Prevalence of overweight and obesity, dietary behaviors, and physical activities among sixth graders: a cross-sectional study in Ho Chi Minh City, Vietnam.

The prevalence of overweight and obesity among adolescents has been increasing worldwide and is a significant public health challenge. Obesity is linked to several non-communicable diseases. This study aimed to determine the prevalence of overweight and obesity based on three growth references and described physical activities and dietary patterns among sixth graders in Ho Chi Minh City (HCMC). From 2018 to 2020, a cross-sectional study was conducted on 1375 students from 16 junior high schools in HCMC. We applied Probability Proportional to Size sampling to select schools. Anthropometric measurements, pubertal status assessment, and diet and physical activity data were collected through Food Frequency and Physical Activity Questionnaires. The study revealed a high prevalence of overweight and obesity among grade 6 students, with ∼45%-56% of students classified as overweight or obese using various growth references. Moreover, most students did not meet the World Health Organization's physical activity and sedentary behavior recommendations. Most students spent <60 min/day on moderate to vigorous physical activity, and over 70% spent at least 120 min/day on sedentary activities during weekdays and weekends. The diet of the students was also imbalanced, with high intakes of protein, lipids, and carbohydrates and low consumption of fruits and vegetables. Nutritionists and policymakers should inform and encourage opportunities for healthier food and more daily activity for children, starting before the sixth-grade, so they can learn how to make healthier choices and change their behavior before they reach adolescence.

Energy intakes, macronutrient intakes and the percentages of energy from macronutrients with adolescent BMI: results from a 5-year cohort study in Ho Chi Minh City, Vietnam.

BACKGROUND: Adolescence is a period of life when dietary patterns and nutrient intakes may greatly influence adult fatness. This study assesses the tracking of energy and nutrient intakes of Ho Chi Minh City adolescents over 5 years. It explores the possible relationships between energy and the percentage of energy from macronutrients with BMI. METHODS: Height, weight, time spent on physical activity, screen time and dietary intakes were collected annually between 2004 and 2009 among 752 junior high school students with a mean age of 11·87 years at baseline. The tracking was investigated using correlation coefficients and weighted kappa statistics (k) for repeated measurements. Mixed effect models were used to investigate the association between energy intakes and percentage energy from macronutrients with BMI. RESULTS: There were increases in the mean BMI annually, but greater in boys than in girls. Correlation coefficients (0·2 < r < 0·4) between participants' intakes at baseline and 5-year follow-up suggest moderate tracking. Extended kappa values were lowest for energy from carbohydrate (CHO) in both girls and boys (k = 0·18 & 0·24, respectively), and highest for protein in girls (k = 0·47) and fat in boys (k = 0·48). The multilevel models showed the following variables significantly correlated with BMI: CHO, fat, percentage of energy from CHO, fat, time spent for moderate to vigorous physical activity, screen time, age and sex. CONCLUSIONS: The poor to fair tracking observed in this cohort suggests that individual dietary patterns exhibited in the first year are unlikely to predict energy and nutrient intakes in the fifth year.

Socio-economic and agricultural factors associated with stunting of under 5-year children: findings from surveys in mountains, dry zone and delta regions of rural Myanmar (2016-2017).

OBJECTIVE: The study's objective was to investigate multiple underlying social, economic and agricultural determinants of stunting among under-five children in three distinct ecological areas in rural Myanmar. DESIGN: Repeated cross-sectional surveys in three states of Myanmar. SETTING: Rural households in Chin (mountainous), Magway (plains) and Ayeyarwady (delta). PARTICIPANTS: From two purposively selected adjacent townships in each state, we randomly selected twenty villages and, in each village, thirty households with under-five children. Households in the first survey in 2016 were revisited in late 2017 to capture seasonal variations. RESULTS: Stunting increased from 40·4 % to 42·0 %, with the highest stunting prevalence in Chin state (62·4%). Univariate Poisson regression showed factors contributing to child stunting varied across the regions. Adjusted Poisson regression models showed that child's age and short maternal stature (aRR = 1·14 for Chin, aRR = 1·89 for Magway and aRR = 1·86 for Ayeyarwady) were consistently associated with child stunting across three areas. For Chin, village-level indicators such as crop consumption (aRR = 1·18), crop diversity (aRR = 0·82) and land ownership (aRR = 0·89) were significantly associated with stunting. In Magway, the number of household members (aRR = 1·92), wealth status (aRR = 0·46), food security status (aRR = 1·14), land ownership (aRR = 0·85) and in Ayeyarwady, women's decision-making (aRR = 0·67) and indicators related to hygiene (aRR = 1·13) and sanitation (aRR = 1·45) were associated with stunting. CONCLUSIONS: Area-specific factors were associated with stunting. Maternal short stature and child age were consistent determinants of stunting. A multi-sectoral local approach, including improvements in transport, is needed to address the intergenerational malnutrition problem.

Effectiveness of peer-led programs for overweight and obesity in children: systematic review and meta-analysis.

Child health promotion has used peer-led interventions for decades, but their effectiveness for childhood obesity is unknown. This review assesses the effectiveness of peer-led interventions on child and adolescent obesity using a range of adiposity outcomes. We included studies that used a peer-led approach for delivering behavior change communications with a minimum intervention duration of four weeks. Studies needed to report results for any of the outcomes: BMI, BMI z-score or BMI percentile. The review included 14 studies of moderate to high quality from high-income countries. A meta-analysis involving 2506 children from 9 studies showed that programs were effective with a mean difference in BMI of -0.15 kg/m2 (95% confidence interval [-0.26, -0.03]), p = 0.01. Heterogeneity was low (I2 = 28%, p = 0.19) for children in the intervention group. The mean difference varied with subgroups with significantly greater effects from interventions that focused on physical activity alone or with longer duration of implementation. Sensitivity analysis showed similar significant findings to the primary meta-analysis. We found moderately strong evidence to support the advantageous effect of peer-led interventions for obesity prevention in children and adolescents. However, given the small number of studies included, and possible reporting bias, the results must be interpreted cautiously.

Postnatal Stature Does Not Largely Mediate the Relation between Adverse Birth Outcomes and Cognitive Development in Mid-Childhood and Early Adolescence in Rural Western China.

BACKGROUND: Preterm birth and fetal growth restriction are associated with linear growth faltering and suboptimal cognitive development in childhood. OBJECTIVES: We aimed to investigate whether and to what extent the associations between adverse birth outcomes and cognitive development in mid-childhood and early adolescence are mediated by postnatal stature. METHODS: We used data from a prospective birth cohort of children born to women who participated in a large cluster-randomized trial of antenatal micronutrient supplementation in rural western China. Children were followed up for anthropometric assessments at 6, 12, and 24 mo of age and in mid-childhood (7-9 y). Cognitive development was assessed in mid-childhood (n = 669) and early adolescence (n = 735; 10-12 y) using the Wechsler Intelligence Scale for Children-IV. We conducted a causal mediation analysis to evaluate the proportion of the association of low birth weight (LBW; <2500 g), small-for-gestational age (SGA; <10th percentile), and preterm birth (<37 weeks of gestation) with cognitive development in mid-childhood and early adolescence that was mediated by postnatal length/height-for-age and -sex z score (LAZ/HAZ) during the first 2 y of life and in mid-childhood. RESULTS: LBW and SGA, but not preterm birth, were associated with lower cognitive test scores in mid-childhood and early adolescence. The proportion of the total association of SGA with adolescent cognitive development that was mediated by LAZ/HAZ at 6, 12, and 24 mo of age and in mid-childhood was 25%, 32%, 32%, and 27%, respectively. The corresponding proportions for LBW were 25%, 32%, 16%, and 24%, respectively. CONCLUSIONS: The association of LBW and SGA with cognitive development in mid-childhood and adolescence is not largely mediated by postnatal stature during the first 2 y of life. Postnatal interventions that address the antecedent causes of poor child growth and development, rather than early childhood growth alone, are more likely to mitigate the risk of suboptimal development among SGA and LBW children. This trial was registered at www.isrctn.com as ISRCTN08850194.

Effect of baseline physical activity on the fat gain of adolescents in a 5-year cohort study in Ho Chi Minh City, Viet Nam.

Differences in physical activity (PA) might lead to long-term weight control. Studies on inverse relations between PA and changes in fatness among adolescents are limited. This paper examined the effect of PA on adolescents' changing body fatness over 5 years in Ho Chi Minh City (HCMC). Two hundred thirty-five boys and 247 girls who have had skinfold thickness measurements in the baseline survey in 2004 were selected to follow yearly. We estimated PA as the average number of accelerometers' counts/h. Slopes of triceps, sub-scapular skinfolds and BMI were calculated and classified as increasing or stable/decreasing. To assess the effects of the low level of activity (i.e. below the median of the average number of counts) on the fat gain (i.e. increasing slopes), relative risk and 95 % CI were estimated using Poisson regression. The average number of counts/h in boys (7·8) was significantly higher than that in girls (5·0) (P < 0·001). On average, active girls still gained 0·51 mm in triceps skinfold (TSF) over 5 years, while active boys lost 0·12 mm. After controlling for baseline energy intake, baseline triceps and baseline age, inactive adolescents were 1·39 times higher than active ones to increase the slope of triceps (95 % CI 1·19, 1·63). The risk ratio was 1·62 for those with more body fat at baseline. In general, inactive students gained substantially more subcutaneous fat, especially in their TSF, than more active ones. Thus, strategies to prevent adolescent obesity in HCMC should consider the important role of PA to control this problem in adolescents effectively.

Head circumference trajectories during the first two years of life and cognitive development, emotional, and behavior problems in adolescence: a cohort study.

The associations of early-life head circumference (HC) with child neurodevelopmental and mental health among generally healthy population remain unclear. We aimed to examine the associations of early-life HC trajectories with cognitive development and emotional and behavioral problems in adolescence and to identify the HC growth-sensitive period. We conducted a prospective, community-based birth cohort study in rural western China, and 745 adolescents aged 10-14 years were followed between June and December 2016. We assessed their HC eight times during the first 2 years of life and their adolescent cognitive, emotional, and behavioral outcomes using the Wechsler Intelligence Scale for Children-IV and Youth Self-Report-2001, respectively. We applied group-based trajectory modeling to identify the HC trajectories and conditional growth to derive the HC growth-sensitive periods. We identified five distinct HC trajectories characterized as Start below average-then decrease (7.8% of the sample), Start below average-then increase (6.8%), Start average-then decrease (33%), Consistently average (38%), and Consistently above average (14%). Infants in the trajectory of consistently above average had higher cognitive scores in adolescence compared to those from suboptimal trajectories, with adjusted mean differences ranging from 2.84 to 8.99 points. The conditional gains showed that the HC growth-sensitive period was between 0 and 18 months for child cognition. We found null associations between HC measures and adolescent emotional and behavioral problem scores. CONCLUSION: Early-life HC trajectories were associated with adolescent cognitive development. HC may serve as an inexpensive screening tool to monitor child development at risk during the first 18 months, particularly in resource-limited settings. WHAT IS KNOWN: • Postnatal head circumference (HC) has been shown to be associated with cognitive development in infants who were born premature and/or fetal growth restriction, while inconsistent associations were reported among generally healthy populations, especially in low- and middle- income countries, challenging its utility in public health practices. WHAT IS NEW: • Adolescents in the HC growth trajectory of consistently above average had higher cognitive scores compared to those with other suboptimal trajectories, while null findings were observed for adolescent emotional and behavioral health. • HC may serve as an inexpensive screening tool to monitor child development at risk during the first 18 months of life, particularly in resource-limited settings.

Breastfeeding perceptions and exclusive breastfeeding practices: A qualitative comparative study in rural and urban Central Java, Indonesia.

Breastfeeding has been associated with improved growth, development, and health outcomes for infants and children. However, the exclusive breastfeeding rate in Indonesia is suboptimal (37%). There is limited contextualised understanding of mothers' perceptions of breastfeeding and the factors behind exclusive breastfeeding practices. The aim of this qualitative study was to compare breastfeeding perceptions and exclusive breastfeeding practices between rural and urban mothers. We conducted a qualitative comparative study through in-depth interviews with 46 caregivers of children aged 6-23 months, two health professionals, and ten kader (frontline female health workers at the village level) in Central Java, Indonesia. We analysed the data using thematic analysis. Urban mothers had better knowledge and perceptions of breastfeeding and more access to breastfeeding information sources. However, exclusive breastfeeding practice was more frequent among rural mothers. Family and healthcare workers acted as both facilitators and barriers to exclusive breastfeeding practice in both settings. Perceptions of insufficient breast milk supply, infant illness, and breast problems prevented rural and urban mothers to breastfeed exclusively. Mother-infant separation after birth, breast rejection, latching difficulty, and maternal employment were among the factors that caused urban mothers to discontinue breastfeeding exclusively. Breastfeeding promotion strategies should focus on enhancing maternal breastfeeding knowledge and problem-solving skills by considering the individual and social context, particularly in urban areas where exclusive breastfeeding obstacles are more nuanced.

The effect of electronic job aid assisted one-to-one counselling to support exclusive breastfeeding among 0-5-month-old infants in rural Bangladesh.

Exclusive breastfeeding (EBF) for the first 6 months has established benefits, yet had slow improvements globally. Little is known about electronic job aid-assisted counselling to support EBF. As a secondary outcome of a cluster randomized controlled trial in Bangladesh, we assessed the effect of electronic job aid-supported nutrition counselling and practical demonstration on EBF. We randomized pregnant women to one of five study arms in the trial and followed mother-child dyads until 2 years of age. Community health workers (CHWs) provided breastfeeding counselling with or without prenatal and complementary nutrient supplements in all four intervention arms. The comparison arm continued with the usual practice where mothers could receive nutrition counselling at routine antenatal and postnatal care, and during careseeking for childhood illnesses. We assessed breastfeeding indicators at birth and monthly until the child was 6 months old, in both intervention and comparison arms. To evaluate the effect of nutrition counselling on breastfeeding, we combined all four intervention arms and compared them with the comparison arm. Intervention newborns had half the risk (relative risk [RR]: 0.54, 95% confidence interval [CI]: 0.39, 0.76) of receiving prelacteal feeds than those in the comparison arm. EBF declined steeply in the comparison arm after 3 months of age. EBF was 16% higher in the intervention than the comparison arm at 4 months (RR: 1.16, 95% CI: 1.08, 1.23) and 22% higher at 5 months of age (RR: 1.22, 95% CI: 1.12, 1.33). Maternal background and household characteristics did not modify the intervention effect, and we observed no difference in EBF among caesarean versus vaginal births. Breastfeeding counselling and practical demonstration using an electronic job aid by CHWs are promising interventions to improve EBF and are scalable into existing community-based programmes.

The impact of a package of behaviour change interventions on breastfeeding practices in East Java Province, Indonesia.

Suboptimal infant young child feeding practices are frequently reported globally, including in Indonesia. This analysis examined the impact of a package of behaviour change interventions on breastfeeding practices in Malang and Sidoarjo Districts, East Java Province, Indonesia. The BADUTA study (which in the Indonesian Language is an acronym for BAwah DUa TAhun, or children aged less than 2 years) was an impact evaluation using a cluster-randomized controlled trial with two parallel treatment arms. We conducted household surveys in 12 subdistricts from Malang and Sidoarjo. We collected information from 5175 mothers of children aged 0-23 months: 2435 mothers at baseline (February 2015) and 2740 mothers at endline (January to February 2017). This analysis used two indicators for fever and diarrhoea and seven breastfeeding indicators (early initiation of breastfeeding, prelacteal feeding, exclusive breastfeeding under 6 months, predominant breastfeeding, continued breastfeeding, age-appropriate breastfeeding and bottle-feeding). We used multilevel logistic regression analysis to assess the effect of the intervention. After 2 years of implementation of interventions, we observed an increased odds of exclusive breastfeeding under 6 months (adjusted odds ratio [aOR] = 1.85; 95% confidence interval [CI]: 1.35-2.53) and age-appropriate breastfeeding (aOR = 1.39; 95% CI: 1.07-1.79) in the intervention group than in the comparison group, at the endline survey. We found significantly lower odds for prelacteal feeding (aOR = 0.52; 95% CI: 0.41-0.65) in the intervention than in the comparison group. Our findings confirmed the benefits of integrated, multilayer behaviour change interventions to promote breastfeeding practices. Further research is required to develop effective interventions to reduce bottle use and improve other breastfeeding indicators that did not change with the BADUTA intervention.

Trends and determinants of minimum dietary diversity among children aged 6-23 months: a pooled analysis of Indonesia Demographic and Health Surveys from 2007 to 2017.

OBJECTIVE: To examine minimum dietary diversity (MDD) trends and determinants among children aged 6-23 months. DESIGN: Secondary analysis of the Indonesia Demographic and Health Surveys (IDHS) between 2007 and 2017. The primary outcome was MDD, the consumption of at least five out of eight food groups (MDD-8). We included a total of 5015 (IDHS 2007), 5050 (IDHS 2007) and 4925 (IDHS 2017) children aged 6 to 23 months to estimate trends of MDD-8 and to identify factors associated with MDD-8. We used multiple logistic regression analysis adjusted for the complex sampling design to investigate the association between the study factors and MDD-8. SETTING: Indonesia. PARTICIPANT: A total of 14 990 children aged 6-23 months. RESULTS: Over the 10 years, the percentage of children who consumed a diversified diet was 53·1 % in 2007, 51·7 % in 2012 and 53·7 % in 2017. Multivariate analyses showed that older age children, higher maternal education, maternal weekly access to media, paternal non-agricultural occupation, history of at least four antenatal care visits and wealthier households were associated with the increased odds of MDD-8. Children living in rural areas, Sulawesi and Eastern Indonesia, were less likely to eat a diversified diet. CONCLUSIONS: The proportion of children meeting MDD-8 has stagnated in the last decade. Child, parental, health care, household and community factors are associated with MDD-8. Therefore, nutrition education programmes and behaviour change communication activities should target mothers and families from socio-economically and geographically disadvantaged populations.

Anemia and associated factors among adolescent girls and boys at 10-14 years in rural western China.

BACKGROUND: Evidence on anemia and associated factors among young adolescent girls and boys in rural western China is limited. METHODS: We used data from a follow-up study of adolescents (10-14 years) born to women who participated in a randomized trial of antenatal micronutrient supplementation in western China. Anemia was defined by World Health Organization standards. Logistic regression was used to examine the factors associated with anemia. RESULTS: The overall prevalence of anemia was 11.7% (178/1517). Female adolescents were 1.73 (95% CI 1.21, 2.48) times more likely to have anemia as compared to males. Adolescents whose mothers had completed high school were 0.35 (95% CI 0.13, 0.93) times less likely to be anemic, compared to those of whom had < 3 years of formal education. Household wealth was also inversely associated with anemia. The association of puberty status with anemia was modified by adolescent sex (P-value for interaction was 0.04); males with greater than mild pubertal development had reduced odds (OR 0.35, 95% CI 0.15, 0.83) of anemia while there was no association among females (OR 0.72, 95% CI 0.29, 1.78). Consumption of flesh foods (OR 0.58, 95% CI 0.38, 0.89), eggs (OR 0.60, 95% CI 0.38, 0.93), and having a meal frequency of three times or more per day (OR 0.68, 95% CI 0.48, 0.96) were also associated with a lower likelihood of anemia. CONCLUSIONS: Anemia was a mild public health problem among young adolescents in rural western China. Nutritional and social determinants were identified as predictors, warranting interventions to reduce the risk of anemia among this critical age group.

Overweight and obesity among urban women with iron deficiency anaemia in Bangladesh.

In this study, we aimed to determine the prevalence and factors associated with overweight and obesity among nonpregnant and nonlactating (NPNL) women of reproductive age with iron deficiency anaemia (IDA) in urban Bangladesh. We obtained data from the baseline assessment of a randomized control trial conducted among 525 women of reproductive age (18-49 years) with IDA (Hb < 12 gdl-1 and serum ferritin <30 µg L-1 ). The study was carried out in Mirpur, Dhaka, Bangladesh, between December 2017 and January 2019. We collected information on women's socio-demographic characteristics and anthropometry. Body mass index (BMI) was calculated using the following formula: weight in kilograms per height in square metres. BMI ≥ 25-29.9 kg m-2 was considered as overweight, whereas BMI ≥ 30 kg m-2 as obese. A multivariable logistic regression model was used to ascertain the risk factors of overweight and obesity. The prevalence of overweight and obesity was 29.9% (95% CI: 26.0-34.0) and 13.1% (95% CI: 10.4-16.3), respectively. The combined prevalence of overweight and obesity was 43.0% (95% CI: 38.7-47.4). The multivariable analysis showed married women (aOR: 4.4; CI: 1.8-11.1), women aged 30-49 years (aOR: 7.6; CI: 2.4-24.1), unemployed women (aOR 1.5; CI: 1.0-2.4) and women from the wealthier households (aOR 3.9; CI: 2.3-6.8) had the highest risk of being overweight and obese compared with their counterparts. Both age and household wealth statuses showed dose-response relationships. Combination of overweight and obesity with IDA poses a particular challenge for public health interventions. The policymakers should consider what new interventions and policy initiatives are needed to address this combination of overweight and obesity with IDA.

Association of infant and young child feeding practices with cognitive development at 10-12 years: a birth cohort in rural Western China.

We aimed to comprehensively examine the association of breast-feeding, types and initial timing of complementary foods with adolescent cognitive development in low- and middle-income countries. We conducted a prospective cohort study of 745 adolescents aged 10-12 years who were born to women who participated in a randomised trial of prenatal micronutrient supplementation in rural Western China. An infant feeding index was constructed based on the current WHO recommendations. Full-scale intelligence quotient (FSIQ) was assessed and derived by the fourth edition of the Wechsler Intelligence Scale for Children. The duration of exclusive or any breast-feeding was not significantly associated with adolescent cognitive development. Participants who regularly consumed Fe-rich or Fe-fortified foods during 6-23 months of age had higher FSIQ than those who did not (adjusted mean differences 4·25; 95 % CI 1·99, 6·51). For cows'/goats' milk and high protein-based food, the highest FSIQ was found in participants who initially consumed at 10-12 and 7-9 months, respectively. A strong dose-response relationship of the composite infant feeding index was also identified, with participants in the highest tertile of overall feeding quality having 3·03 (95 % CI 1·37, 4·70) points higher FSIQ than those in the lowest tertile. These findings suggest that appropriate infant feeding practices (breast-feeding plus timely introduction of appropriate complementary foods) were associated with significantly improved early adolescent cognitive development scores in rural China. In addition, improvement in Fe-rich or Fe-fortified foods complementary feeding may produce better adolescent cognitive development outcomes.

Shonjibon cash and counselling: a community-based cluster randomised controlled trial to measure the effectiveness of unconditional cash transfers and mobile behaviour change communications to reduce child undernutrition in rural Bangladesh.

BACKGROUND: Undernutrition is strongly associated with poverty - levels of undernutrition are higher in poor countries than in better-off countries. Social protection especially cash transfer is increasingly recognized as an important strategy to accelerate progress in improving maternal and child nutrition. A critical method to improve nutrition knowledge and influence feeding practices is through behaviour change communication intervention. The Shonjibon Cash and Counselling study aims to assess the effectiveness of unconditional cash transfers combined with a mobile application on nutrition counselling and direct counselling through mobile phone in reducing the prevalence of stunting in children at 18 months. METHOD: The study is a longitudinal cluster randomised controlled trial, with two parallel groups, and cluster assignment by groups of villages. The cohort of mother-child dyads will be followed-up over the intervention period of approximately 24 months, starting from recruitment to 18 months of the child's age. The study will take place in north-central Bangladesh. The primary trial outcome will be the percentage of stunted children at 18 m as measured in follow up assessments starting from birth. The secondary trial outcomes will include differences between treatment arms in (1) Mean birthweight, percentage with low birthweight and small for gestational age (2) Mean child length-for age, weight for age and weight-for-length Z scores (3) Prevalence of child wasting (4) Percentage of women exclusively breastfeeding and mean duration of exclusive breastfeeding (5) Percentage of children consuming > 4 food groups (6) Mean child intake of energy, protein, carbohydrate, fat and micronutrients (7) Percentage of women at risk of inadequate nutrient intakes in all three trimesters (8) Maternal weight gain (9) Household food security (10) Number of events for child suffering from diarrhoea, acute respiratory illness and fever (11) Average costs of mobile phone BCC and cash transfer, and benefit-cost ratio for primary and secondary outcomes. DISCUSSION: The proposed trial will provide high-level evidence of the efficacy and cost-effectiveness of mobile phone nutrition behavior change communication, combined with unconditional cash transfers in reducing child undernutrition in rural Bangladesh. TRIAL REGISTRATION: The study has been registered in the Australian New Zealand Clinical Trials Registry ( ACTRN12618001975280 ).

Determinants of age-appropriate breastfeeding, dietary diversity, and consumption of animal source foods among Indonesian children.

Global child feeding practices remain suboptimal. In this study, we assess the determinants of age-inappropriate breastfeeding, dietary diversity, and consumption of 3+ types of animal source foods (ASFs) using 11,687 observations from combined data from the Indonesian Demographic Health Survey of 2012 and 2017. We used linear and logistic regression after adjusting for the complex sampling design. Child's age and quality of antenatal care (ANC) were associated with all outcomes. Socio-economic status and labour force participation were positively associated with higher dietary diversity score, ASF consumption, and age-inappropriate breastfeeding. More ANC visits and having consultation at ANC were associated with more dietary diversity. Higher women's knowledge level was associated with more dietary diversity and consuming more ASF. Compared with western Indonesia, more children in eastern Indonesia were age-inappropriately breastfed and had lower dietary diversity. The Indonesian government needs to develop programmes to improve child feeding particularly in eastern Indonesia, focusing on improving dietary diversity and ASF consumption in poorer households and on prolonging breastfeeding in richer households. Women's labour force participation should be encouraged, but programmes for working mothers are also needed to support continued breastfeeding and to express breast milk. ANC and postnatal programmes need improved consultation sessions for child feeding.

Early initiation of breastfeeding and severe illness in the early newborn period: An observational study in rural Bangladesh.

BACKGROUND: In Bangladesh, neonatal sepsis is the cause of 24% of neonatal deaths, over 65% of which occur in the early-newborn stage (0-6 days). Only 50% of newborns in Bangladesh initiated breastfeeding within 1 hour of birth. The mechanism by which early initiation of breastfeeding reduces neonatal deaths is unclear, although the most likely pathway is by decreasing severe illnesses leading to sepsis. This study explores the effect of breastfeeding initiation time on early newborn danger signs and severe illness. METHODS AND FINDINGS: We used data from a community-based trial in Bangladesh in which we enrolled pregnant women from 2013 through 2015 covering 30,646 newborns. Severe illness was defined using newborn danger signs reported by The Young Infants Clinical Science Study Group. We categorized the timing of initiation as within 1 hour, 1 to 24 hours, 24 to 48 hours, ≥48 hours of birth, and never breastfed. The analysis includes descriptive statistics, risk attribution, and multivariable mixed-effects logistic regression while adjusting for the clustering effects of the trial design, and maternal/infant characteristics. In total, 29,873 live births had information on breastfeeding among whom 19,914 (66.7%) initiated within 1 hour of birth, and 4,437 (14.8%) neonates had a severe illness by the seventh day after birth. The mean time to initiation was 3.8 hours (SD 16.6 hours). The proportion of children with severe illness increased as the delay in initiation increased from 1 hour (12.0%), 24 hours (15.7%), 48 hours (27.7%), and more than 48 hours (36.7%) after birth. These observations would correspond to a possible reduction by 15.9% (95% CI 13.2-25.9, p < 0.001) of severe illness in a real world population in which all newborns had breastfeeding initiated within 1 hour of birth. Children who initiated after 48 hours (odds ratio [OR] 4.13, 95% CI 3.48-4.89, p < 0.001) and children who never initiated (OR 4.77, 95% CI 3.52-6.47, p < 0.001) had the highest odds of having severe illness. The main limitation of this study is the potential for misclassification because of using mothers' report of newborn danger signs. There could be a potential for recall bias for mothers of newborns who died after being born alive. CONCLUSIONS: Breastfeeding initiation within the first hour of birth is significantly associated with severe illness in the early newborn period. Interventions to promote early breastfeeding initiation should be tailored for populations in which newborns are delivered at home by unskilled attendants, the rate of low birth weight (LBW) is high, and postnatal care is limited. TRIAL REGISTRATION: Trial Registration number: anzctr.org.au ID ACTRN12612000588897.

Understanding country-specific determinants of stillbirth using household surveys: The case of Afghanistan.

BACKGROUND: Stillbirth rates in Afghanistan have declined little in the past decade with no data available on key risk factors. Health care utilisation and maternal complications are important factors influencing pregnancy outcomes but rarely captured for stillbirth in national surveys from low- and middle-income countries. The 2010 Afghanistan Mortality Survey (AMS) is one of few surveys with this information. METHODS: We used data from the 2010 AMS that included a full pregnancy history and verbal autopsy. Our sample included the most recent live birth or stillbirth of 13 834 women aged 12-49 years in the three years preceding the survey. Multivariable Poisson regression was used to identify sociodemographic, maternal, and health care utilisation risk factors for stillbirth. RESULTS: The risk of stillbirth was increased among women in the Central Highlands (aRR: 3.01, 95% CI 1.35, 6.70) and of Nuristani ethnicity (aRR: 9.15, 95% CI 2.95, 28.74). Women who did not receive antenatal care had three times increased risk of stillbirth (aRR: 3.03, 95% CI 1.73, 5.30), while high-quality antenatal care was important for reducing the risk of intrapartum stillbirth. Bleeding, infection, headache, and reduced fetal movements were antenatal complications strongly associated with stillbirth. Reduced fetal movements in the delivery period increased stillbirth risk by almost seven (aRR: 6.82, 95% CI 4.20, 11.10). Facility births had a higher risk of stillbirths overall (aRR: 1.55, 95% CI 1.12, 2.16), but not for intrapartum stillbirths. CONCLUSIONS: Targeted interventions are needed to improve access and utilisation of services for high-risk groups. Early detection of complications through improved quality of antenatal and obstetric care is imperative. We demonstrate the potential of household surveys to provide country-specific evidence on stillbirth risk factors for LMICs where data are lacking.

M-SAKHI-Mobile health solutions to help community providers promote maternal and infant nutrition and health using a community-based cluster randomized controlled trial in rural India: A study protocol.

Reduction of childhood stunting is difficult to achieve by interventions that focus only on improving nutrition during infancy. Comprehensive interventions that extend through the continuum of care from pregnancy to infancy are needed. Mobile phones are now successfully being used for behaviour change communication to improve health. We present the methodology of an mHealth intervention "Mobile Solutions Aiding Knowledge for Health Improvement" (M-SAKHI) to be delivered by rural community health workers or Accredited Social Health Activists (ASHAs) for rural women, below or up to 20 weeks of pregnancy through delivery until their infant is 12 months of age. This protocol paper describes the cluster randomized controlled trial to evaluate the effectiveness of M-SAKHI. The primary objective of the trial is to reduce the prevalence of stunting (height-for-age < -2 z-score) in children at 18 months of age by 8% in the intervention as compared with control. The secondary objectives include evaluating the impact on maternal dietary diversity, birth weight, infant and young child feeding practices, infant development, and child morbidity, along with a range of intermediate outcomes for maternal, neonatal, and infant health. A total of 297 ASHAs, five trained counsellors, and 2,501 participants from 244 villages are participating in this study. The outcome data are being collected by 51 field research officers. This study will provide evidence regarding the efficacy of M-SAKHI to reduce stunting in young children in rural India, and if effective, the cost-effectiveness of M-SAKHI.