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Richardson TN, Ventura AK, Brewer A, Shirwani A, de la Barrera B, Kay MC. Awareness and Support of Responsive Bottle Feeding Among WIC Counselors and Caregivers: A Formative Qualitative Study. JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR 2024; 56:342-350. [PMID: 38466247 PMCID: PMC11081858 DOI: 10.1016/j.jneb.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE To understand the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) counselor experiences discussing responsive bottle feeding during counseling and WIC participants' knowledge, understanding, and use of responsive bottle feeding. METHODS Qualitative descriptive, semistructured interviews with 23 participants (8 WIC counselors and 15 WIC participants) were conducted online via Zoom. The WIC counselors and mothers of WIC-enrolled bottle-fed infants were recruited through a network of WIC clinics in North Carolina. Interviews were recorded, transcribed, and collaboratively analyzed using content analysis. RESULTS The WIC participants received responsive infant feeding support from WIC counselors but often in the context of breastfeeding. WIC counselors provided valuable support for families but were challenged by limited training on responsive bottle feeding, balancing promoting breastfeeding with supporting mothers' feeding decisions, and time constraints. CONCLUSIONS AND IMPLICATIONS Findings provide preliminary support for the need to develop and pilot an intervention focused on promoting responsive feeding for parents of bottle-fed infants.
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Affiliation(s)
- Taylor N Richardson
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Alison K Ventura
- Department of Kinesiology and Public Health and Center for Health Research, California Polytechnic State University, San Luis Obispo, CA
| | | | - Avan Shirwani
- School of Osteopathic Medicine, Campbell University, Lillington, NC
| | | | - Melissa C Kay
- Department of Pediatrics, Duke University, Durham, NC
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Moschonis G, Halilagic A, Karaglani E, Mavrogianni C, Mourouti N, Collins CE, Manios Y. Likelihood of obesity in early and late childhood based on growth trajectory during infancy. Int J Obes (Lond) 2023:10.1038/s41366-023-01310-8. [PMID: 37076589 DOI: 10.1038/s41366-023-01310-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Childhood obesity rates have reached epidemic levels with Mediterranean countries reporting among the highest numbers globally. Evidence suggests early life factors, including infant growth rate, increase the likelihood of obesity later in childhood. However, optimal rates of infant growth associated with lower odds of future obesity still remain undetermined. The study aim was to determine the optimal infant growth rate associated with a lower likelihood of childhood overweight and obesity. METHODS Perinatal and anthropometric data collected from 1778 Greek preschool (2-5 years old) and 2294 Greek preadolescent (10-12 years old) children participating in the ToyBox and the Healthy Growth Study (HGS) respectively, was combined for examination. Logistic regression models and receiver operating curves were used to determine the association between infant growth rate and development of childhood overweight and obesity, as well as optimal infant growth rate, respectively. RESULTS Rapid weight gain during the first 6 months of life was positively associated with overweight and obesity in preadolescent children (OR:1.36, 95% CI: 1.13-1.63). Optimal cut-off points for several infancy growth rate indices (i.e., WAZ, WLZ, HAZ, BAZ) associated with a lower likelihood of overweight and obesity in preschool years and preadolescence were also identified. CONCLUSIONS The current findings could possibly set the basis for healthcare professionals and families to better monitor, assess, and control infant growth rates, thus providing another obesity prevention strategy from early life. These findings, however, and the recommended optimal cut-offs need to be confirmed through further prospective research.
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Affiliation(s)
- George Moschonis
- Department of Food, Nutrition and Dietetics, School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, VIC, 3086, Australia.
| | - Anela Halilagic
- Department of Food, Nutrition and Dietetics, School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, VIC, 3086, Australia
| | - Eva Karaglani
- Department of Nutrition and Dietetics, School of Health Science and Education, Harokopio University, 17671, Athens, Greece
| | - Christina Mavrogianni
- Department of Nutrition and Dietetics, School of Health Science and Education, Harokopio University, 17671, Athens, Greece
| | - Niki Mourouti
- Department of Nutrition and Dietetics, School of Health Science and Education, Harokopio University, 17671, Athens, Greece
- Department of Nutrition and Dietetics, Hellenic Mediterranean University, Sitia, Greece
| | - Clare E Collins
- School of Health Sciences, College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, Australia
| | - Yannis Manios
- Department of Nutrition and Dietetics, School of Health Science and Education, Harokopio University, 17671, Athens, Greece.
- Institute of Agri-food and Life Sciences, Hellenic Mediterranean University Research Centre, Heraklion, Greece.
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Fangupo L, Daniels L, Taylor R, Glover M, Taungapeau F, Sa'u S, Cutfield W, Taylor B. The care of infants with rapid weight gain: Should we be doing more? J Paediatr Child Health 2022; 58:2143-2149. [PMID: 36259748 PMCID: PMC10092129 DOI: 10.1111/jpc.16247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/27/2022] [Accepted: 10/02/2022] [Indexed: 11/28/2022]
Abstract
Rapid weight gain (RWG) during infancy is a known risk factor for later childhood obesity. It can be measured using a range of definitions across various time periods in the first 2 years of life. In recent years, some early childhood obesity prevention trials have included a focus on preventing RWG during infancy, with modest success. Overall, RWG during infancy remains common, yet little work has examined whether infants with this growth pattern should receive additional care when it is identified in health-care settings. In this viewpoint, we contend that RWG during infancy should be routinely screened for in health-care settings, and when identified, viewed as an opportunity for health-care professionals to instigate non-stigmatising discussions with families about RWG and general healthy practices for their infants. If families wish to engage, we suggest that six topics from early life obesity prevention studies (breastfeeding, formula feeding, complementary feeding, sleep, responsive parenting, and education around growth charts and monitoring) could form the foundations of conversations to help them establish and maintain healthy habits to support their infant's health and well-being and potentially lower the risk of later obesity. However, further work is needed to develop definitive guidelines in this area, and to address other gaps in the literature, such as the current lack of a standardised definition for RWG during infancy and a clear understanding of the time points over which it should be measured.
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Affiliation(s)
- Louise Fangupo
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Lisa Daniels
- Department of Medicine, University of Otago, Dunedin, New Zealand.,Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand
| | - Rachael Taylor
- Department of Medicine, University of Otago, Dunedin, New Zealand.,A Better Start National Science Challenge, University of Auckland, Auckland, New Zealand
| | - Marewa Glover
- Papaharakeke International Ltd, Auckland, New Zealand
| | | | | | - Wayne Cutfield
- A Better Start National Science Challenge, University of Auckland, Auckland, New Zealand.,The Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Barry Taylor
- Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand.,A Better Start National Science Challenge, University of Auckland, Auckland, New Zealand
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Zheng M, Hesketh KD, Vuillermin P, Dodd J, Wen LM, Baur LA, Taylor R, Byrne R, Mihrshahi S, Sly PD, Tang MLK, Campbell KJ. Determinants of rapid infant weight gain: A pooled analysis of seven cohorts. Pediatr Obes 2022; 17:e12928. [PMID: 35510714 PMCID: PMC9540679 DOI: 10.1111/ijpo.12928] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/15/2022] [Accepted: 04/13/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Rapid weight gain (RWG) in infancy is strongly associated with subsequent obesity risk, but little is known about the factors driving RWG. This study explored the child and maternal factors associated with infant RWG. METHODS Data from seven Australian and New Zealand cohorts were used (n = 4542). Infant RWG was defined as a change in weight z-score ≥0.67 from birth to age 1 year. Univariable and multivariable logistic regression assessed the association between child and maternal factors and infant RWG in each cohort. Meta-analysis was conducted to obtain pooled effect sizes. RESULTS Multivariable analyses revealed boys were more likely to experience RWG (OR 1.42 95% CI 1.22, 1.66) than girls. Higher birth weight in kg (OR 0.09, 95% CI 0.04, 0.20) and gestational age in weeks (OR 0.69, 95% CI 0.48, 0.98) were associated with lower RWG risk. Children who were breastfed for ≥6 months showed lower RWG risk (OR 0.45, 95% CI 0.38, 0.53). Children of native-born versus overseas-born women appeared to have higher RWG risk (OR 1.37, 95% CI 0.99, 1.90). Maternal smoking during pregnancy increased RWG risk (OR 1.60, 95% CI 1.28, 2.01), whereas children who started solids ≥6 months (OR 0.77, 95% CI 0.63, 0.93) and children with siblings (OR 0.68, 95% CI 0.57, 0.81) showed lower RWG risk in univariable analysis, but these associations were attenuated in multivariable analysis. No association was found for maternal age, education, marital status and pre-pregnancy BMI. CONCLUSION Maternal country of birth, smoking status, child sex, birth weight, gestational age, infant feeding and parity were potential determinants of infant RWG.
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Affiliation(s)
- Miaobing Zheng
- Deakin University, Institute for Physical Activity and Nutrition, School of Exercise and Nutrition SciencesGeelongAustralia
| | - Kylie D. Hesketh
- Deakin University, Institute for Physical Activity and Nutrition, School of Exercise and Nutrition SciencesGeelongAustralia
| | | | - Jodie Dodd
- Discipline of Obstetrics and GynaecologyThe Robinson Research Institute, The University of AdelaideAdelaideSouth AustraliaAustralia
| | - Li Ming Wen
- School of Public Health and Sydney Medical SchoolThe University of SydneySydneyAustralia
| | - Louise A. Baur
- School of Public Health and Sydney Medical SchoolThe University of SydneySydneyAustralia
| | - Rachael Taylor
- Department of MedicineUniversity of OtagoDunedinNew Zealand
| | - Rebecca Byrne
- School of Exercise and Nutrition Sciences, Faculty of HealthQueensland University of TechnologyKelvin GroveQueenslandAustralia
| | - Seema Mihrshahi
- Department of Health Sciences, Faculty of MedicineHealth and Human Sciences, Macquarie UniversitySydneyNew South WalesAustralia
| | - Peter D. Sly
- Children's Health and Environment ProgramThe University of QueenslandBrisbaneAustralia
| | | | - Karen J. Campbell
- Deakin University, Institute for Physical Activity and Nutrition, School of Exercise and Nutrition SciencesGeelongAustralia
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Demmelmair H, Fleddermann M, Koletzko B. Infant Feeding Choices during the First Post-Natal Months and Anthropometry at Age Seven Years: Follow-Up of a Randomized Clinical Trial. Nutrients 2022; 14:nu14193900. [PMID: 36235553 PMCID: PMC9572598 DOI: 10.3390/nu14193900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/10/2022] [Accepted: 09/13/2022] [Indexed: 11/16/2022] Open
Abstract
The Belgrade–Munich Infant Milk Trial (BeMIM) randomized healthy term infants into either a protein-reduced intervention infant formula (IF) group, with an α-lactalbumin-enriched whey and long-chain polyunsaturated fatty acids, or a control infant formula (CF) group. A non-randomized breastfed group (BF) was studied for reference. We assessed the long-term effects of these infant feeding choices on growth measures until the age of seven years. Weight, standing height, head circumference, and percent body fat (using skinfolds and bioelectrical impedance) were determined with standardized methods. A total of 161 children out of the 256 completers of the initial study (63%) participated in the seven-year follow-up. Children in the three study groups did not differ in their anthropometric measures, including body mass index (IF 16.1 ± 2.6, CF: 15.6 ± 1.7, BF: 15.6 ± 2.5 kg/m2, mean ± SD). IGF-1 serum concentrations determined at the age of 4 months contributed to explaining the variances in weight (p = 0.001), height (p = 0.001) and BMI (p = 0.035) z-scores at the age of seven years, whereas insulin levels at four months did not. Different feeding choices during the first four months of life leading to higher energy efficiency and increased growth with IF did not affect later growth outcomes at an early school age. Diet-induced modulation of IGF-1 in the first months of life may have lasting programming effects on later growth.
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Affiliation(s)
- Hans Demmelmair
- Dr. Von Hauner Children’s Hospital, University of Munich Medical Centre, Ludwig-Maximilians-Universiät München, 80337 Munich, Germany
- Correspondence: (H.D.); (B.K.)
| | | | - Berthold Koletzko
- Dr. Von Hauner Children’s Hospital, University of Munich Medical Centre, Ludwig-Maximilians-Universiät München, 80337 Munich, Germany
- Correspondence: (H.D.); (B.K.)
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Lindholm A, Almquist-Tangen G, Alm B, Bremander A, Dahlgren J, Roswall J, Staland-Nyman C, Bergman S. Early rapid weight gain, parental body mass index and the association with an increased waist-to-height ratio at 5 years of age. PLoS One 2022; 17:e0273442. [PMID: 36070291 PMCID: PMC9451094 DOI: 10.1371/journal.pone.0273442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 08/08/2022] [Indexed: 11/27/2022] Open
Abstract
Background/Objectives Obesity-related adverse health consequences are closely associated with abdominal obesity. Risk factors for overweight and obesity have been studied but there is a lack of information regarding risk factors for abdominal obesity, especially in the preschool population. The aim of the present study was to examine early life risk factors for an increased waist-to-height ratio (WHtR) in children at five years of age and, in addition, to investigate if these risk factors also were associated with overweight or obesity. Subjects/Methods The study population comprised 1,540 children from a population-based longitudinal birth cohort study that included 2,666 Swedish children. The children were included if they had complete growth data for the analyses used in this study. Children were classified as having WHtR standard deviation scores (SDS) ≥ 1 or < 1 at five years of age, according to Swedish reference values, and as having body mass index standard deviation scores (BMISDS) for overweight/obesity, or normal weight/underweight according to the International Obesity Task Force criteria. Associations between child-related, socioeconomic status-related, parental health-related and nutrition- and feeding practice-related factors during the first two years and a WHtRSDS ≥ 1 or a BMISDS for overweight/obesity at five years were investigated with logistic regression analyses. Results At five years of age, 15% of the children had WHtRSDS ≥ 1 and 11% had overweight or obesity. In multivariable analyses, rapid weight gain (RWG) during 0–6 months (OR: 1.90, 95% CI: 1.23–2.95, p = 0.004), maternal pre-pregnancy BMI (1.06, 1.01–1.11, p = 0.019) and paternal BMI (1.11, 1.01–1.21, p = 0.028) were associated with WHtRSDS ≥ 1. RWG during 0–6 months (2.53, 1.53–4.20, p<0.001), 6–12 months (2.82, 1.37–5.79, p = 0.005), and maternal pre-pregnancy BMI (1.11, 1.06–1.17, p<0.001) were associated with overweight or obesity. Conclusions Early risk factors, including rapid weight gain, are associated with increased WHtRSDS and overweight or obesity at 5 years of age. Preventive interventions should target early RWG and parental overweight and obesity.
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Affiliation(s)
- Annelie Lindholm
- School of Health and Welfare, Halmstad University, Halmstad, Sweden
- Research and Development Center Spenshult, Halmstad, Sweden
- * E-mail:
| | - Gerd Almquist-Tangen
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Child Health Care Unit, Region Halland, Halmstad, Sweden
| | - Bernt Alm
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ann Bremander
- Research and Development Center Spenshult, Halmstad, Sweden
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Jovanna Dahlgren
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Josefine Roswall
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Pediatrics, Halland Hospital, Halmstad, Sweden
| | | | - Stefan Bergman
- Research and Development Center Spenshult, Halmstad, Sweden
- Primary Health Care Unit, Department of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Fox K, Vadiveloo M, McCurdy K, Benjamin-Neelon SE, Østbye T, Tovar A. Maternal Stress and Excessive Weight Gain in Infancy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:5743. [PMID: 35565137 PMCID: PMC9105332 DOI: 10.3390/ijerph19095743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/28/2022] [Accepted: 05/04/2022] [Indexed: 12/03/2022]
Abstract
Rapid weight gain in infancy increases the risk of developing obesity early in life and contributes significantly to racial and ethnic disparities in childhood obesity. While maternal perceived stress is associated with childhood obesity, little is known about the impact it has on infant weight gain. Therefore, this study explores the impact of maternal perceived stress on change in weight-for-length (WFL) z-scores and the risk of rapid weight gain in infancy. We conducted a secondary data analysis of the longitudinal Nurture birth cohort (n = 666). Most mothers in the cohort were non-Hispanic/Latinx Black (71.6%). About one-half of mothers had a body mass index (BMI) greater than 25 prior to pregnancy, were unemployed, and had a low income. Most infants in the cohort were born full-term and were of normal weight. Data were collected at 3-, 6-, 9-, and 12-months postpartum. At each assessment, mothers completed the Cohen’s Perceived Stress Scale (PSS), and research assistants weighed and measured each infant. Tertiles were used to compare mothers with high and low perceived stress. A mixed model analysis of repeated measures assessed the associations between baseline perceived stress and the change in infant WFL z-scores over time. Log-binomial models assessed the association between baseline perceived stress and rapid weight gain, defined as a change in WFL z-score > 0.67 standard deviations from three to twelve months. Just under one-half of the infants (47%) experienced rapid weight gain between three and twelve months of age. Birthweight for gestational age (RR = 1.18, 95% CI = 1.08−1.29, p-value = 0.004), gestational age at birth (RR = 1.07, 95% CI = 1.01−1.14, p-value = 0.031), and weeks breastfed (0.99, 95% CI 0.99−1.00, p-value 0.044) were associated with risk of rapid weight gain in unadjusted analyses. WFL z-scores increased significantly over time, with no effect of perceived stress on change in WFL z-score or risk of rapid weight gain. Rapid weight gain in infancy was prevalent in this sample of predominately Black infants in the Southeastern US. We did not find evidence to support the hypothesis that maternal perceived stress influenced the risk of rapid weight gain. More work is needed to identify and assess the risk factors for rapid weight gain in infancy and to understand the role that maternal stress plays in the risk of childhood obesity so that prevention efforts can be targeted.
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Affiliation(s)
- Katelyn Fox
- Department of Nutrition and Food Science, University of Rhode Island, Kingston, RI 02881, USA;
| | - Maya Vadiveloo
- Department of Nutrition and Food Science, University of Rhode Island, Kingston, RI 02881, USA;
| | - Karen McCurdy
- Department of Human Development and Family Science, University of Rhode Island, Kingston, RI 02881, USA;
| | - Sara E. Benjamin-Neelon
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Truls Østbye
- Department of Community and Family Medicine, Duke University Medical Center, Durham, NC 27710, USA;
| | - Alison Tovar
- Department of Behavioral and Social Sciences, Brown University, Providence, RI 02912, USA;
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Naja F, Ayoub J, Baydoun S, Nassour S, Zgheib P, Nasreddine L. Development of national dietary and lifestyle guidelines for pregnant women in Lebanon. MATERNAL & CHILD NUTRITION 2021; 17:e13199. [PMID: 33973717 PMCID: PMC8476423 DOI: 10.1111/mcn.13199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/01/2021] [Accepted: 04/08/2021] [Indexed: 01/23/2023]
Abstract
Although a number of international diet and lifestyle guidelines during pregnancy (DLGP) exist in the literature, contextualization to low- and middle-income settings is less common. The aim of this study was to present the Lebanese DLGP and to describe the process followed for their development. A mixed-method approach was used including a review and synthesis of existing international DLGP and a consensus building nominal group technique (NGT) with a multidisciplinary group of experts (n = 11). During the meeting, participants identified the themes of the guidelines, formulated the wording of each themes' guideline and translated the guidelines to the Arabic language. Consensus was defined as an agreement of 80%. Reviewing the literature, a list of 17 main topics were found to be common themes for the DLGP. For the Lebanese DLGP, participants in the NGT meeting selected seven themes from this list: gestational weight gain, diet diversity, hydration, food safety, harmful foods, physical activity and breastfeeding. In addition, the group formulated three themes based on merging/modifying existing themes: supplementation, alcohol and smoking and religious fasting. Two context-specific new themes emerged: wellbeing and nutrition resilience. For each of the identified themes, the group agreed upon the wording of its guidelines and description. This study is the first from the Eastern Mediterranean Region to develop through consensus building, context and culture-specific dietary and lifestyle guidelines for pregnant women. Putting maternal nutrition at the heart of tackling malnutrition and its detrimental health outcomes is a core investment for a better maternal and child health.
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Affiliation(s)
- Farah Naja
- Department of Clinical Nutrition and Dietetics, Research Institute of Medical & Health Sciences (RIMHS), College of Health SciencesUniversity of SharjahSharjahUnited Arab Emirates
- Department of Nutrition and Food SciencesAmerican University of BeirutBeirutLebanon
| | - Jennifer Ayoub
- Department of Nutrition and Food SciencesAmerican University of BeirutBeirutLebanon
| | - Samar Baydoun
- Faculty of Agricultural and Food Sciences/Faculty of Health SciencesAmerican University of BeirutBeirutLebanon
| | - Sahar Nassour
- Faculty of Agricultural and Food Sciences/Faculty of Health SciencesAmerican University of BeirutBeirutLebanon
| | - Pamela Zgheib
- Mother, Child and School Health UnitMinistry of Public HealthBeirutLebanon
| | - Lara Nasreddine
- Department of Nutrition and Food SciencesAmerican University of BeirutBeirutLebanon
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