Use of designing for behaviour change framework in identifying and addressing barriers to and enablers of animal source feeding to children ages 8-23 months in Bandarban Hill District in Bangladesh: Implications for a nutrition-sensitive agriculture programme

Inadequate diet quality is a cause of undernutrition among children 6-23 months of age in Bangladesh, particularly in remote and isolated areas such as Bandarban District. Feeding animal source foods can help to combat stunting and wasting problems among children, but it may not be accessible or acceptable. A barrier analysis using the Designing for Behavior Change Framework was conducted in Bandarban district with participants from 4 ethnic groups, to explore potential barriers and key motivators by examining 12 behavioural determinants of consumption of animal-source food in complementary feeding for children 8-23 months. Data were collected from 45 mothers of children 8-23 months, who provided animal-source foods to their children (doers), and from 45 mothers who did not (non-doers), for a total of 90 interviews. Nine determinants were statistically significantly different between doers and non-doers as follows: self-efficacy, positive consequences, negative consequences, social norms, access, reminders, perceived risk, perceived severity and perceived action efficacy. Nearby access to purchase animal-source foods, rearing poultry or livestock at home and the support of household and community members are enablers to feeding animal-source food. In contrast, these same factors are barriers for non-doers. The lack of money to spend on animal-source foods is also a barrier. An integrated nutrition-sensitive and gender-transformative animal-based food production, and inclusive market programme could increase access to meat and eggs at the household level, increase opportunities to earn income and support gender-equitable household workloads and decision-making for optimal child feeding.

Comparing two simplified questionnaire-based methods with 24-h recalls for estimating fortifiable wheat flour and oil consumption in Mandaluyong City, Philippines

Information on fortifiable food consumption is essential to design, monitor and evaluate fortification programmes, yet detailed methods like 24-h recalls (24HRs) that provide such data are rarely conducted. Simplified questionnaire-based methods exist but their validity compared with 24HRs has not been shown. We compared two simplified methods (i.e., a household food acquisition and purchase questionnaire [FAPQ] and a 7-day semiquantitative food frequency questionnaire [SQ-FFQ]) against 24HRs for estimating fortifiable food consumption. We assessed the consumption of fortifiable wheat flour and oil using a FAPQ and, for wheat flour only, a 7-day SQ-FFQ and compared the results against 24HRs. The participants included children 12-18 months (n = 123) and their mothers 18-49 years selected for a study assessing child vitamin A intake and status in Mandaluyong City, Philippines. For fortifiable wheat flour, the FAPQ estimated considerably lower mean intakes compared to 24HRs for children and mothers (2.2 vs. 14.1 g/day and 5.1 vs. 42.3 g/day, respectively), while the SQ-FFQ estimated slightly higher mean intakes (15.7 vs. 14.1 g/day and 51.5 vs. 42.3 g/day, respectively). For fortifiable oil, the FAPQ estimated considerably higher mean intakes compared to 24HRs for children and mothers (4.6 vs. 1.8 g/day and 12.5 vs. 6.1 g/day, respectively). The SQ-FFQ, but not the FAPQ, generated useful information on fortifiable food consumption that can inform fortification programme design and monitoring decisions in the absence of more detailed individual-level data. Potential adaptations to improve the FAPQ, such as additional questions on foods prepared away from home and usage patterns, merit further research.

Filipino Children with High Usual Vitamin A Intakes and Exposure to Multiple Sources of Vitamin A Have Elevated Total Body Stores of Vitamin A But Do Not Show Clear Evidence of Vitamin A Toxicity

Background

Young children exposed to high-dose vitamin A supplements (VAS) and vitamin A (VA)-fortified foods may be at risk of high VA intake and high VA total body stores (TBS).

Objectives

TBS and estimated liver VA concentration were compared among children with adequate or high VA intake and different timing of exposure to VAS, and associations between estimated liver VA concentrations and biomarkers of VA toxicity were examined.

Methods

Children 12-18 mo of age (n = 123) were selected for 3 groups: 1) retinol intake >600 µg/d and VAS within the past mo, 2) retinol intake >600 µg/d and VAS in the past 3-6 mo, and 3) VA intake 200-500 µg retinol activity equivalents (RAE)/d and VAS in the past 3-6 mo. Dietary intake data were collected to measure VA intakes from complementary foods, breast milk, and low-dose, over-the-counter supplements. TBS were assessed by retinol isotope dilution, and VA toxicity biomarkers were measured. Main outcomes were compared by group.

Results

Mean (95% CI) VA intakes excluding VAS were 1184 (942, 1426), 980 (772, 1187), and 627 (530, 724) µg RAE/d, in groups 1-3, respectively; mean VA intake was higher in groups 1 and 2 compared with group 3 (P < 0.05). Geometric mean (GM) (95% CI) TBS were 589 (525, 661), 493 (435, 559), and 466 (411, 528) µmol, respectively. GM TBS and GM liver VA concentrations were higher in group 1 compared with group 3 (liver VA concentration: 1.62 vs. 1.33 µmol/g; P < 0.05). Plasma retinyl ester and 4-oxo-retinoic acid concentrations and serum markers of bone turnover and liver damage did not indicate VA toxicity.

Conclusions

In this sample, most children had retinol intakes above the Tolerable Upper Intake Level (UL) and liver VA concentrations above the proposed cutoff for "hypervitaminosis A" (>1 µmol/g liver). There was no evidence of chronic VA toxicity, suggesting that the liver VA cutoff value should be re-evaluated. This trial was registered at www.clinicaltrials.gov as NCT03030339.

Determination of Vitamin A Total Body Stores in Children from Dried Serum Spots: Application in a Low- and Middle-Income Country Community Setting

BACKGROUND

The retinol isotope dilution (RID) method has been used to evaluate vitamin A (VA) status in healthy adults and children in low- and middle-income countries (LMIC) and to assess the efficacy of various VA interventions.

OBJECTIVE

The study was designed to examine whether dried serum spots (DSS) can be applied to RID when conducting VA total body store (TBS) assessments in community settings.

METHODS

Four days after an oral dose of 0.4 mg [13C10]retinyl acetate was administered to Filipino children (12-18 mo), a single blood draw was divided to isolate both serum and plasma. Serum (40 μL) was spotted and dried on Whatman 903 cards and shipped at ambient temperature whereas liquid plasma (LP) was frozen at -80°C and shipped on dry ice. The VA tracer to tracee ratio from DSS and LP was quantified by LC-MS/MS. Comparisons between DSS and LP paired samples (n = 72) were made for [13C10]retinol specific activity (SAp) by Pearson's correlation and for VA TBS by Bland-Altman analysis.

RESULTS

The sum of 3 coextracted DSS were required to consistently detect [13C10]retinol above the LC-MS/MS limit of quantitation (LOQ). [13C10]retinol SAp from DSS was highly correlated with SAp from LP (r = 0.945; P < 0.01). A comparison of methods for TBS determination using Bland-Altman analysis indicated agreement with an intraindividual difference of 24.7 μmol (4.6%). Mean total liver reserve (TLR) values from DSS and LP were 1.7 μmol/g (± 0.6 SD) and 1.6 μmol/g (± 0.6 SD), respectively.

CONCLUSIONS

VA TBS can be determined from DSS thereby reducing the logistics and cost of maintaining a cold chain by shipping samples at ambient temperature and, thus, making the RID technique more feasible in LMIC community settings. This trial was registered at https://clinicaltrials.gov as NCT03030339.

Development of a Screening Tool to Estimate Vitamin A Intake and Comparison with Detailed Dietary Assessment Methods

Objectives

We aimed to develop and validate a tool to estimate vitamin A (VA) intake and identify children at risk of intake above the tolerable upper intake level (UL).

Methods

We developed, pilot-tested, and refined a screening tool to estimate VA intake among Filipino children 12–18 mo of age. Data were entered into tablets with pre-loaded food composition data to calculate VA intake immediately. The screening tool was used to identify children likely to have “adequate” (one group: 200–500 µg retinol activity equivalents, RAE/d) or “high” (two groups: &gt;600 µg retinol/d) intake. Interviewers administered four 24-h recalls, one 12-h observed weighed record with 12-h recall, and a 30-d supplement questionnaire. Breastmilk intake and VA concentration were measured among breastfeeding children. We compared the screening tool and detailed dietary assessment (DDA) results for primary VA sources, group mean usual intake, and prevalence of intakes above the UL.

Results

Major VA sources were similar between methods: fortified milk powders, multivitamin supplements, and breastmilk; contributions from intervention programs (e.g., micronutrient powders, fortified staple foods) were low. Mean usual retinol intakes for the high groups (n = 47 and 39, respectively) were 1218 and 1313 µg/d by screening tool vs. 1096 and 931 by DDA; 70 and 77% had usual intake above 600 µg/d. In the adequate group (n = 37), mean total VA intake was 375 and 559 µg RAE/d by screening and DDA, respectively.

Conclusions

This screening tool provides a reasonably good rapid estimate of VA intake among Filipino children and can be useful for identifying groups with adequate to excessive intakes.

Funding Sources

Bill & Melinda Gates Foundation.

Assessment of Vitamin A (VA) Total Body Stores (TBS) Using Dried Derum Spots (DSS)

Objectives

The retinol isotope dilution method has been successfully applied to assess the efficacy of VA interventions in low and middle-income countries. However, the current method is limited in its applicability because it relies on keeping serum samples in the cold chain. To overcome that limitation, we assessed the feasibility of using DSS for assessing TBS in Filipino children 12–18 months of age.

Methods

Serum (40 µL) from Filipino children, who had received an oral dose of [,13C10]-retinyl acetate was spotted and dried on Whatman 903 cards then stored at −20°C before shipment at room temperature; aliquots of liquid serum were kept frozen at −80°C until analysis. DSS and liquid serum were extracted by established methods and then analysed by LC-MS/MS to quantify the [,13C]/[,12C] retinol ratio and TBS.

Results

Mean ± SD TBS of 57 Filipino infants aged 12–18 mo were 507.6 ± 185.8 µmol and 495.5 ± 170.1 µmol from either serum or DSS samples, respectively. Comparison of methods using Bland-Altman analysis indicated agreement between both methods with an intra-individual mean difference for TBS of 22.1 µmol (4.5%).

Conclusions

TBS can be determined using serum spot samples in field settings, thus reducing the costs and limitations of shipping serum samples on dry ice and reducing the need for −80C storage in field stations.

Funding Sources

Medical Research Council UK; Bill and Melinda Gates Foundation.

Promotions of breastmilk substitutes, commercial complementary foods and commercial snack products commonly fed to young children are frequently found in points-of-sale in Bandung City, Indonesia

Few studies have documented the marketing of commercial foods and beverages for infants and young children in West Java, Indonesia. To assess the prevalence of promotions at points-of-sale for commercially produced products commonly fed to young children in Bandung City, 43 small and large stores were visited in 2017. Promotions for breastmilk substitutes (BMS), commercially produced complementary foods (CPCF), and select types of commercial snack products were photographed and information recorded on promotion characteristics. There were 402 and 206 promotions observed with BMS and CPCF products, respectively. Sixteen promotions with BMS products for infants under 12 months were found in 42.9% of stores selling BMS, violating national regulations. Almost all BMS promotions (98.3%) included BMS products for ages 1 year and above ("growing-up milks"). Of all BMS products available for sale, half of all infant/follow-up formula and 77.2% of growing-up milks were promoted. CPCF were found in 97.7% of stores, and 81.0% of these stores had promotions; 70.5% of all available CPCF products were promoted. Of the 2,451 promotions observed for commercial snack products, 17.3% used promotional techniques targeting young children or caregivers. Joint-promotions were common, with BMS and CPCF marketed in combination with commercial snack products; 49.0% of BMS promotions were joint BMS-snack promotions, and 80.0% or more of infant/follow-up formula promotions included a commercial snack. Revising and enforcing infant food and beverage marketing regulations to ensure consistency with global standards are necessary to protect and promote optimal infant and young child feeding in Indonesia.

Pilot implementation of a monitoring and enforcement system for the International Code of Marketing of Breast-milk Substitutes in Cambodia

Globally, monitoring and enforcement mechanisms for the World Health Organization's International Code of Marketing of Breast‐milk Substitutes are often lacking. The Cambodian government adopted the Code as the national standard in Sub‐Decree 133 on Marketing of Products for Infant and Young Child Feeding. Following the formation of a multisectoral Oversight Board and development of detailed guidance documents for the implementation and enforcement of Sub‐Decree 133, a 7‐month pilot was conducted in 2017 to trial a monitoring system in four urban areas of Cambodia. The pilot included training of monitors from the Ministries of Health and Commerce, screening for violations at retail locations and health facilities, testing reporting mechanisms, and taking actions against violators. During the pilot, 85 national‐ and subnational‐level monitors were trained, 392 site visits were made, 2,377 monitoring checklists were completed, and 11 warning letters were issued to violators. Half of the completed checklists (52.9%) indicated Code violations, yet monitors submitted zero violation reports. The pilot revealed modifications needed to the monitoring system: integrate monitor trainings into existing ministry training curricula for sustainability; enhance targeting of monitors for Sub‐Decree training; delineate clear roles and responsibilities for the national and subnational levels; simplify monitoring checklists and violation reports; and improve integration of monitoring activities into routine ministry operations. Before the Sub‐Decree 133 monitoring and enforcement system is implemented throughout Cambodia, revisions must be made to ensure the viability of this system. Challenges and lessons learned can also guide Code monitoring efforts being undertaken by other countries.

Effect of enhanced homestead food production on anaemia among Cambodian women and children: A cluster randomized controlled trial

There is inconsistent evidence on the efficacy of agriculture programmes at improving women and children's anaemia and nutritional status. The primary aim of this study was to evaluate the impact of a nutrition‐sensitive enhanced homestead food production (EHFP) programme on anaemia in women (18–45 years) and children (6–59 months) in rural Cambodia. Secondary outcomes were women's micronutrient status and women and children's anthropometry. In this cluster‐randomized controlled trial, 900 households from 90 villages (clusters) were randomized to either (a) home gardens and behaviour change communication (BCC) on nutrition, hygiene, women's empowerment, and marketing (EHFP); (b) home gardens plus fishponds and BCC (EHFP + F); or (c) control (no intervention). Haemoglobin concentration and anthropometry were measured in women and children at baseline and at 22 months. Venous blood samples were collected in a subset of women (n = 450) at baseline and at 22 months. Generalized linear mixed effect models with repeated measures were used to evaluate the difference across groups and the change from baseline to end of study. Ninety clusters, 552 women, and 754 children completed the trial. Compared with control, we found a statistically significant impact on anaemia prevalence in children (−14.0 percentage points; P = 0.02) and retinol binding protein concentrations in women (difference in difference: 0.34; P = 0.02) randomized to EHFP and EHFP + F groups, respectively. No other statistically significant effects on anaemia, nutritional biomarker concentrations, or anthropometry were observed. Future research is needed to examine longer term impacts of EHFP on anthropometry in women and children and into the nutritional causes of anaemia among children in Cambodia.

Evidence-based evolution of an integrated nutrition-focused agriculture approach to address the underlying determinants of stunting

Despite progress in reducing hunger and malnutrition since the 1990s, many still suffer from undernutrition and food insecurity, particularly women and young children, resulting in preterm birth, low birthweight and stunting, among other conditions. Helen Keller International (HKI) has addressed malnutrition and household food insecurity through implementation of an Enhanced Homestead Food Production (EHFP) programme that increases year‐round availability and intake of diverse micronutrient‐rich foods and promotes optimal nutrition and hygiene practices among poor households. This paper reviews the evolution and impact of HKI's EHFP programme and identifies core components of the model that address the underlying determinants of stunting. To date, evaluations of EHFP have shown impact on food production, consumption by women and children and household food security. Sale of surplus produce has increased household income, and the use of a transformative gender approach has empowered women. EHFP has also realized nutrition improvements in many project sites. Results from a randomized control trial (RCT) in Baitadi district, Nepal showed a significant improvement in a range of practices known to impact child growth, although no impact on stunting. Additional non‐RCT evaluations in Kailali district of Nepal, demonstrated a 10.5% reduction in stunting and in the Chittagong Hill Tracts in Bangladesh, revealed an 18% decrease in stunting. Based on evidence, the EHFP has evolved into an integrated package that includes agriculture, nutrition, water/hygiene/sanitation, linkages to health care, women's empowerment, income generation and advocacy. Closing the stunting gap requires long‐term exposure to targeted multi‐sectoral solutions and rigorous evaluation to optimize impact.

The effect of oral iron with or without multiple micronutrients on hemoglobin concentration and hemoglobin response among nonpregnant Cambodian women of reproductive age: a 2 x 2 factorial, double-blind, randomized controlled supplementation trial

Background: Despite a high prevalence of anemia among nonpregnant Cambodian women, current reports suggest that iron deficiency (ID) prevalence is low. If true, iron supplementation will not be an effective anemia reduction strategy.Objective: We measured the effect of daily oral iron with or without multiple micronutrients (MMNs) on hemoglobin concentration in nonpregnant Cambodian women screened as anemic.Design: In this 2 × 2 factorial, double-blind, randomized trial, nonpregnant women (aged 18-45 y) with hemoglobin concentrations ≤117 g/L (capillary blood) were recruited from 26 villages in Kampong Chhnang province and randomly assigned to receive 12 wk of iron (60 mg; Fe group), MMNs (14 other micronutrients; MMN group), iron plus MMNs (Fe+MMN group), or placebo capsules. A 2 × 2 factorial intention-to-treat analysis with the use of a generalized mixed-effects model was used to assess the effects of iron and MMNs and the interaction between these factors. Results: In July 2015, 809 women were recruited and 760 (94%) completed the trial. Baseline anemia prevalence was 58% (venous blood). Mean (95% CI) hemoglobin concentrations at 12 wk in the Fe, MMN, Fe+MMN, and placebo groups were 121 (120, 121), 116 (116, 117), 123 (122, 123), and 116 (116, 117) g/L, with no iron × MMN interaction (P = 0.66). Mean (95% CI) increases in hemoglobin were 5.6 g/L (3.8, 7.4 g/L) (P < 0.001) among women who received iron (n = 407) and 1.2 g/L (-0.6, 3.0 g/L) (P = 0.18) among women who received MMNs (n = 407). The predicted proportions (95% CIs) of women with a hemoglobin response (≥10 g/L at 12 wk) were 19% (14%, 24%), 9% (5%, 12%), 30% (24%, 35%), and 5% (2%, 9%) in the Fe, MMN, Fe+MMN, and placebo groups, respectively.Conclusions: Daily iron supplementation for 12 wk increased hemoglobin in nonpregnant Cambodian women; however, MMNs did not confer additional significant benefit. Overall, ∼24% of women who received iron responded after 12 wk; even fewer would be likely to respond in the wider population. This trial was registered at clinicaltrials.gov as NCT02481375.

An analysis of respondent driven sampling with Injection Drug Users (IDU) in Albania and the Russian Federation

Injection drug users in Tirana, Albania and St. Petersburg, Russia were recruited into a study assessing HIV-related behaviors and HIV serostatus using Respondent Driven Sampling (RDS), a peer-driven recruitment sampling strategy that results in a probability sample. (Salganik M, Heckathorn DD. Sampling and estimation in hidden populations using respondent-driven sampling. Sociol Method. 2004;34:193-239). This paper presents a comparison of RDS implementation, findings on network and recruitment characteristics, and lessons learned. Initiated with 13 to 15 seeds, approximately 200 IDUs were recruited within 8 weeks. Information resulting from RDS indicates that social network patterns from the two studies differ greatly. Female IDUs in Tirana had smaller network sizes than male IDUs, unlike in St. Petersburg where female IDUs had larger network sizes than male IDUs. Recruitment patterns in each country also differed by demographic categories. Recruitment analyses indicate that IDUs form socially distinct groups by sex in Tirana, whereas there was a greater degree of gender mixing patterns in St. Petersburg. RDS proved to be an effective means of surveying these hard-to-reach populations.

Development of a spanish-language version of the U.S. household food security survey module

A survey module used to monitor the prevalence of household food insecurity and hunger in the United States was developed by a broadly based collaborative project with leadership from the USDA and the National Center for Health Statistics (NCHS). It has been administered annually since 1995 as a supplement to the Census Bureau's Current Population Survey (CPS) and is part of the National Health and Nutrition Examination Survey (NHANES) and other national surveys. Spanish is the second most common language in the United States, yet no standardized Spanish-language version of this instrument has yet been sanctioned by the relevant federal agencies. In the CPS, interviewers free-translate the questions while interviewing respondents who prefer to have the interview conducted in Spanish. National prevalence data indicate relatively high rates of food insecurity for Hispanic households, raising the question whether methodological artifacts may contribute to these rates. We analyzed eight Spanish-language versions of the instrument that have been used in published work for variability in wording and phrasing. We then conducted focus groups of low-income Spanish-speaking participants from Mexico, Central America, Puerto Rico and Cuba to refine a single Spanish-language instrument. We also employed professional translators to render the English instrument into "standard" Spanish; both instruments were then back-translated. The focus group-derived instrument uses simpler language and grammar; its back-translation integrity to the English version was slightly better than the professionally translated version. We provide the instrument for use and further testing by other investigators.

Underreporting of food intake by dietary recall is not universal: a comparison of data from egyptian and american women

Underreporting of dietary intake has been observed consistently in food consumption surveys in affluent societies and in clinical studies in a variety of settings. Almost one third of quantitative 24-h recalls provided by adults in U.S. surveys appear to result in estimates that are biologically implausible. Underreporting has been linked to obesity in both the U.S. and Europe, with heavier individuals underreporting to a greater degree than lean persons. A relative dearth of data exists from developing countries and those in transition to address the question whether such underreporting is universal. We present the first data from a large survey of women in a rapidly urbanizing developing country to address this question. More than 4500 adult women in Egypt provided quantitative 24-h recalls of food intake on the previous day in 1993-1994, and weights and heights were measured. We compared the data, in terms of the ratio of reported energy intake to estimated basal metabolic rate, to data from 3010 women in the 1994-1996 U.S. Continuing Survey of Food Intake by Individuals, on whom quantitative 24-h recalls were also conducted. The Egyptian women reported food intakes consistent with FAO/WHO recommendations for energy intakes for women of comparable activity levels, whereas the data for U.S. women showed underreporting consistent with other U.S. surveys. Only 10% of Egyptian women reported energy intakes below accepted criteria for plausibility, compared with one third of American women. We discuss possible reasons for this difference, including cultural and food supply differences, and methodological differences between the two surveys.