Nutrition environments in early childhood education: do they align with best practice?

OBJECTIVE: To assess the comprehensiveness (scope of nutrition guidance) and strength (clarity of written language) of centre-based nutrition policies (CBNP) within early childhood education (ECE) centres. To also consider the applicability of an existing CBNP assessment tool and policy alignment with best practice food provision and feeding practices. DESIGN: Cross-sectional online study to assess written ECE CNBP using the Wellness Child Care Assessment Tool. SETTING: Licenced ECE centres in the state of Victoria, Australia. PARTICIPANTS: ECE centres (operating at least 8 h per d, 48 weeks per annum), stratified by location (rural and metropolitan), centre management type (profit and not-for-profit) and socio-economic area (low, middle, high). RESULTS: Included individual CBNP (n 118), predominantly from metropolitan centres (56 %) and low-medium socio-economic areas (78 %). Policies had low overall Wellness Child Care Assessment Tool scores, particularly strength scores which were low across all four domains (i.e. nutrition education, nutrition standards, health promotion and communication/evaluation). The nutrition standards domain had the lowest strength score. The communication/evaluation domain had the lowest comprehensiveness score. Content analysis indicated low scores may relate to the Wellness Child Care Assessment Tool applicability for the Australian context due to differences in best practice guidance. CONCLUSION: Despite the presence of written nutrition policies in ECE centres, many showed weak language and lacked comprehensiveness and strength. This may relate to poor implementation of best practice food provision or feeding practices. Low scores, however, may partly stem from using an assessment tool that is not country-specific. The redevelopment of country-specific tools to assess ECE CNBP may be warranted.

Post-nursing early life macronutrient balance promotes persistent and malleable biometric and metabolic traits in mice.

It is known that dietary factors within the gestational and nursing period affect early life and stably affect later life traits in animals. However, there is very little understanding of whether dietary factors within the early life period from post-nursing to adulthood affect traits in adulthood. To address this, we conducted studies on male C57Bl/6J mice fed from 3 weeks (immediately post-nursing) until 12 weeks (full maturity) using nine different diets varying in all three major macronutrients to parse out the effects of individual macronutrients. Early life macronutrient balance affected body composition and glucose homeostasis in early adulthood, with dietary protein and fat showing major effects. Despite this, mice showed rapid reversal of the effects on body composition and glucose homeostasis of early life diet feeding, upon standard diet feeding in adulthood. However, some traits were persistent, with early life low dietary protein levels stably affecting lean and muscle mass, and early life dietary fat levels stably affecting serum and liver triglyceride levels. In summary, macronutrient balance in the post-nursing early life period does not stably affect adiposity or glucose homeostasis but does impact muscle mass and lipid homeostasis in adulthood, with prominent effects of both protein and fat levels. KEY POINTS: Early life dietary low protein and high fat levels lowered and heightened body mass, respectively. These effects did not substantially persist into adulthood with rapid catch-up growth on a normal diet. Early life protein (negative) and fat (positive) levels affected fat mass. Early life low protein levels negatively affected lean mass. Low protein effects on lower lean and muscle mass persisted into adulthood. Early life macronutrient balance effects did not affect later life glucose homeostasis but early life high fat level affected later life dyslipidaemia. Effects of dietary carbohydrate levels in early and later life were minor.

Adoption, implementation, and sustainability of early childhood feeding, nutrition and active play interventions in real-world settings: a systematic review.

BACKGROUND: Instilling healthy dietary habits and active play in early childhood is an important public health focus. Interventions supporting the establishment of nutrition and active play behaviours in the first years of life have shown positive outcomes and long-term cost-effectiveness, however, most are research trials, with limited evidence regarding real-world application. Implementation science theories, models and frameworks (TMFs) can guide the process of research translation from trial to real-world intervention. The application of TMFs within nutrition and active play intervention studies in early childhood (< 5 years) is currently unknown. This systematic review identified the use of TMFs and barriers/ enablers associated with intervention adoption, implementation, and sustainability in early childhood nutrition and active play interventions implemented under real-world conditions. METHODS: Six databases were searched for peer-reviewed publications between 2000-2021. Studies were included if primary outcomes reported improvement in diet, physical activity or sedentary behaviours amongst children aged < 5 years and interventions were delivered under real-world conditions within a community and/or healthcare setting. Two reviewers extracted and evaluated studies, cross checked by a third and verified by all authors. Quality assessment of included studies was completed by two authors using the Mixed Methods Appraisal Tool (MMAT). RESULTS: Eleven studies comprising eleven unique interventions were included. Studies represented low, middle and high-income countries, and were conducted across a range of settings. Five TMFs were identified representing four of Nilsen's implementation model categories, predominantly 'evaluation models'. Ninety-nine barriers/facilitators were extracted across the three intervention phases-Implementation (n = 33 barriers; 33 facilitators), Sustainability (n = 19 barriers; n = 9 facilitators), Adoption (n = 2 barriers; n = 3 facilitators). Identified barriers/facilitators were mapped to the five domains of the Durlak and DuPre framework, with 'funding', 'compatibility' and 'integration of new programming' common across the three intervention phases. CONCLUSIONS: Findings demonstrate that there is no systematic application of TMFs in the planning, implementation and/or evaluation of early childhood nutrition and active play interventions in real-world settings, and selective and sporadic application of TMFs occurs across the intervention lifespan. This apparent limited uptake of TMFs is a missed opportunity to enhance real-world implementation success. TRIAL REGISTRATION: PROSPERO (CRD42021243841).

Protein-Energy Supplementation in Early-Life Decreases the Odds of Mental Distress in Later Adulthood in Guatemala.

BACKGROUND: The prevalence of mental health concerns is growing worldwide, along with lack of access to and receipt of needed treatment. Current gaps in treatment provision have led to exploring alternative methods of prevention, with research linking nutrition and mental health, of particular relevance in low- and middle-income countries, with a high prevalence of undernutrition. OBJECTIVES: To examine whether exposure to a protein-energy nutritional supplement during the first 1000 d of life decreased odds of mental distress in adulthood among men and women in Guatemala compared with receiving a low energy-no protein supplement or supplementation outside the 1000-d window. METHODS: Data from participants (n = 1249) in a longitudinal cohort protein-energy supplementation trial (early-life, supplementation data from 1969 to 1977, ages 0-7 y; life course, outcome data from 2017-2018 follow-up, ages 40-57 y) were analyzed for associations between nutrition in the first 1000 d and mental distress in adulthood (WHO Self-Reporting Questionnaire 20 [SRQ-20]), controlling for early-life variables and current life stress; life course variables (e.g. education) were examined as potential mediators of this relation. Generalized linear mixed models and zero-inflated Poisson generalized linear mixed models were utilized. RESULTS: Both partial and full supplementation with Atole during the first 1000 d were associated with 63% (95% CI: 0.16, 0.87) and 56% (95% CI: 0.19, 1.03) lower odds, respectively, of experiencing mental distress in adulthood. Results did not differ by sex. These inverse relations remained relatively unchanged (partial OR = 0.34 [95% CI: 0.14, 0.83]; full OR = 0.38 [95% CI: 0.16, 0.92]) after controlling for early-life and life course variables, including life stress. CONCLUSIONS: Protein-energy supplementation during the first 1000 d of life in Guatemala, where undernutrition is prevalent, may reduce the prevalence of later mental distress in adulthood. This effect appears to occur directly, rather than indirectly, through pathways of life course variables such as education, wealth, and marital status.

Protein-Energy Supplementation in Early-Life Decreases the Odds of Mental Distress in Later Adulthood in Guatemala.

BACKGROUND: The prevalence of mental health concerns is growing worldwide, along with lack of access to and receipt of needed treatment. Current gaps in treatment provision have led to exploring alternative methods of prevention, with research linking nutrition and mental health, of particular relevance in low- and middle-income countries, with a high prevalence of undernutrition. OBJECTIVES: To examine whether exposure to a protein-energy nutritional supplement during the first 1000 d of life decreased odds of mental distress in adulthood among men and women in Guatemala compared with receiving a low energy-no protein supplement or supplementation outside the 1000-d window. METHODS: Data from participants (n = 1249) in a longitudinal cohort protein-energy supplementation trial (early-life, supplementation data from 1969 to 1977, ages 0-7 y; life course, outcome data from 2017-2018 follow-up, ages 40-57 y) were analyzed for associations between nutrition in the first 1000 d and mental distress in adulthood (WHO Self-Reporting Questionnaire 20 [SRQ-20]), controlling for early-life variables and current life stress; life course variables (e.g. education) were examined as potential mediators of this relation. Generalized linear mixed models and zero-inflated Poisson generalized linear mixed models were utilized. RESULTS: Both partial and full supplementation with Atole during the first 1000 d were associated with 63% (95% CI: 0.16, 0.87) and 56% (95% CI: 0.19, 1.03) lower odds, respectively, of experiencing mental distress in adulthood. Results did not differ by sex. These inverse relations remained relatively unchanged (partial OR = 0.34 [95% CI: 0.14, 0.83]; full OR = 0.38 [95% CI: 0.16, 0.92]) after controlling for early-life and life course variables, including life stress. CONCLUSIONS: Protein-energy supplementation during the first 1000 d of life in Guatemala, where undernutrition is prevalent, may reduce the prevalence of later mental distress in adulthood. This effect appears to occur directly, rather than indirectly, through pathways of life course variables such as education, wealth, and marital status.

Use of the Essential Nutrition Actions framework improved child growth in Bangladesh.

The Essential Nutrition Actions (ENA) framework is an evidence-based set of cost-effective, integrated tools for training health and community workers to promote optimal nutrition practices for the first 1,000 days. This ENA pilot project (ENAPP) was implemented with United States Agency for International Development (USAID) funding from August 2008 to September 2009 in six unions of the working area of an existing USAID-funded, Title II programme in southern Bangladesh. ENAPP, which targeted governmental and non-governmental service providers, was intended to strengthen the behaviour change component of the nutrition strategy of this project. Following a qualitative review of ENAPP's activities, this evaluation uses administrative (growth monitoring) data and propensity score matching of pre-intervention characteristics to create multiple counterfactuals for difference-in-difference estimations of the impact of ENAPP on child nutritional status. Records indicated that government and community healthcare workers received intensive training, and these staff reported that they could effectively integrate ENA messages into their existing responsibilities. Both longitudinal and cross-sectional analyses indicate that ENAPP was successful in increasing children's weight-for-age z-scores, and the difference in z-scores between the treatment and the comparison group increased with time. The materials and methods used in this pilot project should be scaled up, based on the success of these tools and the project's ability to link with and influence the local health system.

Maternal Perceptions and Views About Breastfeeding Practices Among Emirati Mothers.

BACKGROUND: Understanding women's breastfeeding perceptions and experiences is increasingly recognized as a vital tool to provide effective support that would encourage the extension of the breastfeeding period. OBJECTIVE: To identify and explore the perceptions and views that influence the feeding and weaning decisions of Emirati mother. METHODS: A qualitative study using indepth interviews was undertaken with a convenience sample of 45 Emirati mothers who had infants aged between 6 months and 2 years. Participants were interviewed in the health centers in 3 cities in United Arab Emirates. Data were recorded through field notes and analyzed thematically using grounded theory analysis. RESULTS: The following themes emerged: influences of others on the decisions to breastfeed, sources of information, infants' behavior and participants' views and decisions about when to introduce supplementary feeding, knowledge of and attitudes toward current World Health Organization recommendations, and mothers' perception of the benefits of breastfeeding. Grandmothers in this study played an important role in the breastfeeding practices of Emirati mothers. They supported breastfeeding, however, some encouraged giving the infants prelacteal feeds for a variety of reasons: colic, hunger, promoting growth, and hydration. Fathers, according to the mothers, either supported or ignored breastfeeding practices. CONCLUSION: Health promotions and health care facilities failed to deliver the message of exclusive breastfeeding. Mothers in our study were resorting to the expertise of the grandmothers and receiving information and advice about child feeding from them. The findings highlight the need for successful intervention programs to be implemented for mothers and grandmothers through health care providers.

Early Childhood Nutrition Is Positively Associated with Adolescent Educational Outcomes: Evidence from the Andhra Pradesh Child and Parents Study (APCAPS).

BACKGROUND: India's Integrated Child Development Scheme, which provides supplementary nutrition and other public health services to >91 million women and children aged <6 y, is the largest program of its kind in the world. OBJECTIVE: We estimated the long-term associations of maternal and early childhood nutrition provided under the Integrated Child Development Scheme with educational outcomes when the children became adolescents. METHODS: We used longitudinal data from a controlled nutrition trial conducted near the city of Hyderabad, India. From 1987 to 1990, a balanced protein-energy supplement (corn-soya meal, called upma) was offered to pregnant women and children aged <6 y in 15 intervention villages, whereas no supplementation was offered in 14 control villages. Both groups had equal access to other public programs such as immunization and anemia control in pregnancy. Children born during the original trial period were resurveyed (654 intervention and 511 control group children) in 2003-2005. We used propensity score matching methods to correct for estimation bias in our regression models to assess the associations of supplementary nutrition with school enrollment, schooling grades completed, and academic test performance of these adolescents. RESULTS: Children born in intervention villages were 7.8% (95% CI: 0.1%, 15.4%; P < 0.05) more likely to be enrolled in school and completed 0.84 (95% CI: 0.28, 1.39; P < 0.005) more schooling grades than children born in control villages. We found no association between supplementary nutrition and academic performance, as measured by school test scores. CONCLUSION: Offering a nutritional supplement to pregnant women and children <6 y of age during the Hyderabad Nutrition Trial was associated with improved school enrollment and completion of more schooling grades when the children became adolescents.

Factors Associated with Daily Fruit and Vegetable Intakes among Children Aged 1-5 Years in the United States.

To describe child, caregiver, and household characteristics associated with fruit and vegetable intakes among US children aged 1-5 years, we examined fruit and vegetable intakes (less than daily vs. daily) using data from the 2021 National Survey of Children's Health among children aged 1-5 years. Multiple logistic regression provided adjusted odds ratios for factors associated with (1) daily fruit and (2) daily vegetable intakes. Among children aged 1-5 years, 68% (n = 11,124) consumed fruit daily, and 51% (n = 8292) consumed vegetables daily. Both daily fruit and daily vegetable intake were associated with child age, child race and ethnicity, and frequency of family meals. For example, children who ate a family meal 4-6 days/week (aOR 0.69; 95% CI 0.57, 0.83) or 0-3 days/week (aOR 0.57; 95% CI 0.46, 0.72) were less likely to consume fruit daily compared to children who had a family meal every day. Participation in food assistance programs, food insufficiency, and household income were not significantly associated with odds of daily fruit or daily vegetable intake in the adjusted models. Several factors were associated with daily fruit and vegetable intake among children aged 1-5. Strategies aimed at increasing fruit and vegetable consumption in early childhood may consider these child, caregiver, and household characteristics. Pediatric healthcare providers, early childhood education centers, and families of young children may be important partners in this work.

Breakfast consumption trends among young Australian children aged up to 5 years: results from InFANT program.

Breakfast is considered a healthy dietary habit which can track over time from childhood to adulthood. The breakfast meal has the potential to improve daily dietary quality, particularly if it includes a range of food groups and adequate nutrient intakes. However, research on breakfast consumption trends among young Australian children aged up to 5 years is currently limited. This study assessed children's usual breakfast food group and nutrient intakes at ages 1.5 (n = 369), 3.5 (n = 242), and 5.0 (n =240) years using three 24-hour dietary recalls from the Melbourne InFANT program. Tracking of food groups at breakfast across the three ages was assessed by Pearson correlation of energy-adjusted food intake residuals. The main food groups consumed at breakfast were grains, milk/alternatives and discretionary items, with vegetables rarely consumed at any age. Our study found that while breakfast contributed about 20% of total daily energy, this provided 20%-29.1% of total daily intake across all ages for carbohydrates, total sugars, calcium and potassium. For the contribution to daily recommendations, breakfast contributed more than about a third of daily recommended intakes for some micronutrients (e.g., iron, calcium and zinc), and a large proportion (over 40%) of sodium intake. Children consumed 11.9% -15.2% of their energy at breakfast from saturated fat, which is higher than the recommended total energy contribution of saturated fat (no more than 10% from saturated fat). For tracking of most food groups and nutrients, tracking was found to be low or moderate over time. Given the contribution that breakfast can make to ensure children achieve their daily dietary intakes, early interventions for young Australian children should focus on practical strategies to increase vegetable intake while reducing sodium and saturated fat intake at breakfast.

Nutrition and Brain Development.

All nutrients are essential for brain development, but pre-clinical and clinical studies have revealed sensitive periods of brain development during which key nutrients are critical. An understanding of these nutrient-specific sensitive periods and the accompanying brain regions or processes that are developing can guide effective nutrition interventions as well as the choice of meaningful circuit-specific neurobehavioral tests to best determine outcome. For several nutrients including protein, iron, iodine, and choline, pre-clinical and clinical studies align to identify the same sensitive periods, while for other nutrients, such as long-chain polyunsaturated fatty acids, zinc, and vitamin D, pre-clinical models demonstrate benefit which is not consistently shown in clinical studies. This discordance of pre-clinical and clinical results is potentially due to key differences in the timing, dose, and/or duration of the nutritional intervention as well as the pre-existing nutritional status of the target population. In general, however, the optimal window of success for nutritional intervention to best support brain development is in late fetal and early postnatal life. Lack of essential nutrients during these times can lead to long-lasting dysfunction and significant loss of developmental potential.

Dietary Intake among Children Attending Childcare Centers: Impact of the New CACFP Meal Guidelines.

Through the Healthy, Hunger-Free Kids Act of 2010, USDA (US Department of Agriculture) made the first major changes in the CACFP (Child and Adult Care Food Program) meal and snack menu patterns. Childcare centers that serve low-income families qualify to participate and receive reimbursement for meals and snacks served. The purpose of this study was to assess what changes in children's dietary behaviors occurred as a result of the new CACFP meal pattern requirements. This study evaluated these changes at childcare centers operating in Houston and San Antonio, Texas, USA, areas enrolled in the CACFP, pre- (Spring 2016) and post-implementation (Fall 2016-Spring 2017) of the new meal patterns. Dietary intake was assessed via observations of children, 3-5 years old, conducted at breakfast, lunch, and snack times. Results showed improvements in adjusted means of several nutrients and food groups consumption, post-implementation of new CACFP meal guidelines compared to baseline, specifically intake of whole grains, milk, and juice. Additional studies are needed to confirm the impact of the revised CACFP meal patterns along with strategies to assist providers in meeting the new standards to increase the access to and intake of items in accordance with the CACFP meal pattern requirements in childcare settings.

Impact of Nutrition on the Next Generation: The INCAP Longitudinal Study.

BACKGROUND: The design of the original nutrition supplementation trial that was conducted from 1969 to 1977 in 4 villages in rural Guatemala to evaluate the benefits of improving nutrition during pregnancy and early childhood, combined with several follow-up studies, provides unique data to examine the effects of improving nutrition on the next generation. OBJECTIVE: This article provides a summary of the key findings from the INCAP Longitudinal Study on the intergenerational effects of improving nutrition on the growth and well-being of the next generation. METHODS: The key outcomes include offspring birth size as well as attained size and body composition through age 11 years. The sample sizes varied from approximately 200 to 800 depending on the timing of the follow-up studies and data collection protocols. The effects of parental birth size, maternal linear growth from birth through adulthood, and exposure to the nutrition intervention, that is, Atole versus Fresco during critical periods from prenatal through age 15 years, have been examined using complex models and approaches. RESULTS: Overall, these publications demonstrate clear improvements in the growth of the next generation. Effects were seen primarily for maternal exposure to Atole and were larger for boys compared to girls. Stunting during early childhood among girls was also a significant predictor of offspring birth size, and younger age at first pregnancy (<20 years) was associated with an increased risk of stunting in the offspring. CONCLUSIONS: These studies have contributed significantly to our understanding of the importance of investing in nutrition, especially during early childhood for future generations.

Changes in Child and Adult Care Food Program (CACFP) Practices at Participating Childcare and Education Centers in the United States Following Updated National Standards, 2017-2019.

The U.S. Department of Agriculture's (USDA) Child and Adult Care Food Program (CACFP) updated meal pattern standards took effect in October 2017. The aim of this quasi-experimental, pre-post study is to identify changes in food and beverage practices of CACFP-participating centers due to implementation of updated CACFP meal patterns over a 21-month period. Eight hundred and fifty-eight centers located in 47 states and the District of Columbia completed a survey (primarily electronic) at both time points (67.6% follow-up response rate). Multivariable logistic regressions with robust standard errors assessed changes over time, accounting for repeated observations within each site. From baseline to follow-up, centers reported the increased familiarity and implementation, albeit with time, money, and staffing-related challenges. Significant improvements were seen in not serving sugary cereals or flavored milk, in serving 100% whole grains, and serving processed meats less than once a week. While CACFP-participating centers reported making significant progress in meeting the updated meal pattern standards and suggested best practices within 15-19 months of their effective date, reported compliance and adherence to the standards and best practices was not universal. USDA, state agencies, and technical assistance providers should work to provide centers with additional guidance to help them with implementation.

The Case for Investing in Young Children: Contributions of the INCAP Longitudinal Study.

This article highlights the important contributions that the Institute of Nutrition of Central America and Panama longitudinal study has made to global development efforts. The studies have made a unique contribution to our understanding of the role of early life nutrition on many outcomes of interest to the global nutrition community and have strengthened narratives such as human capital.

Nutrition, Adult Cognitive Skills, and Productivity: Results and Influence of the INCAP Longitudinal Study.

This article summarizes research based on the INCAP Longitudinal Study that demonstrates the positive effects of the atole intervention on prime-age adult cognitive skills and productivities. The findings are interpreted in the context of a life-cycle stages model in which various factors and investments at each stage of life influence outcomes not only in that stage but in subsequent ones. The results point to the likely importance of improvements in adult cognitive skills due to better early-life nutrition on adult male labor market outcomes as well as on women's "home productivity" in terms of anthropometrics for the next generation. Possible mechanisms are also explored, including the impacts of early-life exposure to atole on children's height when starting school, on grades of schooling attainment, and on the extent of experience with higher-skilled jobs, as well as the impacts of improved cognitive skills on wages. Not only are investments in early-life nutrition important for immediate welfare but also they have significant productivity payoffs in adulthood.

Study of the Determinants of Chronic Malnutrition in Northern Nigeria: Quantitative Evidence from the Nigeria Demographic and Health Surveys International Food Policy Research Institute (IFPRI) Working Paper 45 (September 2017).

BACKGROUND: Close to half of all children younger than 5 years in the Northeast and Northwest geopolitical zones were estimated to be stunted in their growth for their age in 2013 compared to 22% of children in the rest of Nigeria. OBJECTIVES: We examine the drivers of chronic child undernutrition in northern Nigeria and how those drivers differ from other areas of the country. METHODS: Both a standard child-level regression-based approach and decomposition analysis were used to address the determinants of stunting and decompose how drivers differ between northern Nigeria and other areas of the country using 2008 and 2013 Nigeria DHS data. RESULTS: There are strong differences in the levels of the determinants of undernutrition in young children between the 2 parts of the country. However, equally important, the decomposition analysis shows that there are significant differences between northern Nigeria and other areas of Nigeria in the effect of the same determinant of nutritional status in accelerating or retarding the linear growth of young children. CONCLUSIONS: A national program to address child undernutrition must recognize this heterogeneity in its design. To impose across Nigeria, a single set of approaches to address the factors which results in stunted children is likely to fail for large numbers of children if these strong geographical differences in how these determinants operate to affect child nutritional status are not considered. Solutions need to be developed within northern Nigeria to more closely reflect the way the determinants of nutritional status operate in this area of the country.

A Primary Care-Based Early Childhood Nutrition Intervention: Evaluation of a Pilot Program Serving Low-Income Hispanic Women.

Nutrition in early childhood can significantly impact physical and mental health outcomes for children. However, research on broadly defined pre/postnatal nutrition interventions is sparse. The present study is a process and outcome evaluation of a primary care-based nutrition intervention targeting low-income Hispanic women. Pregnant women enrolled in the program were in their first trimester and received services through their 6-month well child check. The program provided vouchers for fruits and vegetables from the local farmers' market, nutrition classes, cooking classes, and lactation counseling. We conducted a prospective study of program participants (n = 32) and a comparable group of women for whom the program was not available (n = 29). Panel survey data measured maternal diet, exercise, stress, depression, social support, infant feeding practices, and demographics. Outcome measures obtained from medical records included pregnancy weight gain, infant weight at 6 and 12 months, and infant development at 9 months. Findings reveal that the program was not associated with infant weights. However, despite similar profiles at baseline, women in the intervention group were more likely than women in the comparison group to have significant improvements in diet, exercise, and depression (p ≤ .05). In addition, participants were more likely to breastfeed (p = .07) and their infants were more likely to pass the ages and stages developmental screen (p = .06) than women in the comparison group. The study was limited by a lack of random assignment and small samples. However, the breadth and size of the effects suggest pre/postnatal nutrition interventions integrated into primary care warrant additional investigation.