Academy of Nutrition and Dietetics Nutrition Research Network: A Home Garden Intervention Improves Child Length-for-Age Z-Score and Household-Level Crop Count and Nutritional Functional Diversity in Rural Guatemala.

Home gardens may help address childhood malnutrition in low- and middle-income countries. In this quasi-experimental pilot study, the Academy of Nutrition and Dietetics, in collaboration with Maya Health Alliance, evaluated the feasibility of augmenting a standard-of-care nutrition-specific package for Maya children with length-for-age z score ≤-2 (stunting) in rural Guatemala with a nutrition-sensitive home garden intervention. Two agrarian municipalities in Guatemala were included. Families of 70 children with stunting from 1 municipality received the standard-of-care package (food supplementation, multiple micronutrient powders, monthly nutrition home visits, group nutrition classes). Families of 70 children with stunting from another municipality received the standard-of-care package plus a home garden intervention (garden materials, monthly agricultural home visits, agriculture classes). Maternal and child dietary diversity, household food insecurity, child growth, and agricultural indicators were collected at baseline and 6 months later and were analyzed using mixed linear and logistic regression models. Compared with the standard-of-care group, the garden intervention group had improved child (odds ratio [OR] 3.66, 95% CI 0.89-15.10, P = 0.07) and maternal dietary diversity (OR 2.31, 95% CI 0.80-6.65, P = 0.12) and decreased food insecurity (OR 0.38, 95% CI 0.11-1.35, P = 0.14); however, these effects were not statistically significant. Participation in gardens predicted a higher length-for-age z-score (change difference [CD] 0.22 SD, 95% CI 0.05-0.38, P = 0.009), greater crop species count (CD 2.97 crops, 95% CI 1.79-4.16, P < 0.001), and greater nutritional functional diversity (CD 0.04 points, 95% CI 0.01-0.07, P = 0.006) than standard-of-care alone. Home garden interventions are feasible in rural Guatemala and may have potential benefits for child growth when added to other nutrition-specific interventions.

Erythrocyte fatty acid composition of Nepal breast-fed infants.

PURPOSE: Essential fatty acids play a critical role in the growth and development of infants, but little is known about the fatty acid status of populations in low-income countries. The objective was to describe the fatty acid composition of red blood cells (RBC) in breastfeed Nepali infants and a subsample of their mothers and to identify the main sources of fatty acids in the mother's diet, as well as the fatty acid composition of breast milk. METHODS: RBC fatty acid composition was analyzed in a random sample of 303 infants and 72 mother, along with 68 breastmilk samples. Fatty acid profiles of the most important dietary fat sources were analyzed. Information on mother's diet and intake of fat was collected by three 24-h dietary recalls. RESULTS: In infant RBC's, docosahexaenoic acid (DHA) was the main n-3 fatty acid, and arachidonic acid (AA) was the major n-6 fatty acid. Total n-6 PUFA was three times higher than total n-3 PUFA. Height-for-age (HAZ) was positively associated with DHA status and AA status in multivariable models. The concentration of all fatty acids was higher in children, compared to mothers, except Total n-6 PUFA and Linoleic acid (LA) where no differences were found. The mother's energy intake from fat was 13% and cooking oil (sesame, mustard, soybean or sunflower oil) contributed 52% of the fat intake. CONCLUSIONS: RBC-DHA levels in both infants and mother was unexpected high taking into account few dietary DHA sources and the low DHA concentrations in breastmilk.

Program considerations for integration of nutrition and family planning: Beliefs around maternal diet and breastfeeding within the context of the nutrition transition in Egypt.

In Egypt, rising maternal overweight and obesity is consistent with the transition to westernized diets and a growing reliance on energy-dense, low nutrient foods. Although the first 1,000 days of life are the focus of many programmes designed to prevent many forms of malnutrition, little attention has been paid to maternal dietary practices and weight gain during pregnancy. This study used in-depth interviews with pregnant women (N = 40), lactating women (N = 40), and nonlactating women (N = 40) to gain an understanding of behaviours, perceptions, and cultural beliefs in relation to maternal dietary intake during pregnancy, lactation, and nonlactation; weight gain during pregnancy; birth spacing; and family planning. Study findings reveal that food choice was driven by affordability, favoured foods, or foods considered appropriate for a specific life stage (pregnant, lactating, and nonlactating). Knowledge of weight gain during pregnancy is limited, especially with regards to excessive weight gain during pregnancy. Diet is often modified during lactation to support breast milk production, and a normal diet resumed when breastfeeding ceases. Within the context of breastfeeding, the lactational amenorrhea method provides an opportunity to improve exclusive breastfeeding practices, maternal diet during lactation, and the transition to other family planning methods by 6 months postpartum. Health care providers should discuss limiting maternal consumption of low nutrient foods such as junk foods, soda, and teas during pregnancy and postpartum. Dietary counselling should accompany information on appropriate weight gain during pregnancy and exercise to prevent excessive weight gain, in the context of the nutrition transition.

Influences of early child nutritional status and home learning environment on child development in Vietnam.

Early childhood development plays a key role in a child's future health, educational success, and economic status. However, suboptimal early development remains a global challenge. This study examines the influences of quality of the home learning environment (HOME) and child stunting in the first year of life on child development. We used data collected from a randomized controlled trial of preconceptional micronutrient supplementation in Vietnam (n = 1,458). The Bayley Scales of Infant Development-III were used to assess cognition, language, and motor development domains at 2 years. At 1 year, 14% of children were stunted, and 15%, 58%, and 28% of children lived in poor, medium, and high HOME environments, respectively. In multivariate generalized linear regression models, living in a high HOME environment was significantly associated with higher scores (0.10 to 0.13 SD) in each of the developmental domains. Stunted children scored significantly lower for cognitive, language, and motor development (-0.11 to -0.18), compared to nonstunted children. The negative associations between stunting on development were modified by HOME; the associations were strong among children living in homes with a poor learning environment whereas they were nonsignificant for those living in high-quality learning environments. In conclusion, child stunting the first year of life was negatively associated with child development at 2 years among children in Vietnam, but a high-quality HOME appeared to attenuate these associations. Early interventions aimed at improving early child growth as well as providing a stimulating home environment are critical to ensure optimal child development.

Nutrition education linked to agricultural interventions improved child dietary diversity in rural Cambodia.

Poor infant and young child feeding (IYCF) practices are major determinants of chronic malnutrition. The main objective of this study was to assess the impact of a nutrition education (NE) programme aimed at promoting improved IYCF behaviours in combination with an agriculture intervention on children's dietary diversity and nutritional status. From 2012 to 2014, a cluster randomised trial was rolled out in Cambodia in the context of an agriculture and nutrition project of the FAO of the UN. The cross-sectional baseline study was carried out in sixteen pre-selected communes in 2012. Restricted randomisation allotted the communes to either intervention (NE and agriculture intervention) or comparison arms (agriculture intervention only). The impact survey was conducted as a census in all FAO project villages in 2014. Caregivers of children aged 0-23 months were interviewed using standardised questions on socio-economic status and dietary diversity (24-h recall). Anthropometric measurements were taken. A difference-in-differences model was applied. The sample comprised 743 households with children ≥6 months of age at baseline and 921 at impact. After 1 year of NE, 69 % of the intervention households reported to have participated in the NE. Estimated mean child dietary diversity was significantly different at impact between comparison and intervention (3·6 and 3·9, respectively). In particular, the consumption of pro-vitamin A-rich foods and other fruits and vegetables increased. No treatment effects on height-for-age Z-scores could be shown. NE led to improvements in children's diets. For effects on growth, it is assumed that longer NE activities are required to achieve sustainable behaviour change of age-appropriate infant feeding.

Small-quantity, lipid-based nutrient supplements provided to women during pregnancy and 6 mo postpartum and to their infants from 6 mo of age increase the mean attained length of 18-mo-old children in semi-urban Ghana: a randomized controlled trial.

BACKGROUND: Childhood stunting usually begins in utero and continues after birth; therefore, its reduction must involve actions across different stages of early life. OBJECTIVE: We evaluated the efficacy of small-quantity, lipid-based nutrient supplements (SQ-LNSs) provided during pregnancy, lactation, and infancy on attained size by 18 mo of age. DESIGN: In this partially double-blind, individually randomized trial, 1320 women at ≤20 wk of gestation received standard iron and folic acid (IFA group), multiple micronutrients (MMN group), or SQ-LNS (LNS group) daily until delivery, and then placebo, MMNs, or SQ-LNS, respectively, for 6 mo postpartum; infants in the LNS group received SQ-LNS formulated for infants from 6 to 18 mo of age (endline). The primary outcome was child length by 18 mo of age. RESULTS: At endline, data were available for 85% of 1228 infants enrolled; overall mean length and length-for-age z score (LAZ) were 79.3 cm and -0.83, respectively, and 12% of the children were stunted (LAZ <-2). In analysis based on the intended treatment, mean ± SD length and LAZ for the LNS group (79.7 ± 2.9 cm and -0.69 ± 1.01, respectively) were significantly greater than for the IFA (79.1 ± 2.9 cm and -0.87 ± 0.99) and MMN (79.1 ± 2.9 cm and -0.91 ± 1.01) groups (P = 0.006 and P = 0.009, respectively). Differences were also significant for weight and weight-for-age z score but not head or midupper arm circumference, and the prevalence of stunting in the LNS group was 8.9%, compared with 13.7% in the IFA group and 12.9% in the MMN group (P = 0.12). In analysis based on actual supplement provided at enrollment, stunting prevalences were 8.9% compared with 15.1% and 11.5%, respectively (P = 0.045). CONCLUSION: Provision of SQ-LNSs to women from pregnancy to 6 mo postpartum and to their infants from 6 to 18 mo of age may increase the child's attained length by age 18 mo in similar settings. This trial was registered at clinicaltrials.gov as NCT00970866.

Informing a Behavior Change Communication Strategy: Formative Research Findings From the Scaling Up Nutrition Movement in Mozambique.

BACKGROUND: Nutrition interventions targeting the first 1000 days show promise to improve nutritional status, but they require effective implementation. Formative research is thus invaluable for developing such interventions, but there have been few detailed studies that describe this phase of work within the Scaling Up Nutrition (SUN) movement. OBJECTIVE: To inform a stunting prevention intervention in Cabo Delgado, Mozambique, by describing the sociocultural landscape and elucidating characteristics related to young child food, illness, and health. METHODS: This formative research utilized a rapid assessment procedures (RAP) approach with 3 iterative phases that explored local perceptions and behaviors around food and illness among the Macua, Mwani, and Maconde ethnic groups. Ethnographic methods, including in-depth interviews, direct observations, free lists, and pile sorts, were used to collect data from community leaders, caregivers, and children 6 to 23 months. Data were analyzed drawing from grounded theory and cultural domain analysis. RESULTS: Geographic differences drive sociocultural characteristics amid 3 ethnic groups that allow for segmentation of the population into 2 distinct audiences for behavior change communications. These 2 communities have similar classification systems for children's foods but different adult dietary patterns. Small-quantity lipid-based nutrient supplement did not fall into the existing food classification systems of either community, and participants preferred its promotion through community leader channels. Community members in both groups have little recognition of and perceived severity toward nutrition-related illnesses. CONCLUSION: Within Cabo Delgado, the cultural heterogeneity yields substantial differences related to food, illness, and health that are necessary to consider for developing an effective nutrition intervention.

The production diversity of subsistence farms in the Bolivian Andes is associated with the quality of child feeding practices as measured by a validated summary feeding index.

OBJECTIVE: To determine the validity of a summary infant and child feeding index (ICFI) and the association with the index of factors related to agricultural production. DESIGN: A cross-sectional survey in eight health-post jurisdictions identified as priority nutrition regions. All households with children aged 6-23 months in eligible communities were administered an integrated survey on agricultural production and nutrition-related practices. Quantitative 24 h dietary recall, food frequency data and anthropometric measurements were collected for each child. Ninety-one per cent of eligible families participated. SETTING: The northern region of the Potosí department in the Bolivian highlands. SUBJECTS: Two hundred and fifty-one households with children aged 6-23 months. RESULTS: In multiple regression models controlling for potential confounding variables, infant and young child feeding (IYCF) practices as measured by an ICFI showed positive associations with child length-for-age Z-score (mean difference of 0·47 in length-for-age Z-score between children in the high ICFI tertile compared with the low tertile), child energy intake (mean difference of 1500 kJ between tertiles) and the micronutrient adequacy of child diets (mean difference of 7·2 % in mean micronutrient density adequacy between tertiles; P < 0·05). Examining determinants of IYCF practices, mother's education, livestock ownership and the crop diversity of farms were positively associated with the ICFI, while amount of agricultural land cultivated was negatively associated with the ICFI. Crop diversity and IYCF practices were more strongly positively correlated among households at high elevations. CONCLUSIONS: Nutrition-sensitive investments in agriculture that aim to diversify subsistence agricultural production could plausibly benefit the adequacy of child diets.

Nutrition for refugee children: risks, screening, and treatment.

Pediatric refugees are at an increased risk for growth and nutritional deficits. As more children are resettled to the United States, it is important to screen appropriately in order to identify any growth or nutritional issues. Resettled refugee children continue to be at risk for both over- and undernutrition, therefore culturally appropriate education and counseling should be provided to improve long-term health.

Cost of childhood diarrhoea in rural South Africa: exploring cost-effectiveness of universal zinc supplementation.

OBJECTIVE: To describe the cost of diarrhoeal illness in children aged 6-24 months in a rural South African community and to determine the threshold prevalence of stunting at which universal Zn plus vitamin A supplementation (VAZ) would be more cost-effective than vitamin A alone (VA) in preventing diarrhoea. DESIGN: We conducted a cost analysis using primary and secondary data sources. Using simulations we examined incremental costs of VAZ relative to VA while varying stunting prevalence. SETTING: Data on efficacy and societal costs were largely from a South African trial. Secondary data were from local and international published sources. SUBJECTS: The trial included children aged 6-24 months. The secondary data sources were a South African health economics survey and the WHO-CHOICE (CHOosing Interventions that are Cost Effective) database. RESULTS: In the trial, stunted children supplemented with VAZ had 2·04 episodes (95 % CI 1·37, 3·05) of diarrhoea per child-year compared with 3·92 episodes (95 % CI 3·02, 5·09) in the VA arm. Average cost of illness was $Int 7·80 per episode (10th, 90th centile: $Int 0·28, $Int 15·63), assuming a minimum standard of care (oral rehydration and 14 d of therapeutic Zn). In simulation scenarios universal VAZ had low incremental costs or became cost-saving relative to VA when the prevalence of stunting was close to 20 %. Incremental cost-effectiveness ratios were sensitive to the cost of intervention and coverage levels. CONCLUSIONS: This simulation suggests that universal VAZ would be cost-effective at current levels of stunting in parts of South Africa. This requires further validation under actual programmatic conditions.

Stunting rates in infants and toddlers born in metropolitan Quetzaltenango, Guatemala.

OBJECTIVE: Guatemala has the highest prevalence of stunting (54% of children under age 5 years) in the Americas and the fifth highest in the world. The aim of this study was to describe the stunting prevalence and the association with early feeding practices, morbidity patterns, and socioeconomic status (SES) in a sample of infants and toddlers from urban Quetzaltenango. METHODS: We recruited 299 children (149 boys), ages 6-23 mo from two public health clinics in metropolitan Quetzaltenango. Data on SES, early feeding practices, and morbidity were collected by means of a single face-to-face interview. Recumbent spine length was measured according to standardized procedures and height-for-age (HAZ) z-scores were calculated. HAZ <-2 SD of the World Health Organization's 2006 Growth Standards was considered stunting. Multiple logistic regression analysis was used to examine determinants of stunting. RESULTS: The overall mean HAZ z-score was -1.89 ± 1.11 and 135 (45%) children were stunted. The results of the crude odds ratios showed that place of interview (suburban), being male, being ages 13-18 mo, being born at home, having a mother with a low level of education, being of Mayan (indigenous) ethnicity, having a mother with short stature, and having ever received iron supplementation were strongly and significantly (P < 0.05) associated with stunting. None of the other variables, such as supplement use and morbidity rates, contributed to the predictive model. We did not observe an association between early feeding practices or morbidity and stunting. CONCLUSION: The stunting prevalence exceeds the cut-off of 40% stunting, indicating a community with a high level of malnutrition.

Fish oil supplementation is beneficial on caloric intake, appetite and mid upper arm muscle circumference in children with leukaemia.

A randomised trial was carried out to determine the effect of supplementation of fish oil among 51 children with leukaemia aged 4 to 12 years on appetite level, caloric intake, body weight and lean body mass. They were randomly allocated into the trial group (TG) and the control group (CG). At baseline, 30.8% of TG subjects and 44.0% of CG subjects were malnourished and 7.7% of subject from TG and 28.0% from CG were classified as stunted. The majority of subjects from TG and CG were in the mild malnutrition category for mid upper arm muscle circumference (MUAMC)-for-age. The TG group showed significant increment in MUAMC (0.13 cm vs -0.09 cm) compared with CG at 8 weeks (p<0.001). There was a significant higher increase for appetite level (0.12±0.33) (p<0.05) and an increasing trend on energy and protein intake in the TG group (213±554 kcal; 3.64 ±26.8 g) than in the CG group. In conclusion, supplementation of fish oil has a positive effect on appetite level, caloric intake and MUAMC among children with leukaemia.

Consumption of micronutrient-fortified milk and noodles is associated with lower risk of stunting in preschool-aged children in Indonesia.

BACKGROUND: Stunting is highly prevalent in developing countries and is associated with greater morbidity and mortality. Micronutrient deficiencies contribute to stunting, and micronutrient-fortified foods are a potential strategy to reduce child stunting. OBJECTIVE: To examine the relationship between the use of fortified powdered milk and noodles and child stunting in a large, population-based sample of Indonesian children. METHODS: Consumption of fortified milk and fortified noodles was assessed in children 6 to 59 months of age from 222,250 families living in rural areas and 79,940 families living in urban slum areas in Indonesia. RESULTS: The proportions of children who consumed fortified milk and fortified noodles were 34.0% and 22.0%, respectively, in rural families, and 42.4% and 48.5%, respectively, in urban families. The prevalence of stunting among children from rural and urban families was 51.8% and 48.8%, respectively. Children from rural and urban families were less likely to be stunted if they consumed fortified milk (in rural areas, OR = 0.87; 95% CI, 0.85 to 0.90; p < .0001; in urban areas, OR = 0.80; 95% CI, 0.76 to 0.85; p < .0001) or fortified noodles (in rural areas, OR = 0.95; 95% CI, 0.91 to 0.99;p = .02; in urban areas, OR = 0.95; 95% CI, 0.91 to 1.01; p = .08) in multiple logistic regression models adjusted for potential confounders. In both rural and urban families, the odds of stunting were lower when a child who consumed fortified milk also consumed fortified noodles, or when a child who consumed fortified noodles also consumed fortified milk. CONCLUSIONS: The consumption of fortified milk and noodles is associated with decreased odds of stunting among Indonesian children. These findings add to a growing body of evidence regarding the potential benefits of multiple micronutrient fortification on child growth.

Hyperimmunoglobulinaemia in Babinga Pygmies is present from infancy.

Pygmies, a population characterized by short stature, have high immunoglobulin (Ig) concentrations. In this study, we evaluated Ig levels in Cameroons Babinga Pygmies from infancy to adulthood and the effects of a national health program on these Ig levels. We found that IgG and IgM levels were outside the normal range for Italians of the same age and were comparable to those measured in Babinga Pygmies living in the same region by Siccardi in 1975. In conclusion, the hypergammaglobulinaemia of Babinga Pygmies is already present in infants and is not affected by sanitation improvements, suggesting that it could be partly genetically-determined.

Nutritional status of schoolchildren in rural Iran.

The present study compared the nutritional status of schoolchildren from recently settled, ethnic minority tribespeople with those from a Persian village in southern Iran. Height and weight were measured and blood was collected from school children at three time points over 1.5 years. Supplemental Fe was provided to children with low Hb after the first screening. Twenty-one per cent of the children were wasted, 57 % were stunted and 23 % were anaemic. No statistically significant difference in the prevalence of wasting, stunting and anaemia was found between gender or ethnic groups. Children over the age of 12 years had a higher prevalence of wasting than children aged below 12 years. In a sub-sample of forty-one children the average BMI-for-age decreased. Fe supplementation increased Hb levels to normal in most children, but did not increase Fe level in a few children. Dietary deficiency of micronutrients, especially Zn and Fe, probably accounts for the high prevalence of stunting and anaemia in these children. Infection with Helicobacter pylori is another possible explanation for the Fe-deficiency anaemia. Further investigation is in progress to determine the cause(s) of the observed deficiencies.

Observations on the development of stunting in children of the Khon Kaen region of Thailand.

A cohort of children in North-East Thailand was followed from birth to 2 years of age in an attempt to throw light on factors determining the development of stunting in linear growth. By 2 years the group as a whole had an average deficit in height of nearly -2 standard deviations. Those index children whose sibs were stunted had larger deficits than those with normal sibs. Their mothers were also shorter and lighter. These findings suggest that it is possible to think in terms of stunted families. No differences were identified in socio-economic factors and the prevalence of infection was in general low. Dietary intakes estimated by 24-hour recall, supplemented at 1 and 2 years by 24 h weighing, were satisfactory for most nutrients except iron, calcium and niacin. Intakes of Ca and P were lower in the more stunted children. A number of variables were measured in urine and blood at 1 and 2 years but few relationships could be established with the degree of stunting. Excretions of calcium and phosphorus showed weak negative correlations with height. On average the serum concentration of calcium was satisfactory but that of phosphorus was somewhat low. Concentrations of somatomedin C, thyroxin and vitamin D were within reported normal ranges, with no relation to the degree of stunting. From a comparison of the linear growth of these children with the results of other reports from Thailand it is suggested that environmental factors have produced stunting in the cohort as a whole, but the cohort is essentially homogeneous, showing within it a normal range of genetic variation. If that is so, major differences in intake or biochemistry between the taller and shorter children would not be expected. The problem remains of why the group as a whole is stunted. This is the first systematic attempt to assess biochemical factors that may be related to stunting in Third World children; these results are essentially negative, although there are hints that point at a possible deficiency of calcium.