Identifying and understanding barriers to optimal complementary feeding in Kenya.

Optimal complementary feeding between the ages of 6 and 23 months provides children with the required range of nutritious and safe foods while continuing to be breastfed to meet their needs for essential nutrients and develop their full physical and cognitive potential. The rates of exclusive breastfeeding in the first 6 months of life have increased from 32% in 2008 to 60% in 2022 in Kenya. However, the proportion of children between 6 and 23 months receiving a minimum acceptable diet remains low and has declined from 39% in 2008 to 31% in 2023. The Kenyan Ministry of Health, GAIN and UNICEF collaborated to understand the drivers of complementary feeding practices, particularly proximal determinants, which can be directly addressed and acted upon. A secondary analysis of household surveys and food composition data was conducted to outline children's dietary patterns within the different regions of Kenya and the extent to which the affordability of animal-source foods could be improved. Ethnographic data were analyzed to identify socio-cultural barriers to optimal complementary feeding. Furthermore, we outlined the critical steps for developing user-friendly and low-cost complementary feeding recipes. The results of all the analyses are presented in five of the six papers of this Special Issue with this additional paper introducing the Kenyan context and some of the critical findings. The Special Issue has highlighted multidimensional barriers surrounding the use and availability of animal-source foods. Furthermore, it emphasizes the need for a multi-sectoral approach in enacting policies and programmes that address these barriers.

Modelling policies to improve affordability and consumption of nutritious foods for complementary feeding in Kenya.

In Kenya 26% of children under age 5 experience stunted growth, 4% are wasted and 11% are underweight. In pregnant women, the prevalence of iron deficiency is 36% and iron-deficiency anaemia prevalence is 26%. Previous studies have identified affordability as a key barrier to the intake of nutrients, particularly from animal-source foods (ASFs). Thus, this study analyzes to what extent the affordability of ASF in Kenya can be improved. It focuses on four ASFs: eggs, milk, chicken and beef. Using a computable general equilibrium model, three policy simulations were undertaken to establish the impact of potential changes on nutritious ASF availability and affordability: a 20% increase in total factor productivity (TFP) for the four products; a 20% TFP increase plus a 25% reduction in trade and transportation margins; and a 20% TFP increase for ASF and maize (a key input in animal feed). Simulations suggest increasing the productivity of the four ASF products would increase their availability and lower consumer prices (up to 17% lower). Household consumption of the four commodities would increase, resulting in improved household dietary diversity. Rural households would gain more compared with urban households. Poor households (the lowest 40%) would register larger welfare (Equivalent Variation) gains than other households in both urban and rural areas. The richest 20% of the population would neither lose nor gain following the policy changes. Reducing transportation costs and trade margins and increasing maize productivity could further reduce the price of ASFs through lower production costs and increased consumption.

Improving complementary feeding practices, programs and policies for optimal early childhood nutrition in Kenya: What would work?

Complementary feeding practices are greatly influenced by local contexts. Therefore, national home-grown evidence, policies and guidelines are critical to improving infant and young children's diets. This Special Issue has provided a comprehensive, evidence-based analysis of the situation, gaps and context-specific opportunities for improving young children's diets in Kenya. The primary research findings of the Special Issue supported the identification of a set of recommendations articulated across the four systems (food, health, water, sanitation and hygiene [WASH] and social protection) to improve food availability and accessibility in Kenya at the national and subnational levels. It is anticipated that the decentralised government functions seen in Kenya provide a strong opportunity to develop and mainstream context-specific recommendations into action. This Special Issue recommends adopting a multi-sectoral systems approach, including a shared vision, joint planning, implementation and monitoring, towards improving young children's diets with a focus on service delivery as well as scaled-up community social behaviour change interventions. In particular, the approach should entail advocacy for policy revisions for service delivery that support complementary feeding and development of costed implementation strategies in support of the same, across four critical systems-food, health, WASH and social protection, along with, the strengthening of national coordination, monitoring and accountability structures as per the Kenya Nutrition Action Plan. Finally, the development of a legal framework for enhanced accountability from all relevant sectors towards sustainable, nutritious, safe and affordable children's diets. These recommendations provide a clear direction in addressing the complementary feeding challenges, which the primary research of this Special Issue has presented.

Food choice in transition: adolescent autonomy, agency, and the food environment.

Dietary intake during adolescence sets the foundation for a healthy life, but adolescents are diverse in their dietary patterns and in factors that influence food choice. More evidence to understand the key diet-related issues and the meaning and context of food choices for adolescents is needed to increase the potential for impactful actions. The aim of this second Series paper is to elevate the importance given to adolescent dietary intake and food choice, bringing a developmental perspective to inform policy and programmatic actions to improve diets. We describe patterns of dietary intake, then draw on existing literature to map how food choice can be influenced by unique features of adolescent development. Pooled qualitative data is then combined with evidence from the literature to explore ways in which adolescent development can interact with sociocultural context and the food environment to influence food choice. Irrespective of context, adolescents have a lot to say about why they eat what they eat, and insights into factors that might motivate them to change. Adolescents must be active partners in shaping local and global actions that support healthy eating patterns. Efforts to improve food environments and ultimately adolescent food choice should harness widely shared adolescent values beyond nutrition or health.

Friend or Foe? The Role of Animal-Source Foods in Healthy and Environmentally Sustainable Diets.

Scientific and political discussions around the role of animal-source foods (ASFs) in healthy and environmentally sustainable diets are often polarizing. To bring clarity to this important topic, we critically reviewed the evidence on the health and environmental benefits and risks of ASFs, focusing on primary trade-offs and tensions, and summarized the evidence on alternative proteins and protein-rich foods. ASFs are rich in bioavailable nutrients commonly lacking globally and can make important contributions to food and nutrition security. Many populations in Sub-Saharan Africa and South Asia could benefit from increased consumption of ASFs through improved nutrient intakes and reduced undernutrition. Where consumption is high, processed meat should be limited, and red meat and saturated fat should be moderated to lower noncommunicable disease risk-this could also have cobenefits for environmental sustainability. ASF production generally has a large environmental impact; yet, when produced at the appropriate scale and in accordance with local ecosystems and contexts, ASFs can play an important role in circular and diverse agroecosystems that, in certain circumstances, can help restore biodiversity and degraded land and mitigate greenhouse gas emissions from food production. The amount and type of ASF that is healthy and environmentally sustainable will depend on the local context and health priorities and will change over time as populations develop, nutritional concerns evolve, and alternative foods from new technologies become more available and acceptable. Efforts by governments and civil society organizations to increase or decrease ASF consumption should be considered in light of the nutritional and environmental needs and risks in the local context and, importantly, integrally involve the local stakeholders impacted by any changes. Policies, programs, and incentives are needed to ensure best practices in production, curb excess consumption where high, and sustainably increase consumption where low.

Limitations of the Food Compass Nutrient Profiling System.

Nutrient Profiling Systems provide frameworks to assess the healthfulness of foods based on food composition and are intended as inputs into strategies to improve diets. Many Nutrient Profiling Systems are founded on a reductionist assumption that the healthfulness of foods is determined by the sum of their individual nutrients, with no consideration for the extent and purpose of processing and its health implications. A novel Nutrient Profiling System called Food Compass attempted to address existing gaps and provide a more holistic assessment of the healthfulness of foods. We propose that the chosen algorithm is not well justified and produces results that fail to discriminate for common shortfall nutrients, exaggerate the risks associated with animal-source foods, and underestimate the risks associated with ultraprocessed foods. We caution against the use of Food Compass in its current form to inform consumer choices, policies, programs, industry reformulations, and investment decisions.

Streamlining Micronutrient Biomarker Statistical Analysis in Populations: An Introduction to the SAMBA R Package.

Micronutrient deficiency is a common global health problem, and accurately assessing micronutrient biomarkers is crucial for planning and managing effective intervention programs. However, analyzing micronutrient data and applying appropriate cutoffs to define deficiencies can be challenging, particularly when considering the confounding effects of inflammation on certain micronutrient biomarkers. To address this challenge, we developed the Statistical Apparatus of Micronutrient Biomarker Analysis (SAMBA) R package, a new tool that increases ease and accessibility of population-based micronutrient biomarker analysis. The SAMBA package can analyze various micronutrient biomarkers to assess status of iron, vitamin A, zinc, and B vitamins; adjust for inflammation; account for complex survey design when appropriate; and produce reports of summary statistics and prevalence estimates of micronutrient deficiencies using recommended age-specific and sex-specific cutoffs. In this study, we aimed to provide a step-by-step procedure for how to use the SAMBA R package, including how to customize it for broader use, and made both the package and user manual publicly available on GitHub. SAMBA was validated by comparing results by analyzing 24 data sets on nonpregnant women of reproductive age from 23 countries and 30 data sets on preschool-aged children from 26 countries with those obtained by an independent analyst. SAMBA generated identical means, percentiles, and prevalence of micronutrient deficiencies to those calculated by the independent analyst. In conclusion, SAMBA simplifies and standardizes the process for deriving survey-weighted and inflammation-adjusted (when appropriate) estimates of the prevalence of micronutrient deficiencies, reducing the time from data cleaning to result generation. SAMBA is a valuable tool that facilitates the accurate and rapid analysis of population-based micronutrient biomarker data, which can inform public health research, programs, and policy across contexts.

A subnational affordability assessment of nutritious foods for complementary feeding in Kenya.

Complementary feeding among children aged 6-23 months is a key determinant of micronutrient deficiencies and childhood stunting, the burdens of which remain high in Kenya. This study examines the affordability of complementary foods to increase young children's nutrient consumption across eight provinces in Kenya. We combined data from household surveys, food composition tables and published sources to estimate the cost of portion sizes that could meet half of the children's daily iron, vitamin A, calcium, zinc, folate, vitamin B12 and protein requirements from complementary feeding. These costs were compared to current household food expenditures. The selection of foods and price and expenditure data were stratified by province. Our analysis indicates that vitamin A, vitamin B12 and folate are affordable to most households in Kenya via liver, beans and in some provinces, orange-fleshed fruits and vegetables, avocado and small dried fish. Calcium, animal-source protein, zinc and iron were less affordable and there was more provincial variation. In some provinces, small dried fish were an affordable source of calcium, protein and zinc. In others (North Eastern, Central, Eastern, parts of Rift Valley and Coast), small dried fish were not commonly consumed and other foods were less affordable. Future research should consider interventions aimed at reducing prices, increasing availability and changing behaviours related to these foods. Solutions such as supplementation and fortification may be needed for iron and zinc in some locations. Food affordability presented the greatest barriers in North Eastern province, which had lower dietary diversity and may require additional targeted interventions.

Eating behaviour of Indonesian adolescents: a systematic review of the literature.

OBJECTIVES: Global evidence has shown that behaviour acquired during adolescence often lasts into adulthood. Diet quality of and malnutrition in Indonesian adolescents is a neglected area of research. The current study reviews all studies related to eating behaviour in Indonesian adolescents to support evidence-based policy to improve diets. DESIGN: We searched electronic databases (six international and one local), from January 2000 to April 2018. The search terms used were (1) prevalence (prevalence OR number* OR case*, incidence OR survey), (2) adolescents (adolescen* OR school-age OR young adult), (3) Indonesia (Indonesia*) and (4) eating pattern (eat* OR fruit OR vegetable OR food recall OR food OR frequenc* OR consumption OR dietary intake). Articles were assessed against a critical appraisal tool. SETTING: Indonesia. PARTICIPANTS: 10-19 years. RESULTS: We discovered 15 studies related to eating behaviour, 5 of which were secondary analyses of nationally representative surveys and one was a nationwide survey. Of the nine studies, one study was conducted in multiple cities, and the rest were conducted in a single city or smaller area. There were seven main topics from the included studies: nutrient adequacy, fruit and vegetable consumption, water and beverage intake, Na intake, breakfast habit, snacking frequency and western fast food consumption. CONCLUSIONS: Adolescents consume inadequate amounts of protein, fruits and vegetables, and excessive amounts of Na and western fast food. Measures are needed to improve and motivate adolescents to adopt healthier eating patterns. Furthermore, there is a need to have one standard definition and measurement of eating behaviour in Indonesia.

Bottlenecks and predictors of coverage and adherence outcomes for a micronutrient powder program in Ethiopia.

A theory-driven evaluation was conducted to assess performance of a trial to deliver micronutrient powder (MNP) through the Ethiopian Ministry of Health. We adapted an approach to coverage assessment, originally developed to identify bottlenecks in health service delivery, to examine sequential program outcomes and their correlates using cross-sectional survey data of caregivers of children 6-23 months (N = 1915). Separate multivariable Poisson regression models were used to estimate adjusted risk ratios of conceptually relevant determinants of coverage and adherence. Caregivers of children >11 months were more likely to have received MNP than caregivers of younger infants, yet children 12-17 months were 32% (P < 0.001) and children 18-23 months 38% (P < 0.001) less likely to have been fed MNP in the 14 days preceding the survey than children 6-11 months. Among caregivers who initiated feeding MNP, the most frequently reported reasons for discontinuing use were not obtaining additional supply (36.1%) and perceived child rejection of food with MNP (22.9%). For each additional time a caregiver met with frontline workers in the 3 months preceding the survey, they were 13% more likely to have recently fed MNP (P < 0.001). Caregivers' perception that MNP produced positive changes in children was associated with a 14% increase in the likelihood of having recently fed it (P < 0.001). These results emphasize the importance of counselling for MNP and infant and young child feeding for initial use and the importance of multiple contacts with frontline workers for continued use.

Child stunting is associated with child, maternal, and environmental factors in Vietnam.

Child stunting in Vietnam has reduced substantially since the turn of the century but has remained relatively high for several years. We analysed data on children 6-59 months (n = 85,932) from the Vietnam Nutritional Surveillance System, a nationally representative cross-sectional survey. Multivariable Poisson regression models were used to estimate relative risk (RR) of stunting, stratified by child age and ecological region. Covariates at the child, maternal, household, and environmental levels were included based on available data and the World Health Organization conceptual framework on child stunting. Among children 6-23 months, the strongest associations with child stunting were child age in years (RR: 2.49; 95% CI [2.26, 2.73]), maternal height < 145 cm compared with ≥150 cm (RR: 2.04; 95% CI [1.85, 2.26]), living in the Northeast compared with the Southeast (RR: 2.01; 95% CI [1.69, 2.39]), no maternal education compared with a graduate education (RR: 1.77; 95% CI, [1.44, 2.16]), and birthweight < 2,500 g (RR: 1.75; 95% CI [1.55, 1.98]). For children 24-59 months, the strongest associations with child stunting were no maternal education compared with a graduate education (RR: 2.07; 95% CI [1.79, 2.40]), living in the Northeast compared with the Southeast (RR: 1.94; 95% CI [1.74, 2.16]), and maternal height < 145 cm compared with ≥150 cm (RR: 1.81; 95% CI [1.69, 1.94]). Targeted approaches that address the strongest stunting determinants among vulnerable populations are needed and discussed. Multifaceted approaches outside the health sector are also needed to reduce inequalities in socioeconomic status.

A review of child stunting determinants in Indonesia.

Child stunting reduction is the first of 6 goals in the Global Nutrition Targets for 2025 and a key indicator in the second Sustainable Development Goal of Zero Hunger. The prevalence of child stunting in Indonesia has remained high over the past decade, and at the national level is approximately 37%. It is unclear whether current approaches to reduce child stunting align with the scientific evidence in Indonesia. We use the World Health Organization conceptual framework on child stunting to review the available literature and identify what has been studied and can be concluded about the determinants of child stunting in Indonesia and where data gaps remain. Consistent evidence suggests nonexclusive breastfeeding for the first 6 months, low household socio-economic status, premature birth, short birth length, and low maternal height and education are particularly important child stunting determinants in Indonesia. Children from households with both unimproved latrines and untreated drinking water are also at increased risk. Community and societal factors-particularly, poor access to health care and living in rural areas-have been repeatedly associated with child stunting. Published studies are lacking on how education; society and culture; agriculture and food systems; and water, sanitation, and the environment contribute to child stunting. This comprehensive synthesis of the available evidence on child stunting determinants in Indonesia outlines who are the most vulnerable to stunting, which interventions have been most successful, and what new research is needed to fill knowledge gaps.

Characteristics of Global Data on Adolescent's Dietary Intake: A Systematic Scoping Review.

Data on adolescents' dietary intake are essential to improve their diets and nutrition. However, the availability of (high-quality) data on adolescents' dietary intake is scarce with great global differences. We conducted a systematic scoping review to investigate the availability, characteristics, and gaps in global adolescent dietary data, following the Preferred Reporting Items for Systematic Reviews and Meta Analyses-Extension for Scoping Reviews checklist and guidelines (registered under PROSPERO no. 171170 https://www.crd.york.ac.uk/PROSPERO/). We included peer-reviewed and grey literature articles (2010 onwards) on the dietary intake of male and female adolescents (10-24 y). Studies from all countries and languages and including any information related to types of food consumed, diet composition, dietary diversity, or meal patterns were considered. We excluded studies with insufficient methodological information, unclear description of population, samples sizes <25, school-based data sets containing <6 schools, and studies that focused on pregnant or unhealthy study populations. Data, including year(s) of data collection, age, gender, sample size, dietary assessment methods, number of food items/groups, study design, location, and representativeness, were extracted. A total of 52,889 titles were identified and 722 articles, describing 1,322 data sets, were retained for analysis. Nationally representative, detailed dietary data for adolescents aged 10-24 y are still lacking, particularly in sub-Saharan Africa, South Asia, and low-income countries. Data quality and representativeness remain limited, highlighting the need for data disaggregation by age, gender, locality, comprehensive dietary information, and broader geographic coverage. A notable amount of data was available through grey literature, especially in data-scarce countries. The study underscores the importance of addressing adolescent nutrition, emphasizing the urgent need for more robust, accessible, and representative data on adolescents' dietary intake to support effective nutritional efforts.

Opportunities for Consistent and Holistic Metrics to Support Food Systems Transformation: A Summary of a Symposium Presented at Nutrition 2023.

There is an urgent need for global food systems transformation to realize a future where planetary health reaches its full potential. Paramount to this vision is the ability of stakeholders across sectors to understand how foods and dietary patterns impact food systems inclusive of all domains of sustainability-environmental, nutrition/health, economic and social. This article is a synopsis of presentations by 3 food systems experts to share the latest science in a session entitled "How do you measure sustainability? Opportunities for consistent and holistic metrics to support food systems transformation" at the American Society for Nutrition's 2023 annual conference. As summarized here, global population data showing widespread malnutrition underscore the important role of dietary diversity through a balance of plant- and animal-source foods to achieve nutritionally adequate diets and reduce risk of noncommunicable diseases. Yet, recent international audits of countries, companies, and organizations and their sustainability targets largely demonstrate an underrepresentation of robust nutrition/health metrics to support public nutrition and health progress. Addressing limitations in diet-sustainability modeling systems provides a viable opportunity to accurately reflect the important contributions and trade-offs of diets across all domains of sustainability to ultimately support evidence-based decision making in advancing healthy food systems.

Suitability of Alternative Protein Foods for Agroecological Approaches to Address Nutrition in Low- and Middle-Income Countries.

Agroecology has been proposed as a holistic approach to transform food systems that meet global food requirements with favorable environmental and social impacts. Agroecology relies on science, practices, and social movements that emphasize ecological principles, local knowledge, culture, and traditions to increase the sustainability and equity of the food system. Agroecological practices have demonstrated positive outcomes on food security and nutrition in low- and middle-income countries (LMICs). Agroecology principles can be applied across the food system and could facilitate the integration of certain alternative protein (AP) foods to address multiple issues. In this perspective, agroecological principles were analyzed to compare the suitability of different AP sources: unprocessed/minimally processed legumes, plant-based meats, edible insects, macroalgae (seaweed), fungal biomass, and cultivated meat. Considerations were identified for the feasibility of AP adoption in LMICs within an agroecological framework to provide nutrient-rich and sustainable diets while addressing other principles such as fairness and economic diversity. From this analysis, legumes, simplified plant-based meat analogs such as texturized plant proteins with minimal additives, edible insects, and macroalgae (location dependent) would make excellent nutritional contributions alongside animal-sourced food within LMICs within an agroecological framework. In contrast, highly processed plant-based meats, fungal biomass, and cultivated meat do not align well with agroecological principles for large-scale human consumption within LMICs. Furthermore, the production facilities to make these foods require robust capital investment and there may be issues related to who owns the intellectual property of these technologies. The NOVA classification system categorizes food based on the degree of processing. Our assessment suggests that foods with lower NOVA classification of unprocessed and minimally processed best fit the agroecological principles related to nutrition, agroecosystem, and societal demands for sustainable food systems.

Corrigendum: Priority micronutrient density in foods.

[This corrects the article DOI: 10.3389/fnut.2022.806566.].

Estimated micronutrient shortfalls of the EAT-Lancet planetary health diet.

Unhealthy diets are a major contributor to the global burden of disease, and food systems cause substantial environmental destruction. To lay out how to achieve healthy diets for all, within planetary boundaries, the landmark EAT-Lancet Commission proposed the planetary health diet, which includes a range of possible intakes by food group and substantially restricts the intake of highly processed foods and animal source foods globally. However, concerns have been raised about the extent to which the diet provides adequate essential micronutrients, particularly those generally found in higher quantities and in more bioavailable forms in animal source foods. To address these concerns, we matched each food group point estimate within the respective range with globally representative food composition data. We then compared the resulting dietary nutrient intakes with globally harmonised recommended nutrient intakes for adults and women of reproductive age for six micronutrients that are globally scarce. To fill the dietary gaps that were estimated for vitamin B12, calcium, iron, and zinc, we suggest modifications to the original planetary health diet to achieve micronutrient adequacy (without fortification or supplementation) for adults, which included increasing the proportion of animal source foods and reducing foods high in phytate.

The state of food systems worldwide in the countdown to 2030.

This Analysis presents a recently developed food system indicator framework and holistic monitoring architecture to track food system transformation towards global development, health and sustainability goals. Five themes are considered: (1) diets, nutrition and health; (2) environment, natural resources and production; (3) livelihoods, poverty and equity; (4) governance; and (5) resilience. Each theme is divided into three to five indicator domains, and indicators were selected to reflect each domain through a consultative process. In total, 50 indicators were selected, with at least one indicator available for every domain. Harmonized data of these 50 indicators provide a baseline assessment of the world's food systems. We show that every country can claim positive outcomes in some parts of food systems, but none are among the highest ranked across all domains. Furthermore, some indicators are independent of national income, and each highlights a specific aspiration for healthy, sustainable and just food systems. The Food Systems Countdown Initiative will track food systems annually to 2030, amending the framework as new indicators or better data emerge.