Imran Ahmed

The Central Asia Stunting Initiative (CASI) is a program designed to address malnutrition among women of reproductive age and children under five in Badakhshan Province, Afghanistan, a region facing significant nutritional challenges. This study used a pre‐post design to assess the impact of CASI interventions, with cross‐sectional surveys conducted at baseline and midline among non‐pregnant women of reproductive age (15–49 years) and children under five using a two‐stage stratified random sampling approach; data collection included anthropometric measurements and hemoglobin assessments. Between the baseline and midline surveys, access to safe drinking water improved from 80.9% to 90.7%, and sanitation improved from 37.4% to 88.3%, while the severe food insecurity rate dropped from 94.7% to 30.5% ( p < 0.001). Exclusive breastfeeding among children aged 0–5 months increased from 64.0% to 80.9%, and dietary diversity among children 6–24 months rose from 7.5% to 20.7% (both p < 0.05). Child under nutrition declined significantly, with underweight decreasing from 35.0% to 15.5% (Cohen's h = 0.46) and stunting from 52.3% to 37.3% (Cohen's h = 0.30). The prevalence of moderate anemia among children fell from 59.7% to 41.1%, while normal hemoglobin levels rose from 39.2% to 58.1% (both p < 0.001). Among women, underweight prevalence declined from 20.0% to 9.4% ( p < 0.001), while overweight prevalence rose from 5.4% to 10.7% ( p = 0.003). Adjusted models confirmed lower odds of stunting, underweight, and anemia at midline compared with baseline. These findings suggest that CASI was associated with substantial improvements in maternal and child nutrition indicators in Badakhshan, and policymakers should focus on scaling up effective interventions and ensuring continuous monitoring. However, given the single‐group pre‐post design without a comparison group, these findings should be interpreted as temporal associations rather than causal effects.

Background: Adolescents in low- and middle-income countries face a disproportionate burden of dietary inadequacy, yet evidence on the determinants of overall diet quality remains scarce. This study assessed the prevalence of macro- and micronutrient inadequate intake and identified factors associated with dietary adequacy among adolescents in rural Pakistan. Methods: A cross-sectional survey was conducted among adolescents using multistage cluster sampling. Dietary intake was assessed through a single 24-h dietary recall; nutrient adequacy was determined using age-and sex-specific Dietary Reference Intake (DRI) standards, including Estimated Average Requirements (EARs), Adequate Intakes (AIs), Estimated Energy Requirements (EERs), and Acceptable Macronutrient Distribution Ranges (AMDRs), as appropriate. Overall dietary adequacy was quantified using the Mean Adequacy Ratio (MAR), calculated as the unweighted mean of nutrient adequacy ratios for fourteen nutrients, including protein, fiber, calcium, iron, zinc, thiamin, riboflavin, niacin, vitamins A, B6, C, D, E, and folate, scaled from 0 to 100. Multivariable linear regression incorporating survey weights and clustering was used to identify independent predictors of MAR using STATA. Results: A total of 1132 adolescents were included. Most of the energy was derived from carbohydrates, and a high proportion of adolescents had energy intakes below age- and sex-specific Estimated Energy Requirement (EER) values, while very high levels of inadequacies were observed for protein, fiber, calcium, vitamin D, and vitamin A. The mean MAR score was 54.04 ± 16.51, indicating overall poor dietary adequacy. In multivariable analysis, male sex (β = 3.26; 95% CI: 1.76, 4.75), belonging to the richest wealth quintile (β = 5.81; 95% CI: 1.76, 9.86), always eating between meals (β = 6.70; 95% CI: 3.93, 9.47), and use of bar soap for handwashing (β = 4.97; 95% CI: 2.00, 7.94) were significantly associated with higher dietary adequacy. Adolescents who were underweight (β = −2.40; 95% CI: −4.81, −0.11) and those with moderate physical activity levels (β = −3.96; 95% CI: −7.62, −0.29) had significantly lower dietary adequacy scores. Conclusions: Dietary inadequacy among rural adolescents in Pakistan was highly prevalent and was associated with socioeconomic, behavioral, and nutritional factors. These findings highlight the need for interventions that address food insecurity, promote equitable food distribution, and strengthen nutrition education to support adolescent health and nutrition. However, these findings should be interpreted in light of the cross-sectional design and the use of a single 24-h dietary recall, which may not reflect habitual dietary intake.

Neonatal mortality, defined as death within the first 28 days of life, constitutes 41% deaths in children under five [1]. Most of these deaths occur within the first week of life, at home, and in low-resource settings where health system access and referral mechanisms are weak [2–4]. Pakistan reflects this global burden, with a […]

Background: Anemia is a major public health issue, particularly among women of reproductive age (WRA) in low- and middle-income countries (LMICs). Pakistan’s National Nutrition Survey (NNS) 2011 showed a high prevalence of vitamin B₁₂ (B₁₂) and folate deficiency among WRA, necessitating further investigation in subsequent surveys. Methods: Blood samples from 31,828 WRA (15–49 years old) were collected using a stratified multi-stage sampling technique in NNS-2018. We conducted a secondary analysis using population-weighted logistic regression to assess the association of potential factors with B₁₂ and folate deficiency. B₁₂ (n = 4442) and folate (n = 12,662) samples were measured using an electrochemiluminescence immunoassay and a Centers for Disease Control and Prevention, USA (CDC)-approved microbiologic assay, respectively. Results: Folate deficiency was present in 44.7% WRA, and 20.2% had B₁₂ deficiency. Provincial distribution was associated with folate deficiency, i.e., Sindh (OR = 1.140, 95% CI 1.018, 1.285), Baluchistan (OR = 1.237, 95% CI 1.052, 1.453), and Islamabad (OR = 1.524, 95% CI 1.109, 2.092), while B₁₂ deficiency was prevalent in Islamabad (OR = 1.673, 95% CI 1.122, 2.497), Gilgit Baltistan (OR = 2.472, 95% CI 1.197, 5.106), and newly merged districts of KPK (OR = 1.584, 95% CI 0.977, 2.570). Rural residence (OR = 1.407, 95% CI 1.125, 1.760), obesity (OR = 1.649, 95% CI 1.282, 2.122), and overweight (OR = 1.560, 95% CI 1.262, 1.928) were associated with B₁₂ deficiency. Conclusions: Our results show regional and demographic differences in the prevalence of folate and B₁₂ deficiencies among WRA. This underscores the need for targeted nutritional interventions and further longitudinal studies to identify potentially associated factors.

Introduction: Anemia is a global public health concern affecting mainly women of reproductive age (WRA) and preschoolers (PSC, 6–59 months) due to their higher demand for iron. The etiology of anemia is multifactorial, and nutritional anemia is the most common type worldwide and is predominantly due to deficiencies in iron, vitamin B12, and folate. This study aimed to assess the associated factors, etiology, and prevalence of anemia among WRA and preschoolers in the Gorno-Badakhshan Autonomous Oblast (GBAO) region in Tajikistan. Methods: We conducted a cross-sectional study in the GBAO region of Tajikistan between April 2021 and September 2021, enrolling 500 non-pregnant WRA and 500 children aged 6–59 months in pairs (mother–PSC dyads) from six districts of the GBAO region. The survey was administered through a structured questionnaire at the household level, and information was collected on sociodemographic characteristics, reproductive history, dietary intake, nutritional status, and maternal factors. Blood and stool samples were also collected for micronutrient deficiencies and helminthic infections. Data analysis began with univariate analysis, followed by multivariate logistic regression in Stata (version 18). Results: Biochemical assessment of 473 WRA and 390 preschoolers was carried out; 17.3% of WRA were anemic, and 15.4% of PSC were anemic. Anemia prevalence was 17.3% among WRA and 15.4% among PSC. Among women, low ferritin and elevated serum transferrin receptor (sTfR) levels were associated with higher odds of anemia, whereas overweight status, higher gravidity, and vitamin B12 deficiency were associated with lower odds. Among children, low maternal education, maternal anemia, age < 24 months, and low ferritin were associated with increased odds of anemia. Conclusions: Anemia prevalence in GBAO was substantially lower than reported in the 2016 national survey, potentially reflecting methodological and contextual differences. Findings highlight iron deficiency as a dominant contributor, particularly in young children, underscoring the need for context-specific maternal and child nutrition interventions.

Background: Small vulnerable newborn (SVN) types, defined by combinations of being born too soon or too small, have distinct determinants, health consequences, and prevention strategies. The effects of prenatal balanced energy and protein (BEP) supplementation on SVN types remain unknown. Methods and findings: We conducted a systematic review and meta-analysis of individual participant data from eight randomized controlled trials of prenatal BEP supplements ( N = 10,252, with 5,164 in the BEP arm and 5,088 in the control arm) in low- and middle-income countries were used. The control arms varied across studies and included context-specific standards of care, iron and folic acid supplements, or multiple micronutrient supplements. Newborns were classified into 10 groups through the combinations of preterm birth, small for gestational age (SGA) birth, and low birthweight (LBW), such as term-appropriate-for-gestational-age (AGA)-nonLBW, preterm-SGA-LBW, preterm-large-for-gestational-age-LBW, term-SGA-LBW, preterm-AGA-nonLBW, and other permutations. Newborns were also analyzed using a four-group categorization that included term-nonSGA, preterm-nonSGA, term-SGA, and preterm-SGA. Log-binomial models were used to estimate study-specific risk ratios (RRs), which were pooled using meta-analyses. Subgroup analyses were conducted by maternal age, parity, gestational age at enrollment, early pregnancy body mass index, and maternal anemia status. In the 10-group categorization of SVNs, on average, prenatal BEP supplementation led to a 30% lower risk of preterm-SGA-LBW (RR: 0.70; 95% CI [0.53, 0.91]; P = 0.009), a 25% lower risk of preterm-AGA-LBW (RR: 0.75; 95% CI [0.60, 0.93]; P = 0.009), and a 20% lower risk of term-SGA-LBW (RR: 0.80; 95% CI [0.72, 0.90]; P < 0.001). In the four-group categorization, prenatal BEP supplementation led to a 31% lower risk of preterm-SGA (RR: 0.69; 95% CI [0.52, 0.91]; P = 0.008) and a 12% lower risk of term-SGA (RR: 0.88; 95% CI [0.81, 0.96]; P = 0.005). The protective effect of prenatal BEP supplementation on preterm-SGA was stronger among multiparous women and women without anemia. The protective effects on all three SVN types under the four-group categorization were stronger among women enrolled before 20 weeks of gestation. The main limitations of the study included the absence of some BEP trials and the small event numbers for some SVN types. Conclusions: Prenatal BEP supplementation reduces the risk of SVNs to varying extents. Further research is needed to determine the optimal targeting approach for providing BEP supplements to vulnerable pregnant women who are most likely to benefit from the supplementation.

Introduction: Anemia is a global public health concern affecting mainly women of reproductive age (WRA) and preschoolers (PSC,6-59 months) due to their higher demand for iron. The etiology of anemia is multifactorial, and nutritional anemia is the most common type worldwide and is predominantly due to deficiencies in iron, vitamin B12, and folate. This study aimed to assess the associated factors, etiology, and prevalence of anemia among WRA and preschoolers in the GBAO region in Tajikistan. Methods: We conducted a cross-sectional study in the GBAO province of Tajikistan between April 2021 and September 2021, enrolling 500 WRA and 500 children aged 6-59 months from six districts of the GBAO region. The survey was administered through a structured questionnaire at the household level, and information was collected on sociodemographic characteristics, reproductive history, dietary intake, nutritional status, and maternal factors. Blood and stool samples were also collected for micronutrient deficiencies and helminthic infections. Data analysis began with univariate analysis, followed by multivariate logistic regression in Stata (version 18). Results: Biochemical assessment of 473 WRA and 390 preschoolers was conducted; 17.3% of WRA and 15.4% of PSC were anemic. After adjustment, the following factors were positively associated with anemia in WRA living in the GBAO region; body mass index ( overweight (OR 0.313, p value 0.020), gravidity (OR 0.326,p value 0.009), low ferritin (OR 8.549,p value Conclusions: Anemia in women was strongly associated with low ferritin, high STFR, gravidity, BMI, and vitamin B12; in children, with maternal education, maternal anemia, age <24 months, and low ferritin. These findings underscore the urgent need for locally tailored interventions, both in the short term and the long term.

Background/Objectives: In Pakistan, 41.7% of women of reproductive age and 53.7% of children aged 6–59 months are anaemic. This study aimed to evaluate the effectiveness of a nutritional supplementation programme, underpinned with behaviour change communication and implemented through Lady Health Workers (LHWs), in reducing anaemia among pregnant and lactating women as well as 6–59-month-old children. Methods: This study used a quasi-experimental design with an intervention and a control group. A total of 2821 and 2410 pregnant and lactating women and 3397 and 3277 children aged 6–59 months participated in the baseline and endline surveys, respectively. The study areas were matched for demographic and economic characteristics, and both had routine public-sector health and nutrition programmes, including iron–folic acid supplementation during pregnancy. The participants in the intervention group received additional nutritional support. Throughout the pregnancy and in the first six months of exclusive breast feeding, women were provided 5 kg (165 g/day) of wheat soya blend (WSB) per month. Children aged 6–23 months received lipid-based nutrient supplements (LNS), and those aged 24–59 months received micronutrient powder. We applied a difference-in-difference (DID) analysis with kernel propensity score matching to assess the impact on anaemia, a secondary outcome of a stunting prevention programme. Results: Maternal anaemia (both pregnant and breastfeeding women) declined substantially in the intervention areas from 80.4% to 62.6% compared with a smaller reduction in the control areas (80.0% to 72.9%). The DID estimate showed a 10.7-percentage-point (pp) greater decline in maternal anaemia (p ≤ 0.001). Both pregnant and lactating women benefited, with DID reductions of 16.7 pp (p ≤ 0.001) and 9.4 pp (p = 0.005), respectively. The largest gains occurred among women in higher-wealth quintiles, with reductions up to 22.6 pp (p ≤ 0.001). In contrast, childhood anaemia showed no overall significant difference between intervention and control areas (DID = −0.7 pp, p = 0.73). However, significant improvements were observed among male children (DID = −10.3 pp, p = 0.001) and those in higher-wealth quintiles (DID = −15.0 pp, p = 0.002). Conclusions: Overall, the findings suggest that LHWs can effectively reduce maternal anaemia when iron–folic acid supplementation is complemented with WSB and targeted behaviour change communication.

Background According to the World Health Organization (WHO), worldwide anemia prevalence in children of 6–59 months is 40% [1]. Though iron deficiency is recognized as a significant cause of anemia, vitamin B₁₂ (B₁₂) and folate deficiencies are also important causes. The previous Pakistan National Nutrition Survey (NNS) 2011 showed a high prevalence among women of reproductive age (WRA), which necessitated further investigation in follow-up surveys among children. Methods We performed a secondary analysis of the National Nutrition Survey (NNS) 2018–2019. Blood samples were obtained from 31,828 children (< 5 years), with a subsample analyzed for B₁₂ (n=2693) and folate (n=6690) deficiency. B₁₂ was assessed by electrochemiluminescence immunoassay, and folate by CDC’s microbiologic assay. Logistic regressions were applied to determine factors associated with deficiency. Results 35.1%, while 24.8% of children showed folate and B₁₂ deficiency, respectively. Higher odds of folate and B₁₂ deficiency were observed in Khyber Pakhtunkhwa, OR = 1.424 (95% CI 1.157, 1.752), and newly merged districts of Khyber Pakhtunkhwa, OR = 11.257 (95% CI 2.291, 55.314), respectively. Additionally, mother’s education was associated with B₁₂ deficiency i.e. uneducated OR = 2.017, (95% CI 1.229, 3.308), primary OR = 2.361 (95% CI 1.359, 4.103) and middle OR = 2.108 (95% CI 1.144, 3.882) while underweight was associated with folate deficiency only, OR = 1.181 (95% CI 1.016, 1.371). Conclusion This analysis highlights a considerable burden of folate (35.1%) and vitamin B₁₂ (24.8%) deficiencies among Pakistani children under five years of age, with regional disparities. Socioeconomic and nutritional factors, particularly maternal education and child undernutrition, further influence the risk of deficiency. These results emphasize the need for region-specific nutrition interventions, maternal education programs, and strengthened food fortification strategies.

Background: Anemia is a severe public health issue, particularly among women of reproductive age (WRA) in low-and middle-income countries. Pakistan National Nutrition Survey (NNS) 2011 showed a high prevalence of B12 and folate deficiency in WRA, necessitating further investigation in follow-up surveys. Methods: Using a stratified multi-stage sampling technique, we conducted a secondary analysis of the National Nutrition Survey (NNS) 2018–2019. Blood samples were collected from 31,828 WRA (15–49 years old), and a subsample was examined for folate (n=12662) and B12 deficiencies (n=4442). B12 and folate levels were measured using Electrochemiluminescence immunoassay and a CDC-approved microbiologic assay, respectively. The association of factors was analyzed using logistic regression. Results: 44.7% and 20.2% WRA had folate and B12 deficiency, respectively. Provincial distribution was associated with folate deficiency i.e., Sindh OR=1.140 (95% CI 1.018, 1.285), Baluchistan OR = 1.237 (95% CI 1.052, 1.453), Islamabad OR = 1.524 (95% CI 1.109, 2.092). In comparison, B12 deficiency was prevalent in Islamabad, OR = 1.673 (95% CI 1.122, 2.497), Gilgit Baltistan, OR = 2.472 (95% CI 1.197, 5.106), and the tribal districts of KPK, OR = 1.584 (95% CI 0.977, 2.570). Rural residence OR=1.407 (95% CI 1.125, 1.760), being obese OR=1.649 (95% CI 1.282, 2.122), and being overweight OR=1.560 (95% CI 1.262, 1.928) were also associated with B12 deficiency. Conclusion: Study revealed that nearly half of women were affected by folate deficiency and one in five by B12 deficiency. The findings highlight significant regional disparities and stronger vulnerability among women in rural areas and those with higher body mass indices. These results emphasize the need for targeted nutritional interventions, improved dietary diversity, and public health strategies.