Food, nutrition, and autism: from soil to fork.

Food and nutrition-related factors have the potential to impact development of autism spectrum disorder (ASD) and quality of life for people with ASD, but gaps in evidence exist. On 10 November 2022, Tufts University's Friedman School of Nutrition Science and Policy and Food and Nutrition Innovation Institute hosted a 1-d meeting to explore the evidence and evidence gaps regarding the relationships of food and nutrition with ASD. This meeting report summarizes the presentations and deliberations from the meeting. Topics addressed included prenatal and child dietary intake, the microbiome, obesity, food-related environmental exposures, mechanisms and biological processes linking these factors and ASD, food-related social factors, and data sources for future research. Presentations highlighted evidence for protective associations with prenatal folic acid supplementation and ASD development, increases in risk of ASD with maternal gestational obesity, and the potential for exposure to environmental contaminants in foods and food packaging to influence ASD development. The importance of the maternal and child microbiome in ASD development or ASD-related behaviors in the child was reviewed, as was the role of discrimination in leading to disparities in environmental exposures and psychosocial factors that may influence ASD. The role of child diet and high prevalence of food selectivity in children with ASD and its association with adverse outcomes were also discussed. Priority evidence gaps identified by participants include further clarifying ASD development, including biomarkers and key mechanisms; interactions among psychosocial, social, and biological determinants; interventions addressing diet, supplementation, and the microbiome to prevent and improve quality of life for people with ASD; and mechanisms of action of diet-related factors associated with ASD. Participants developed research proposals to address the priority evidence gaps. The workshop findings serve as a foundation for future prioritization of scientific research to address evidence gaps related to food, nutrition, and ASD.

Plant-Based Dietary Patterns and Incident Diabetes in the Atherosclerosis Risk in Communities (ARIC) Study.

OBJECTIVE: Plant-based dietary patterns emphasize plant foods and minimize animal-derived foods. We investigated the association between plant-based dietary patterns and diabetes in a community-based U.S. sample of Black and White adults. RESEARCH DESIGN AND METHODS: We included middle-aged adults from the Atherosclerosis Risk in Communities (ARIC) study without diabetes at baseline who completed a food-frequency questionnaire (n = 11,965). We scored plant-based diet adherence according to three indices: overall, healthy, and unhealthy plant-based diet indices. Higher overall plant-based diet index (PDI) scores represent greater intakes of all plant foods and lower intakes of animal-derived foods. Higher healthy plant-based diet index (hPDI) scores represent greater healthy plant food intake and lower intakes of animal-derived and unhealthy plant foods. Higher unhealthy plant-based diet index (uPDI) scores represent greater unhealthy plant food intake and lower intakes of animal-derived and healthy plant foods. We used Cox regression to estimate hazard ratios (HRs) for incident diabetes (defined according to self-reported diagnosis, medication use, or elevated blood glucose) associated with each index. RESULTS: Over a median follow-up of 22 years, we identified 4,208 cases of diabetes among subjects. Higher PDI scores were associated with a lower risk of diabetes (quintile 5 vs. 1 HR 0.89 [95% CI 0.80, 0.98]; Ptrend = 0.01). hPDI scores were also inversely associated with diabetes risk (quintile 5 vs. 1 HR 0.85 [95% CI 0.77, 0.94]; Ptrend < 0.001). uPDI scores were not associated with diabetes risk. CONCLUSIONS: A dietary pattern that minimizes animal-derived foods and emphasizes plant foods may reduce diabetes risk.

Short-term dynamics of linear growth among Peruvian infants in the first year of life in a population with linear growth faltering.

OBJECTIVES: Infant growth is recognized to vary over the short term, with periods of greater and lesser linear growth velocity. Our objectives were to (1) examine the potential differences in overall growth profiles between children who experienced cumulative growth faltering in the first year of life consistent with that seen by many children living in poverty in low- and middle-income countries, versus children without growth faltering and (2) test whether biological factors were associated with the timing of magnitude of growth saltations. METHODS: Thrice-weekly measurements of length were recorded for n = 61 Peruvian infants (28 boys and 33 girls) enrolled from birth to 1 year. A total of 6040 measurements were analyzed. We tested for the evidence of saltatory growth and used hurdle models to test whether the timing and magnitude of saltations varied between children with greater or lesser growth faltering. RESULTS: There were no differences in the duration of stasis periods or magnitude of growth saltations between children who were stunted at 1 year old (N = 18) versus those who were not stunted (N = 43). Children who experienced greater declines in LAZ in the first year of life trended toward longer periods between saltations than those with less of a decline (14.5 days vs. 13.4 days, p = .0512). A 1-unit increase in mid upper arm circumference for age Z-score in the 21 days prior was associated with 35% greater odds of a saltation occurring (p < .001), and a 0.128 cm greater saltation (p < .001). CONCLUSIONS: After characterizing infant growth into periods of saltation and stasis, our results suggest that increases in weight preceded increases in length.

Nutrient intakes from complementary foods are associated with cardiometabolic biomarkers among undernourished Peruvian children.

Relatively little is known about how the diet of chronically undernourished children may impact cardiometabolic biomarkers. The objective of this exploratory study was to characterise relationships between dietary patterns and the cardiometabolic profile of 153 3-5-year-old Peruvian children with a high prevalence of chronic undernutrition. We collected monthly dietary recalls from children when they were 9-24 months old. At 3-5 years, additional dietary recalls were collected, and blood pressure, height, weight, subscapular skinfolds and fasting plasma glucose, insulin and lipid profiles were assessed. Nutrient intakes were expressed as average density per 100 kcals (i) from 9 to 24 months and (ii) at follow-up. The treelet transform and sparse reduced rank regress'ion (RRR) were used to summarize nutrient intake data. Linear regression models were then used to compare these factors to cardiometabolic outcomes and anthropometry. Linear regression models adjusting for subscapular skinfold-for-age Z-scores (SSFZ) were then used to test whether observed relationships were mediated by body composition. 26 % of children were stunted at 3-5 years old. Both treelet transform and sparse RRR-derived child dietary factors are related to protein intake and associated with total cholesterol and SSFZ. Associations between dietary factors and insulin were attenuated after adjusting for SSFZ, suggesting that body composition mediated these relationships. Dietary factors in early childhood, influenced by protein intake, are associated with cholesterol profiles, fasting glucose and body fat in a chronically undernourished population.

Maternity care experiences and breastfeeding at discharge among Maryland WIC participants: A qualitative analysis.

BACKGROUND: Breastfeeding imparts numerous health and social benefits for families. Barriers deter some individuals from breastfeeding. Rates are lower among certain populations, including participants of the federally funded Women, Infants, and Children's Program (WIC). Women, Infants, and Children's Program provides low-income pregnant and postpartum women and children under 5 with nutrition education, supplemental foods, breastfeeding education and support, and resource linkages. Investigation of WIC participants' hospital experiences and breastfeeding decisions is limited. We explore qualitative themes associated with breastfeeding-related hospital maternity care practices experienced by WIC participants. METHODS: Thirty pregnant individuals intending to breastfeed were recruited at WIC clinics to complete in-depth interviews at 2 weeks, 3 months, and 6 months of postpartum. Using the Thematic Framework methodology, we analyzed data from the two-week interviews of 29 participants with respect to hospital breastfeeding experiences. RESULTS: Fourteen participants were exclusively breastfeeding at discharge (EBFD). Fifteen were partially breastfeeding at discharge (PBFD). Differences between groups were found in hospital breastfeeding experiences, particularly in staff support. All participants EBFD reported positive breastfeeding-related staff experiences. Most participants PBFD reported limited and ineffective staff interaction, leading to formula introduction. CONCLUSIONS: Individuals EBFD and those PBFD reported about the same rate of hospital breastfeeding difficulties, yet half introduced formula within the first few days postpartum. Results reiterate the importance of hospital staff support to breastfeeding exclusivity at 2-3 days postpartum. The challenges that these individuals faced may have been resolved through available, responsive, and effective intervention. Data-driven breastfeeding education programs for hospital health professionals are critical to affect patient breastfeeding outcomes.

Adequacy of Iodine Status and Associations with Gut Health: A Prospective Cohort Study among Infants in 8 Low- and Middle-Income Countries.

BACKGROUND: Environmental enteric dysfunction increases the likelihood of micronutrient deficiencies among infants, but few studies have assessed the potential impact of gut health on urinary iodine concentration (UIC) among this vulnerable group. OBJECTIVES: We describe the trends of iodine status among infants from 6 to 24 mo old and examine the associations between intestinal permeability, inflammation, and UIC from 6 to 15 mo of age. METHODS: Data from 1557 children enrolled in this birth cohort study conducted in 8 sites were included in these analyses. UIC was measured at 6, 15, and 24 mo of age by using the Sandell-Kolthoff technique. Gut inflammation and permeability were assessed using the concentrations of fecal neopterin (NEO), myeloperoxidase (MPO) and alpha-1-antitrypsin (AAT), and lactulose-mannitol ratio (LM). A multinomial regression analysis was used to assess the classified UIC (deficiency or excess). Linear mixed regression was used to test the effect of interactions among biomarkers on logUIC. RESULTS: All studied populations had adequate (≥100 µg/L) to excess (≥371 µg/L) median UIC at 6 mo. Between 6 and 24 mo, 5 sites displayed a significant decline in the infant's median UIC. However, median UIC remained within the optimal range. An increase of NEO and MPO concentrations by +1 unit in ln scale reduced the risk of low UIC by 0.87 (95% CI: 0.78-0.97) and 0.86 (95% CI: 0.77-0.95), respectively. AAT moderated the association between NEO and UIC (P < 0.0001). The shape of this association appears to be asymmetric and in a reverse J-shape, with a higher UIC observed at both lower NEO and AAT concentrations. CONCLUSIONS: Excess UIC was frequent at 6 mo and tended to normalize at 24 mo. Aspects of gut inflammation and increased permeability appear to reduce the prevalence of low UIC in children aged 6 to 15 mo. Programs addressing iodine-related health should consider the role of gut permeability in vulnerable individuals.

Engagement With and Acceptability of Digital Media Platforms for Use in Improving Health Behaviors Among Vulnerable Families: Systematic Review.

BACKGROUND: The use of digital communication platforms to improve health behaviors has increased dramatically over the last decade. Public health practitioners have adopted digital communication technologies such as text messages, mobile apps, and social media to reach diverse populations. However, the effectiveness of digital communication platforms used by community-serving agencies remains unclear, and patterns of engagement and acceptability of different platforms have not been studied. OBJECTIVE: This review aimed to identify the types of digital communication strategies used by community-serving organizations to promote healthy behaviors, assess the strength of evidence for health behavioral change, and describe the degree of consumer engagement with and acceptability of these strategies. The study population included low-income pregnant women, parents of young children, and adolescents. METHODS: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed, Scopus, Web of Science, CINAHL, and APA PsycInfo, covering research conducted from 2009 to 2022. Studies were included if they examined the use of digital communication (ie, texting, mobile apps, or social media) to promote healthy behaviors in the target population. Risk of bias and strength of evidence were assessed using the Effective Public Health Practice Project Risk of Bias tool and criteria from Agency for Healthcare Research and Quality, respectively. RESULTS: Twenty-three peer-reviewed research studies published between 2012 and 2022, conducted in the United States, the United Kingdom, and Australia, were included in the review. The sample comprised studies exploring the use of texting (n=12), apps (n=6), social media (n=3), and multiple platforms (n=2; eg, texting and mobile apps). Targeted health behaviors included healthy diet, physical activity, obesity prevention, healthy pregnancy, breastfeeding, vaccine use, smoking cessation, and nutrition benefit redemption. The sample included 8 randomized controlled trials, 6 pretest-posttest design, 3 mixed methods studies, 2 pilot studies, 1 feasibility study, 1 prospective cohort study, 1 descriptive study, and 1 cross-sectional study. The median sample size was 77.5. There was no strong evidence to suggest the effectiveness of digital media campaigns in improving health behaviors; however, there were moderate to high levels of engagement and high levels of acceptability across digital platforms. CONCLUSIONS: Low-income pregnant women, parents of young children, and adolescents demonstrated moderate levels of engagement with and high levels of acceptability of digital media health campaigns conducted by community-serving agencies. The effectiveness of these strategies in improving health behaviors was inconclusive. Additional rigorous studies with larger sample sizes are required. In addition, more research is required to consistently measure and report participants' engagement with each platform. Digital communication platforms are critical tools for public health practitioners, and future investigations of the effectiveness of these platforms in engaging clients and improving health behaviors will maximize client services.

Breastfeeding Outcomes Associated With the Special Supplemental Nutrition Program for Women, Infants, and Children: A Systematic Review.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) promotes and supports breastfeeding for low-income women and children. A prior review reported negative associations of WIC with breastfeeding outcomes. WIC food package changes in 2009 increased breastfeeding support. OBJECTIVE: The objectives of this systematic review were to 1) evaluate evidence on WIC participation and breastfeeding outcomes and 2) evaluate breastfeeding outcomes of WIC participants before versus after the 2009 food package. DATA SOURCES: PubMed, Embase®, CINAHL, ERIC, SCOPUS, PsycINFO, and the Cochrane Central Register of Controlled Trials for papers published January 2009 to April 2022. ELIGIBILITY CRITERIA: Included studies compared breastfeeding outcomes (initiation, duration, exclusivity, early introduction of solid foods) of WIC participants with WIC-eligible nonparticipants, or among WIC participants before versus after the 2009 package change. STUDY APPRAISAL METHODS: Two independent reviewers evaluated each study and assessed risk of bias using EHPHP assessment. RESULTS: From 13 observational studies we found: 1) moderate strength of evidence (SOE) of no difference in initiation associated with WIC participation; 2) insufficient evidence regarding WIC participation and breastfeeding duration or exclusivity; 3) low SOE that the 2009 food package change is associated with greater breastfeeding exclusivity; 4) low SOE that WIC breastfeeding support services are positively associated with initiation and duration. LIMITATIONS: Only observational studies, with substantial risk of bias and heterogeneity in outcomes and exposures. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: WIC participation is not associated with a difference in breastfeeding initiation compared to WIC-eligible nonparticipants, but the 2009 food package change may have improved breastfeeding exclusivity among WIC participants and receipt of breastfeeding support services may have improved breastfeeding initiation and duration.

Promising trends and influencing factors of complementary feeding practices in Côte d'Ivoire: An analysis of nationally representative survey data between 1994 and 2016.

Poor complementary feeding (CF) challenges early childhood growth. We examined the trends and influencing factors of CF practices among children aged 6-23 months in Côte d'Ivoire. Using data from Demographic and Health Surveys (DHS, 1994-2011) and Multiple Indicator Cluster Surveys (MICS, 2000-2016), the trends and predictors of World Health Organization-United Nations International Children's Emergency Fund CF indicators including the timely introduction of complementary foods (INTRO), minimum meal frequency (MMF), minimum dietary diversity (MDD) and minimum acceptable diet (MAD) were determined. Using 2016 MICS data, we applied multivariate logistic regression models to identify factors associated with CF indicators. Between 1994 and 2016, the mean proportion of children aged 6-8 months achieving INTRO was 56.9% and increased by about 25% points since 2006. Over 2011-2016, the proportion of children aged 6-23 months meeting MMF, MDD and MAD increased from 40.2% to 47.7%, 11.3% to 26.0% and 4.6% to 12.5%, respectively. Older children and those from urban households had higher odds of meeting MDD and MAD. Maternal TV watching was associated with higher odds of meeting MDD. The secondary or higher education levels of mothers significantly predicted higher odds of meeting INTRO and MDD. Currently, breastfeeding was also positively associated with odds of meeting MMF and MAD. Children from poorer households had lower odds of meeting MMF, MDD and MAD. Despite the improvements, CF practices remain suboptimal in Côte d'Ivoire. Influencing factors associated with CF were distributed across individual, household and community levels, calling for future programmes and policies to implement multi-level strategies to improve young children's diet in Côte d'Ivoire.

Strategies to Improve Adolescent Food Security from the Perspectives of Policy Advocates, Parents, and Adolescents.

This study explored strategies to improve adolescent food security using semi-structured in-depth interviews with 9 policy advocates, 12 parents and 15 adolescents aged between 17 and 20 years, living in households who were eligible for the Supplemental Nutrition Assistance Program in 2020. This study was part of a larger evaluation of adolescent food insecurity conducted in Baltimore, Maryland, USA during the COVID-19 pandemic. Three key strategies arose during analysis-improving federal nutrition assistance programs for households, federal nutrition assistance programs for individual adolescents, and leveraging school programs and resources. Respondents described concordant views regarding the role of the Supplemental Nutrition Assistance Program in supporting households but held discordant views about the role of other federal programs, such as the school nutrition programs and Pandemic Electronic Benefit Transfer program. The results of this study provide important insights about policy and programmatic supports that may assist adolescents to acquire food for themselves and their families. Future research should test how federal programs and policies specifically impact food security and nutrition for adolescents.

Diet Quality and Contextual Factors Influencing Food Choice among Adolescents with Food Security and Food Insecurity in Baltimore City.

This study evaluated differences in overall diet quality, diet quality components, and food-related contextual factors between adolescents with food security and those with food insecurity. Mixed methods analysis was conducted on data from three 24-h dietary recalls from 61 adolescents ages 14-19 years old living in Baltimore, Maryland, USA in 2020-2021. All adolescents were sampled from households eligible for the Supplemental Nutrition Assistance Program in 2020. There were no significant differences in overall diet quality or components between adolescents with food security and those with food insecurity in this sample, except for seafood and plant proteins, which was higher for adolescents with food insecurity. Qualitative analysis found that adolescents were largely influenced by their parents and the home food environment, and that workplace environments enabled adolescents to eat foods high in refined grains, sugar, and saturated fat. These findings provide insight about the experiences of low-income adolescents during times when they are home for prolonged periods (i.e., emergency school closures, summer, and winter breaks). Programs and policies that aim to improve healthy food access may positively impact adolescent food security and diet quality, and it is important to ensure that healthy foods are available and accessible to adolescents in the places where they spend the most time. Multilevel interventions in the home, school, and workplace may be most effective in encouraging healthy eating behaviors among adolescents.

Maternal, Infant, and Child Health Outcomes Associated With the Special Supplemental Nutrition Program for Women, Infants, and Children : A Systematic Review.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is intended to improve maternal and child health outcomes. In 2009, the WIC food package changed to better align with national nutrition recommendations. PURPOSE: To determine whether WIC participation was associated with improved maternal, neonatal-birth, and infant-child health outcomes or differences in outcomes by subgroups and WIC enrollment duration. DATA SOURCES: Search (January 2009 to April 2022) included PubMed, Embase, CINAHL, ERIC, Scopus, PsycInfo, and the Cochrane Central Register of Controlled Trials. STUDY SELECTION: Included studies had a comparator of WIC-eligible nonparticipants or comparison before and after the 2009 food package change. DATA EXTRACTION: Paired team members independently screened articles for inclusion and evaluated risk of bias. DATA SYNTHESIS: We identified 20 observational studies. We found: moderate strength of evidence (SOE) that maternal WIC participation during pregnancy is likely associated with lower risk for preterm birth, low birthweight infants, and infant mortality; low SOE that maternal WIC participation may be associated with a lower likelihood of inadequate gestational weight gain, as well as increased well-child visits and childhood immunizations; and low SOE that child WIC participation may be associated with increased childhood immunizations. We found low SOE for differences in some outcomes by race and ethnicity but insufficient evidence for differences by WIC enrollment duration. We found insufficient evidence related to maternal morbidity and mortality outcomes. LIMITATION: Data are from observational studies with high potential for selection bias related to the choice to participate in WIC, and participation status was self-reported in most studies. CONCLUSION: Participation in WIC was likely associated with improved birth outcomes and lower infant mortality, and also may be associated with increased child preventive service receipt. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERO: CRD42020222452).

Evolution of infant feeding practices in children from 9 to 24 months, considering complementary feeding indicators and food processing: Results from the Brazilian cohort of the MAL-ED study.

Infant feeding practices impact children's nutritional and health status, influencing growth and development. This study aimed to analyse the evolution of infant feeding practices from 9 to 24 months of age, considering infant and young child feeding (IYCF) indicators and food processing. The infant feeding practices in children from the Brazilian site of the MAL-ED study were evaluated at 9 (n = 193), 15 (n = 182) and 24 months (n = 164) using 24-h dietary recalls. IYCF indicators were evaluated, and the extent of food processing was evaluated, using the NOVA classification. Breastfeeding declined significantly over time, from 77.6% at 9 months to 45.1% at 24 months. Although dietary diversity did not significantly change during the study period (80.5% at 24 months), the minimum acceptable diet significantly increased from 67.9% to 76.1% at 24 months (p < 0.0005). All the studied children consumed sweetened beverages from 9 months. Unhealthy food consumption and zero vegetable or fruit consumption significantly increased over time (p < 0.0005). Unprocessed food consumption decreased from 9 to 24 months of age (p < 0.0005), while ultra-processed food consumption increased (p < 0.0005) during the study period. Logistic regressions showed that, at 9 months, breastfed children presented a lower risk for ultra-processed food consumption (odds ratio [OR] = 0.31; 95% confidence interval [CI] = 0.13-0.77); and children reaching the minimum acceptable diet presented more risk for ultra-processed food consumption (OR = 2.31; 95% CI = 1.01-5.27). In conclusion, data showed a reduction in the quality of infant feeding practices over the first 2 years of life, with a decrease in breastfeeding and an increase in the consumption of unhealthy and ultra-processed foods.

Baby Friendly Hospital Designation and Breastfeeding Outcomes Among Maryland WIC Participants.

OBJECTIVES: The Baby-Friendly Hospital Initiative is an effective intervention to support maternal practices around breastfeeding. However, little is known about its impact on participants of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). The purpose of this study was to evaluate whether Baby Friendly Hospital (BFH) designation in Maryland improved breastfeeding practices among Special Supplemental Nutrition Program for Women, Infants and Children (WIC) participants. METHODS: Breastfeeding practices of WIC participants (22,543 mother-infant dyads) were analyzed utilizing WIC management information system de-identified data from four Maryland WIC agencies during 2010-12 and 2017-19. Participants lived in areas served by a hospital that became BFH in 2016 or remained non-BFH. Pre-post implementation breastfeeding practices (breastfeeding initiation, at 3 months and 6 months) of women associated with a BFH were compared to women associated with a non-BFH using propensity score weighting and a difference-in-difference modeling. RESULTS: From pre to post intervention no differences in breastfeeding initiation or any breastfeeding at 6 months were attributable to BFH status. There was some evidence that BFH designation in 2016 was associated with an absolute percent change of 2.4% (P = 0.09) for any breastfeeding at 3 months. DISCUSSION: Few differences in breastfeeding outcomes among WIC participants were attributable to delivery in a BFH. Results from this study inform policy about maternity practices impacting WIC breastfeeding outcomes. More study needed to determine the impact of BFH delivery on differences in breastfeeding outcomes between sub-groups of women.

Exposure to Baby-Friendly Hospital Practices and Breastfeeding Outcomes of WIC Participants in Maryland.

BACKGROUND: The Baby-Friendly Hospital Initiative is an effective intervention to support maternal practices around breastfeeding. However, adherence of hospitals to the Baby-Friendly 10 Steps, as determined from the perspective of women participating in the United States Special Supplemental Nutrition Program for Women, Infants, and Children, has not been assessed. RESEARCH AIMS: (1) To compare maternal perceptions about maternity practices in Baby-Friendly Hospitals and non-Baby-Friendly Hospitals; (2) to evaluate the associations between degree of exposure to the Baby-Friendly 10 Steps and breastfeeding practices through the first 6 months; and (3) to evaluate whether the receipt of specific Steps was associated with breastfeeding practices through 6 months. METHODS: This study was a cross-sectional 2 group comparison, using prospective data collected through a self-report telephone survey and retrospective data gathered from participants' records. Women (N = 182) participating in four Maryland Special Supplemental Nutrition Program for Women, Infants and Children agencies were recruited. One hundred and eight (59%) participants delivered at designated Baby-Friendly Hospitals; 74 (41%) delivered in non-Baby-Friendly designated hospitals. Logistic regression models were utilized to determine the influence of perceived Step adherence on exclusive breastfeeding. RESULTS: Reported adherence to 10-Steps policies ranged from 10%-85% (lowest for Step 9, highest for Step 10) and only Step 9 (give no pacifiers or artificial nipples to breastfeeding infants) differed according to Baby-Friendly Hospital status. Greater exposure to the 10 Steps was positively associated with exclusive breastfeeding during hospitalization. The lack of perceived adherence to Step 6 (no food or drink other than human milk), Step 9, and the International Code of Marketing of Breast-milk Substitutes (no formula, bottles, or artificial nipples) significantly decreased the likelihood of exclusive breastfeeding through 6 months. CONCLUSION: Maternal perception of Baby-Friendly Step adherence was associated with exclusive breastfeeding.

Diet quality scores associated with improved cardiometabolic measures among African American adolescents.

BACKGROUND: The Reversing the Negative cardiovascular Effects on Weight (ReNEW) Clinic is a prospective cohort study in children and adolescents (≤21 years) at the Johns Hopkins Children's Center. METHODS: Cross-sectional analysis between diet quality using the Alternative Healthy Eating Index (AHEI-2010), pro-inflammatory potential using the Children's Dietary Inflammatory Index (C-DII), and cardiometabolic outcomes. AHEI-2010 and C-DII scores were assessed by median intake determined from the sample distribution and associated with cardiometabolic measures using linear regression models. Changes in measures were evaluated in a sub-sample of participants invited to attend follow-up visits due to the presence of hypertensive blood pressure (n = 33). RESULTS: Participants (n = 90) reported an average energy intake of 1790 kcal/day (SD ± 734), AHEI-2010 score of 55.04 (SD ± 9.86) (range: 0 to 110) and C-DII score of -0.12 (±0.86) (range -5 to 5). Participants with higher quality/anti-inflammatory diets trended towards more favorable cardiometabolic measures at baseline. Among the sub-sample (n = 33), there was a significant reduction in total energy (m = -302 kcal/day; p-value= 0.03) but no change in AHEI-2010 (p-value = 0.73) or C-DII score (p-value = 0.85) over follow-up. CONCLUSIONS: Despite stable diet quality scores, outpatient dietary and behavioral counseling may be an effective tool to reduce energy intake in youth with overweight/obesity and elevated blood pressure. IMPACT: Diet quality scores among obese, hypertensive, African American adolescents were low and reflect a pro-inflammatory diet. Reported intake was negligible for fruits, whole grains, nuts, and legumes, and well above the daily limit for sodium and saturated fat. Participants with high quality/anti-inflammatory diet quality scores trended toward improved cardiometabolic measures. Outpatient dietary counseling resulted in reduced total energy intake.

Full breastfeeding protection against common enteric bacteria and viruses: results from the MAL-ED cohort study.

BACKGROUND: Breastfeeding is known to reduce the risk of enteropathogen infections, but protection from specific enteropathogens is not well characterized. OBJECTIVE: The aim was to estimate the association between full breastfeeding (days fed breast milk exclusively or with nonnutritive liquids) and enteropathogen detection. METHODS: A total of 2145 newborns were enrolled at 8 sites, of whom 1712 had breastfeeding and key enteropathogen data through 6 mo. We focused on 11 enteropathogens: adenovirus 40/41, norovirus, sapovirus, astrovirus, and rotavirus, enterotoxigenic Escherichia coli (ETEC), Campylobacter spp., and typical enteropathogenic E. coli as well as entero-aggregative E. coli, Shigella and Cryptosporidium. Logistic regression was used to estimate the risk of enteropathogen detection in stools and survival analysis was used to estimate the timing of first detection of an enteropathogen. RESULTS: Infants with 10% more days of full breastfeeding within the preceding 30 d of a stool sample were less likely to have the 3 E. coli and Campylobacter spp. detected in their stool (mean odds: 0.92-0.99) but equally likely (0.99-1.02) to have the viral pathogens detected in their stool. A 10% longer period of full breastfeeding from birth was associated with later first detection of the 3 E. coli, Campylobacter, adenovirus, astrovirus, and rotavirus (mean HRs of 0.52-0.75). The hazards declined and point estimates were not statistically significant at 3 mo. CONCLUSIONS: In this large multicenter cohort study, full breastfeeding was associated with lower likelihood of detecting 4 important enteric pathogens in the first 6 mo of life. These results also show that full breastfeeding is related to delays in the first detection of some bacterial and viral pathogens in the stool. As several of these pathogens are risk factors for poor growth during childhood, this work underscores the importance of exclusive or full breastfeeding during the first 6 mo of life to optimize early health.

A multi-level, multi-component obesity intervention (Obesity Prevention and Evaluation of InterVention Effectiveness in NaTive North Americans) decreases soda intake in Native American adults.

OBJECTIVE: To evaluate the impact of a multi-level, multi-component (MLMC) adult obesity intervention on beverage intake in Native American adults living in five geographically and culturally diverse tribal communities. DESIGN: A 14-month, community-randomised, MLMC design was utilised, with three communities randomised to Intervention and two communities randomised to Comparison. FFQ were administered pre- and post-interventions, and difference-in-differences (DiD) analysis was used to assess intervention impact on beverage intake. SETTING: The intervention took place within food stores, worksites, schools and selected media outlets located in the five communities. Key activities included working with store owners to stock healthy beverages, display and dispersal of educational materials, support of policies that discouraged unhealthy beverage consumption at worksites and schools and taste tests. PARTICIPANTS: Data were collected from 422 respondents between the ages of 18 and 75 living in the five communities pre-intervention; of those, 299 completed post-intervention surveys. Only respondents completing both pre- and post-intervention surveys were included in the current analysis. RESULTS: The DiD for daily servings of regular, sugar-sweetened soda from pre- to post-intervention was significant, indicating a significant decrease in Intervention communities (P < 0·05). No other changes to beverage intake were observed. CONCLUSIONS: Large, MLMC obesity interventions can successfully reduce the intake of regular, sugar-sweetened soda in Native American adults. This is important within modern food environments where sugar-sweetened beverages are a primary source of added sugars in Native American diets.

Influences on catch-up growth using relative versus absolute metrics: evidence from the MAL-ED cohort study.

BACKGROUND: Poor growth in early childhood has been considered irreversible after 2-3 years of age and has been associated with morbidity and mortality over the short-term and with poor economic and cognitive outcomes over the long-term. The MAL-ED cohort study was performed in eight low-income settings with the goal of evaluating relationships between the child's environment and experience (dietary, illness, and pathogen exposure, among others) and their growth and development. The goal of this analysis is to determine whether there are differences in the factors associated with growth from 24 to 60 months using two different metrics. METHODS: Across six MAL-ED sites, 942 children had anthropometry data at 24 and 60 months, as well as information about socioeconomic status, maternal height, gut permeability (lactulose-mannitol z-score (LMZ)), dietary intake from 9 to 24 months, and micronutrient status. Anthropometric changes were in height- or weight-for-age z-score (HAZ, WAZ), their absolute difference from the growth standard median (HAD (cm), WAD (kg)), as well as recovery from stunting/underweight. Outcomes were modeled using multivariate regression. RESULTS: At 24 months, almost half of the cohort was stunted (45%) and 21% were underweight. Among those who were stunted at 24 months (n = 426), 185 (43%) were no longer stunted at 60 months. Most children increased their HAZ from 24 to 60 months (81%), whereas fewer (33%) had positive changes in their HAD. Linear regression models indicate that girls improved less than boys from 24 to 60 months (HAZ: -0.21 (95% CI -0.27, -0.15); HAD: -0.75 (-1.07, -0.43)). Greater intestinal permeability (higher LMZ) at 0-24 months was associated with lower relative and absolute changes from 24 to 60 months (HAZ: -0.10 (-0.16, -0.04); HAD: -0.47 (-0.73, -0.21)). Maternal height (per 10 cm) was positively associated with changes (HAZ: 0.09 (0.03, 0.15); HAD: 0.45 (0.15, 0.75)). Similar relationships were identified for changes in WAZ and WAD. CONCLUSIONS: The study children demonstrated improved growth from 24 to 60 months of age, but only a subset had positive changes in HAD and WAD. The same environmental factors were associated with growth from 24 to 60 months regardless of metric used (change in HAZ or HAD, or WAZ and WAD).

Mediterranean-Style Diet and Birth Outcomes in an Urban, Multiethnic, and Low-Income US Population.

Findings on the role of Mediterranean-style diet (MSD) on duration of pregnancy and birth weight have been inconsistent and based largely on Non-Hispanic white populations, making it unclear as to whether they could extend to African Americans who are at a higher risk of unfavorable birth outcomes. Our study addresses this gap using a large urban, multiethnic, predominantly low-income cohort of mother-infant dyads from Boston, MA, USA. Dietary information was obtained via food frequency questionnaires; health information including birth outcomes were extracted from medical records. A Mediterranean-style diet score (MSDS) was formulated based on intake history, and linear and log-binomial regressions were performed to assess its association with birth outcomes. After adjustment, the lowest MSDS quintile from the overall sample was found to be associated with an increased relative risk (RR) of overall preterm birth (RR 1.18; 95% CI: 1.06-1.31), spontaneous preterm birth (1.28; 1.11-1.49), late preterm birth (1.21; 1.05-1.39), and low birth weight (1.11; 1.01-1.22), compared to the highest quintile. The findings were similar for the African American sample. Our study adds to the current understanding of the diet's influence on birth outcomes by demonstrating that adherence to MSD may improve birth outcomes for African American women.