Food pattern modeling to inform global guidance on complementary feeding of infants.

Nutrient needs are difficult to meet during infancy due to high nutrient requirements and the small quantities of food consumed. Guidelines to support food choice decisions are critical to promoting optimal infant health, growth and development and food pattern modeling can be used to inform guideline development. We employed the Optifood modeling system to determine if unfortified complementary foods could meet 13 nutrient targets for breastfed infants (6-11 months), and to describe food patterns that met, or came as close as possible to meeting targets. We also examined the impacts of eliminating food groups, increasing starchy staple foods or adding sentinel unhealthy foods. We collated a global food list from dietary studies in 37 countries and used this list to develop nutrient values for a set of 35 food subgroups. We analyzed infant dietary intakes from studies in eight countries to inform maximum quantities and frequencies of consumption for these subgroups in weekly food patterns. We found that unfortified foods could meet targets for most infants for 12 nutrients, but not for iron. For the smallest and youngest infants, with the lowest energy intakes, there were additional deficits for minerals. Best-case food patterns that met targets or came as close as possible to meeting targets included ample amounts of diverse vegetables, diverse plant- and animal-source protein foods, small amounts of whole grain foods and dairy and no refined grains or added fats or sugar. There were nutrient deficits if animal-source foods or vegetables were eliminated or if unhealthy foods were included.

Maternal and child factors associated with child body fatness in a Ghanaian cohort.

OBJECTIVE: We aimed to identify factors (child diet, physical activity; maternal BMI) associated with body composition of Ghanaian pre-school children. DESIGN: Longitudinal analysis of the International Lipid-Based Nutrient Supplements (iLiNS)-DYAD-Ghana randomized trial, which enrolled 1320 pregnant women at ≤20 weeks' gestation and followed them and their infants until 6 and 18 months postpartum, respectively. At follow-up, child age 4-6 years, we collected data on body composition (by 2H dilution), physical activity and diet, extracted dietary patterns using factor analysis, and examined the association of children's percentage body fat with maternal and child factors by regression analysis. SETTING: Eastern Region, Ghana. PARTICIPANTS: Children 4-6 years of age. RESULTS: The analysis included 889 children with percentage body fat and dietary data at follow-up. We identified two major dietary patterns, a snacking and a cooked foods pattern. Percentage body fat was positively associated (standardized ß (se)) with maternal BMI at follow-up (0·10 (0·03); P = 0·003) and negatively associated with physical activity (-0·15 (0·05); P = 0·003, unadjusted for child gender), but not associated with the snacking (0·06 (0·03); P = 0·103) or cooked foods (-0·05 (0·07); P = 0·474) pattern. Boys were more active than girls (1470 v. 1314 mean vector magnitude counts/min; P < 0·0001) and had lower percentage body fat (13·8 v. 16·9 %; P < 0·0001). CONCLUSIONS: In this population, maternal overweight and child physical activity, especially among girls, may be key factors for addressing child overweight/obesity. We did not demonstrate a relationship between the dietary patterns and body fatness, which may be related to limitations of the dietary data available.

Maternal and Infant Lipid-Based Nutritional Supplementation Increases Height of Ghanaian Children at 4-6 Years Only if the Mother Was Not Overweight Before Conception.

BACKGROUND: Few studies have evaluated the long-term effects of nutritional supplementation during the first 1000 d of life. We previously reported that maternal and child lipid-based nutrient supplements (LNS) increased child length by 18 mo. OBJECTIVE: The aim of this study was to examine the effects of LNS on later growth and body composition at 4-6 y of age. DESIGN: This was a follow-up of children in the International Lipid-based Nutrient Supplements (iLiNS)-DYAD trial in Ghana. Women (n = 1320) at ≤20 weeks of gestation were randomly assigned to: 1) iron and folic acid during pregnancy and 200 mg calcium/d for 6 mo postpartum, 2) multiple micronutrients (1-2 RDA of 18 vitamins and minerals) during both periods, or 3) maternal LNS during both periods plus child LNS from 6 to 18 mo. At 4-6 y, we compared height, height-for-age z score (HAZ), and % body fat (deuterium dilution method) between the LNS group and the 2 non-LNS groups combined. RESULTS: Data were available for 961 children (76.5% of live births). There were no significant differences between LNS compared with non-LNS groups in height [106.7 compared with 106.3 cm (mean difference, MD, 0.36; P = 0.226)], HAZ [-0.49 compared with -0.57 (MD = 0.08; P = 0.226)], stunting (< -2 SD) [6.5 compared with 6.3% (OR = 1.00; P = 0.993)], or % body fat [15.5 compared with 15.3% (MD = 0.16; P = 0.630)]. However, there was an interaction with maternal prepregnancy BMI (kg/m2) (P-interaction = 0.046 before correction for multiple testing): among children of women with BMI < 25 , LNS children were taller than non-LNS children (+1.1 cm, P = 0.017), whereas there was no difference among children of women with BMI ≥ 25 (+0.1 cm; P = 0.874). CONCLUSIONS: There was no overall effect of LNS on height at 4-6 y in this cohort, which had a low stunting rate, but height was greater in the LNS group among children of nonoverweight/obese women. There was no adverse impact of LNS on body composition. This trial was registered at clinicaltrials.gov as NCT00970866.

Maternal and Infant Supplementation with Small-Quantity Lipid-Based Nutrient Supplements Increases Infants' Iron Status at 18 Months of Age in a Semiurban Setting in Ghana: A Secondary Outcome Analysis of the iLiNS-DYAD Randomized Controlled Trial.

Background: Interventions are needed to address iron deficiency in low-income settings. Objective: This secondary outcome analysis aimed to compare the hemoglobin (Hb) and iron status [zinc protoporphyrin (ZPP)] of children born to women enrolled in the iLiNS-DYAD trial in Ghana. Methods: Women ≤20 wk pregnant (n = 1320) were assigned to receive 60 mg Fe/d and 400 µg folic acid/d until delivery and placebo thereafter, and no supplementation for infants (IFA group); or multiple micronutrients containing 20 mg Fe/d until 6 mo postpartum and no supplementation for infants (MMN); or small-quantity lipid-based nutrient supplements (SQ-LNSs) containing 20 mg Fe/d until 6 mo postpartum, and SQ-LNSs for infants from 6 to 18 mo of age (LNS). We compared infants' Hb (g/L) and ZPP (µmol/mol heme) at 6 and 18 mo of age. Results: At 6 mo of age, groups did not differ in mean ± SD Hb (overall: 113 ± 9.9 g/L) or geometric mean (95% CI) ZPP [overall: 62.6 (60.6, 64.7)]. At 18 mo of age, mean ± SD Hb (overall: 112 ± 10.4 g/L) did not differ significantly between groups, whereas geometric mean (95% CI) ZPP was lower (P = 0.031) in the LNS group [53.9 (50.7, 57.3)] than the IFA [60.4 (56.7, 64.3)] but not the MMN [58.8 (55.6, 62.2)] group. Further, the LNS group, compared with the IFA and MMN groups combined, had a lower prevalence of elevated (>70) ZPP (27.5% compared with 35%; P = 0.02) and a marginally lower prevalence of anemia (38.7% compared with 44.9%; P = 0.06). These results generally remained unchanged when controlling for prespecified covariates or correcting for inflammation. Conclusions: In this setting, providing SQ-LNSs or multiple micronutrients with 20 mg Fe/d, compared with iron (60 mg/d) and folic acid, to pregnant women does not affect their infants' Hb or iron status at 6 mo of age, but maternal and infant supplementation with SQ-LNSs increases infants' iron status at 18 mo of age. This trial was registered at clinicaltrials.gov as NCT00970866.

Exposure to a Slightly Sweet Lipid-Based Nutrient Supplement During Early Life Does Not Increase the Preference for or Consumption of Sweet Foods and Beverages by 4-6-y-Old Ghanaian Preschool Children: Follow-up of a Randomized Controlled Trial.

BACKGROUND: Whether consuming sweet foods early in life affects sweet food preferences and consumption later in childhood is unknown. OBJECTIVE: We tested the hypothesis that exposure to a slightly sweet lipid-based nutrient supplement (LNS) early in life would not increase preference for or consumption of sweet items at preschool age. METHODS: We followed up children who had participated in a randomized trial in Ghana in which LNS was provided to 1 group of women during pregnancy and 6 mo postpartum and to their infants from ages 6-18 mo (LNS group). The control group (non-LNS group) received iron and folic acid during pregnancy or multiple micronutrients during pregnancy and 6 mo postpartum, with no infant supplementation. At 4-6 y, we obtained data from caregivers on children's food and beverage preferences and consumption (n = 985). For a randomly selected subsample (n = 624), we assessed preference for sweet items using a photo game (range in potential scores, 0-15). For the photo game and reported consumption of sweet items, we examined group differences using predetermined noninferiority margins equivalent to an effect size of 0.2. RESULTS: Median (quartile 1, quartile 3) reported consumption of sweet items (times in previous week) was 14 (8, 23) in the LNS group and 16 (9, 22) in the non-LNS group; in the photo game, the number of sweet items selected was 15 (11, 15) and 15 (11, 15), respectively. The upper level of the 95% CI of the mean difference between LNS and non-LNS groups did not exceed the noninferiority margins for these outcomes. Caregiver-reported preferences for sweet items also did not differ between groups (P = 0.9). CONCLUSION: In this setting, where child consumption of sweet foods was common, exposure to a slightly sweet LNS early in life did not increase preference for or consumption of sweet foods and beverages at preschool age. This trial was registered at clinicaltrials.gov as NCT00970866.

Prevalence thresholds for wasting, overweight and stunting in children under 5 years.

OBJECTIVE: Prevalence ranges to classify levels of wasting and stunting have been used since the 1990s for global monitoring of malnutrition. Recent developments prompted a re-examination of existing ranges and development of new ones for childhood overweight. The present paper reports from the WHO-UNICEF Technical Expert Advisory Group on Nutrition Monitoring. DESIGN: Thresholds were developed in relation to sd of the normative WHO Child Growth Standards. The international definition of 'normal' (2 sd below/above the WHO standards median) defines the first threshold, which includes 2·3 % of the area under the normalized distribution. Multipliers of this 'very low' level (rounded to 2·5 %) set the basis to establish subsequent thresholds. Country groupings using the thresholds were produced using the most recent set of national surveys. SETTING: One hundred and thirty-four countries. SUBJECTS: Children under 5 years. RESULTS: For wasting and overweight, thresholds are: 'very low' (≈6 times 2·5 %). For stunting, thresholds are: 'very low' (≈12 times 2·5 %). CONCLUSIONS: The proposed thresholds minimize changes and keep coherence across anthropometric indicators. They can be used for descriptive purposes to map countries according to severity levels; by donors and global actors to identify priority countries for action; and by governments to trigger action and target programmes aimed at achieving 'low' or 'very low' levels. Harmonized terminology will help avoid confusion and promote appropriate interventions.

The association of early linear growth and haemoglobin concentration with later cognitive, motor, and social-emotional development at preschool age in Ghana.

It is important to identify the periods during childhood when exposure to environmental risk factors results in long-term neurodevelopmental deficits. Stunting and anaemia may be sensitive indicators of exposure to such risks. In a prospective cohort enrolled before birth, we investigated the association of developmental scores at 4-6 years with (a) birth length and linear growth during three postnatal periods and (2) haemoglobin (Hb) concentration at three time points. Children were participants in a follow-up study of a randomized controlled trial of nutritional supplementation in Ghana. At 4-6 years, cognitive, motor, and social-emotional developments were assessed using standard tests adapted for this population. We estimated the associations of length-for-age z-score (LAZ) at birth and postnatal linear growth (n = 710) and Hb (n = 617) with developmental scores in regression models, using multistage least squares analysis to calculate uncorrelated residuals for postnatal growth. Cognitive development at 4-6 years was significantly associated with LAZ at birth (ß = 0.12, 95% CI = 0.05, 0.19), ΔLAZ from 6 to 18 months (ß = 0.16, 95% CI = 0.04, 0.28), and Hb at 18 months (ß = 0.13, 95% CI = 0.06, 0.20), but not with ΔLAZ during 0-6 months, ΔLAZ from 18 months to 4-6 years, Hb at 6 months, or Hb at 4-6 years. No evidence of associations with motor or social-emotional development were found. These results suggest that in similar contexts, the earlier periods prior to birth and up to 18 months are more sensitive to risk factors for long-term cognitive development associated with LAZ and Hb compared with later childhood. This may inform the optimal timing of interventions targeting improved cognitive development.

Comparison of an interactive 24-h recall and weighed food record for measuring energy and nutrient intakes from complementary foods among 9-10-month-old Malawian infants consuming lipid-based nutrient supplements.

Fortifying complementary foods with lipid-based nutrient supplements (LNS) may improve energy and nutrient intakes of infants at risk for undernutrition. We aimed to determine the relative validity of an interactive 24-h recall (i-24-HR) for assessing the impact of an LNS intervention on dietary intakes of energy and nutrients among rural Malawian 9-10-month-old infants (n 132) participating in the International Lipid-Based Nutrient Supplements Dose (iLiNS-DOSE) trial. Dietary data were collected for the same day via i-24-HR and weighed food records. Inter-method agreements were estimated overall and by intervention group, using Bland-Altman plots and paired t tests; measurement error models (differential error); and percentage of food omissions and intrusions were estimated. Overall, inter-method differences in mean intakes of energy and most nutrients were not significant. When stratified by group, recalled energy intakes were under-estimated (-368 kJ; P=0·01) in the control but not in the intervention group (-42 kJ; P=0·6). This differential reporting error was related to an over-estimation of recalled LNS (8·1 v. 4·5 g; P30 % eating occasions) omissions were milk/fish/eggs, starchy roots/vegetables and sweetened snacks. Common intrusions were milk/yogurt. Starchy staples and LNS were recalled when consumed (>85 %) (i.e. matched). These results emphasise the importance of considering differential error when interpreting dietary results in LNS trials.

Unintended effects of a targeted maternal and child nutrition intervention on household expenditures, labor income, and the nutritional status of non-targeted siblings in Ghana.

It is common for health and nutrition interventions to target specific household members and for evaluations of their effects to focus exclusively on those members. However, if a targeted intervention changes a household's utility maximization problem or influences decision-making, households might respond to the intervention in unintended ways with the potential to affect the wellbeing of non-targeted members. Using panel data from a randomized controlled nutrition trial in Ghana, we evaluate household behavioral responses to the provision of small-quantity lipid-based nutrient supplements (SQ-LNS) to mothers and their infants to prevent undernutrition. We find that targeted supplementation with SQ-LNS had a positive effect on household expenditures on food, including some nutrient-rich food groups, as well as on non-food goods and services. We also find a positive impact on labor income, particularly among fathers. We then explore intrahousehold spillover effects on the nutritional status of non-targeted young children in the household. We find evidence that the targeted provision of SQ-LNS led to higher height-for-age z-scores among non-targeted children in the LNS group compared to the non-LNS group, though only among those with relatively taller mothers, which is an indicator of a child's growth potential. These findings support existing evidence and suggest that unintended behavioral responses and spillover are a real possibility in the context of nutrition interventions targeting nutritionally-vulnerable household members. Thoughtfully considering this possibility in the design, analyses, and evaluation of targeted nutrition interventions may provide a more complete picture of overall effects.

Local foods can meet micronutrient needs for women in urban Burkina Faso, but only if rarely consumed micronutrient-dense foods are included in daily diets: A linear programming exercise.

Women of reproductive age are at nutritional risk due to their need for nutrient-dense diets. Risk is further elevated in resource-poor environments. In one such environment, we evaluated feasibility of meeting micronutrient needs of women of reproductive age using local foods alone or using local foods and supplements, while minimizing cost. Based on dietary recall data from Ouagadougou, we used linear programming to identify the lowest cost options for meeting 10 micronutrient intake recommendations, while also meeting energy needs and following an acceptable macronutrient intake pattern. We modeled scenarios with maximum intake per food item constrained at the 75th percentile of reported intake and also with more liberal maxima based on recommended portions per day, with and without the addition of supplements. Some scenarios allowed only commonly consumed foods (reported on at least 10% of recall days). We modeled separately for pregnant, lactating, and nonpregnant, nonlactating women. With maxima constrained to the 75th percentile, all micronutrient needs could be met with local foods but only when several nutrient-dense but rarely consumed items were included in daily diets. When only commonly consumed foods were allowed, micronutrient needs could not be met without supplements. When larger amounts of common animal-source foods were allowed, all needs could be met for nonpregnant, nonlactating women but not for pregnant or lactating women, without supplements. We conclude that locally available foods could meet micronutrient needs but that to achieve this, strategies would be needed to increase consistent availability in markets, consistent economic access, and demand.

Predictors of complementary feeding practices in Afghanistan: Analysis of the 2015 Demographic and Health Survey.

Despite improvements over the past 20 years, high burdens of child mortality and undernutrition still coexist in Afghanistan. Global evidence indicates that complementary feeding (CF) practices predict child survival and nutritional status. Our study aims to describe CF practices in Afghanistan and to discern underlying predictors of CF by analysing data from Afghanistan's 2015 Demographic and Healthy Survey. Multilevel models were constructed comprising potential predictors at individual, household, and community levels and four CF indicators: timely introduction of solid, semi-solid, or soft foods (INTRO), minimum meal frequency (MMF), minimum dietary diversity (MDD), and minimum acceptable diet (MAD) among breastfed children. INTRO prevalence among children aged 6-8 months was 56%, whereas the prevalence of MMF, MDD, and MAD among children aged 6-23 months was 55%, 23%, and 18%, respectively. Of the seven food groups considered, four were consumed by 20% or fewer children: eggs (20%), legumes and nuts (18%), fruits and vegetables (15%), and flesh foods (14%). Increasing child age and more antenatal care visits were significantly and positively associated with greater odds of meeting all CF indicators. Lower household wealth and lower community-level access to health care services were associated with lower odds of MDD and MAD. Disparities in achieving recommended CF practices were observed by region. CF practices in Afghanistan are poor and significant socioeconomic inequities in CF are observed across the country. Our study calls for urgent policy and programme attention to improve complementary feeding practices as an intrinsic part of the national development agenda.

Stagnating trends in complementary feeding practices in Bangladesh: An analysis of national surveys from 2004-2014.

Bangladesh has experienced steady socio-economic development. However, improvements in child growth have not kept pace. It is important to document complementary feeding (CF) practices-a key determinant of children's growth-and their trends over time. The study aims to examine trends in CF practices in children aged 6-23 months using data from Bangladesh Demographic and Health Surveys conducted in 2004, 2007, 2011, and 2014. Multilevel logistic regression models were applied to identify independent predictors of four CF practice indicators among children 6-23 months, namely, timely introduction of complementary foods, minimum meal frequency, minimum dietary diversity, and minimum acceptable diet. Introduction of complementary foods was achieved among 64-71% of children between 2004 and 2014. The proportion meeting minimum meal frequency increased from 2004 to 2007 (71-81%) and declined and held steady at 65% from 2011 to 2014. The proportion meeting minimum dietary diversity in 2011 and 2014 was low (25% and 28%), and so was minimum acceptable diet (19% and 20%). From 2007 to 2014, child dietary diversity decreased and the most decline was in the consumption of legumes and nuts (29% to 8%), vitamin A-rich fruits and vegetables (54% to 41%), and other fruits and vegetables (47% to 20%). Young child age (6-11 months), poor parental education, household poverty, and residence in the Chittagong and Sylhet independently predicted poorer feeding practices. Dietary diversity and overall diet in Bangladeshi children are strikingly poor. Stagnation or worsening of feeding practices in the past decade are concerning and call for decisive policy and programme action to address inappropriate child feeding practices.

Trends and predictors of appropriate complementary feeding practices in Nepal: An analysis of national household survey data collected between 2001 and 2014.

There is evidence that suboptimal complementary feeding contributes to poor child growth. However, little is known about time trends and determinants of complementary feeding in Nepal, where the prevalence of child undernutrition remains unacceptably high. The objective of the study was to examine the trends and predictors of suboptimal complementary feeding in Nepali children aged 6-23 months using nationally representative data collected from 2001 to 2014. Data from the 2001, 2006, and 2011 Nepal Demographic and Health Surveys and the 2014 Multiple Indicator Cluster Survey were used to estimate the prevalence, trends and predictors of four WHO-UNICEF complementary feeding indicators: timely introduction of complementary foods (INTRO), minimum meal frequency (MMF), minimum dietary diversity (MDD), and minimum acceptable diet (MAD). We used multilevel logistic regression models to identify independent factors associated with these indicators at the individual, household and community levels. In 2014, the weighted proportion of children meeting INTRO, MMF, MDD, and MAD criteria were 72%, 82%, 36% and 35%, respectively, with modest average annual rate of increase ranging from 1% to 2%. Increasing child age, maternal education, antenatal visits, and community-level access to health care services independently predicted increasing odds of achieving MMF, MDD, and MAD. Practices also varied by ecological zone and sociocultural group. Complementary feeding practices in Nepal have improved slowly in the past 15 years. Inequities in the risk of inappropriate complementary feeding are evident, calling for programme design and implementation to address poor feeding and malnutrition among the most vulnerable Nepali children.

Willingness to pay for small-quantity lipid-based nutrient supplements for women and children: Evidence from Ghana and Malawi.

Small-quantity lipid-based nutrient supplements (SQ-LNS) are designed to enrich maternal and child diets with the objective of preventing undernutrition during the first 1,000 days. Scaling up the delivery of supplements such as SQ-LNS hinges on understanding private demand and creatively leveraging policy-relevant factors that might influence demand. We used longitudinal stated willingness-to-pay (WTP) data from contingent valuation studies that were integrated into randomized controlled nutrition trials in Ghana and Malawi to estimate private valuation of SQ-LNS during pregnancy, postpartum, and early childhood. We found that average stated WTP for a day's supply of SQ-LNS was more than twice as high in Ghana than Malawi, indicating that demand for SQ-LNS (and by extension, the options for effective delivery of SQ-LNS) may be very context specific. We also examined factors associated with WTP, including intervention group, household socioeconomic status, birth outcomes, child growth, and maternal and child morbidity. In both sites, WTP was consistently negatively associated with household food insecurity, indicating that subsidization might be needed to permit food insecure households to acquire SQ-LNS if it is made available for purchase. In Ghana, WTP was higher among heads of household than among mothers, which may be related to control over household resources. Personal experience using SQ-LNS was not associated with WTP in either site.

Association between breast milk intake at 9-10 months of age and growth and development among Malawian young children.

World Health Organization recommends exclusive breastfeeding for infants for the first 6 months of life, followed by introduction of nutritious complementary foods alongside breastfeeding. Breast milk remains a significant source of nourishment in the second half of infancy and beyond; however, it is not clear whether more breast milk is always better. The present study was designed to determine the association between amount of breast milk intake at 9-10 months of age and infant growth and development by 12-18 months of age. The study was nested in a randomized controlled trial conducted in Malawi. Regression analysis was used to determine associations between breast milk intake and growth and development. Mean (SD) breast milk intake at 9-10 months of age was 752 (244) g/day. Mean (SD) length-for-age z-score at 12 months and change in length-for-age z-score between 12 and 18 months were -1.69 (1.0) and -0.17 (0.6), respectively. At 18 months, mean (SD) expressive vocabulary score was 32 (24) words and median (interquartile range) skills successfully performed for fine, gross, and overall motor skills were 21 (19-22), 18 (16-19), and 38 (26-40), respectively. Breast milk intake (g/day) was not associated with either growth or development. Proportion of total energy intake from breast milk was negatively associated with fine motor (ß = -0.18, p = .015) but not other developmental scores in models adjusted for potential confounders. Among Malawian infants, neither breast milk intake nor percent of total energy intake from breast milk at 9-10 months was positively associated with subsequent growth between 12 and 18 months, or development at 18 months.

Ghanaian parents' perceptions of pre and postnatal nutrient supplements and their effects.

Small-quantity lipid-based nutrient supplements (SQ-LNS) have been studied in efficacy and effectiveness trials, but little is known about how parents perceive the products and their effects. In a randomised trial in Ghana, efficacy of SQ-LNS provided to women during pregnancy and the first 6 months postpartum and to their children from 6 to 18 months of age was assessed by comparison with iron-folic acid (IFA) capsules and multiple micronutrient (MMN) capsules provided to women. In a follow-up study conducted when the index children from the original trial were between 4 and 6 years of age, we used survey-based methods to assess retrospective and current parental perceptions of nutrient supplements generally and of SQ-LNS and their effects compared with perceptions IFA and MMN capsules. Most parents perceived that the assigned supplements (SQ-LNS, IFA, or MMN) positively impacted the mother during pregnancy (approximately 89% of both mothers and fathers) and during lactation (84% of mothers and 86% of fathers). Almost all (≥90%) of mothers and fathers perceived that the assigned supplement positively impacted the index child and expected continued positive impacts on the child's health and human capital into the future. A smaller percentage of parents perceived negative impacts of the supplements (7%-17% of mothers and 4%-12% of fathers). Perceptions of positive impacts and of negative impacts did not differ by intervention group. The results suggest that similar populations would likely be receptive to programs to deliver SQ-LNS or micronutrient capsules.

Maternal Supplementation with Small-Quantity Lipid-Based Nutrient Supplements Compared with Multiple Micronutrients, but Not with Iron and Folic Acid, Reduces the Prevalence of Low Gestational Weight Gain in Semi-Urban Ghana: A Randomized Controlled Trial.

Background: It is unclear whether maternal supplementation with small-quantity lipid-based nutrient supplements (SQ-LNSs; 118 kcal/d) affects maternal weight.Objective: We compared several secondary anthropometric measures between 3 groups of women in the iLiNS (International Lipid-based Nutrient Supplements)-DYAD trial in Ghana.Methods: Women (n = 1320; <20 wk of gestation) were randomly assigned to receive 60 mg Fe + 400 µg folic acid/d (IFA), 18 vitamins and minerals/d [multiple micronutrients (MMNs)], or 20 g SQ-LNSs with 22 micronutrients/d (LNS) during pregnancy and a placebo (200 mg Ca/d), MMNs, or SQ-LNSs, respectively, for 6 mo postpartum. Weight, midupper arm circumference (MUAC), and triceps skinfold (TSF) thickness at 36 wk of gestation and 6 mo postpartum were analyzed, as were changes from estimated prepregnancy values. We assessed the adequacy of estimated gestational weight gain (GWG) by using Institute of Medicine (IOM) and International Fetal and Newborn Growth Standards for the 21st Century (INTERGROWTH-21st) guidelines.Results: The estimated prepregnancy prevalence of overweight or obesity was 38.5%. By 36 wk of gestation, women (n = 1015) had a mean ± SD weight gain of 7.4 ± 3.7 kg and changes of -1.0 ± 1.7 cm in MUAC and -2.8 ± 4.1 mm in TSF thickness. The LNS group had a lower prevalence of inadequate GWG on the basis of IOM guidelines (57.4%) than the MMN (67.2%) but not the IFA (63.1%) groups (P = 0.030), whereas the prevalence of adequate (26.9% overall) and excessive (10.4% overall) GWG did not differ by group. The percentages of normal-weight women (in kg/m2: 18.5 < body mass index < 25.0; n = 754) whose GWG was less than the third centile of the INTERGROWTH-21st standards were 23.0%, 28.7%, and 28.5% for the LNS, MMN, and IFA groups, respectively (P = 0.36). At 6 mo postpartum, the prevalence of overweight or obesity was 45.3%, and the risk of becoming overweight or obese did not differ by group.Conclusion: SQ-LNS supplementation is one potential strategy to address the high prevalence of inadequate GWG in women in settings similar to Ghana, without increasing the risk of excessive GWG. This trial was registered at clinicaltrials.gov as NCT00970866.

Maternal and Child Supplementation with Lipid-Based Nutrient Supplements, but Not Child Supplementation Alone, Decreases Self-Reported Household Food Insecurity in Some Settings.

Background: It is unknown whether self-reported measures of household food insecurity change in response to food-based nutrient supplementation.Objective: We assessed the impacts of providing lipid-based nutrient supplements (LNSs) to women during pregnancy and postpartum and/or to their children on self-reported household food insecurity in Malawi [DOSE and DYAD trial in Malawi (DYAD-M)], Ghana [DYAD trial in Ghana (DYAD-G)], and Bangladesh [Rang-Din Nutrition Study (RDNS) trial].Methods: Longitudinal household food-insecurity data were collected during 3 individually randomized trials and 1 cluster-randomized trial testing the efficacy or effectiveness of LNSs (generally 118 kcal/d). Seasonally adjusted Household Food Insecurity Access Scale (HFIAS) scores were constructed for 1127 DOSE households, 732 DYAD-M households, 1109 DYAD-G households, and 3671 RDNS households. The impact of providing LNSs to women during pregnancy and the first 6 mo postpartum and/or to their children from 6 to 18-24 mo on seasonally adjusted HFIAS scores was assessed by using negative binomial models (DOSE, DYAD-M, and DYAD-G trials) and mixed-effect negative binomial models (RDNS trial).Results: In the DOSE and DYAD-G trials, seasonally adjusted HFIAS scores were not different between the LNS and non-LNS groups. In the DYAD-M trial, the average household food-insecurity scores were 14% lower (P = 0.01) in LNS households than in non-LNS households. In the RDNS trial, compared with non-LNS households, food-insecurity scores were 17% lower (P = 0.02) during pregnancy and the first 6 mo postpartum and 15% lower (P = 0.02) at 6-24 mo postpartum in LNS households.Conclusions: The daily provision of LNSs to mothers and their children throughout much of the "first 1000 d" may improve household food security in some settings, which could be viewed as an additional benefit that may accrue in households should policy makers choose to invest in LNSs to promote child growth and development. These trials were registered at clinicaltrials.gov as NCT00945698 (DOSE) NCT01239693 (DYAD-M), NCT00970866 (DYAD-G) and NCT01715038 (RDNS).

Predictors and pathways of language and motor development in four prospective cohorts of young children in Ghana, Malawi, and Burkina Faso.

BACKGROUND: Previous reviews have identified 44 risk factors for poor early child development (ECD) in low- and middle-income countries. Further understanding of their relative influence and pathways is needed to inform the design of interventions targeting ECD. METHODS: We conducted path analyses of factors associated with 18-month language and motor development in four prospective cohorts of children who participated in trials conducted as part of the International Lipid-Based Nutrient Supplements (iLiNS) Project in Ghana (n = 1,023), Malawi (n = 675 and 1,385), and Burkina Faso (n = 1,122). In two cohorts, women were enrolled during pregnancy. In two cohorts, infants were enrolled at 6 or 9 months. In multiple linear regression and structural equation models (SEM), we examined 22 out of 44 factors identified in previous reviews, plus 12 additional factors expected to be associated with ECD. RESULTS: Out of 42 indicators of the 34 factors examined, 6 were associated with 18-month language and/or motor development in 3 or 4 cohorts: child linear and ponderal growth, variety of play materials, activities with caregivers, dietary diversity, and child hemoglobin/iron status. Factors that were not associated with child development were indicators of maternal Hb/iron status, maternal illness and inflammation during pregnancy, maternal perceived stress and depression, exclusive breastfeeding during 6 months postpartum, and child diarrhea, fever, malaria, and acute respiratory infections. Associations between socioeconomic status and language development were consistently mediated to a greater extent by caregiving practices than by maternal or child biomedical conditions, while this pattern for motor development was not consistent across cohorts. CONCLUSIONS: Key elements of interventions to ensure quality ECD are likely to be promotion of caregiver activities with children, a variety of play materials, and a diverse diet, and prevention of faltering in linear and ponderal growth and improvement in child hemoglobin/iron status.

Dietary gap assessment: an approach for evaluating whether a country's food supply can support healthy diets at the population level.

OBJECTIVE: Dietary diversity, and in particular consumption of nutrient-rich foods including fruits, vegetables, nuts, beans and animal-source foods, is linked to greater nutrient adequacy. We developed a 'dietary gap assessment' to evaluate the degree to which a nation's food supply could support healthy diets at the population level. Design/Setting In the absence of global food-based dietary guidelines, we selected the Dietary Approaches to Stop Hypertension (DASH) diet as an example because there is evidence it prevents diet-related chronic disease and supports adequate micronutrient intakes. We used the DASH guidelines to shape a hypothetical 'healthy' diet for the test country of Cameroon. Food availability was estimated using FAO Food Balance Sheet data on country-level food supply. For each of the seven food groups in the 'healthy' diet, we calculated the difference between the estimated national supply (in kcal, edible portion only) and the target amounts. RESULTS: In Cameroon, dairy and other animal-source foods were not adequately available to meet healthy diet recommendations: the deficit was -365 kcal (-1527 kJ)/capita per d for dairy products and -185 kcal (-774 kJ)/capita per d for meat, poultry, fish and eggs. Adequacy of fruits and vegetables depended on food group categorization. When tubers and plantains were categorized as vegetables and fruits, respectively, supply nearly met recommendations. Categorizing tubers and plantains as starchy staples resulted in pronounced supply shortfalls: -109 kcal (-457 kJ)/capita per d for fruits and -94 kcal (-393 kJ)/capita per d for vegetables. CONCLUSIONS: The dietary gap assessment illustrates an approach for better understanding how food supply patterns need to change to achieve healthier dietary patterns.