Food pattern modeling to inform global guidance on complementary feeding of infants.

Nutrient needs are difficult to meet during infancy due to high nutrient requirements and the small quantities of food consumed. Guidelines to support food choice decisions are critical to promoting optimal infant health, growth and development and food pattern modeling can be used to inform guideline development. We employed the Optifood modeling system to determine if unfortified complementary foods could meet 13 nutrient targets for breastfed infants (6-11 months), and to describe food patterns that met, or came as close as possible to meeting targets. We also examined the impacts of eliminating food groups, increasing starchy staple foods or adding sentinel unhealthy foods. We collated a global food list from dietary studies in 37 countries and used this list to develop nutrient values for a set of 35 food subgroups. We analyzed infant dietary intakes from studies in eight countries to inform maximum quantities and frequencies of consumption for these subgroups in weekly food patterns. We found that unfortified foods could meet targets for most infants for 12 nutrients, but not for iron. For the smallest and youngest infants, with the lowest energy intakes, there were additional deficits for minerals. Best-case food patterns that met targets or came as close as possible to meeting targets included ample amounts of diverse vegetables, diverse plant- and animal-source protein foods, small amounts of whole grain foods and dairy and no refined grains or added fats or sugar. There were nutrient deficits if animal-source foods or vegetables were eliminated or if unhealthy foods were included.

Approaches to Defining Healthy Diets: A Background Paper for the International Expert Consultation on Sustainable Healthy Diets.

BACKGROUND: Healthy diets promote optimal growth and development and prevent malnutrition in all its forms, including undernutrition, obesity, and diet-related noncommunicable diseases (NCDs). OBJECTIVE: This background paper for the International Expert Consultation on Sustainable Healthy Diets characterizes healthy diets and their implications for food system sustainability. METHODS: Three complementary approaches to defining healthy diets are compared: World Health Organization (WHO) guidelines or recommendations developed between 1996 and 2019; 2017 Global Burden of Disease (GBD) risk factor study estimates of diet-related risk-outcome associations; and analyses associating indices of whole dietary patterns with health outcomes in population studies and clinical trials. RESULTS: World Health Organization dietary recommendations are global reference points for preventing undernutrition and reducing NCD risks; they emphasize increasing intakes of fruits, vegetables (excepting starchy root vegetables), legumes, nuts, and whole grains; limiting energy intake from free sugars and total fats; consuming unsaturated rather than saturated or trans fats; and limiting salt intake. Global Burden of Disease findings align well with WHO recommendations but include some additional risk factors such as high consumption of processed meat; this approach quantifies contributions of diet-related risks to the NCD burden. Evidence on whole dietary patterns supports WHO and GBD findings and raises concerns about potential adverse health effects of foods with high levels of industrial processing. CONCLUSIONS: Implied shifts toward plant foods and away from animal foods (excepting fish and seafood), and for changes in food production systems have direct relevance to the sustainability agenda.

Implications of Updating the Minimum Dietary Diversity for Children Indicator for Tracking Progress in the Eastern and Southern Africa Region.

Minimum dietary diversity (MDD), a population-level dietary quality indicator, is commonly used across low- and middle-income countries to characterize diets of children aged 6-23 mo. The WHO and UNICEF recently updated the MDD definition from consumption of ≥4 of 7 food groups in the previous 24 h (MDD-7) to ≥5 of 8 food groups (MDD-8), adding a breastmilk group. The implications of this definition change were examined across 14 countries in Eastern and Southern Africa where improving complementary feeding is a policy priority. A lower MDD-8 score was found compared with MDD-7 across all countries; in 3 countries the difference between indicators was >5 percentage points. Country-level variability is driven by differences in breastfeeding rates and dietary diversity score. As countries transition to the new indicator it is important to actively publicize changes and to promote valid interpretation of MDD trends.

Assessing Dietary Diversity in Pregnant Women: Relative Validity of the List-Based and Open Recall Methods.

BACKGROUND: The Minimum Dietary Diversity for Women (MMD-W) was validated as a proxy of micronutrient adequacy for nonpregnant women, with proposed data collection being either a list-based or a qualitative open recall method. Few studies have compared the performance of these 2 methods. OBJECTIVES: We compared performance in predicting micronutrient adequacy of food group indicators (FGIs) measured by the list-based and the quantitative open recall methods using varying quantity cut-offs. We also examined the agreement between list-based and open recall FGIs. METHODS: Data were collected in Bangladesh (n = 600 pregnant women) and India (n = 655). The performance of different indicators to predict micronutrient adequacy was compared using receiver operating characteristic (ROC) analysis. Correlations between list-based and open recall FGIs were calculated using Spearman's rank test; agreement was assessed by the intraclass correlation coefficient (ICC) and kappa statistics. Food groups that were most often misreported by the list-based method were identified. RESULTS: There were no statistically significant differences in ROC curves between list-based and open recall FGIs in either country. In Bangladesh, correlations between list-based and open recall FGIs varied between 0.6 and 0.8; ICC values were 0.43-0.75; kappa values were 0.51-0.53 when using a cut-off of any quantity or 15 g for open recall, but were lower (k = 0.24) with the cut-off of 1 portion. In India, these values were lower: ∼0.4 for correlation, 0.32-0.37 for ICCs, and 0.17-0.22 for kappas. Food groups most susceptible to misreporting using the list-based method were beans/peas in Bangladesh and other vegetables in India. CONCLUSIONS: Our study provides initial support for the use of list-based questionnaires in assessing food group diversity or prevalence of MDD-W in pregnant women. Additional and context-specific work may be required to understand the potential of simple methodologies to assess consumption of specific food groups. This trial was registered at clinicaltrials.gov as NCT02745249 (Bangladesh) and NCT03378141 (India).

Maternal and child factors associated with child body fatness in a Ghanaian cohort.

OBJECTIVE: We aimed to identify factors (child diet, physical activity; maternal BMI) associated with body composition of Ghanaian pre-school children. DESIGN: Longitudinal analysis of the International Lipid-Based Nutrient Supplements (iLiNS)-DYAD-Ghana randomized trial, which enrolled 1320 pregnant women at ≤20 weeks' gestation and followed them and their infants until 6 and 18 months postpartum, respectively. At follow-up, child age 4-6 years, we collected data on body composition (by 2H dilution), physical activity and diet, extracted dietary patterns using factor analysis, and examined the association of children's percentage body fat with maternal and child factors by regression analysis. SETTING: Eastern Region, Ghana. PARTICIPANTS: Children 4-6 years of age. RESULTS: The analysis included 889 children with percentage body fat and dietary data at follow-up. We identified two major dietary patterns, a snacking and a cooked foods pattern. Percentage body fat was positively associated (standardized ß (se)) with maternal BMI at follow-up (0·10 (0·03); P = 0·003) and negatively associated with physical activity (-0·15 (0·05); P = 0·003, unadjusted for child gender), but not associated with the snacking (0·06 (0·03); P = 0·103) or cooked foods (-0·05 (0·07); P = 0·474) pattern. Boys were more active than girls (1470 v. 1314 mean vector magnitude counts/min; P < 0·0001) and had lower percentage body fat (13·8 v. 16·9 %; P < 0·0001). CONCLUSIONS: In this population, maternal overweight and child physical activity, especially among girls, may be key factors for addressing child overweight/obesity. We did not demonstrate a relationship between the dietary patterns and body fatness, which may be related to limitations of the dietary data available.

A Global Review of Food-Based Dietary Guidelines.

The objective of this review is to provide a concise, descriptive global review of current food-based dietary guidelines (FBDG), and to assess similarities and differences in key elements of a healthy diet articulated across countries. Information was sourced from the FBDG repository of the FAO, which catalogs FBDG for all countries where they are available, including a description of the food guide (the graphic representation of the dietary guidelines), a set of key messages, and downloadable documents provided by the countries. FBDG are currently available for 90 countries globally: 7 in Africa, 17 in Asia and the Pacific, 33 in Europe, 27 in Latin America and the Caribbean, 4 in the Near East, and 2 in North America. The year of publication of current versions ranges from 1986 to 2017 (mean 2009). This review provides summaries of the key messages and food guides that are used to communicate national dietary guidance, organized by food group, and evaluates the extent to which each set of FBDG includes existing recommendations articulated by the WHO. Some guidance appears nearly universally across countries: to consume a variety of foods; to consume some foods in higher proportion than others; to consume fruits and vegetables, legumes, and animal-source foods; and to limit sugar, fat, and salt. Guidelines on dairy, red meat, fats and oils, and nuts are more variable. Although WHO global guidance encourages consumption of nuts, whole grains, and healthy fats, these messages are not universally echoed across countries. Future frontiers in FBDG development include the incorporation of environmental sustainability and increased attention to sociocultural factors including rapidly changing dietary trends. Steps toward regional and global dietary recommendations could be helpful for refinement of country-level FBDG, and for clear communication and measurement of diet quality both nationally and globally.

The association of early linear growth and haemoglobin concentration with later cognitive, motor, and social-emotional development at preschool age in Ghana.

It is important to identify the periods during childhood when exposure to environmental risk factors results in long-term neurodevelopmental deficits. Stunting and anaemia may be sensitive indicators of exposure to such risks. In a prospective cohort enrolled before birth, we investigated the association of developmental scores at 4-6 years with (a) birth length and linear growth during three postnatal periods and (2) haemoglobin (Hb) concentration at three time points. Children were participants in a follow-up study of a randomized controlled trial of nutritional supplementation in Ghana. At 4-6 years, cognitive, motor, and social-emotional developments were assessed using standard tests adapted for this population. We estimated the associations of length-for-age z-score (LAZ) at birth and postnatal linear growth (n = 710) and Hb (n = 617) with developmental scores in regression models, using multistage least squares analysis to calculate uncorrelated residuals for postnatal growth. Cognitive development at 4-6 years was significantly associated with LAZ at birth (ß = 0.12, 95% CI = 0.05, 0.19), ΔLAZ from 6 to 18 months (ß = 0.16, 95% CI = 0.04, 0.28), and Hb at 18 months (ß = 0.13, 95% CI = 0.06, 0.20), but not with ΔLAZ during 0-6 months, ΔLAZ from 18 months to 4-6 years, Hb at 6 months, or Hb at 4-6 years. No evidence of associations with motor or social-emotional development were found. These results suggest that in similar contexts, the earlier periods prior to birth and up to 18 months are more sensitive to risk factors for long-term cognitive development associated with LAZ and Hb compared with later childhood. This may inform the optimal timing of interventions targeting improved cognitive development.

Maternal and Infant Lipid-Based Nutritional Supplementation Increases Height of Ghanaian Children at 4-6 Years Only if the Mother Was Not Overweight Before Conception.

BACKGROUND: Few studies have evaluated the long-term effects of nutritional supplementation during the first 1000 d of life. We previously reported that maternal and child lipid-based nutrient supplements (LNS) increased child length by 18 mo. OBJECTIVE: The aim of this study was to examine the effects of LNS on later growth and body composition at 4-6 y of age. DESIGN: This was a follow-up of children in the International Lipid-based Nutrient Supplements (iLiNS)-DYAD trial in Ghana. Women (n = 1320) at ≤20 weeks of gestation were randomly assigned to: 1) iron and folic acid during pregnancy and 200 mg calcium/d for 6 mo postpartum, 2) multiple micronutrients (1-2 RDA of 18 vitamins and minerals) during both periods, or 3) maternal LNS during both periods plus child LNS from 6 to 18 mo. At 4-6 y, we compared height, height-for-age z score (HAZ), and % body fat (deuterium dilution method) between the LNS group and the 2 non-LNS groups combined. RESULTS: Data were available for 961 children (76.5% of live births). There were no significant differences between LNS compared with non-LNS groups in height [106.7 compared with 106.3 cm (mean difference, MD, 0.36; P = 0.226)], HAZ [-0.49 compared with -0.57 (MD = 0.08; P = 0.226)], stunting (< -2 SD) [6.5 compared with 6.3% (OR = 1.00; P = 0.993)], or % body fat [15.5 compared with 15.3% (MD = 0.16; P = 0.630)]. However, there was an interaction with maternal prepregnancy BMI (kg/m2) (P-interaction = 0.046 before correction for multiple testing): among children of women with BMI < 25 , LNS children were taller than non-LNS children (+1.1 cm, P = 0.017), whereas there was no difference among children of women with BMI ≥ 25 (+0.1 cm; P = 0.874). CONCLUSIONS: There was no overall effect of LNS on height at 4-6 y in this cohort, which had a low stunting rate, but height was greater in the LNS group among children of nonoverweight/obese women. There was no adverse impact of LNS on body composition. This trial was registered at clinicaltrials.gov as NCT00970866.

Exposure to a slightly sweet lipid-based nutrient supplement during early life does not increase the level of sweet taste most preferred among 4- to 6-year-old Ghanaian children: follow-up of a randomized controlled trial.

BACKGROUND: The impact of feeding a slightly sweet nutrient supplement early in life on later sweet taste preference is unknown. OBJECTIVE: We tested the hypothesis that the level of sucrose most preferred by 4-6-y-old children exposed to a slightly sweet lipid-based nutrient supplement (LNS) early in life would not be higher than that of children never exposed to LNS. DESIGN: We followed up children born to women (n = 1,320) who participated in a randomized trial in Ghana. In one group, LNS was provided to women on a daily basis during pregnancy and the first 6 mo postpartum and to their infants from age 6 to 18 mo (LNS group). The control groups received daily iron and folic acid or multiple micronutrients during pregnancy and the first 6 mo postpartum, with no infant supplementation (non-LNS group). At age 4-6 y, we randomly selected a subsample of children (n = 775) to assess the concentration of sucrose most preferred using the Monell 2-series, forced-choice, paired-comparison tracking procedure. We compared LNS with non-LNS group differences using a noninferiority margin of 5% weight/volume (wt/vol). RESULTS: Of the 624 children tested, most (61%) provided reliable responses. Among all children, the mean ± SD sucrose solution most preferred (% wt/vol) was 14.6 ± 8.6 (LNS group 14.9 ± 8.7; non-LNS group 14.2 ± 8.4). However, among children with reliable responses, it was 17.0 ± 10.2 (LNS group 17.5 ± 10.4; non-LNS group 16.5 ± 10.0). The upper level of the 95% CI of the difference between groups did not exceed the noninferiority margin in either the full sample or those with reliable responses, indicating that the LNS group did not have a higher sweet preference than the non-LNS group. CONCLUSION: Exposure to a slightly sweet nutrient supplement early in life did not increase the level of sweet taste most preferred during childhood. This trial was registered at clinicaltrials.gov as NCT00970866.

Path analyses of risk factors for linear growth faltering in four prospective cohorts of young children in Ghana, Malawi and Burkina Faso.

Stunting prevalence is an indicator of a country's progress towards United Nations' Sustainable Development Goal 2, which is to end hunger and achieve improved nutrition. Accelerating progress towards reducing stunting requires a deeper understanding of the factors that contribute to linear growth faltering. We conducted path analyses of factors associated with 18-month length-for-age z-score (LAZ) in four prospective cohorts of children who participated in trials conducted as part of the International Lipid-Based Nutrient Supplements Project in Ghana (n=1039), Malawi (n=684 and 1504) and Burkina Faso (n=2619). In two cohorts, women were enrolled during pregnancy. In two other cohorts, infants were enrolled at 6 or 9 months. We examined the association of 42 indicators of environmental, maternal, caregiving and child factors with 18-month LAZ. Using structural equation modelling, we examined direct and indirect associations through hypothesised mediators in each cohort. Out of 42 indicators, 2 were associated with 18-month LAZ in three or four cohorts: maternal height and body mass index (BMI). Six factors were associated with 18-month LAZ in two cohorts: length for gestational age z-score (LGAZ) at birth, pregnancy duration, improved household water, child dietary diversity, diarrhoea incidence and 6-month or 9-month haemoglobin concentration. Direct associations were more prevalent than indirect associations, but 30%-62% of the associations of maternal height and BMI with 18-month LAZ were mediated by LGAZ at birth. Factors that were not associated with LAZ were maternal iron status, illness and inflammation during pregnancy, maternal stress and depression, exclusive breast feeding during 6 months post partum, feeding frequency and child fever, malaria and acute respiratory infections. These findings may help in identifying interventions to accelerate progress towards reducing stunting; however, much of the variance in linear growth status remained unaccounted for by these 42 individual-level factors, suggesting that community-level changes may be needed to achieve substantial progress.

Exposure to a Slightly Sweet Lipid-Based Nutrient Supplement During Early Life Does Not Increase the Preference for or Consumption of Sweet Foods and Beverages by 4-6-y-Old Ghanaian Preschool Children: Follow-up of a Randomized Controlled Trial.

BACKGROUND: Whether consuming sweet foods early in life affects sweet food preferences and consumption later in childhood is unknown. OBJECTIVE: We tested the hypothesis that exposure to a slightly sweet lipid-based nutrient supplement (LNS) early in life would not increase preference for or consumption of sweet items at preschool age. METHODS: We followed up children who had participated in a randomized trial in Ghana in which LNS was provided to 1 group of women during pregnancy and 6 mo postpartum and to their infants from ages 6-18 mo (LNS group). The control group (non-LNS group) received iron and folic acid during pregnancy or multiple micronutrients during pregnancy and 6 mo postpartum, with no infant supplementation. At 4-6 y, we obtained data from caregivers on children's food and beverage preferences and consumption (n = 985). For a randomly selected subsample (n = 624), we assessed preference for sweet items using a photo game (range in potential scores, 0-15). For the photo game and reported consumption of sweet items, we examined group differences using predetermined noninferiority margins equivalent to an effect size of 0.2. RESULTS: Median (quartile 1, quartile 3) reported consumption of sweet items (times in previous week) was 14 (8, 23) in the LNS group and 16 (9, 22) in the non-LNS group; in the photo game, the number of sweet items selected was 15 (11, 15) and 15 (11, 15), respectively. The upper level of the 95% CI of the mean difference between LNS and non-LNS groups did not exceed the noninferiority margins for these outcomes. Caregiver-reported preferences for sweet items also did not differ between groups (P = 0.9). CONCLUSION: In this setting, where child consumption of sweet foods was common, exposure to a slightly sweet LNS early in life did not increase preference for or consumption of sweet foods and beverages at preschool age. This trial was registered at clinicaltrials.gov as NCT00970866.

Maternal and Infant Supplementation with Small-Quantity Lipid-Based Nutrient Supplements Increases Infants' Iron Status at 18 Months of Age in a Semiurban Setting in Ghana: A Secondary Outcome Analysis of the iLiNS-DYAD Randomized Controlled Trial.

Background: Interventions are needed to address iron deficiency in low-income settings. Objective: This secondary outcome analysis aimed to compare the hemoglobin (Hb) and iron status [zinc protoporphyrin (ZPP)] of children born to women enrolled in the iLiNS-DYAD trial in Ghana. Methods: Women ≤20 wk pregnant (n = 1320) were assigned to receive 60 mg Fe/d and 400 µg folic acid/d until delivery and placebo thereafter, and no supplementation for infants (IFA group); or multiple micronutrients containing 20 mg Fe/d until 6 mo postpartum and no supplementation for infants (MMN); or small-quantity lipid-based nutrient supplements (SQ-LNSs) containing 20 mg Fe/d until 6 mo postpartum, and SQ-LNSs for infants from 6 to 18 mo of age (LNS). We compared infants' Hb (g/L) and ZPP (µmol/mol heme) at 6 and 18 mo of age. Results: At 6 mo of age, groups did not differ in mean ± SD Hb (overall: 113 ± 9.9 g/L) or geometric mean (95% CI) ZPP [overall: 62.6 (60.6, 64.7)]. At 18 mo of age, mean ± SD Hb (overall: 112 ± 10.4 g/L) did not differ significantly between groups, whereas geometric mean (95% CI) ZPP was lower (P = 0.031) in the LNS group [53.9 (50.7, 57.3)] than the IFA [60.4 (56.7, 64.3)] but not the MMN [58.8 (55.6, 62.2)] group. Further, the LNS group, compared with the IFA and MMN groups combined, had a lower prevalence of elevated (>70) ZPP (27.5% compared with 35%; P = 0.02) and a marginally lower prevalence of anemia (38.7% compared with 44.9%; P = 0.06). These results generally remained unchanged when controlling for prespecified covariates or correcting for inflammation. Conclusions: In this setting, providing SQ-LNSs or multiple micronutrients with 20 mg Fe/d, compared with iron (60 mg/d) and folic acid, to pregnant women does not affect their infants' Hb or iron status at 6 mo of age, but maternal and infant supplementation with SQ-LNSs increases infants' iron status at 18 mo of age. This trial was registered at clinicaltrials.gov as NCT00970866.

Prevalence thresholds for wasting, overweight and stunting in children under 5 years.

OBJECTIVE: Prevalence ranges to classify levels of wasting and stunting have been used since the 1990s for global monitoring of malnutrition. Recent developments prompted a re-examination of existing ranges and development of new ones for childhood overweight. The present paper reports from the WHO-UNICEF Technical Expert Advisory Group on Nutrition Monitoring. DESIGN: Thresholds were developed in relation to sd of the normative WHO Child Growth Standards. The international definition of 'normal' (2 sd below/above the WHO standards median) defines the first threshold, which includes 2·3 % of the area under the normalized distribution. Multipliers of this 'very low' level (rounded to 2·5 %) set the basis to establish subsequent thresholds. Country groupings using the thresholds were produced using the most recent set of national surveys. SETTING: One hundred and thirty-four countries. SUBJECTS: Children under 5 years. RESULTS: For wasting and overweight, thresholds are: 'very low' (≈6 times 2·5 %). For stunting, thresholds are: 'very low' (≈12 times 2·5 %). CONCLUSIONS: The proposed thresholds minimize changes and keep coherence across anthropometric indicators. They can be used for descriptive purposes to map countries according to severity levels; by donors and global actors to identify priority countries for action; and by governments to trigger action and target programmes aimed at achieving 'low' or 'very low' levels. Harmonized terminology will help avoid confusion and promote appropriate interventions.

Predictors of complementary feeding practices in Afghanistan: Analysis of the 2015 Demographic and Health Survey.

Despite improvements over the past 20 years, high burdens of child mortality and undernutrition still coexist in Afghanistan. Global evidence indicates that complementary feeding (CF) practices predict child survival and nutritional status. Our study aims to describe CF practices in Afghanistan and to discern underlying predictors of CF by analysing data from Afghanistan's 2015 Demographic and Healthy Survey. Multilevel models were constructed comprising potential predictors at individual, household, and community levels and four CF indicators: timely introduction of solid, semi-solid, or soft foods (INTRO), minimum meal frequency (MMF), minimum dietary diversity (MDD), and minimum acceptable diet (MAD) among breastfed children. INTRO prevalence among children aged 6-8 months was 56%, whereas the prevalence of MMF, MDD, and MAD among children aged 6-23 months was 55%, 23%, and 18%, respectively. Of the seven food groups considered, four were consumed by 20% or fewer children: eggs (20%), legumes and nuts (18%), fruits and vegetables (15%), and flesh foods (14%). Increasing child age and more antenatal care visits were significantly and positively associated with greater odds of meeting all CF indicators. Lower household wealth and lower community-level access to health care services were associated with lower odds of MDD and MAD. Disparities in achieving recommended CF practices were observed by region. CF practices in Afghanistan are poor and significant socioeconomic inequities in CF are observed across the country. Our study calls for urgent policy and programme attention to improve complementary feeding practices as an intrinsic part of the national development agenda.

Comparison of an interactive 24-h recall and weighed food record for measuring energy and nutrient intakes from complementary foods among 9-10-month-old Malawian infants consuming lipid-based nutrient supplements.

Fortifying complementary foods with lipid-based nutrient supplements (LNS) may improve energy and nutrient intakes of infants at risk for undernutrition. We aimed to determine the relative validity of an interactive 24-h recall (i-24-HR) for assessing the impact of an LNS intervention on dietary intakes of energy and nutrients among rural Malawian 9-10-month-old infants (n 132) participating in the International Lipid-Based Nutrient Supplements Dose (iLiNS-DOSE) trial. Dietary data were collected for the same day via i-24-HR and weighed food records. Inter-method agreements were estimated overall and by intervention group, using Bland-Altman plots and paired t tests; measurement error models (differential error); and percentage of food omissions and intrusions were estimated. Overall, inter-method differences in mean intakes of energy and most nutrients were not significant. When stratified by group, recalled energy intakes were under-estimated (-368 kJ; P=0·01) in the control but not in the intervention group (-42 kJ; P=0·6). This differential reporting error was related to an over-estimation of recalled LNS (8·1 v. 4·5 g; P30 % eating occasions) omissions were milk/fish/eggs, starchy roots/vegetables and sweetened snacks. Common intrusions were milk/yogurt. Starchy staples and LNS were recalled when consumed (>85 %) (i.e. matched). These results emphasise the importance of considering differential error when interpreting dietary results in LNS trials.

Stagnating trends in complementary feeding practices in Bangladesh: An analysis of national surveys from 2004-2014.

Bangladesh has experienced steady socio-economic development. However, improvements in child growth have not kept pace. It is important to document complementary feeding (CF) practices-a key determinant of children's growth-and their trends over time. The study aims to examine trends in CF practices in children aged 6-23 months using data from Bangladesh Demographic and Health Surveys conducted in 2004, 2007, 2011, and 2014. Multilevel logistic regression models were applied to identify independent predictors of four CF practice indicators among children 6-23 months, namely, timely introduction of complementary foods, minimum meal frequency, minimum dietary diversity, and minimum acceptable diet. Introduction of complementary foods was achieved among 64-71% of children between 2004 and 2014. The proportion meeting minimum meal frequency increased from 2004 to 2007 (71-81%) and declined and held steady at 65% from 2011 to 2014. The proportion meeting minimum dietary diversity in 2011 and 2014 was low (25% and 28%), and so was minimum acceptable diet (19% and 20%). From 2007 to 2014, child dietary diversity decreased and the most decline was in the consumption of legumes and nuts (29% to 8%), vitamin A-rich fruits and vegetables (54% to 41%), and other fruits and vegetables (47% to 20%). Young child age (6-11 months), poor parental education, household poverty, and residence in the Chittagong and Sylhet independently predicted poorer feeding practices. Dietary diversity and overall diet in Bangladeshi children are strikingly poor. Stagnation or worsening of feeding practices in the past decade are concerning and call for decisive policy and programme action to address inappropriate child feeding practices.

Unintended effects of a targeted maternal and child nutrition intervention on household expenditures, labor income, and the nutritional status of non-targeted siblings in Ghana.

It is common for health and nutrition interventions to target specific household members and for evaluations of their effects to focus exclusively on those members. However, if a targeted intervention changes a household's utility maximization problem or influences decision-making, households might respond to the intervention in unintended ways with the potential to affect the wellbeing of non-targeted members. Using panel data from a randomized controlled nutrition trial in Ghana, we evaluate household behavioral responses to the provision of small-quantity lipid-based nutrient supplements (SQ-LNS) to mothers and their infants to prevent undernutrition. We find that targeted supplementation with SQ-LNS had a positive effect on household expenditures on food, including some nutrient-rich food groups, as well as on non-food goods and services. We also find a positive impact on labor income, particularly among fathers. We then explore intrahousehold spillover effects on the nutritional status of non-targeted young children in the household. We find evidence that the targeted provision of SQ-LNS led to higher height-for-age z-scores among non-targeted children in the LNS group compared to the non-LNS group, though only among those with relatively taller mothers, which is an indicator of a child's growth potential. These findings support existing evidence and suggest that unintended behavioral responses and spillover are a real possibility in the context of nutrition interventions targeting nutritionally-vulnerable household members. Thoughtfully considering this possibility in the design, analyses, and evaluation of targeted nutrition interventions may provide a more complete picture of overall effects.

Ghanaian parents' perceptions of pre and postnatal nutrient supplements and their effects.

Small-quantity lipid-based nutrient supplements (SQ-LNS) have been studied in efficacy and effectiveness trials, but little is known about how parents perceive the products and their effects. In a randomised trial in Ghana, efficacy of SQ-LNS provided to women during pregnancy and the first 6 months postpartum and to their children from 6 to 18 months of age was assessed by comparison with iron-folic acid (IFA) capsules and multiple micronutrient (MMN) capsules provided to women. In a follow-up study conducted when the index children from the original trial were between 4 and 6 years of age, we used survey-based methods to assess retrospective and current parental perceptions of nutrient supplements generally and of SQ-LNS and their effects compared with perceptions IFA and MMN capsules. Most parents perceived that the assigned supplements (SQ-LNS, IFA, or MMN) positively impacted the mother during pregnancy (approximately 89% of both mothers and fathers) and during lactation (84% of mothers and 86% of fathers). Almost all (≥90%) of mothers and fathers perceived that the assigned supplement positively impacted the index child and expected continued positive impacts on the child's health and human capital into the future. A smaller percentage of parents perceived negative impacts of the supplements (7%-17% of mothers and 4%-12% of fathers). Perceptions of positive impacts and of negative impacts did not differ by intervention group. The results suggest that similar populations would likely be receptive to programs to deliver SQ-LNS or micronutrient capsules.

Association between breast milk intake at 9-10 months of age and growth and development among Malawian young children.

World Health Organization recommends exclusive breastfeeding for infants for the first 6 months of life, followed by introduction of nutritious complementary foods alongside breastfeeding. Breast milk remains a significant source of nourishment in the second half of infancy and beyond; however, it is not clear whether more breast milk is always better. The present study was designed to determine the association between amount of breast milk intake at 9-10 months of age and infant growth and development by 12-18 months of age. The study was nested in a randomized controlled trial conducted in Malawi. Regression analysis was used to determine associations between breast milk intake and growth and development. Mean (SD) breast milk intake at 9-10 months of age was 752 (244) g/day. Mean (SD) length-for-age z-score at 12 months and change in length-for-age z-score between 12 and 18 months were -1.69 (1.0) and -0.17 (0.6), respectively. At 18 months, mean (SD) expressive vocabulary score was 32 (24) words and median (interquartile range) skills successfully performed for fine, gross, and overall motor skills were 21 (19-22), 18 (16-19), and 38 (26-40), respectively. Breast milk intake (g/day) was not associated with either growth or development. Proportion of total energy intake from breast milk was negatively associated with fine motor (ß = -0.18, p = .015) but not other developmental scores in models adjusted for potential confounders. Among Malawian infants, neither breast milk intake nor percent of total energy intake from breast milk at 9-10 months was positively associated with subsequent growth between 12 and 18 months, or development at 18 months.

Local foods can meet micronutrient needs for women in urban Burkina Faso, but only if rarely consumed micronutrient-dense foods are included in daily diets: A linear programming exercise.

Women of reproductive age are at nutritional risk due to their need for nutrient-dense diets. Risk is further elevated in resource-poor environments. In one such environment, we evaluated feasibility of meeting micronutrient needs of women of reproductive age using local foods alone or using local foods and supplements, while minimizing cost. Based on dietary recall data from Ouagadougou, we used linear programming to identify the lowest cost options for meeting 10 micronutrient intake recommendations, while also meeting energy needs and following an acceptable macronutrient intake pattern. We modeled scenarios with maximum intake per food item constrained at the 75th percentile of reported intake and also with more liberal maxima based on recommended portions per day, with and without the addition of supplements. Some scenarios allowed only commonly consumed foods (reported on at least 10% of recall days). We modeled separately for pregnant, lactating, and nonpregnant, nonlactating women. With maxima constrained to the 75th percentile, all micronutrient needs could be met with local foods but only when several nutrient-dense but rarely consumed items were included in daily diets. When only commonly consumed foods were allowed, micronutrient needs could not be met without supplements. When larger amounts of common animal-source foods were allowed, all needs could be met for nonpregnant, nonlactating women but not for pregnant or lactating women, without supplements. We conclude that locally available foods could meet micronutrient needs but that to achieve this, strategies would be needed to increase consistent availability in markets, consistent economic access, and demand.