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.

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.

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.

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.

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.

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.

Maternal exposure to multiple mycotoxins and adverse pregnancy outcomes: a prospective cohort study in rural Bangladesh.

There is limited and inconsistent evidence, primarily from cross-sectional studies, linking mycotoxins to adverse birth outcomes. This study investigates the potential role of maternal dietary exposure to multiple mycotoxins in the development of several adverse pregnancy and birth outcomes. We analyzed data from 436 singleton pregnancies enrolled in a prospective cohort study in the rural Habiganj district, Bangladesh, between July 2018 and November 2019. Thirty-five urinary mycotoxin biomarkers were quantified using liquid chromatography coupled with tandem mass spectrometry and used to estimate dietary mycotoxin exposure. Multivariable regression models, adjusted for potential confounding and clustering, were fitted to assess the associations between maternal exposure to frequently occurring mycotoxins (ochratoxin A-OTA, citrinin- CIT, and Deoxynivalenol- DON) and pregnancy loss, preterm birth (PTB), low birth weight (LBW), born small-for-gestational-age (SGA) and small-vulnerable newborn. The results indicate that only in 16 of 436 pregnancies (4%) were urine samples free from all investigated mycotoxins. Biomarkers for six major mycotoxins were detected in the urine samples. OTA (95%), CIT (61%), and DON (6%) were most frequently detected, with at least two mycotoxins co-occurring in the majority of women (63%). There was evidence that maternal dietary intake of OTA was associated with higher odds of having an LBW baby, with the odds increasing in a dose-dependent manner. We found no evidence of associations between pregnancy loss, PTB, SGA, small-vulnerable newborns, and maternal dietary exposure to OTA, CIT, and DON, albeit with large confidence intervals, so findings are consistent with protective as well as large harmful effects. Exposure to multiple mycotoxins during pregnancy is widespread in this rural community and represents a health risk for mothers and babies. Tailored public health policies and interventions must be implemented to reduce mycotoxin exposure to the lowest possible level.

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.

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.

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.

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 ).

Awareness, Experience, and Knowledge of Farming Households in Rural Bangladesh Regarding Mold Contamination of Food Crops: A Cross-Sectional Study.

Aside from specific environmental conditions, poor agricultural practices contribute to mold and thus the mycotoxin contamination of crops. This study investigated Bangladeshi farming households' (i) awareness of and experience with mold contamination of food crops; (ii) knowledge and awareness of the timing, causes, and consequences of mold and mycotoxin contamination; and (iii) knowledge of the recommended agricultural practices for controlling and preventing mold contamination of food crops. A survey was conducted with 1280 households in rural areas of Habiganj district, Bangladesh. Basic descriptive statistics were calculated, and mixed-effects linear regression analyses were performed to examine associations between household characteristics and overall knowledge scores. The awareness of mold contamination of food crops was very high (99%; 95% CI: 98-100%) and a shared experience among households (85%; 95% CI: 80-88%). Yet, the majority (80%; 95% CI: 76-84%) demonstrated a low level of knowledge of the timing, causes, and preventive practices regarding mold contamination of crops. Knowledge scores were similar over demographic groups and better for households with more arable land. The findings suggest a generally insufficient knowledge of the conditions that favor mold contamination and the measures for preventing mold contamination of food crops. These findings underline the need for tailored interventions to promote good agricultural practices and reduce mold contamination of food crops.

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.

The ongoing nutrition transition thwarts long-term targets for food security, public health and environmental protection.

The nutrition transition transforms food systems globally and shapes public health and environmental change. Here we provide a global forward-looking assessment of a continued nutrition transition and its interlinked symptoms in respect to food consumption. These symptoms range from underweight and unbalanced diets to obesity, food waste and environmental pressure. We find that by 2050, 45% (39-52%) of the world population will be overweight and 16% (13-20%) obese, compared to 29% and 9% in 2010 respectively. The prevalence of underweight approximately halves but absolute numbers stagnate at 0.4-0.7 billion. Aligned, dietary composition shifts towards animal-source foods and empty calories, while the consumption of vegetables, fruits and nuts increases insufficiently. Population growth, ageing, increasing body mass and more wasteful consumption patterns are jointly pushing global food demand from 30 to 45 (43-47) Exajoules. Our comprehensive open dataset and model provides the interfaces necessary for integrated studies of global health, food systems, and environmental change. Achieving zero hunger, healthy diets, and a food demand compatible with environmental boundaries necessitates a coordinated redirection of the nutrition transition. Reducing household waste, animal-source foods, and overweight could synergistically address multiple symptoms at once, while eliminating underweight would not substantially increase food demand.

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.

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.

Food and Agricultural Approaches to Reducing Malnutrition (FAARM): protocol for a cluster-randomised controlled trial to evaluate the impact of a Homestead Food Production programme on undernutrition in rural Bangladesh.

INTRODUCTION: Chronic undernutrition affects over 150 million children worldwide and has serious consequences. The causes are complex and include insufficient dietary diversity and poor hygiene practices. Systematic reviews of nutrition-sensitive agricultural interventions concluded that while these hold promise, there is insufficient evidence for their impact on child growth. The Food and Agricultural Approaches to Reducing Malnutrition (FAARM) project is a 1:1 cluster-randomised trial aiming to evaluate the impact of a Homestead Food Production (HFP) programme implemented by Helen Keller International on women's and children's undernutrition. METHODS AND ANALYSIS: The HFP intervention comprises training of women's groups and asset distribution to support year-round home gardening, poultry rearing and improved nutrition and hygiene practices. Formal trainings are supplemented by behaviour change communication during household visits, and facilitated links between producer groups and market actors. The FAARM trial will examine if and how this complex intervention reduces undernutrition. In 2015, FAARM enrolled married women and their children (0-3 years) in 96 rural settlements of Habiganj district in Sylhet division, Bangladesh. Covariate-constrained randomisation was used to assign 48 settlements to receive a 3-year HFP intervention, with the other 48 acting as controls, targeting over 2700 women. To study impact pathways, a surveillance system collects data on all participants every 2 months. In late 2019, children 0-3 years of age (born during the intervention period) will be surveyed, thus capturing impact during the critical first 1000 days of life. Children's length/height-for-age z-scores will be compared between intervention and control arms using mixed-effects linear regression. Secondary outcomes include women's and children's micronutrient status, dietary intake, dietary diversity and other indicators of child growth, development and morbidity. ETHICS AND DISSEMINATION: Ethical approval was received in Bangladesh and Germany. Results will be disseminated through peer-reviewed publications and presentations in Bangladesh and internationally. TRIAL REGISTRATION NUMBER: NCT02505711; Pre-results.

Dietary Patterns and Determinants of Changing Diets in Bangladesh from 1985 to 2010.

BACKGROUND: The government of Bangladesh has implemented multiple policies since 1971 to provide the population with more diverse and nutritious diets. OBJECTIVE: The aim of this study was to examine the drivers of dietary change over time and the roles agriculture and economic development have played. METHODS: We used principal component analysis to derive dietary patterns from 7 cross-sectional rounds of the Bangladesh Household [Income and] Expenditure Survey. We then used linear probability models to estimate associations of adherence to dietary patterns with socio-economic characteristics of households, and with agricultural production on the household and regional level. For dietary patterns that increased or decreased over time, Blinder-Oaxaca decomposition was used to assess factors associated with these changes. RESULTS: Seven dietary patterns were identified: modern, traditional, festival, winter, summer, monotonous, and spices. All diets were present in all survey rounds. In 1985, over 40% of households had diets not associated with any identified pattern, which declined to 12% by 2010. The proportion of the population in households adhering to the modern, winter, summer, and monotonous diets increased over time, whereas the proportion adhering to the traditional diet decreased. Although many factors were associated with adherence to dietary patterns in the pooled sample, changes in observed factors only explained a limited proportion of change over time due to variation in coefficients between periods. Increased real per capita expenditure was the largest driver of elevated adherence to dietary patterns over time, whereas changes in the agricultural system increased adherence to less diverse dietary patterns. CONCLUSIONS: These findings highlight the need for both diversified agricultural production and a continued reduction in poverty in order to drive dietary improvement. This study lays the groundwork for further analysis of the impact of changing diets on health and nutrition.