Conceptualizing multi-level determinants of infant and young child nutrition in the Republic of Marshall Islands-a socio-ecological perspective.

The East and Pacific region includes 14 Pacific Island Countries where, between 2000 and 2016, indicators of stunting, wasting, and micronutrient deficiencies have plateaued or worsened, while rates of overweight, obesity, and associated disease have risen. The Republic of Marshall Islands (RMI) is no exception: maternal and child nutrition indicators have not improved in decades. A study of the contemporary factors shaping the RMI nutrition situation was needed for informing policy and tailoring interventions. This formative study had an iterative design utilizing qualitative methods. An exploratory Phase 1 included 59 semi-structured interviews with community members, 86 free lists with caregivers, 8 participatory workshops, and 20 meal observations (round 1). Findings were synthesized to inform a confirmatory Phase 2 where 13 focus groups, 81 pile sorts, 15 meal observations (round 2), and 2 seasonal food availability workshops were conducted. Textual data were analyzed thematically using NVivo while cultural domain analysis was conducted in Anthropac. RMI faces interrelated challenges that contribute to a lack of nutritious and local food availability, which is compounded by high food costs relative to household incomes. A decades-long cultural transition from local to processed diets has resulted in infant and young child diets now characterized by morning meals of doughnuts, bread, and ramen with tea, coffee, or Kool-Aid and afternoon meals that include rice with canned meats (e.g., store-bought chicken, hot dogs). Individual preferences for processed food imports have increased their supply. Low maternal risk perception toward nutrition-related illnesses may further explain sub-optimal diets. Improving the RMI food environment will require approaches that align with the multi-level determinants of sub-optimal diets found in this study. As the ten-year 2013 RMI Food Security Policy soon ends, study findings may be used to inform new policy development and investments for improving the nutrition situation.

Determinants of maternal, infant, and young child nutrition during the 1,000-day window of opportunity in Solomon Islands: A focused ethnographic study.

Introduction: This focused ethnographic study used qualitative, ethnographic, and participatory methods to explore determinants of maternal, infant, and young child nutrition (MIYCN) during the first 1,000 days of life as part of efforts to address the double burden of malnutrition in Solomon Islands. Methods: An iterative study design was used to first explore and then confirm findings related to food and nutrition security and social and behavioral determinants of MIYCN in urban and rural settings. The first phase included in-depth interviews, household observations, free lists, and seasonal food availability calendar workshops while the second phase included focus group discussions, pile sorts, participatory community workshops, and repeated household observations. Results and discussion: We found that MIYCN is shaped by a complex interaction of factors at the macro- and micro-levels. At the macro-level, globalization of the food system, a shifting economy, and climate change are driving a shift toward a delocalized food system based on imported processed foods. This shift has contributed to a food environment that leaves Solomon Islanders vulnerable to food and nutrition insecurity, which we found to be the primary determinant of MIYCN in this context. At the micro-level, this food environment leads to household- and individual-level food decisions that often do not support adequate MIYCN. Multi-sectoral interventions that address the macro- and micro-level factors shaping this nutrition situation may help to improve MIYCN in Solomon Islands.

Severe malnutrition or famine exposure in childhood and cardiometabolic non-communicable disease later in life: a systematic review.

INTRODUCTION: Child malnutrition (undernutrition) and adult non-communicable diseases (NCDs) are major global public health problems. While convincing evidence links prenatal malnutrition with increased risk of NCDs, less is known about the long-term sequelae of malnutrition in childhood. We therefore examined evidence of associations between postnatal malnutrition, encompassing documented severe childhood malnutrition in low/middle-income countries (LMICs) or famine exposure, and later-life cardiometabolic NCDs. METHODS: Our peer-reviewed search strategy focused on 'severe childhood malnutrition', 'LMICs', 'famine', and 'cardiometabolic NCDs' to identify studies in Medline, Embase, Global Health, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. We synthesised results narratively and assessed study quality with the UK National Institute for Health and Care Excellence checklist. RESULTS: We identified 57 studies of cardiometabolic NCD outcomes in survivors of documented severe childhood malnutrition in LMICs (n=14) and historical famines (n=43). Exposure to severe malnutrition or famine in childhood was consistently associated with increased risk of cardiovascular disease (7/8 studies), hypertension (8/11), impaired glucose metabolism (15/24) and metabolic syndrome (6/6) in later life. Evidence for effects on lipid metabolism (6/11 null, 5/11 mixed findings), obesity (3/13 null, 5/13 increased risk, 5/13 decreased risk) and other outcomes was less consistent. Sex-specific differences were observed in some cohorts, with women consistently at higher risk of glucose metabolism disorders and metabolic syndrome. CONCLUSION: Severe malnutrition or famine during childhood is associated with increased risk of cardiometabolic NCDs, suggesting that developmental plasticity extends beyond prenatal life. Severe malnutrition in childhood thus has serious implications not only for acute morbidity and mortality but also for survivors' long-term health. Heterogeneity across studies, confounding by prenatal malnutrition, and age effects in famine studies preclude firm conclusions on causality. Research to improve understanding of mechanisms linking postnatal malnutrition and NCDs is needed to inform policy and programming to improve the lifelong health of severe malnutrition survivors.

Socio-Ecological Factors That Influence Infant and Young Child Nutrition in Kiribati: A Biocultural Perspective.

This study sought to elucidate the multi-level factors that influence behaviors underlying high childhood stunting and widespread micronutrient deficiencies in Kiribati. This two-phase formative research study had an emergent and iterative design using the socio-ecological model as the guiding theoretical framework. Phase 1 was exploratory while phase 2 was confirmatory. In phase 1, in-depth interviews, free lists, seasonal food availability calendar workshops, and household observations were conducted. In phase 2, focus group discussions, pile sorts, participatory workshops, and repeat observations of the same households were completed. Textual data were analyzed using NVivo software; ethnographic data were analyzed with Anthropac software for cultural domain analysis. We found a combination of interrelated structural, community, interpersonal, and individual-level factors contributing to the early child nutrition situation in Kiribati. Despite widespread knowledge of nutritious young child foods among community members, households make dietary decisions based not only on food availability and access, but also longstanding traditions and social norms. Diarrheal disease is the most salient young child illness, attributable to unsanitary environments and sub-optimal water, sanitation, and hygiene behaviors. This research underscores the importance of a multi-pronged approach to most effectively address the interrelated policy, community, interpersonal, and individual-level determinants of infant and young child nutrition in Kiribati.