Maternal, Infant, and Child Health Outcomes Associated With the Special Supplemental Nutrition Program for Women, Infants, and Children : A Systematic Review.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is intended to improve maternal and child health outcomes. In 2009, the WIC food package changed to better align with national nutrition recommendations. PURPOSE: To determine whether WIC participation was associated with improved maternal, neonatal-birth, and infant-child health outcomes or differences in outcomes by subgroups and WIC enrollment duration. DATA SOURCES: Search (January 2009 to April 2022) included PubMed, Embase, CINAHL, ERIC, Scopus, PsycInfo, and the Cochrane Central Register of Controlled Trials. STUDY SELECTION: Included studies had a comparator of WIC-eligible nonparticipants or comparison before and after the 2009 food package change. DATA EXTRACTION: Paired team members independently screened articles for inclusion and evaluated risk of bias. DATA SYNTHESIS: We identified 20 observational studies. We found: moderate strength of evidence (SOE) that maternal WIC participation during pregnancy is likely associated with lower risk for preterm birth, low birthweight infants, and infant mortality; low SOE that maternal WIC participation may be associated with a lower likelihood of inadequate gestational weight gain, as well as increased well-child visits and childhood immunizations; and low SOE that child WIC participation may be associated with increased childhood immunizations. We found low SOE for differences in some outcomes by race and ethnicity but insufficient evidence for differences by WIC enrollment duration. We found insufficient evidence related to maternal morbidity and mortality outcomes. LIMITATION: Data are from observational studies with high potential for selection bias related to the choice to participate in WIC, and participation status was self-reported in most studies. CONCLUSION: Participation in WIC was likely associated with improved birth outcomes and lower infant mortality, and also may be associated with increased child preventive service receipt. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERO: CRD42020222452).

When increasing vegetable production may worsen food availability gaps: A simulation model in India.

Translating agricultural productivity into food availability depends on food supply chains. Agricultural policy and research efforts promote increased horticultural crop production and yields, but the ability of low-resource food supply chains to handle increased volumes of perishable crops is not well understood. This study developed and used a discrete event simulation model to assess the impact of increased production of potato, onion, tomato, brinjal (eggplant), and cabbage on vegetable supply chains in Odisha, India. Odisha serves as an exemplar of vegetable supply chain challenges in many low-resource settings. Model results demonstrated that in response to increasing vegetable production 1.25-5x baseline amounts, demand fulfillment at the retail level fluctuated by + 3% to -4% from baseline; in other words, any improvements in vegetable availability for consumers were disproportionately low compared to the magnitude of increased production, and in some cases increased production worsened demand fulfillment. Increasing vegetable production led to disproportionately high rates of postharvest loss: for brinjal, for example, doubling agricultural production led to a 3% increase in demand fulfillment and a 19% increase in supply chain losses. The majority of postharvest losses occurred as vegetables accumulated and expired during wholesale-to-wholesale trade. In order to avoid inadvertently exacerbating postharvest losses, efforts to address food security through agriculture need to ensure that low-resource supply chains can handle increased productivity. Supply chain improvements should consider the constraints of different types of perishable vegetables, and they may need to go beyond structural improvements to include networks of communication and trade.

A Randomized Multiple Micronutrient Powder Point-of-Use Fortification Trial Implemented in Indian Preschools Increases Expressive Language and Reduces Anemia and Iron Deficiency.

BACKGROUND: Anemia is a global public health problem that undermines childhood development. India provides government-sponsored integrated nutrition/child development preschools. OBJECTIVES: This double-masked, cluster-randomized controlled trial examines whether point-of-use multiple micronutrient powder (MNP) compared with placebo fortification of preschool meals impacts child development and whether effects vary by preschool quality (primary outcome) and biomarkers of anemia and micronutrients (secondary outcomes). We also measured growth and morbidity. METHODS: We randomly assigned 22 preschools in rural India to receive MNP/placebo fortification. We administered baseline and endline blood sampling and measures of childhood development (Mullen Scales of Early Learning, inhibitory control, social-emotional), anthropometry, and morbidity to preschoolers (aged 29-49 mo). Preschools added MNP/placebo to meals 6 d/wk for 8 mo. We conducted linear mixed-effects regression models accounting for preschool clustering and repeated measures. We evaluated child development, examining effects in high- compared with low-quality preschools using the Early Childhood Environment Rating Scale-Revised and the Home Observation for the Measurement of the Environment Inventory, modified for preschools. RESULTS: At baseline, mean age ± SD was 36.6 ± 5.7 mo, with 47.8% anemic, 41.9% stunted, and 20.0% wasted. Baseline expressive/receptive language scores were higher in high-quality compared with low-quality preschools (P = 0.02 and P = 0.03, respectively). At endline (91% retention, n = 293/321), we found MNP compared with placebo effects in expressive language (Cohen's standardized effect d = 0.4), inhibitory control (d = 0.2), and social-emotional (d = 0.3) in low-quality, not high-quality, preschools. MNP had significantly greater reduction of anemia and iron deficiency compared with placebo (37% compared with 13.5% and 41% compared with 1.2%, respectively). There were no effects on growth or morbidity. CONCLUSIONS: Providing multiple micronutrient-fortified meals in government-sponsored preschools is feasible; reduced anemia and iron deficiency; and, in low-quality preschools, increased preschoolers' expressive language and inhibitory control and reduced developmental disparities. Improving overall preschool quality by incorporating multiple components of nurturing care (responsive care, learning, and nutrition) may be necessary to enhance preschoolers' development. This trial was registered at clinicaltrials.gov as NCT01660958.

Toddler obesity prevention: A two-generation randomized attention-controlled trial.

Rapid weight gain increases risks of obesity and associated co-morbidities. The objective was to reduce the rate of body mass index (BMI) growth (BMI z score), relative to control. Secondary outcomes were toddler-mother physical activity, mealtime interactions and fruit/vegetable intake. The randomized three-arm, eight-session, 4-month trial, conducted 2009-2013, included two intervention arms (responsive parenting and maternal lifestyle) and an attention control (home safety). Baseline and 6- and 12-month follow-up evaluations included weight and length/height, ankle accelerometry, video-recorded mealtime interactions (Emotional Availability Scales) and 24-h diet recalls (Healthy Eating Index-2015 [HEI-2015]). Analyses used linear mixed-effects models with repeated measures comparing intervention versus control changes in BMI z score. We recruited 277 racially mixed (70% African American) toddler-mother dyads (mean ages 20.1 months and 27.3 years) from US WIC and primary care clinics and randomized them into intervention versus control; 31% toddlers and 73% mothers were overweight/obese. At follow-up, changes in the rate of toddler BMI z score and maternal BMI were non-significant. Maternal lifestyle group toddlers and mothers spent 24.43 and 11.01 more minutes in physical activity (95% confidence interval [CI]: 2.55, 46.32, and 95% CI: 1.48, 20.54, respectively). Fruit intake increased in both intervention groups. Hostile mealtime interactions increased in the maternal lifestyle group, and in supplementary analyses, mealtime interactions were significantly higher in the responsive parenting group than in the maternal lifestyles group, suggesting that toddler dietary interventions include responsive parenting. Intervention effects were stronger among older versus younger toddlers. Despite no impact on weight gain, additional research should examine integrated two-generation responsive parenting and maternal lifestyle interventions among toddler-mother dyads.

Impact Evaluation of a Comprehensive Nutrition Program for Reducing Stunting in Children Aged 6-23 Months in Rural Malawi.

BACKGROUND: The prevalence of stunting in central rural Malawi is ∼50%, which prompted a multipronged nutrition program in 1 district from 2014 to 2016. The program distributed a daily, fortified, small-quantity lipid-based nutritional supplement, providing 110 kcal and 2.6 g of protein to children aged 6-23 mo, and behavior change messages around optimal infant and young child feeding (IYCF) and water, sanitation, and hygiene. OBJECTIVES: Our objective was to perform an impact evaluation of the program using a neighboring district as comparison. METHODS: Using a quasi-experimental study design, with cross-sectional baseline (January-March, 2014; n = 2404) and endline (January-March, 2017; n = 2453) surveys, we evaluated the program's impact using a neighboring district as comparison. Impact on stunting was estimated using propensity score weighted difference-in-differences regression analyses to account for baseline differences between districts. RESULTS: No differences in mean length-for-age z-score or prevalence of stunting were found at endline. However, mean weight, weight-for-length z-score, and mid-upper arm circumference were higher at endline by 150 g, 0.22, and 0.19 cm, respectively, in the program compared with the comparison district (all P < 0.05). Weekly reports of high fever and malaria were also lower by 6.4 and 4.7 percentage points, respectively, in the program compared with the comparison district (both P < 0.05). There was no impact on anemia. Children's dietary diversity score improved by 0.17, and caregivers' infant and young child feeding and hand-washing practices improved by 8-11% in the program compared with the comparison district (all P < 0.05). CONCLUSIONS: An impact evaluation of a comprehensive nutrition program in rural Malawi demonstrated benefit for child ponderal growth and health, improved maternal IYCF and hand-washing practices, but a reduction in stunting prevalence was not observed.

Maternal anxiety and diet quality among mothers and toddlers from low-income households.

We evaluated the association between maternal anxiety score and diet quality over time among mothers and toddlers in low-income families. Longitudinal data were collected from 267 mother-toddler dyads in an obesity prevention trial. Participants were recruited from the Special Supplemental Nutrition Program for Women, Infants and Children and paediatric clinics between 2007 and 2010. Dyads were assessed at study enrolment (Time 1), 6-month (Time 2), and 12-month follow-up (Time 3). On the basis of a 1-day 24-hr dietary recall, we estimated maternal and toddler diet quality using the Healthy Eating Index 2015. Anxiety, a time-varying variable, was assessed via the State-Trait Anxiety Inventory. Associations between maternal anxiety score and maternal and toddler diet quality over time were assessed in adjusted mixed models. Maternal and toddler diet quality were positively correlated (r = .48, p < .001). Higher maternal anxiety scores were related to lower toddler Healthy Eating Index scores (b = -0.51, 95% confidence interval, CI [-0.87, -0.15]) with no significant variation over time. The relation between maternal diet quality and anxiety score varied over time (b = 0.28, p = .03, for time-anxiety interaction). Higher maternal anxiety scores were associated with lower maternal diet quality at Time 1 (b = -0.71, 95% CI [-1.09, 0.34]) and at Time 2 (b = -0.51, 95% CI [-0.97, -0.05]), but not at Time 3 (b = -0.14, 95% CI [-0.54, 0.26]). Findings suggest that mothers and toddlers exhibited similar low-quality dietary patterns and that lower diet quality was associated with higher maternal anxiety scores. Approaches to enhance diet quality may consider incorporating anxiety-reducing strategies into maternal and toddler care and feeding behaviour guidelines.

Zinc deficiency associated with anaemia among young children in rural Guatemala.

One in four children younger than age five in Guatemala experiences anaemia (haemoglobin <11.0 g/dl). This study characterized the factors and micronutrient deficiencies associated with anaemia in a baseline cross-sectional sample of 182 Guatemalan infants/toddlers and 207 preschoolers, using generalized linear mixed models. Associations between anaemia and maternal, child and household variables, and biomarkers (soluble transferrin receptor, ferritin, zinc, folate, vitamin B12, C-reactive protein, and α1-acid glycoprotein) were explored. Rates of anaemia were 56% among infants/toddlers and 12.1% among preschoolers. In children with anaemia, rates of iron deficiency (low ferritin based on inflammation status, and/or high soluble transferrin receptor, ≥1.97 mg/L) and zinc deficiency (serum zinc <65 µg/dl) were 81.1% and 53.7%, respectively. Folate deficiency (either plasma folate <3 ng/ml or erythrocyte folate <100 ng/ml) was 3.3%. Vitamin B12 deficiency (plasma vitamin B12 <148 pmol/L) was 7.5%. For infants and toddlers (<24 months), the odds ratio of anaemia was lower when higher number of adults lived in the household (OR = 0.69; 95% CI [0.53, 0.90]), and higher when children were zinc deficient (OR = 3.40; 95% CI [1.54, 7.47]). For preschoolers (36-60 months), the odds ratio of anaemia was lower for every additional month of age (OR = 0.90; 95% CI [0.81, 1.00]). Findings suggest that micronutrient deficiencies coexist in Guatemalan rural children, and zinc deficiency is associated with anaemia in children <24 months, highlighting the need of continued multidisciplinary interventions with multiple micronutrients. Further research examining how household composition, feeding practices, and accessibility to micronutrient supplements and to animal source foods is needed to incorporate strategies to improve the nutritional status of Guatemalan children.

Mechanisms linking height to early child development among infants and preschoolers in rural India.

Stunting has been negatively associated with children's development. We examined the range of height by testing hypotheses: (a) height is positively associated with children's development, with associations moderated by inflammation and (b) home environments characterized by nurturance and early learning opportunities is positively associated with children's development over time and attenuate associations with height. Data included 513 infants (mean age 8.6 months) and 316 preschoolers (mean age 36.6 months) in rural India from a randomized controlled trial of multiple micronutrient powders (MNPs). Measures included height (height-for-age z-scores based on WHO standards), inflammation (C-reactive protein concentration >5 mg/L), nurturance (HOME Inventory), child development (Mullens Scales of Early Learning), and inhibitory control (preschoolers). Linear mixed effects models accounting for repeated measures, clustering, and confounders were used to assess associations between height and child development over time (infants: enrollment, 6 and 12 months; preschoolers: enrollment and 8 months). Moderating effects of inflammation and nurturance were tested with interaction terms. Among infants and preschoolers, height and nurturance were positively associated with all domains of child development over time, with the exception of inhibitory control. Among preschoolers, in the presence of inflammation, height was not associated with child development. Among infants, but not preschoolers, a nurturant home environment attenuated significant associations between height with fine motor and receptive language development. The mechanisms associated with children's development over time are multifactorial and include direct and indirect associations among nutrition, health, and the home environment, as supported by the Nurturing Care Framework.

Obese women's perceptions of weight gain during pregnancy: a theory-based analysis.

OBJECTIVE: Excess gestational weight gain (GWG) in obese women is linked to adverse maternal outcomes and is particularly pervasive among African Americans, who have the highest obesity rates in the USA. A better understanding of culturally relevant attitudes and perceptions of GWG is needed to develop targeted interventions to prevent excess GWG among this group. DESIGN: Using the constructs of Social Cognitive Theory, we explored attitudes and perceptions surrounding diet and exercise among low-income obese African-American pregnant women in Baltimore. We conducted twenty-one semi-structured in-depth interviews with pregnant adult women. SETTING: Participants were recruited from a referral clinic for obese pregnant women at a large urban hospital in Baltimore, MD, USA. PARTICIPANTS: Twenty-one low-income African-American adult females in the first two trimesters of pregnancy with BMI > 30·0 kg/m2. RESULTS: Lack of knowledge was not the main obstacle to healthy behaviours during pregnancy. Rather, food cravings and fatigue, an unhealthy physical food environment, limited self-efficacy for controlling excessive GWG, and a lack of adequate emotional and informational support impacted women's agency. While digital technology was discussed as a vehicle to promote maintenance of a healthy weight in pregnancy, further research is needed to test how it can be used to empower women to engage in healthy behaviours during pregnancy. CONCLUSION: Interventions to prevent excess GWG among African-American pregnant women should harness support from partners and family and must go beyond sharing of clinical knowledge to also include strategies that improve the food environment, diet quality and self-efficacy.

Household food insecurity is associated with low dietary diversity among pregnant and lactating women in rural Malawi.

OBJECTIVE: To examine the association between household food insecurity and dietary diversity in the past 24h (dietary diversity score (DDS, range: 0-9); minimum dietary diversity (MDD, consumption of three or more food groups); consumption of nine separate food groups) among pregnant and lactating women in rural Malawi. DESIGN: Cross-sectional study. SETTING: Two rural districts in Central Malawi. SUBJECTS: Pregnant (n 589) and lactating (n 641) women. RESULTS: Of surveyed pregnant and lactating women, 66·7 and 68·6 %, respectively, experienced moderate or severe food insecurity and only 32·4 and 28·1 %, respectively, met MDD. Compared with food-secure pregnant women, those who reported severe food insecurity had a 0·36 lower DDS (P<0·05) and more than threefold higher risk (OR; 95 % CI) of not consuming meat/fish (3·19; CI 1·68, 6·03). The risk of not consuming eggs (3·77; 1·04, 13·7) was higher among moderately food-insecure pregnant women. Compared with food-secure lactating women, those who reported mild, moderate and severe food insecurity showed a 0·36, 0·44 and 0·62 lower DDS, respectively (all P<0·05). The risk of not achieving MDD was higher among moderately (1·95; 1·06, 3·59) and severely (2·82; 1·53, 5·22) food-insecure lactating women. The risk of not consuming meat/fish and eggs increased in a dose-response manner among lactating women experiencing mild (1·75; 1·01, 3·03 and 2·81; 1·09, 7·25), moderate (2·66; 1·47, 4·82 and 3·75; 1·40, 10·0) and severe (5·33; 2·63, 10·8 and 3·47; 1·19, 10·1) food insecurity. CONCLUSIONS: Addressing food insecurity during and after pregnancy needs to be considered when designing nutrition programmes aiming to increase dietary diversity in rural Malawi.

Complementary Food Supplements Increase Dietary Nutrient Adequacy and Do Not Replace Home Food Consumption in Children 6-18 Months Old in a Randomized Controlled Trial in Rural Bangladesh.

Background: Inadequate complementary feeding is common in low- and middle-income countries, contributing to growth deficits. Complementary food supplements (CFSs) aim to fill dietary gaps, but few CFS studies have measured nutrient intake. In a community-based, randomized CFS trial in Bangladesh, we previously reported poor dietary diversity in 6-18-mo-old participants. Objective: We investigated, in a secondary analysis in the same trial, micronutrient intake adequacy in supplemented compared with control-arm children. Methods: At age 6 mo, children were assigned to 1 y of child-feeding counseling for mothers (control) or counseling plus 1 of 4 CFS formulations. Mothers were administered quantitative past 24-h diet questionnaires for their children at ages 6, 9, 12, 15, and 18 mo. Nutrient intakes were estimated with local recipes and food composition tables assuming average age-specific breastmilk intake. Adequacy was evaluated relative to estimated average requirements or adequate intakes. Multivariate analysis of variance and generalized estimating equation (GEE) regression models estimated the effect of each CFS on nutrient adequacy. GEE models tested dietary predictors of nutrient adequacy in the control arm. Results: A total of 25,964 dietary modules across 5 interviews were completed. Nutrient adequacy from home foods combined with assumed breastmilk intake was low. Only 5 of 16 micronutrients were adequately consumed by >60% of children at 18 mo of age. Daily CFSs did not affect energy-adjusted micronutrient intake from home foods at any follow-up age (P > 0.05). CFSs increased the mean adequacy ratio for all micronutrients (P < 0.001 at all ages), to ≥1 for 14 of 16 micronutrients at 18 mo. Dietary diversity predicted adequate iron, zinc and calcium intake at 15 mo in unsupplemented controls. Conclusions: Home foods did not meet the estimated micronutrient needs of 9-18-mo-old children in rural Bangladesh. Daily supplementation with fortified complementary foods filled many micronutrient intake gaps and did not displace home foods. Previously, CFSs were shown to also improve linear growth and reduce stunting in this cohort. Findings support the need for CFSs in similar settings to promote nutritional well being and growth. This trial was registered at clinicaltrials.gov as NCT01562379.

Comparison of the HEI and HEI-2010 Diet Quality Measures in Association with Chronic Disease Risk among Low-Income, African American Urban Youth in Baltimore, Maryland.

OBJECTIVE: Overall diet patterns may be a better predictor of disease risk than specific nutrients or individual foods. The purpose of this study is to examine how overall diet patterns relate to nutritional intake, body composition, and physiological measures of chronic disease risk among low-income, urban African American adolescents. METHODS: Cross-sectional data were collected from two samples of African American adolescents (n = 317) from a low-income urban community, including dietary intake using the food frequency Youth/Adolescent Questionnaire and anthropometric measures. Serum cholesterol, serum lipoproteins, and glucose tolerance were measured in a subsample. Means testing compared differences in Healthy Eating Index (HEI) and Healthy Eating Index-2010 (HEI-2010) component and total scores. Pearson correlations examined how HEI and HEI-2010 scores related to nutrient, food intakes, and markers of disease risk, including body mass index, percent body fat, abdominal fat, serum cholesterol, serum lipoproteins, and impaired glucose tolerance. Fisher R-Z transformations compared magnitude differences between HEI and HEI-2010 correlations to nutritional intake and chronic disease risk. RESULTS: Both HEI and HEI-2010 scores were positively associated with micronutrient intakes. Higher HEI scores were inversely related to serum cholesterol, low-density lipoprotein, impaired glucose tolerance, percent body fat, and percent abdominal fat. HEI-2010 scores were not related to biomarkers of chronic disease risk. CONCLUSIONS: Compared to the HEI-2010, the HEI is a better indicator of chronic disease risk among low-income, urban African American adolescents.

Pathways of the association between maternal employment and weight status among women and children: Qualitative findings from Guatemala.

The double burden of malnutrition, defined by the coexistence of undernutrition and overweight, is well documented in low- and middle-income countries. However, the mechanisms by which employment may be related to maternal and child weight status in low- and middle-income countries are not well understood. We conducted in-depth interviews among 20 mothers who participated in Project MIEL, a contemporary trial which evaluated the effects of an integrated micronutrient supplement and parenting intervention in rural Guatemala. We utilized semi-structured interviews to explore the pathways by which maternal employment might influence bodyweight. Interviews were structured to explore the factors that mothers considered when deciding whether or not to participate in the labor force and how mothers perceived the influence of employment on determinants of their own bodyweight and that of their children. Themes were used to develop a conceptual framework. Mothers described four pathways through which employment could lead to changes in weight status: changes in food purchasing; improved household well-being; changes in time allocation; and psychological effects. Mothers described purchasing increased quantities and more varied types of food, as well as the purchase of energy-dense foods. Less time to devote to food preparation resulted in mothers preparing quicker meals and relying on substitute childcare. Mothers also expressed feelings of worry and neglect in relation to being employed, and perceived that these feelings would affect weight. A better understanding of these mechanisms is important for developing policies and programs to support women in the workplace and also reducing maternal and child overweight in Guatemala.

Physical and sociocultural facilitators and barriers to access and utilization of a nutrition program in rural Malawi: a qualitative study.

Childhood stunting holds consequences for child development. A nutrition program delivering small-quantity lipid based nutrient supplements (SQ-LNS) to children 6-23 months and child feeding messages was implemented in Malawi to reduce stunting. This study sought to understand the facilitators and barriers to program participation using in-depth interviews, pile sorts, direct observations, and focus group discussions with caretakers, village leaders and program volunteers. Perceptions of the LNS were positive, and visible changes in child health contributed to program participation. Conflicting priorities that prevented monthly collection of SQ-LNS and limited knowledge of child feeding messages constituted barriers to program participation.

Factors Associated with Home Meal Preparation and Fast-Food Sources Use among Low-Income Urban African American Adults.

This study aimed to assess the factors associated with home meal preparation (HMP) and fast-food sources use (FFS) frequencies of low-income African-American adults and their healthy food beliefs and attitudes, food-related psychosocial factors, food acquisition patterns, food sources use, and BMI. We used cross-sectional data from 295 adults living in Baltimore, USA. HMP was inversely associated with FFS, which had lower odds of HMP ≥1 time/day and higher BMI scores. HMP was positively associated with positive beliefs and self-efficacy toward healthy foods, getting food from healthier food sources, and lower FFS. Higher odds of HMP ≥1 time/day were associated with getting food from farmers' market and supermarkets or grocery stores. FFS had an inverse association with positive beliefs and self-efficacy toward healthy foods, and a positive association with less healthy food acquisition scores. Higher odds of FFS ≥1 time/week were associated with getting food from corner stores, sit-down restaurants, and convenience stores.

Food swamps and food deserts in Baltimore City, MD, USA: associations with dietary behaviours among urban adolescent girls.

OBJECTIVE: To determine whether living in a food swamp (≥4 corner stores within 0·40 km (0·25 miles) of home) or a food desert (generally, no supermarket or access to healthy foods) is associated with consumption of snacks/desserts or fruits/vegetables, and if neighbourhood-level socio-economic status (SES) confounds relationships. DESIGN: Cross-sectional. Assessments included diet (Youth/Adolescent FFQ, skewed dietary variables normalized) and measured height/weight (BMI-for-age percentiles/Z-scores calculated). A geographic information system geocoded home addresses and mapped food deserts/food swamps. Associations examined using multiple linear regression (MLR) models adjusting for age and BMI-for-age Z-score. SETTING: Baltimore City, MD, USA. SUBJECTS: Early adolescent girls (6th/7th grade, n 634; mean age 12·1 years; 90·7 % African American; 52·4 % overweight/obese), recruited from twenty-two urban, low-income schools. RESULTS: Girls' consumption of fruit, vegetables and snacks/desserts: 1·2, 1·7 and 3·4 servings/d, respectively. Girls' food environment: 10·4 % food desert only, 19·1 % food swamp only, 16·1 % both food desert/swamp and 54·4 % neither food desert/swamp. Average median neighbourhood-level household income: $US 35 298. In MLR models, girls living in both food deserts/swamps consumed additional servings of snacks/desserts v. girls living in neither (ß=0·13, P=0·029; 3·8 v. 3·2 servings/d). Specifically, girls living in food swamps consumed more snacks/desserts than girls who did not (ß=0·16, P=0·003; 3·7 v. 3·1 servings/d), with no confounding effect of neighbourhood-level SES. No associations were identified with food deserts or consumption of fruits/vegetables. CONCLUSIONS: Early adolescent girls living in food swamps consumed more snacks/desserts than girls not living in food swamps. Dietary interventions should consider the built environment/food access when addressing adolescent dietary behaviours.

Maternal mental health symptoms are positively related to emotional and restrained eating attitudes in a statewide sample of mothers participating in a supplemental nutrition program for women, infants and young children.

Postpartum, low-income mothers are at risk for mental health symptoms and obesity, and disordered eating attitudes may be associated with both mental health and obesity in this vulnerable population. The study objective is to determine whether higher levels of mental health symptoms are associated with increased odds of emotional and restrained eating attitudes in this sample of Special Supplemental Nutrition Program for Women, Infants and Children (WIC) participants. Data on 711 mothers of infants <13 months from a statewide sample of Maryland WIC participants were collected via telephone survey. Maternal mental health symptoms were measured on continuous scales for depression (PRIME-MD), stress (Perceived Stress Scale) and anxiety (Spielberger State-Trait Anxiety Inventory). Emotional and restrained eating attitudes were measured with questions adapted from the Dutch Eating Behavior Questionnaire. Multivariate logistic regression analysis was used. Obesity [body mass index (BMI) ≥ 30] was explored as a moderating variable. Mothers reporting higher levels of depression symptoms [odds ratio (OR) = 3.93, 95%CI: 2.71-5.69], anxiety symptoms (OR = 1.96, 95%CI: 1.47-2.65), stress symptoms (OR = 2.09, 95%CI: 1.67-2.61) and high overall mental health symptomatology (OR = 3.51, 95%CI: 2.43-5.3) had increased odds of emotional eating attitudes. There were significant associations between symptoms of depression (OR = 1.59, 95% CI: 1.12-2.25) and increased odds of restrained eating attitudes. Obesity did not moderate the association. Mothers with mental health symptoms are at risk for disordered eating attitudes, which may increase risk of poor diet. These findings underscore the need for greater focus on addressing maternal mental health status and eating attitudes in the postpartum period.

Characterisation of anaemia and associated factors among infants and pre-schoolers from rural India.

OBJECTIVE: In India, national databases indicate anaemia prevalence of 80 % among 6-35-month-old children and 58 % among 36-59-month-old children. The present study aimed to characterise anaemia and the associated factors among infants and pre-schoolers living in rural India. DESIGN: Multivariate logistic regression analysis of data collected prior to an intervention trial. Fe-deficiency with anaemia (IDA), Fe deficiency with no anaemia (IDNA) and anaemia without Fe deficiency were defined. Serum ferritin, soluble transferrin receptor (sTfR) and sTfR/log ferritin index were used to indicate Fe status. SETTING: Twenty-six villages of Nalgonda district, Telangana, India. Data were collected in community sites. Participants Four hundred and seventy-six infants (aged 6-12 months), 316 pre-schoolers (aged 29-56 months) and their mothers. RESULTS: Prevalence of anaemia among infants and pre-schoolers was 66·4 and 47·8 %, prevalence of IDA was 52·2 and 42·1 %, prevalence of IDNA was 22·2 and 29·8 %, prevalence of anaemia without Fe deficiency was 14·2 and 5·7 %. Among infants, anaemia was positively associated with maternal anaemia (OR=3·31; 95 % CI 2·10, 5·23; P<0·001), and sTfR/log ferritin index (OR=2·21; 95 % CI 1·39, 3·54; P=0·001). Among pre-schoolers, anaemia was positively associated with maternal anaemia (OR=3·77; 95 % CI 1·94, 7·30; P<0·001), sTfR/log ferritin index (OR=5·29; 95 % CI 2·67, 10·50; P<0·001), high C-reactive protein (OR=4·39; 95 % CI 1·91, 10·06, P<0·001) and young age (29-35 months: OR=1·92; 05 % CI 1·18, 3·13, P=0·009). CONCLUSIONS: Anaemia prevalence continues to be high among infants and pre-schoolers in rural India. Based on sTfR/ferritin index, Fe deficiency is a major factor associated with anaemia. Anaemia is also associated with inflammation among pre-schoolers and with maternal anaemia among infants and pre-schoolers, illustrating the importance of understanding the aetiology of anaemia in designing effective control strategies.

Household, psychosocial, and individual-level factors associated with fruit, vegetable, and fiber intake among low-income urban African American youth.

BACKGROUND: Childhood obesity, one of the greatest challenges to public health, disproportionately affects low-income urban minority populations. Fruits and vegetables (FV) are nutrient dense foods that may be inversely associated with excessive weight gain. We aimed to identify the individual characteristic, psychosocial, and household factors influencing FV and fiber consumption in low-income African-American (AA) youth in Baltimore, MD. METHODS: Cross-sectional analysis of data collected from 285 low-income AA caregiver-youth (age range: 10-14 y) dyads participating in the baseline evaluation of the B'More Healthy Communities for Kids obesity prevention trial. The Kid's Block FFQ was used to estimate daily intakes of FV (including 100 % fruit juice) and dietary fiber. Questionnaires were used to assess household socio-demographics, caregiver and youth food purchasing and preparation behavior, and youth psychosocial information. Ordered logit regression analyses were conducted to examine psychosocial and food-related behavior associated with FV and dietary fiber intake (quartile of intake) controlling for youth age, sex, BMI percentile, total calorie intake and household income. RESULTS: On average, youth consumed 1.5 ± 1.1 (M ± SD) servings of fruit, 1.8 ± 1.7 serving of vegetables, and 15.3 ± 10.9 g of fiber/day. There were no differences by gender, age or household income. Greater youth's healthy eating intentions and self-efficacy scores were associated with greater odds ratio for higher intake of FV and fiber (Intention: ORfruit 1.22; 95 % CI: 1.06-1.41, ORvegetable 1.31; 1.15-1.51 and ORfiber 1.46; 1.23-1.74, Self-efficacy: ORfruit 1.07; 1.03-1.12, ORvegetable 1.04; 1.01-1.09, ORfiber 1.10; 1.04-1.16). Youth receiving free/low-cost breakfast were more than twice as likely to have higher fiber intake than those who did not receive free breakfast (OR 2.7; 1.10; 6.9). In addition, youth shopping more frequently at supermarkets were more likely to have greater vegetable and fiber intake (OR 1.26; 1.06-1.50; OR 1.28; 1.03-1.58, respectively). Also, youth with parents who shopped more frequently at fast-food stores had 7 % lower odds for higher vegetable intake (95 % CI: 0.88-0.99). CONCLUSION: In this study, both, youth and household factors were associated with youth FV and fiber intake, underscoring the need for a multi-level approach to increasing youths' diet quality. These results will inform and shape an effective intervention program for improving youth dietary intakes.

Guatemalan school food environment: impact on schoolchildren's risk of both undernutrition and overweight/obesity.

Guatemala suffers the double burden of malnutrition with high rates of stunting alongside increasing childhood overweight/obesity. This study examines the school food environment (SFE) at low-income Guatemalan elementary schools and discusses its potential impact on undernutrition and overweight/obesity. From July through October 2013, direct observations, in-depth interviews with school principals (n = 4) and food kiosk vendors (n = 4, 2 interviews each) and also focus groups (FGs) with children (n = 48, 8 FGs) were conducted. The SFE comprises food from school food kiosks (casetas); food from home or purchased in the street; and food provided by the school (refacción). School casetas, street vendors and children's parents largely provide sandwiches, calorie-rich snacks and sugar-sweetened beverages. Refacción typically serves energy dense atol, a traditional beverage. The current school food program (refacción), the overall SFE and the roles/opinions of vendors and principals reveal persistent anxiety concerning undernutrition and insufficient concern for overweight/obesity. Predominant concern for elementary schoolchildren remains focused on undernutrition. However, by the time children reach elementary school (ages 6-12+), food environments should encourage dietary behaviors to prevent childhood overweight/obesity.