Farmers' and millers' experiences and attitudes towards the production and processing of zinc biofortified wheat in Pakistan: a mixed methods study.

Background: Zinc biofortified wheat may be a sustainable strategy to increase zinc intake in areas where fortification and dietary diversification are not feasible or are limited by household purchasing power. This convergent mixed methods study aimed to explore the farmers' and millers' experiences and attitudes towards the production and processing of zinc biofortified wheat in Pakistan. Methods: A telephone survey was conducted with farmers (n = 418) who were provided with Zincol-2016 biofortified wheat seed for the 2019-2020 growing season, as part of a wheat grain micronutrient mapping study across Punjab Province. The survey explored the farmers' experiences of growing Zincol-2016 and whether they opted to grow it again in the subsequent season. Semi-structured focus group discussions were undertaken in a separate group of farmers in Khyber Pakhtunkhwa (KP) province (n = 12) who grew Zincol-2016 for the BiZiFED2 RCT. Millers were also interviewed in KP, both those who had processed Zincol-2016 for the trial (n = 12) and those who had no experience of processing biofortified wheat (n = 12). Survey data were analyzed using descriptive statistics and transcripts of focus groups were analyzed using thematic analysis. Results: Nearly half of farmers who responded to the survey (47%) re-cultivated Zincol-2016 in the following season. The drivers for Zincol-2016 re-cultivation were seed availability (100%), grain yield and growth resistance (98%), quality of the flour from the previous harvest (97%) and nutritional benefit (94.5%). Discussions with farmers suggested that the main motivators for potential scale-up of biofortified wheat were the perceived quality of the grain, wheat, and flour. Millers saw it as an opportunity to expand their business. Farmers and millers valued the health benefits of the wheat. Challenges for scale-up include the need of additional support to produce it, unfamiliarity with the biofortification process, production costs, and external threats to the supply chain. Conclusion: Farmers and millers showed a strong implicit preference for Zincol-2016 over alternative varieties. Crop performance and product yield were the most cited motivators for growing Zincol-2016. Farmers and millers are willing to produce and process biofortified wheat if financial and educational support is provided.

Urban nutrition situation in the slums of three cities in Asia during the COVID-19 pandemic.

Urban-poor households are disproportionately food insecure. The Status and Determinants of Food Insecurity and Undernutrition in Poor Urban Settings (SDFU) cross-sectional surveys were conducted in 2020-2021 to assess the impacts of COVID-19 on food security and diet quality among urban poor women of reproductive age (WRA) and children under 5 (CU5) in Jakarta, Quezon City, and Yangon. Data, collected on food insecurity and child and maternal diet quality using Computer Assisted Telephone Interviewing (CATI), were compared with prepandemic surveys. Prevalence for food insecurity and diet quality indicators were computed. Eight in 10 households in all three cities reported reduced incomes, with 6 in 10 worried about food the previous year. Over 10% of households in all cities substituted nutrient-dense (ND) foods with cheaper alternatives; yet less than 50% of children 6-59 months ate sugar-sweetened beverages or sweet and savoury snacks. Compared with baseline, women's minimum dietary diversity (MDD) in the three cities was significantly lower (up to 30% lower in Yangon and Jakarta), while the prevalence of children (6-23 months) meeting MDD was lower by 17.4%-42.5% in all cities. MDD was attained by >40% of children (24-59 months) in Yangon and Jakarta but only 12.6% in Quezon City. To improve food security and diet quality, multi-sectoral interventions are needed, including distributing ND foods and cash assistance to vulnerable households with CU5 and WRA and delivering targeted nutrition training to encourage appropriate complementary feeding practices and purchasing and consumption of ND foods.

Community Perceptions of Zinc Biofortified Flour during an Intervention Study in Pakistan.

Zinc-biofortified flour may be a cost-effective approach to improve zinc status of populations in low-resource settings. The success of biofortification programmes is subject to acceptability and uptake by consumers. This study explored community leaders' and community members' (n = 72) experiences and attitudes towards the flour provided during a cluster randomised controlled trial of zinc biofortified wheat in rural Pakistan (BiZiFED2). Focus group discussions (n = 12) were conducted and thematic analysis applied using an inductive, semantic, contextualist approach. Five themes were identified: (1) Contribution to food security; (2) Better sensory and baking properties than local flour; (3) Perceived health benefits; (4) Willingness to pay for the flour; and (5) Importance of trusted promoters/suppliers. Although the participants were blind to whether they had received control or biofortified flour, referred to collectively as "study flour", the results indicated that the study flour performed well in terms of its taste and bread making qualities, with no adverse reports from participants in either arm of the BIZIFED2 RCT. Participants suggested that they would buy the biofortified wheat if this was available at a fair price due to perceived health benefits, reporting positive sensory characteristics and cooking attributes when compared to the flour available in the local markets. Overall, there was a positive reception of the programme and flour among the participants, and members of the community hoped for its continuation and expansion.

Biofortified Wheat Increases Dietary Zinc Intake: A Randomised Controlled Efficacy Study of Zincol-2016 in Rural Pakistan.

A new variety of zinc biofortified wheat (Zincol-2016) was released in Pakistan in 2016. The primary aim of this study was to examine the effects of consuming Zincol-2016 wheat flour on biochemical and functional markers of zinc status in a population with widespread zinc deficiency. An individually-randomised, double-blind, placebo-controlled cross over design was used. Fifty households were recruited to participate in the study, with each household included at least one woman of reproductive age (16-49 years) who was neither pregnant nor breast feeding or currently taking nutritional supplements. All households were provided with control flour for an initial 2-week baseline period, followed by the intervention period where households were randomly allocated in a 1:1 ratio to receive biofortified flour (group A; n = 25) and control flour (group B; n = 25) for 8-weeks, then switched to the alternate flour for 8-weeks. The trial has been registered with the ISRCTN (https://www.isrctn.com), ID ISRCTN83678069. The primary outcome measure was plasma zinc concentration, and the secondary outcome measures were plasma selenium and copper concentrations, plasma copper:zinc ratio and fatty acid desaturase and elongase activity indices. Nutrient intake was assessed using 24-h dietary recall interviews. Mineral concentrations in plasma were measured using inductively coupled plasma mass spectrometry and free fatty acids and sphingolipids by mass spectrometry. Linear Mixed Model regression and General Linear Model with repeated measures were used to analyse the outcomes. Based on an average flour consumption of 224 g/day, Zincol-2016 flour provided an additional daily zinc intake of between 3.0 and 6.0 mg for white and whole grain flour, respectively. No serious adverse events were reported. This resulted in significant, increase in plasma zinc concentration after 4 weeks [mean difference 41.5 µg/L, 95% CI (6.9-76.1), p = 0.02]. This was not present after 8 weeks (p = 0.6). There were no consistent significant effects of the intervention on fatty acid desaturase and elongase activity indices. Regular consumption of Zincol-2016 flour increased the daily zinc intake of women of reproductive age by 30-60%, however this was not associated with a sustained improvement in indices of zinc status.

Biofortification of wheat with zinc for eliminating deficiency in Pakistan: study protocol for a cluster-randomised, double-blind, controlled effectiveness study (BIZIFED2).

INTRODUCTION: Micronutrient deficiencies, commonly referred to as 'hidden hunger', affect more than two billion people worldwide, with zinc and iron-deficiency frequently reported. The aim of this study is to examine the impact of consuming zinc biofortified flour (Zincol-2016) on biochemical and functional measures of status in adolescent girls and children living in a low-resource setting in Pakistan. METHODS AND ANALYSIS: We are conducting a pragmatic, cluster-randomised, double-blind, controlled trial. A total of 482 households have been recruited from two catchment areas approximately 30-40 km distance from Peshawar. Household inclusion criteria are the presence of both an adolescent girl, aged 10-16 years, and a child aged 1-5 years. The study duration is 12 months, divided into two 6-month phases. During phase 1, all households will be provided with locally procured flour from standard varieties of wheat. During phase 2, clusters will be paired, and randomised to either the control or intervention arm of the study. The intervention arm will be provided with zinc biofortified wheat flour, with a target zinc concentration of 40 mg/kg. The control arm will be provided with locally procured wheat flour from standard varieties with an expected zinc concentration of 20 mg/kg. The primary outcome measure is plasma zinc concentration. Secondary outcomes include anthropometric measurements, biomarkers of iron and zinc status, and the presence and duration of respiratory tract infections and diarrhoea. ETHICS AND DISSEMINATION: Ethical approval was granted from the University of Central Lancashire STEMH Ethics Committee (reference number: STEMH 1014) and Khyber Medical University Ethics Committee (DIR/KMU-EB/BZ/000683). The final study methods will be published in peer-reviewed journals, alongside the study outcomes. In addition, findings will be disseminated to the scientific community via conference presentations and abstracts and communicated to the study participants through the village elders at an appropriate community forum. TRIAL REGISTRATION NUMBER: ISRCTN17107812; Pre-results.

Micronutrient Status and Dietary Diversity of Women of Reproductive Age in Rural Pakistan.

Consuming a diverse diet is essential to ensure an adequate intake of micronutrients. The aim of this study was to assess the nutritional status and dietary diversity of women of reproductive age (WRA) living in a marginalized community in rural Pakistan. Forty-seven WRA (35 ± 7 years old) who were not pregnant or lactating at enrollment, were recruited to participate in the study. Twenty-four-hour dietary recall interviews were conducted by the study nutritionist, and the data collected were used to create a minimum dietary diversity for women score (MDD-W) on five occasions during the monsoon and winter seasons (October to February). Nutritional status was assessed using anthropometry and biochemical markers of micronutrient status. Height and weight were used to determine body mass index (BMI), and mid-upper-arm circumference was measured. Plasma zinc, iron, and selenium concentrations were measured using inductively coupled mass spectrometry, and iron status was assessed using serum ferritin and blood hemoglobin concentrations. The mean (±SD) food group diversity score was 4 ± 1 with between 26% and 41% of participants achieving an MDD-W of 5. BMI was 27.2 ± 5.5 kg/m2 with 28% obese, 34% overweight, and 6% underweight. The prevalence of zinc deficiency, based on plasma zinc concentration, was 29.8%; 17% of the participants had low plasma selenium levels; 8.5% were iron deficient; and 2% were suffering from iron deficiency anemia. The findings indicate that the women living in this community consume a diet that has a low diversity, consistent with a diet low in micronutrients, and that zinc deficiency is prevalent. Public health interventions aimed at increasing the dietary diversity of WRA are needed to improve the micronutrient intake, particularly of zinc, in this population.

Exploring community perceptions in preparation for a randomised controlled trial of biofortified flour in Pakistan.

BACKGROUND: Biofortification of staple food crops may be a cost-effective and sustainable approach to reducing micronutrient deficiencies in resource-poor settings with low dietary diversity. However, its success depends on uptake by the local population. This paper presents formative research conducted in a remote, rural community in North West Pakistan, prior to commencing a randomised controlled trial to test the effectiveness of consuming zinc-biofortified wheat flour for alleviating zinc deficiency. It explored local community members' knowledge, understanding and attitudes towards biofortification and views on members of their community taking part in the trial. METHODS: Four focus group discussions were conducted with male and female community members (separately for cultural reasons) and four in-depth interviews were conducted with Jirga members-respected male elders. Participation was limited to households that were ineligible for the trial so that we could explore the perspectives of community members who were not influenced by the incentives of the trial. Focus group participants were selected at community events for transparency. Data collection took place at the local school and homes of Jirga members. Thematic analysis was undertaken, using a combination of deductive and inductive approaches to identify key themes. RESULTS: A total of 47 men and women participated in this study. Participants reported clear motivation to access and consume more nutritious flour, believing this would bring health benefits, particularly to women and children. Trusted members of the local community, including Jirga members and female health workers, should be involved in providing information on biofortified flour (and the trial) to increase levels of awareness and acceptance. Without their involvement, there is a risk that biofortified flour would be mistrusted. The cost of flour is the main factor affecting purchasing decisions, and biofortified flour will need to be cost-competitive to achieve widespread uptake in marginalised, rural communities. CONCLUSION: This formative study generated rich, qualitative data from a range of community stakeholders to improve the understanding of important barriers and facilitators to the widespread acceptability and adoption of biofortified wheat. Implementation research such as this will inform future decision-making in relation to scaling up biofortified wheat in Pakistan.

A realist qualitative study to explore how low-income pregnant women use Healthy Start food vouchers.

Healthy Start is the UK government's food voucher programme for low-income pregnant women and young children. It was introduced in 2006, but the impact of the programme on nutritional outcomes remains understudied. This study sought to explore potential outcomes of the Healthy Start programme (including intended and unintended outcomes) and develop explanations for how and why these outcomes might occur. A realist review preceded this study, in which programme theories were developed and tested using existing evidence. This qualitative study aimed to further refine and consolidate the programme theories from the realist review while remaining open to new and emerging theories (or hypotheses) about how low-income pregnant women use Healthy Start vouchers. Semistructured interviews were conducted with 11 low-income women from North West England, who received Healthy Start vouchers during pregnancy. A realist logic of analysis was applied to generate clear and transparent linkages between outcomes and explanations. The findings suggested that some women used the vouchers to improve their diets during pregnancy (intended outcome), whereas some women were diverted towards alternative or unintended outcomes. Women's circumstances, values, beliefs, and motivations influenced how they perceived and responded to the vouchers. This paper presents four evidence-based programme theories to explain four contrasting (and potentially overlapping) outcomes: dietary improvements (theory refined from review), shared benefits (new theory), financial assistance (theory refined from review), and stockpiling formula (new theory). It considers how the Healthy Start programme could be improved, to increase the possibilities for low-income women to experience the intended outcome of dietary improvements.

Examining the effectiveness of consuming flour made from agronomically biofortified wheat (Zincol-2016/NR-421) for improving Zn status in women in a low-resource setting in Pakistan: study protocol for a randomised, double-blind, controlled cross-over trial (BiZiFED).

INTRODUCTION: Dietary zinc (Zn) deficiency is a global problem, particularly in low-income and middle-income countries where access to rich, animal-source foods of Zn is limited due to poverty. In Pakistan, Zn deficiency affects over 40% of the adult female population, resulting in suboptimal immune status and increased likelihood of complications during pregnancy. METHODS AND ANALYSIS: We are conducting a double-blind, randomised controlled feeding study with cross-over design in a low-resource setting in Pakistan. Households were provided with flour milled from genetically and agronomically biofortified grain (Zincol-2016/NR-421) or control grain (Galaxy-2013). Fifty households were recruited. Each household included a woman aged 16-49 years who is neither pregnant nor breastfeeding, and not currently consuming nutritional supplements. These women were the primary study participants. All households were provided with control flour for an initial 2-week baseline period, followed by an 8-week intervention period where 25 households receive biofortified flour (group A) and 25 households receive control flour (group B). After this 8-week period, groups A and B crossed over, receiving control and biofortified flour respectively for 8 weeks. Tissue (blood, hair and nails) have been collected from the women at five time points: baseline, middle and end of period 1, and middle and end of period 2. ETHICS AND DISSEMINATION: Ethical approval was granted from the lead university (reference no. STEMH 697 FR) and the collaborating institution in Pakistan. The final study methods (including any modifications) will be published in peer-reviewed journals, alongside the study outcomes on completion of the data analysis. In addition, findings will be disseminated to the scientific community via conference presentations and abstracts and communicated to the study participants through the village elders at an appropriate community forum. REGISTRATION DETAILS: The trial has been registered with the ISRCTN registry, study ID ISRCTN83678069.

A realist review to explore how low-income pregnant women use food vouchers from the UK's Healthy Start programme.

OBJECTIVES: To explore how low-income pregnant women use Healthy Start food vouchers, the potential impacts of the programme, and which women might experience these impacts and why. DESIGN: A realist review. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Primary or empirical studies (of any design) were included if they contributed relevant evidence or insights about how low-income women use food vouchers from the Healthy Start (UK) or the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) programmes. The assessment of 'relevance' was deliberately broad to ensure that reviewers remained open to new ideas from a variety of sources of evidence. ANALYSIS: A combination of evidence synthesis and realist analysis techniques was used to modify, refine and substantiate programme theories, which were constructed as explanatory 'context-mechanism-outcome'-configurations. RESULTS: 38 primary studies were included in this review: four studies on Healthy Start and 34 studies on WIC. Two main outcome strands were identified: dietary improvements (intended) and financial assistance (unintended). Three evidence-informed programme theories were proposed to explain how aspects of context (and mechanisms) may generate these outcomes: the 'relative value' of healthy eating (prioritisation of resources); retailer discretion (pressure to 'bend the rules'); the influence of other family members (disempowerment). CONCLUSIONS: This realist review suggests that some low-income pregnant women may use Healthy Start vouchers to increase their consumption of fruits and vegetables and plain cow's milk, whereas others may use them to reduce food expenditure and save money for other things.

Attention Restoration Theory: A systematic review of the attention restoration potential of exposure to natural environments.

Attention Restoration Theory (ART) suggests the ability to concentrate may be restored by exposure to natural environments. Although widely cited, it is unclear as to the quantity of empirical evidence that supports this. A systematic review regarding the impact of exposure to natural environments on attention was conducted. Seven electronic databases were searched. Studies were included if (1) they were natural experiments, randomized investigations, or recorded "before and after" measurements; (2) compared natural and nonnatural/other settings; and (3) used objective measures of attention. Screening of articles for inclusion, data extraction, and quality appraisal were performed by one reviewer and checked by another. Where possible, random effects meta-analysis was used to pool effect sizes. Thirty-one studies were included. Meta-analyses provided some support for ART, with significant positive effects of exposure to natural environments for three measures (Digit Span Forward, Digit Span Backward, and Trail Making Test B). The remaining 10 meta-analyses did not show marked beneficial effects. Meta-analysis was limited by small numbers of investigations, small samples, heterogeneity in reporting of study quality indicators, and heterogeneity of outcomes. This review highlights the diversity of evidence around ART in terms of populations, study design, and outcomes. There is uncertainty regarding which aspects of attention may be affected by exposure to natural environments.

A systematic review of the health and well-being impacts of school gardening: synthesis of quantitative and qualitative evidence.

BACKGROUND: School gardening programmes are increasingly popular, with suggested benefits including healthier eating and increased physical activity. Our objectives were to understand the health and well-being impacts of school gardens and the factors that help or hinder their success. METHODS: We conducted a systematic review of quantitative and qualitative evidence (PROSPERO CRD42014007181). We searched multiple databases and used a range of supplementary approaches. Studies about school gardens were included if they reported on physical or mental health or well-being. Quantitative studies had to include a comparison group. Studies were quality appraised using appropriate tools. Findings were narratively synthesised and the qualitative evidence used to produce a conceptual framework to illustrate how benefits might be accrued. RESULTS: Evidence from 40 articles (21 quantitative studies; 16 qualitative studies; 3 mixed methods studies) was included. Generally the quantitative research was poor. Evidence for changes in fruit and vegetable intake was limited and based on self-report. The qualitative research was better quality and ascribed a range of health and well-being impacts to school gardens, with some idealistic expectations for their impact in the long term. Groups of pupils who do not excel in classroom activities were thought to particularly benefit. Lack of funding and over reliance on volunteers were thought to threaten success, while involvement with local communities and integration of gardening activities into the school curriculum were thought to support success. CONCLUSION: More robust quantitative research is needed to convincingly support the qualitative evidence suggesting wide ranging benefits from school gardens.

A qualitative study exploring parental accounts of feeding pre-school children in two low-income populations in the UK.

Good nutrition in the early years of life is essential, yet the diets of many pre-school children in the UK are known to be poor. Understanding the decisions parents make when feeding young children is very important in determining what type and nature of interventional support may be developed to promote good nutrition. The aim of this study was to explore using qualitative methods, parental perceptions of feeding their children in order to inform the development of a nutrition intervention. Focus groups (n = 33) and individual interviews (n = 6) were undertaken with parents, most of whom were attending children's centres in two deprived populations from one urban (Islington, north London) and one rural (Cornwall) location in England. Accounts of feeding pre-school children were primarily concerned with dealing with the practicalities of modern life, in particular the cost of food and the need to manage on a restricted household budget. Time pressures, a lack of perceived knowledge and confidence in preparing food and managing conflict over food choices between family members were also strong themes. Parents commonly reported differences between how they would like to feed their children and the reality of what they were able to do in their circumstances. These findings suggest that the poor eating habits of many pre-school children may be less a case of parental ignorance but rather the product of a range of coping strategies. Designing an intervention, which helps parents to build their confidence and self-efficacy, may enable them to make positive changes to their children's diets.

Methodological development of an exploratory randomised controlled trial of an early years' nutrition intervention: the CHERRY programme (Choosing Healthy Eating when Really Young).

Good nutrition in the early years of life is vitally important for a child's development, growth and health. Children's diets in the United Kingdom are known to be poor, particularly among socially disadvantaged groups, and there is a need for timely and appropriate interventions that support parents to improve the diets of young children. The Medical Research Council has highlighted the importance of conducting developmental and exploratory research prior to undertaking full-scale trials to evaluate complex interventions, but have provided very limited detailed guidance on the conduct of these initial phases of research. This paper describes the initial developmental stage and the conduct of an exploratory randomised controlled trial undertaken to determine the feasibility and acceptability of a family-centred early years' nutrition intervention. Choosing Healthy Eating when Really Young (CHERRY) is a programme for families with children aged 18 months to 5 years, delivered in children's centres in one urban (Islington) and one rural (Cornwall) location in the United Kingdom. In the development stage, a mixed-methods approach was used to investigate the nature of the problem and options for support. A detailed review of the evidence informed the theoretical basis of the study and the creation of a logic model. In the feasibility and pilot testing stage of the exploratory trial, 16 children's centres, with a sample of 394 families were recruited onto the study. We hope that the methodology, which we present in this paper, will inform and assist other researchers in conducting community-based, exploratory nutrition research in early years settings.

Parental food involvement predicts parent and child intakes of fruits and vegetables.

In order to develop successful interventions to improve children's diets, the factors influencing food choice need to be understood. Parental food involvement - the level of importance of food in a person's life - may be one of many important factors. The aim of this study was to determine whether parental food involvement is associated with parents' and children's diet quality. As part of an intervention study, 394 parents with children aged between 18 months and 5 years were recruited from children's centres in Cornwall and Islington, UK. Questionnaires were used to collect data on socio-demographic characteristics, parents' diets, and attitudes towards food including food involvement. Children's diets were assessed using the multiple pass 24 h recall method. Parents reported low intakes of fruits and vegetables and high intakes of sugary items for themselves and their young children. Parental food involvement was strongly correlated with consumption of fruits and vegetables (amount and diversity) for both parents and children. Correlations with consumption of sugary drinks and snacks/foods were not significant. These findings indicate that parental food involvement may influence consumption of fruits and vegetables, more so than sugary items. Further research is needed to investigate how parental food involvement could mediate dietary changes.

Developing a nutrition intervention in children's centres: exploring views of parents in rural/urban settings in the UK.

OBJECTIVE: The present study explored parents' requirements for healthy eating support prior to the development of a tailored intervention. DESIGN: A cross-sectional study of parents attending children's centres. SETTING: Children's centres in Cornwall (rural south-west England) and Islington (urban London borough). SUBJECTS: A total of 261 parents (94.2% female) of pre-school children (aged 2­5 years) completed a questionnaire on factors influencing food choice, and preferences for and views on healthy eating support. RESULTS: Parents reported that health, taste, freshness and quality were the most important factors influencing their food choices for their pre-school children. The importance of individual factors varied according to level of educational attainment. Over a third (38 %) of parents said they wanted more advice on healthy eating for children. Less educated parents showed the greatest interest in learning more about several aspects: what a 'healthy diet' means, how to prepare and cook healthy food, how to understand food labels, budgeting for food, examples of healthy food and snacks for children, appropriate portion sizes for children and ways to encourage children to eat well. CONCLUSIONS: There was demand for healthy eating support among parents of pre-school children, especially those who are less educated, in one rural and one urban area of England