Links to pediatric HIV, pica, and anemia publications


Pediatric HIV-related

Young, S.L., Israel-Ballard, K., Dantzer, E., Nyambo, M., Ash, D., Chantry, C.J. (2010) Infant feeding practices among HIV-positive women in Dar es Salaam, Tanzania indicate a need for more intensive infant feeding counseling. Public Health Nutrition 29:1-7. Young 2010 Public health nutrition-1.pdf

    OBJECTIVE: To assess feeding practices of infants born to HIV-positive women in Dar es Salaam, Tanzania. These data then served as a proxy to evaluate the adequacy of current infant feeding counselling. DESIGN: A cross-sectional survey of infant feeding behaviours. SETTING: Four clinics in greater Dar es Salaam in early 2008. SUBJECTS: A total of 196 HIV-positive mothers of children aged 6-10 months recruited from HIV clinics. RESULTS: Initiation of breast-feeding was reported by 95.4 % of survey participants. In the entire sample, 80.1 %, 34.2 % and 13.3 % of women reported exclusive breast-feeding (EBF) up to 2, 4 and 6 months, respectively. Median duration of EBF among women who ever breast-fed was 3 (interquartile range (IQR): 2.1, 4.0) months. Most non-breast-milk foods fed to infants were low in nutrient density. Complete cessation of breast-feeding occurred within 14 d of the introduction of non-breast-milk foods among 138 of the 187 children (73.8 %) who had ever received any breast milk. Of the 187 infants in the study who ever received breast milk, 19.4 % received neither human milk nor any replacement milks for 1 week or more (median duration of no milk was 14 (IQR: 7, 152) d). CONCLUSIONS: Infant feeding practices among these HIV-positive mothers resulted in infants receiving far less breast milk and more mixed complementary feeds than recommended, thus placing them at greater risk of both malnutrition and HIV infection. An environment that better enables mothers to follow national guidelines is urgently needed. More intensive infant feeding counselling programmes would very likely increase rates of optimal infant feeding.

Young, S. L., Chantry, C. J., Vosti, S. A., Rennie, W. (2009). Infant feeding counseling: a neglected strategy for the reduction of MTCT. AIDS. 23(18):2543-2544. Young 2009 AIDS.pdf

Young, S.L., Chantry, C., Ngonyani, M., Israel-Ballard, K., Ash, D., Nyambo, M. Flash-heating breastmilk is feasible in Dar es Salaam Tanzania. Experimental Biology. New Orleans, Louisiana, April 2009. FH_Feasibility_EB_handout.pdf


Young, S.L. (2010) Pica in Pregnancy: New Ideas About An Old Condition. Annual Review of Nutrition 30: 403-422. Young 2010 Annual Review of Nutrition-1.pdf

    Pica, the purposive consumption of nonfood substances, is a millennia-old nutritional enigma. Its worldwide ubiquity, prevalence among pregnant women and children, and association with both positive and negative health outcomes, especially micronutrient deficiencies, underscore the importance of understanding this behavior. Multiple proposed etiologies of pica are reviewed, including cultural expectations, psychological stress, hunger, dyspepsia, micronutrient deficiencies (Fe, Zn, and Ca), and protection against toxins and pathogens. Currently available data, although limited, best support the protection hypothesis as a cause of most types of pica, although some evidence suggests that pagophagy (ice consumption) may occur during iron deficiency. It is possible that the binding capacity of pica substances explains the association with micronutrient deficiencies; earth, starch, etc. may render micronutrients in ingesta unavailable for absorption. Increased research efforts are warranted and must be hypothesis driven, interdisciplinary, and permit the testing of multiple causal inferences.

Young, S.L., Khalfan, S., Farag, T., Kavle, J., Rasmussen, K., Pelto, G., Ali, S. M., Hamadi, B.,  Tielsch, J., Stoltzfus, R. (2010). Pica is associated with anemia and gastrointestinal distress among pregnant Zanzibari women. American Journal of Tropical Medicine & Hygiene 83(1):144-151. Young 2010 American Journal of Tropical Medicine & Hygiene.pdf

    The etiology of pica, the purposive consumption of non-food substances, is not understood, despite its ubiquity among gravidae. We examined correlates of pica in a representative obstetric population (n = 2,368) on Pemba Island, Zanzibar, Tanzania to examine proposed etiologies. Cross-sectional data were collected on socioeconomic characteristics, food intake, geophagy (earth consumption), amylophagy (raw starch consumption), anthropometry, iron status, parasitic burden, and gastrointestinal morbidities. Amylophagy was reported by 36.3%, geophagy by 5.2%, and any pica by 40.1%. There was a strong additive relationship of geophagy and amylophagy with lower hemoglobin (Hb) concentration and iron deficiency anemia. By multivariate logistic regression, any pica was associated with Hb level (odds ratio [OR] = 0.76, 95% confidence interval [CI] = 0.72-0.81), nausea (OR = 1.45, 95% CI = 1.20-1.73), and abdominal pain (OR = 1.22, 95% CI = 1.01-1.48). These striking results indicate that the nature of the relationship between pica, pregnancy, gastrointestinal distress, and iron deficiency anemia merits further investigation.

Young, S.L., Wilson, M.J., Hillier, S., Delbos, E. (2010). Differences and commonalities in physical, chemical and mineralogical properties of Zanzibari geophagic soils. Journal of Chemical Ecology 36(1): 129-140. Young 2010 Journal of Chemical Ecology.pdf

    The function of human geophagy has long been questioned. We sought to test hypotheses concerning its potential physiological effects through analysis of soils and patterns in geophagy behavior. Eleven samples of geophagic soils consumed by pregnant women on Pemba Island, Zanzibar, Tanzania, were characterized according to their color, texture, major element chemistry, trace element chemistry, bulk mineralogy, and clay mineralogy. An epidemiological study (N = 2367) and ethnographic interviews (N = 57) on Pemba yielded information about geophagic behaviors and socio-demographic and biological characteristics of those who consumed earth. The soils varied widely in color, ranging from light red to white through various shades of brown and yellow, and texture ranged from clay to sand. Major element chemistry of the soils also varied greatly; most were low in Fe and Ca. Trace elements, whether of biological or non-biological significance, were uniformly low when compared with normal ranges of mineral soils. The sole commonality among the samples is that all clay fractions were dominated by a kaolin mineral: kaolinite, halloysite, or a mixture of both. Geophagy behavior also varied greatly, with one major exception: a greater proportion of pregnant women (7.1%) and young children (4.5%) consumed earth than non-pregnant women (0.2%) or men (0%). The presence of kaolin mineral in all samples, its palliative and detoxifying properties, and the highest prevalence of geophagy among those most biologically vulnerable suggest that geophagy may be a protective behavior.

Young, S., Wilson, M. J., Hillier, S., & Miller, D. D. (2009). Toward a comprehensive approach to the collection and analysis of pica substances, with emphasis on geophagic materials. PLoS One 3(9): e3147 doi:10.1371/journal.pone.0003147. paper

    Background: Pica, the craving and subsequent consumption of non-food substances such as earth, charcoal, and raw starch, has been an enigma for more than 2000 years. Currently, there are little available data for testing major hypotheses about pica because of methodological limitations and lack of attention to the problem.

Methodology: In this paper we critically review procedures and guidelines for interviews and sample collection that are appropriate for a wide variety of pica substances. In addition, we outline methodologies for the physical, mineralogical, and chemical characterization of these substances, with particular focus on geophagic soils and clays. Many of these methods are standard procedures in anthropological, soil, or nutritional sciences, but have rarely or never been applied to the study of pica.

Principal findings: Physical properties of geophagic materials including color, particle size distribution, consistency and dispersion/flocculation (coagulation) should be assessed by appropriate methods. Quantitative mineralogical analyses by X-ray diffraction should be made on bulk material as well as on separated clay fractions, and the various clay minerals should be characterized by a variety of supplementary tests. Concentrations of minerals should be determined using X-ray fluorescence for non-food substances and inductively coupled plasma–atomic emission spectroscopy for food-like substances. pH, salt content, cation exchange capacity, organic carbon content and labile forms of iron oxide should also be determined. Finally, analyses relating to biological interactions are recommended, including determination of the bioavailability of nutrients and other bioactive components from pica substances, as well as their detoxification capacities and parasitological profiles.

Significance: This is the first review of appropriate methodologies for the study of human pica. The comprehensive and multi-disciplinary approach to the collection and analysis of pica substances detailed here is a necessary preliminary step to understanding the nutritional enigma of non-food consumption.

Young, S. L., D. Goodman, T. H. Farag, S. M. Ali, M. R. Khatib, S. S. Khalfan, J. M. Tielsch, and R. J. Stoltzfus. Geophagia is not associated with Trichuris or hookworm transmission in Zanzibar Tanzania. Transactions of the Royal Society of Tropical Medicine and Hygiene, 101(8) 766-772. Young 2007 Transactions of the Royal Society of Tropical Medicine and Hygiene.pdf

    Geophagia may be harmful as a vector for the transmission of geohelminths. In this study, we pose two questions in a representative sample of 970 pregnant women from Pemba Island, Zanzibar, Tanzania: 1) Can consumed earth be a vector for geohelminth infection? 2) Do geophagists have differential parasitic infection? We analyzed the parasitological content of 59 samples of non-food substances. Cross-sectional data about pica behavior was collected through interviews conducted by local researchers. Ascaris, Trichuris and hookworm status was ascertained through Kato-Katz smears. The prevalence of geophagia at baseline was 5.6%, and overall prevalence of Ascaris, Trichuris and hookworm was 5.6%, 33.2% and 32.9%, respectively. No consumed soil samples contained infectious parasitic stages, and only one of the consumed pica substances, charcoal, contained parasites of potential risk to human health. Neither the prevalence nor the intensity of infection with Ascaris, Trichuris or hookworm differed significantly by geophagia status. Furthermore, in multivariate models, geophagia was not a significant predictor of helminth infection status. We conclude that geophagia is not a source of Trichuris or hookworm infection among pregnant women in Pemba (insufficient power to evaluate effect of Ascaris), which is in contrast to existing findings of helminth infection and geophagia.

Young, S. L. 2007 "Evidence for the Consumption of the Inedible- Who, What, When, Where, and Why.pdf." In Consuming the Inedible: Cross-Disciplinary Approaches, edited by Jeremy MacClancy, Helen MacBeth, and Jeya Henry, pp 17-30. Berghahn Press.

Young, Sera. 2007. "A Vile Habit? The Potential Biological Consequences of Geophagia, With Special Attention to Iron.pdf." In Consuming the Inedible: Cross-Disciplinary Approaches, edited by Jeremy MacClancy, Helen MacBeth, and Jeya Henry, pp. 67-79. Bergahn Press.

Young, Sera L., and Gretel H. Pelto. "Core Concepts in Nutritional Anthropology.pdf." In Nutritional Health: Strategies for Disease Prevention, edited by Norman J Temple, Ted Wilson, and David R Jacobs, 425-37. Totowa, NJ: Humana Press, 2006.


Young, S.L., Hernandez Cordero, S., Blanco, I., Pelto, G. H., & Neufeld, L. M. (2010). Organoleptic properties, ease of use, and perceived health effects are determinants of acceptability of micronutrient supplements among poor Mexican women. Journal of Nutrition 140 (3): doi:10.3945/jn.109.113498. email me for copy of the paper

    We assessed the acceptability of 3 micronutrient supplements for pregnant and lactating women: micronutrient powder (Sprinkles), a fortified food (Nutrivida), and tablets. Pregnant or lactating beneficiaries of the Oportunidades program participating in a cluster randomized supplementation trial in urban Mexico were surveyed about the acceptability of 1 of 3 supplements (n = 268). Semistructured interviews (n = 40) were also conducted with a subset of women in the trial and from adjacent rural areas. Acceptability of the supplements was evaluated based on women's perceptions and experiences with organoleptic qualities, ease of use, and perceived health effects (positive and negative). The median Likert scale ranking of organoleptic and use qualities for all 3 supplements was "I liked it" (2 on a scale of 1-5). However, responses to open-ended survey questions and semistructured interviews indicated decided preferences. Tablets and Sprinkles were strongly preferred over Nutrivida. In interviews, women expressed dislike of the smell, taste, and texture of Nutrivida; they found it cumbersome to store and prepare and reported the most negative effects with it. Between tablets and Sprinkles, tablets were preferred because of the absence of perceptible taste or smell and the simplicity of use. This study provides valuable insights into our currently limited understanding of women's perceptions and preferences among supplements by broadening the concept of acceptability beyond organoleptic properties. Such an analytical approach is useful for identifying both appropriate nutritional supplements within a given sociocultural context as well as the information that should be included in nutrition education to improve adherence.

Young, S.L., Beckham, S, and Ali, S. M. (2009) Blood, pills, and the power of the private sector: Accessing private pharmacies for the treatment of maternal anemia in Zanzibar, Tanzania. Food & Nutrition Bulletin 30(1):16-23. Food Nutr Bull 2009 Young.pdf

    BACKGROUND: The reduction of maternal anemia is an agreed public health goal but one that has been very difficult to achieve. On Pemba Island, Tanzania, more than 90% of pregnant women are anemic, despite government efforts to identify and treat anemia during antenatal clinic visits. OBJECTIVE: To investigate the potential of private pharmacies to be accessed for iron supplements for maternal anemia. METHODS: We compared and contrasted the care given at private pharmacies and public clinics in terms of six characteristics: accuracy, affordability, availability, geographic accessibility, accommodation, and acceptability. We used data from in-depth interviews, surrogate customer encounters, governmental medicine record reviews, and participant observation. RESULTS: The accuracy of health care workers' advice about the treatment of anemia at private pharmacies and government clinics was similar. Supplements purchased at pharmacies were sometimes cheaper than the free supplements from the government, when the costs of transportation and time spent at the clinic were considered. Supplements at private pharmacies were always available, whereas the supply at government clinics was erratic. Private pharmacies were physically closer, socially less distant, and more accommodating than government clinics. Both clinics and private pharmacies were socially acceptable to pregnant women, although government clinics were typically not attended until later in pregnancy. CONCLUSIONS: The private sector probably has untapped potential for the reduction of maternal anemia in settings in which public health services fall short. Private pharmacies can contribute to the reduction of maternal anemia on Pemba Island and beyond.

Young, Sera L., and Ali, Said M. "Conceptual Links Between Traditional Treatments of Maternal Anemia and Iron Supplements: A Case Study From Pemba Island, Zanzibar" Maternal and Child Nutrition 1, no. 1 (2005): 51-58. Young 2005 Matern Child Nutr.pdf

Key words: anemia, Zanzibar, Africa, iron supplements, ethnography, traditional medicine.

Abstract: Iron deficiency anemia is the most common form of malnutrition in the world. Pregnant women are particularly at risk for anemia. Insufficient attention has been paid to the reasons underlying the only moderate success of iron supplementation. In this article an additional factor that can affect the use of iron supplements is proposed: their relevance to 'traditional' or nonbiomedical treatments of anemia. This paper represents what is to our knowledge the first ethnographic description of nonbiomedical treatments for maternal anemia. The research was conducted over several months on Pemba, one of the islands of the Zanzibar archipelago. Data were collected using a variety of qualitative methods, including in-depth interviews, focus group discussions and participant observation. Informants included 25 mothers and 27 traditional and biomedical health care workers. The resulting ethnography elucidates Pembans' beliefs about the relationship of food, traditional medicine, spirits and biomedical medicine in relation to anemia. In the analysis of the ethnography, both anthropology and public health perspectives are incorporated to suggest how the understanding of these beliefs is useful for increasing iron supplement use.

Young, Sera L. ""Listen, Without Blood There is No Life": An Ethnography of Anemia During Pregnancy." Nutritional Anthropology 26, no. 1-2 (2004): 10-19.  Young 2003.pdf

    Few studies of iron-deficiency anemia examine the emic context of the disease among pregnant women. Twenty-five mothers from Wete town, Pemba, Zanzibar were observed and interviewed over about one month in 2002 as a part of an author-funded study. From this work, plus additional interviews with health care workers, a Pemban emic model of the production of anemia was developed. Pemban definitions of anemia and the physical and psychosocial symptoms of these anemias are described. The explanatory model is grounded in the context of existing social realities of Pemban women and their families and also incorporates explanations rooted in beliefs about the relationship of spirits to blood and well-being.

Young, Sera. "Critically Ecological Medical Anthropology: Selecting and Applying Theory to Anemia During Pregnancy on Pemba, Zanzibar." Medische Anthropologie 14, no. 2 (2002): 321-52.

Key words: Critical medical anthropology, ecological medical anthropology, theory, anemia, Pemba, Zanzibar

A novel theoretical framework is presented that is an amalgamation of seemingly discordant theoretical stances: critical (medical) anthropology and (medical) ecological anthropology. Yet the significance of this article does not lie in the theoretical framework as much as it does in its elucidation of the process of picking and choosing aspects from various theoretical frameworks. This contribution is important primarily because it demonstrates how theories can be combined and what the implications thereof are for analysis. In the first section, some brief ethnographic notes about anemia during pregnancy on Pemba, the second largest island of the archipelago of Zanzibar, are presented. Next, the virtues and weaknesses in the bodies of work of critical (medical) anthropology and ecological (medical) anthropology are discussed. I then explain how and why I have selected components from each to create a bricolage theory I fondly (if not imaginatively) call “critical ecological medical anthropology” (CEMA). Finally, I illustrate how ethnographic flesh can hang on these conglomerated theoretical bones by showing how the model can be applied to the ethnographic observations.

Young, Sera. "On the Role of the Individual in the Micro-ecological Approach to Health Framework." Medische Anthropologie 16, no. 2 (2004): 280-81.