Background: Findings of the association between iron status and depressive symptoms in non-pregnant women of reproductive age (WRA) are equivocal, limited by a small sample size, or did not consistently control for confounders. Objective: We tested the association between iron status and depressive symptoms in WRA with the NHANES data (2005-2010). Methods: Non-pregnant WRA (20-44 y) with complete data on iron (ferritin and transferrin receptor (TfR)) and anemia (hemoglobin) biomarkers, depressive symptoms (Patient Health Questionnaire-9), and sociodemographic variables were included. Logistic and negative binomial regressions were used to estimate presence (odds ratios) and magnitude (prevalence ratios), respectively, for depressive symptoms by iron deficiency (ID)/anemia/ID anemia in the total sample and stratified by poverty:income ratio (≤ 1.85 or >1.85). Results: Among 2516 women, the prevalence of ID was 8-16% (depending on the iron biomarker used), of anemia 8%, of which 52-65% were also ID. The prevalence of depressive symptoms was 10%. Crude logistic models showed that women with ID (TfR≥8.3 mg/L or body iron<0 mg/kg) from the total sample had 1.82 (95% CI: 1.24-2.68) and 1.62 (95% CI: 1.05-2.48), respectively, higher odds of depressive symptoms than women with iron sufficiency; these associations were attenuated after adjustments for confounders. Adjusted negative binomial models showed that women with ID (TfR≥8.3 mg/L) from the total and low-income samples, showed 1.19 (95% CI: 1:00-1.40) and 1.27 (95% CI: 1.03-1.58), respectively higher prevalence ratios of depressive symptoms scores than women with iron sufficiency. Conclusions: These nationally representative data indicate that non-pregnant WRA with ID (based on high TfR) in the US have higher prevalence of somatic depressive symptoms scores than those with iron sufficiency, especially if they are of low income.

Background/Objectives: Antenatal multiple micronutrient supplementation (MMS) improves birth outcomes more effectively than iron and folic acid (IFA) supplementation alone. However, the acceptability of MMS among pregnant individuals, a critical factor for adherence and program success, remains poorly defined and inconsistently assessed. This narrative review proposes a comprehensive definition of “acceptability” in the context of nutritional supplementation and evaluates the evidence on the acceptability of MMS compared to IFA in low- and middle-income countries (LMICs). Methods: We conducted a systematic literature search across Embase, Medline, and Scopus to identify studies (including grey literature) reporting on acceptability-related outcomes for MMS versus IFA among pregnant individuals. Studies exploring dimensions such as organoleptic properties, ease of consumption, side effects, cultural appropriateness, and socioeconomic factors were included. Results: Out of 1056 screened studies, five informed a novel multi-dimensional definition of acceptability. Six studies assessed acceptability-related characteristics. MMS was generally accepted across most organoleptic domains. Most studies reported fewer or comparable adverse side effects for MMS as compared to IFA. Studies consistently reported more perceived benefits for MMS than IFA. Facilitating factors included trust in health professionals, free provision, and family support. Barriers included poor taste or smell, fear of side effects, misconceptions, cost, and lack of family support. Conclusions: Antenatal MMS is widely acceptable in LMICs. Addressing socio-cultural, sensory, and socioeconomic factors is essential to increase uptake and adherence. This review provides a clear, standardized definition of acceptability to guide future research and inform effective program design.

Maternal undernutrition in Africa remains a public health challenge, contributing to negative pregnancy outcomes, neonatal mortality, and perpetuating intergenerational cycles of poor health. Antenatal multiple micronutrient supplementation (MMS), a cost-effective intervention recognized for its potential to improve maternal and neonatal health, reduces risks of low birth weight, preterm birth, small for gestational age, and stillbirth while offering a $37 return for every $1 invested. Despite its benefits, MMS adoption across African countries remains suboptimal. This position paper synthesizes the outcomes of the 2nd Africa Maternal Nutrition and MMS Technical Meeting: A Path Toward Introduction and Scale-up of MMS in Africa, held in Nairobi, Kenya, in October 2024. The 3-d meeting convened government representatives from 17 African member states, donors, and experts to align on a shared vision for MMS introduction and scale-up in Africa. Participants emphasized MMS integration into antenatal care as a cornerstone of maternal nutrition strategies and identified actionable recommendations to overcome policy, supply chain, financing, and implementation barriers. Key messages include the urgency of scaling MMS, the role of implementation science in tailoring programs to local contexts, and the necessity of regional collaboration to share lessons and facilitate progress. It outlines a pathway for integrating MMS into antenatal care services, ensuring a quality supply, securing financial commitments, strengthening delivery, and engaging communities. The accompanying "Call to Action" provides a detailed roadmap to guide stakeholders in scaling up MMS as an urgent priority to enhance maternal and neonatal health, advance gender equality, and fulfill Africa's global health commitments.

* Background The high prevalence of infant stunting and maternal undernutrition in low- and middle-income countries poses a significant public health threat. The World Health Organization recommends balanced energy-protein (BEP) supplementation to pregnant women from populations with a high prevalence of underweight (prepregnancy BMI <18.5 kg/m2), leaving a notable gap in guidance for lactating women. Therefore, we established the Maternal BEP Studies Harmonization Initiative (BEP Initiative) to investigate the impact of BEP supplementation given to pregnant and/or lactating women on maternal and infant outcomes by synthesizing data from multiple clinical trials. This is a study protocol for our prospective individual participant data (IPD) meta-analysis on BEP lactation trials. Methods Data from four randomized controlled trials that include mother-infant dyads in India (n=816), Pakistan (n=957), Burkina Faso (n=800), and Nepal (n=726) will be pooled and analysed. Women were randomized to BEP (one trial had a third arm with maternal BEP plus infants receiving azithromycin) or control groups at baseline (during the first week) and received the intervention through six months postpartum. A one-stage IPD meta-analysis will be done using mixed-effects linear and log-binomial regression models to account for between-trial heterogeneity. The primary outcome of infant length-for-age z scores (LAZ) and secondary outcomes of maternal and infant indicators of nutritional status, all at six months of age, will be examined. Also, we will assess baseline characteristics as covariates and effect modifiers for the BEP to outcome relationship. Discussion This prospective IPD meta-analysis uses a one-stage IPD meta-analysis, which allows for higher statistical power to examine outcomes, more flexibility in defining variables, and can examine effect modifiers, which could inform which individuals or populations may benefit more from BEP given during lactation.

There is a tacit assumption that the majority of nutritional anemia is caused by iron deficiency. However, several other key micronutrients are involved in iron and/or erythrocyte metabolism and thus play a role in the development of nutritional anemia. This consensus paper provides an updated review that synthesizes current evidence on the role of individual micronutrients, beyond iron, in the development of nutritional anemia and identifies emerging hypotheses and potential mechanistic links to erythropoiesis and iron metabolism involving nutrients of both established and growing interest. To achieve this, we convened leading experts in micronutrients and nutritional anemia to categorize 10 key micronutrients of interest into a hierarchy based on the scope and strength of evidence for their roles in the development of anemia, erythropoiesis, and iron metabolism. Folate, vitamin B12, and vitamin A were ranked as having strong evidence, meaning data are consistent in describing a causal association between nutrient status and anemia development, and the evidence for the proposed mechanism(s) is well-established. Riboflavin, zinc, vitamin B6, vitamin C, and vitamin E were ranked as having moderate evidence, and vitamin D and copper were ranked as having potential and/or emerging evidence. We also identify critical gaps in the current evidence and propose priority areas for future research for each micronutrient. This perspective paper aims to serve as a comprehensive reference to inform future research priorities and guide global nutrition policy, strategy, and programming related to anemia prevention and control.

In settings where more than 20% of women of reproductive age are classified as underweight, the World Health Organization recommends balanced energy and protein (BEP) supplementation during pregnancy to reduce adverse birth outcomes. However, guidance on contextually acceptable and feasible supplement delivery platforms remains limited, posing critical challenges for implementation. We synthesized literature on acceptable and feasible delivery platforms for BEP supplementation (direct evidence), as well as iron and folic acid (IFA) or multiple micronutrient supplements (MMS; indirect evidence) to pregnant and breastfeeding women (PBW) to broaden the search scope. A systematic search was conducted across five databases and grey literature to identify studies that addressed the acceptability and feasibility of BEP supplement delivery platforms in low- and middle-income countries (LMICs), at facility and community levels. We identified 48 studies conducted in LMICs: 22 specifically evaluated BEP supplement delivery, while 26 evaluated IFA or MMS. In the direct evidence, home delivery (11/22) was the most frequently mentioned delivery platforms of BEP supplements followed by community-level feeding centers (provided cooked meals or take-home rations) anchored by frontline community health workers (8/22 studies) and antenatal care (ANC) at health facilities (6/22; some studies assessed multiple delivery platforms). Only four studies assessed preferred BEP delivery platforms, and PBW favored home over facility-based delivery. Authors attributed this preference to the comprehensive nutrition education and behavior change communication (BCC) provided during home delivery. Indirect evidence showed that enhancing delivery of IFA or MMS at health facilities (not specific) through strategies such as BCC and home visits may improve supplement compliance. Overall, limited evidence exists regarding market-based approaches for delivering any of these interventions. Based on existing evidence, scale-up delivery of BEP supplementation through ANC at health centers, enhanced by community health workers may be feasible in reaching PBW, especially when combined with BCC.