Breastfeeding media coverage and beliefs during the COVID-19 pandemic in Mexico: implications for breastfeeding equity.

BACKGROUND: Because breastfeeding offers short- and long- term health benefits to mothers and children, breastfeeding promotion and support is a public health priority. Evidence shows that SARS-CoV-2 is not likely to be transmitted via breastmilk. Moreover, antibodies against SARS-CoV-2 are thought to be contained in breastmilk of mothers with history of COVID-19 infection or vaccination. WHO recommends direct breastfeeding as the preferred infant feeding option during the COVID-19 pandemic, even among women with COVID-19; but conflicting practices have been adopted, which could widen existing inequities in breastfeeding. This study aims to describe how information about breastfeeding was communicated in Mexican media during the pandemic and assess Mexican adults' beliefs regarding breastfeeding among mothers infected with COVID-19. METHODS: We conducted a retrospective content analysis of media coverage on breastfeeding in Mexico between March 1 and September 24, 2020, excluding advertisements. For the content analysis, we performed both a sentiment analysis and an analysis based on strengths, weaknesses, opportunities, and threats (SWOT) for breastfeeding promotion. Additionally, we conducted a descriptive analysis of nationally representative data on adults' beliefs about breastfeeding from the July 2020 round of the ENCOVID-19 survey in Mexico and stratified the results by gender, age, and socioeconomic status. RESULTS: A total of 1014 publications on breastfeeding were identified on the internet and television and in newspapers and magazines. Most information was published during World Breastfeeding Week, celebrated in August. The sentiment analysis showed that 57.2% of all information was classified as positive. The SWOT analysis indicated that most information focused on current actions, messages, policies, or programs that enable breastfeeding (i.e., strengths) or those not currently in place but that may enable breastfeeding (i.e., opportunities) for breastfeeding promotion. However, ENCOVID-19 survey results showed that 67.3% of adults living in households with children under 3 years of age believe that mothers with COVID-19 should not breastfeed, and 19.8% do not know whether these mothers should breastfeed. These beliefs showed differences both by gender and by socioeconomic status. CONCLUSIONS: While the Mexican government endorsed the recommendation on breastfeeding during the COVID-19 pandemic, communication was sporadic, inconstant and unequal across types of media. There was a widespread notion that mothers with COVID-19 should not breastfeed and due to differences on beliefs by socioeconomic status, health inequities could be exacerbated by increasing the risk of poorer breastfeeding practices and preventing vulnerable groups from reaping the short and long-term benefits of breastfeeding.

Breastfeeding Media Coverage and Beliefs During the COVID-19 Pandemic in Mexico: Implications for Breastfeeding Equity.

BACKGROUND: Breastfeeding offers short- and long- term health benefits to mothers and children and constitutes a priority for public health. Evidence shows that SARS-CoV-2 is not likely to be transmitted via breastmilk. Moreover, antibodies against SARS-CoV-2 are presumably contained in breastmilk of mothers with history of COVID-19 infection or vaccination. Direct breastfeeding is the preferred infant feeding option during the pandemic, but conflicting practices have been adopted, which could widen existing disparities in breastfeeding. This study aims to describe how was information about breastfeeding communicated in Mexican media during the pandemic and assess Mexican adults' beliefs regarding breastfeeding among mothers infected with COVID-19. METHODS: A retrospective content analysis of media coverage on breastfeeding in Mexico between March 1 and September 24, 2020, excluding advertisements, was done. For the content analysis, both a sentiment analysis and an analysis based on strengths, weaknesses, opportunities and threats for breastfeeding promotion were performed. Also, we incorporated a descriptive analysis from the July 2020 wave of the ENCOVID-19 survey, which included questions on beliefs about breastfeeding. This information was stratified by gender, age, and socioeconomic status. RESULTS: 1014 publications on breastfeeding were identified in internet, newspapers, TV, and magazines. Most information was published during World Breastfeeding Week, celebrated in August. Based on the sentiment analysis, 57.2% of all information was classified as positive, and based on the SWOT analysis, most information was classified either as strengths or opportunities for breastfeeding promotion. However, the ENCOVID-19 data showed that 67.3% of people living in households with children under 3 years of age believe that mothers with COVID-19 should not breastfeed, and 19.8% stated that they simply didn't know. These beliefs showed differences both by gender and by socioeconomic status. CONCLUSIONS: While the Mexican government endorsed the recommendations on breastfeeding during the COVID-19 pandemic, communication of those messages was sporadic, inconstant and unequal across types of media. Moreover, there were also negative messages for breastfeeding circulating on the media. There continues to be a widespread notion that mothers with COVID-19 should not breastfeed and, due to differences on beliefs by socioeconomic status, health inequities could be exacerbated.

Design and testing of communication materials for a breastfeeding social media marketing campaign: Breastfeed4Ghana.

Breastfeed4Ghana was a social media-based campaign implemented to address identified gaps in the protection, promotion, and support of breastfeeding in Ghana. This paper describes the process of campaign materials development and testing to ensure their cultural and content appropriateness. The 60 campaign materials, each consisting of an image and text message, underwent a process of creation, testing, revision, and finalization. Existing research evidence and infant and young child feeding communication tools that were culturally relevant for Ghana were used to develop the materials. All materials were tested and finalized through an iterative process that incorporated input from six focus group discussions (FGDs) with mothers, and content and technical experts. The materials were revised to ensure scientific accuracy, understandability, and cultural appropriateness of the messages, as well as alignment of the messages with the images. Finalized materials were reviewed and approved by the Ghana Food and Drugs Authority. Analysis for this paper involved summarizing and categorizing the types and sources of input as well as the research team's responses to the input received. The 60 campaign materials received a total of 132 inputs. Most inputs came from FGDs (78.4%); and most inputs were on the campaign material images. The evidence-informed process of materials creation, use of multiple input sources, and a broad-based iterative process allowed the creation of 60 evidence-based and culturally appropriate materials for a breastfeeding social media campaign in Ghana. This paper could serve as a guide for other social media campaign efforts looking to develop culturally appropriate materials.

Ultra-processed foods consumption among inmates in a women's prison in São Paulo, Brazil.

OBJECTIVES: To assess the consumption of ultra-processed foods among inmates in a women's prison in the State of São Paulo, Brazil. METHODS: We conducted a cross-sectional study in 2012/2013 with 1,013 female inmates. A structured interview questionnaire was used to collect socio-demographic, self-reported morbidity and healthy lifestyles and health-related behaviors data. The inmates' usual diet was assessed with a food frequency questionnaire. Foods were classified as either natural or minimally processed, processed or ultra-processed. RESULTS: Inmates age ranged from 18 to 65 years, 51.7% were black, 80.3% had children, 69.5% smoked, 47% were overweight/obese and half of them had high blood triglycerides. The prevalence of daily consumption of natural or minimally processed foods (rice, beans and cassava flour) was 87.7%. The prevalence of daily consumption of green leafy and other vegetables was 63.7%. Almost two-thirds reported consuming milk and fried chicken frequently. A high prevalence of daily consumption of ultra-processed foods was observed in this study. Hot dog bread and sweet bread with margarine were consumed by 86.5% of the interviewees on a daily basis; sugar sweetened beverages by 68.4%, and biscuits as well as candies by 77.1%. CONCLUSIONS: The women's diet in the prison is of low quality, and may lead to metabolic alterations, obesity and other comorbidities. It is recommended that the prison's Food Evaluation Committee considers improvements to the quality of the prisoners' diets.

Lactation Advice through Texting Can Help: An Analysis of Intensity of Engagement via Two-Way Text Messaging.

Rates of breastfeeding initiation and duration among women who attend the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are dramatically lower than nonparticipants. Innovative solutions are needed to improve breastfeeding rates in this population. The Lactation Advice through Texting Can Help (LATCH) study was one such approach, designed to augment and reinforce the WIC breastfeeding peer counseling process. The purpose of the present study was to examine engagement via two-way text messaging in a sample of women attending the WIC breastfeeding peer counseling program and enrolled in LATCH. The objectives were to: (1) describe text message engagement in the context of LATCH; and (2) assess the association between engagement variables and exclusive breastfeeding status. Text messaging data were first coded qualitatively by two independent researchers and engagement variables created. An analysis of engagement was conducted using descriptive statistics for normally distributed data and binary logistic regression. In the multivariable model, intensity of engagement during the first 2 weeks post partum was the single strongest predictor of exclusive breastfeeding status. LATCH is an innovative intervention designed to enhance the capacity of breastfeeding peer counselors and holds much potential for improving exclusive breastfeeding rates in this population.

Chile Crece Contigo: Implementation, results, and scaling-up lessons.

BACKGROUND: Chile Crece Contigo (ChCC) is defined as a comprehensive, intersectoral, and multicomponent policy that aims to help all children reach their full potential for development, regardless of their socio-economic status. METHODS: This case study was developed on the basis of grey literature review and key informants' interviews. RESULTS: ChCC behaves as a complex adaptive system that combines universal and targeted benefits for the more vulnerable starting since gestation and until the children are 4 years old. Three key ministries are involved in ChCC management: health, education, and social development. Studies show adequate programme implementation and positive effects of ChCC on child development. In addition, it was found that the more families use ChCC benefits and the longer the subsystem has been operating in the commune, the greater the positive effects. CONCLUSIONS: Strong political support based on principles of equity and child rights combined with strong evidence and funding commitment from government has been central to emergence, scaling up, and sustainability of ChCC. Further sustainability of ChCC will rely on firmly establishing a well-trained and compensated cadre of early child development professionals and paraprofessionals as well as an improved management and evaluation decentralized system.

Scaling up Integrated Early Childhood Development programs: lessons from four countries.

BACKGROUND: There is still limited knowledge regarding the translation of early child development (ECD) knowledge into effective policies and large-scale programmes. A variety of frameworks that outline the key steps in scaling up exist, but we argue that taking a complex adaptive systems (CAS) approach assists in understanding the complex, dynamic processes that result in programmes being taken to scale. OBJECTIVES: The objective of this study is to examine the process of scaling up four major country-level ECD programmes through the application of a CAS framework. METHODS: Nine key informants with a deep knowledge of how each ECD programme was established and brought to scale were interviewed via Skype or phone by using open-ended interviews. The interviews were tape recorded and then transcribed verbatim for subsequent coding by using CAS domains. The coding and integration of the results to identify unique and common CAS scaling up features across the case studies involved an iterative process of reaching consensus. RESULTS: The scaling up of all four programmes behaved as a CAS including as follows: (i) positive feedback loops (five themes) and negative feedback loops (two themes); (ii) scale-free networks (two themes); (iii) phase transitions (four themes); (iv) path dependence (two themes); and (v) emergent behaviour (six themes). Five additional themes were identified for sustainability, which was repeatedly mentioned as an important consideration when deciding how to scale up programmes. CONCLUSIONS: CAS analysis is likely to improve our understanding of how effective ECD programmes become scaled up. Prospective CAS implementation research is needed to continue advancing the knowledge in the field.

Consumo de alimentos ultra-procesados en reclusas de una cárcel femenina de São Paulo Brasil / Ultra-processed foods consumption among inmates in a women's prison in São Paulo, Brazil

Objetivo: Evaluar el consumo de alimentos ultra-procesados entre las reclusas en una prisión femenina en el Estado de São Paulo, Brasil. Métodos: Se realizó un estudio transversal en 2012/2013 con 1.013 reclusas. El instrumento de recolección de datos contempló cuestiones sociodemográficas, morbilidad referida y acciones de prevención, indicadores relacionados al estilo de vida y comportamientos de salud. El consumo de alimentos se verificó de acuerdo con el grado de procesamiento de los alimentos: in natura o mínimamente procesados, procesados y ultraprocesados. Resultados: La edad varió de 18 a 65 años, el 51,7% eran negras, el 80,3% tenían hijos, el 69,5% fumaban, el 47% tenía sobrepeso/obesidad y la mitad de ellas tenían hipertrigliceridemia. La prevalencia de consumo diario de alimentos naturales o mínimamente procesados (arroz, frijoles y harina de mandioca) fue del 87,7%. La prevalencia de consumo diario de hojas verdes y otros vegetales fue del 63,7%. Alrededor de dos tercios reportaron consumir frecuentemente leche y pollo frito. Se observó una alta prevalencia de consumo diario de alimentos ultra-procesados en este estudio. El pan de perro caliente o "hot dog" y el pan dulce con margarina fueron consumidos por el 86,5% de las entrevistadas, refrescos por el 68,4%, galletas y dulces por el 77,1%. Conclusiones: El alimento servido en la cárcel es de baja calidad, y puede llevar a cambios metabólicos, obesidad y otras comorbilidades. Se recomienda que el Comité de Evaluación de Alimentos de la cárcel considere la mejora de la calidad de los alimentos servidos

Objectives: To assess the consumption of ultra-processed foods among inmates in a women's prison in the State of São Paulo, Brazil. Methods: We conducted a cross-sectional study in 2012/2013 with 1,013 female inmates. A structured interview questionnaire was used to collect socio-demographic, self-reported morbidity and healthy lifestyles and health-related behaviors data. The inmates' usual diet was assessed with a food frequency questionnaire. Foods were classified as either natural or minimally processed, processed or ultra-processed. Results: Inmates age ranged from 18 to 65 years, 51.7% were black, 80.3% had children, 69.5% smoked, 47% were overweight/obese and half of them had high blood triglycerides. The prevalence of daily consumption of natural or minimally processed foods (rice, beans and cassava flour) was 87.7%. The prevalence of daily consumption of green leafy and other vegetables was 63.7%. Almost two-thirds reported consuming milk and fried chicken frequently. A high prevalence of daily consumption of ultra-processed foods was observed in this study. Hot dog bread and sweet bread with margarine were consumed by 86.5% of the interviewees on a daily basis; sugar sweetened beverages by 68.4%, and biscuits as well as candies by 77.1%. Conclusions: The women's diet in the prison is of low quality, and may lead to metabolic alterations, obesity and other comorbidities. It is recommended that the prison's Food Evaluation Committee considers improvements to the quality of the prisoners' diets

Prevention of childhood obesity and food policies in Latin America: from research to practice.

BACKGROUND: Addressing childhood obesity in Latin America requires a package of multisectoral, evidence-based policies that enable environments conducive to healthy lifestyles. OBJECTIVE: Identify and examine key elements to translating research into effective obesity policies in Latin America. METHODS: We examined obesity prevention policies through case studies developed with an expert in the specific policy. Policies were selected based on their level of implementation, visibility and potential impact to reduce childhood obesity. They include: (i) excise taxes on sugar sweetened beverages and energy-dense foods; (ii) front-of-package food label legislation; (iii) trans fatty acids removal from processed foods; and (iv) Ciclovías recreativas or 'open streets'. Case studies were coded to identify components that explained successful implementation and sustainability using the Complex Adaptive Health Systems framework. RESULTS: The analysis identified key elements for effective and sustainable policy, including evidence justifying policy; evidence-based advocacy by civil society; political will; and legislation and skillful negotiations across government, academia, the private sector and civil society. Scientific evidence and evaluation played an important role in achieving tipping points for policies' launch and sustain effective implementation. CONCLUSIONS: Well-coordinated, intersectoral partnerships are needed to successfully implement evidence-based anti-obesity policies. Prospective policy research may be useful for advancing knowledge translation.

An assessment of the social cognitive predictors of exclusive breastfeeding behavior using the Health Action Process Approach.

RATIONALE: In the United States rates of exclusive breastfeeding duration remain exceedingly low. Exclusive breastfeeding is a complex learned behavior that is influenced by social cognitive, interpersonal, and structural factors. Interventions are needed that address factors at multiple levels of the social-ecological model. This study was designed to examine the social cognitive predictors of exclusive breastfeeding behavior in a sample of low-income women attending the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) breastfeeding peer counseling program and enrolled in the Lactation Advice Through Texting Can Help (LATCH) study. OBJECTIVES: The objectives were to examine whether: (1) the theoretical model, the Health Action Process Approach (HAPA), fit the data well; (2) planning mediated the effect of intentions and maintenance self-efficacy on exclusive breastfeeding; and (3) recovery self-efficacy mediated the association between maintenance self-efficacy and exclusive breastfeeding behavior. METHODS: Outcome expectancies, action self-efficacy and intentions were assessed prenatally at baseline in N = 119 participants. Maintenance self-efficacy, planning, recovery self-efficacy and breastfeeding behavior were measured at two weeks post partum. Structural equation modeling with mean and variance adjusted Weighted Least Squares estimation was used to examine the applicability of the HAPA model to the data. RESULTS: Phase specific self-efficacy and planning significantly predicted exclusive breastfeeding status. Planning and recovery self-efficacy mediated the association between maintenance self-efficacy and exclusive breastfeeding. Planning did not emerge as a mediator between intentions and behavior. CONCLUSION: These results demonstrate the utility of the HAPA model in predicting exclusive breastfeeding behavior among low-income women attending WIC. LATCH is a theoretically sound text messaging intervention that can be used to augment and reinforce the WIC breastfeeding peer counseling process.

Is the Latin American and Caribbean Food Security Scale an Appropriate Instrument for Mexican Urban Older Adults?

BACKGROUND: Older adults in Mexico are a growing share of the population and are a largely vulnerable group with increased risk of food insecurity and potential detrimental health effects stemming from it. OBJECTIVES: This study assesses the face validity of the Latin American and Caribbean Food Security Scale (ELCSA) among Mexican urban older adults of low socioeconomic status. DESIGN: Qualitative study based on 4 focus groups. SETTING: The focus groups were conducted in community organizations for the elderly in an area of Mexico City with a high proportion of poverty. PARTICIPANTS: The focus groups included a total of 36 older adults aged 65 and over who consented to participate. MEASUREMENTS: Two initial focus groups were conducted to assess how older adults understood the food security construct and each of the ELCSA items. Based on these findings, ELCSA was modified and retested for face validity through two additional focus groups. RESULTS: The initial focus groups suggested that several of the scale items were not well understood, leading to editorial modifications of the scale. The final focus groups indicated that the modified version of the scale improved substantially ELCSA's face validity in this sample. CONCLUSIONS: The modified ELCSA led to a greater understanding of most scale items. Further qualitative research is needed to improve food insecurity measurements among older adults in Latin America.

Education for childhood obesity prevention across the life-course: workshop conclusions.

The objectives of this paper are to present the conclusions from the workshop 'Education for childhood obesity prevention: a life-course approach', coordinated by the Pan-American Health Organization and the Pan-American Health and Education Foundation, and held on 14 June 2012 in Aruba, as part of the II Pan-American Conference on Childhood Obesity (http://www.paco.aw/). This workshop focused on the need to recognize the life-course framework and education as a social determinant of health to address the childhood obesity epidemic through diverse education-based initiatives. Workshop participants agreed that both education per se and the education sector are key for obesity prevention and must form part of multidisciplinary interventions and collaboration between schools, families and the entire society. Capacity building in obesity prevention is required and should include the entire learning community, teachers, leaders, health-care providers, related services personnel, university professors and other interested community members. Obesity prevention initiatives should also engage key community institutions outside the formal education system, including early childhood centers, churches, pediatric/family medicine clinics, among others, to support family nutrition education, healthy food access and daily physical activity-all of which are key to promote a child's 'healthy weight'.

Childhood obesity prevention: a life-course framework.

Overweight/obese women are more likely to deliver newborns that also have a predisposition to store excessive amounts of fat since the early infancy period. Two evidence-based cycles are considered on the explanation of the maternal-child life-course approach for obesity prevention. The 'maternal' cycle indicates that pre-pregnancy overweight primiparous women are more likely to gain excessive weight during gestation and to retain excessive weight postpartum. The 'offspring' cycle indicates that newborns of pre-pregnancy overweight/obese women are more likely themselves to store excessive body fat starting very early on in life. The social ecological model (SEM) has been adopted as the framework needed to guide obesity prevention initiatives. The SEM considers the complex interrelationship among highly interconnected systems embedded within each other and having the individual on its inner most. Recommendations to women should include prevention of overweight/obesity prenatally, to attain adequate gestational weight and to lose the weight normally gained as part of the physiological response to pregnancy in the postpartum period. For the 'offspring' the aims should be to promote optimal breastfeeding and complementary feeding practices, and to foster physical activity and adequate dietary habits. Well-coordinated inter-sectorial national obesity prevention programs built upon the life-course framework foundation requires in-depth early life systems analyses driven by the SEM.

Nutrition transition and obesity prevention through the life-course.

The aim of this paper is to discuss concepts regarding the nutrition transition (NT), the several stages it has encompassed over human history, dietary shifts it is associated with and its implications to the life-course approach for obesity prevention. NT is a phenomenon characterized by an inversion of the nutrition profile, that is, an increase in obesity and a reduction in undernutrition. Obesity and associated chronic diseases are the most important expressions of NT today. Some important dietary changes happened in the last decades as a result of the complex determinants of NT, such as urbanization, the economic growth dynamic, cultural and behavioral shifts. The NT has involved an increased consumption of caloric beverages, ultra-processed products, animal foods, edible oils and soft drinks, accompanied by a significant reduction in the consumption of fruits, vegetables, pulses and milk. Global obesity prevalence increased from 4.8% in 1980 to 9.8% in 2008 for men, and from 7.9% in 1980 to 13.8% in 2008 for women, representing 205 million men and 297 million women with obesity and 1.46 billion with overweight in 2008. The context of the NT needs to be taken into account when developing effective obesity prevention strategies across the life-course.

Psychometric properties of a modified US-household food security survey module in Campinas, Brazil.

OBJECTIVE: To assess the internal validity of a multiple-item measure of household food security in Brazil using statistical methods based on the single-parameter logistic (Rasch) measurement model. SUBJECTS/METHODS: Sample of the non-institutionalized civilian population living in the municipality of Campinas selected using stratified cluster sampling. Of the 1000 households randomly chosen, 847 responded to the interview. Responses to each of the 15 questions were coded into dichotomous items indicating whether the specific food-insecure condition had occurred (other than in just 1 or 2 days) during the 3 months before the survey. Scaling analyses were conducted separately as well as jointly for adult/household-related items and child-related items. Item-fit statistics were examined to determine the extent to which the items appear to measure the same underlying phenomenon, and item severity scores were compared with those of equivalent items in the US Current Population Survey. CONCLUSIONS: Except for one item, infit statistics were within a range considered adequate (0.80-1.2), indicating a common phenomenon being measured with approximately equal discrimination. The relative severities of the items in the Campinas survey were generally similar to those of equivalent items in the US Current Population Survey. Analysis of all 15 items together indicates a higher severity level for child-related items compared with equivalent adult-related items.

Factors associated with exclusive breastfeeding in Accra, Ghana.

OBJECTIVE: To assess factors associated with exclusive breast-feeding (EBF) in Accra, Ghana. DESIGN, SUBJECTS, SETTING: Data on current and past infant feeding patterns, sociodemographic, biomedical and biocultural factors were collected using a cross-sectional design, from a sample of 376 women with infants 0-6 months, attending maternal and child health (MCH) clinics in Accra. EBF was defined in two ways: (a) based on a 24-h recall, and (b) based on a recall of liquids or foods given since birth. RESULTS: Although 99.7% of mothers were currently breastfeeding (BF), only half (51.6%) of them EBF their infants. About 98% of participants had heard about EBF, and 85.6% of them planned to EBF on delivery. Based on 'since birth' EBF, planned EBF on delivery was associated with higher likelihood of EBF (OR=2.56; 95% CI, 1.06-6.17) and delivery at a hospital/polyclinic was associated with a two times higher likelihood of EBF (OR=1.96; 95% CI, 1.08-3.54). Women living in their own houses were more likely to EBF (OR=3.96; 95% CI, 1.02-15.49) than those living in rented accommodations and family houses. Those with a more positive attitude towards EBF were more likely to EBF (OR=2.0; 95% CI, 1.11-3.57) than their counterparts with more negative attitudes. The '24-h recall' EBF model yielded similar results. CONCLUSION: In this population, EBF was associated with delivery at hospital/polyclinic, having secondary school education, intention to EBF prior to delivery, owning a home and having a positive attitude to EBF.

Validity and public health implications of maternal perception of the onset of lactation: an international analytical overview.

The main objective of this analytical overview is to assess the validity of maternal perception of the onset of lactation (OL) as an indicator of lactogenesis stage II (LS-II). Prospective studies that assessed OL and/or LS-II [based on test-weighing milk volume (MV) and/or breast milk biomarkers (BMB)] were identified. OL is a clearly defined and easily identified event across cultures, with the overwhelming majority of women being able to report when they experience it. Mean OL ranges from 50 to 73 h postpartum across studies and from 1 to 148 h postpartum within studies. The wide range detected within samples is fully consistent with the wide within sample LS-II variability as determined by BMB or MV. Studies have identified similar risk factors for delayed LS-II, such as labor and delivery stress, primiparity and insulin-dependent diabetes mellitus, regardless of marker used (i.e., OL, MV or BMB). The correlation between OL and MV (r = -0.60) is of similar magnitude to that between OL and BMB (r = 0.50) and that between BMB and MV (r = 0.47-0.69). In conclusion, OL is a valid clinical indicator of LS-II. This has public health relevance because studies have identified delayed OL (i.e., >72 h postpartum) as a risk factor for shorter breastfeeding duration and for greater infant weight loss by d 3 postpartum. Multidisciplinary studies are needed to standardize the definition of OL and to confirm its validity in different sociocultural contexts.