Maternal, infant, and young child nutrition: combining efforts to maximize impacts on child growth and micronutrient status

A quasi-experimental study assessing the effectiveness of a community-based egg intervention in the nutritional and health status of young children from rural Honduras

OBJECTIVE

This community-public-private-academic coalition project implemented and evaluated the effectiveness of a rural, community-based egg intervention that aimed to support the nutrition and health of children living in rural, poor communities from Intibucá, Honduras, during the COVID-19 pandemic.

DESIGN

This investigator-blind, non-randomized, controlled study was informed by a community health improvement process and participatory research. Women from 13 communities were given a microloan to start an egg farm that supplied 1 egg daily to 201 children ages 6-24 months for 1 year (intervention group). Control communities (n = 14) were selected from neighboring municipalities with similar sociodemographic backgrounds based on size. Sociodemographic-, anthropometric-, and morbidity data were collected biannually between January 2021 to January 2022. Outcome changes were compared with linear-, generalized- or Poisson- mixed models adjusted by sex, age, maternal education, breastfeeding status, assets, adults living at home, baseline outcomes, and community-cluster.

RESULTS

Baseline to 6- and 12-month weekly frequency of egg intake significantly increased in the intervention vs. the control group: 6-month change = 1.86; 95%CI (1.61, 2.14); 12-month change = 1.63; 95%CI (1.42, 1.87 p<0.001), respectively. Baseline to 12-month changes in the intervention group were not significant for length/height-for-age-z-scores = 0.12, p = 0.187; weight-for-length/height-z-scores = -0.02, p = 0.78; and diarrhea prevalence, AOR = 1.69; 95%CI (0.53, 5.42), p = 0.378. Lower odds of respiratory infections were observed for the intervention vs. the control group at 6- and 12-month post: AOR = 0.28; 95%CI (0.12, 0.63), p = 0.002; AOR = 0.30; 95%CI (0.12, 0.75), p = 0.010, respectively.

CONCLUSIONS AND RELEVANCE

Children in the intervention group reported consuming eggs more days per week relative to the control group. Lower odds of respiratory infections were observed in the intervention group throughout the study. Ongoing follow-up will offer more insights on the intervention's effectiveness in linear growth, dietary diversity, food security, and other nutritional outcomes.

A New Murine Undernutrition Model Based on Complementary Feeding of Undernourished Children Causes Damage to the Morphofunctional Intestinal Epithelium Barrier

BACKGROUND

Complementary feeding is critical in establishing undernutrition. However, experimental undernourished diets do not represent the amount of nutrients in the complementary diets of undernourished children.

OBJECTIVES

To develop, validate, and evaluate the impact of a new murine model of undernutrition on the intestinal epithelium, based on the complementary diet of undernourished children from 7 countries with low-socioeconomic power belonging to the Malnutrition-Enteric Diseases (MAL-ED) cohort study.

METHODS

We used the difference in the percentage of energy, macronutrients, fiber and zinc in the complementary diet of children without undernutrition compared with stunting (height-for-age Z-score < -2) for the MAL-ED diet formulation. Subsequently, C57BL/6 mice were fed a control diet (AIN-93M diet) or MAL-ED diet for 28 d. Weight was measured daily; body composition was measured every 7 d; lactulose:mannitol ratio (LM) and morphometry were evaluated on days 7 and 28; the cotransport test and analysis of intestinal transporters and tight junctions were performed on day 7.

RESULTS

The MAL-ED diet presented -8.03% energy, -37.46% protein, -24.20% lipid, -10.83% zinc, +5.93% carbohydrate, and +45.17% fiber compared with the control diet. This diet rapidly reduced weight gain and compromised body growth and energy reserves during the chronic period (P < 0.05). In the intestinal epithelial barrier, this diet caused an increase in the LM (P < 0.001) and reduced (P < 0.001) the villous area associated with an increase in FAT/CD36 in the acute period and increased (P < 0.001) mannitol excretion in the chronic period.

CONCLUSIONS

The MAL-ED diet induced undernutrition in mice, resulting in acute damage to the integrity of the intestinal epithelial barrier and a subsequent increase in the intestinal area during the chronic period. This study introduces the first murine model of undernutrition for the complementary feeding phase, based on data from undernourished children in 7 different countries.

Childhood stunting is highly clustered in Northern Province of Rwanda: A spatial analysis of a population-based study

Background

In Northern Province, Rwanda, stunting is common among children aged under 5 years. However, previous studies on spatial analysis of childhood stunting in Rwanda did not assess its randomness and clustering, and none were conducted in Northern Province. We conducted a spatial-pattern analysis of childhood undernutrition to identify stunting clusters and hotspots for targeted interventions in Northern Province.

Methods

Using a household population-based questionnaire survey of the characteristics and causes of undernutrition in households with biological mothers of children aged 1-36 months, we collected anthropometric measurements of the children and their mothers and captured the coordinates of the households. Descriptive statistics were computed for the sociodemographic characteristics and anthropometric measurements. Spatial patterns of childhood stunting were determined using global and local Moran's I and Getis-Ord Gi* statistics, and the corresponding maps were produced.

Results

The z-scores of the three anthropometric measurements were normally distributed, but the z-scores of height-for-age were generally lower than those of weight-for-age and weight-for-height, prompting us to focus on height-for-age for the spatial analysis. The estimated incidence of stunting among 601 children aged 1-36 months was 27.1 %. The sample points were interpolated to the administrative level of the sector. The global Moran's I was positive and significant (Moran's I = 0.403, p < 0.001, z-score = 7.813), indicating clustering of childhood stunting across different sectors of Northern Province. The local Moran's I and hotspot analysis based on the Getis-Ord Gi* statistic showed statistically significant hotspots, which were strongest within Musanze district, followed by Gakenke and Gicumbi districts.

Conclusion

Childhood stunting in Northern Province showed statistically significant hotspots in Musanze, Gakenke, and Gicumbi districts. Factors associated with such clusters and hotspots should be assessed to identify possible geographically targeted interventions.

Complementary Feeding Practices among Young Children in China, India, and Indonesia: A Narrative Review

Under- and overnutrition are co-existing health issues in several countries across Asia. Poor complementary feeding (CF) is a significant determinant of malnutrition in children and a major cause of morbidity and mortality. The purpose of this narrative review is to summarize the most recent evidence regarding the CF practices in 3 countries with a high prevalence of stunting and overweight, and currently undergoing rapid economic and nutritional transition: China, India, and Indonesia. We focused particularly on the adequacy of CF, based on the WHO feeding indicators (2021) regarding timing, frequency, diversity, as well as the consumption of specific food groups. According to the findings, the majority of infants in the 3 countries are introduced to CF at an inappropriate time: either too early (particularly in urban/rural areas of China and Indonesia) or too late (India) compared with the WHO recommendation. Furthermore, in all countries, diets are characterized by a low variety and frequency of CF and consist mainly of staple foods with poor nutritional quality, such as rice, cereals, or noodles. Nutrient-dense and protein-rich foods, such as foods of animal origin, are either inadequately consumed (rural areas of China and India) or introduced too late (urban areas of China and Indonesia) in the diets of children. In all countries, the consumption of fruit and vegetables, especially during the early CF period, is poor. In contrast, a significant proportion of both urban and rural children, particularly in Indonesia and India, are consuming energy-dense/nutrient-poor snacks and sugary drinks during the CF period. The described practices may pose a significant risk for the development of energy and/or nutrient gaps, magnifying the double and triple burden of malnutrition present in these countries. Further research is warranted to understand the significance of the observed practices for stunting and/or overweight/obesity risk.

Prenatal breastfeeding knowledge, attitude and intention, and their associations with feeding practices during the first six months of life: a cohort study in Lebanon and Qatar

Background

Prenatal knowledge, attitude, and intention related to breastfeeding are postulated as important modulators of feeding practices. Using data from the Mother and Infant Nutritional Assessment (MINA) study, a three year cohort conducted in Lebanon and Qatar, this study aimed to characterize breastfeeding practices during the first six months postnatally and examine their associations with prenatal breastfeeding knowledge, attitude, exposure, and intention.

Methods

Pregnant women during their first trimester were recruited from primary healthcare centers in Beirut and Doha. Data collection was conducted in 2015 − 2018. Participants were followed-up until the child was twoyears old. Exposure, knowledge, attitude, and intentions regarding breastfeeding were assessed during the third trimester of pregnancy (n = 230), using validated questionnaires and scales. Breastfeeding practices were evaluated at four months (n = 185) and six months (n = 151) postpartum. Early initiation of breastfeeding was defined as putting the infant to the breast within one hour of birth, and exclusive breastfeeding (EBF) as feeding exclusively with breast milk.

Results

Breastfeeding practices were as follows: ever breastfeeding: 95.8%; early initiation of breastfeeding: 72.8%; breastfeeding at four and six months: 70.3% and 62.3%; EBF at four and six months: 35.7% and 18.5%. Over 95% of participants had high breastfeeding exposure, and 68.8% had strong / very strong intentions to breastfeed. Only 25% had very good knowledge, and 9.2% reported positive/strong positive attitude towards breastfeeding. After adjustment, high exposure was associated with greater odds of breastfeeding initiation (OR 10.1: 95% CI 1.25, 80.65). Both positive attitude towards breastfeeding and strong intention to breastfeed were associated with EBF at four months (OR 2.51; 95% CI 1.02, 6.16 and OR 4.0; 95% CI 1.67, 9.6), breastfeeding at four months (OR 2.92: 95% CI 1.29, 6.62 and OR 5.00: 95% CI 2.25, 11.1), and breastfeeding at six months (OR 3.74: 95% CI 1.24, 11.32 and OR 8.29: 95% CI 2.9, 23.68).

Conclusions

Findings of this study documented suboptimal knowledge and attitude towards breastfeeding and showed that prior exposure, a positive attitude, and a strong intention to breastfeed prenatally were significant predictors of breastfeeding practices postnatally. This highlights the need to develop specific interventions and policies aimed at improving breastfeeding attitudes and creating an enabling environment that supports women throughout their breastfeeding journey.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-022-00456-x.

Bayesian geostatistical modelling of stunting in Rwanda: risk factors and spatially explicit residual stunting burden

Background

Stunting remains a significant public health issue in Rwanda and its prevalence exhibits considerable geographical variation. We apply Bayesian geostatistical modelling to study the spatial pattern of stunting in children less than five years considering anthropometric, socioeconomic and demographic risk factors in Rwanda. In addition, we predict the spatial residuals effects to quantify the burden of stunting not accounted for by our geostatistical model.

Methods

We used the data from the 2015 Rwanda Demographic and Health Survey. We fitted two spatial logistic models with similar structures, only differentiated by the inclusion or exclusion of spatially structured random effects.

Results

The risk factors of stunting identified in the geostatistical model were being male (OR = 1.32, 95% CI: 1.16, 1.47), lower birthweight (kg) (OR = 0.96, 95% CI: 0.95, 0.97), non-exclusive breastfeeding (OR = 1.24, 95% CI: 1.04, 1.45), occurrence of diarrhoea in the last two weeks (OR = 1.18, 95% CI: 1.02, 1.37), a lower proportion of mothers with overweight (BMI ≥ 25) (OR = 0.82, 95% CI: 0.71, 0.95), a higher proportion of mothers with no or only primary education (OR = 1.14, 95% CI: 0.99, 1.36). Also, a higher probability of living in a house with poor flooring material (OR = 1.22, 95% CI: 1.06, 1.41), reliance on a non-improved water source (OR = 1.13, 95% CI: 1.00, 1.27), and a low wealth index were identified as risk factors of stunting. Mapping of the spatial residuals effects showed that, in particular, the Northern and Western regions, followed by the Southern region of Rwanda, still exhibit a higher risk of stunting even after accounting for all the covariates in the spatial model.

Conclusions

Further studies are needed to identify the still unknown spatially explicit factors associated with higher risk of stunting. Finally, given the spatial heterogeneity of stunting, interventions to reduce stunting should be geographically targeted.

Seasonal Variations in Dietary Diversity and Nutrient Intakes of Women and Their Children (6-23 Months) in Western Kenya

Seasonal variations in food availability and access contributes to inadequate nutrient intakes, particularly in low income countries. This study assessed the effect of seasonality on dietary diversity (DD) and nutrient intakes of women and children aged 6–23 months in a rural setting in Western Kenya. A longitudinal study was conducted among 426 mother-child pairs during the harvest and post-harvest seasons in 2012. Dietary intakes were assessed using 24-h dietary recalls and dietary diversity scores (DDS) and nutrient intakes calculated for both seasons. Effect of seasonality on women dietary diversity scores (WDDS) and children's dietary diversity scores (CDDS) were assessed using generalised linear mixed models (GLMM). The proportion of women consuming diets with high DDS (>4 out of 9 food groups) increased from 36.4 to 52.4% between the two seasons, with mean WDDS being significantly higher in November compared to July/August (4.62 ± 1.43 vs. 4.16 ± 1.14, P < 0.001). A significantly higher proportion of children consumed foods from ≥4 out of 7 food groups in November compared to July/August (62.4 vs. 52.6%, P = 0.004). Mean CDDS (3.91 vs. 3.61, P = 0.004) was low but significantly higher in November compared to July/August. Estimated marginal mean WDDS increased from 4.17 to 4.38, and decreased for CDDS from 3.73 to 3.60 between the seasons. Seasonality had a small but significant effect on WDDS, P = 0.008 but not on CDDS, P = 0.293. Increase in CDDS in November was due to age and not seasonal effect. Higher women education and household food security were associated with higher WDDS and CDDS. Intakes of iron, calcium and vitamin E were higher among women in November and significantly different between the seasons. Agro-ecological zone, ethnic group and home gardening influenced nutrient intakes of the women. Seasonality had an effect on the DD of women but not of children, thus other factors apart from food availability influence the quality of children's diets during the complementary feeding period. With increasing age and transition to family foods, children's DD is expected to be affected by seasonality. Integrated interventions to alleviate seasonal food insecurity and strengthen rural households' resilience against seasonal deterioration in diet quality are recommended.

The "weanling's dilemma" revisited: Evolving bodies of evidence and the problem of infant paleodietary interpretation

Breastfeeding is known to be a powerful mediator of maternal and childhood health, with impacts throughout the life course. Paleodietary studies of the past 30 years have accordingly taken an enduring interest in the health and diet of young children as a potential indicator of population fertility, subsistence, and mortality patterns. While progress has been made in recent decades toward acknowledging the agency of children, many paleodietary reconstructions have failed to incorporate developments in cognate disciplines revealing synergistic dynamics between maternal and offspring biology. Paleodietary interpretation has relied heavily on the "weanling's dilemma," in which infants are thought to face a bleak choice between loss of immunity or malnutrition. Using a review of immunological and epidemiological evidence for the dynamic and supportive role that breastfeeding plays throughout the complementary feeding period, this article offers context and nuance for understanding past feeding transitions. We suggest that future interpretative frameworks for infant paleodietary and bioarchaeological research should include a broad knowledge base that keeps pace with relevant developments outside of those disciplines.

Higher Energy and Zinc Intakes from Complementary Feeding Are Associated with Decreased Risk of Undernutrition in Children from South America, Africa, and Asia

BACKGROUND

Few studies have focused on quantitatively analyzing nutrients from infant diets, compromising complementary feeding evaluation and health promotion worldwide.

OBJECTIVES

This study aimed to describe dietary intake in infants from 9 to 24 mo of age, determining nutrient intakes associated with the risk of underweight, wasting, and stunting.

METHODS

Usual nutrient intakes from complementary feeding were determined by 24-h recalls collected when infants were 9-24 mo of age in communities from 7 low- and middle-income countries: Brazil (n = 169), Peru (n = 199), South Africa (n = 221), Tanzania (n = 210), Bangladesh (n = 208), India (n = 227), and Nepal (n = 229), totaling 1463 children and 22,282 food recalls. Intakes were corrected for within- and between-person variance and energy intake. Multivariable regression models were constructed to determine nutrient intakes associated with the development of underweight, wasting, and stunting at 12, 18, and 24 mo of age.

RESULTS

Children with malnutrition presented significantly lower intakes of energy and zinc at 12, 18, and 24 mo of age, ranging from -16.4% to -25.9% for energy and -2.3% to -48.8% for zinc. Higher energy intakes decreased the risk of underweight at 12 [adjusted odds ratio (AOR): 0.90; 95% CI: 0.84, 0.96] and 24 mo (AOR: 0.91; 95% CI: 0.86, 0.96), and wasting at 18 (AOR: 0.91; 95% CI: 0.83, 0.99) and 24 mo (AOR: 0.83; 95% CI: 0.74, 0.92). Higher zinc intakes decreased the risk of underweight (AOR: 0.12; 95% CI: 0.03, 0.55) and wasting (AOR: 0.19; 95% CI: 0.04, 0.92) at 12 mo, and wasting (AOR: 0.05; 95% CI: 0.00, 0.76) at 24 mo.

CONCLUSIONS

Higher intakes of energy and zinc in complementary feeding were associated with decreased risk of undernutrition in the studied children. Data suggest these are characteristics to be improved in children's complementary feeding across countries.

A Novel method for the identification and quantification of weight faltering

Objective

We describe a new method for identifying and quantifying the magnitude and rate of short‐term weight faltering episodes, and assess how (a) these episodes relate to broader growth outcomes, and (b) different data collection intervals influence the quantification of weight faltering.

Materials and methods

We apply this method to longitudinal growth data collected every other day across the first year of life in Gambian infants (n = 124, males = 65, females = 59). Weight faltering episodes are identified from velocity peaks and troughs. Rate of weight loss and regain, maximum weight loss, and duration of each episode were calculated. We systematically reduced our dataset to mimic various potential measurement intervals, to assess how these intervals affect the ability to derive information about short‐term weight faltering episodes. We fit linear models to test whether metrics associated with growth faltering were associated with growth outcomes at 1 year, and generalized additive mixed models to determine whether different collection intervals influence episode identification and metrics.

Results

Three hundred weight faltering episodes from 119 individuals were identified. The number and magnitude of episodes negatively impacted growth outcomes at 1 year. As data collection interval increases, weight faltering episodes are missed and the duration of episodes is overestimated, resulting in the rate of weight loss and regain being underestimated.

Conclusions

This method identifies and quantifies short‐term weight faltering episodes, that are in turn negatively associated with growth outcomes. This approach offers a tool for investigators interested in understanding how short‐term weight faltering relates to longer‐term outcomes.

Prenatal infant feeding intentions and actual feeding practices during the first six months postpartum in rural Rwanda: a qualitative, longitudinal cohort study

Background

Exclusive breastfeeding (EBF) is advocated by the WHO for the first 6 months. In Rwanda, the percentage of infants who are exclusively breastfed decreases from 94% among infants aged 0–1 month to 81% among those aged 4–5 months. Little is known about what influences mothers’ breastfeeding practices. This study aimed to gain insights into expectant mothers’ prenatal feeding intentions, the underlying reasons, actual practices after birth, and factors facilitating or impeding EBF for the first 6 months of a child’s life in Muhanga District, Rwanda.

Methods

This qualitative longitudinal study, conducted between December 2016 and October 2017 as part of a larger study, recruited a purposive sample of 39 pregnant women attending prenatal consultations during their last trimester in two rural health centers. Women were interviewed during pregnancy, within the first week after birth and at 4 and 6 months postpartum to explore intentions, actual practices, critical transition points, and facilitating or impeding factors. Interviews were recorded, transcribed verbatim, and analyzed thematically.

Results

Of the 39 participants, 38 intended to breastfeed within the first hour after birth, and 32 intended to breastfeed exclusively for the first 6 months. In practice, 34 initiated breastfeeding within the first hour, and 12 breastfed exclusively for 6 months. Impeding factors include perceived breastmilk insufficiency, pressure from family members, past experiences, mothers’ concerns over their infants’ health, mothers’ heavy workload, poverty and food insecurity. Factors facilitating early initiation and EBF include mothers’ awareness of EBF’s advantages, confidence in their breastfeeding ability, and support from health professionals and family members.

Conclusion

Despite participants’ intentions about breastfeeding, there was a gap between intentions and actual practices. An interplay of barriers at individual, group and societal levels impeded women from EBF for the first 6 months. EBF promotion interventions should consider supporting and equipping breastfeeding mothers with skills to deal with perceived breastmilk insufficiency and to recognize the true signs of baby hunger cues. Furthermore, important influential family and community members should be targeted to support mothers to breastfeed. Interventions that consider addressing the issue of poverty-driven food insecurity should not be overlooked either.

Daily Supplementation With Egg, Cow Milk, and Multiple Micronutrients Increases Linear Growth of Young Children with Short Stature

BACKGROUND

Childhood stunting is the most prevalent public health nutrition problem in low- and middle-income countries.

OBJECTIVE

This study aimed to determine whether daily supplementation in 12-18-mo-old undernourished Bangladeshi children with egg, cow milk, and multiple micronutrients improves linear growth.

METHODS

In the Bangladesh Environmental Enteric Dysfunction (BEED) study, a community-based intervention study, 12-18-mo-old children with length-for-age z score (LAZ) <1 were supplemented daily with an egg and 150 mL of milk for 90 feeding days, and 1 sachet of multiple micronutrient powder was provided daily for 60 feeding days. The change in LAZ over this period was compared with that in children of the same age and same baseline LAZ who were enrolled in the recently completed Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health (MAL-ED) Dhaka birth cohort study conducted in the same community where no nutrition intervention was provided. Difference-in-difference (DID) analysis was done and the effect size was adjusted for other possible covariates using a generalized estimating equation in a regression model.

RESULTS

A total of 472 children with LAZ <1 completed the intervention and data were available for 174 children in the comparison group. Compared with the comparison group, adjusted DID analysis revealed a change in LAZ in the intervention group of +0.23 (95% CI: 0.18, 0.29; P < 0.05). In a subgroup analysis, the changes were +0.27 (95% CI: 0.18, 0.35; P < 0.05) in stunted (LAZ <2) children and +0.19 (95% CI: 0.12, 0.27; P < 0.05) in children at risk of stunting (LAZ -1 to -2). No allergic reactions or other adverse events related to milk and egg consumption were observed.

CONCLUSIONS

Daily directly observed milk, egg, and multiple micronutrient supplementation may improve linear growth of stunted children. A randomized controlled trial with longer duration of supplementation coupled with an additional intervention aimed at reducing pathogen burden is warranted to confirm these results. This trial was registered at clinicaltrials.gov as NCT02812615.

Effectiveness of a locally produced ready-to-use supplementary food in preventing growth faltering for children under 2 years in Cambodia: a cluster randomised controlled trial

This cluster randomised controlled trial tested the effectiveness of a locally produced, fish-based, ready-to-use supplementary food (RUSF) to prevent growth faltering (decline in z-scores). Cambodian infants (n= 485), aged 6 to 11 months, were randomised by site to receive the RUSF, Corn-Soy Blend++ (CSB++), micronutrient powders (MNP), or no supplement (control). The intervention was for 6 months. In unadjusted analysis, the control group had statistically significantly decreased weight-for-age z-scores (WAZ; -0.02, 95%CI = -0.03 - -0.01, P= 0.001) and height-for-age z-scores (HAZ; -0.07, 95%CI = -0.09 - -0.05, P < 0.001), and increased mid-upper arm-circumference (MUAC; 0.02cm, 95%CI = 0.01 - 0.04, P = 0.010), but no statistically significant change in weight-for-height z-scores (WHZ). The RUSF group did not differ significantly from the control for WAZ, HAZ or WHZ (in other words, WAZ and HAZ decreased and WHZ did not change), but had increased MUAC in comparison to the control (0.04cm, 95%CI = 0.01 - 0.06, P = 0.008). There were no statistically significant differences between the RUSF group and the CSB++ or MNP groups with respect to WAZ, HAZ, WHZ or MUAC. Interestingly, in adjusted analysis, low consumers of RUSF had increased WAZ, WHZ and MUAC (0.03, 95%CI = 0.01-0.06, P = 0.006; 0.04, 95%CI = 0.01-0.08, P = 0.026; and 0.05cm, 95%CI = 0.02-0.09, P = 0.004, respectively) compared with the control. The novel RUSF, particularly in small quantities, protected against ponderal growth faltering, but the improvements were of limited clinical significance.

Can Diets Be Healthy, Sustainable, and Equitable?

PURPOSE

The purpose of this study was to review the evidence on global dietary intake and trends in dietary patterns over time and to examine associations between diets and health, environment, and equity.

RECENT FINDINGS

Diets now serve as a significant risk factor for the global burden of disease and death. Diet-related non-communicable disease and rising obesity are increasingly prevalent, affecting much of the global population. At the same time, the food system is producing food in ways that are not aligned with planetary health. Inequity restricts access to healthy diets and is associated with broad social determinants. Current dietary patterns are increasingly unhealthy, unsustainable, and inequitable for many populations. Multi-pronged interventions are needed to address the impacts of diets in order to improve human and planetary well-being.

Mitigated Impact of Provision of Local Foods Combined with Nutrition Education and Counseling on Young Child Nutritional Status in Cambodia

BACKGROUND

In Cambodia, stunting and wasting affect, respectively, 32% and 10% of children 0⁻59 months while 55% are anemic. Our research aims to assess the efficiency of two local foods combined with nutritional education and counseling (CEN) activities as compared to CEN alone on improving child nutritional status and dietary intake.

METHODS

A cluster-randomized controlled trial was conducted in Soth Nikum area over a six-month period among children 6⁻23 months (n = 360) assigned to receive either moringa +CEN, cricket +CEN or CEN alone. Anthropometric measurements were performed and hemoglobin and ferritin levels assessed.

RESULTS

Overall, no significant increase in the mean length/height-for-age z-score was observed, although a small increase of the weight-for-length/height was noted in intervention groups. Hemoglobin and ferritin mean values increased in all groups. The degree of satisfaction of energy, proteins, iron, and zinc requirements improved in all groups, but to a greater extent in the intervention groups and more children were healthy.

CONCLUSION

Our research shows no significant impact of the provision of two local foods combined with CEN on the improvement of child nutritional status as compared to CEN alone. However, children consuming them better fulfilled their energy, iron, and zinc requirements and were healthier.

Can early initiation to breastfeeding prevent stunting in 6–59 months old children?

Purpose

The prevalence of stunting in children under five years old is high (37.9 percent). The health advantage of breast milk as a prevention is recognized. The purpose of this paper is to examine the relationship of early initiation to breastfeeding, wherein a child is breastfed within an hour of birth, as a means of preventing stunted growth in 6–59 month old children in Jambi province, Indonesia.

Design/methodology/approach

This paper used data from the 2015 National Nutrition Survey in Jambi province. A total of 2,502 children aged 6–59 months were analyzed by binary logistic regression.

Findings

The results showed that as many as 27.5 percent (95% CI: 25.2–29.9) children aged 6–59 months were stunted and 54.1 percent (95% CI: 51.1–57.1) had not been introduced to breastfeeding soon after birth. The analysis showed that delayed initiation to breastfeeding is a significant factor in stunting amongst 6–59 month old children. (p=0.024; AOR=1.3; 95% CI: 1.0–1.6). Other results of the analysis showed a significant association between water source and birth weight issues as causes for stunting.

Originality/value

Research revealed that delayed initiation into breastfeeding results in a 1.3 times higher risk of stunting. Furthermore, early initiation to breastfeeding reduces the risk of consuming polluted river water that is a health risk and cause of stunting.

Predictors of stunting with particular focus on complementary feeding practices: A cross-sectional study in the northern province of Rwanda

OBJECTIVES

The aim of this study was to review the factors associated with stunting in the northern province of Rwanda by assessing anthropometric status, dietary intake, and overall complementary feeding practices.

METHODS

This was a cross-sectional study with 138 children 5 to 30 mo of age. A structured questionnaire was used to collect information on sociodemographic characteristics of each mother and child and breastfeeding and complementary feeding practices. Anthropometric status was assessed using height-for-age z-scores for children and body mass index for caregivers. Dietary intakes were estimated using a 24-h recall. Multiple linear and logistic regression models were performed to study the predictors of height-for-age z scores and stunting.

RESULTS

There was a 42% stunting prevalence. Prevalence of continued breastfeeding and exclusive breastfeeding were 92% and 50%, respectively. Most children (62%) fell into the low dietary diversity score group. The nutrient intake from complementary foods was below recommendations. The odds of stunting were higher in children >12 mo of age (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.08-1.29). Exclusive breastfeeding (OR, 0.22; 95% CI, 0.10-0.48) and deworming tablet use in the previous 6 mo (OR, 0.25; 95% CI, 0.07-0.80) decreased significantly the odds of stunting in children. Also, the body mass index of the caretaker (β = 0.08 kg/m²; 95% CI, 0.00-0.17) and dietary zinc intake (β = 1.89 mg/d; 95% CI, 0.29-3.49) were positively associated with the height-for-age z scores.

CONCLUSION

Interventions focusing on optimal nutrition during the complementary feeding stage, exclusive breastfeeding, and the use of deworming tablets have the potential to substantially reduce stunting in children in the northern province of Rwanda.

Complementary Food Supplements Increase Dietary Nutrient Adequacy and Do Not Replace Home Food Consumption in Children 6-18 Months Old in a Randomized Controlled Trial in Rural Bangladesh

Background

Inadequate complementary feeding is common in low- and middle-income countries, contributing to growth deficits. Complementary food supplements (CFSs) aim to fill dietary gaps, but few CFS studies have measured nutrient intake. In a community-based, randomized CFS trial in Bangladesh, we previously reported poor dietary diversity in 6-18-mo-old participants.

Objective

We investigated, in a secondary analysis in the same trial, micronutrient intake adequacy in supplemented compared with control-arm children.

Methods

At age 6 mo, children were assigned to 1 y of child-feeding counseling for mothers (control) or counseling plus 1 of 4 CFS formulations. Mothers were administered quantitative past 24-h diet questionnaires for their children at ages 6, 9, 12, 15, and 18 mo. Nutrient intakes were estimated with local recipes and food composition tables assuming average age-specific breastmilk intake. Adequacy was evaluated relative to estimated average requirements or adequate intakes. Multivariate analysis of variance and generalized estimating equation (GEE) regression models estimated the effect of each CFS on nutrient adequacy. GEE models tested dietary predictors of nutrient adequacy in the control arm.

Results

A total of 25,964 dietary modules across 5 interviews were completed. Nutrient adequacy from home foods combined with assumed breastmilk intake was low. Only 5 of 16 micronutrients were adequately consumed by >60% of children at 18 mo of age. Daily CFSs did not affect energy-adjusted micronutrient intake from home foods at any follow-up age (P > 0.05). CFSs increased the mean adequacy ratio for all micronutrients (P < 0.001 at all ages), to ≥1 for 14 of 16 micronutrients at 18 mo. Dietary diversity predicted adequate iron, zinc and calcium intake at 15 mo in unsupplemented controls.

Conclusions

Home foods did not meet the estimated micronutrient needs of 9-18-mo-old children in rural Bangladesh. Daily supplementation with fortified complementary foods filled many micronutrient intake gaps and did not displace home foods. Previously, CFSs were shown to also improve linear growth and reduce stunting in this cohort. Findings support the need for CFSs in similar settings to promote nutritional well being and growth. This trial was registered at clinicaltrials.gov as NCT01562379.

Tools to improve planning, implementation, monitoring, and evaluation of complementary feeding programmes

Adequate nutrient intake is a prerequisite for achieving good nutrition status. Suboptimal complementary feeding practices are a main risk factor for stunting. The need for systematic and user-friendly tools to guide the planning, implementation, monitoring, and evaluation of dietary interventions for children aged 6-23 months has been recognized. This paper describes five tools, namely, ProPAN, Optifood, Cost of the Diet, Fill the Nutrient Gap, and Monitoring Results for Equity System that can be used in different combinations to improve situation analysis, planning, implementation, monitoring, or evaluation approaches for complementary feeding in a particular context. ProPAN helps with development of strategies and activities designed to change the behaviours of the target population. Optifood provides guidance for developing food-based recommendations. The Cost of the Diet can provide insight on economic barriers to accessing a nutritious and balanced diet. The Fill the Nutrient Gap facilitates formulation of context-specific policies and programmatic approaches to improve nutrient intake, through a multistakeholder process that uses insights from linear programming and secondary data. The Monitoring Results for Equity System helps with analysis of gaps, constraints, and determinants of complementary feeding interventions and adoption of recommended practices especially in the most vulnerable and deprived populations. These tools, and support for their use, are readily available and can be used either alone and/or complementarily throughout the programme cycle to improve infant and young child-feeding programmes at subnational and national levels.

Complementary feeding practices: Current global and regional estimates

Insufficient quantities and inadequate quality of complementary foods, together with poor feeding practices, pose a threat to children's health and nutrition. Interventions to improve complementary feeding are critical to reduce all forms of malnutrition, and access to data to ascertain the status of complementary feeding practices is essential for efforts to improve feeding behaviours. However, sufficient data to generate estimates for the core indicators covering the complementary feeding period only became available recently. The current situation of complementary feeding at the global and regional level is reported here using data contained within the UNICEF global database. Global rates of continued breastfeeding drop from 74.0% at 1 year of age to 46.3% at 2 years of age. Nearly a third of infants 4-5 months old are already fed solid foods, whereas nearly 20% of 10-11 months old had not consumed solid foods during the day prior to their survey. Of particular concern is the low rate (28.2%) of children 6-23 months receiving at least a minimally diverse diet. Although rates for all indicators vary by background characteristics, feeding behaviours are suboptimal even in richest households, suggesting that cultural factors and poor knowledge regarding an adequate diet for young children are important to address. In summary, far too few children are benefitting from minimum complementary feeding practices. Efforts are needed not only to improve children's diets for their survival, growth, and development but also for governments to report on progress against global infant and young child feeding indicators on a regular basis.

Study of the Determinants of Chronic Malnutrition in Northern Nigeria: Quantitative Evidence from the Nigeria Demographic and Health Surveys International Food Policy Research Institute (IFPRI) Working Paper 45 (September 2017)

Background:

Close to half of all children younger than 5 years in the Northeast and Northwest geopolitical zones were estimated to be stunted in their growth for their age in 2013 compared to 22% of children in the rest of Nigeria.

Objectives:

We examine the drivers of chronic child undernutrition in northern Nigeria and how those drivers differ from other areas of the country.

Methods:

Both a standard child-level regression-based approach and decomposition analysis were used to address the determinants of stunting and decompose how drivers differ between northern Nigeria and other areas of the country using 2008 and 2013 Nigeria DHS data.

Results:

There are strong differences in the levels of the determinants of undernutrition in young children between the 2 parts of the country. However, equally important, the decomposition analysis shows that there are significant differences between northern Nigeria and other areas of Nigeria in the effect of the same determinant of nutritional status in accelerating or retarding the linear growth of young children.

Conclusions:

A national program to address child undernutrition must recognize this heterogeneity in its design. To impose across Nigeria, a single set of approaches to address the factors which results in stunted children is likely to fail for large numbers of children if these strong geographical differences in how these determinants operate to affect child nutritional status are not considered. Solutions need to be developed within northern Nigeria to more closely reflect the way the determinants of nutritional status operate in this area of the country.

Micronutrient adequacy is poor, but not associated with stunting between 12-24 months of age: A cohort study findings from a slum area of Bangladesh

The prevalence of stunting among children below 5 years of age is higher in the slum-dwelling population of Bangladesh compared to that in both urban and rural areas. Studies have reported that several factors such as inadequate nutrition, low socio-economic status, poor hygiene and sanitation and lack of maternal education are the substantial predictors of childhood stunting. Almost all these factors are universally present in the slum-dwelling population of Bangladesh. However, few studies have prospectively examined such determinants of stunting among slum populations. In this paper, we reveal the findings of a cohort study with an aim to explore the status of micronutrient adequacy among such vulnerable children and establish its association with stunting along with other determinants. Two-hundred-sixty-five children were enrolled and followed since birth until 24 months of age. We collected anthropometric, morbidity and dietary intake data monthly. We used the 24-hour multiple-pass recall approach to collect dietary intake data from the age of 9 months onward. Micronutrient adequacy of the diet was determined by the mean adequacy ratio (MAR) which was constructed from the average intake of 9 vitamins and 4 minerals considered for the analysis. We used generalized estimating equation (GEE) regression models to establish the determinants of stunting between 12–24 months of age in our study population. The prevalence of low-birth-weight (LBW) was about 28.7% and approximately half of the children were stunted by the age of 24 months. The average micronutrient intake was considerably lower than the recommended dietary allowance and the MAR was only 0.48 at 24 months of age compared to the optimum value of 1. However, the MAR was not associated with stunting between 12–24 months of age. Rather, LBW was the significant determinant (AOR = 3.03, 95% CI: 1.69–5.44) after adjusting for other factors such as age (AOR = 2.12, 95% CI: 1.45–3.11 at 24 months and AOR = 1.97, 95% CI: 1.49–2.59 at 18 months, ref: 12 months) and sex (AOR = 1.98, 95% CI: 1.17–3.33, ref: female). Improving the nutritional quality of complementary food in terms of adequacy of micronutrients is imperative for optimum growth but may not be adequate to mitigate under-nutrition in this setting. Further research should focus on identifying multiple strategies that can work synergistically to diminish the burden of stunting in resource-poor settings.

Risk factors of stunting among children living in an urban slum of Bangladesh: findings of a prospective cohort study

BACKGROUND

Bangladesh is one of the 20 countries with highest burden of stunting globally. A large portion (around 2.2 million) of the population dwells in the slum areas under severe vulnerable conditions. Children residing in the slums are disproportionately affected with higher burden of undernutrition particularly stunting. In this paper, findings of a prospective cohort study which is part of a larger multi-country study are presented.

METHODS

Two hundred and sixty five children were enrolled and followed since their birth till 24 months of age. Anthropometric measurements, dietary intake and morbidity information were collected monthly. Data from 9 to 12, 15-18 and 21-24 months were collated to analyze and report findings for 12, 18 and 24 months of age. Generalized estimating equation models were constructed to determine risk factors of stunting between 12 and 24 months of age.

RESULT

Approximately, 18% of children were already stunted (LAZ < -2SD) at birth and the proportion increased to 48% at 24 months of age. Exclusive breastfeeding prevalence was only 9.4% following the WHO definition at 6 months. Dietary energy intake as well as intakes of carbohydrate, fat and protein were suboptimal for majority of the children. However, in regression analysis, LAZ at birth (AOR = 0.40, 95% CI: 0.26, 0.61), household with poor asset index (AOR = 2.81, 95% CI: 1.43, 5.52; ref.: average asset index), being male children (AOR = 1.75, 95% CI: 1.04, 2.95; ref.: female) and age (AOR = 2.34, 95% CI: 1.56, 3.52 at 24 months, AOR = 2.13, 95% CI: 1.55, 2.92 at 18 months; ref.: 12 months of age) were the significant predictors of stunting among this population.

CONCLUSION

As the mechanism of stunting begins even before a child is born, strategies must be focused on life course approach and preventive measurement should be initiated during pregnancy. Alongside, government and policymakers have to develop sustainable strategies to improve various social and environmental factors those are closely interrelated with chronic undernutrition particularly concentrating on urban slum areas.

Adaptation of New Colombian Food-based Complementary Feeding Recommendations Using Linear Programming

OBJECTIVE

The aim of the study was to use linear programming (LP) analyses to adapt New Complementary Feeding Guidelines (NCFg) designed for infants aged 6 to 12 months living in poor socioeconomic circumstances in Bogota to ensure dietary adequacy for young children aged 12 to 23 months.

DESIGN

A secondary data analysis was performed using dietary and anthropometric data collected from 12-month-old infants (n = 72) participating in a randomized controlled trial. LP analyses were performed to identify nutrients whose requirements were difficult to achieve using local foods as consumed; and to test and compare the NCFg and alternative food-based recommendations (FBRs) on the basis of dietary adequacy, for 11 micronutrients, at the population level.

RESULTS

Thiamine recommended nutrient intakes for these young children could not be achieved given local foods as consumed. NCFg focusing only on meat, fruits, vegetables, and breast milk ensured dietary adequacy at the population level for only 4 micronutrients, increasing to 8 of 11 modelled micronutrients when the FBRs promoted legumes, dairy, vitamin A-rich vegetables, and chicken giblets. None of the FBRs tested ensured population-level dietary adequacy for thiamine, niacin, and iron unless a fortified infant food was recommended.

CONCLUSIONS

The present study demonstrated the value of using LP to adapt NCFg for a different age group than the one for which they were designed. Our analyses suggest that to ensure dietary adequacy for 12- to 23-month olds these adaptations should include legumes, dairy products, vitamin A-rich vegetables, organ meat, and a fortified food.

Population-attributable risk estimates for factors associated with inappropriate complementary feeding practices in The Gambia

OBJECTIVE

The present cross-sectional study aimed to determine population-attributable risk (PAR) estimates for factors associated with inappropriate complementary feeding practices in The Gambia.

DESIGN

The study examined the first and most recent Demographic and Health Survey of The Gambia (GDHS 2013). The four complementary feeding indicators recommended by the WHO were examined against a set of individual-, household- and community-level factors, using multilevel logistic analysis. PAR estimates were obtained for each factor associated with inappropriate complementary feeding practices in the final multivariate logistic regression model.

SETTING

The Gambia.

SUBJECTS

Last-born children (n 2362) aged 6-23 months.

RESULTS

Inadequate meal frequency was attributed to 20 % (95 % CI 15·5 %, 24·2 %) of children belonging to the youngest age group (6-11 months) and 9 % (95 % CI 3·2 %, 12·5 %) of children whose mothers were aged less than 20 years at the time of their birth. Inadequate dietary diversity was attributed to 26 % (95 % CI 1·9 %, 37·8 %) of children who were born at home and 20 % (95 % CI 8·3, 29·5 %) of children whose mothers had no access to the radio. Inadequate introduction of solid, semi-solid or soft foods was attributed to 30 % (95 % CI 7·2 %, 38·9 %) of children from poor households.

CONCLUSIONS

Findings of the study suggest the need for community-based public health nutrition interventions to improve the nutritional status of Gambian children, which should focus on sociocultural and economic factors that negatively impact on complementary feeding practices early in infancy (6-11 months).

Childhood stunting: a global perspective

Childhood stunting is the best overall indicator of children's well-being and an accurate reflection of social inequalities. Stunting is the most prevalent form of child malnutrition with an estimated 161 million children worldwide in 2013 falling below -2 SD from the length-for-age/height-for-age World Health Organization Child Growth Standards median. Many more millions suffer from some degree of growth faltering as the entire length-for-age/height-for-age z-score distribution is shifted to the left indicating that all children, and not only those falling below a specific cutoff, are affected. Despite global consensus on how to define and measure it, stunting often goes unrecognized in communities where short stature is the norm as linear growth is not routinely assessed in primary health care settings and it is difficult to visually recognize it. Growth faltering often begins in utero and continues for at least the first 2 years of post-natal life. Linear growth failure serves as a marker of multiple pathological disorders associated with increased morbidity and mortality, loss of physical growth potential, reduced neurodevelopmental and cognitive function and an elevated risk of chronic disease in adulthood. The severe irreversible physical and neurocognitive damage that accompanies stunted growth poses a major threat to human development. Increased awareness of stunting's magnitude and devastating consequences has resulted in its being identified as a major global health priority and the focus of international attention at the highest levels with global targets set for 2025 and beyond. The challenge is to prevent linear growth failure while keeping child overweight and obesity at bay.

Community-based educational intervention improved the diversity of complementary diets in western Kenya: results from a randomized controlled trial

OBJECTIVE

Lack of diversity is a major factor contributing to inadequate nutrient intakes among children during the complementary feeding period in many rural areas in developing countries. This has been attributed to inadequate feeding practices and nutrition knowledge among their caregivers. The aim of the present study was to assess the effect of an educational intervention on children's dietary diversity and nutrition knowledge of caregivers.

DESIGN

Cluster randomization was applied and twenty matched village pairs were randomly assigned to the intervention or control group. The nutrition education intervention consisted of four sessions comprising of group trainings and cooking demonstrations that were conducted over a period of 5 months.

SETTING

Households in rural communities in Bondo and Teso South sub-counties, western Kenya.

SUBJECTS

Caregivers with children aged 6-17 months receiving nutrition education.

RESULTS

The children's dietary diversity scores (CDDS) and nutrition knowledge scores of the caregivers improved significantly in the intervention group at endline. The treatment effect on CDDS was positive and significant (P=0.001). The CDDS rate of the children in the intervention group was 27% larger than it would have been without the treatment effect. The intervention also had a significant effect on the caregivers' nutrition knowledge scores (incidence rate ratio=2.05; P<0.001). However, the nutrition knowledge of the caregivers did not have a significant effect on CDDS (P=0.731).

CONCLUSIONS

The nutrition education intervention led to improvements in children's dietary diversity and nutrition knowledge of the caregivers.

Successive 1-Month Weight Increments in Infancy Can Be Used to Screen for Faltering Linear Growth

BACKGROUND

Linear growth faltering in the first 2 y contributes greatly to a high stunting burden, and prevention is hampered by the limited capacity in primary health care for timely screening and intervention.

OBJECTIVE

This study aimed to determine an approach to predicting long-term stunting from consecutive 1-mo weight increments in the first year of life.

METHODS

By using the reference sample of the WHO velocity standards, the analysis explored patterns of consecutive monthly weight increments among healthy infants. Four candidate screening thresholds of successive increments that could predict stunting were considered, and one was selected for further testing. The selected threshold was applied in a cohort of Bangladeshi infants to assess its predictive value for stunting at ages 12 and 24 mo.

RESULTS

Between birth and age 12 mo, 72.6% of infants in the WHO sample tracked within 1 SD of their weight and length. The selected screening criterion ("event") was 2 consecutive monthly increments below the 15th percentile. Bangladeshi infants were born relatively small and, on average, tracked downward from approximately age 6 to <24 mo (51% stunted). The population-attributable risk of stunting associated with the event was 14% at 12 mo and 9% at 24 mo. Assuming the screening strategy is effective, the estimated preventable proportion in the group who experienced the event would be 34% at 12 mo and 24% at 24 mo.

CONCLUSIONS

This analysis offers an approach for frontline workers to identify children at risk of stunting, allowing for timely initiation of preventive measures. It opens avenues for further investigation into evidence-informed application of the WHO growth velocity standards.

Health of Indigenous Peoples

Indigenous populations worldwide are experiencing social, cultural, demographic, nutritional, and psychoemotional changes that have a profound impact on health. Regardless of their geographical location or sociopolitical situation, health indicators are always poorer for indigenous populations than for nonindigenous ones. The determinants of this gap are multiple and interactive, and their analysis requires a biocultural framework. Indigenous populations suffer from lower life expectancy, high infant and child mortality, high maternal morbidity and mortality, heavy infectious disease loads, malnutrition, stunted growth, increasing levels of cardiovascular and other chronic diseases, substance abuse, and depression. The devastating effects of colonization, the loss of ancestral land, and language and cultural barriers for access to health care are among the most salient themes characterizing the poor health situation of indigenous people. Anthropology is extremely well suited to address the interplay among social, economic, and political forces that shape the local experiences of illness.

Can an integrated approach reduce child vulnerability to anaemia? Evidence from three African countries

Addressing the complex, multi-factorial causes of childhood anaemia is best done through integrated packages of interventions. We hypothesized that due to reduced child vulnerability, a "buffering" of risk associated with known causes of anaemia would be observed among children living in areas benefiting from a community-based health and nutrition program intervention. Cross-sectional data on the nutrition and health status of children 24-59 mo (N=2405) were obtained in 2000 and 2004 from program evaluation surveys in Ghana, Malawi and Tanzania. Linear regression models estimated the association between haemoglobin and immediate, underlying and basic causes of child anaemia and variation in this association between years. Lower haemoglobin levels were observed in children assessed in 2000 compared to 2004 (difference -3.30 g/L), children from Tanzania (-9.15 g/L) and Malawi (-2.96 g/L) compared to Ghana, and the youngest (24-35 mo) compared to oldest age group (48-59 mo; -5.43 g/L). Children who were stunted, malaria positive and recently ill also had lower haemoglobin, independent of age, sex and other underlying and basic causes of anaemia. Despite ongoing morbidity, risk of lower haemoglobin decreased for children with malaria and recent illness, suggesting decreased vulnerability to their anaemia-producing effects. Stunting remained an independent and unbuffered risk factor. Reducing chronic undernutrition is required in order to further reduce child vulnerability and ensure maximum impact of anaemia control programs. Buffering the impact of child morbidity on haemoglobin levels, including malaria, may be achieved in certain settings.

The challenge of meeting nutrient needs of infants and young children during the period of complementary feeding: an evolutionary perspective

Breast-fed infants and young children need complementary foods with a very high nutrient density (particularly for iron and zinc), especially at ages 6-12 mo. However, in low-income countries, their diet is usually dominated by cereal-based porridges with low nutrient density and poor mineral bioavailability. Complementary feeding diets typically fall short in iron and zinc and sometimes in other nutrients. These gaps in nutritional adequacy of infant diets have likely been a characteristic of human diets since the agricultural revolution ~10,000 y ago. Estimates of nutrient intakes before then, based on hypothetical diets of preagricultural humans, suggest that infants had much higher intakes of key nutrients than is true today and would have been able to meet their nutrient needs from the combination of breast milk and premasticated foods provided by their mothers. Strategies for achieving adequate nutrition for infants and young children in modern times must address the challenge of meeting nutrient needs from largely cereal-based diets.

Contextualising complementary feeding in a broader framework for stunting prevention

An estimated 165 million children are stunted due to the combined effects of poor nutrition, repeated infection and inadequate psychosocial stimulation. The complementary feeding period, generally corresponding to age 6-24 months, represents an important period of sensitivity to stunting with lifelong, possibly irrevocable consequences. Interventions to improve complementary feeding practices or the nutritional quality of complementary foods must take into consideration the contextual as well as proximal determinants of stunting. This review presents a conceptual framework that highlights the role of complementary feeding within the layers of contextual and causal factors that lead to stunted growth and development and the resulting short- and long-term consequences. Contextual factors are organized into the following groups: political economy; health and health care systems; education; society and culture; agriculture and food systems; and water, sanitation and environment. We argue that these community and societal conditions underlie infant and young child feeding practices, which are a central pillar to healthy growth and development, and can serve to either impede or enable progress. Effectiveness studies with a strong process evaluation component are needed to identify transdisciplinary solutions. Programme and policy interventions aimed at preventing stunting should be informed by careful assessment of these factors at all levels.

The World Health Organization's global target for reducing childhood stunting by 2025: rationale and proposed actions

In 2012, the World Health Organization adopted a resolution on maternal, infant and young child nutrition that included a global target to reduce by 40% the number of stunted under-five children by 2025. The target was based on analyses of time series data from 148 countries and national success stories in tackling undernutrition. The global target translates to a 3.9% reduction per year and implies decreasing the number of stunted children from 171 million in 2010 to about 100 million in 2025. However, at current rates of progress, there will be 127 million stunted children by 2025, that is, 27 million more than the target or a reduction of only 26%. The translation of the global target into national targets needs to consider nutrition profiles, risk factor trends, demographic changes, experience with developing and implementing nutrition policies, and health system development. This paper presents a methodology to set individual country targets, without precluding the use of others. Any method applied will be influenced by country-specific population growth rates. A key question is what countries should do to meet the target. Nutrition interventions alone are almost certainly insufficient, hence the importance of ongoing efforts to foster nutrition-sensitive development and encourage development of evidence-based, multisectoral plans to address stunting at national scale, combining direct nutrition interventions with strategies concerning health, family planning, water and sanitation, and other factors that affect the risk of stunting. In addition, an accountability framework needs to be developed and surveillance systems strengthened to monitor the achievement of commitments and targets.

Global policy and programme guidance on maternal nutrition: what exists, the mechanisms for providing it, and how to improve them?

Undernutrition in one form or another affects the majority of women of reproductive age in most developing countries. However, there are few or no effective programmes trying to solve maternal undernutrition problems. The purpose of the paper is to examine global policy and programme guidance mechanisms for nutrition, what their content is with regard to maternal nutrition in particular, as well as how these might be improved. Almost all countries have committed themselves politically to ensuring the right of pregnant and lactating women to good nutrition through the Convention on the Elimination of all Forms of Discrimination Against Women. Despite this, the World Health Organization (WHO) has not endorsed any policy commitments with regard to maternal nutrition. The only policy guidance coming from the various technical departments of WHO relates to the control of maternal anaemia. There is no policy or programme guidance concerning issues of maternal thinness, weight gain during pregnancy and/or low birthweight prevention. Few if any countries have maternal nutrition programmes beyond those for maternal anaemia, and most of those are not effective. The lack of importance given to maternal nutrition is related in part to a weakness of evidence, related to the difficulty of getting ethical clearance, as well as a generalised tendency to downplay the importance of those interventions found to be efficacious. No priority has been given to implementing existing policy and programme guidance for the control of maternal anaemia largely because of a lack of any dedicated funding, linked to a lack of Millennium Development Goals indicator status. This is partly due to the poor evidence base, as well as to the common belief that maternal anaemia programmes were not effective, even if efficacious. The process of providing evidence-based policy and programme guidance to member states is currently being revamped and strengthened by the Department of Nutrition for Health and Development of WHO through the Nutrition Guidance Expert Advisory Group processes. How and if programme guidance, as well as policy commitment for improved maternal nutrition, will be strengthened through the Nutrition Guidance Expert Advisory Group process is as yet unclear. The global movement to increase investment in programmes aimed at maternal and child undernutrition called Scaling Up Nutrition offers an opportunity to build developing country experience with efforts to improve nutrition during pregnancy and lactation. All member states are being encouraged by the World Health Assembly to scale-up efforts to improve maternal infant and young child nutrition. Hopefully Ministries of Health in countries most affected by maternal and child undernutrition will take leadership in the development of such plans, and ensure that the control of anaemia during pregnancy is given a great priority among these actions, as well as building programme experience with improved nutrition during pregnancy and lactation. For this to happen it is essential that donor support is assured, even if only to spearhead a few flagship countries.

Long-term consequences of stunting in early life

This review summarizes the impact of stunting, highlights recent research findings, discusses policy and programme implications and identifies research priorities. There is growing evidence of the connections between slow growth in height early in life and impaired health and educational and economic performance later in life. Recent research findings, including follow-up of an intervention trial in Guatemala, indicate that stunting can have long-term effects on cognitive development, school achievement, economic productivity in adulthood and maternal reproductive outcomes. This evidence has contributed to the growing scientific consensus that tackling childhood stunting is a high priority for reducing the global burden of disease and for fostering economic development. Follow-up of randomized intervention trials is needed in other regions to add to the findings of the Guatemala trial. Further research is also needed to: understand the pathways by which prevention of stunting can have long-term effects; identify the pathways through which the non-genetic transmission of nutritional effects is mediated in future generations; and determine the impact of interventions focused on linear growth in early life on chronic disease risk in adulthood.

Nutritional enhancement of US Title II food aid products

BACKGROUND

Food aid provided by the United States has saved the lives of the vulnerable for many years. Recognizing the need for a thorough review of product formulations and specifications, the US Agency for International Development (USAID) commissioned a 2-year assessment of quality issues relating to Title II food aid products. This article presents findings and recommendations of that review relating to product enhancements.

OBJECTIVE

The core question addressed was: Are current commodity specifications for enriched FBFs appropriate in light of evolving nutritional science and food fortification technology, or do they need to be updated?

METHODS

Empirical data were derived from a number of sources, including a survey of Title II implementing partners focusing on procurement and logistics, and uses of FBFs and other foods. Input of implementing partners, civil society, and donor organizations was obtained through individual consultations, international and small group meetings. More than 400 individuals accessed the project's website. The project convened a panel of experts in food technology and science, food policy, law, industry, medicine, development and humanitarian work, and the maritime industry, and held regular joint meetings with USDA and USAID. The draft report was widely disseminated and posted on the website.

RESULTS AND CONCLUSIONS

The findings of this research led to the following broad areas of improvement in US Title II food aid products: 1) Improve the formulation of existing FBF products used in Title II programming. This includes the addition of a dairy source of protein to products targeted to children 6 to 24 months of age, pregnant and lactating women, wasted children, and wasted individuals undergoing HIV/AIDS treatment. 2) Upgrade the vitamin and mineral mixes used and diversify approaches to addressing micronutrient needs. Enhance the composition of premixes used to fortify blended foods as well as milled grains and vegetable oil; facilitate shipping offortificant premix with bulk cereals for in-country fortification; and develop micronutrient powders (sachets) and other point-of-use fortification options. 3) Develop or adopt non-cereal-based (e.g., lipid-based) products for the management of nutritional deficiencies. This is an argument for more choice among appropriate tools, not for discarding products that have already shown their value over many years. It also does not reduce the need to maintain a focus on supplying high volumes of quality grains as the main staple in food aid baskets.

Vitamins and minerals for women: recent programs and intervention trials

Women's nutrition has received little attention in nutrition programming, even though clinical trials and intervention trials have suggested that dietary improvement or supplementation with several nutrients may improve their health, especially in low-income settings, the main focus of this paper. Most attention so far has focused on how improvements in maternal nutrition can improve health outcomes for infants and young children. Adequate vitamin D and calcium nutrition throughout life may reduce the risk of osteoporosis, and calcium supplementation during pregnancy may reduce preeclampsia and low birth weight. To reduce neural tube defects, additional folic acid and possibly vitamin B(12) need to be provided to non-deficient women before they know they are pregnant. This is best achieved by fortifying a staple food. It is unclear whether maternal vitamin A supplementation will lead to improved health outcomes for mother or child. Iron, iodine and zinc supplementation are widely needed for deficient women. Multimicronutrient supplementation (MMS) in place of the more common iron-folate supplements given in pregnancy in low-income countries may slightly increase birth weight, but its impact on neonatal mortality and other outcomes is unclear. More sustainable alternative approaches deserve greater research attention.

Integrating Maternal, Infant, and Young Child Nutrition: Report on the Ten Year Strategy Infant and Young Child Nutrition (IYCN) Working Group October 2008 Workshop

Members of the Infant and Young Child Nutrition (IYCN) Working Group of the Ten Year Strategy for the Reduction of Vitamin and Mineral Deficiencies and several guests and speakers participated in a workshop in Geneva on 10 October 2008. The workshop had two broad objectives. The first objective was to review the evidence base for maternal and IYCN actions and explore how to integrate action throughout the window of opportunity from the prenatal period through the first 2 years of life. The second objective was to discuss the development of the Maternal, Infant, and Young Child Nutrition (MIYCN) Network in relation to the IYCN Working Group's role and structure. The speakers identified a spectrum of efforts needed to improve maternal, infant, and young child nutrition. The group decided to continue discussion on initiating a structure for an MIYCN Network to enhance collaboration.