Browsing by Author "Arimond, M."
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Item The association of early linear growth and haemoglobin concentration with later cognitive, motor, and social–emotional development at preschool age in Ghana(Matern Child Nutrition, 2019-05-01) Adu‐Afarwuah, S.; Ocansey, M.E.; Kumordzie, S.M.; Okronipa, H.; Young, R.R.; Tamakloe, S.M.; Oaks, B.M.; Arimond, M.; Dewey, K.G.; Prado, E.L.It is important to identify the periods during childhood when exposure to environmental risk factors results in long‐term neurodevelopmental deficits. Stunting and anaemia may be sensitive indicators of exposure to such risks. In a prospective cohort enrolled before birth, we investigated the association of developmental scores at 4– 6 years with (a) birth length and linear growth during three postnatal periods and (2) haemoglobin (Hb) concentration at three time points. Children were participants in a follow‐up study of a randomized controlled trial of nutritional supplementation in Ghana. At 4–6 years, cognitive, motor, and social–emotional developments were assessed using standard tests adapted for this population. We estimated the associations of length‐for‐age z‐score (LAZ) at birth and postnatal linear growth (n = 710) and Hb (n = 617) with developmental scores in regression models, using multistage least squares analysis to calculate uncorrelated residuals for postnatal growth. Cognitive development at 4–6 years was significantly associated with LAZ at birth (β = 0.12, 95% CI = 0.05, 0.19), ΔLAZ from 6 to 18 months (β = 0.16, 95% CI = 0.04, 0.28), and Hb at 18 months (β = 0.13, 95% CI = 0.06, 0.20), but not with ΔLAZ during 0– 6 months, ΔLAZ from 18 months to 4–6 years, Hb at 6 months, or Hb at 4– 6 years. No evidence of associations with motor or social–emotional development were found. These results suggest that in similar contexts, the earlier periods prior to birth and up to 18 months are more sensitive to risk factors for long‐term cognitive development associated with LAZ and Hb compared with later childhood. This may inform the optimal timing of interventions targeting improved cognitive development.Item Exposure to a Slightly Sweet Lipid-Based Nutrient Supplement During Early Life Does Not Increase the Preference for or Consumption of Sweet Foods and Beverages by 4-6-y-Old Ghanaian Preschool Children: Follow-up of a Randomized Controlled Trial(Journal of Nutrition, 2019-03) Okronipa, H.; Arimond, M.; Young, R.R.; Arnold, C.D.; Adu-Afarwuah, S.; Tamakloe, S.M.; Bentil, H.J.; Ocansey, M.E.; Kumordzie, S.M.; Oaks, B.M.; Dewey, K.G.Background: Whether consuming sweet foods early in life affects sweet food preferences and consumption later in childhood is unknown. Objective: We tested the hypothesis that exposure to a slightly sweet lipid-based nutrient supplement (LNS) early in life would not increase preference for or consumption of sweet items at preschool age. Methods: We followed up children who had participated in a randomized trial in Ghana in which LNS was provided to 1 group of women during pregnancy and 6 mo postpartum and to their infants from ages 6-18 mo (LNS group). The control group (non-LNS group) received iron and folic acid during pregnancy or multiple micronutrients during pregnancy and 6 mo postpartum, with no infant supplementation. At 4-6 y, we obtained data from caregivers on children's food and beverage preferences and consumption (n = 985). For a randomly selected subsample (n = 624), we assessed preference for sweet items using a photo game (range in potential scores, 0-15). For the photo game and reported consumption of sweet items, we examined group differences using predetermined noninferiority margins equivalent to an effect size of 0.2. Results: Median (quartile 1, quartile 3) reported consumption of sweet items (times in previous week) was 14 (8, 23) in the LNS group and 16 (9, 22) in the non-LNS group; in the photo game, the number of sweet items selected was 15 (11, 15) and 15 (11, 15), respectively. The upper level of the 95% CI of the mean difference between LNS and non-LNS groups did not exceed the noninferiority margins for these outcomes. Caregiver-reported preferences for sweet items also did not differ between groups (P = 0.9). Conclusion: In this setting, where child consumption of sweet foods was common, exposure to a slightly sweet LNS early in life did not increase preference for or consumption of sweet foods and beverages at preschool age. This trial was registered at clinicaltrials.gov as NCT00970866.Item Exposure to a Slightly Sweet Lipid-Based Nutrient Supplement During Early Life Does Not Increase the Preference for or Consumption of Sweet Foods and Beverages by 4-6-y-Old Ghanaian Preschool Children: Follow-up of a Randomized Controlled Trial(American Journal of Clinical Nutrition, 2019-03) Okronipa, H.; Arimond, M.; Arnold, C.D.; Young, R.R.; Adu-Afarwuah, S.; Tamakloe, S.M.; Ocansey, M.E.; Kumordzie, S.M.; Oaks, B.M.; Mennella, J.A.; Dewey, K.G.Background The impact of feeding a slightly sweet nutrient supplement early in life on later sweet taste preference is unknown. Objective We tested the hypothesis that the level of sucrose most preferred by 4–6-y-old children exposed to a slightly sweet lipid-based nutrient supplement (LNS) early in life would not be higher than that of children never exposed to LNS. Design We followed up children born to women (n = 1,320) who participated in a randomized trial in Ghana. In one group, LNS was provided to women on a daily basis during pregnancy and the first 6 mo postpartum and to their infants from age 6 to 18 mo (LNS group). The control groups received daily iron and folic acid or multiple micronutrients during pregnancy and the first 6 mo postpartum, with no infant supplementation (non-LNS group). At age 4–6 y, we randomly selected a subsample of children (n = 775) to assess the concentration of sucrose most preferred using the Monell 2-series, forced-choice, paired-comparison tracking procedure. We compared LNS with non-LNS group differences using a noninferiority margin of 5% weight/volume (wt/vol). Results Of the 624 children tested, most (61%) provided reliable responses. Among all children, the mean ± SD sucrose solution most preferred (% wt/vol) was 14.6 ± 8.6 (LNS group 14.9 ± 8.7; non-LNS group 14.2 ± 8.4). However, among children with reliable responses, it was 17.0 ± 10.2 (LNS group 17.5 ± 10.4; non-LNS group 16.5 ± 10.0). The upper level of the 95% CI of the difference between groups did not exceed the noninferiority margin in either the full sample or those with reliable responses, indicating that the LNS group did not have a higher sweet preference than the non-LNS group. Conclusion Exposure to a slightly sweet nutrient supplement early in life did not increase the level of sweet taste most preferred during childhood. This trial was registered at clinicaltrials.gov as NCT00970866.Item Ghanaian parents' perceptions of pre and postnatal nutrient supplements and their effects(Maternal and Child Nutrition, 2018-10) Adams, K.P.; Okronipa, H.; Adu-Afarwuah, S.; Arimond, M.; umordzie, S.; Oaks, B.M.; Ocansey, M.E.; Young, R.R.; Vosti, S.A.; Dewey, K.G.Small-quantity lipid-based nutrient supplements (SQ-LNS) have been studied in efficacy and effectiveness trials, but little is known about how parents perceive the products and their effects. In a randomised trial in Ghana, efficacy of SQ-LNS provided to women during pregnancy and the first 6 months postpartum and to their children from 6 to 18 months of age was assessed by comparison with iron-folic acid (IFA) capsules and multiple micronutrient (MMN) capsules provided to women. In a follow-up study conducted when the index children from the original trial were between 4 and 6 years of age, we used survey-based methods to assess retrospective and current parental perceptions of nutrient supplements generally and of SQ-LNS and their effects compared with perceptions IFA and MMN capsules. Most parents perceived that the assigned supplements (SQ-LNS, IFA, or MMN) positively impacted the mother during pregnancy (approximately 89% of both mothers and fathers) and during lactation (84% of mothers and 86% of fathers). Almost all (≥90%) of mothers and fathers perceived that the assigned supplement positively impacted the index child and expected continued positive impacts on the child's health and human capital into the future. A smaller percentage of parents perceived negative impacts of the supplements (7%-17% of mothers and 4%-12% of fathers). Perceptions of positive impacts and of negative impacts did not differ by intervention group. The results suggest that similar populations would likely be receptive to programs to deliver SQ-LNS or micronutrient capsules.Item Impact of small quantity lipid-based nutrient supplements on infant and young child feeding practices at 18 months of age: results from four randomized controlled trials in Africa(Maternal and Child Nutrition, 2017-07) Arimond, M.; Abbeddou, S.; Kumwenda, C.; Okronipa, H.; Hemsworth, J.; Jimenez, E.Y.; Ocansey, E.; Lartey, A.; Ashorn, U.; Adu-Afarwuah, S.; Vosti, S.A.; Hess, S.Y.; Dewey, K.G.Optimal infant and young child feeding (IYCF) practices can help ensure nutrient adequacy and support healthy growth and development. Small-quantity lipid-based nutrient supplements (SQ-LNS) have been proposed to help fill nutrient gaps, but little is known about the impact of provision of SQ-LNS on breastfeeding or complementary feeding practices. In the context of four coordinated randomized controlled nutrient supplementation trials in diverse sites in Africa, we compared IYCF practices at infant age 18 months (after 9–12 months of supplementation) between those receiving and not receiving SQ-LNS. Practices were assessed by caregiver recall. Continued breastfeeding ranged from 74% (Ghana site) to 97% (Burkina Faso site) and did not differ between groups in any site; prevalence of frequent breastfeeding also did not differ. In two sites (Burkina Faso and Malawi), infants receiving SQ-LNS were more likely to meet the World Health Organization recommendations for frequency of feeding (percentage point differences of 12–14%, P < 0.0001 and P = 0.005, respectively; the remaining two sites did not have data for this indicator). Most indicators of infant dietary diversity did not differ between groups in any site, but in the same two sites where frequency of feeding differed, infants receiving SQ-LNS were less likely to have low frequency of consumption of animal-source foods in the previous week (percentage point differences of 9–19% for lowest tertile, P =.02 and P = 0.04, respectively). We conclude that provision of SQ-LNS did not negatively impact self-reported IYCF practices and may have positively impacted frequency of feeding. © 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.Item Lipid-based nutrient supplement increases the birth size of infants of primiparous women in Ghana(American Journal of Clinical Nutrition, 2015-04) Adu-Afarwuah, S.; Lartey, A.; Okronipa, H.; Ashorn, P.; Zeilani, M.; Peerson, J.M.; Arimond, M.; Vosti, S.; Dewey, K.G.Background: The International Lipid-Based Nutrient Supplements Project developed a small-quantity (20 g/d) lipid-based nutrient supplement (LNS) for pregnant and lactating women. Objective: We evaluated the effects of prenatal LNS supplementation on fetal growth. Design: In a community-based, partially double-blind, individually randomized controlled trial, 1320 women ≤20 wk pregnant received 60 mg Fe/400 mg folic acid (IFA), or 1-2 Recommended Dietary Allowances of 18 micronutrients, including 20 mg Fe (MMN), or LNS with the same micronutrients as the MMN group, plus 4 minerals and macronutrients contributing 118 kcal (LNS) daily until delivery. Fetal growth was compared across groups by using intention- to-treat analysis. The primary outcome was birth length. Results: This analysis included 1057 women (IFA = 349, MMN = 354, LNS = 354). Groups did not differ significantly in mean birth length, length-for-age z score (LAZ), head circumference, or percentage low birth length but differed in mean birth weight (P = 0.044), weight-for-age z score (WAZ; P = 0.046), and BMI-forage z score (BMIZ; P = 0.040), with a trend toward differences in low birth weight (P = 0.069). In pairwise comparisons, the LNS group had greater mean birth weight (+85 g; P = 0.040), WAZ (+0.19; P = 0.045), and BMIZ (+0.21; P = 0.035) and a lower risk of low birth weight (RR: 0.61, 95% CI: 0.39, 0.96; P = 0.032) than did the IFA group. The other group differences were not significant. The effect of intervention was modified by mother's parity, age, height, baseline hemoglobin, household food insecurity, and child sex, with parity being the most consistent modifier. Among primiparous women (IFA = 131; MMN = 110; LNS = 128), the LNS group had greater mean birth length (+0.91 cm; P = 0.001), LAZ (+0.47; P = 0.001), weight (+237 g; P < 0.001), WAZ (+0.56; P < 0.001), BMIZ (+0.52; P < 0.001), head circumference (0.50 cm; P = 0.017), and head circumference-for-age z score (+0.40; P = 0.022) than did the IFA group; similar differences were found when comparing the LNS and MMN groups among primiparous women, and no group differences were found among multiparous women. Conclusion: Prenatal LNS supplementation can improve fetal growth among vulnerable women in Ghana, particularly primiparous women. © 2015 American Society for Nutrition.Item Maternal and child factors associated with child body fatness in a Ghanaian cohort(Public Health Nutrition, 2019-07-25) Adu-Afarwuah, S.; Kumordzie, S.M.; Okronipa, H.; Arimond, M.; Ocansey, M.E.; Young, R.R.; Bentil, H.J.; Tamakloe, S.M.; Oaks, B.M.; Dewey, K.G.Objective: We aimed to identify factors (child diet, physical activity; maternal BMI) associated with body composition of Ghanaian pre-school children. Design: Longitudinal analysis of the International Lipid-Based Nutrient Supplements (iLiNS)-DYAD-Ghana randomized trial, which enrolled 1320 pregnant women at ≤20 weeks’ gestation and followed them and their infants until 6 and 18 months postpartum, respectively. At follow-up, child age 4–6 years, we collected data on body composition (by 2H dilution), physical activity and diet, extracted dietary patterns using factor analysis, and examined the association of children’s percentage body fat with maternal and child factors by regression analysis. Setting: Eastern Region, Ghana. Participants: Children 4–6 years of age. Results: The analysis included 889 children with percentage body fat and dietary data at follow-up. We identified two major dietary patterns, a snacking and a cooked foods pattern. Percentage body fat was positively associated (standardized β (SE)) with maternal BMI at follow-up (0·10 (0·03); P = 0·003) and negatively associated with physical activity (−0·15 (0·05); P = 0·003, unadjusted for child gender), but not associated with the snacking (0·06 (0·03); P = 0·103) or cooked foods (−0·05 (0·07); P = 0·474) pattern. Boys were more active than girls (1470 v. 1314 mean vector magnitude counts/min; P < 0·0001) and had lower percentage body fat (13·8 v. 16·9 %; P < 0·0001). Conclusions: In this population, maternal overweight and child physical activity, especially among girls, may be key factors for addressing child overweight/ obesity. We did not demonstrate a relationship between the dietary patterns and body fatness, which may be related to limitations of the dietary data available.Item Maternal and Infant Lipid-Based Nutritional Supplementation Increases Height of Ghanaian Children at 4–6 Years Only if the Mother Was Not Overweight Before Conception(The Journal of nutrition, 2019-05) Kumordzie, S.M.; Adu-Afarwuah, S.; Arimond, M.; Young, R.R.; Adom, T.; Boatin, R.; Ocansey, M.E.; Okronipa, H.; Prado, E.L.; Oaks, B.M.; Dewey, K.G.Background Few studies have evaluated the long-term effects of nutritional supplementation during the first 1000 d of life. We previously reported that maternal and child lipid-based nutrient supplements (LNS) increased child length by 18 mo. Objective The aim of this study was to examine the effects of LNS on later growth and body composition at 4–6 y of age. Design This was a follow-up of children in the International Lipid-based Nutrient Supplements (iLiNS)-DYAD trial in Ghana. Women (n = 1320) at ≤20 weeks of gestation were randomly assigned to: 1) iron and folic acid during pregnancy and 200 mg calcium/d for 6 mo postpartum, 2) multiple micronutrients (1–2 RDA of 18 vitamins and minerals) during both periods, or 3) maternal LNS during both periods plus child LNS from 6 to 18 mo. At 4–6 y, we compared height, height-for-age z score (HAZ), and % body fat (deuterium dilution method) between the LNS group and the 2 non-LNS groups combined. Results Data were available for 961 children (76.5% of live births). There were no significant differences between LNS compared with non-LNS groups in height [106.7 compared with 106.3 cm (mean difference, MD, 0.36; P = 0.226)], HAZ [−0.49 compared with −0.57 (MD = 0.08; P = 0.226)], stunting (< -2 SD) [6.5 compared with 6.3% (OR = 1.00; P = 0.993)], or % body fat [15.5 compared with 15.3% (MD = 0.16; P = 0.630)]. However, there was an interaction with maternal prepregnancy BMI (kg/m2) (P-interaction = 0.046 before correction for multiple testing): among children of women with BMI < 25 , LNS children were taller than non-LNS children (+1.1 cm, P = 0.017), whereas there was no difference among children of women with BMI ≥ 25 (+0.1 cm; P = 0.874). Conclusions There was no overall effect of LNS on height at 4–6 y in this cohort, which had a low stunting rate, but height was greater in the LNS group among children of nonoverweight/obese women. There was no adverse impact of LNS on body composition. This trial was registered at clinicaltrials.gov as NCT00970866.Item Maternal and Infant Supplementation with Small-Quantity Lipid-Based Nutrient Supplements Increases Infants’ Iron Status at 18 Months of Age in a Semiurban Setting in Ghana: A Secondary Outcome Analysis of the iLiNS-DYAD Randomized Controlled Trial(Journal of Nutrition, 2019-01) Adu-Afarwuah, S.; Young, R.T.; Lartey, A.; Okronipa, H.; Ashorn, P.; Ashorn, U.; Oaks, B.M.; Arimond, M.; Dewey, K.G.Background Interventions are needed to address iron deficiency in low-income settings. Objective This secondary outcome analysis aimed to compare the hemoglobin (Hb) and iron status [zinc protoporphyrin (ZPP)] of children born to women enrolled in the iLiNS-DYAD trial in Ghana. Methods Women ≤20 wk pregnant (n = 1320) were assigned to receive 60 mg Fe/d and 400 µg folic acid/d until delivery and placebo thereafter, and no supplementation for infants (IFA group); or multiple micronutrients containing 20 mg Fe/d until 6 mo postpartum and no supplementation for infants (MMN); or small-quantity lipid-based nutrient supplements (SQ-LNSs) containing 20 mg Fe/d until 6 mo postpartum, and SQ-LNSs for infants from 6 to 18 mo of age (LNS). We compared infants’ Hb (g/L) and ZPP (µmol/mol heme) at 6 and 18 mo of age. Results At 6 mo of age, groups did not differ in mean ± SD Hb (overall: 113 ± 9.9 g/L) or geometric mean (95% CI) ZPP [overall: 62.6 (60.6, 64.7)]. At 18 mo of age, mean ± SD Hb (overall: 112 ± 10.4 g/L) did not differ significantly between groups, whereas geometric mean (95% CI) ZPP was lower (P = 0.031) in the LNS group [53.9 (50.7, 57.3)] than the IFA [60.4 (56.7, 64.3)] but not the MMN [58.8 (55.6, 62.2)] group. Further, the LNS group, compared with the IFA and MMN groups combined, had a lower prevalence of elevated (>70) ZPP (27.5% compared with 35%; P = 0.02) and a marginally lower prevalence of anemia (38.7% compared with 44.9%; P = 0.06). These results generally remained unchanged when controlling for prespecified covariates or correcting for inflammation. Conclusions In this setting, providing SQ-LNSs or multiple micronutrients with 20 mg Fe/d, compared with iron (60 mg/d) and folic acid, to pregnant women does not affect their infants’ Hb or iron status at 6 mo of age, but maternal and infant supplementation with SQ-LNSs increases infants’ iron status at 18 mo of age. This trial was registered at clinicaltrials.gov as NCT00970866.Item A mixed method study exploring adherence to and acceptability of small quantity lipid-based nutrient supplements (SQ-LNS) among pregnant and lactating women in Ghana and Malawi(BioMed Central Ltd., 2016) Klevor, M.K.; Adu-Afarwuah, S.; Ashorn, P.; Arimond, M.; Dewey, K.G.; Lartey, A.; Maleta, K.; Phiri, N.; Pyykkö, J.; Zeilani, M.; Ashorn, U.Background: Supplementing pregnant and lactating mothers with small quantity lipid-based nutrient supplements (SQ-LNS) has resulted in improvements in birth outcomes in some low-income settings. In order to be effective, SQ-LNS must be consumed regularly over sustained periods. Methods: The objective was to assess and compare acceptability of and adherence to SQ-LNS consumption among pregnant and lactating women in Ghana and Malawi throughout 12 months of supplementation. We enrolled women before 20 gestation weeks into randomized trials in Ghana (n=1320) and Malawi (n=869). In the SQ-LNS group participants received a 20 g sachet of supplement per day during pregnancy and the first 6 months of lactation. In the control groups participants received multiple micronutrients (MMN) during pregnancy and lactation or iron and folic acid (IFA) during pregnancy and calcium during lactation. We used questionnaires to collect data on self-reported adherence to daily use of supplements and conducted in-depth interviews with women in the SQ-LNS group to examine acceptability. Results: The mean self-reported adherence during the supplementation period was lower in Ghana (79.9 %) than in Malawi (91.7 %) for all supplements (difference 11.8 %, P<0.001). Over time, adherence increased in Malawi but decreased in Ghana. In both countries, adherence in the SQ-LNS group was non-inferior to that in the control groups. Participants typically reported consuming SQ-LNS as instructed but when interviewers queried about experiences, most of the women described incidents of non-adherence. A usual reason for not consuming SQ-LNS was nausea and vomiting during pregnancy. Especially in Malawi, women reported sharing SQ-LNS with families and friends. Sustained use of SQ-LNS was attributed to expected health benefits and favorable sensory attributes. Often women compared their pregnancy to previous ones, and were of the view that SQ-LNS made a positive difference. Conclusion: Self-reported sustained adherence to consume SQ-LNS daily was high in both sites but lower in Ghana than in Malawi. In Ghana, adherence decreased over time whereas in Malawi adherence increased. Acceptability and adherence appeared interlinked, complex and context-related. Sustained consumption of SQ-LNS may require tailoring interventions by context. Trial registration: The Ghana trial was registered at clinicaltrials.gov as NCT00970866, and the Malawi trial as NCT01239693.Item Predictors and pathways of language and motor development in four prospective cohorts of young children in Ghana, Malawi, and Burkina Faso(Journal of Child Psychology and Psychiatry and Allied Disciplines, 2017-11) Prado, E.L.; Abbeddou, S.; Adu-Afarwuah, S.; Arimond, M.; Ashorn, P.; Ashorn, U.; Bendabenda, J.; Brown, K.H.; Hess, S.Y.; Kortekangas, E.; Lartey, A.; Maleta, K.; Oaks, B.M.; Ocansey, E.; Okronipa, H.; Ouédraogo, J.B.; Pulakka, A.; Somé, J.W.; Stewart, C.P.; Stewart, R.C.; Vosti, S.A.; Yakes Jimenez, E.; Dewey, K.G.Background: Previous reviews have identified 44 risk factors for poor early child development (ECD) in low- and middle-income countries. Further understanding of their relative influence and pathways is needed to inform the design of interventions targeting ECD. Methods: We conducted path analyses of factors associated with 18-month language and motor development in four prospective cohorts of children who participated in trials conducted as part of the International Lipid-Based Nutrient Supplements (iLiNS) Project in Ghana (n = 1,023), Malawi (n = 675 and 1,385), and Burkina Faso (n = 1,122). In two cohorts, women were enrolled during pregnancy. In two cohorts, infants were enrolled at 6 or 9 months. In multiple linear regression and structural equation models (SEM), we examined 22 out of 44 factors identified in previous reviews, plus 12 additional factors expected to be associated with ECD. Results: Out of 42 indicators of the 34 factors examined, 6 were associated with 18-month language and/or motor development in 3 or 4 cohorts: child linear and ponderal growth, variety of play materials, activities with caregivers, dietary diversity, and child hemoglobin/iron status. Factors that were not associated with child development were indicators of maternal Hb/iron status, maternal illness and inflammation during pregnancy, maternal perceived stress and depression, exclusive breastfeeding during 6 months postpartum, and child diarrhea, fever, malaria, and acute respiratory infections. Associations between socioeconomic status and language development were consistently mediated to a greater extent by caregiving practices than by maternal or child biomedical conditions, while this pattern for motor development was not consistent across cohorts. Conclusions: Key elements of interventions to ensure quality ECD are likely to be promotion of caregiver activities with children, a variety of play materials, and a diverse diet, and prevention of faltering in linear and ponderal growth and improvement in child hemoglobin/iron status. © 2017 The Authors. Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.Item Unintended effects of a targeted maternal and child nutrition intervention on household expenditures, labor income, and the nutritional status of non-targeted siblings in Ghana(ScienceDirect, 2018-03) Adams, K.P.; Lybbert, T.J.; Vosti, S.A.; Ayifah, E.; Arimond, M.; Adu-Afarwuah, S.; Dewey, K.G.It is common for health and nutrition interventions to target specific household members and for evaluations of their effects to focus exclusively on those members. However, if a targeted intervention changes a household’s utility maximization problem or influences decision-making, households might respond to the intervention in unintended ways with the potential to affect the wellbeing of nontargeted members. Using panel data from a randomized controlled nutrition trial in Ghana, we evaluate household behavioral responses to the provision of small-quantity lipid-based nutrient supplements (SQLNS) to mothers and their infants to prevent undernutrition. We find that targeted supplementation with SQ-LNS had a positive effect on household expenditures on food, including some nutrient-rich food groups, as well as on non-food goods and services. We also find a positive impact on labor income, particularly among fathers. We then explore intrahousehold spillover effects on the nutritional status of nontargeted young children in the household. We find evidence that the targeted provision of SQ-LNS led to higher height-for-age z-scores among non-targeted children in the LNS group compared to the non-LNS group, though only among those with relatively taller mothers, which is an indicator of a child’s growth potential. These findings support existing evidence and suggest that unintended behavioral responses and spillover are a real possibility in the context of nutrition interventions targeting nutritionallyvulnerable household members. Thoughtfully considering this possibility in the design, analyses, and evaluation of targeted nutrition interventions may provide a more complete picture of overall effects. 2018 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY licenseItem Willingness to pay for small‐quantity lipid‐based nutrient supplements for women and children: Evidence from Ghana and Malawi(Wiley, 2017-08) Adams, K.P.; Vosti, S.A.; Ayifah, E.; Phiri, T.E.; Adu‐Afarwuah, S.; Maleta, K.; Ashorn, U.; Arimond, M.; Dewey, K.G.Small‐quantity lipid‐based nutrient supplements (SQ‐LNS) are designed to enrich maternal and child diets with the objective of preventing undernutrition during the first 1,000 days. Scaling up the delivery of supplements such as SQ‐LNS hinges on understanding private demand and creatively leveraging policy‐relevant factors that might influence demand. We used longitudinal stated willingness‐to‐pay (WTP) data from contingent valuation studies that were integrated into randomized controlled nutrition trials in Ghana and Malawi to estimate private valuation of SQLNS during pregnancy, postpartum, and early childhood. We found that average stated WTP for a day's supply of SQ‐LNS was more than twice as high in Ghana than Malawi, indicating that demand for SQ‐LNS (and by extension, the options for effective delivery of SQ‐LNS) may be very context specific. We also examined factors associated with WTP, including intervention group, household socioeconomic status, birth outcomes, child growth, and maternal and child morbidity. In both sites, WTP was consistently negatively associated with household food insecurity, indicating that subsidization might be needed to permit food insecure households to acquire SQ‐LNS if it is made available for purchase. In Ghana, WTP was higher among heads of household than among mothers, which may be related to control over household resources. Personal experience using SQ‐LNS was not associated with WTP in either site.