Associations between early introduction to complementary foods, subsequent cereal-added bottle feeding and daily macronutrient intake among infants.

Introducing complementary foods early during infancy has been associated with an increased risk of overweight later in life, but the pathway is an understudied topic. Hence the study was conducted with low-income and primarily minority mother-infant dyads to: 1) understand how the introduction of complementary foods prior to 4 months was associated with socio-demographic characteristics and food security status; 2) determine the association between early introduction to complementary foods and breastfeeding and adding cereal into the bottle in later infancy (i.e., at 6 and 9 months), and; 3) examine how adding infant cereal into the bottle was related to daily calorie and macronutrient intake in infancy. We conducted interviews with mothers (n = 201) at 4 months of age and 24-h feeding recalls at age 6 and 9 months. Results indicated that 29% of the infants were fed complementary foods before 4 months of age. Introducing complementary foods early was negatively associated with breastfeeding and positively associated with adding cereal into the bottle at 6-months. This practice was more common among those who experienced marginal to very low levels of food security. Comparing by race/ethnicity, Latinx mothers were significantly less likely to introduce solids early. After controlling for sex, infants fed cereal in the bottle were consuming significantly more calories compared to their counterparts. Specifically, adding cereal into the bottle resulted in approximately 10% additional daily calorie intake among infants. Understanding how these feeding practices affect appetite development and weight status during infancy is warranted.

Maternal participation in a nutrition education program in Uganda is associated with improved infant and young child feeding practices and feeding knowledge: a post-program comparison study.

BACKGROUND: Cost-effective approaches to improve feeding practices and to reduce undernutrition are needed in low-income countries. Strategies such as nutritional counseling, food supplements, and cash transfers can substantially reduce undernutrition among food-insecure populations. Lipid-based nutrient supplements (LNS) are an increasingly popular strategy for treating and preventing undernutrition and are often delivered with nutrition education. The post-program effects of participation in a LNS-supported supplemental feeding program on Infant and Young Child Feeding (IYCF) practices and caregiver child feeding knowledge are not well understood. The objective of this study was to understand whether children's diet quality and caregiver nutrition knowledge was improved after participation in such a program. METHODS: We conducted a post-program comparison group study to compare feeding practices and caregiver nutrition knowledge among mother-child dyads who completed a nutrition education program and a community comparison group in western Uganda. We administered a feeding practices survey and two 24-hour dietary recalls to 61 Post-Program (PP) caregivers and children ages 6 to 59 months (mean age = 25.1 months) who participated in a supplemental feeding program (which included growth monitoring, caregiver nutrition education, and LNS) and a Comparison Group (CG) of 61 children and caregivers. PP caregivers were recruited 4 to 8 weeks after program participation ended. We hypothesized that PP caregivers would report better IYCF practices and greater knowledge of key nutrition education messages related to IYCF. RESULTS: PP children had higher dietary diversity scores (3.0 vs 2.1, p =0.001) than CG children, and were more fed more frequently (3.0 vs 2.1 times per day, p=0.001). IYCF indicators were higher in the PP group for minimum meal frequency (44.8% vs. 37.9%), minimum dietary diversity (10.3 vs. 3.4%), iron-rich complementary foods (17.2 vs. 20.7%), and minimally acceptable diet (10.3% vs 3.6%), but differences were non-significant. Caregivers in the PP group demonstrated greater knowledge of healthful IYCF practices. CONCLUSIONS: Nutrition education can be effective to improve caregiver feeding practices and children's dietary diversity and the frequency by which they are fed. A 10-week nutrition education and supplemental feeding program appears to provide some benefit to children in terms of dietary diversity and frequency of meals, and caregiver knowledge of feeding 1 to 2 months after program completion. However, children in this rural Ugandan region have diets that are still largely inadequate, highlighting the need for enhanced interventions and policies to promote diverse and appropriate diets for young children in this region. Future follow-up work in LNS-supported programs is recommended to understand how other similar approaches influence children's diet quality after program completion in other contexts.

Multilevel Interventions To Address Health Disparities Show Promise In Improving Population Health.

Multilevel interventions are those that affect at least two levels of influence-for example, the patient and the health care provider. They can be experimental designs or natural experiments caused by changes in policy, such as the implementation of the Affordable Care Act or local policies. Measuring the effects of multilevel interventions is challenging, because they allow for interaction among levels, and the impact of each intervention must be assessed and translated into practice. We discuss how two projects from the National Institutes of Health's Centers for Population Health and Health Disparities used multilevel interventions to reduce health disparities. The interventions, which focused on the uptake of the human papillomavirus vaccine and community-level dietary change, had mixed results. The design and implementation of multilevel interventions are facilitated by input from the community, and more advanced methods and measures are needed to evaluate the impact of the various levels and components of such interventions.

Impact of lipid-based nutrient supplementation (LNS) on children's diet adequacy in Western Uganda.

Lipid-based nutrient supplements (LNS) can help treat undernutrition; however, the dietary adequacy of children supplemented with LNS, and household utilisation patterns are not well understood. We assessed diet adequacy and the quality of complementary foods by conducting a diet assessment of 128 Ugandan children, ages 6-59 months, who participated in a 10-week programme for children with moderate acute malnutrition (MAM, defined as weight-for-age z-score < -2). Caregivers were given a weekly ration of 650 kcal day(-1) (126 g day(-1) ) of a peanut/soy LNS. Two 24-h dietary recalls were administered per child. LNS was offered to 86% of targeted children at least once. Among non-breastfed children, over 90% met their estimated average requirement (EAR) cut-points for all examined nutrients. Over 90% of breastfed children met EAR cut-points for nutrient density for most nutrients, except for zinc where 11.7% met cut-points. A lower proportion of both breastfed and non-breastfed children met adjusted EARs for the specific nutritional needs of MAM. Fewer than 20% of breastfed children met EAR nutrient-density guidelines for MAM for zinc, vitamin C, vitamin A and folate. Underweight status, the presence of a father in the child's home, and higher programme attendance were all associated with greater odds of feeding LNS to targeted children. Children in this community-based supplemental feeding programme who received a locally produced LNS exhibited substantial micronutrient deficiencies given the special dietary needs of this population. These results can help inform programme strategies to improve LNS targeting, and highlight potential nutrient inadequacies for consumers of LNS in community-based settings.

Linking clinical care to community resources for cardiovascular disease prevention: the North Carolina Enhanced WISEWOMAN project.

BACKGROUND: The Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) project addresses the need for effective cardiovascular disease (CVD) prevention among underserved, midlife women. We describe an Enhanced Intervention that addressed environmental and individual factors within the context of a clinic-based intervention. We also present the study design and baseline results of the randomized trial to evaluate the enhanced intervention. METHODS: The multicomponent behavior change intervention addressed many elements of the Chronic Care Model (CCM), including the community resources and policy element, wherein Enhanced Intervention participants were encouraged to overcome environmental barriers to a healthy lifestyle by using community resources. Study participants were enrolled at one community health center; all were low-income, underinsured, midlife (40-64 years) women. RESULTS: A total of 236 participants were randomized to receive the Enhanced Intervention or the Minimum Intervention. At baseline, over three fourths of the participants were overweight or obese. Participants reported a variety of problematic neighborhood characteristics, including a paucity of restaurants with healthy food choices (41% reported as a problem); not enough farmer's markets or produce stands (50%), not enough affordable exercise places (52%), not enough physical activity programs that met women's needs (42%), heavy traffic (47%), and speeding drivers (53%). Overall, women knew little about affordable exercise venues and nutrition classes. CONCLUSIONS: In this clinic-based intervention, we addressed environmental factors related to a healthy lifestyle. Results indicate the need for effective and feasible intervention strategies to address the environments in which individuals are making behavior changes. The effectiveness of the WISEWOMAN Enhanced Intervention will be assessed in a randomized trial.

Effects of a tailored follow-up intervention on health behaviors, beliefs, and attitudes.

BACKGROUND: The high rates of relapse that tend to occur after short-term behavioral interventions indicate the need for maintenance programs that promote long-term adherence to new behavior patterns. Computer-tailored health messages that are mailed to participants or given in brief telephone calls offer an innovative and time-efficient alternative to ongoing face-to-face contact with healthcare providers. METHODS: Following a 1-year behavior change program, 22 North Carolina health departments were randomly assigned to a follow-up intervention or control condition. Data were collected from 1999 to 2001 by telephone-administered surveys at preintervention and postintervention for 511 low-income, midlife adult women enrolled in the Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program at local North Carolina health departments. During the year after the behavior change program, intervention participants were mailed six sets of computer-tailored health messages and received two computer-tailored telephone counseling sessions. Main outcomes of dietary and physical activity behaviors, beliefs, and attitudes were measured. RESULTS: Intervention participants were more likely to move forward into more advanced stages of physical activity change (p = 0.02); control participants were more likely to increase their level of dietary social support at follow-up (p = 0.05). Both groups maintained low levels of reported saturated fat and cholesterol intake at follow-up. No changes were seen in physical activity in either group. CONCLUSIONS: Mailed computer-tailored health messages and telephone counseling calls favorably modified forward physical activity stage movement but did not appreciably affect any other psychosocial or behavioral outcomes.

Integrating preventive health services within community health centers: lessons from WISEWOMAN.

BACKGROUND: Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) provides low-income, underserved women ages 40-64 with risk factor screening and lifestyle intervention and referral services to prevent cardiovascular disease (CVD). Integrating WISEWOMAN's services with the culturally appropriate medical care and support services offered by community health centers may improve the program's ability to reduce CVD burden among underserved women. METHODS: We conducted a formative assessment of the perceived opportunities, challenges, and strategies associated with integrating WISEWOMAN into community health center settings. A panel of stakeholders that included health center and WISEWOMAN representatives was convened in 2002, and a semistructured discussion guide was used to elicit perspectives about integration. We also conducted an in-depth review of WISEWOMAN's history of collaboration with health centers in North Carolina. RESULTS: Stakeholders perceived a clear need for integrating WISEWOMAN within health center settings, indicating that centers have few other resources to expand preventive services delivery and offer effective lifestyle interventions for underserved populations. Perceived barriers to integration included competing demands on health center resources, difficulties hiring staff for new programs, and administrative burdens associated with data collection and reporting. Experiences within North Carolina's WISEWOMAN project demonstrate, however, that lifestyle interventions can be designed in ways that facilitate integration by health centers. CONCLUSIONS: Integration strategies need to be tailored to the resources, skills, and capacities available within health centers. As health centers and WISEWOMAN projects gain more experience in collaborating, additional research should be conducted to identify how best to achieve integration within specific institutional and community contexts.

Associations of micronutrients with colon cancer risk in African Americans and whites: results from the North Carolina Colon Cancer Study.

African Americans have the highest incidence of colon cancer among United States racial/ethnic groups, but these disparities are largely unexplained. This report describes associations of micronutrients with colon cancer risk in African Americans and whites using data from a case-control study in North Carolina. Incident cases of histologically confirmed colon cancer, age 40-80 years (n = 613), and matched controls (n = 996) were interviewed in person to elicit information on potential colon cancer risk factors. A previously validated food frequency questionnaire adapted to include regional foods was used to assess diet over the year prior to diagnosis or interview date. Micronutrient exposure included food sources and dietary supplements. Multivariate logistic regression models estimated energy-adjusted and non-energy-adjusted odds ratios (ORs). African Americans reported lower mean micronutrient intakes than whites, primarily due to larger contributions from dietary supplements in whites. Controls generally reported higher micronutrient intakes than cases; however, these differences were only statistically significant for whites. In whites, high beta-carotene, vitamin C, and calcium intakes were associated with 40-60% reductions in colon cancer risk when contrasting highest to lowest quartiles in both energy-adjusted and non-energy-adjusted models, e.g., OR = 0.4 (95% confidence interval, 0.3-0.6) for the highest quartile of calcium in the energy-adjusted model. In African Americans, vitamins C and E were strongly inversely associated using both statistical approaches: high vitamin E intake was associated with a 70% reduced risk for colon cancer, and the OR comparing the highest to lowest quartiles of vitamin C was 0.5 (95% confidence interval, 0.3-0.8). Folate and lutein were not statistically significantly associated with colon cancer risk in either racial group. These results suggest that at high intakes, micronutrients commonly found in plant and other foods (in particular, beta-carotene, vitamin C, and calcium in whites and vitamins C and E in African Americans) exhibit independent associations consistent with 30-70% reductions in colon cancer risk.

Medical nutrition therapy for hypercholesterolemia positively affects patient satisfaction and quality of life outcomes.

Following a heart-healthy diet to lower cholesterol levels is often assumed to be difficult, to be burdensome, and to have a negative impact on quality of life (QOL). The purpose of this study was to evaluate the impact of medical nutrition therapy (MNT) versus usual care (UC) for hypercholesterolemia on patient satisfaction and QOL. Ninety ambulatory care patients (60 men and 30 women), age 28 to 66, were randomly assigned to receive either MNT from dietitians using a National Cholesterol Education Program-based protocol or UC from their physicians. Patients who received MNT reported no difference in QOL related to the taste or enjoyment of food compared with UC patients. However, the MNT group reported initial improvements in QOL related to the convenience and cost of following a low-fat diet when compared with the UC group. The MNT group also reported significant and lasting improvements in perceived QOL related to self-care compared with the UC group. MNT patients were more satisfied with the interaction at visits, knowledge and ability to manage their cholesterol, eating habits, appearance, time spent exercising, and life in general. Moreover, MNT patients did not report any negative impact related to following a low-fat diet in regard to feeling restricted by diet; interference with lifestyle activities; or difficulty planning, purchasing, or preparing meals or eating away from home. Contrary to popular belief there is no apparent reduction but rather an improvement in some measures of QOL and patient satisfaction with MNT for hypercholesterolemia.