Maternal knowledge and use of a micronutrient supplement was improved with a programmatically feasible intervention in Mexico.

In Mexico, the potential impact on child malnutrition from a nutritional supplement (papilla) delivered through a conditional transfer program (Oportunidades) was attenuated by problems of household utilization. A behavioral change through communication intervention was developed to improve supplement utilization. Our study assessed the efficacy of this intervention through the results of a randomized trial. In 2 states (Veracruz and Chiapas) 2 clusters of communities were randomly assigned to intervention or control groups. Data were obtained from 176-198 mothers in intervention and control communities using a survey questionnaire at preintervention baseline and at a 5-mo follow-up. Concordance between reported and observed behaviors was examined through an observational substudy. The 4 behavioral recommendations were: 1) prepare papilla as a pap; 2) administer the preparation every day; 3) administer it between breakfast and dinner; and 4) administer it only to target children. The intervention resulted in a significant increase (P<0.05) in the prevalence of reported correct behaviors in the intervention group compared with the control for 3 of the behaviors: a mean increase of 42.5% for preparing papilla as pap, 64.4% for daily administration, and 61.5% for giving papilla between breakfast and dinner. Administering to a target child increased significantly in Veracruz (from 51.5% to 90.6%), but not in Chiapas (20.6% to 33.3%). Reported behaviors agreed with observed behaviors in the substudy. With the exception of the target-child administration in Chiapas, adopting the recommendations was culturally acceptable and feasible. The results indicate that improvements in household utilization of the supplement can be achieved with a communication intervention that is potentially feasible for implementation on a large scale within the Oportunidades Program.

The association between prolonged breastfeeding and poor growth--what are the implications?

The smaller size of breast fed children in infancy and thereafter in malnourished and well-nourished populations has resulted in rushes to judgement that have been shown to be ill-advised. The reasons for the smaller size in malnourished populations is due to retaining the small and sickly child at the breast (reverse causality) and the consequent continuing sickliness of this breast fed child (negative confounding). Once the reverse causality and negative confounding have been taken into account breast feeding improves growth, at least through the second year of life. Thus prolonged breastfeeding should always be fostered, especially in malnourished populations. An exception remains when breast milk may transmit disease to the suckling child. In well-nourished populations the magnitude of the difference between breast fed and weaned children is much less than in malnourished populations, is observed to increase over the first year of life, but to have disappeared by the end of the second year. One may never-the-less be concerned that complimentary feeding practices are not adequate for these children.

Evaluation designs for adequacy, plausibility and probability of public health programme performance and impact.

The question of why to evaluate a programme is seldom discussed in the literature. The present paper argues that the answer to this question is essential for choosing an appropriate evaluation design. The discussion is centered on summative evaluations of large-scale programme effectiveness, drawing upon examples from the fields of health and nutrition but the findings may be applicable to other subject areas. The main objective of an evaluation is to influence decisions. How complex and precise the evaluation must be depends on who the decision maker is and on what types of decisions will be taken as a consequence of the findings. Different decision makers demand not only different types of information but also vary in their requirements of how informative and precise the findings must be. Both complex and simple evaluations, however, should be equally rigorous in relating the design to the decisions. Based on the types of decisions that may be taken, a framework is proposed for deciding upon appropriate evaluation designs. Its first axis concerns the indicators of interest, whether these refer to provision or utilization of services, coverage or impact measures. The second axis refers to the type of inference to be made, whether this is a statement of adequacy, plausibility or probability. In addition to the above framework, other factors affect the choice of an evaluation design, including the efficacy of the intervention, the field of knowledge, timing and costs. Regarding the latter, decision makers should be made aware that evaluation costs increase rapidly with complexity so that often a compromise must be reached. Examples are given of how to use the two classification axes, as well as these additional factors, for helping decision makers and evaluators translate the need for evaluation--the why--into the appropriate design--the how.

Food insecurity: consequences for the household and broader social implications.

A conceptual framework showing the household and social implications of food insecurity was elicited from a qualitative and quantitative study of 98 households from a heterogeneous low income population of Quebec city and rural surroundings; the study was designed to increase understanding of the experience of food insecurity in order to contribute to its prevention. According to the respondents' description, the experience of food insecurity is characterized by two categories of manifestations, i.e., the core characteristics of the phenomenon and a related set of actions and reactions by the household. This second category of manifestations is considered here as a first level of consequences of food insecurity. These consequences at the household level often interact with the larger environment to which the household belongs. On a chronic basis, the resulting interactions have certain implications that are tentatively labeled "social implications" in this paper. Their examination suggests that important aspects of human development depend on food security. It also raises questions concerning the nature of socially acceptable practices of food acquisition and food management, and how such acceptability can be assessed. Guidelines to that effect are proposed. Findings underline the relevance and urgency of working toward the realization of the right to food.

Impact of food supplementation during lactation on infant breast-milk intake and on the proportion of infants exclusively breast-fed.

To evaluate whether milk production can be improved by increasing food intake, a randomized, double-blind, supplementation trial was completed among 102 lactating Guatemalan women. The subjects were undernourished, as indicated by their low values for calf circumference (CC) and the small size of their infants at birth. A high-energy (2.14 MJ/d, HES) and a low-energy (0.50 MJ/d, LES) supplement were distributed 6 d/wk from wk 5 to 25 of lactation. Data were evaluated using repeated-measures analysis of variance on the increments from initial values for each outcome variable with one-tailed tests of statistical significance. The maternal energy intake increased 1.18 MJ/d (P < 0.01) more among the HES than the LES women. Benefit from supplementation was more evident among the more undernourished (CC

Serum retinol concentrations in children are affected by food sources of beta-carotene, fat intake, and anthelmintic drug treatment.

The provision of vitamin A in food sources of beta-carotene is an alternative to the distribution of high-dose capsules. To examine factors that may influence the success of food-based programs, a study was carried out in Sumatra, Indonesia, of the effect of food sources of beta-carotene, extra dietary fat, and Ascaris lumbricoides infection on serum retinol concentrations in children. Meals and snacks with various amounts of beta-carotene and fat were fed at midday to children 3-6 y of age for 3 wk. Some groups of children were dewormed with the anthelmintic levamisole before the feeding period, whereas others remained infected. Results showed that the incorporation of beta-carotene sources (mainly in the form of red sweet potatoes) into the meal significantly increased serum retinol concentrations. The greatest rise in serum retinol occurred when meals contained added beta-carotene sources and added fat and the children were dewormed. Adding more fat to the meal and deworming the children caused a rise in serum retinol similar to that seen when feeding additional beta-carotene sources. Moreover, the effects of fat and deworming together were additive to the effects of additional beta-carotene sources. When the meal contained additional beta-carotene sources, added fat caused a further improvement in serum retinol concentrations but only if A. lumbricoides infection was low. These studies indicated that food-based interventions in vitamin A-deficient areas might be successful and that other interventions such as increasing dietary fat concentrations and anthelmintic treatment should be considered along with increasing consumption of beta-carotene-rich food.

Linking maternal and infant benefits of a nutritional supplement during pregnancy and lactation.

To evaluate the effect of a nutritional supplement on change in women's weight during a reproductive cycle and on the difference in birth weight between one infant and the previous one, we analyzed data on 176 complete reproductive cycles from an experiment that was conducted in rural Guatemala. Women with an initial weight <50 kg were classified as marginally nourished or malnourished. Women whose intake of the supplement was in the top 2 tertiles were distinguished from those whose intake was in the lowest tertile. Linear regression modeling was used to estimate the effect of supplementation on these outcomes and to control for confounding factors. Malnourished women gained weight during the reproductive cycle, but their second (study) infant tended to weigh less at birth than their prior-born infant. Higher intakes of supplement were associated with a less negative difference in birth weight. Marginally nourished women lost weight during the reproductive cycle and their second (study) infant tended to weigh more at birth than their prior-born infant. Higher intakes of supplement were associated with a less negative weight [corrected] trend for the women themselves. Well-nourished women and their infants did not show any of these benefits from supplementation. These findings help explain past contradictory findings on maternal depletion as well as on the benefits of nutritional supplementation for mothers and their infants.

Research steps in the development and evaluation of public health interventions.

Presented is a conceptual framework for planning intervention-related research. Altogether, nine steps in the process of developing and evaluating public health interventions are specified. This process is dynamic and iterative, and all steps are not always required, or need follow in sequence. The framework can be used to set research priorities by verifying where there is sufficient knowledge to move forward and by identifying critical information gaps. It can also help select appropriate research designs, as each step is characterized by certain types of studies. Greater effort is required to move beyond descriptive epidemiological and behavioural studies, to intervention studies. Field trials of public health interventions require particular attention as they are often neglected, despite their significance for public health policy and practice.

Household participation in the Food Stamp and WIC programs increases the nutrient intakes of preschool children.

We examined the effects of household participation in the Food Stamp and WIC Nutrition Programs on the nutrient intakes of preschoolers using data from the 1989-1991 Continuing Survey of Food Intake by Individuals. Nonbreastfeeding children, 1-4 y of age, with 3 d of dietary data and whose households had incomes < 130% of the poverty level were included in the study sample (n = 499). Nutrient adequacy ratios for each of 15 nutrients were the dependent variables in multiple regression models that controlled for the following: age, sex and ethnicity of the individual; income, size and location of the household; schooling of the household head; home ownership; school lunch and breakfast participation; and season in which the interview was conducted. WIC benefits positively influenced (P < 0. 05) the intakes of 10 nutrients. For iron and zinc, the average increase due to WIC represented 16.6 and 10.6%, respectively, of the preschooler recommended dietary allowance (RDA) for these nutrients. The same analyses of the Food Stamp Program revealed increases in five nutrients. For iron and zinc, the average increase due to Food Stamps represented 12.3 and 9.2%, respectively, of the preschooler RDA. The effects of the WIC Program on the intakes of iron and zinc were greater than that of cash income, and neither program affected the intakes of fat, saturated fat or cholesterol.

Sales of food aid as sign of distress, not excess.

In 1996 the sale and export of food aid from refugee camps near Uvira, Zaire, prompted a reduction in donated rations. However, research has revealed that the sales did not reflect an excess of food in the camps. They were provoked by the absence of important components of the food basket, by cultural aversion to the staple (maize) and oil provided, by difficulties in food preparation, and by the refugees' limited ability to diversify their diet and cover pressing non-food needs. Food sales improved the micronutrient content of diets but at the expense of energy lost from an already energy-deficient diet. At most 23% of the refugee households were eating sufficient and adequate diets; the poorest one-fifth of households were twice as likely to sell or exchange food as were other households and their diets were the worst. These findings demonstrate the perils of the gap between policy and practice in food-aid distribution.

Breast milk or animal-product foods improve linear growth of Peruvian toddlers consuming marginal diets.

Although breast-feeding is widely accepted as important for infant health, its benefits during the second year of life have been questioned. We analyzed data from 107 breast-fed and weaned Peruvian children living in a periurban community to determine whether breast milk contributed to improved linear growth between 12 and 15 mo of age. Breast-feeding frequency was self-reported; intakes of complementary foods and animal products were estimated from a food-frequency survey. Multivariate-linear-regression analysis was used to predict the length of the children at 15 mo of age. Determinants of length included length and weight-for-length at 12 mo of age (US National Center for Health Statistics standards), interval between 12- and 15-mo measurements, breast-feeding frequency, incidence of diarrhea, and intakes of complementary and animal-product foods. Complementary foods, animal-product foods, and breast milk all promoted toddlers' linear growth. In subjects with low intakes of animal-product foods, breast-feeding was positively associated (P < 0.05) with linear growth. There was a 0.5-cm/3 mo difference in linear growth between weaned toddlers and children who consumed the average number of feedings of breast milk. Linear growth was also positively associated with intake of animal-product foods in children with low intakes of complementary foods. The negative association between diarrhea and linear growth did not occur in subjects with high complementary-food intakes. When the family's diet is low in quality, breast milk is an especially important source of energy, protein, and accompanying micronutrients in young children. Thus, continued breast-feeding after 1 y of age, in conjunction with feeding of complementary foods, should be encouraged in toddlers living in poor circumstances.

PIP: The contribution of prolonged breast feeding to linear growth at 12-15 months of age was investigated in 107 breast-fed and weaned toddlers from a low-income neighborhood in Lima, Peru. The median duration of breast feeding in this sample was 17.1 months; by 15 months, 46 children had been weaned. The prevalence of stunting (length-for-age score -2 SD below the reference standard) was 17.8% at 12 months and 24.3% at 15 months; no child was wasted. Complementary foods, animal product foods, and breast milk all promoted toddlers' linear growth. In children with low intakes of animal product foods, breast feeding was positively associated with linear growth at 15 months (p 0.05). There was a 0.5 cm/3 months difference in linear growth between weaned toddlers and those who consumed the average number (6.3/day) of breast feeds. Linear growth was further positively associated with intake of animal product foods in children with low intakes of complementary foods. The negative association between diarrhea and linear growth did not occur in children with high intakes of complementary foods. When the household diet is of poor quality, breast feeding is an especially important source of energy, protein, and micronutrients in toddlers and should be continued beyond 12 months of age in conjunction with the provision of complementary foods. Breast milk not only added to the total diet of these young children, but also potentiated the beneficial effects of complementary foods consumed by increasing their growth promotion capacity.

The deterioration in children's nutritional status in rural Chad: the effect of mothers' influence on feeding.

OBJECTIVES: This study examined how maternal influence on child feeding modified the deterioration of child nutritional status in Chad. METHODS: The pattern of height with age was examined in 98 rural Chadian children aged 12 through 71 months from 64 households randomly chosen. RESULTS: Younger children were more stunted than older ones, probably reflecting secular deterioration in weanlings' nutritional status from 1982 to 1987. Children of mothers with influence over child feeding were taller than children of mothers with less influence, but this held only for the youngest children. CONCLUSIONS: Height-for-age can be a useful indicator of recent changes in social and environmental effects on child health. The mother's influence may have buffered the negative impact of socioeconomic conditions on child growth.

Association of breastfeeding and stunting in Peruvian toddlers: an example of reverse causality.

BACKGROUND: Child feeding recommendations include breastfeeding beyond 12 months, however, some researchers have reported increased rates of malnutrition in breastfed toddlers. A negative association between growth and breast-feeding may reflect reverse causality; that is, the outcome (growth) is a determinant of the predictor (breastfeeding), and not vice versa. We examined this question with data from 134 Peruvian toddlers. METHODS: A linear regression analysis predicted length at the age of 15 months by length at 12 months, study interval, and 12-14.9-month breastfeeding, complementary food intake, and diarrhoeal incidence. This analysis defined the association between breastfeeding and linear growth. To elucidate the direction of the effect between breastfeeding and linear growth, logistic regression was used to predict the probability of weaning by the end of 14 months. Determinants included weight-for-age (W/A) at 12 months, complementary food intake at 9-11.9 months, and change in diarrhoeal incidence between 9 and 14.9 months. RESULTS: There was a significant (P < 0.01) interaction of breastfeeding, diarrhoeal incidence, and complementary food intake on length at 15 months. Increased breastfeeding was associated with a 1.0 cm decrease in length gain when dietary intake was low and diarrhoeal morbidity was high, implying that breastfeeding is harmful. The logistic analysis, however, demonstrated that the risk of weaning decreased only when W/A and dietary intake were low and diarrhoeal morbidity was high. CONCLUSIONS: The negative association between breastfeeding and linear growth reflected reverse causality. Increased breastfeeding did not lead to poor growth; children's poor growth and health led to increased breastfeeding. Children's health must be considered when evaluating the association of breastfeeding with anthropometric outcomes.

PIP: There has been a perplexing finding, in many developing countries, of increased rates of stunting and growth faltering in breast-fed toddlers receiving complementary foods relative to their non-breast-fed counterparts. Longitudinal data on 134 children 12-15 months of age from Lima, Peru, were used to investigate the hypothesis that the negative association between growth and breast feeding reflects reverse causality. The toddlers were participants in a broader persistent diarrhea surveillance survey conducted during 1985-87. 72.9% of children were breast-fed beyond 12 months (median duration, 16.8 months). Anthropometric measurements revealed stunting in 19.4% of toddlers at 12 months and in 29.1% at 15 months. Linear growth between 12 and 15 months had a complex relationship with breast feeding, diarrhea, and dietary factors. Increased breast feeding was associated with a 1.0 cm decrease in length gain between 12 and 15 months when dietary intake was low and diarrheal morbidity was high. However, logistic analysis demonstrated that mothers whose children had low dietary intakes, low weight-for-age, and increased incidence of diarrhea were less likely to wean their infants at 12 and 14 months. This finding that mothers modified their children's feeding practices according to the child's health and growth status supports a reverse causality process in which poor growth is a determinant rather than a result of breast feeding.

Time for a new growth reference.

The National Center for Health Statistics growth reference, recommended by the World Health Organization for international use since the late 1970s, has served many useful purposes. Among the most important are the provision of a single set of growth references for the assessment of the general nutritional status of populations of children in diverse settings, as an ancillary tool to screen children for health and nutrition disorders, and as a basis for educational materials that promote improved child care by families. However, because of serious drawbacks due to the origin and type of data used for their construction and the analytical methods applied in their derivation, the suitability of these curves for international purposes has been challenged recently.

Investigating the weanling's dilemma: lessons from Honduras.

When complementary foods should be introduced in the diets of infants in poor environments remains controversial. Resolution has been hampered by inadequate study designs. A study in Honduras has demonstrated an experimental design assessing multiple infant and maternal outcomes and provides information for planning sample size and accounting for dropouts in future studies. Further research to understand the cultural, social, and biologic aspects of complementary feeding is needed.

Anthropometric reference data for international use: recommendations from a World Health Organization Expert Committee.

The World Health Organization (WHO) convened an Expert Committee to reevaluate the use of anthropometry at different ages for assessing health, nutrition, and social wellbeing. The Committee's task included identifying reference data for anthropometric indexes when appropriate, and providing guidelines on how the data should be used. For fetal growth, the Committee recommended an existing sex-specific multiracial reference. In view of the significant technical drawbacks of the current National Center for Health Statistics (NCHS)/WHO reference and its inadequacy for assessing the growth of breast-fed infants, the Committee recommended the development of a new reference concerning weight and length/height for infants and children, which will be a complex and costly undertaking. Proper interpretation of midupper arm circumference for preschoolers requires age-specific reference data. To evaluate adolescent height-for-age, the Committee recommended the current NCHS/WHO reference. Use of the NCHS body mass index (BMI) data, with their upper percentile elevations and skewness, is undesirable for setting health goals; however, these data were provisionally recommended for defining obesity based on a combination of elevated BMI and high subcutaneous fat. The NCHS values were provisionally recommended as reference data for subscapular and triceps skinfold thicknesses. Guidelines were also provided for adjusting adolescent anthropometric comparisons for maturational status. Currently, there is no need for adult reference data for BMI; interpretation should be based on pragmatic BMI cutoffs. Finally, the Committee noted that few normative anthropometric data exist for the elderly, especially for those > 80 y of age. Proper definitions of health status, function, and biologic age remain to be developed for this group.