Reply to correspondence: is the strength of association between indicators of dietary quality and the nutritional status of children being underestimated?

Seasonality of Consumption of Nonstaple Nutritious Foods among Young Children from Nepal's 3 Agroecological Zones

BACKGROUND

Children's dietary patterns vary seasonally, particularly in subsistence agriculture settings like Nepal, but the seasonality of nutritious nonstaple food consumption is not well explored in the literature.

OBJECTIVE

This study aimed to examine seasonal differences in children's consumption of provitamin A-rich fruit and vegetables, dairy, eggs, meat, and fish in Nepal's 3 agroecological zones, and to assess whether seasonal patterns vary by wealth and caste/ethnicity.

METHODS

Multivariable negative binomial regression models were used to analyze dietary data from 7-d food-frequency questionnaires, producing coefficient estimates in the form of incidence rate ratios (IRRs). Data were collected 3 times per year for 2 y from children aged 6-72 mo in Nepal's mountains (n = 226), hills (n = 168), and plains (n = 225).

RESULTS

There were significant seasonal differences in children's consumption of provitamin A-rich fruit and vegetables, dairy, meat, and fish that varied by agroecological zone. Adopting monsoon season as the referent for all comparisons, children in the mountains ate provitamin A-rich fruit and vegetables less frequently during the postmonsoon and winter seasons (IRRs: 0.5 and 0.7, respectively; both P < 0.004), whereas in the plains, children's consumption of these foods was lower only during the postmonsoon season (IRR: 0.2; P < 0.001). Children's dairy intake frequency increased during the winter in the mountains (IRR: 0.7; P < 0.004) and decreased during the winter in the hills (IRR: 1.5; P < 0.001). Only in the plains did children's meat and fish intakes vary seasonally, increasing during the postmonsoon season (IRR: 1.6; P < 0.004). Wealth and caste/ethnicity variability influenced children's consumption of each of these nutritious groups of foods, and moderated seasonal effects in some instances.

CONCLUSIONS

Children's diets varied differently by season within each agroecological zone of Nepal and in some cases across socioeconomic groups, revealing the importance of taking a season- and location-specific approach to assessing diets and tailoring dietary strategies.

Diet quality and risk of stunting among infants and young children in low- and middle-income countries

Age-appropriate complementary feeding practices are far from optimal among low- and middle-income countries with available data. The evidence on the association between feeding practices and linear growth is mixed. We sought to systematically examine the association between two indictors of dietary quality-dietary diversity and animal source food (ASF) consumption (WHO, 2008)-and stunting (length-for-age z-score) employing existing data from 39 Demographic and Health Surveys. Data on 74,548 children aged 6-23 months were pooled and multiple logistic regression models, adjusting for child, maternal, and household characteristics, employed to assess the association between dietary quality and stunting. Stratified models by child age and by World Bank country-income classifications (World Bank, 2015) were also applied. Children aged 6-23 months consuming zero food groups in the previous day had a 1.345 higher odds of being stunted when compared to the reference group (≥5 food groups); those who did not consume any ASF in the previous day had a 1.436 higher odds of being stunted compared to children consuming all three types of ASF (egg, meat, and dairy). We estimated that 2,629 cases of stunting would have been averted (12.6% of those stunted) among the population studied if all children had consumed five or more food groups. Outcomes by country-income groupings showed larger associations of diet diversity and ASF consumption for upper- and lower-middle income countries compared to low-income countries. In summary, dietary diversity and ASF consumption were associated with stunting, with associations varying by stratified groups.

Enhancing Nutrition Security via India's National Food Security Act: Using an Axe instead of a Scalpel?

In September 2013, India passed a historic National Food Security Act. This paper examines the potential impact of the two central pillars of this act - expansion of the Public Distribution System and strengthening of the Integrated Child Development Schemes - on child nutrition. Using new data from the India Human Development Survey of 2011-12, this paper shows that access to subsidized grains via PDS is not related to improved child nutrition, and while ICDS seems to be related to lower child undernutrition, it has a limited reach in spite of the universalization of the program. The paper suggests that a tiered strategy in dealing with child undernutrition that starts with the identification of undernourished children and districts and follows through with different strategies for dealing with severe, acute malnutrition, followed by a focus on moderate malnutrition, could be more effective than the existing focus on cereal distribution rooted in the NFSA.