The effect of an intervention to reduce aflatoxin consumption from 6 to 18 months of age on length-for-age Z-scores in rural Tanzania: a cluster-randomized trial

E Phillips; F M Ngure; N Kassim; P C Turner; E Makule; L E Smith; N Makori; B Cramer; H-U Humpf; R J Nelson; R J Stoltzfus

doi:10.1016/j.ajcnut.2024.11.022

The effect of an intervention to reduce aflatoxin consumption from 6 to 18 months of age on length-for-age Z-scores in rural Tanzania: a cluster-randomized trial

Am J Clin Nutr. 2024 Nov 26:S0002-9165(24)01417-5. doi: 10.1016/j.ajcnut.2024.11.022. Online ahead of print.

Authors

E Phillips¹, F M Ngure², N Kassim³, P C Turner⁴, E Makule³, L E Smith⁵, N Makori⁶, B Cramer⁷, H-U Humpf⁷, R J Nelson⁸, R J Stoltzfus⁹

Affiliations

¹ Division of Nutritional Sciences, Cornell University, 244 Garden, Ithaca, NY 14853, USA. Electronic address: elp28@cornell.edu.
² Cornell University, Arusha, Tanzania and Nairobi, Kenya.
³ Department of Food Biotechnology and Nutritional Sciences (FBNS), School of Life Science and Bio-Engineering, The Nelson Mandela African Institution of Science and Technology (NM-AIST), P.O.Box 447, Arusha, Tanzania.
⁴ GEOH, School of Public Health, University of Maryland, College Park, MD 20740, USA.
⁵ Department of Public and Ecosystem Health, Cornell University, 14853, USA.
⁶ Tanzania Food and Nutrition Centre, P.O. Box 977, Dar es Salaam, Tanzania.
⁷ Institute of Food Chemistry, University of Muenster, Muenster, Germany, 48149.
⁸ School of Integrative Plant Science, Department of Global Development, Cornell University, 14853, USA.
⁹ Division of Nutritional Sciences, Cornell University, 244 Garden, Ithaca, NY 14853, USA; Goshen College, 1700 S. Main Street, Goshen, Indiana, 46526, USA.

PMID: 39608608
DOI: 10.1016/j.ajcnut.2024.11.022

Abstract

Introduction: Linear growth faltering continues to negatively affect children in low- and middle-income countries and is associated with poor cognitive, developmental, and educational outcomes. Laboratory and observational data suggest aflatoxin (AF) is a contributor to stunting.

Methods: The Mycotoxin Mitigation Trial was a cluster-randomized, community-based two-group trial conducted in Kongwa District, Tanzania between 2018 and 2020. The trial assessed whether a 12-mo intervention to reduce AF consumption increased length-for-age Z scores (LAZ) at 18 mos. Low-AF maize and groundnut flours were provided to the intervention group each month; skin lotion was distributed to the control group monthly. Infant and young child feeding education was delivered equally in 52 health facilities (clusters). Anthropometry and the blood biomarker (AF-alb) were assessed at 6, 12, and 18 mos of age. Outcomes were analyzed as intention-to-treat and per-protocol using linear mixed-effects models.

Results: 2,842 maternal-infant dyads were recruited into the study. The intervention was not successful in creating a contrast in AF-alb. At 18 mos 36% (n=186/520) of infants had detectable levels of AF-alb compared to 54% (n=195/364) at baseline, with no difference between groups. Mean LAZ in the intervention group at 18 mos was -1.83 (n=1,231, 95% CI: -1.93, -1.73) compared to -1.90 (n=1,287, 95%CI:-1.99, -1.82) in the control group (p=0.28).

Discussion and conclusions: An intervention to reduce AF exposure did not alter AF-alb nor anthropometric measures between treatment groups. Drought and agricultural data indicated less favorable conditions for toxin production, resulting in low levels of exposure in both trial arms. Annual, seasonal, and geographic heterogeneity of AF contamination make it difficult to study in an ethically-designed trial. Our formative research and early trial data indicate that stunting and intermittent AF exposure continue to be a problem in this area. However, the low AF exposure levels during the trial led to inconclusive results.

Keywords: Aflatoxin Exposure; Community-based trial; Infant and Young Child Feeding; Linear growth; Low- and Middle-Income Countries; Stunting.