Global nutrition

Brief description of the research field

Nutrition in early life has both short- and long-term health consequences affecting an individuals’ ability to participate in and contribute to the society she is a member of emphasizing the central role of nutrition in sustainable health and development.

Our research evolves around the mother and infant dyad in disadvantaged settings. By increasing the understanding of biological and socio-behavioural determinants for their food and nutrition security our aim is to identify factors of importance for developing effective community based interventions. When implementing efficacious interventions at large scale the capacity and quality of the system that provides the interventions is critical. Further, as most interventions are directed to mothers and young children the capacity of women to make use of the provided service and other existing resources in their environment is critical. Our research projects in Bangladesh, Ethiopia and Nicaragua have in common a focus on nutrition in early life and the role of mothers in interacting with the resources of their environment.

Project descriptions Ongoing projects

MINIMat trial Bangladesh
The Maternal and Infant Nutrition Interventions trial in Matlab, (ISRRCTN16581394), in short the MINIMat trial, combined a number of early life nutrition interventions (prenatal food and micronutrient supplementations, exclusive breastfeeding promotion) which in line with the Developmental Origins of Health and Disease aims to evaluate both short and long-term health and nutrition related outcomes in the offspring. In addition, efforts were taken to include assessments of environmental exposures such as toxic metals but also exposure to social factors such as domestic violence. The cohort of children has repeatedly (1-24m, 4.5y, 10y) been followed-up on various nutrition, growth and cognitive developmental outcomes. In fall 2017 the follow-up at 15 years of age is starting. So far, more than 100 publications have been published and 18 PhD students have defended their theses based on data from the MINIMat trial.  A bibliography can be found here:
Maternal and Infant Nutrition Interventions in Matlab. (MINIMat trial), Bangladesh

Collaborators (main)
International Centre for Diarrhoeal Disease Research (icddr,b),Bangladesh research groups at Karolinska Institutet, London School of Hygiene and Tropical Medicine, Institute of Child Health, London, UK, University of California at Davis and Cornell University and Ithaca College in Ithaca, USA, Faculty of medicine, University of Tsukuba, Japan, National Institute for Health and Welfare, Helsinki, Finland 

Funding (main)
icddr,b, UNICEF, Swedish International Development Cooperative Agency (Sida), Swedish Research council, Uppsala University, Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning (FORMAS), UK Medical research, Department International Development (DFID), Japan Society for the promotion of Science, Child Health and Nutrition research

Responsible researcher/contact person
Eva-Charlotte Ekström, lotta.ekstrom@kbh.uu.se

EAT Addis, Ethiopia
Food and nutrition security is a cornerstone for achieving global sustainable development. In Africa’s rapidly growing cities, unemployment and widespread poverty currently leads to high levels of food and nutrition insecurity for a large share of the population. Undernutrition as well as overnutrition cause health related problems affecting individuals and society at large. In spite of these pressing challenges, the factors influencing the access to and consumption of food among urban people in low-income countries, remain insufficiently studied and understood. In the research project EAT Addis we aim to evaluate the social, economic and gender stratification of household food security and their accessibility to safe and nutritious foods with a particular focus on young children. The influence of the urban food environment and its seasonal dynamic will be evaluated as well as the role of women empowerment in their role as gatekeeper between the food environment and the family.

Collaborators
Addis Continental Institute of Public Health, Addis Ababa, Ethiopia, Lund University, Swedish University of Agricultural Sciences, Lund

Funding
Swedish Research Council FORMAS

Responsible researcher/contact person
Eva-Charlotte Ekström, lotta.ekstrom@kbh.uu.se

Betel chewing in pregnancy, Bangladesh
Betel chewing is prevalent in Asia including among women in pregnancy. Betel is known as carcinogenic but little is known about health risks for mother and fetus. Studies suggest that health risks are similar to that of undernourishment in early life; adverse pregnancy outcome, poor fetal and infant growth and increased risk for metabolic syndrome in adulthood. Thus if poor nutrition and betel chewing are combined synergetic affects are plausible. Set in a rural Bangladesh our is aim of this project is to evaluate the health consequences for mother and offspring of betel chewing.

Collaborators
International Centre for Diarrhoeal Disease Research (icddr,b), Bangladesh, and BRAC, Dhaka, Bangladesh

Funding
Swedish Research Council

Responsible researcher/contact person
Eva-Charlotte Ekström, lotta.ekstrom@kbh.uu.se

Community based management of severe acute child malnutrition rural Ethiopia
Effective nutrition interventions exist to prevent and manage mother and child malnutrition. Scaling up of such interventions is less successful and influenced by the context where it is implemented. This study was done within Ethiopia’s community-based program for management of severe acute malnourished children. The study was done within a nationally scaled up nutrition program. It analyses the influence of women’s empowerment on the outcome of rehabilitation of their severely malnourished children as well as the importance of the quality of the program.   

Collaborators
Addis Continental Institute of Public Health, Addis Ababa, Ethiopia

Funding
Swedish Agency for Research Cooperation (SAREC), and Uppsala University

Responsible researcher/contact person
Eva-Charlotte Ekström, lotta.ekstrom@kbh.uu.se

Food and nutrition security in young children, rural Nicaragua
Recent calls to tackle child malnutrition include interventions to improve quality of infants and young children’s diet. Our project was set in a community undergoing the nutrition transition in which traditional diets and ways of feeding young children are influenced by the increased availability of commercial infant foods as well as high-energy dense (but nutrient poor) snack foods and sugar-sweetened beverages.  Our aims were to evaluate the diet of young children both in terms of recommended feeding practices but also to understand feeding of food items with limited nutritional benefits. This included analysing the role of household socio-economic situation and food security and empowerment of women (such as education, autonomy and social support).

Collaborators
Aphrodese (non-governmental organisation), and The National Autonomous University of Nicaragua, Leon, Nicaragua

Funding
Swedish Agency for Research Cooperation (SAREC) and Uppsala University

Responsible researcher/contact person
Eva-Charlotte Ekström, lotta.ekstrom@kbh.uu.se

Improved childhood fever and malaria case management

Brief description of the research field

Malaria, pneumonia and diarrhoeal diseases that present as acute febrile illness, account for more than half of the deaths among children 1 to 59 months old. Fever case management is a major challenge for improved child health globally.

The changing malaria epidemiology in sub-Saharan Africa have provided opportunities but also added to the current challenges encountered in management of febrile children. Availability of reliable and accurate malaria rapid diagnostic tests promotes the targeting of effective artemisinin-based combination therapies (ACT) to parasitologically confirmed malaria cases. Increasingly, it has become important to also detect and manage non-malaria febrile illnesses and malnutrition. Integrated community case management intervention improves the appropriateness of care for malaria, pneumonia symptoms and diarrhoeal diseases among the poor in rural areas of low and middle income countries. Rational use of ACT and appropriate antibiotics for pneumonia conserves and sustains their efficacy, respectively. Other interventions used are vaccinations for bacterial and viral infections, and malaria preventive measures such as insecticide treated nets and indoor residual spraying. 

The success of malaria control efforts has created regions that are heterogenous in malaria endemicity, that require different combinations and intensities of implementation of malaria and other child survival interventions. Delivery of child survival interventions can be a challenge in resource constrained health systems, threatened farther by antimicrobial resistance. Hence, our research group is implementing research activities to provide evidence for febrile illness management and malaria control interventions in high malaria transmission setting of Uganda and Tanzania, and for malaria elimination in low malaria transmission setting of Zanzibar.

Project descriptions

Ongoing projects in Uganda
Together with Makerere University and other collaborators, we are conducting studies to increase coverage and penetration of the integrated community case management (iCCM) intervention for febrile children in rural areas in Uganda. Our studies have shown improvement in the quality of diagnosis and management of febrile children and findings have contributed to changing the policy on community case management of malaria, pneumonia, and diarrhoea at national level, in UNICEF, WHO and Global Fund. Currently, together with collaborators in Uganda, we are evaluating how to embed the iCCM intervention in the existing health systems and scale it up while applying real-world supervision models and medicine supply chains. In addition, we have proposed to develop and implement a franchise model for the drug shops implementing iCCM intervention and management of moderate malnutrition.

Collaborators
Makerere University, Clinton Health Access Initiative, Uganda, UNICEF, Uganda Country Office

Funding
WHO affiliated Alliance for Health Policy and Systems Research, Swedish Research Council, Einhorn Family Foundation and friends, UNICEF, Uganda Country Office.

Responsible researcher/contact person
Stefan Swartling Peterson, stefan.peterson@kbh.uu.se

Ongoing projects in Tanzania
Together with partners in Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, we are conducting longitudinal surveillance of the efficacy of the first line ACT, i.e. artemether-lumefantrine (AL), for the treatment of uncomplicated Plasmodium falciparum malaria in Bagamoyo district. The efficacy of AL is assessed by parasite clearance times, crude and PCR adjusted cure rates, and temporal selection of genetic markers of drug resistance among the parasite population. In addition we are evaluating the diagnostic accuracy and utility of new point-of-care diagnostic tools for improved malaria case detection.

Collaborators
MUHAS, KI.

Funding
Swedish Research Council, Sida

Responsible researcher/contact person
Andreas Mårtensson, andreas.martensson@kbh.uu.se

Ongoing projects in Zanzibar
Together with the Zanzibar Malaria Elimination Programme (ZAMEP) and partners, we are conducting longitudinal surveillance of the impact of malaria interventions on community parasite prevalence, confirmed malaria infections at public health care facilities and all cause child mortality, as well as uptake of the interventions by triangulating data from community based cross sectional surveys, records on confirmed malaria infection from all public health care facilities and vital statistics. The aim of the project is to assess if it is possible to eliminate malaria in Zanzibar as a case study for sub-Saharan Africa.

Collaborators
ZAMEP, KI, UCSF, CDC/PMI.

Funding
Swedish Research Council

Responsible researcher/contact person
Andreas Mårtensson, andreas.martensson@kbh.uu.se