resulted in a significant improvement in child weight gain, though not ideal. These findings suggest that, in the absence of programs which reduce economic barriers, it is economically feasible for families to close the nutrient gaps for weaning-age breastfed children in Bangladesh, but not for lactating women. Thus, education to improve women's diets should be incorporated into programs that make these improvements affordable, whereas education to improve weaning-age children's diets can be implemented with or without other program supports.

A community-based nutrition education intervention taught 48 Bangladeshi families with breast-feeding infants how to improve the mothers' diet. The energy adequacy of the women's diets and of 30 comparable controls averaged 65% + 14% of the FAD/WHO/ UNU requirement at baseline and declined to 55% + 7% immediately after the education (Post1) and to 52% + 6% after eight months of study (Post2). This decline was probably a seasonal effect resulting from lower food availability at Post1 and Post2. The adjusted declines in adequacy of treatments and controls did not differ at Post1 (-9.9% v.-9.5%; p = .806) when behavioural changes were expected. Adjusted declines from baseline to Post2 were significantly less for treatments than controls (-10.1% v.-15.5%; p =.001), but results may have been influenced by flooding that affected food distribution and production. Arm circumferences (MUAC) of both groups remained along the fifth percentile of the international reference. No significant differences were found between the average weight for age (WAZ) or MUAC of the breast-fed children in the two groups, although a greater percentage of control children became severely malnourished (p =.011). The evaluation raises concerns about the effectiveness of nutrition education for improving the diets of poor women if given in isolation of programmes that make improvements affordable. Evaluation of the impact of messages to improve the diets of lactating rural A rural woman's day is consumed with cooking, collecting firewood and water, cleaning and caring for children and elders. Women have no control over the food budget-the men buy and sell food in the market. Nearly 80% of women have never been to school and cannot read, write, or understand numbers at a functional level [7]. Adding to this powerlessness, the newlywed goes to live with her husband's family, often a less supportive environment than her own parents' home. Nutrition education Exposure to education and information can empower a woman to maximize the few resources around her for the health of her family [27, 28]. An education intervention to improve the diets of weaning-age children, conducted in the same setting as this study, resulted in greater energy intakes and weight gains of treatment children compared with controls [29]. This study, however, questions the sources of nutrition education alone in improving maternal diets under conditions of extreme poverty and possible discrimination against women in intrahousehold food distribution. Nutrition messages were designed for the Bangladesh Rural Advancement Committee's (BRAC) Child Survival Programme to improve lactating women's diets. Field observations suggested that, in general, the mothers wished to eat more during lactation. Yet, despite the project's promotion of low-cost traditional foods and inclusion of other family members in the teaching, the mothers reported that financial barriers limited their ability to comply with messages. This study evaluates the impact of the messages on the dietary adequacy and nu...