EAT-Lancet diet score requires minimum intake values to predict higher micronutrient adequacy of diets in rural women of reproductive age from five low- and middle-income countries.

The EAT-Lancet Commission promulgated a universal reference diet. Subsequently, researchers constructed an EAT-Lancet diet score (0-14 points), with minimum intake values for various dietary components set at 0 g/d, and reported inverse associations with risks of major health outcomes in a high-income population. We assessed associations between EAT-Lancet diet scores, without or with lower bound values, and the mean probability of micronutrient adequacy (MPA) among nutrition-insecure women of reproductive age (WRA) from low- and middle-income countries (LMIC). We analysed single 24-h diet recall data (n 1950) from studies in rural DRC, Ecuador, Kenya, Sri Lanka and Vietnam. Associations between EAT-Lancet diet scores and MPA were assessed by fitting linear mixed-effects models. Mean EAT-Lancet diet scores were 8·8 (SD 1·3) and 1·9 (SD 1·1) without or with minimum intake values, respectively. Pooled MPA was 0·58 (SD 0·22) and energy intake was 10·5 (SD 4·6) MJ/d. A one-point increase in the EAT-Lancet diet score, without minimum intake values, was associated with a 2·6 (SD 0·7) percentage points decrease in MPA (P < 0·001). In contrast, the EAT-Lancet diet score, with minimum intake values, was associated with a 2·4 (SD 1·3) percentage points increase in MPA (P = 0·07). Further analysis indicated positive associations between EAT-Lancet diet scores and MPA adjusted for energy intake (P < 0·05). Our findings indicate that the EAT-Lancet diet score requires minimum intake values for nutrient-dense dietary components to avoid positively scoring non-consumption of food groups and subsequently predicting lower MPA of diets, when applied to rural WRA in LMIC.

Seasonality modifies the effect of a lipid-based nutrient supplement for pregnant rural women on birth length.

BACKGROUND: Maternal nutritional status is a major determinant of low birth weight and fluctuates across seasons. Seasonality may influence the outcome of prenatal nutrition interventions that aim to enhance fetal growth. OBJECTIVE: This study investigated seasonal modifications of the efficacy of a randomized controlled prenatal nutrition intervention trial in pregnant women to improve fetal growth in rural Burkina Faso. METHODS: The second Micronutriments et Santé de la Mère et de l'Enfant study compared a lipid-based nutrient supplement (LNS) fortified with multiple micronutrients (MMNs) to an MMN supplement. Truncated Fourier series were used to characterize seasonality in birth outcomes. Models that included the Fourier series and newborn and maternal characteristics were used to assess seasonal effect modifications of prenatal supplementation on birth outcomes. RESULTS: Birth weight, birth length, small for gestational age as a proxy for intrauterine growth retardation, and preterm birth were significantly related to date of birth and showed important seasonal variations. LNSs, which supply energy in addition to MMNs, resulted in a significant increase in birth length (+13.5 mm, 95% CI: 6.5, 20.5 mm) at the transition from rain to dry season (September to November) compared to MMNs alone. CONCLUSIONS: The climatologic and agricultural seasonal patterns in Burkina Faso affect the efficacy of prenatal LNSs on birth length. In this context, prenatal MMN supplementation programs should be complemented by energy supplementation during the annual rain season to promote fetal growth. This trial was registered at clinicaltrials.gov as NCT00909974.

Feeding practices and nutrient content of complementary meals in rural central Tanzania: implications for dietary adequacy and nutritional status.

BACKGROUND: Stunting and micronutrient deficiencies are significant health problems among infants and young children in rural Tanzania. Objective of the study was to assess feeding practices, nutrient content of complementary meals, and their implications for dietary adequacy and nutritional status. METHODS: A cross-sectional study was conducted in six randomly selected villages in Mpwapwa District, Tanzania during the post-harvest season. Information on feeding practices, dietary consumption and anthropometric measurements of all infants below the age of one year were collected. Forty samples of common meals were collected and analysed for proximate composition, iron, zinc and calcium. Results were expressed per 100 g dry weight. RESULTS: Energy, protein and fat content in porridge ranged from 40.67-63.92 kcal, 0.54-1.74% and 0.30-2.12%, respectively. Iron, zinc and calcium contents (mg/100 g) in porridge were 0.11-2.81, 0.10-3.23, and 25.43-125.55, respectively. Median portion sizes were small (porridge: 150-350 g; legumes and meats: 39-90 g). Very few children (6.67%) consumed animal-source foods. Low meal frequency, low nutrient content, small portion size and limited variety reduced the contribution of meals to daily nutritional needs. CONCLUSIONS: Findings of the study highlight inadequate feeding practices, low nutritional quality of meals and high prevalence of stunting. Feasible strategies are needed to address the dietary inadequacies and chronic malnutrition of rural infants.

Association of out-of-home eating with anthropometric changes: a systematic review of prospective studies.

In the present review, the association of out-of-home eating with anthropometric changes was examined. Peer-reviewed studies in eight databases were searched, and 15 prospective studies were included in the review. The quality of the data was assessed by considering risks of bias in sample selection, data collection methods, and the appropriateness of statistical tests. From this, seven studies, which used relatively large samples or had a follow-up period longer than 10 years, were retained for further analysis. It was concluded that eating out-of-home frequently, in the broad sense, is positively associated with the risk of becoming overweight or obese and weight change. With regard to specific out-of-home sources, the review shows that eating at fast-food outlets is associated with a greater increase in body weight and waist circumference over time than eating at restaurants and takeaway foods positively predict BMI change in women. More research is needed on out-of-home foods other than fast-foods and restaurant foods, such as street, canteen, and school foods.

Effectiveness of a nutrition education package in improving feeding practices, dietary adequacy and growth of infants and young children in rural Tanzania: rationale, design and methods of a cluster randomised trial.

BACKGROUND: Strategies to improve infant and young child nutrition in low- and middle- income countries need to be implemented at scale. We contextualised and packaged successful strategies into a feasible intervention for implementation in rural Tanzania. Opportunities that can optimise delivery of the intervention and encourage behaviour change include mothers willingness to modifying practices; support of family members; seasonal availability and accessibility of foods; established set-up of village peers and functioning health system. The primary objective of the study is to evaluate the effectiveness of a nutrition education package in improving feeding practices, dietary adequacy and growth as compared to routine health education. METHODS/DESIGN: A parallel cluster randomised controlled trial will be conducted in rural central Tanzania in 9 intervention and 9 control villages. The control group will receive routine health education offered monthly by health staff at health facilities. The intervention group will receive a nutrition education package in addition to the routine health education. The education package is comprised of four components: 1) education and counselling of mothers, 2) training community-based nutrition counsellors and monthly home visits, 3) sensitisation meetings with health staff and family members, and 4) supervision of community-based nutrition counsellors. The duration of the intervention is 9 months and infants will be recruited at 6 months of age. Primary outcome (linear growth as length-for-age Z-scores) and secondary outcomes (changes in weight-for-length Z-scores; mean intake of energy, fat, iron and zinc from complementary foods; proportion of children consuming 4 or more food groups and recommended number of semi-solid/soft meals and snacks per day; maternal level of knowledge and performance of recommended practices) will be assessed at baseline and ages 9, 12 and 15 months. Process evaluation will document reach, dose and fidelity of the intervention and context at 8 and 15 months. DISCUSSION: Results of the trial will provide evidence of the effectiveness of the nutrition education package in community settings of rural Tanzania. They will provide recommendations for strengthening the nutrition component of health education in child health services. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02249754, September 25, 2014.

Nutrition Education Package Focusing on Infant and Young Child Feeding in Tanzania.

OBJECTIVE: To evaluate the effectiveness of a nutrition education package on feeding practices, nutrient intakes and growth of infants in rural Tanzania. DESIGN: Cluster-randomized controlled trial in 18 villages allocated to nutrition education package (n = 9) or routine health education (n = 9 villages), measured at baseline (6 months) and end of the trial (12 months). SETTING: Mpwapwa district. PARTICIPANTS: Infants aged 6-12 months and their mothers. INTERVENTION(S): Six months of nutrition education package (group education, counseling, cooking demonstrations) and regular home visits by village health workers. MAIN OUTCOME MEASURE(S): Primary outcome measure was the mean change in length-for-age z-scores. Secondary outcomes included mean changes in weight-for-length z-scores (WLZ), intakes of energy, fat, iron and zinc, the proportion of children consuming foods from ≥ 4 food groups (ie, dietary diversity) and consuming the recommended number of semisolid/soft meals and snacks per day (ie, meal frequency). ANALYSIS: Multilevel mixed-effects regression models. RESULTS: Mean change in length-for-age z-scores (ß = 0.20, P = 0.02), energy (in kcal) (ß = 43.8, P = 0.02), and fat (in grams) (ß =2.7, P = 0.03) intakes were significant in the intervention but not in the control group. There was no effect on iron and zinc intakes. More infants in the intervention than the control group consumed meals from ≥ 4 food groups (71.8% vs 45.3%, P = 0.002). The mean increase in meal frequency (ß = 0.29, P = 0.02) and dietary diversity (ß = 0.40, P = 0.01) were more significant in the intervention than control. CONCLUSIONS AND IMPLICATIONS: The nutrition education package is feasible and can be implemented with high coverage, demonstrating the potential to improve feeding practices, nutrient intake and growth in rural Tanzania.

Food, energy and macronutrient contribution of out-of-home foods in school-going adolescents in Cotonou, Benin.

The objective of the present study was to document the food, energy and macronutrient contribution of out-of-home prepared foods in school-going adolescents in Cotonou (Benin) and compare the food, energy and macronutrient intakes of low and high out-of-home consumers. We used a cross-sectional study with 24 h dietary recalls on two non-consecutive school days to collect food intake data. Low and high consumers were defined respectively as subjects whose percentage of daily energy intake from out-of-home foods was in the first and the third terciles of the sample distribution. The setting was twelve secondary schools in Cotonou with 656 adolescents aged 13-19 years. Out-of-home prepared foods contributed more than 40 % of the daily energy, fat, protein, carbohydrate and fibre intakes and of the daily weight of food in the adolescents. They were highly present at breakfast and as afternoon snacks in high consumers, providing respectively 94 and 82 % of the energy intake of high consumers at breakfast and as afternoon snacks. Low consumers ate more fruit and vegetables and cereal grain products than high consumers whereas high consumers consumed more sweet energy-dense foods. Both categories had a diet poor in fruit and vegetables (hardly one-fourth of the recommended 400 g) and high in fat. We concluded that out-of-home foods are important in the diet of urban school adolescents in Benin. Therefore, they should be investigated in depth and taken into account in the development of interventions to promote healthy diet and lifestyles in adolescents.

Minimum Dietary Diversity for Women of Reproductive Age (MDD-W) Data Collection: Validity of the List-Based and Open Recall Methods as Compared to Weighed Food Record.

Minimum dietary diversity for women of reproductive age (MDD-W) was validated as a population-level proxy of micronutrient adequacy, with indicator data collection proposed as either list-based or open recall. No study has assessed the validity of these two non-quantitative proxy methods against weighed food records (WFR). We assessed the measurement agreement of list-based and open recall methods as compared to WFR (i.e., reference method of individual quantitative dietary assessment) for achieving MDD-W and an ordinal food group diversity score. Applying a non-inferiority design, data were collected from non-pregnant women of reproductive age in Cambodia (n = 430), Ethiopia (n = 431), and Zambia (n = 476). For the pooled sample (n = 1337), proportions achieving MDD-W from both proxy methods were compared to WFR proportion by McNemar's chi-square tests, Cohen's kappa, and receiver operating characteristic (ROC) analysis. Ordinal food group diversity (0-10) was compared by Wilcoxon matched-pairs signed-rank tests, intraclass correlation coefficients (ICC), and weighted kappa. MDD-W food groups that were most frequently misreported (i.e., type I and II errors) by the proxy methods were determined. Our findings indicate statistically significant differences in proportions achieving MDD-W, ordinal food group diversity scores, and ROC curves between both proxy methods and WFR (p < 0.001). List-based and open recall methods overreported women achieving MDD-W by 16 and 10 percentage points, respectively, as compared to WFR (proportion achieving MDD-W: 30%). ICC values between list-based or open recall and WFR were 0.50 and 0.55, respectively. Simple and weighted kappa values both indicated moderate agreement between list-based or open recall against WFR. Food groups most likely to be misreported using proxy methods were beans and peas, dark green leafy vegetables, vitamin A-rich fruit and vegetables, and other fruits. Our study provides statistical evidence for overreporting of both list-based and open recall methods for assessing prevalence of MDD-W or ordinal food group diversity score in women of reproductive age in low- and middle-income countries. Operationalizing MDD-W through qualitative recall methods should consider potential trade-offs between accuracy and simplicity.

Availability of free fruits and vegetables at canteen lunch improves lunch and daily nutritional profiles: a randomised controlled trial.

Canteens are known to be promising settings for activities to promote intake of fruits and vegetables, but it remains unclear to what extent distributing free fruits and vegetables can influence dietary patterns of customers. The present study evaluated the effect of providing fruits and vegetables for free in a university canteen on the daily diet of university canteen customers. Canteen customers (n 209) were randomly allocated to a fruit and vegetable group (FVG) and a control group (CG). FVG participants were given two portions of fruits and one portion of vegetables for free at lunchtime. Food and beverage intake was measured using a dietary record for 3 d and dietary quality was appraised using a comprehensive scoring system. The FVG participants ate 80 g more fruits (P < 0.01) and 108 g more vegetables (P < 0.001) on a daily basis compared with the CG participants. No differences were found for energy density, total energy, Na and energy from fat between the groups per day. A higher intake of fruits and vegetables was observed at lunch and of vegetables during the dinner and evening snacks. The FVG participants were more likely to comply with dietary recommendations for fruits and vegetables and had a better dietary profile on the study days and for the lunch consumed on those days. The results of the present study demonstrate how modifications of a canteen lunch can be instrumental to enhance the nutritional quality of lunch as well as the overall quality of the diet of the customers.

Validity of two physical activity questionnaires (IPAQ and PAQA) for Vietnamese adolescents in rural and urban areas.

BACKGROUND: Although physical activity is recognised to be an important determinant of health and nutritional status, few instruments have been developed to assess physical activity in developing countries. The aim of this study was to compare the validity of the short form of the International Physical Activity Questionnaire (IPAQ) and a locally adapted version of the Physical Activity Questionnaire for Adolescents (PAQA) for use in school going adolescents in rural and urban areas in Vietnam. METHODS: Sixteen year old adolescents from rural areas (n = 137) and urban areas (n = 90) completed the questionnaires in 2006. Test-retest reliability was assessed by comparing registrations after 2 weeks. Criterion validity was assessed by comparison with 7 days continuous accelerometer logging. Validity of the two methods was assessed using Spearman correlation coefficient, intra class correlation coefficients (ICC) and Kappa statistics. RESULTS: Reliability of both questionnaires was poor for both the IPAQ (ICC = 0.37) and the PAQA (ICC = 0.40). Criterion validity of both questionnaires was acceptable and similar for the IPAQ (rho = 0.21) and the PAQA (rho = 0.27) but a significantly lower validity was observed in rural areas. Both forms poorly estimated time spent on light, moderate and vigorous physical activity. Agreement of both questionnaires to classify individuals was also low but the IPAQ performed better than the PAQA. CONCLUSION: Both questionnaires have a similar and overall poor validity to be used as a population instrument in Vietnam. Low reliability and classification properties in rural areas call for further research for specific use in such settings.

Effects of separate delivery of zinc or zinc and vitamin A on hemoglobin response, growth, and diarrhea in young Peruvian children receiving iron therapy for anemia.

INTRODUCTION: Anemia is the most prevalent nutritional deficiency in the world. Attempts to improve iron indexes are affected by deficiency of and interaction between other micronutrients. OBJECTIVE: Our goal was to assess whether zinc added to iron treatment alone or with vitamin A improves iron indexes and affects diarrheal episodes. DESIGN: This was a randomized, placebo-controlled, double-blind trial conducted in Peru. Anemic children aged 6-35 mo were assigned to 3 treatment groups: ferrous sulfate (FS; n = 104), ferrous sulfate and zinc sulfate (FSZn; n = 109), and ferrous sulfate, zinc sulfate, and vitamin A (FSZnA; n = 110). Vitamin A or its placebo was supplied only once; iron and zinc were provided under supervision >/=1 h apart 6 d/wk for 18 wk. RESULTS: The prevalence of anemia was 42.97%. The increase in hemoglobin in the FS group (19.5 g/L) was significantly less than that in the other 2 groups (24.0 and 23.8 g/L in the FSZn and FSZnA groups, respectively). The increase in serum ferritin in the FS group (24.5 mug/L) was significantly less than that in the other 2 groups (33.0 and 30.8 mug/L in the FSZn and FSZnA groups, respectively). The median duration of diarrhea and the mean number of stools per day was significantly higher in the FS group than in other 2 groups (P < 0.005). CONCLUSION: Adding zinc to iron treatment increases hemoglobin response, improves iron indexes, and has positive effects on diarrhea. No additional effect of vitamin A was found.

Food safety is a key determinant of fruit and vegetable consumption in urban Beninese adolescents.

OBJECTIVE: To identify the determinants of fruit and vegetable consumption in urban Beninese adolescents and elements to develop a school-based fruit and vegetable program. DESIGN: Sixteen focus groups conducted with a key word guide. SETTING AND PARTICIPANTS: Two private and 2 public secondary schools in Cotonou, Benin. One hundred fifty-three students aged 13 to 19 years, 54% girls. ANALYSIS: The focus groups were audiotaped, transcribed, and analyzed. Three a priori categories from the Social Cognitive Theory were used for the coding: socioenvironmental, personal, and behavioral factors. Additionally, the data were checked to determine whether new categories should be created. RESULTS: Major determinants in the school were availability and accessibility of fruits and vegetables, nutrition education, and the competition of unhealthful foods. Food safety emerged as a strong barrier to the adolescents' fruit and vegetable consumption outside home and particularly at school. CONCLUSIONS AND IMPLICATIONS: Except for food safety, the determinants of fruit and vegetable intake in Beninese adolescents were similar to those in high-income countries. The food safety of fruits and vegetables outside home is a key issue to be studied in detail and integrated in any intervention in Benin and potentially other low- and middle-income countries.

Effectiveness of preventive school-based obesity interventions in low- and middle-income countries: a systematic review.

BACKGROUND: The prevalence of childhood obesity is increasing rapidly in low- and middle-income countries, and informed policies to tackle the problem must be defined. OBJECTIVE: We systematically reviewed the evidence on the effectiveness of school-based interventions targeting dietary behavior and/or physical activity for the primary prevention of obesity in children and adolescents aged 6-18 y in low- and middle-income countries. DESIGN: We searched the MEDLINE, EMBASE, Web of Science, CENTRAL, ERIC, Cochrane Library, and Centre for Reviews and Dissemination databases for peer-reviewed controlled studies published in English, Spanish, French, German, or Dutch between January 1990 and July 2011. The quality of the included studies was appraised independently by 2 authors who used the Effective Public Health Practice Project tool. RESULTS: From a total of 7218 unique references, we retained 22 studies. Most of the interventions (82%) had a positive effect on dietary behavior and physical activity behavior (effect size ranged from -0.48 to 1.61). BMI decreased in 8 studies (effect size ranged from -0.7 to 0.0). Effective interventions targeted both diet and physical activity, involved multiple stakeholders, and integrated educational activities into the school curriculum. CONCLUSIONS: School-based interventions have the potential to improve dietary and physical activity behavior and to prevent unhealthy body weights in low- and middle-income countries. To reach their full potential, interventions should conduct process evaluations to document program implementation. The effect and the pathways through which interventions have this effect need to be better documented through rigorous evaluation studies.

Nutritional profile of foods offered and consumed in a Belgian university canteen.

OBJECTIVE: To evaluate the nutritional profile of a lunch offered and consumed in a university canteen in Belgium. DESIGN: The qualitative and quantitative content of 4,365 meals theoretically available and 330 meals consumed was recorded during five weekdays spread over three weeks. Meal combinations were evaluated using a scoring system based on recommendations for Na content, energy from fat, and fruit and vegetable portions. SETTING: University canteen in Belgium. RESULTS: Only a 5 % of the meal combinations available and consumed complied with the three basic dietary recommendations for a hot lunch. The nutritional profile of the meals consumed was in line with that of the meals available. CONCLUSIONS: Our results show how the nutritional profile of what is eaten is largely determined by what is offered. To ensure overall compliance with dietary recommendations, considerable changes on the supply side, i.e. an increase in fruit and vegetable portions and a reduction in salt and fat of the lunch, are needed first in our setting. Our assessment provides baseline data to pilot a nutrient profiling intervention and shows how a nutrient profiling system can be used for meal evaluation purposes.

Processing of complementary food does not increase hair zinc levels and growth of infants in Kilosa district, rural Tanzania.

A community-based, randomized, placebo-controlled, double-blind trial was conducted from March 2001 to March 2002 in Kilosa, a rural district of Morogoro Region in Tanzania. One hundred and fifty-eight infants were selected randomly from lists of local Maternal and Child Health Care Centres and received either processed complementary food (PCF) or unprocessed complementary food (UPCF) from age 6 to 12 months. Processing increased Zn solubility and energy density of the porridge prepared from the complementary food (CF) as determined in vitro. Phytate:Zn molar ratio of the PCF and UPCF was 25.8 and 47.5, respectively. Under the study conditions, the processing of CF did not improve Zn status as measured by hair analysis. No significant correlations were found between hair Zn values and anthropometric measurements. Our findings suggest that processing alone of cereal-based CF may be insufficient to ensure an adequate supply of Zn to improve growth and Zn status of infants. Dietary modification to tackle Zn deficiencies in similar target groups may therefore only be successful when other Zn-rich foods such as meat and fish are included.

Processed complementary food does not improve growth or hemoglobin status of rural tanzanian infants from 6-12 months of age in Kilosa district, Tanzania.

A double-blind, randomized, placebo-controlled trial was conducted from March 2001 to March 2002 involving 309 infants who received either a processed complementary food (CF) or an unprocessed placebo from 6 to 12 mo of age. The groups were comparable in baseline characteristics. The study took place in Kilosa district, Tanzania. The processed CF contained germinated, autoclaved, and dried finger millet (65.2%), kidney beans (19.1%), roasted-peanuts (8%), and mango purée (7.7%). The same blend, but not processed, served as the placebo. Processing increased iron solubility and energy density without affecting viscosity. Mean length for age, weight for age, hemoglobin, and zinc protoporphyrin at 6 and 12 mo did not differ between the 2 groups. The results show that the processed food did not differ from the unprocessed placebo in improving growth, hemoglobin, and iron status of infants when given under the study conditions. The control group consumed equal amounts of macronutrients, and the higher energy density in this study did not seem to have any benefits. In our study, there was a very intensive follow-up; at every encounter with mothers, giving the required amounts and adding extra lipids was strongly reinforced. Under those conditions, a well-balanced complementary food with additional lipids can meet the energy needs of young children. The reduction in phytates by 34% and improvement in iron solubility to 19% due to processing might not have been enough to compensate for the rather low iron content of the complementary food.