High proportions of children under 3 years of age consume commercially produced snack foods and sugar-sweetened beverages in Bandung City, Indonesia.

Child undernutrition continues to be a national concern in Indonesia, whereas childhood overweight/obesity rises. Economic development has led to wide availability of highly processed foods and beverages, with growing evidence that children are consuming commercial snack products during the critical complementary feeding period. This study assessed the prevalence and patterns of consumption of commercially produced snack foods and sugar-sweetened beverages among Indonesian children. A cross-sectional survey was conducted with 495 mothers of children aged 6-35 months living in Bandung City, Indonesia. Among all children, 81.6% consumed a commercial snack food and 40.0% consumed a sugar-sweetened beverage in the day preceding the interview. At 6-11 months, 46.5% of children consumed a snack food and 2.0% consumed a sugar-sweetened beverage. Snack foods were consumed 3 or more times a day by 60.0% of children 24-35 months of age. Sweet biscuits and savory snacks were the most commonly consumed snack foods; sweetened milks and sweetened teas were the most common beverages. Maternal education, child age, and consumption of a commercially produced complementary food were associated with snack food consumption. Factors associated with sugar-sweetened beverage consumption were child age and consumption of a commercially produced complementary food or breastmilk substitute. These findings reflect a high presence of processed, high-sugar/salt commercial snack products in the diets of children 6-35 months. National attention should focus on interventions to reduce reliance on processed snack products and increase consumption of nutrient-rich, locally available foods during the complementary feeding period.

Commercially produced complementary foods in Bandung City, Indonesia, are often reported to be iron fortified but with less than recommended amounts or suboptimal forms of iron.

Commercially produced complementary foods (CPCF) that are iron fortified can help improve iron status of young children. We conducted a review of 217 CPCF sold in 42 stores in Bandung, Indonesia, in 2017. There were 95 (44%) infant cereals, 71 (33%) snacks or finger foods (biscuits or cookies, puffs, and noodles or crackers), 35 (16%) purees, and 16 (7%) other foods for which we obtained label information. Nearly 70% of CPCF reported iron content on their labels, but only 58% of products were reported to be fortified with iron according to ingredient lists. Among iron-fortified products, only one fifth indicated a specific type of iron used as the fortificant, but all of these were recommended by the World Health Organization for fortifying complementary foods. Infant cereal was more likely to contain added iron (81%) compared with snacks or finger food (58%) and purees (14%) and had higher iron content per median serving size (cereal = 3.8 mg, snacks or finger food = 1.3 mg, mixed meals = 2.7 mg, and purees = 0.9 mg). Infant cereal was most likely to meet the recommended daily intakes for iron (41% for infants 6-12 months of age and 66% for children 12-36 months) compared with snacks or finger food (infants = 14%, children = 22%), mixed meals (infants = 28%, children = 46%), or purees (infants = 9%, children = 15%). Regulations on fortification of complementary foods need to specify minimum levels and forms of iron and require reporting in relation to requirements by child age and serving size. Monitoring and enforcement of regulations will be essential to ensure compliance.

Predictors of breast milk substitute feeding among newborns in delivery facilities in urban Cambodia and Nepal.

Introducing breast milk substitutes (BMS) in the first days after birth can increase infant morbidity and reduce duration and exclusivity of breastfeeding. This study assessed determinants of BMS feeding among newborns in delivery facilities in Phnom Penh, Cambodia, and Kathmandu Valley, Nepal. Cross-sectional surveys were conducted among mothers upon discharge from health facilities after delivery: 304 mothers in Kathmandu Valley and 306 mothers in Phnom Penh participated. On the basis of a conceptual framework for prelacteal feeding, multivariable logistic regression was used to identify factors associated with BMS feeding prior to facility discharge. In both Phnom Penh and Kathmandu Valley, feeds of BMS were reported by over half of mothers (56.9% and 55.9%, respectively). Receiving a health professional's recommendation to use BMS increased the odds of BMS feeding in both Kathmandu Valley and Phnom Penh (odds ratio: 24.87; confidence interval [6.05, 102.29]; odds ratio: 2.42; CI [1.20, 4.91], respectively). In Kathmandu Valley, recommendations from friends/family and caesarean delivery were also associated with BMS use among mothers. Early initiation of breastfeeding and higher parity were protective against the use of BMS in Kathmandu Valley. Breastfeeding support from a health professional lowered the odds of BMS feeding among newborns. Exposure to BMS promotions outside the health system was prevalent in Phnom Penh (84.6%) and Kathmandu Valley (27.0%) but was not associated with BMS feeds among newborns. Establishment of successful breastfeeding should be prioritized before discharging mothers from delivery facilities, and health professionals should be equipped to support and encourage breastfeeding among all new mothers.

Prevalence, duration, and content of television advertisements for breast milk substitutes and commercially produced complementary foods in Phnom Penh, Cambodia and Dakar, Senegal.

Promotion of breast milk substitutes (BMS) and inappropriate marketing of commercially produced complementary foods (CPCF), including through television, can negatively influence infant and young child feeding. The World Health Organization International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly (WHA) resolutions prohibit such advertising and require manufacturers and distributors to comply with its provisions; however, such regulations at national level may vary. Advertisements require Ministry of Health approval in Cambodia but are not regulated in Senegal. Television stations were monitored for 13 months in Phnom Penh and for 3 months in Dakar to assess advertisements for BMS and CPCF. Ten television channels (out of 16) in Phnom Penh and four (out of 20) in Dakar aired advertisements for BMS. Three and five channels, respectively, aired advertisements for CPCF. All BMS advertised in Phnom Penh were for children over 1 year of age. BMS products for children 6+ months of age and 1+ years of age were advertised in Dakar. Average air time for BMS advertisements was 189.5 min per month in Phnom Penh and 29.7 min in Dakar. Air time for CPCF advertisements averaged 3.2 min per month and 13.6 min, respectively. Fewer than half of BMS advertisements and three quarters of CPCF advertisements explicitly stated an age of use for products. Nutrition and health claims were common across BMS advertisements. This study illustrates the need to adopt, regulate, monitor, and enforce legislation prohibiting BMS promotion, as well as to implement regulations to prevent inappropriate promotion of CPCF.

Consumption of commercially produced snack foods and sugar-sweetened beverages during the complementary feeding period in four African and Asian urban contexts.

The availability and consumption of commercially produced foods and beverages have increased across low-income and middle-income countries. This cross-sectional survey assessed consumption of commercially produced foods and beverages among children 6-23 months of age, and mothers' exposure to promotions for these products. Health facility-based interviews were conducted among 218 randomly sampled mothers utilizing child health services in Dakar, Senegal; 229 in Dar es Salaam, Tanzania; 228 in Kathmandu Valley, Nepal; and 222 in Phnom Penh, Cambodia. In the day prior to the interview, 58.7% of 6-23-month-olds in Dakar, 23.1% in Dar es Salaam, 74.1% in Kathmandu Valley, and 55.0% in Phnom Penh had consumed a commercially produced snack food. In the previous week, the majority of children in Dakar (79.8%), Kathmandu Valley (91.2%), and Phnom Penh (80.6%) had consumed such products. Consumption of commercially produced sugar-sweetened beverages was noted among 32.0% of Phnom Penh, 29.8% of Dakar, 23.1% of Dar es Salaam, and 16.2% of Kathmandu Valley children. Maternal education was negatively associated with commercial snack food consumption in Dakar and Kathmandu Valley. Children of Phnom Penh mothers in the lowest wealth tercile were 1.5 times more likely to consume commercial snack food products, compared to wealthier mothers. These snack consumption patterns during the critical complementary feeding period demand attention; such products are often high in added sugars and salt, making them inappropriate for infants and young children.

Promotion and prelacteal feeding of breastmilk substitutes among mothers in Kathmandu Valley, Nepal.

UNLABELLED: In 1992, Nepal passed the Mother's Milk Substitutes (Control of Sale and Distribution) Act in order to regulate the sale, distribution and promotion of substitutes for breastmilk within Nepal, in an effort to protect and promote breastfeeding. Helen Keller International, in collaboration with Nepal's Ministry of Health and Population's Child Health Division, implemented a study to assess mothers' exposure to promotions for and utilization of breastmilk substitutes in Kathmandu Valley, Nepal. A health facility-based, cross-sectional survey was conducted among 304 mothers being discharged after delivery. Prelacteal feeding of breastmilk substitutes is prevalent (55.9% of mothers, n = 170). Reported recommendations during antenatal checks and after delivery from health professionals to use breastmilk substitutes were prevalent, occurring among 47.4% (n = 144) of mothers; rates of these recommendations were significantly higher for mothers that delivered in private health facilities, as compared with public (67.7% vs. 38.0%, P < 0.001). Mothers that received a recommendation to use a breastmilk substitute from a health worker were 16.7 times more likely to provide a prelacteal feed of a breastmilk substitute, as compared with mothers that did not receive a recommendation (P < 0.001). Few mothers reported observation of commercial advertisements for breastmilk substitutes inside a health facility (reported by 3.6% of mothers). No mothers reported receiving a sample of a breastmilk substitute, bottle or teat from a health professional. More information is needed to determine why there is such a high rate of health worker recommendations for breastmilk substitute use in the first few days after delivery. KEY MESSAGES: While utilization of breastmilk substitutes is low among mothers of young children in Nepal, prelacteal feeding of breastmilk substitutes is highly prevalent in Kathmandu Valley. Reported recommendations from health professionals to use breastmilk substitutes are common (over 40%) and are associated with prelacteal feeding among Nepal mothers included in this study. Provision of lactation management training to health workers and monitoring their practices regularly could strengthen breastfeeding counselling, aid in reducing high rates of prelacteal feeding and contribute to improved infant feeding practices.

Pervasive promotion of breastmilk substitutes in Phnom Penh, Cambodia, and high usage by mothers for infant and young child feeding.

UNLABELLED: In 2005, Cambodia passed the Sub-Decree on Marketing of Products for Infant and Young Child Feeding (no. 133) to regulate promotion of commercial infant and young child food products, including breastmilk substitutes. Helen Keller International assessed mothers' exposure to commercial promotions for breastmilk substitutes and use of these products through a cross-sectional survey among 294 mothers of children less than 24 months of age. Eighty-six per cent of mothers reported observing commercial promotions for breastmilk substitutes, 19.0% reported observing infant and young child food product brands/logos on health facility equipment and 18.4% reported receiving a recommendation from a health professional to use a breastmilk substitute. Consumption of breastmilk substitutes was high, occurring among 43.1% of children 0-5 months and 29.3% of children 6-23 months of age. Findings also indicated a need to improve breastfeeding practices among Phnom Penh mothers. Only 36.1% of infants 0-5 months of age were exclusively breastfed, and 12.5% of children 20-23 months of age were still breastfed. Children that received a breastmilk substitute as a prelacteal feed were 3.9 times more likely to be currently consuming a breastmilk substitute than those who did not. Despite restriction of commercial promotions for breastmilk substitutes without government approval, occurrence of promotions is high and use is common among Phnom Penh mothers. In a country with high rates of child malnutrition and pervasive promotions in spite of restrictive national law, full implementation of Cambodia's Sub-Decree 133 is necessary, as are policies and interventions to support exclusive and continued breastfeeding. KEY MESSAGES: Despite prohibition without specific approval by the national government, companies are pervasively promoting breast-milk substitutes in Phnom Penh, particularly on television and at points of sale. Strengthened implementation and enforcement of Cambodia's subdecree 133 are needed to better regulate promotion in order to protect breastfeeding for the nutrition and health of infants and young children in Cambodia. Mothers who used a breast-milk substitute as a prelacteal feed were 3.9 times more likely to currently feed this same child a breast-milk substitute, as compared with mothers who did not provide breast-milk substitute as a prelacteal feed. Supporting breastfeeding among mothers after delivery is critical to establish and sustain optimal breastfeeding practices. Use of breast-milk substitutes is also very common among mothers of children under 2 years of age in Phnom Penh. We recommend promoting exclusive and continued breastfeeding as beneficial to children's health and development, and supporting policy and workplace environments that enable breastfeeding up to and beyond 24 months of age.

High use of commercial food products among infants and young children and promotions for these products in Cambodia.

Despite national improvements in child survival, 40% of Cambodian children less than 5 years of age are stunted. Commercially produced complementary foods could be nutritionally beneficial for young children in Cambodia if fortified and of optimal nutrient composition. However, other nutrient-poor commercially produced snack foods may be detrimental to young child feeding by displacing consumption of other nutritious foods. This study assessed consumption of commercial food products among infants and young children and their mothers' exposure to promotions for these products. A cross-sectional survey was conducted among 294 mothers of children less than 24 months of age living in Phnom Penh. Of children 6-23 months of age, 55.0% consumed a commercially produced snack food product on the prior day, and 80.6% had consumed one in the prior week. Only 12 (5.4%) children 6-23 months of age had consumed a commercially produced complementary food. Almost all mothers (96.9%) had observed a promotion for a commercially produced snack food product, and 29.3% reported observation of a promotion for a commercial complementary food. Only one-third (32.9%) of children 6-23 months of age achieved a minimum acceptable diet. Findings indicate that there is a need to improve infant and young child feeding practices among children less than 24 months of age living in Phnom Penh. Nutritious options should be promoted, and consumption of unhealthy commercially produced snack food products should be discouraged.

High consumption of commercial food products among children less than 24 months of age and product promotion in Kathmandu Valley, Nepal.

Commercially produced complementary foods can help improve nutritional status of young children if they are appropriately fortified and of optimal nutrient composition. However, other commercially produced snack food products may be nutritionally detrimental, potentially increasing consumption of foods high in salt or sugar and displacing consumption of other more nutritious options. Helen Keller International, in collaboration with the Nepal government, implemented a study to assess mothers' utilization of commercial food products for child feeding and exposure to commercial promotions for these products. A cross-sectional survey was conducted among 309 mothers of children less than 24 months of age across 15 health facilities. Utilization of breastmilk substitutes was low, having been consumed by 6.2% of children 0-5 months of age and 7.5% of children 6-23 months of age. Approximately one-fourth (24.6%) of children 6-23 months age had consumed a commercially produced complementary food in the prior day. Twenty-eight percent of mothers reported observing a promotion for breastmilk substitutes, and 20.1% reported promotions for commercially produced complementary foods. Consumption of commercially produced snack food products was high at 74.1% of children 6-23 months. Promotions for these same commercially produced snack food products were highly prevalent in Kathmandu Valley, reported by 85.4% of mothers. In order to improve diets during the complementary feeding period, development of national standards for complementary food products is recommended. Nutritious snack options should be promoted for the complementary feeding period; consumption of commercially produced snack food products high in sugar and salt and low in nutrients should be discouraged.

Infant and young child feeding practices among children under 2 years of age and maternal exposure to infant and young child feeding messages and promotions in Dar es Salaam, Tanzania.

There are limited data describing infant and young child feeding practices (IYCF) in urban Tanzania. This study assessed the types of foods consumed by children under 2 years of age and maternal exposure to promotions of these foods in Dar es Salaam, Tanzania. A cross-sectional survey was conducted among 305 mothers of children less than 24 months of age who attended child health services in October and November, 2014. Among infants less than 6 months of age, rates of exclusive breastfeeding were low (40.8%) and a high proportion (38.2%) received semi-solid foods. Continued breastfeeding among 20-23-month-olds was only 33.3%. Consumption of breastmilk substitutes was not prevalent, and only 3.9% of infants less than 6 months of age and 4.8% of 6-23 month-olds were fed formula. Among 6-23-month-olds, only 38.4% consumed a minimum acceptable diet (using a modified definition). The homemade complementary foods consumed by the majority of 6-23-month-olds (85.2%) were cereal-dominated and infrequently contained micronutrient-rich ingredients. Only 3.1% of 6-23-month-olds consumed commercially produced infant cereal on the day preceding the interview. In contrast, commercially produced snack foods were consumed by 23.1% of 6-23-month-olds. Maternal exposure to commercial promotions of breastmilk substitutes and commercially produced complementary foods was low (10.5% and 1.0%, respectively), while exposure to promotions of commercially produced snack foods was high (45.9%). Strategies are needed to improve IYCF practices, particularly with regard to exclusive and continued breastfeeding, increased dietary diversity and consumption of micronutrient-rich foods, and avoidance of feeding commercially produced snack foods.

Promotion and consumption of commercially produced foods among children: situation analysis in an urban setting in Senegal.

This study assessed the promotion of commercially produced foods and consumption of these products by children less than 24 months of age in Dakar Department, Senegal. Interviews with 293 mothers of children attending child health clinics assessed maternal exposure to promotion and maternal recall of foods consumed by the child on the preceding day. Promotion of breastmilk substitutes and commercially produced complementary foods outside health facilities was common with 41.0% and 37.2% of mothers, respectively, reporting product promotions since the birth of their youngest child. Promotion of commercially produced snack food products was more prevalent, observed by 93.5% of mothers. While all mothers reported having breastfed their child, only 20.8% of mothers breastfed their newborn within the first hour after delivery, and 44.7% fed pre-lacteal feeds in the first 3 days after delivery. Of children 6-23 months of age, 20.2% had consumed a breastmilk substitute; 49.1% ate a commercially produced complementary food, and 58.7% ate a commercially produced snack food product on the previous day. There is a need to stop the promotion of breastmilk substitutes, including infant formula, follow-up formula, and growing-up milks. More stringent regulations and enforcement could help to eliminate such promotion to the public through the media and in stores. Promotion of commercial snack foods is concerning, given the high rates of consumption of such foods by children under the age of 2 years. Efforts are needed to determine how best to reduce such promotion and encourage replacement of these products with more nutritious foods.

Point-of-sale promotion of breastmilk substitutes and commercially produced complementary foods in Cambodia, Nepal, Senegal and Tanzania.

UNLABELLED: In order to assess the prevalence of point-of-sale promotions of infant and young child feeding products in Phnom Penh, Cambodia; Kathmandu Valley, Nepal; Dakar Department, Senegal; and Dar es Salaam, Tanzania, approximately 30 retail stores per site, 121 in total, were visited. Promotional activity for breastmilk substitutes (BMS) and commercially produced complementary foods in each site were recorded. Point-of-sale promotion of BMS occurred in approximately one-third of sampled stores in Phnom Penh and Dakar Department but in 3.2% and 6.7% of stores in Kathmandu Valley and Dar es Salaam, respectively. Promotion of commercially produced complementary foods was highly prevalent in Dakar Department with half of stores having at least one promotion, while promotions for these products occurred in 10% or less of stores in the other three sites. While promotion of BMS in stores is legal in Senegal, it is prohibited in Cambodia without prior permission of the Ministry of Health/Ministry of Information and prohibited in both Nepal and Tanzania. Strengthening legislation in Senegal and enforcing regulations in Cambodia could help to prevent such promotion that can negatively affect breastfeeding practices. KEY MESSAGES: Even in countries such as Cambodia, Nepal and Tanzania where point-of-sale promotion is restricted, promotions of BMS were observed (in nearly one-third of stores in Phnom Penh and less than 10% in Dar es Salaam and Kathmandu). Limited promotion of commercially produced complementary foods was evident (less than 10% of stores had a promotion for such foods), except in Dakar Department, where promotions were found in half of stores. Efforts are needed to strengthen monitoring, regulation and enforcement of restrictions on the promotion of BMS. Manufacturers and distributors should take responsibility for compliance with national regulations and global policies pertaining to the promotion of breastmilk substitutes.

The Impact of Marketing of Breast-Milk Substitutes on WHO-Recommended Breastfeeding Practices.

BACKGROUND: Suboptimal breastfeeding results in 800 000 child deaths annually. There are multiple causes of suboptimal breastfeeding, including marketing of breast-milk substitutes. OBJECTIVES: To describe sales and marketing of breast-milk substitutes and their influence on World Health Organization-recommended breastfeeding behaviors, focusing on low- and middle-income countries. METHODS: Literature review. RESULTS: Global sales of breast-milk substitutes reached US$40 billion in 2013. Growth in sales exceeds 10% annually in many low- and middle-income countries, while it is close to stagnant in high-income countries. Breast-milk substitutes are marketed directly to consumers via mass media and print advertisements and indirectly via incentives, free supplies, and promotions to and through health workers and facilities, retailers, and policy makers. Internet marketing via company web sites and social media is on the rise. Marketing influences social norms by making formula use seem to be extensive, modern, and comparable to or better than breast milk. Clear evidence of a negative impact is found when breast-milk substitutes are provided for free in maternity facilities and when they are promoted by health workers and in the media. Influences through other channels are plausible, but rigorous studies are lacking. It was not possible with the data available to quantify the impact of marketing relative to other factors on suboptimal breastfeeding behaviors. Marketing remains widespread even in countries that have adopted the International Code of Marketing of Breast-milk Substitutes to restrict such activities. CONCLUSION: Adoption of stricter regulatory frameworks coupled with independent, quantitative monitoring and compliance enforcement are needed to counter the impacts of formula marketing globally.

Babies, soft drinks and snacks: a concern in low- and middle-income countries?

Undernutrition in infants and young children is a global health priority while overweight is an emerging issue. Small-scale studies in low- and middle-income countries have demonstrated consumption of sugary and savoury snack foods and soft drinks by young children. We assessed the proportion of children 6-23 months of age consuming sugary snack foods in 18 countries in Asia and Africa using data from selected Demographic and Health Surveys and household expenditures on soft drinks and biscuits using data from four Living Standards Measurement Studies (LSMS). Consumption of sugary snack foods increased with the child's age and household wealth, and was generally higher in urban vs. rural areas. In one-third of countries, >20% of infants 6-8 months consumed sugary snacks. Up to 75% of Asian children and 46% of African children consumed these foods in the second year of life. The proportion of children consuming sugary snack foods was generally higher than the proportion consuming fortified infant cereals, eggs or fruit. Household per capita daily expenditures on soft drinks ranged from $0.03 to $0.11 in three countries for which LSMS data were available, and from $0.01 to $0.04 on biscuits in two LSMS. Future surveys should include quantitative data on the purchase and consumption of snack foods by infants and young children, using consistent definitions and methods for identifying and categorising snack foods across surveys. Researchers should assess associations between snack food consumption and stunting and overweight, and characterise household, maternal and child characteristics associated with snack food consumption.

Modelling linoleic acid and α-linolenic acid requirements for infants and young children in developing countries.

Essential fatty acids (EFAs), linoleic acid (LA) and α-linolenic acid (ALA), play a critical role in the growth and development of infants and young children. However, national guidelines for recommended intakes of EFAs are lacking in most developing countries. The objective of this study was to convert international EFA recommendations based on % of daily energy intake to recommended daily amounts for children aged 6-23 months in developing countries. The Food and Agriculture Organization (FAO) reports adequate intakes (AIs) for ALA as 0.4-0.6% of energy intake for children 6-23 months of age and as 3.0-4.5% of energy intake for LA. In order to estimate energy intakes, FAO daily energy requirements based on body weight were used. The daily AI amounts for these EFAs were calculated using the median body weight of the World Health Organization (WHO) Growth Standard population and median body weights with varying levels of malnutrition. The AI for ALA is equivalent to 0.3-0.4, 0.3-0.5 and 0.4-0.6 g day(-1), and the AI for LA is equivalent to 2.1-3.1, 2.4-3.5 and 2.8-4.3 g day(-1) for children aged 6-8, 9-11 and 12-23 months, respectively. While the lower median body weights of children in developing countries and associated reduced energy intake recommendations give lower estimated EFA requirements, recommendations based on median body weights in the WHO Reference Growth Standard is suggested. The upper levels of these calculated AIs are lower than or equal to those in North America (ALA: 0.5 and 0.7 g day(-1); LA: 4.6 and 7 g day(-1) for children aged 6-12 months and 1-3 years, respectively). The FAO AIs (g day(-1)) calculated here for ALA and LA can serve as a guideline for developing countries for setting national standards.

Nutrition in pregnancy and early childhood and associations with obesity in developing countries.

Concerns about the increasing rates of obesity in developing countries have led many policy makers to question the impacts of maternal and early child nutrition on risk of later obesity. The purposes of the review are to summarise the studies on the associations between nutrition during pregnancy and infant feeding practices with later obesity from childhood through adulthood and to identify potential ways for preventing obesity in developing countries. As few studies were identified in developing countries, key studies in developed countries were included in the review. Poor prenatal dietary intakes of energy, protein and micronutrients were shown to be associated with increased risk of adult obesity in offspring. Female offspring seem to be more vulnerable than male offspring when their mothers receive insufficient energy during pregnancy. By influencing birthweight, optimal prenatal nutrition might reduce the risk of obesity in adults. While normal birthweights (2500-3999 g) were associated with higher body mass index (BMI) as adults, they generally were associated with higher fat-free mass and lower fat mass compared with low birthweights (<2500 g). Low birthweight was associated with higher risk of metabolic syndrome and central obesity in adults. Breastfeeding and timely introduction of complementary foods were shown to protect against obesity later in life in observational studies. High-protein intake during early childhood however was associated with higher body fat mass and obesity in adulthood. In developed countries, increased weight gain during the first 2 years of life was associated with a higher BMI in adulthood. However, recent studies in developing countries showed that higher BMI was more related to greater lean body mass than fat mass. It appears that increased length at 2 years of age was positively associated with height, weight and fat-free mass, and was only weakly associated with fat mass. The protective associations between breastfeeding and obesity may differ in developing countries compared to developed countries because many studies in developed countries used formula feeding as a control. Future research on the relationship between breastfeeding, timely introduction of complementary feeding or rapid weight gain and obesity are warranted in developing countries. The focus of interventions to reduce risk of obesity in later life in developing countries could include: improving maternal nutritional status during pregnancy to reduce low birthweight; enhancing breastfeeding (including durations of exclusive and total breastfeeding); timely introduction of high-quality complementary foods (containing micronutrients and essential fats) but not excessive in protein; further evidence is needed to understand the extent of weight gain and length gain during early childhood are related to body composition in later life.

Screening for anti-nutritional compounds in complementary foods and food aid products for infants and young children.

A range of compounds with negative nutritional impact - 'anti-nutrients' - are found in most plant foods. The contents of anti-nutrients in processed foods depend on the ingredients and processing. Anti-nutrients in complementary foods for children can have a negative impact on nutritional status. The aim of this study was to screen complementary foods from developing countries for the anti-nutritional compounds, phytate, polyphenols, inhibitors of trypsin and chymotrypsin, and lectins. Commercial products based on whole grain cereals were included as a 'worst-case' scenario for anti-nutrient exposure in Europe. Contents of minerals (iron, zinc and calcium), in which absorption or utilisation is affected by anti-nutrients, were analysed. Thirty-six products representing foods used in food aid programmes, local blended foods, fortified instant porridges and 'baby foods' were analysed. The content of minerals indicated that the fortification of a number of products did not meet the declared levels of iron, zinc and calcium. The phytate content ranged from 68 to 1536 mg/100 g, confirming a persistent problem of high levels of phytate in processed cereal- and legume-based products. The phytate : Fe molar ratio exceeded the recommended level of <1.0 in 32 of the 36 products. The total polyphenols varied from 1.3 to 9.3 mg gentisic acid equivalents g(-1) . Screening low-molecular weight soluble polyphenols may be more relevant in complementary foods than total polyphenolic compounds. Trypsin and chymotrypsin inhibitors and lectins were found in residual amounts in most products, indicating efficient degradation by heat processing. However, young infants and malnourished children may have reduced pancreatic function, and upper limits for residual trypsin inhibitors are needed.

Inequality in early childhood: risk and protective factors for early child development.

Inequality between and within populations has origins in adverse early experiences. Developmental neuroscience shows how early biological and psychosocial experiences affect brain development. We previously identified inadequate cognitive stimulation, stunting, iodine deficiency, and iron-deficiency anaemia as key risks that prevent millions of young children from attaining their developmental potential. Recent research emphasises the importance of these risks, strengthens the evidence for other risk factors including intrauterine growth restriction, malaria, lead exposure, HIV infection, maternal depression, institutionalisation, and exposure to societal violence, and identifies protective factors such as breastfeeding and maternal education. Evidence on risks resulting from prenatal maternal nutrition, maternal stress, and families affected with HIV is emerging. Interventions are urgently needed to reduce children's risk exposure and to promote development in affected children. Our goal is to provide information to help the setting of priorities for early child development programmes and policies to benefit the world's poorest children and reduce persistent inequalities.

Review of fortified food and beverage products for pregnant and lactating women and their impact on nutritional status.

Fortified beverages and supplementary foods, when given during pregnancy, have been shown to have positive effects on preventing maternal anaemia and iron deficiency. Studies show that use of micronutrient fortified supplementary foods, especially those containing milk and/or essential fatty acids during pregnancy, increase mean birthweight by around 60-73 g. A few studies have also shown that fortified supplementary foods have impacts on increasing birth length and reducing preterm delivery. Fortification levels have ranged generally from 50% to 100% of the recommended nutrient intake (RNI). Iron, zinc, copper, iodine, selenium, vitamins A, D, E, C, B1, B2, B6, and B12, folic acid, niacin and pantothenic acid are important nutrients that have been included in fortified beverages and supplemental foods for pregnant and lactating women. While calcium has been shown to reduce the risk of pre-eclampsia and maternal mortality, calcium, phosphorus, potassium, magnesium and manganese can have negative impacts on organoleptic properties, so many products tested have not included these nutrients or have done so in a limited way. Fortified food supplements containing milk and essential fatty acids offer benefits to improving maternal status and pregnancy outcome. Fortified beverages containing only multiple micronutrients have been shown to reduce micronutrient deficiencies such as anaemia and iron deficiency.