Animal-based food taboos during pregnancy and the postpartum period of Southeast Asian women - A review of literature

Food avoidance taboos during breastfeeding are widespread and associated with large declines in maternal dietary diversity in Myanmar

BACKGROUND

Maternal food avoidance practices during pregnancy and breastfeeding have been documented in several Asian countries, but their prevalence and impacts on dietary diversity are not well quantified.

OBJECTIVES

This study: (1) assessed the prevalence of beliefs around maternal food avoidance during breastfeeding in Myanmar; (2) explored the correlates of women's food avoidance beliefs as well as mother's stated rationales for avoiding specific foods; and (3) assessed how minimum dietary diversity (MDD-W) of mothers changed from pregnancy to postpartum/breastfeeding.

METHODS

We added a novel nutrition module to a nationally representative survey (N=12,353) in Myanmar to estimate the prevalence of beliefs around maternal food avoidance during breastfeeding and re-surveyed a subsample of mothers (N=155) to understand avoidance of specific foods. We then used a high-frequency panel of mothers in Yangon (N=3,541) to assess how MDD-W changed from pregnancy to postpartum/breastfeeding using mother fixed effects regressions.

RESULTS

40 percent of adult women in Myanmar believe breastfeeding mothers should avoid at least one food group that nutritionists would typically define as a healthy (e.g. vegetables, fruits). Regression analysis indicated these beliefs were less prevalent among women with more education and nutritional knowledge, and with exposure to nutrition counselling from community health workers. Mothers rationalized food avoidance by referring to a variety of perceived maternal and child health risks. MDD-W of mothers in the Yangon panel fell by 43 percentage points from pregnancy to the first month after birth, including significant declines in eight of the ten MDD-W food groups. MDD-W remained significantly lower up to six months after birth than during pregnancy.

CONCLUSIONS

Food avoidance taboos during breastfeeding pose a potentially serious risk of micronutrient deficiencies for mothers and infants and warrant more extensive monitoring in nutrition surveys and more research on how to redress these nutritionally harmful beliefs and practices.

Improving Nutrition Security in Low- and Middle-Income Countries and the Role of Animal-Source Foods

Nutrition security is challenging in regions where resources are limited and food production is naturally constrained. In low- and middle-income countries (LMICs), undernutrition is high for many reasons, including lack of nutritional diversity and low high-quality protein content. Interest in the role of animal-source food (ASF) in reducing nutrition insecurity is increasing, as evidence from LMICs suggests that consumption of ASF is strongly associated with reduction in stunting, improved diet quality, and overall nutrition, particularly in early stages of life. We review the strengths and limitations of ASF consumption in terms of accessibility, safety, and nutritional benefits compared to non-ASF sources. We present a critical discussion on existing barriers to ASF consumption and its future directions in LMICs. Understanding the role of ASF in improving nutrition security in LMICs is crucial to optimizing public health, designing appropriate interventions, and implementing effective policy in resource-poor settings.

Dietary habit and lifestyle of postpartum women in South China: a mixed methods research

OBJECTIVE

To investigate the dietary and hygiene behaviours and influencing factors of women during the puerperium in South China.

DESIGN

A cross-sectional study.

SETTING

Three tertiary hospitals in Guangdong Province, China PARTICIPANTS: From November 2022 to March 2023, 327 women with puerperal experience were enrolled using the purposive sampling method, with 323 valid questionnaires collected for data analysis. Semistructured interviews were conducted with six puerperium women and five primary caregivers.

PRIMARY AND SECONDARY OUTCOME MEASURES

This study used a questionnaire survey to collect and analyse the current postpartum dietary and hygiene behaviours among women in the South China region, along with their influencing factors.

RESULTS

Multinomial logistics regression revealed women residing in urban-rural fringe were more likely to use ventilated rooms (OR 4.496, 95% CI 2.363 to 8.552) and avoid hair washing (OR 0.345, 95% CI 0.159 to 0.749) compared with urban residents. Additionally, women who practiced Buddhism were more likely to wash their hair (OR 11.070, 95% CI 2.339 to 52.379) and take baths (OR 6.856, 95% CI 2.057 to 22.855) compared with those with no religious affiliation. Lastly, those whose primary caregiver was their husband were more likely to consume watermelon (OR 2.235, 95% CI 1.119 to 4.463), persimmon (OR 4.395, 95% CI 1.886 to 10.242) and longan (OR 2.612, 95% CI 1.362 to 5.010). The qualitative study identified five themes: dietary practices, hygiene habits, personal attitude, sources of information and support.

CONCLUSION

The dietary and hygiene behaviours of puerperium women in South China are significantly influenced by the residen, primary caregivers and religious beliefs. Medical care providers should adopt a precision postpartum care strategy to improve the quality of care.

Assessment of Erythrocyte Transketolase, Whole Blood Thiamine Diphosphate, and Human Milk Thiamine Concentrations to Identify Infants and Young Children Responding Favorably to Therapeutic Thiamine Administration: Findings from the Lao Thiamine Study, a Prospective Cohort Study

Background

There is limited information on relationships among biomarkers of thiamine status (whole blood thiamine diphosphate [ThDP], erythrocyte transketolase activity coefficient [ETKac], and human milk thiamine [MTh]) and clinical manifestations of thiamine deficiency.

Objectives

This study aimed to explore correlations among these biomarkers and thiamine responsive disorders (TRDs), a diagnosis based on favorable clinical response to thiamine.

Methods

Hospitalized infants and young children (aged 21 d to <18 mo) with respiratory, cardiac, and/or neurological symptoms suggestive of thiamine deficiency were treated with parenteral thiamine (100 mg daily) for ≥3 d alongside other treatments and re-examined systematically. Clinical case reports were reviewed by 3 pediatricians, who determined TRD or non-TRD status. Children in a community comparison group were matched by age, sex, and residence. Venous whole blood ThDP and MTh were determined by high-performance liquid chromatography fluorescence detection and ETKac in washed erythrocytes by ultraviolet spectrophotometry. Associations between biomarkers were assessed using Spearman correlations, and biomarker cutoffs predictive of TRD and ETKac >1.25 were explored using area under the receiver operating characteristic curve framework.

Results

Thiamine biomarkers were available for 287 hospitalized children and 228 community children (mean age 4.7 mo; 59.4% male). Median (interquartile range [IQR]) ThDP and ETKac were 66.9 nmol/L (IQR: 41.4, 96.9 nmol/L) and 1.25 nmol/L (IQR: 1.11, 1.48 nmol/L), respectively, among hospitalized children, and 64.1 nmol/L (IQR: 50.0, 85.3 nmol/L) and 1.22 nmol/L (IQR: 1.12, 1.37 nmol/L) among 228 community children (P > 0.05 for both). Forty-five percent of breastfeeding mothers of infants <6 mo had MTh <90 μg/L. ThDP and ETKac, but not MTh, were significantly different between 152 children with TRD and 122 without TRD, but overlapping distributions undermined prediction of individual responses to thiamine.

Conclusions

Although ETKac, ThDP, and MTh are useful biomarkers of population thiamine status, none of the biomarkers reliably identified individual children with TRD. ThDP is more practical for population assessment because preparing washed erythrocytes is not required.This trial was registered at clinicaltrials.gov as NCT03626337.

Common misconceptions and myths about ovarian cancer causation: a national cross-sectional study from palestine

BACKGROUND

Women's inability to recognize ovarian cancer (OC) causation myths to be incorrect may lead to behavioral changes that could distract them from actual risk factors and impact their treatment decision making. This study examined Palestinian women's recognition of OC mythical causes, and explored factors associated with good recognition.

METHODS

A national cross-sectional study was conducted. Adult Palestinian women were recruited from hospitals, primary healthcare facilities, and public areas in 11 governorates. The Cancer Awareness Measure-Mythical Causes Scale was modified and utilized for data collection. Awareness level was determined based on the number of myths around OC causation recognized to be incorrect: poor (0-4), fair (5-9), and good (10-13).

RESULTS

A total of 5618 participants agreed and completed the questionnaire out of 6095 approached (response rate = 92.1%), and 5411 questionnaires were included in the final analysis. The most recognized food-related myth was 'drinking from plastic bottles' (n = 1370, 25.3%) followed by 'eating burnt food' (n = 1298, 24.0%). The least recognized food-related myth was 'eating food containing additives' (n = 611, 11.3%). The most recognized food-unrelated myth was 'having a physical trauma' (n = 2899, 53.6%), whereas the least recognized was 'using mobile phones' (n = 1347, 24.9%). Only 273 participants (5.1%) had good awareness of OC causation myths as incorrect. Earning higher monthly incomes as well as visiting governmental healthcare facilities were associated with a decrease in the likelihood of exhibiting good awareness.

CONCLUSION

The overall recognition of OC causation myths was low. Addressing mythical beliefs should be included in OC prevention strategies and public health interventions to improve women's understanding of OC risk factors versus mythical causes.

Cross-cultural food practices and nutrition seeking behaviors among pregnant and postpartum Indian women living in Australia

No research has explored the experiences of Indian women who become pregnant after they migrate to Australia, and how their existing traditions mix with their new environment and subsequently impact eating patterns. Semi-structured interviews were conducted with eleven women of Indian heritage who were living in Australia, and data were thematically analyzed. The researchers identified two main themes were identified (a) foods to eat and which to avoid, and (b) support networks and sources of health information during pregnancy. Women get advice and information from a range of sources and have diverse attitudes and beliefs about cultural food practices. that are both rigid and flexible, as well as traditional and contemporary.

Taboos, food avoidances, and diseases: Local epistemologies of health among Coastal Endenese in Eastern Indonesia

To advance interventions targeting malnutrition among small-scale fishing societies, knowledge on the role played by taboos and dietary avoidances on the consumption of fish related products becomes crucial. The article builds upon ethnographic fieldwork (participant observation, focus groups and interviews), dietary questionnaires (n: 112), and archival research among Coastal Endenese in Eastern Indonesia to understand the role played by taboos and dietary preferences in regulating intake of marine products. Moving beyond binary notions of “good” and “bad” when considering the food-system implications of taboos, it explores how local beliefs about illness and food shape dietary practices that can have concrete consequences for an individual's health. Endenese consider fish as having originated from terrestrial creatures, creating a continuous cycle of movement from land to sea and back. Within this cosmology, food is seen as a medium that can bring about healthy outcomes but also disease. Results emphasize the need to understand taboos and food avoidances within the larger cosmological and religious system but also underscore the changing nature of dietary preferences and values due to market integration processes which may have long-term repercussions on health. This information is key to the design of culturally sensitive dietary strategies and alternative livelihoods approaches that seek to minimize poverty.

Ethnic Differences in Preferences for Lifestyle Intervention among Women after Childbirth: A Multi-Methods Study in Australia

Postpartum weight retention contributes to maternal obesity and varies by ethnicity. Despite the well-established benefits of lifestyle intervention on weight management, little is known about how to engage postpartum women effectively, especially among ethnic minority groups. This multi-methods study aimed to explore ethnic differences in women's preferences for lifestyle intervention after childbirth. Women within five years of childbirth and living with their youngest child in Australia were recruited in an online survey (n = 504) and semi-structured interviews (n = 17). The survey and interview questions were structured based on the Template for Intervention Description and Replication (TIDieR) framework. Ethnic groups were categorized as Oceanian, Asian and Other according to the Australian Bureau of Statistics. Chi-square tests were used to compare the preferred intervention characteristics between groups. Qualitative data were thematically analysed. The survey showed that most women across all ethnic groups were interested in receiving lifestyle support in the early postpartum period (from 7 weeks to 3 months postpartum). All ethnic groups preferred a regular lifestyle intervention delivered by health professionals that promotes accountability and provides practical strategies. However, Asian women had a higher desire for infant care and a lower desire for mental health in the intervention content compared with Oceanian women. Moreover, Asian women were more likely to favour interventions that are initiated in a later postpartum period, over a shorter duration, and with less intervention frequency, compared with Oceanian women. The interviews further indicated the need for intervention adaptations in the Asian group to address the cultural relevance of food and postpartum practices. These ethnic-specific preferences should be considered in the development of culturally appropriate intervention strategies to optimize engagement in healthy lifestyles among the targeted ethnic groups.

Weight Gain and Nutrition during Pregnancy: An Analysis of Clinical Practice Guidelines in the Asia-Pacific Region

Nutrition and weight gain during pregnancy can influence the life-course health of offspring. Clinical practice guidelines play an important role in ensuring appropriate nutrition and weight gain among pregnant women. This study aims to identify clinical practice guidelines on gestational weight gain and/or maternal nutrition across the Asia-Pacific region and to determine the quality of the guidelines and variability in the recommendations. Through a systematic search of grey literature from 38 Asia-Pacific countries, 23 published guidelines were obtained. Of these, 10 eligible clinical practice guidelines reporting nutrition- or/and weight-related recommendations for pregnant women were selected and reviewed. Guideline quality was determined using the Assessment of Guidelines for Research Evaluation II (AGREE II) instrument. Of the 10 guidelines, 90% were classified as low-quality in the AGREE II appraisal. Several variations were found with respect to recommendations on gestational weight gain, including those specific to Asian populations. The recommendations on dietary advice, additional energy intake, and nutritional supplementation during pregnancy were varied. Clinical practice guidelines on weight gain and nutrition in pregnancy across the Asia-Pacific region are generally of poor quality, reflecting significant variation, and need to be improved to ensure pregnant women receive appropriate advice. (PROSPERO registration no. CRD42021291395).

Traditional prenatal and postpartum food restrictions among women in northern Lao PDR

Culturally determined food restrictions are common among pregnant and postpartum women in Asia. This study aimed to describe perinatal dietary restrictions, factors associated with food avoidances and attainment of minimum dietary diversity (MDD‐W) among women in Lao PDR. Mother–child (aged 21 days to <18 months) dyads (n = 682) were enrolled into a cohort study in northern Lao PDR and interviewed at one time point postpartum. During pregnancy and postpartum, 1.6% and 97% of women reported following dietary restrictions, respectively. Cluster analysis identified four distinct postpartum dietary patterns: most restrictive (throughout first 2 months postpartum); least restrictive; 2 weeks highly restrictive and 1 month highly restrictive, followed by 19%, 15%, 5% and 62% of women, respectively. Greater maternal age, gravidity and higher household socioeconomic status were associated with allowing more diverse foods, while women from food insecure households followed more restrictive diets for longer. Women belonging to the Hmong ethnic group followed a highly restrictive diet of white rice and chicken for the first month postpartum. MDD‐W was achieved by 10% of women restricting their diet at the time of the interview compared with 17% of women who were consuming their normal diet (p = 0.04). Postpartum dietary restrictions are widespread among women in northern Lao PDR. These highly restrictive diets, low dietary diversity and food insecurity likely contribute to micronutrient deficiencies in women that may have important consequences for their breastfed infants through reduced breastmilk micronutrient content, which requires further exploration. Culturally appropriate strategies to increase micronutrient intakes among women should be considered.

The link between knowledge of the maternal diet and breastfeeding practices in mothers and health workers in Poland

BACKGROUND

There are multiple misconceptions concerning the breastfeeding mother's diet and its adverse impact on breast milk composition and the breastfed child's health, which might lead to breastfeeding cessation. Although prophylactic maternal dietary restrictions are not recommended, mothers all over the world are often recommended to avoid certain foods, due to cultural beliefs, social pressure and even outdated or ambiguous medical recommendations. In Poland, there is no systematic approach to breastfeeding education in the form of nationwide educational programs for particular social groups. It was estimated that in 2017 only 3-4% of Polish infants were exclusively breastfed at 6 months of age. The aim of this study was to recognize the scale of common dietary misconceptions among lactating mothers in Poland and to compare knowledge and opinions between medical staff and mothers who have ever breastfed a child. In addition, the paper is an attempt to identify factors contributing to the still current practice of recommending prophylactic dietary restrictions to breastfeeding mothers by medical staff.

METHODS

The study was conducted in Poland, in January - February 2019. The study used a diagnostic poll method and was conducted mainly in an electronic form. A total of 1159 completed questionnaires data were analyzed: 35.1% completed by medical staff and 64.9% by mothers in non-medical professions. Statistical calculations were conducted with Chi-square test, logistic regression and U Mann Whitney test (level of significance set at 0.05).

RESULTS

The respondents presented a good level of knowledge and predominantly assessed the questioned statements correctly. Duration of breastfeeding was found to be the main factor determining respondents' knowledge (p <  0.05). Concerning medical staff, the parity (p <  0.001) and applying an elimination diet when themselves breastfeeding (p <  0.001) had a significant impact on recommendation of prophylactic dietetic restrictions to the lactating women.

CONCLUSIONS

Regardless of a resonably good level of knowledge on maternal nutrition in the lactation period, both breastfeeding mothers and medical staff are still convinced of the beneficial effect of preventive dietary restrictions, which affects further lactational counselling and lactational performance.

Thiamine fortification strategies in low- and middle-income settings: a review

Thiamine (vitamin B1 ) is an essential micronutrient in energy metabolism and cognitive and neurological health. Thiamine deficiency disorders (TDDs) have a range of clinical presentations that result in various morbidities and can be fatal if not promptly recognized and treated, especially in infants. To intervene, thiamine intakes by breastfeeding mothers and others at risk of thiamine deficiency should be increased to ensure adequate thiamine intake. Although thiamine fortification programs have a long history in high-income countries, there are few mandatory fortification programs to address TDDs in low- and middle-income countries (LMICs), particularly in the regions of greatest concern, South and Southeast Asia. This review highlights essential aspects for consideration in the development of a mandatory fortification program in LMICs, including an overview of the data required to model fortification dosing schemes, available thiamine fortificants, and potential fortification vehicles, as well as identifies current knowledge gaps.

Postpartum depression symptoms in survey-based research: a structural equation analysis

BACKGROUND

Since the last decade, postpartum depression (PPD) has been recognized as a significant public health problem, and several factors have been linked to PPD. Mothers at risk are rarely undetected and underdiagnosed. Our study aims to determine the factors leading to symptoms of depression using Structural Equation Modeling (SEM) analysis. In this research, we introduced a new framework for postpartum depression modeling for women.

METHODS

We structured the model of this research to take into consideration the Malaysian culture in particular. A total of 387 postpartum women have completed the questionnaire. The symptoms of postpartum depression were examined using the Edinburgh Postnatal Depression Scale (EPDS), and they act as a dependent variable in this research model.

RESULTS

Four hundred fifty mothers were invited to participate in this research. 86% of the total distributed questionnaire received feedback. The majority of 79.6% of respondents were having depression symptoms. The highest coefficients of factor loading analysis obtained in every latent variable indicator were income (β = 0.77), screen time (β = 0.83), chips (β = 0.85), and anxiety (β = 0.88). Lifestyle, unhealthy food, and BMI variables were directly affected by the dependent variable. Based on the output, respondents with a high level of depression symptoms tended to consume more unhealthy food and had a high level of body mass indexes (BMI). The highest significant impact on depression level among postpartum women was unhealthy food consumption. Based on our model, the findings indicated that 76% of the variances stemmed from a variety of factors: socio-demographics, lifestyle, healthy food, unhealthy food, and BMI. The strength of the exogenous and endogenous variables in this research framework is strong.

CONCLUSION

The prevalence of postpartum women with depression symptoms in this study is considerably high. It is, therefore, imperative that postpartum women seek medical help to prevent postpartum depressive symptoms from worsening.

Infantile thiamine deficiency in South and Southeast Asia: An age-old problem needing new solutions

Infantile beriberi, a potentially fatal disorder caused by thiamine deficiency, is often viewed as a disease confined to history in regions of the world with predominant white rice consumption. Recent case reports have, however, highlighted the persistence of thiamine deficiency as a cause of infant mortality in South and Southeast Asia. Low infant thiamine status and incidence of beriberi is attributable to maternal thiamine deficiency and insufficient breast milk thiamine. Poor dietary diversity, food preparation and cooking practices and traditional post‐partum food restrictions likely play a role in these high‐risk regions. Given the contribution of thiamine deficiency to infant mortality and emerging evidence of long‐lasting neurodevelopmental deficits of severe and even subclinical deficiency in early life, public health strategies to prevent thiamine deficiency are urgently needed. However, efforts are hampered by uncertainties surrounding the identification and assessment of thiamine deficiency, due to the broad non‐specific clinical manifestations, commonly referred to as thiamine deficiency disorders (TDD), that overlap with other conditions resulting in frequent misdiagnosis and missed treatment opportunities, and secondly the lack of readily available and agreed upon biomarker analysis and cut‐off thresholds. This review will discuss the key challenges and limitations in the current understanding of TDD and explore how ongoing initiatives plan to fill persistent knowledge gaps, namely in the development of a standardised case definition to help more accurately diagnose and treat TDD in low‐resource settings. Given more attention and ensuring greater recognition of TDD will support the design and implementation of treatment and prevention programmes, and ensure beriberi can truly be considered ‘the forgotten disease of Asia’.

Thiamine deficiency disorders: a clinical perspective

Thiamine is an essential water‐soluble vitamin that plays an important role in energy metabolism. Thiamine deficiency presents many challenges to clinicians, in part due to the broad clinical spectrum, referred to as thiamine deficiency disorders (TDDs), affecting the metabolic, neurologic, cardiovascular, respiratory, gastrointestinal, and musculoskeletal systems. Concurrent illnesses and overlapping signs and symptoms with other disorders can further complicate this. As such, TDDs are frequently misdiagnosed and treatment opportunities missed, with fatal consequences or permanent neurologic sequelae. In the absence of specific diagnostic tests, a low threshold of clinical suspicion and early therapeutic thiamine is currently the best approach. Even in severe cases, rapid clinical improvement can occur within hours or days, with neurological involvement possibly requiring higher doses and a longer recovery time. Active research aims to help better identify patients with thiamine‐responsive disorders and future research is needed to determine effective dosing regimens for the various clinical presentations of TDDs. Understanding the clinical diagnosis and global burden of thiamine deficiency will help to implement national surveillance and population‐level prevention programs, with education to sensitize clinicians to TDDs. With concerted effort, the morbidity and mortality related to thiamine deficiency can be reduced.

Foods to Avoid While Breastfeeding? Experiences and Opinions of Polish Mothers and Healthcare Providers

Popular beliefs regarding a mother’s diet during lactation have a significant impact on breastfeeding practices among mothers, as well on breastfeeding counseling among healthcare providers worldwide. The objective of this study was to assess mothers’ and medical professionals’ knowledge and opinions on the “lactating mother’s diet”. An electronic survey, prepared in Polish, was administered to healthcare providers, as well as mothers who have breastfed a child. The chi-square test, logistic regression, and Mann Whitney U test were used for statistical calculations. Out of a total of 1180 responses received, 1159 were analyzed, and 21 were excluded because they did not meet the inclusion criteria. The survey was completed by 407 (35%) medical healthcare providers and 752 (65%) lactating mothers in non-medical professions. In total, the study included 1074 mothers who have breastfed a child, and 29.14% of them reported that they eliminated certain foods from their diet when breastfeeding. There was no statistically significant difference in the responses received from mothers and medical staff providing maternal care (for each of 17 products, e.g., steak tartare, sushi, legumes, dairy products, p > 0.05 by the Mann-Whitney test). However, a logistic regression revealed some significant correlations with other variables (e.g., duration of lactation). The respondents revealed an appropriate level of knowledge on nutrition during lactation and the majority of participants neither adhered to nor recommended a prophylactic elimination diet. Among other evaluated factors, the experience of following an elimination diet affected respondents’ knowledge of nutrition during breastfeeding. Both mothers and healthcare providers require good nutritional education.