Impact of a Homestead Food Production Program on Dietary Diversity: Seasonal and Annual Results from the Cluster-Randomized FAARM Trial in Sylhet, Bangladesh.

BACKGROUND: Rice-predominant diets are common in Bangladesh, leading to widespread nutritional deficiencies. The Food and Agricultural Approaches to Reducing Malnutrition (FAARM) cluster-randomized controlled trial in rural Sylhet, Bangladesh evaluated a homestead food production intervention implemented 2015-2018 through Helen Keller International, aiming to improve child growth. OBJECTIVES: We estimated the intervention's impact on women's and children's dietary diversity, a secondary trial objective. METHODS: We collected dietary diversity throughout the trial (March 2015 to June 2020) at multiple times each year using standard, United Nations-endorsed, self-reported measures for women (10-food group scale) and children (7-food group scale). We included 28,282 observations of 2701 women (out of 2705 enrolled) and 17,445 observations of their 3257 children (aged 6-37 mo) in 96 settlements, 48 of which received the intervention. We estimated the intervention's impact on dietary diversity by year of intervention, overall periods following the start of the intervention, and seasonally, using multilevel regression with the control group as the counterfactual, controlling for seasonality, baseline dietary diversity, and clustering by settlement and repeated measures. RESULTS: At baseline, approximately one-third of women and children consumed a minimally diverse diet. Over the entire intervention and postintervention period, women's and children's odds of consuming a minimally diverse diet nearly doubled (odds ratio [OR] 1.8, P < 0.001, for both). This benefit was barely present in the first year, increased in the second, and peaked in the last intervention year (OR 2.4 for women, OR 2.5 for children, both P < 0.001) before settling at around double the odds in postintervention years (P < 0.001). Dietary improvement was observed throughout the year for both women and children with incremental increases in nearly all food groups. CONCLUSIONS: The nutrition-sensitive agriculture intervention successfully increased dietary diversity in women and children, and these impacts persisted after the project closed, including during the early COVID 19 lockdown period. This trial was registered at clinicaltrials.gov as NCT02505711.

The role of self-efficacy in women's autonomy for health and nutrition decision-making in rural Bangladesh.

BACKGROUND: Agency - including the sub-domains of intrinsic agency, instrumental agency, and collective agency - is a critical component of the women's empowerment process. Self-efficacy (a component of intrinsic agency) may operate as a motivational influence for women to make choices according to their own preferences or goals, such that higher self-efficacy would be associated with more autonomous decision-making (a key component of instrumental agency). METHODS: We examine these relationships using mixed methods. We developed a series of decision-making autonomy indices, which captured alignment between the woman's reported and preferred roles in health and nutrition decisions. Using ordinal logistic regression, we assessed the relationship between generalized self-efficacy and decision-making autonomy. RESULTS: There was a consistently positive association across all categories of decision-making, controlling for a number of individual and household-level covariates. In a sub-sample of joint decision-makers (i.e., women who reported making decisions with at least one other household member), we compared the association between generalized self-efficacy (i.e., one's overall belief in their ability to succeed) and decision-making autonomy to that of domain-specific self-efficacy (i.e., one's belief in their ability to achieve a specific goal) and decision-making autonomy. Across all decision-making categories, domain-specific self-efficacy was more strongly associated with decision-making autonomy than generalized self-efficacy. In-depth interviews provided additional context for interpretation of the regression analyses. CONCLUSIONS: The results indicate the importance of the role of self-efficacy in the women's empowerment process, even in the traditionally female-controlled areas of health and nutrition decision-making. The development of the decision-making autonomy index is an important contribution to the literature in that it directly recognizes and captures the role of women's preferences regarding participation in decision-making.

Maternal low and high hemoglobin concentrations and associations with adverse maternal and infant health outcomes: an updated global systematic review and meta-analysis.

BACKGROUND: Growing evidence suggests low and high maternal hemoglobin (Hb) concentrations may have adverse consequences for maternal and child health. There remain questions on specific Hb thresholds to define anemia and high Hb as well as how cutoffs may vary by anemia etiology and timing of assessment. METHODS: We conducted an updated systematic review (using PubMed and Cochrane Review) on low (< 110 g/L) and high (≥ 130 g/L) maternal Hb concentrations and associations with a range of maternal and infant health outcomes. We examined associations by timing of Hb assessment (preconception; first, second, and third trimesters, as well as at any time point in pregnancy), varying cutoffs used for defining low and high hemoglobin concentrations and performed stratified analyses by iron-deficiency anemia. We conducted meta-analyses to obtain odds ratios (OR) and 95% confidence intervals. RESULTS: The updated systematic review included 148 studies. Low maternal Hb at any time point in pregnancy was associated with: low birthweight, LBW (OR (95% CI) 1.28 (1.22-1.35)), very low birthweight, VLBW (2.15 (1.47-3.13)), preterm birth, PTB (1.35 (1.29-1.42)), small-for-gestational age, SGA (1.11 (1.02-1.19)), stillbirth 1.43 (1.24-1.65)), perinatal mortality (1.75 (1.28-2.39)), neonatal mortality (1.25 (1.16-1.34), postpartum hemorrhage (1.69 (1.45-1.97)), transfusion (3.68 (2.58-5.26)), pre-eclampsia (1.57 (1.23-2.01)), and prenatal depression (1.44 (1.24-1.68)). For maternal mortality, the OR was higher for Hb < 90 (4.83 (2.17-10.74)) than for Hb < 100 (2.87 (1.08-7.67)). High maternal Hb was associated with: VLBW (1.35 (1.16-1.57)), PTB (1.12 (1.00-1.25)), SGA (1.17 (1.09-1.25)), stillbirth (1.32 (1.09-1.60)), maternal mortality (2.01 (1.12-3.61)), gestational diabetes (1.71 (1.19-2.46)), and pre-eclampsia (1.34 (1.16-1.56)). Stronger associations were noted earlier in pregnancy for low Hb and adverse birth outcomes while the role of timing of high Hb was inconsistent. Lower Hb cutoffs were associated with greater odds of poor outcomes; for high Hb, data were too limited to identify patterns. Information on anemia etiology was limited; relationships did not vary by iron-deficiency anemia. CONCLUSION: Both low and high maternal Hb concentrations during pregnancy are strong predictors of adverse maternal and infant health outcomes. Additional research is needed to establish healthy reference ranges and design effective interventions to optimize maternal Hb during pregnancy.

Diagnosing norms and norm change in rural Bangladesh: an exploration of gendered social norms and women's empowerment.

BACKGROUND: Gender-transformative public health programs often aim to address power inequities between men and women and promote women's empowerment. However, to achieve transformative change, it is necessary to first identify the underlying norms that perpetuate these power imbalances. The objective of our study was to use Bicchieri's theory of social norms and model of norm change to identify gendered norms and evidence of norm change amongst participants of the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) trial in rural Sylhet Division, Bangladesh. METHODS: We conducted ten life history interviews, 16 key informant interviews, and four focus group discussions with women and men in communities within the FAARM study site in rural, north-eastern Bangladesh. We performed a thematic analysis as well as a relational analysis of the data. RESULTS: We found that social norms dictated the extent and ways in which women participated in household decisions, the locations they could visit, and their autonomy to use household resources. We also found evidence of changes to gendered social norms over time and the desire amongst some men and women to abandon restrictive norms. Certain intersecting factors, such as education and employment, were identified as facilitators and barriers to women's empowerment and the related gendered expectations. CONCLUSIONS: Our findings corroborate existing norms literature, which highlights the strong role social norms play in influencing women's empowerment and behaviour. Our study provides an example of rigorous qualitative methodology that others may follow to assess gendered social norms that can be targeted for transformative change.

Impact of a Homestead Food Production program on poultry rearing and egg consumption: A cluster-randomized controlled trial in Bangladesh.

Women and children in Bangladesh face high levels of micronutrient deficiencies from inadequate diets. We evaluated the impact of a Homestead Food Production (HFP) intervention on poultry production, as a pathway outcome, and women's and children's egg consumption, as secondary outcomes, as part of the Food and Agricultural Approaches to Reducing Malnutrition cluster-randomized trial in Sylhet division, Bangladesh. The 3-year intervention (2015-2018) promoted home gardening, poultry rearing, and nutrition counseling. We randomly allocated 96 clusters to intervention (48 clusters; 1337 women) or control (48 clusters; 1368 women). Children < 3 years old born to participants were enrolled during the trial. We analyzed poultry production indicators, measured annually, and any egg consumption (24-h recall), measured every 2-6 months for women and their children. We conducted intention-to-treat analyses using mixed-effects logistic regression models with repeat measures, with minimal adjustment to increase precision. Poultry ownership increased by 16% points (pp) and egg production by 13 pp in the final intervention year. The intervention doubled women's odds of egg consumption in the final year (Odds Ratio [OR]: 2.31, 95% CI: 1.68-3.18), with positive effects sustained 1-year post-intervention (OR: 1.58, 95% CI: 1.16-2.15). Children's odds of egg consumption were increased in the final year (OR: 3.04, 95% CI: 1.87-4.95). Poultry ownership was associated with women's egg consumption, accounting for 12% of the total intervention effect, but not with children's egg consumption. Our findings demonstrate that an HFP program can have longer-term positive effects on poultry production and women's and children's diets.

Design, delivery, and determinants of uptake: findings from a food hygiene behavior change intervention in rural Bangladesh.

BACKGROUND: Microbial food contamination, although a known contributor to diarrheal disease and highly prevalent in low-income settings, has received relatively little attention in nutrition programs. Therefore, to address the critical pathway from food contamination to infection to child undernutrition, we adapted and integrated an innovative food hygiene intervention into a large-scale nutrition-sensitive agriculture trial in rural Bangladesh. In this article, we describe the intervention, analyze participation and uptake of the promoted food hygiene behaviors among intervention households, and examine the underlying determinants of behavior adoption. METHODS: The food hygiene intervention employed emotional drivers, engaging group activities, and household visits to improve six feeding and food hygiene behaviors. The program centered on an 'ideal family' competition. Households' attendance in each food hygiene session was documented. Uptake of promoted behaviors was assessed by project staff on seven 'ideal family' indicators using direct observations of practices and spot checks of household hygiene conditions during household visits. We used descriptive analysis and mixed-effect logistic regression to examine changes in household food hygiene practices and to identify determinants of uptake. RESULTS: Participation in the food hygiene intervention was high with more than 75% attendance at each session. Hygiene behavior practices increased from pre-intervention with success varying by behavior. Safe storage and fresh preparation or reheating of leftover foods were frequently practiced, while handwashing and cleaning of utensils was practiced by fewer participants. In total, 496 of 1275 participating households (39%) adopted at least 5 of 7 selected practices in all three assessment rounds and were awarded 'ideal family' titles at the end of the intervention. Being an 'ideal family' winner was associated with high participation in intervention activities [adjusted odds ratio (AOR): 11.4, 95% CI: 5.2-24.9], highest household wealth [AOR: 2.3, 95% CI: 1.4-3.6] and secondary education of participating women [AOR: 2.2, 95% CI: 1.4-3.4]. CONCLUSION: This intervention is an example of successful integration of a behavior change food hygiene component into an existing large-scale trial and achieved satisfactory coverage. Future analysis will show if the intervention was able to sustain improved behaviors over time and decrease food contamination and infection.

Women's empowerment through homestead food production in rural Bangladesh.

BACKGROUND: Women in rural Bangladesh face multiple, inter-related challenges including food insecurity, malnutrition, and low levels of empowerment. We aimed to investigate the pathway towards empowerment experienced by women participating in a three-year nutrition-sensitive homestead food production (HFP) program, which was evaluated through the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) cluster-randomized controlled trial. METHODS: We conducted 44 in-depth interviews and 12 focus group discussions with men and women in both intervention and control communities of the FAARM study site in rural, north-eastern Bangladesh. Using a modified grounded theory approach to data collection and analysis, we developed a framework to explain the pathway towards empowerment among HFP program participants. RESULTS: The analysis and resulting framework identified seven steps towards empowerment: 1) receiving training and materials; 2) establishing home gardens and rearing poultry; 3) experiencing initial success with food production; 4) generating social or financial resources; 5) expanding agency in household decision-making; 6) producing renewable resources (e.g. farm produce) and social resources; and 7) sustaining empowerment. The most meaningful improvements in empowerment occurred among participants who were able to produce food beyond what was needed for household consumption and were able to successfully leverage these surplus resources to gain higher bargaining power in their household. Additionally, women used negotiation skills with their husbands, fostered social support networks with other women, and developed increased self-efficacy and motivation. Meanwhile, the least empowered participants lacked support in critical areas, such as support from their spouses, social support networks, or sufficient space or time to produce enough food to meaningfully increase their contribution and therefore bargaining power within their household. CONCLUSIONS: This study developed a novel framework to describe a pathway to empowerment among female participants in an HFP intervention, as implemented in the FAARM trial. These results have implications for the design of future nutrition-sensitive agriculture interventions, which should prioritize opportunities to increase empowerment and mitigate the barriers identified in our study. TRIAL REGISTRATION: FAARM is registered with ClinicalTrials.gov ( NCT02505711 ).

Impact of a homestead food production program on women's empowerment: Pro-WEAI results from the FAARM trial in Bangladesh.

Nutrition-sensitive agricultural programs have the potential to improve women's and children's nutrition, along with women's empowerment. The project-level Women's Empowerment in Agriculture Index (pro-WEAI) aims to standardize the measurement of women's agency and enable the assessment of impact over typical project timelines. Within the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) cluster-randomized controlled trial in rural Habiganj, Sylhet, Bangladesh, we examined quantitative pro-WEAI data collected from a subsample of trial participants and their husbands (n = 885) approximately four months after the end of the intervention. We evaluated the impact of a three-year homestead food production program on men's and women's agency separately by pro-WEAI domain and indicator, using multilevel logistic and linear regression. We show that women in the FAARM intervention group had levels of agency similar to men and much higher than women in the control group (Odds Ratio [OR] 7.7, p < 0.001), corresponding to better gender equity in intervention areas (OR 3.5, p < 0.001). The higher levels of agency among intervention women were driven by greater intrinsic and collective agency but not by instrumental agency. Compared to controls, more women in the intervention group found intimate partner violence unacceptable (OR 3.5, p < 0.001), had greater ownership of assets (OR 2.6, p = 0.001), better control of income (OR 1.8, p = 0.042), higher levels of group membership (OR 14.0, p < 0.001), and membership in groups they considered influential (OR 166.8, p < 0.001). Self-efficacy was greater in intervention areas for both women (OR 3.2, p < 0.001) and men (OR 2.3, p = 0.002). Our results contribute to the development of benchmarks for interpreting pro-WEAI scores across programs. Our assessment of the impact of a homestead food production program on women's agency provides additional rationale for women-led agricultural projects. We plan to build on these findings by examining the role of improved women's agency on the pathway from the intervention to nutritional impacts.

What Were the Drivers of Improving Child Nutritional Status in Bangladesh? An Analysis of National Household Data from 1992 to 2005 Guided by the UNICEF Framework.

BACKGROUND: Bangladesh has experienced rapid reductions in child undernutrition and poverty, increases in maternal education, and dietary change over the past 3 decades. OBJECTIVE: We aimed to quantify the determinants of the improvement in child nutritional status among preschool-aged children in Bangladesh from 1992 to 2005. METHODS: We utilized data from 4 rounds of 2 linked and seasonally balanced survey systems: the Bangladesh Household [Income and] Expenditure Surveys (H[I]ES) and the Child [and Mother] Nutrition Survey (C[M]NS). We analyzed 10,780 children aged 6-59 mo, divided into 2 age groups (6-23 mo and 24-59 mo). We used Blinder-Oaxaca decomposition to assess the impact of changing determinants on nutritional status over time, guided by the UNICEF conceptual framework for the causes of child malnutrition. RESULTS: There were significant improvements in child growth over time for all z-score measures-length/height-for-age (LAZ/HAZ), weight-for-length/height (WLZ/WHZ), and weight-for-age (WAZ)-and in many potential determinants of child growth across domains of the UNICEF framework. Among younger children, decomposition explained 67% of the observed change in LAZ, 130% of WLZ, and 73% of WAZ. Among older children, decomposition explained 41% of the observed change in HAZ and 36% of WAZ. Drivers varied, with improvements in care of children as the only driver in both age groups and for all growth measures. Declines in disease prevalence drove improvements in weight-based measures. For younger children, household diets and household environments were significant drivers of improvement in LAZ and WAZ. For older children, increasing income was the largest driver of HAZ and WAZ. CONCLUSIONS: Increasing income did not independently drive improvements for younger children but drove improved growth among children aged 2-4 y. This points to the need to focus on nutrition-specific and nutrition-sensitive interventions to decrease child undernutrition in the vulnerable first 1000 days of life.

Women's fasting habits and dietary diversity during Ramadan in rural Bangladesh.

Little is known about fasting practices and dietary changes during Ramadan in low- and lower-middle-income countries. Although pregnant women are exempt from fasting, they may still fast. This is of interest as dietary habits during pregnancy may affect the development of the unborn child. In a community-based sample of young women in rural Sylhet division, Bangladesh, we described fasting practices and beliefs (n = 852). We also examined reported food group consumption and minimally adequate dietary diversity for women (MDD-W) by Ramadan occurrence (n = 1,895) and by fasting adherence (n = 558) using logistic regression with Hindu women as a seasonal control. During Ramadan in 2018, 78% of pregnant Muslim women fasted every day. Over 80% of Muslim women believe that they should fast during pregnancy and over 50% expect positive health effects on the mother and the unborn child. We found strong evidence that Muslim women have more diverse diets during Ramadan, with higher odds of MDD-W (OR [95% CI]: 5.0 [3.6, 6.9]) and increased consumption of pulses, dairy, fruit, and large fish. Dietary diversity increased to a lesser extent on non-fasting days during Ramadan. Ramadan appears to improve dietary quality in both fasting and non-fasting Muslim women in a rural population in Bangladesh. These results help to interpret findings from studies on Ramadan during pregnancy on later-life outcomes and thus contribute to a better understanding of intrauterine influences of maternal nutrition on healthy child development.

Depression among women of reproductive age in rural Bangladesh is linked to food security, diets and nutrition.

OBJECTIVE: To quantify the relationship between screening positive for depression and several indicators of the food and nutrition environment in Bangladesh. DESIGN: We used cross-sectional data from the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) trial in Bangladesh to examine the association of depression in non-peripartum (NPW) and peripartum women (PW) with food and nutrition security using multivariable logistic regression and dominance analysis. SETTING: Rural north-eastern Bangladesh. PARTICIPANTS: Women of reproductive age. RESULTS: Of 2599 women, 40 % were pregnant or up to 1 year postpartum, while 60 % were not peripartum. Overall, 20 % of women screened positive for major depression. In the dominance analysis, indicators of food and nutrition security were among the strongest explanatory factors of depression. Food insecurity (HFIAS) and poor household food consumption (FCS) were associated with more than double the odds of depression (HFIAS: NPW OR = 2·74 and PW OR = 3·22; FCS: NPW OR = 2·38 and PW OR = 2·44). Low dietary diversity (<5 food groups) was associated with approximately double the odds of depression in NPW (OR = 1·80) and PW (OR = 1·99). Consumption of dairy, eggs, fish, vitamin A-rich and vitamin C-rich foods was associated with reduced odds of depression. Anaemia was not associated with depression. Low BMI (<18·5 kg/m2) was also associated with depression (NPW: OR = 1·40). CONCLUSIONS: Depression among women in Bangladesh was associated with many aspects of food and nutrition security, also after controlling for socio-economic factors. Further investigation into the direction of causality and interventions to improve diets and reduce depression among women in low- and middle-income countries are urgently needed.

Identifying bottlenecks in the iron and folic acid supply chain in Bihar, India: a mixed-methods study.

BACKGROUND: Maternal anaemia prevalence in Bihar, India remains high despite government mandated iron supplementation targeting pregnant women. Inadequate supply has been identified as a potential barrier to iron and folic acid (IFA) receipt. Our study objective was to examine the government health system's IFA supply and distribution system and identify bottlenecks contributing to insufficient IFA supply. METHODS: Primary data collection was conducted in November 2011 and July 2012 across 8 districts in Bihar, India. A cross-sectional, observational, mixed methods approach was utilized. Auxiliary Nurse Midwives were surveyed on current IFA supply and practices. In-depth interviews (n = 59) were conducted with health workers at state, district, block, health sub-centre, and village levels. RESULTS: Overall, 44% of Auxiliary Nurse Midwives were out of IFA stock. Stock levels and supply chain practices varied greatly across districts. Qualitative data revealed specific bottlenecks impacting IFA forecasting, procurement, storage, disposal, lack of personnel, and few training opportunities for key players in the supply chain. CONCLUSIONS: Inadequate IFA supply is a major constraint to the IFA supplementation program, the extent of which varies widely across districts. Improvements at all levels of infrastructure, practices, and effective monitoring will be critical to strengthen the IFA supply chain in Bihar.

Obese women less likely to have low serum ferritin, Nicaragua.

OBJECTIVE: To examine the association between overweight and obesity and serum ferritin among women of reproductive age (15-49 years) in Nicaragua, considering the effect of α1-acid glycoprotein (AGP), a marker of inflammation. DESIGN: We analysed data from the 2004-05 Nicaraguan Integrated Surveillance System for Nutrition Interventions. Three logistic regression models were analysed with low serum ferritin (<15 µg/l) as the dependent variable: (i) overweight or obese status and covariates; (ii) model 1 plus AGP; and (iii) model 1 restricted to only women with normal AGP levels (≤1.0 g/l). SETTING: Nicaragua. SUBJECTS: Included in this analysis were 832 non-pregnant mother/caregivers (15-49 years) surveyed in 2004-2005. RESULTS: In the sample, prevalence of overweight and obesity was 31.8 % and 19.2 %, respectively, and 27.6 % had low serum ferritin. In model 1, the adjusted OR of low serum ferritin was 0.74 (95 % CI 0.52, 1.05) for overweight women and 0.42 (95 % CI 0.26, 0.65) for obese women. In model 2, AGP was significantly independently associated with low serum ferritin (adjusted OR=0.56, 95 % CI 0.34, 0.92) while the adjusted OR for overweight and obesity were largely unchanged. Excluding women with elevated AGP did not appreciably affect the relationship between overweight or obesity and low serum ferritin (model 3). CONCLUSIONS: Overall, in this population of reproductive-age women, obese women were less likely to have low serum ferritin levels, and this was independent of inflammation as measured by AGP.

Thalassemia and hemoglobinopathy prevalence in a community-based sample in Sylhet, Bangladesh.

BACKGROUND: Inherited blood disorders affect 7% of the population worldwide, with higher prevalences in countries in the "thalassemia belt," which includes Bangladesh. Clinical management options for severely affected individuals are expensive; thus, targeted government policies are needed to support prevention and treatment programs. In Bangladesh, there is a lack of data, in particular community-based estimates, to determine population prevalence. This study aims to estimate the prevalence of a wide range of hemoglobinopathies and their associations with anemia in a community-based sample of women and young children in rural Sylhet, Bangladesh. METHODS: Capillary blood samples from 900 reproductive-aged women and 395 children (aged 6-37 months) participating in the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) trial in two sub-districts of Habiganj, Sylhet Division, Bangladesh were analyzed for alpha thalassemia, beta thalassemia, and other hemoglobinopathies. We examined the association of each inherited blood disorder with hemoglobin concentration and anemia using linear and logistic regression. RESULTS: We identified at least one inherited blood disorder in 11% of women and 10% of children. Alpha thalassemia was most prevalent, identified in 7% of women and 5% of children, followed by beta thalassemia and hemoglobin E in 2-3%. We also identified cases of hemoglobin S and hemoglobin D in this population. Having any of the identified inherited blood disorders was associated with lower hemoglobin values among non-pregnant women, largely driven by alpha and beta thalassemia. Pregnant women with beta thalassemia were also more likely to have lower hemoglobin concentrations. Among children, we found weak evidence for a relationship between hemoglobinopathy and lower hemoglobin concentrations. CONCLUSIONS: We found a high prevalence of alpha thalassemia among both women and children in rural Sylhet, Bangladesh-higher than all other identified hemoglobinopathies combined. Community-based estimates of alpha thalassemia prevalence in Bangladesh are scarce, yet our findings suggest that alpha thalassemia may comprise the majority of inherited blood disorders in some regions of the country. We recommend that future research on inherited blood disorders in Bangladesh include estimates of alpha thalassemia in their reporting for public health awareness and to facilitate couples  counseling.

Effect of a Homestead Food Production Program on the Prevalence of Diarrhea and Acute Respiratory Infection in Children in Sylhet, Bangladesh: A Cluster-Randomized Controlled Trial.

Diarrhea and respiratory illness are leading causes of mortality and morbidity among young children. We assessed the impact of a homestead food production intervention on diarrhea and acute respiratory infection (ARI) in children in Bangladesh, secondary outcomes of the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) cluster-randomized trial. The trial enrolled 2,705 married women and their children 3 years or younger in 96 rural settlements (geographic clusters) in Sylhet Division, Bangladesh. The intervention promoted home gardening and poultry rearing alongside child nutrition and health counseling over 3 years (2015-2018). An 8-month food hygiene behavior change component using emotional drivers was delivered beginning in mid-2017. Caregiver-reported diarrhea and symptoms of ARI in the week preceding the survey were recorded every 2 months. We analyzed 32,460 observations of 3,276 children over 4 years and found that 3.9% of children had diarrhea and 3.4% had an ARI in the prior 7 days. There was no overall effect of the intervention on 7-day diarrhea period prevalence (odds ratio [OR], 0.92; 95% CI, 0.71-1.19), diarrhea point prevalence (OR, 1.03; 95% CI, 0.78-1.36), or 7-day ARI period prevalence (OR, 1.18; 95% CI, 0.88-1.60). There was no impact on diarrhea severity or differences in health-seeking behaviors. Our findings suggest that this homestead food production program was insufficient to reduce morbidity symptoms among children in a rural setting. More comprehensive water, sanitation, and hygiene measures, and behavioral recommendations may be needed to achieve impacts on child health.

Effect of a Homestead Food Production and Food Hygiene Intervention on Biomarkers of Environmental Enteric Dysfunction in Children Younger Than 24 Months in Rural Bangladesh: A Cluster-Randomized Controlled Trial.

Poor sanitation and hygiene practices and inadequate diets can contribute to environmental enteric dysfunction (EED). We evaluated the impact of a combined homestead food production and food hygiene intervention on EED biomarkers in young children in rural Bangladesh. The analysis was conducted within the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) cluster-randomized trial in Sylhet, Bangladesh. The FAARM trial enrolled 2,705 married women and their children younger than 3 years of age in 96 settlements (geographic clusters): 48 intervention and 48 control. The 3-year intervention (2015-2018) included training on gardening, poultry rearing, and improved nutrition practices and was supplemented by an 8-month food hygiene behavior change component, implemented from mid-2017. We analyzed data on 574 children age 0 to 24 months with multilevel linear regression. We assessed fecal myeloperoxidase (MPO), neopterin (NEO), and alpha-1-antitrypsin (AAT) as biomarkers of EED, and serum C-reactive protein (CRP) and alpha-1-acid glycoprotein (AGP) as biomarkers of systemic inflammation, using ELISA. There was no intervention effect on NEO, AAT, CRP, and AGP concentrations, but, surprisingly, MPO levels were increased in children of the intervention group (0.11 log ng/mL; 95% CI, 0.001-0.22). This increase was greater with increasing child age and among intervention households with poultry that were not kept in a shed. A combined homestead food production and food hygiene intervention did not decrease EED in children in our study setting. Small-scale poultry rearing promoted by the intervention might be a risk factor for EED.

Key Food Hygiene Behaviors to Reduce Microbial Contamination of Complementary Foods in Rural Bangladesh.

Microbial contamination of complementary foods puts young children at risk of developing intestinal infections and could be reduced by improved handwashing and food hygiene practices. We aimed to identify which promoted food hygiene practices are associated with reduced complementary food contamination in a rural population in Bangladesh. We collected cross-sectional data on reported and observed maternal food hygiene behaviors and measured Escherichia coli counts as an indicator of microbial contamination in complementary food samples from 342 children of women enrolled in the Food and Agricultural Approaches to Reducing Malnutrition trial in Sylhet, Bangladesh. We used multivariable logistic regression to examine associations of food hygiene behaviors with food contamination. Approximately 46% of complementary food samples had detectable levels of E. coli. Handwashing with soap at critical times and fresh preparation of food before feeding were strongly associated with reduced odds of food sample contamination (odds ratio [OR]: 0.8, 95% confidence interval [CI]: 0.6-0.9 and OR: 0.3, 95% CI: 0.1-0.7, respectively); in contrast, there was no or only weak evidence that reheating of stored food, safe food storage, and cleanliness of feeding utensils reduced contamination. Reduction in food contamination could be more than halved only when several food hygiene behaviors were practiced in combination. In conclusion, single food hygiene practices showed limited potential and a combined practice of multiple food hygiene behaviors may be needed to achieve a substantial reduction of complementary food contamination.

The Impact of School-Based Nutrition Interventions on Parents and Other Family Members: A Systematic Literature Review.

Little is known about the impact of school-based nutrition interventions on parents and other family members. This systematic review aims to explore the impact of school-based nutrition interventions on different parental/family outcomes, mainly dietary intake, nutrition knowledge, and health outcomes. PubMed, Web of Science, PsycINFO, EconLit, Cochrane Reviews, and Google Scholar were systematically searched for controlled trials or natural experiments measuring the impact of school-based nutrition interventions, with or without parental involvement, on parents/families of school children. Twenty-two studies met the inclusion criteria. Of which, 15 studies assessed the impact of school-based nutrition interventions on parental/family dietary intake, 10 on parental/family nutrition knowledge, and 2 on parental/family health outcomes. Inconsistent results were found for parental dietary intake with six studies reporting favorable effects. Most studies found improved parental nutrition knowledge. Positive impacts were seen by both studies that assessed the impact on a parental health outcome. Overall, we found that there is potential for school-based nutrition interventions to result in positive effects for parents, in particular for nutrition knowledge. More research is needed to assess the impacts of school-based nutrition interventions on parents and other family members and to assess important intervention characteristics in creating a positive impact.

Long-Term Outcomes of in Utero Ramadan Exposure: A Systematic Literature Review.

Health outcomes of in utero Ramadan exposure have been reported in a systematic literature review; however, the available literature on long-term effects were not fully covered. Our study aims to specifically review the long-term outcomes of in utero Ramadan exposure. We searched for original research articles analyzing any long-term outcome of in utero Ramadan exposure, excluding maternal and perinatal outcomes. Sixteen studies from 8304 non-duplicate search results were included. Most studies suggest negative consequences from in utero Ramadan exposure on health, as well as on economic outcomes later in adulthood. Higher under-five mortality rate, higher mortality under three months, and under one year, shorter stature, lower body mass index, increased incidence of vision, hearing and learning disabilities, lower mathematics, writing and reading scores, as well as a lower probability to own a home were associated with Ramadan exposure during conception or the first trimester of pregnancy. Furthermore, age and sex seem to play a pivotal role on the association. Existing studies suggest that in utero Ramadan exposure may adversely impact long-term health and economic well-being. However, evidence is limited. Meanwhile, increasing awareness of the potential risks of Ramadan fasting during pregnancy should be raised among pregnant women and clinicians and other antenatal care workers should promote better maternal healthcare.

Dietary Factors Moderate the Relation between Groundwater Iron and Anemia in Women and Children in Rural Bangladesh.

BACKGROUND: Anemia affects ∼1.6 billion people worldwide, often owing to iron deficiency. In Bangladesh, high levels of anemia have been observed alongside little iron deficiency. Elevated concentrations of groundwater iron could constitute a significant source of dietary iron. OBJECTIVE: We aimed to quantify the effect of groundwater iron on anemia in nonpregnant women and young children in Bangladesh, taking into account dietary factors that may affect iron absorption. METHODS: We analyzed data on 1871 nonpregnant women and 987 children (6-37 mo) from the 2015 baseline survey of the Food and Agricultural Approaches to Reducing Malnutrition cluster-randomized trial in Sylhet, Bangladesh. We used logistic regression with robust standard errors to assess effects of self-reported groundwater iron, dietary intake, and sociodemographic characteristics on anemia, considering interactions between groundwater iron and dietary factors. RESULTS: Groundwater iron presence was associated with less anemia in women (OR: 0.74; 95% CI: 0.60, 0.90) and children (OR: 0.58; 95% CI: 0.44, 0.76). This effect was modified by dietary factors. In women, the effect of groundwater iron on anemia was stronger if no vitamin C-rich or heme-iron foods were consumed, and there was a clear dose-response relation. In children, intake of vitamin C-rich foods strengthened the effect of groundwater iron on anemia, and there was no evidence for interaction by intake of iron-rich foods. CONCLUSIONS: Heme-iron and vitamin C consumption reduced the effect of groundwater iron on anemia among women but not children in Bangladesh, which may be due to higher levels of iron deficiency and lower levels of iron intake among children. Vitamin C consumption appears to enhance iron absorption from groundwater in children and they may thus benefit from consuming more vitamin C-rich fruits and vegetables. Even among women and children consuming heme-iron or vitamin C-rich foods and groundwater iron, anemia prevalence remained elevated, pointing to additional causes of anemia beyond iron deficiency.This trial was registered at clinicaltrials.gov as NCT02505711.