Biological Mechanisms

The Nutrition Innovation Lab will be exploring several important potential contributors to child stunting including water quality, aflatoxins, gut microbiota and environmental enteropathy, and animal source protein

Overview & ActivitiesRelated Publications

Some of the key elements largely missing from past consideration of agriculture to nutrition pathway analysis relates to biological mechanisms, as opposed to cultural or economic mechanisms. In collaboration with other Innovation labs, the Nutrition Innovation Lab will be exploring several important potential contributors to child stunting:

  • Water Quality
  • Aflatoxins
  • Gut Microbiota and Environmental Enteropathy
  • Animal Source Protein in the Asian Diet

There are two potential approaches to examining the aflatoxins issue in the first phase of the Nutrition Innovation Lab’s research. The first is an assessment of the PoSHAN Study sites of the extent of aflatoxin contamination levels using validated field tools. The second, a collaboration with AusAID, UNICEF and the University of Jakarta, is a nationally representative assessment of aflatoxin levels in the blood of mothers and children in Timor Leste, and associated nutritional status markers and indices of household food security. A study is planned in collaboration with Virginia Tech University on the potential for pathogens shared in the gut microbiota of humans and animals as determinants of nutrition outcomes. The objective of the research is to generate data on the human and livestock microbiome from distinct ecological regions of Nepal both in the rainy and dry seasons, and to measure link of the zoonotic disease burden to nutrition outcomes. The potential for collaboration with AquaFish and WorldFish is being explored to consider the role of aquatic protein sources in Asian diets and nutrition. The development of pond-based aquaculture in tandem with horticulture promotion and behavior change communication is being considered in certain parts of Nepal, as well as in Bangladesh and Cambodia. Theme3-Illustration

Browse through related publications here, or search through all of our publications.

Infant Nutritional Status and Markers of Environmental Enteric Dysfunction are Associated with Midchildhood Anthropometry and Blood Pressure in Tanzania

Authors: Lindsey Locks; Ramadhani Mwiru; Expeditho Mtisi; Karim Manji; Christine McDonald; Enju Lui; Roland Kupa; Rodick Kisenge; Said Aboud; Kerri Gosselin; Matthew Gillman; Andrew Gewirtz; Wafaie Fawzi; Christopher Duggan August 2017
Children who participated in 2 randomized trials of micronutrient supplements in infancy were followed up in midchildhood (4.6-9.8 years of age). Anthropometry was measured at age 6 and 52 weeks in both trials, and blood samples were available from children at 6 weeks and 6 months from 1 trial. Linear regression was used for height-for-age z-score, body mass index-for-age z-score, and weight for age z-score, and blood pressure analyses; log-binomial models were used to estimate risk of overweight, obesity, and stunting in midchildhood.
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Food insecurity, but not HIV-infection status, is associated with adverse changes in body composition during lactation in Ugandan women of mixed HIV status

Authors: Elizabeth Widen; Shalean Collins; Hijab Khan; Claire Biribawa; Daniel Acidri; Winifred Achoko; Harriet Achola; Shibani Ghosh; Jeffrey Griffiths; Sera Young January 2017
A cohort of 246 women [36.5% of whom were HIV positive (HIV+) and were receiving ART] were followed to 12 mo postpartum. Repeated measures included weight, fat mass, fat-free mass, mid upper arm circumference, triceps skin fold thickness [which allowed for the derivation of arm muscle area (AMA) and arm fat area (AFA)], breastfeeding, and individual food insecurity. Longitudinal regression models were constructed to assess associations between HIV and food insecurity and changes in body composition over time.
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Climatic conditions and child height: Sex-specific vulnerability and the protective effects of sanitation and food markets in Nepal

Authors: Prajula Mulmi; Steven Block; Gerald Shively; William A. Masters December 2016
Abstract Environmental conditions in early life are known to have impacts on later health outcomes, but causal mechanisms and potential remedies have been difficult to discern. This paper uses the Nepal Demographic and Health Surveys of 2006 and 2011, combined with earlier NASA satellite observations of variation in the Normalized Difference Vegetation Index (NDVI) at each child’s location and time of birth to identify the trimesters of gestation and periods of infancy when climate variation is linked to attained height later in life. We find Continue reading →
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PoSHAN Community Studies: Panel 3 Report

Authors: Nutrition Innovation Lab November 2016
The goal of PoSHAN Community Studies is to understand the factors that link agriculture to nutrition. This involves researching the determinants of household food security, dietary intake, and nutritional status of children under 5 years of age and their mothers in relation to changes in agriculture and exposure to agricultural and microeconomic extension, as well as nutrition and health programs in Nepal. This descriptive report summarizes the main findings of the third panel survey.
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PoSHAN Community Studies: Panel 2 Report

Authors: Nutrition Innovation Lab October 2016
The goal of PoSHAN Community Studies is to understand the factors that link agriculture to nutrition. This involves researching the determinants of household food security, dietary intake, and nutritional status of children under 5 years of age and their mothers in relation to changes in agriculture and exposure to agricultural and microeconomic extension, as well as nutrition and health programs in Nepal. This descriptive report summarizes the main findings of the second panel survey conducted between May – July 2014.
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Relationship of Stunting and Overweight in Egyptian children under five years of age: Trends and associated risk factors.

Authors: Shibani Ghosh; Grace Namirembe; Marwa Moaz; Ashish Pokharel; Elizabeth Marino-Costello; Jeffrey Griffiths; Patrick Webb September 2016
Egypt’s emerging economy faces a dual burden wherein there is coexistence of under and over nutrition, either in the same population, community, household or same individual. The dual burden of disease can be extremely variable in its manifestation. It can, for example, be manifested as stunted children who are concurrently obese, or as stunted children who may not be currently obese but who are at risk of early onset chronic diseases. Secondary Analysis provided by the Nutrition Innovation Lab.  
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The association between food insecurity and depressive symptoms severity among pregnant women differs by social support category: a cross-sectional study

Authors: Barnabas Natamba; Jane Achan; Rebecca Stoltzfus; Sera Young August 2016
Abstract Common mental disorders, such as depression and anxiety, affect approximately 16% of pregnant women in low- and middle-income countries. Food insecurity (FI) has been shown to be associated with depressive symptoms. It has also been suggested that the association between FI and depressive symptoms is moderated by social support (SS); however, there is limited evidence of these associations among pregnant women living in low-income and middle-income countries. We studied the association between FI and depressive symptoms severity and assessed whether such an association varied Continue reading →
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Protein Quality in the First Thousand Days of Life

Authors: Shibani Ghosh May 2016
The aim of this article is to provide an overview of the role of protein quality within the first 1000 days of life. The article outlines the importance of protein quality in pregnancy and early growth and examines the potential of high-quality protein in prevention of stunting and treatment of severe and moderate acute malnutrition. The article also provides a summary of the recent changes in protein quality evaluation and the development of a new index, the Digestibility Corrected Amino Acid Score, examining the opportunities Continue reading →
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Global dietary quality, undernutrition and non-communicable disease: a longitudinal modelling study

Authors: Rosemary Green; Jennifer Sutherland; Alan D Dangour; Bhavani Shankar; Patrick Webb January 2016
The objective is to determine the relationship between global dietary energy availability and dietary quality, and nutrition-related health outcomes.
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Head Growth of undernourished children in rural Nepal: Association with demographics, health, and diet

Authors: Laurie Miller; Neena Joshi; Beatrice Rodgers; Jeffrey Griffiths; Shubh Mahato; Padma Singh; Patrick Webb January 2016
Background: Brain development in early childhood is a key determinant of later cognition, social achievement and educational success. Head circumference (HC) measurements are a simple method to assess brain growth, yet reports of these measurements are uncommon in nutritional surveys of undernourished children. To cite this article: Laurie C. Miller, Neena Joshi, Mahendra Lohani, Rupa Singh, Nisha Bhatta, Beatrice Rogers, Jeffrey K. Griffiths, Shibani Ghosh, Shubh Mahato, Padma Singh & Patrick Webb (2016): Head growth of undernourished children in rural Nepal: Association with demographics, health Continue reading →
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The prevalence of anemia and iron deficiency is more common in breastfed infants than their mothers in Bhaktapur, Nepal

Authors: R.K. Chandyo; Sigrun Henjum; P. Shrestha; L. Locks; Wafie Fawzi; Tor Strand December 2015
Iron deficiency anemia is a widespread public health problem, particularly in low- and middle-income countries. Maternal iron status around and during pregnancy may influence infant iron status. We examined multiple biomarkers to determine the prevalence of iron deficiency and anemia among breastfed infants and explored its relationship with maternal and infant characteristics in Bhaktapur, Nepal.
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UNICEF: Timor-Leste Food and Nutrtion Survey 2013- Final Report

Authors: Nutrition Innovation Lab October 2015
UNICEF Report: The data collection for this survey was carried out between May and September 2013 among children aged 0-59 months and their non-pregnant mothers (aged 14 – 60 years). The survey assessed the risk factors for undernutrition based on Conceptual Framework of Malnutrition (UNICEF, 1990) which is being used for nutrition programming worldwide for the past 25 years. The prevalence of micronutrient deficiencies (vitamin A, iron, zinc, and iodine deficiency), and the iodine content of household iodised salt and aflatoxin exposure among children (aged 6 – 59 Continue reading →
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Agricultural Diversity and Child Stunting in Nepal

Authors: Gerald Shively; Celeste Sununtnasuk September 2015
This article investigates empirical connections between agriculture and child nutrition in Nepal. We augment the standard approach to explaining child nutrition outcomes by including information about household level agricultural production characteristics, including indicators of agricultural diversity. Data from the 2010/2011 Nepal Living Standards Survey (NLSS) are used in a series of regression models to explain stunting outcomes and variation in height-for-age Z-scores among 1,769 children 0–59 months of age. Results highlight the relative importance of overall agricultural yields, specific crop groups, and the consumption of own-production as factors correlated Continue reading →
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Maternal Food Insecurity is Associated with Loss of Fat, but not Lean Mass during Lactation among Ugandans of Mixed-HIV Status

Authors: E. Widen; B. Natamba; S. Ghosh; J. Griffiths April 2015
HIV-infected women lose more weight during lactation than HIV-uninfected women. Whether this loss is fat-mass (FM) or fat-free mass (FFM) is unknown, but important, as lean mass loss accelerates HIV progression.
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UNICEF: Timor-Leste Food and Nutrtion Survey 2013- Summary of Key Findings and Recommendations

Authors: Nutrition Innovation Lab April 2015
UNICEF Report: The data collection for this survey was carried out between May and September 2013 among children aged 0-59 months and their non-pregnant mothers (aged 14 – 60 years). The survey assessed the risk factors for undernutrition based on Conceptual Framework of Malnutrition (UNICEF, 1990) which is being used for nutrition programming worldwide for the past 25 years. The prevalence of micronutrient deficiencies (vitamin A, iron, zinc, and iodine deficiency), and the iodine content of household iodised salt and aflatoxin exposure among children (aged 6 – 59 Continue reading →
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Low dietary diversity and micronutrient adequacy among lactating women in a peri-urban area of Nepal

Authors: Sigrun Henjum; Liv Elin Torheim; Andrew L Thorne-Lyman January 2015
The main objectives were to assess the adequacy of the micronutrient intakes of lactating women in a peri-urban area in Nepal and to describe the relationships between micronutrient intake adequacy, dietary diversity and sociodemographic variables. Breast-feeding is one of the most important factors that can influence child health in low- and middle-income countries. During lactation, women have increased requirements for energy and micronutrients. An inadequate maternal intake of certain nutrients during this period may have consequences for both the mother’s health and nutritional status, as well as those of the breast-fed Continue reading →
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The 3rd Annual Scientific Symposium: Agriculture, Food Systems, and Nutrition: Connecting the Evidence To Action

Authors: Nutrition Innovation Lab December 2014
Briefing from the 3rd Annual Scientific Symposium The Nutrition Innovation Lab’s partner, Johns Hopkins University, in collaboration with the Institute of Medicine and the Nepal Agriculture Research Council, hosted its 3rd annual Scientific Symposium in Kathmandu, Nepal on November 18-20, 2014. The question driving this symposium was simple: how can agriculture improve household food security and nutrition outcomes? Yet the work of understanding the agriculture to nutrition pathway is complex. Building sustainable systems that promote food security, nutrition, and health in Nepal requires the utilization of high-quality, empirical evidence. The Continue reading →
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Household food insecurity, maternal nutritional status, and infant feeding practices among HIV-infected Ugandan women receiving combination antiretroviral therapy

Authors: Sera Young; Flavia Luwedde; Paul Natureeba; Jane Achan ; Veronica Ades; Beth Osterbauer; Edwin Charlebois; Moses Kamya; Diane Havlir; Deborah Cohan November 2014
Household food insecurity (HHFI) may be a barrier to both optimal maternal nutritional status and infant feeding practices, but few studies have tested this relationship quantitatively, and never among HIV-infected individuals. We therefore described the prevalence of HHFI and explored if it was associated with poorer maternal nutritional status, shorter duration of exclusive breastfeeding (EBF) and fewer animal-source complementary foods. We assessed these outcomes using bivariate and multivariate analyses among 178 HIV-infected pregnant and breastfeeding (BF) women receiving combination antiretroviral therapy in the PROMOTE trial Continue reading →
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Cover Image: Reliability and validity of the Center for Epidemiologic Studies- Depression scale in screening for depression among HIV infected and uninfected pregnant women attending antenatal services in northern Uganda

Reliability and validity of the Center for Epidemiologic Studies- Depression scale in screening for depression among HIV infected and uninfected pregnant women attending antenatal services in northern Uganda

Authors: Barnabas K. Natamba; Thomas O. Oyok; Angela Arbach; Jane Achan; Shibani Ghosh; Saurabh Mehta; Rebecca J. Stoltzfus; Jeffrey K. Griffiths; Sera L. Young November 2014
In the two decades since the first Global Burden of Disease (GBD) report was released in 1990, the impacts that HIV infection and major depressive disorders (MDDs) have had on medical and public health systems have changed profoundly. The 2010 GBD report indicates that HIV infection has risen from being the 33rd to the 5th contributor to the global burden of disease (Murray et al. 2013). At the same time, the disease burden attributable to MDDs has risen from being the 15th to the 11th. Continue reading →
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“I Have Remained Strong Because of That Food”: Acceptability and Use of Lipid-Based Nutrient Supplements Among Pregnant HIV-Infected Ugandan Women Receiving Combination Antiretroviral Therapy

Authors: SL Young; F Luwedde; B. Okia; P Natureeba; L. Johnson; C. Michel; M. Robine; E. Charlebois; D. Havlir November 2014
We evaluated the acceptability and use of macronutrient supplementation among HIV-infected pregnant Ugandan women receiving antiretroviral therapy in a clinical study (NCT 00993031). We first conducted formative research among 56 pregnant and lactating women to select a supplement regimen. Acceptability and use of the supplementation regimen (35 sachets of lipid-based nutrient supplements (LNS) and 4 or 6 kg of instant soy porridge for the household provided monthly) were evaluated among 87 pregnant women. Organoleptic assessments of LNS were favorable. Participants reported consuming LNS a mean Continue reading →
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Determinants of Stunting and Severe Stunting among under-fives: Evidence from the 2011 Nepal Demographic and Health Survey

Authors: Rina Tiwari; Lynne M Ausman; Kingsley Emwinyore Agho September 2014
Stunting remains a major public health concern in Nepal as it increases the risk of illness, irreversible body damage and mortality in children. Public health planners can reshape and redesign new interventions to reduce stunting and severe stunting among children aged less than 5 years in this country by examining their determinants. Hence, this study identifies factors associated with stunting and severe stunting among children aged less than five years in Nepal.
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Cover Image:Reliability and validity of an individually-focused food insecurity access scale for assessing inadequate access to food among pregnant Ugandan women of mixed HIV status

Reliability and validity of an individually-focused food insecurity access scale for assessing inadequate access to food among pregnant Ugandan women of mixed HIV status

Authors: Barnabas K. Natamba; Angela Arbach; Hillary Kilama; Jane Achah; Jeffrey Griffiths; Sera Young August 2014
Food security occurs “when all people, at all times, have physical, social, and economic access to sufficient, safe, and nutritious food that meets their dietary needs and food preferences for an active and healthy life.” Food insecurity (FI) exists when these conditions are not met and is a major underlying cause of undernutrition enshrined in the UNICEF conceptual framework. FI is a major risk factor for adverse health outcomes among specific vulnerable populations including persons infected with HIV, women and children. Women’s responsibilities in managing family Continue reading →
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Henjum et al 2014

Iron deficiency is uncommon among lactating women in urban Nepal, despite a high risk of inadequate dietary iron intake

Authors: Sigrun Henjum; Mari Manger; Eli Skeie; Manjeswori Ulak; Andrew L. Thorne-Lyman; Ram Chandyo; Prakash S. Shrestha; Lindsey Locks; Rune J. Ulvik; Wafaie W. Fawzi; Tor A. Strand July 2014
The main objective of the present study was to examine the association between dietary Fe intake and dietary predictors of Fe status and Hb concentration among lactating women in Bhaktapur, Nepal. We included 500 randomly selected lactating women in a cross-sectional survey. Dietary information was obtained through three interactive 24 h recall interviews including personal recipes. Concentrations of Hb and plasma ferritin and soluble transferrin receptors were measured. The daily median Fe intake from food was 17·5 mg, and 70% of the women were found Continue reading →
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Uganda Baseline Report: Assessing the Linkage Between Agriculture, Food Security, Nutrition and Health Among Women and Children in Rural Ugandan Households.

Authors: Nutrition Innovation Lab October 2013
This report provides baseline and nationally representative data regarding nutritional and health issues in Uganda, particularly in terms of maternal and child health. Areas of assessment include livestock, malaria, aflatoxin exposure, water access, sanitation, and dietary information
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