* Indicates significance of difference by t -tests between no pica and any pica groups. † Values are mean (SD). 147PICA, ANEMIA, AND GI DISTRESS IN ZANZIBAR, TANZANIA The prevalence of IDA followed a similar pattern, with the prevalence of IDA significantly higher among amylophagists than among those who reported no pica at any point in pregnancy (52.6% versus 36.1%; P < 0.001) and highest among women who ate both pica substances (57.0% versus 36.1%; P < 0.001) ( Figure 2 ). The effect of uncooked rice and earth on iron status was independent; there was no evidence of interaction between the two types of pica behavior on Hb or ZPP.A significantly higher proportion of women who had eaten earth in the current pregnancy had experienced abdominal pain and constipation than non-geophagic women ( Table 4 ). A significantly higher proportion of pregnant women who had consumed uncooked rice at some point in the current pregnancy had experienced nausea and abdominal pain than those who had not. More women who had engaged in any form of pica had experienced nausea, abdominal pain, and constipation in this pregnancy than those who had not. There were no significant differences in loss of appetite, diarrhea, or vomiting between the pica versus non-pica group.Statistical models of pica. We built a multivariate logistic regression model of any pica to examine the relative strength of the association of the correlates of pica when considered jointly ( Table 5 ). Hookworm was not included for three reasons: it greatly limited the sample size, the effects of hookworm on iron status are largely captured by the inclusion of Hb, and we have already established that geophagy is not a vector for hookworm transmission in this population. 15Women with lower Hb concentrations, women who were later in gestation, and women who had experienced abdominal pain or nausea were more likely to engage in pica. Older women and women whose husbands had received formal education were less likely to engage in pica. The variable with the strongest association with any pica was nausea (OR = 1.45, 95% CI = 1.20-1.73), followed by Hb. For every g/dL decrease in Hb concentration, the likelihood of engaging in pica increased by 31.5% (OR = 0.76, 95% CI = 0.73-0.81).We then examined how the predictors of any pica determined geophagy and amylophagy separately ( Table 5 ). The ORs in logistic models of geophagy and amylophagy separately were consistently in the same direction and of similar magnitude as they were for any pica. DISCUSSIONOf the 2,367 pregnant women, 897 (37.9%) had engaged in geophagy by the time of their enrollment into the larger study of the prevention of severe anemia in pregnancy. Of these, 36.3% were amylophagists, 5.2% were geophagists, and 3.6% had eaten raw rice and earth.The prevalence of geophagy among pregnant women in Africa has been reported to range from 28% to 100% [31][32][33][34][35][36][37][38][39][40] ; the prevalence on Pemba Island was markedly lower (5.2%). However, the amounts of earth consumed in Pemba (26.5 grams/day)...

Iron and zinc deficiencies have been associated with delayed motor development in nutritionally at-risk children, albeit inconsistently. In this community-based, randomized double-blind trial, iron+folic acid (FeFA) (12.5 mg Fe + 50 mug folic acid), zinc (Zn) (10 mg), and iron+folic acid+zinc (FeFA+Zn) supplements or a placebo were given daily for 1 y to nutritionally at-risk children in Pemba, Zanzibar. The effects of these treatments on attaining unassisted walking were evaluated using survival analysis for 354 children aged 5-11 mo at the start of supplementation. Treatment effects on changes in hemoglobin (Hb) and zinc protoporphyrin (ZPP) and height-for-age (HAZ) and weight-for-age (WAZ) Z scores were evaluated using linear regression. Attained motor milestone was recorded every 2 wk for 1 y. Hb, ZPP, HAZ, and WAZ were measured at baseline and after 6 mo of treatment. FeFA with or without Zn reduced the time it took for children to walk assisted. Children who received any iron walked unassisted sooner than those who received no iron [median difference approximately 15 d, P = 0.035, risk ratio (RR) = 1.28, 95% CI = 1.02, 1.61] and this effect was stronger in those who had iron deficiency anemia (IDA) at baseline (median difference was approximately 30 d; P = 0.002; RR = 1.68; 95% CI = 1.21, 2.32). FeFA alone and Zn alone improved Hb and ZPP compared with placebo. There were no significant treatment effects on changes in HAZ or WAZ. The effects of treatment on time to walking may have been mediated by improvements in iron status or hemoglobin, but were not mediated through improvements in growth.

Motor activity improves cognitive and social-emotional development through a child's exploration of his or her physical and social environment. This study assessed anemia, iron deficiency, hemoglobin (Hb), length-for-age Z-score (LAZ), and malaria infection as predictors of motor activity in 771 children aged 5-19 mo. Trained observers conducted 2-to 4-h observations of children's motor activity in and around their homes. Binary logistic regression assessed the predictors of any locomotion. Children who did not locomote during the observation (nonmovers) were excluded from further analyses.Linear regression evaluated the predictors of total motor activity (TMA) and time spent in locomotion for all children who locomoted during the observation combined (movers) and then separately for crawlers and walkers. Iron deficiency (77.0%), anemia (58.9%), malaria infection (33.9%), and stunting (34.6%) were prevalent. Iron deficiency with and without anemia, Hb, LAZ, and malaria infection significantly predicted TMA and locomotion in all movers. Malaria infection significantly predicted less TMA and locomotion in crawlers. In walkers, iron deficiency anemia predicted less activity and locomotion, whereas higher Hb and LAZ significantly predicted more activity and locomotion, even after controlling for attained milestone. Improvements in iron status and growth and prevention or effective treatment of malaria may improve children's motor, cognitive, and social-emotional development either directly or through improvements in motor activity.However, the relative importance of these factors is dependent on motor development, with malaria being important for the younger, less developmentally advanced children and Hb and LAZ becoming important as children begin to attain walking skills.

Locomotion allows infants to explore their environment, promoting development in other domains. Motor progression involves biological systems and experiential factors. Nutritional deficiencies could interfere with systems involved in locomotion. This study examined the associations between height-for-age (HAZ), weight-for-height (WHZ) Z-scores and anemia-iron status on locomotion in 646 Zanzibari infants. Motor milestones were assessed by trained observers using a 14-item scale. Two mutually exclusive samples were created. The crawling sample (n = 167, 6-18 mo old) included infants that crawled only or did not crawl; the walking sample (n = 479, 9-18 mo old) included children that walked alone or did not walk alone. Of the crawling and walking samples, 82.6 and 83.9% respectively, were iron deficient and/or anemic (hemoglobin < 100 g/L; zinc protoporphyrin > or = 90 micromol/mol heme). Stunting (HAZ less than -2) occurred in 30.5% of the crawling sample and 38.4% of the walking sample. Logistic regression models estimated the influence of factors on crawling vs. not crawling or walking vs. not walking. Two models were tested: 1) included sex, age, SES, HAZ and WHZ; 2) added anemia-iron status category to Model 1. HAZ improved the odds of crawling by 30%, but was not significant in either model. Model 2 fit the walking sample data best (P < 0.0001); an increase in HAZ doubled the odds of walking and nonanemic, noniron deficient children were 66% more likely to walk than those with anemia and/or iron deficiency. In this sample of poorly nourished infants, growth and anemia-iron status are significant predictors of walking, but not crawling.

Background. The role of context has not been elaborated with respect to current recommendations for complementary feeding interventions, apart from a gross distinction based on food security.Objective. Our objective was to compare two foodinsecure settings in sub-Saharan Africa to determine how context (i.e., the set of local social, cultural, and physical circumstances) influences complementary feeding practices and nutrient intakes and how the results can help in the design of a suitable intervention strategy.Methods. We conducted formative research using 24-hour dietary recalls, household interviews, and focus group discussions with mothers of 6-to 12-month-old infants in rural Zimbabwe (n = 32) and Pemba Island, Zanzibar, Tanzania (n = 44).Results. In both settings, many infants had suboptimal nutrient intakes, poor dietary diversity, and poor hygiene. Breastfeeding practices were poor in Pemba, and the infants' diet had low energy density in Zimbabwe. Beyond food insecurity, contextual determinants of practices included inaccurate indigenous knowledge, time-consuming maternal livelihoods, family eating behaviors, local agriculture, and the local ecosystem. Both settings would require nutrition education, but it should target the broader indigenous ways of learning and family eating behaviors in order to achieve the necessary behavior change. A home-based fortificant would probably be enough for Pemban children, because the ecosystem of the island provides sufficient sources of macronutrients. However, Zimbabwean children appear to need a fortified food-based supplement to overcome the poor agricultural and economic context.Conclusions. Assessing context was essential to intervention design. A framework to guide future formative research is proposed.