A Comparative Analysis of Maternal Nutrition Decision-Making Autonomy During Pregnancy-An Application of the Food Choice Process Model in Burkina Faso and Madagascar.

BACKGROUND: Adequate nutrition has been cited as one of the most critical components for optimal health outcomes during pregnancy. Women in Burkina Faso and Madagascar experience high rates of undernutrition due to lack of knowledge, finances, cultural norms, and autonomy. Therefore, this study aimed (1) to describe typical maternal diets during pregnancy in Burkina Faso and Madagascar, (2) to understand the multilevel factors that influence women's nutrition decision-making, and (3) to explore the extent to which women have nutrition decision-making autonomy during pregnancy. METHODS: This study was conducted between October 2020 and February 2021 in Burkina Faso and Madagascar. Semi-structured interviews, focus group interviews, and free lists were conducted among women of reproductive age and pregnant and lactating women. Textual data from interviews were recorded and translated verbatim from local languages into French. The Food Choice Process Model guided textual content analysis using Dedoose software. Free list data were analyzed using cultural domain analysis approaches. RESULTS: In Burkina Faso and Madagascar, women primarily consumed staple foods such as rice and tô during pregnancy. Participants cited eating fruits and vegetables when available, while the animal source foods were rarely consumed. Across both contexts, nutrition during pregnancy was influenced by factors that impact food choices, such as social factors, resources, ideals, and personal factors. While women and men in Madagascar had more shared decision-making on critical domains such as finances, men were the primary decision-makers in most areas of inquiry (eg, finances) in Burkina Faso. CONCLUSIONS: The lack of adequate diverse diet consumed during pregnancy is primarily due to important factors including social factors and resources. Understanding the ability for women to consume optimal diets during pregnancy is needed to target behavioral change in maternal nutrition programming.

Plain language titleA comparison of How Pregnant Women Make Decisions About What to Eat in Burkina Faso and Madagascar Using a Model Called the Food Choice Process ModelPlain language summaryHaving a proper diet is very important for the health of pregnant women. In Burkina Faso and Madagascar, many women do not get enough nutritious food due to lack of knowledge on what to eat, lack of money, cultural traditions, and not having control over their own choices. This study wants to find out (1) what women eat during pregnancy in Burkina Faso and Madagascar, (2) what influences the decisions women make about what to eat during pregnancy, and (3) explore how women had decision-making autonomy during pregnancy. The study took place in Burkina Faso and Madagascar. The researchers talked to women who could have babies and women who were already pregnant or breastfeeding. They used different methods like focus group discussions and semi-structured interviews to gather information. They recorded and translated everything that was said from the local languages to French. They used special software to analyze the information from the interviews. They also used a free list to understand the things women mentioned most often when talking about food. In Burkina Faso and Madagascar, women mostly ate basic foods like rice and tô during pregnancy. Sometimes they ate fruits and vegetables when they were available, but they did not eat much meat or other foods from animals. In both places, the women's food choices during pregnancy were influenced by different things like what their friends and family thought, how much money they had, their personal preferences, and other factors. In Madagascar, men and women made decisions together about important things like money, but in Burkina Faso, men were usually the ones making the decisions. The lack of a proper diverse diet during pregnancy in Burkina Faso and Madagascar is primarily caused by social factors and resources. To help women make better food choices during pregnancy, it's important to understand what affects their ability to have a healthy diet. This can help programs that aim to improve the nutrition of pregnant women by encouraging them to change their behavior.

Precision Nutrition Opportunities to Help Mitigate Nutrition and Health Challenges in Low- and Middle-Income Countries: An Expert Opinion Survey.

Precision nutrition involves several data collection methods and tools that aim to better inform nutritional recommendations and improve dietary intake, nutritional status, and health outcomes. While the benefits of collecting precise data and designing well-informed interventions are vast, it is presently unclear whether precision nutrition is a relevant approach for tackling nutrition challenges facing populations in low- and middle-income countries (LMIC), considering infrastructure, affordability, and accessibility of approaches. The Swiss Food & Nutrition Valley (SFNV) Precision Nutrition for LMIC project working group assessed the relevance of precision nutrition for LMIC by first conducting an expert opinion survey and then hosting a workshop with nutrition leaders who live or work in LMIC. The experts were interviewed to discuss four topics: nutritional problems, current solutions, precision nutrition, and collaboration. Furthermore, the SFNV Precision Nutrition for LMIC Virtual Workshop gathered a wider group of nutrition leaders to further discuss precision nutrition relevance and opportunities. Our study revealed that precision public health nutrition, which has a clear focus on the stratification of at-risk groups, may offer relevant support for nutrition and health issues in LMIC. However, funding, affordability, resources, awareness, training, suitable tools, and safety are essential prerequisites for implementation and to equitably address nutrition challenges in low-resource communities.

Innovative Research for Nutrition- and Climate-Smart Food Systems in Low- and Middle-Income Countries.

The world is off-track to end world hunger, food insecurity, and malnutrition in all its forms by 2030 [...].

Knowledge, Attitudes and Practices of Pregnant Women and Healthcare Providers in Bangladesh regarding Multivitamin Supplements during Pregnancy.

Micronutrient deficiencies are widespread among pregnant women in low- and middle-income countries (LMIC) and lead to potentially adverse effects for mother and baby. In Bangladesh, maternal malnutrition remains a severe problem, with high rates of anemia (49.6% of pregnant women and 47.8% of lactating women are anemic) and other nutritional deficiencies. A Knowledge, Attitudes, and Practices (KAP) study was conducted to assess Bangladeshi pregnant women's perceptions and related behaviors, as well as awareness and knowledge among pharmacists and healthcare professionals concerning prenatal multivitamin supplements. This was done in both rural and urban areas across Bangladesh. A total of 732 quantitative interviews were conducted (330 with providers and 402 with pregnant women, with an equal split between urban and rural areas for both sets of audiences; 200 women were users of prenatal multivitamin supplements, while 202 women were aware non-users). The study identified a few findings that can guide further research or market-based interventions to reduce micronutrient deficiencies. These include most pregnant women not knowing the right time to start multivitamin supplements (56.0%, [n = 225], stating that a woman should start taking supplements 'after the first trimester'), not knowing their benefits, and how they help both the mother and baby-only 29.5% [n = 59] stated that they believed the supplements helped their baby to grow well). Further, barriers to taking the supplements include women believing a nutritious diet is a substitute (88.7% [n = 293]), and a perceived lack of support from other family members (21.8%, [n = 72]). This suggests that there is a need for further awareness-raising among all pregnant women, their family members, and providers.

Nutrition in City Ecosystems (NICE): Protocol of a multi-sectoral development project to improve food and nutrition security of secondary city populations in Bangladesh, Kenya and Rwanda.

Background: Secondary cities tend to be better linked with local food systems than primate cities, acting as important platforms to trade agricultural produce with rural surrounding. COVID-19, conflicts and climate change continue to expose inefficiencies in food systems and have further exacerbated malnutrition, calling for substantial food systems transformations. However, tackling current food systems' challenges requires new approaches to ensure food and nutrition security. Nutritious and agroecologically produced food offer the potential to transform food systems by improving diets and alleviating pressure on the environment, as well as by creating jobs and reducing poverty. This paper describes the design of a project by a Swiss public-private consortium to improve food and nutrition security and to reduce poverty in city ecosystems in six secondary cities in Bangladesh, Kenya and Rwanda through governance/policy and supply and demand side interventions. Methods: The Nutrition in City Ecosystems (NICE) project promotes well-balanced nutrition for city populations through interdisciplinary agricultural, food, and health sector collaborations along city-specific value chains. Adopting a transdiciplinary systems approach, the main interventions of NICE are (i) advocacy and policy dialogue, (ii) building of decentralized institutional capacity in multi-sectoral collaborations, (iii) support of data-driven planning, coordination and resource mobilization, (iv) anchoring of innovations and new approaches in city-level partnerships, (v) capacity building in the agricultural, retail, health and education sectors, as well as (vi) evidence generation from putting policies into practice at the local level. NICE is coordinated by in-country partners and local offices of the Swiss public-private consortium partners. Discussion: The NICE project seeks to contribute to urban food system resilience and enhanced sustainable nutrition for city populations by (A) strengthening urban governance structures involving key stakeholders including women and youth, (B) generating income for producers along the supply chain, (C) triggering change in producers' and consumers' behavior such that nutritious and agroecologically produced foods are both in demand as well as available and affordable in urban markets, and (D) allowing a scale up of successful approaches to other national and international cities and city networks.

Evaluation of spray-dried eggs as a micronutrient-rich nutritional supplement.

Regular consumption of hen eggs can help to prevent deficiencies of essential nutrients, such as essential amino acids, vitamin A and E or trace elements zinc and selenium, for vulnerable populations. This study focused on assessing the nutritional value of spray-dried eggs, favored by their manufacturability, storability and ease of addition to (complementary) foods. Using a wide range of analytical techniques, we recorded and compared the nutrient profiles of commercially produced pasteurized whole eggs and their respective powder samples spray-dried at 160°C. Important nutrients that were not significantly affected by spray-drying include total fat content, several amino acids, α- and δ-tocopherol, lutein, zeaxanthin, essential trace elements and cobalamin. The most notable mean losses were found for unsaturated fatty acids, e.g., linoleic (by -38.7%, from 4.11 ± 0.45 to 2.52 ± 0.75 g/100 g DM) and linolenic acid (by -60.8%, from 0.76 ± 0.05 to 0.30 ± 0.04 g/100 g DM). Despite recording significant retinol losses in two out of three batches, the overall low reduction of -14% recommend spray-dried eggs as a valuable source of vitamin A. A daily intake of spray-dried egg powder corresponding to one medium sized egg meets dietary reference values for children, e.g., by 100% for vitamin E, by 24% for retinol, by 61% for selenium and by 22% for zinc. In conclusion, even though a dry weight comparison favors supplementation with pasteurized whole eggs, our results demonstrate a high potential for spray-dried eggs as nutritional supplement. However, the spray-drying process should be optimized toward higher retentions of unsaturated fatty acids and retinol.

Small and Medium Enterprises' Perspectives on Food Fortification Amid the Growing Burden of Malnutrition.

The need for a profound food system transformation has never been greater. The growing burden of malnutrition has become the new normal, with two billion people who are overweight, over 140 million children under five who are stunted and over two billion people affected by hidden hunger. Food fortification has been recognized as a cost-effective strategy to address micronutrient deficiencies. Small and medium enterprises (SMEs) play a strategic role in the food supply chain in low- and middle-income countries, accounting for over 80% of food sales. It is therefore critical to create an enabling environment to facilitate SMEs' involvement in food fortification practices as a potential solution to tackle all forms of malnutrition. This review highlights SMEs' relevance as agents of change in the food system through food fortification practices and their indirect yet key role in producing nutritious, tasty and affordable foods. It discusses their challenges (e.g., access to long-term finance, sustainable technical assistance, limited capacity), presents solutions and discusses how different actors can help SMEs to overcome these challenges. Furthermore, it presents a relevant public-private partnership case study to demonstrate how SMEs can address the growing burden of malnutrition through food fortification practices, nutrient profiling schemes and demand generation.

Principles for Evidence-Based and Sustainable Food System Innovations for Healthier Diets.

Climate change, rapid urbanization, war, and economic recession are key drivers of the current food systems' disruption, which has been exacerbated by the COVID pandemic. Local, regional, and global food systems are unable to provide consumers with nutritious and affordable diets. Suboptimal diets exacerbate the triple burden of malnutrition, with micronutrient deficiencies affecting more than two billion people, two billion people suffering from overweight, and more than 140 million children who are stunted. The unaffordability of nutritious diets represents an obstacle for many, especially in low- and middle-income countries where healthy diets are five times more expensive than starchy staple diets. Food system transformations are urgently required to provide consumers with more affordable and nutritious diets that are capable of meeting social and environmental challenges. In this review, we underline the critical role of innovation within the food system transformation discourse. We aim to define principles for implementing evidence-based and long-term food system innovations that are economically, socially, and environmentally sustainable and, above all, aimed at improving diets and public health. We begin by defining and describing the role of innovation in the transformation of food systems and uncover the major barriers to implementing these innovations. Lastly, we explore case studies that demonstrate successful innovations for healthier diets.

Effect of multiple micronutrient supplements vs iron and folic acid supplements on neonatal mortality: a reanalysis by iron dose.

OBJECTIVE: Antenatal multiple micronutrient supplements (MMS) are a cost-effective intervention to reduce adverse pregnancy and birth outcomes. However, the current WHO recommendation on the use of antenatal MMS is conditional, partly due to concerns about the effect on neonatal mortality in a subgroup of studies comparing MMS with iron and folic acid supplements (IFA) containing 60 mg of iron. We aimed to assess the effect of MMS vs IFA on neonatal mortality stratified by iron dose in each supplement. METHODS: We updated the neonatal mortality analysis of the 2020 WHO guidelines using the generic inverse variance method and applied the random effects model to calculate the effect estimates of MMS vs. IFA on neonatal mortality in subgroups of trials (n=13) providing the same or different amounts of iron, i.e. MMS with 60 mg of iron vs IFA with 60 mg of iron; MMS with 30 mg of iron vs IFA with 30 mg of iron; MMS with 30 mg of iron vs IFA with 60 mg of iron; and MMS with 20 mg of iron vs IFA with 60 mg of iron. RESULTS: There were no statistically significant differences in neonatal mortality between MMS and IFA within any of the subgroups of trials. Analysis of MMS with 30 mg vs IFA with 60 mg of iron (7 trials, 14,114 participants), yielded a nonsignificant Risk Ratio (RR) of 1.12 (95% CI 0.83 to 1.50). CONCLUSION: Neonatal mortality did not differ between MMS and IFA regardless of iron dose in either supplement.

Interventions to improve calcium intake through foods in populations with low intake.

Calcium intake remains inadequate in many low- and middle-income countries, especially in Africa and South Asia, where average intakes can be below 400 mg/day. Given the vital role of calcium in bone health, metabolism, and cell signaling, countries with low calcium intake may want to consider food-based approaches to improve calcium consumption and bioavailability within their population. This is especially true for those with low calcium intake who would benefit the most, including pregnant women (by reducing the risk of preeclampsia) and children (by reducing calcium-deficiency rickets). Specifically, some animal-source foods that are naturally high in bioavailable calcium and plant foods that can contribute to calcium intake could be promoted either through policies or educational materials. Some food processing techniques can improve the calcium content in food or increase calcium bioavailability. Staple-food fortification with calcium can also be a cost-effective method to increase intake with minimal behavior change required. Lastly, biofortification is currently being investigated to improve calcium content, either through genetic screening and breeding of high-calcium varieties or through the application of calcium-rich fertilizers. These mechanisms can be used alone or in combination based on the local context to improve calcium intake within a population.

Multiple micronutrient supplements versus iron-folic acid supplements and maternal anemia outcomes: an iron dose analysis.

Antenatal multiple micronutrient supplements (MMS) are more effective than iron and folic acid (IFA) supplements in reducing adverse pregnancy outcomes. Questions remain, however, about the ability of MMS to prevent anemia as effectively as IFA, especially at a lower dose of daily iron and in areas of high anemia prevalence. Analyzing data from 11 trials from a recent Cochrane review, we compared MMS to IFA, delivering either 30 or 60 mg of iron, in sustaining hemoglobin and preventing third trimester anemia and iron deficiency anemia (IDA), accounting for daily iron dose, total supplemental iron intake, and baseline prevalence of anemia. There were no differences between MMS and IFA in third trimester hemoglobin concentration or risks of anemia or IDA by iron dose or total supplemental iron consumed. MMS providing 30 mg of iron was comparable to IFA with 60 mg of iron: mean hemoglobin difference of -0.26 g/L (95% CI: -1.41 to 0.89), risk ratios of 0.99 (95% CI: 0.92-1.07) for anemia, and 1.31 (95% CI: 0.66-2.60) for IDA. Baseline prevalence of anemia did not explain heterogeneity in findings. Compared to IFA, MMS results in comparable hemoglobin concentration and protection against anemia during pregnancy, independently of iron dose.

The Potential Impact of Climate Change on the Micronutrient-Rich Food Supply.

Micronutrient deficiencies are a major cause of morbidity and mortality in low- and middle-income countries worldwide. Climate change, characterized by increasing global surface temperatures and alterations in rainfall, has the capacity to affect the quality and accessibility of micronutrient-rich foods. The goals of this review are to summarize the potential effects of climate change and its consequences on agricultural yield and micronutrient quality, primarily zinc, iron, and vitamin A, of plant foods and upon the availability of animal foods, to discuss the implications for micronutrient deficiencies in the future, and to present possible mitigation and adaptive strategies. In general, the combination of increasing atmospheric carbon dioxide and rising temperature is predicted to reduce the overall yield of major staple crops, fruits, vegetables, and nuts, more than altering their micronutrient content. Crop yield is also reduced by elevated ground-level ozone and increased extreme weather events. Pollinator loss is expected to reduce the yield of many pollinator-dependent crops such as fruits, vegetables, and nuts. Sea-level rise resulting from melting of ice sheets and glaciers is predicted to result in coastal inundation, salt intrusion, and loss of coral reefs and mangrove forests, with an adverse impact upon coastal rice production and coastal fisheries. Global ocean fisheries catch is predicted to decline because of ocean warming and declining oxygen. Freshwater warming is also expected to alter ecosystems and reduce inland fisheries catch. In addition to limiting greenhouse gas production, adaptive strategies include postharvest fortification of foods; micronutrient supplementation; biofortification of staple crops with zinc and iron; plant breeding or genetic approaches to increase zinc, iron, and provitamin A carotenoid content of plant foods; and developing staple crops that are tolerant of abiotic stressors such as elevated carbon dioxide, elevated temperature, and increased soil salinity.

Nutrition as a driver and outcome of agroecology.

The principles of agroecology do not explicitly state a link with nutrition. Yet, we argue that among them, input reduction, biodiversity, economic diversification, social values and diets, fairness, connectivity and participation are directly linked to nutrition. Nutrition can serve as a critical outcome and driver of agroecological practices and can drive transformative change across the food system.

The Future of Moringa Foods: A Food Chemistry Perspective.

The tree Moringa oleifera Lam. provides its leaves, pods, flowers and seeds for human nutrition. The chemical profile of all these Moringa products varies substantially, not only among the different parts of the plants used. Cultivating, processing as well as storage conditions chiefly determine the contents of nutrients and anti-nutritive constituents. Anti-nutrients, e.g., phytic acid or tannins, are present in notable amounts and may affect micronutrient bioavailability. Although Moringa oleifera products have been promoted for several health benefits and are discussed as an alternative treatment in various diseases, risk assessment studies evaluating contamination levels are scarce. Recent investigations have demonstrated alarming contents of heavy metals, polycyclic aromatic hydrocarbons and mycotoxins in Moringa oleifera products, indicating the need for a comprehensive risk assessment and contingent legal regulation of these products. In this mini review, we briefly outline pivotal, food chemistry and nutrition related data on Moringa preparations in order to stimulate in-depth research to close the presented knowledge gaps.

Nutrient Density as a Dimension of Dietary Quality: Findings of the Nutrient Density Approach in a Multi-Center Evaluation.

The nutrient adequacy of a diet is typically assessed by comparing estimated nutrient intakes with established average nutrient requirements; this approach does not consider total energy consumed. In this multinational survey investigation in Indonesia, Mexico, and South Africa, we explore the applications of the "critical nutrient-density approach"-which brings energy requirements into the equation-in the context of public health epidemiology. We conducted 24 h dietary recalls in convenience samples of normal-weight (BMI 18.5-25 kg/m2) or obese (BMI > 30 kg/m2), low-income women in three settings (n = 290). Dietary adequacy was assessed both in absolute terms and using the nutrient density approach. No significant differences in energy and nutrient intakes were observed between normal-weight and obese women within any of the three samples (p > 0.05). Both the cut-point method (% of EAR) and critical nutrient density approach revealed a high probability of inadequate intakes for several micronutrients but with poor concordance between the two methods. We conclude that it may often require some approximate estimate of the habitual energy intake from an empirical source to apply a true critical nutrient density reference for a population or subgroup. This will logically signify that there would be more "problem nutrients" in the diets examined with this nutrient density approach, and efforts toward improved food selection or food- or biofortification will frequently be indicated.

The Triple Burden of Malnutrition Among Adolescents in Indonesia.

BACKGROUND: Indonesia is a prime example of the triple burden of malnutrition. Indonesian adolescents are among the hardest hit, with approximately one in four adolescent girls suffering from anemia, while nearly one in seven adolescents is overweight or obese. OBJECTIVES: The present editorial provides a snapshot of the various research papers included in this Supplement, which calls for increased attention to adolescent nutrition in Indonesia and beyond. RESULTS: Despite major steps to reduce undernutrition and overweight, including a renewed focus on anemia among adolescent girls, major gaps remain in our understanding of various nutrition issues concerning adolescents. These include various drivers and determinants of the triple burden of malnutrition, evidence-based interventions that are supported by large-scale implementation research and evaluation, and effective delivery platforms to reach the most vulnerable groups of adolescents. CONCLUSION: The time has come to position adolescent nutrition as central to development, and mainstream it into health sector plans, strategies, and policies. It is our hope that this issue will stimulate the urgently needed interventions, implementation research and required programs that will safeguard the nutritional wellbeing of today's forgotten generation.

Knowledge Gaps in Understanding the Etiology of Anemia in Indonesian Adolescents.

BACKGROUND: Anemia is a public health problem among adolescents in Indonesia. Strategies to prevent or treat anemia should be tailored to local conditions, taking into account its specific etiology and prevalence in a given setting and population group. OBJECTIVE: This review aims to (1) identify and synthesize the current knowledge on the etiology of anemia among adolescents in Indonesia, (2) reveal knowledge gaps in this area, and (3) suggest directions for future research and programmatic work. METHODS: We systematically searched PubMed, Web of Science, Scopus, Medline, and WorldCat databases for peer-reviewed journal articles to identify which etiological factors were related to anemia among Indonesian adolescents. Research papers were reviewed and included in the review according to inclusion criteria. RESULTS: Of 13 studies, 8 showed that anemia was associated with iron deficiency; 4 are suggestive of vitamin A deficiency; and 2 of folic acid deficiency. Five studies underscore different etiological determinants for anemia, such as malaria, protein and energy malnutrition, vitamin B2 deficiency, calcium, and vitamin C deficiency. Based on these findings, we developed a framework on knowledge gaps on the etiology of anemia among adolescents in Indonesia, divided in 3 levels of knowledge: (1) significant knowledge gaps, (2) knowledge gaps, and (3) established knowledge. CONCLUSIONS: The knowledge gaps around the etiology of anemia among Indonesian adolescents are significant. Our framework emphasizes the need for further research across all etiological factors, namely inadequate nutritional intake and absorption, genetic hemoglobin disorders, infection and inflammation, and menstrual disorders.

Food Fortification: The Advantages, Disadvantages and Lessons from Sight and Life Programs.

Deficiencies in one or more micronutrients such as iron, zinc, and vitamin A are widespread in low- and middle-income countries and compromise the physical and cognitive capacity of millions of people. Food fortification is a cost-effective strategy with demonstrated health, economic and social benefits. Despite ongoing debates globally and in some countries regarding the performance and safety of food fortification, the practice offers significant benefits across each of the main vehicles for food fortification (large-scale food fortification, biofortification and point-of-use or home fortification) ranging from reducing the prevalence of nutritional deficiencies and economic benefits to societies and economies. Using Sight and Life's global and national experiences in implementing food fortification efforts, we demonstrate how different programs in LMICs have successfully addressed challenges with food fortification and in doing so, find that these efforts are most successful when partnerships are formed that include the public and private sector as well as other parties that can provide support in key areas such as advocacy, management, capacity building, implementation and regulatory monitoring.