Low dietary diversity is a predictor of child stunting in rural Bangladesh

Concordance of Mother-Child (6-23 Months) Dietary Diversity and Its Associated Factors in Kucha District, Gamo Zone, Southern Ethiopia: A Community-Based Cross-Sectional Study

Meeting minimum standards of dietary quality in mothers and children is a challenge in many developing countries including Ethiopia. Emerging evidence suggests that maternal and child dietary diversity is associated, but little is known about the associated factors of concordance of mother-child dietary diversity in Ethiopia and none is documented in the study area. This study examines the concordance between mother-child (6-23 months) dyads dietary diversity and the associated factors in Kucha District, Gamo Zone, Southern Ethiopia. A community-based cross-sectional study was conducted among 791 mother-child (6-23 months) pairs from 11 selected kebeles on March 6 to April 13, 2017. Multistage cluster sampling technique was used to select the study subjects. The sampling frame was obtained from the family folder of health posts in each kebele. The mother-child pairs were selected by the simple random sampling method. The 7 food groups of the World Health Organization (WHO) for children and the 10 food groups of FANTA/FAO 2016 for mothers were used to analyze the dietary diversity. Cohen's kappa statistics was calculated to see the strength of concordance. The multivariable logistic regression model was fitted to determine factors affecting mother-child dietary diversity concordance. A good concordance was noted between mother-child dietary diversity scores (Kappa = 0.43). Only 56 (7.1%) mothers were negative deviants, and 133 (16.8%) mothers were positive deviants in dietary diversity consumption. Rural residence (AOR = 3.49; 95% CI: 1.90-6.41), having no formal education (AOR = 1.8; 95% CI: 1.08-3.05), not owning milking cow (AOR = 1.7; 95% CI: 1.10-2.56), children with low dietary diversity (AOR = 8.23; 95% CI: 5.17-13.08), and mothers with low dietary diversity (AOR = 0.46; 95% CI: 0.29-0.74) were found to be factors associated with mother-child dietary diversity concordance. An increase in the percentage of children reaching the minimum dietary diversity was greater with a successive increase in maternal dietary diversity. Despite interesting similarities between mothers and children dietary consumption, more than three-quarters of concordants did not achieve the recommended dietary diversity score (were low concordants). Interventions targeting on rural women's access to high school education, home-based milking cow rearing, and promoting nutrition-sensitive agriculture to meet the dietary requirements of mothers and children in a sustainable manner and public health efforts to improve child nutrition may be strengthened by promoting maternal dietary diversity due to its potential effect on the entire family.

Food Insecurity, Nutritional Inequality, and Maternal–Child Health: A Role for Biocultural Scholarship in Filling Knowledge Gaps

Food insecurity, a significant contributor to nutritional inequality, disproportionately affects women and children in low- and middle-income countries. The magnitude of the problem has inspired research on its impacts on health, especially on nutritional status and, more recently, mental well-being. Current research is dominated by surveillance-type studies that emphasize access, one of food security's four dimensions. Findings are inconclusive regarding the association between food insecurity and women and children's nutritional status, but some evidence indicates that it is a key contributor to mental distress in women. To understand these inconsistent findings, we emphasize the need for research on the strategies that people use to cope with inadequate access to food. We contend that biocultural approaches that recognize the importance of local contexts and the role of broader political-economic factors in shaping them are well suited for addressing current knowledge gaps.

The effects of income fluctuations on undernutrition and overnutrition across the lifecycle

This study uses individual level data from a 13-year, nationally representative rotating panel survey of Kyrgyzstan to estimate the effects of fluctuations in predicted income on health and nutrition outcomes from early childhood to adulthood. We consider impacts on both undernutrition and overnutrition side-by-side, and carefully consider the mechanisms at work. We address the endogeneity of income following Bartik (1991): We construct a measure of predicted income, obtained using the household's initial period share of income from different sources and aggregate national growth rates over time in each source. We find that young children (under age 5) exposed to reductions in predicted income experienced reductions in important measures of health and nutrition: weight, weight-for-age Z-scores, and weight-for-height Z-scores. We further identify reductions in both weight and height among older children (aged 5-18). Declines in child health and nutrition are most pronounced among households most dependent on agriculture and those living in rural areas. Reduced consumption of healthy foods and reduced parental time spent with children may help explain the results. A channel possibly offsetting negative impacts is increased use of contraceptives. At the same time, older children and adults experienced decreases in body mass index and-for adults-decreases in the incidence of overweight and obesity, suggesting selective health benefits for some groups.

The Association of Feeding Practices and Sociodemographic Factors on Underweight and Wasting in Children in Ethiopia: A Secondary Analysis of Four Health Surveys from 2000 to 2016

BACKGROUND

Feeding practices highly influence the nutritional status of children between 6 and 23 months of age in developing countries, including Ethiopia. Therefore, this study was conducted to investigate the association of feeding practices and sociodemographic factors on underweight and wasting of children aged 6-23 months in Ethiopia.

METHODS

Data on 8003 children 6-23 months of age from four Ethiopia demographic and health surveys (EDHS) from 2000 to 2016 were analyzed using complex sample crosstabs for multivariate analysis. The association of feeding practices and sociodemographic factors on underweight and wasting was assessed via multiple logistic regression analyses adjusting the covariates. The outcomes were reported based on the adjusted odds ratios (ORs) with 95% confidence interval (CI).

RESULTS

Male children, very small at birth size children, diarrhea and fever, and short stature mother were risk factors for underweight and wasting (p < 0.05-0.001). Also, minimum dietary diversity, rich and middle-income families, vitamin A in the previous 6 months and antenatal care visits during pregnancy were protective factors for both underweight and wasting (p < 0.05-0.001). Minimum meal frequency was significantly related to lower odds of wasting (p < 0.001). Higher age of the child was significantly associated with underweight (p < 0.05-0.001); however, it was less likely wasted (p < 0.05-0.01).

CONCLUSION

The present study depicted that among infant young children feeding core indicators except breastfed, all the other indicators did not met the required standard; however, sociodemographic factors on four health surveys from 2000 to 2016 were associated with underweight and wasting in children in Ethiopia.

LAY SUMMARY

• Over the years the prevalence of underweight in children aged 6-23 months in the country has shown a significant improvement from 40.2% in 2000 to 34.7% in 2005, then further reduced to 28.9% and 20.0% in 2011 and 2016 EDHS, respectively.• In the same manner, the prevalence of wasting in children aged 6-23 months in Ethiopia also observed improvement from 18.9% in 2000 to 16.7% in 2005, then further reduced to 15.4% and 13.9% in 2011 and 2016 EDHS, respectively.• Male children, very small at birth size children, diarrhea and fever (for the last 2 weeks), and short stature mother were risk factors for underweight and wasting.• Minimum dietary diversity, rich and middle-income families, vitamin A in the previous 6 months and antenatal care visits during pregnancy were protective factors for both underweight and wasting.• Minimum meal frequency was significantly related to lower odds of wasting.• Higher age of the children was significantly associated with underweight; however, less likely wasted.

Child Dietary Diversity and Associated Factors Among Children in Somalian IDP Camps

BACKGROUND

Malnutrition and food insecurity are major challenges in Somalia, particularly among small children living in internally displaced person (IDP) camps. Poor diet has been identified as a key driver of malnutrition in young children who depend for their diets on their household's socioeconomic standing and access to food, as well as on the family's caring and feeding practices.

OBJECTIVE

To assess the dietary diversity and identify the factors associated with it among children (6-23 months) in Somalian IDP camps.

METHODS

We used a cross-sectional survey conducted in 11 IDP camps in Somalia in June 2014 and in June 2015. A total of 3188 children aged 6 to 23 months were surveyed. Child diets were assessed using food frequency questionnaires, and dietary diversity was categorized using the minimum child dietary diversity (MDDC) indicator. Multivariable logistic regressions were used to identify the factors associated with the children's dietary diversity. We built and compared 2 models using alternatively the household dietary diversity score (HDDS) and the food consumption score (FCS) as food security proxies.

RESULTS

Around 15% of children in IDP camps reached the minimum dietary diversity. Overall, our results confirm that not only are food security proxies the factors most associated with MDDC, but HDDS performs better than FCS. In addition, results identify that women as key decision-maker in the household, duration of household permanence in the settlement, women's physiological status, frequency of milk feeding to child, type of toilet, and measles vaccination are positively associated with MDDC.

CONCLUSIONS

To improve child dietary diversity in IDP camps, food security interventions should be broadened to include female empowerment and inclusive nutrition education (encouraging male participation) programs, as well as initiatives targeting children who do not live with pregnant or lactating women and that can support families beyond the first months after their arrival.

Market Access, Production Diversity, and Diet Diversity: Evidence From India

BACKGROUND

Recent literature, largely from Africa, shows mixed effects of own-production on diet diversity. However, the role of own-production, relative to markets, in influencing food consumption becomes more pronounced as market integration increases.

OBJECTIVE

This paper investigates the relative importance of two factors - production diversity and household market integration - for the intake of a nutritious diet by women and households in rural India.

METHODS

Data analysis is based on primary data from an extensive agriculture-nutrition survey of 3600 Indian households that was collected in 2017. Dietary diversity scores are constructed for women and households is based on 24-hour and 7-day recall periods. Household market integration is measured as monthly household expenditure on key non-staple food groups. We measure production diversity in two ways - field-level and on-farm production diversity - in order to account for the cereal centric rice-wheat cropping system found in our study locations. The analysis is based on Ordinary Least Squares regressions where we control for a variety of village, household, and individual level covariates that affect food consumption, and village fixed effects. Robustness checks are done by way of using a Poisson regression specifications and 7-day recall period.

RESULTS

Conventional measures of field-level production diversity, like the number of crops or food groups grown, have no significant association with diet diversity. In contrast, it is on-farm production diversity (the field-level cultivation of pulses and on-farm livestock management, and kitchen gardens in the longer run) that is significantly associated with improved dietary diversity scores, thus suggesting the importance of non-staples in improving both individual and household dietary diversity. Furthermore, market purchases of non-staples like pulses and dairy products are associated with a significantly higher dietary diversity. Other significant determinants of dietary diversity include women's literacy and awareness of nutrition. These results mostly remain robust to changes in the recall period of the diet diversity measure and the nature of the empirical specification.

CONCLUSIONS

This study contributes to the scarce empirical evidence related to diets in India. Additionally, our results indicate some key intervention areas - promoting livestock rearing, strengthening households' market integration (for purchase of non-staples) and increasing women's awareness about nutrition. These are more impactful than raising production diversity.

Food quality score and anthropometric status among 6-year-old children: A cross-sectional study

OBJECTIVE

Weight status and growth during childhood are indicative of healthy development throughout the lifespan. It is well understood that dietary patterns and overall quality of diet can prevent disease, improve health status and optimise growth and development. The current study investigates the relationship between overall diet quality and measures of childhood development including body mass index and height-for-age in 6-year-old children.

METHODS

This cross-sectional study was conducted across 788 6-year-old children from Tehran, Iran, in 2018. Food quality score (FQS) was used to assess overall diet quality, in addition to a modified food-based diet quality score specific to children (modified FQS) developed by our group.

RESULTS

Participants in the highest tertile using the modified FQS had the highest height-for-age z-score (HAZ) (-0.509 ± 0.028 vs -0.605 ± 0.028; P = .048). In contrast, participants in the highest tertile assessed using the original FQS had a higher BMI for age z-score (BAZ) compared to participants in the first tertile (0.391 ± 0.072 vs 0.266 ± 0.072; P = .023). Children within the highest tertile, according to the original FQS, compared to those within the lowest tertile were 49% less likely to be categorised as severely underweight (OR: 0.51; 95% CI: 0.47-0.98).

CONCLUSIONS

Findings presented in this study demonstrate that FQS was significantly associated with participants characterised as severely underweight; however, FQS was not associated with other anthropometric parameters. Therefore, future well-designed cohort studies are required to address limitations of the current study.

Determinants of minimum acceptable diet feeding among children aged 6-23 months in Odisha, India

OBJECTIVE

To assess the level, pattern and determinants of minimum acceptable diet (MAD) feeding in Odisha, India.

DESIGN

Utilising cross-sectional data, the MAD was estimated through a dietary assessment method wherein the child's mother was asked to recall all the food intake of the youngest child the previous day and night of the surveyed date.

SETTING

National Family Health Survey 2015-2016.

PARTICIPANTS

Children aged 6-23 months, living with mother and for whom complete information on MAD was available (n 3073).

RESULTS

Only 8·4 % of the children aged 6-23 months were fed MAD, and the MAD feeding varies considerably by socio-demographic characteristics. Children aged 12-17 months had two times (OR: 2·51, 95 % CI (1·48, 4·26)) and those aged 18-23 months had three times (OR: 3·77, 95 % CI (2·25, 6·30)) higher odds of having a MAD than their counterparts aged 6-8 months. Children whose mother was exposed to any mass media had a higher chance of MAD feeding (OR: 1·46, 95 % CI (1·01, 2·11)).

CONCLUSIONS

The children of higher age, second or higher-order births, with mother exposed to mass media are significantly more likely to be fed with a MAD. At the same time, children from scheduled caste (SC) households have a lower probability of MAD feeding. The lower MAD feeding among the SC households suggests strengthening the ongoing programmes with a higher emphasis on the inclusion of this disadvantaged and marginalised group. Findings from the current study would assist policymakers, and public health managers improve MAD feeding practices in Odisha, India, in a targeted manner.

A 6-week healthy eating intervention with family engagement improves food knowledge and preferences but not dietary diversity among urban preschool children in Sri Lanka

OBJECTIVE

To evaluate the effectiveness of a multicomponent intervention (MCI) on children's dietary diversity and its impact pathway components of children's food knowledge and healthy food preferences.

DESIGN

A 6-week cluster randomised controlled trial with a MCI consisting of child nutrition education plus family engagement through parental nutrition education, meal preparation and tasting was compared with two groups: single component intervention (SCI) of child nutrition education, and control, conducted during February to July 2018. Preschool centres were randomly assigned to one of the three arms. Children's food knowledge, healthy food preferences and dietary diversity scores were collected. Intervention effects were analysed using a pre-post analysis and a difference-in-difference model.

SETTING

Fourteen preschool centres in an urban area of Kurunegala, Sri Lanka.

PARTICIPANTS

Child-parent dyads of children aged 4-6 years. Final analyses included 306 (for food knowledge and preferences) and 258 (for dietary diversity) dyads.

RESULTS

MCI significantly influenced the impact pathways to children's dietary diversity by increasing children's food knowledge and healthy food preferences scores by 3·76 and 2·79 (P < 0·001), respectively, but not the dietary diversity score (P = 0·603), compared with the control arm. Relative to SCI, MCI significantly improved children's food knowledge score by 1·10 (P < 0·001), but no significant effects were noted for other outcome variables.

CONCLUSIONS

Improved food knowledge and preferences require a positive food environment and time to develop into healthy eating behaviours. Research into dietary diversity should broaden to incorporate the contextual roles of the home and general food environments to more completely understand food choices of children.

Model and variable selection using machine learning methods with applications to childhood stunting in Bangladesh

Childhood stunting is a serious public health concern in Bangladesh. Earlier research used conventional statistical methods to identify the risk factors of stunting, and very little is known about the applications and usefulness of machine learning (ML) methods that can identify the risk factors of various health conditions based on complex data. This research evaluates the performance of ML methods in predicting stunting among under-5 aged children using 2014 Bangladesh Demographic and Health Survey data. Besides, this paper identifies variables which are important to predict stunting in Bangladesh. Among the selected ML methods, gradient boosting provides the smallest misclassification error in predicting stunting, followed by random forests, support vector machines, classification tree and logistic regression with forward-stepwise selection. The top 10 important variables (in order of importance) that better predict childhood stunting in Bangladesh are child age, wealth index, maternal education, preceding birth interval, paternal education, division, household size, maternal age at first birth, maternal nutritional status, and parental age. Our study shows that ML can support the building of prediction models and emphasizes on the demographic, socioeconomic, nutritional and environmental factors to understand stunting in Bangladesh.

Not water, sanitation and hygiene practice, but timing of stunting is associated with recovery from stunting at 24 months: results from a multi-country birth cohort study

OBJECTIVES

To measure the role of water, sanitation and hygiene (WASH) practices on recovery from stunting and assess the role of timing of stunting on the reversal of this phenomenon.

DESIGN

Data from the MAL-ED multi-country birth cohort study was used for the current analysis. Generalised linear mixed-effects models were used to estimate the probability of reversal of stunting with WASH practice and timing of stunting as the exposures of interest.

SETTING

Seven different countries across three continents.

PARTICIPANTS

A total of 612 children <2 years of age.

RESULTS

We found that not WASH practice but timing of stunting had statistically significant association with recovery from stunting. In comparison with the children who were stunted at 6 months, children who were stunted at 12 months had 1·9 times (β = 0·63, P = 0·03) more chance of recovery at 24 months of age. And, children who were stunted at 18 months of age even had higher odds (adjusted OR = 3·01, β = 1·10, P < 0·001) of recovery than children who were stunted at 6 months. Additionally, mother's height (β = 0·59, P = 0·04) and household income (β = 0·02, P < 0·05) showed statistically significant associations with the outcome.

CONCLUSIONS

The study provided evidence for the role of timing of stunting on the recovery from the phenomenon. This novel finding indicates that the programmes to promote linear growth should be directed at the earliest possible timepoints in the course of life.

Experience of the COVID-19 Pandemic in Rural Odisha, India: Knowledge, Preventative Actions, and Impacts on Daily Life

We conducted 131 semi-structured phone interviews with householders in rural Odisha, India to explore participants’ COVID-19 related knowledge, perceptions, and preventative actions, as well as how the pandemic affected their daily life, economic and food security, and the village-level response. Interviews were conducted with 73 heads of household, 37 primary caregivers, and 21 members of village water and sanitation committees from 43 rural villages in Ganjam and Gajapati districts in Odisha state. The study took place between May–July 2020 throughout various lockdown restrictions and at a time when many migrant workers were returning to their villages and cases were rising. Most respondents could name at least one correct symptom of COVID-19 (75%), but there was lower knowledge about causes of the disease and high-risk groups, and overall COVID-19 knowledge was lowest among caregivers. Respondents reported high compliance with important preventative measures, including staying home as much as possible (94%), social distancing (91%), washing hands frequently (96%), and wearing a facial mask (95%). Additionally, many respondents reported job loss (31%), financial challenges (93%), challenges related to staying home whether as a preventative measure or due to lockdowns (57%), changes in types and/or amount of food consumed (61%), and adverse emotional effects as a result of the pandemic and lockdown. We also provide detailed summaries of qualitative responses to allow for deeper insights into the lived experience of villagers during this pandemic. Although the research revealed high compliance with preventative measures, the pandemic and associated lockdowns also led to many challenges and hardships faced in daily life particularly around job loss, economic security, food security, and emotional wellbeing. The results underscore the vulnerability of marginalized populations to the pandemic and the need for measures that increase resilience to large-scale shocks.

Socioeconomic and Geographic Pattern of Food Consumption and Dietary Diversity among Children Aged 6-23 Months Old in Ghana

Dietary inadequacy is a major challenge among young children in Ghana. Nutritional policies are required for optimum child nutrition and development. This study explored food consumption and dietary diversity by socioeconomic status and geographical location among children aged 6–23 months in Ghana. We used the latest national representative, cross-sectional data from the Ghana Demographic and Health Survey (GDHS-2014). A total of 887 children aged 6–23 months were used in the final analysis. The survey collected data on children’s food consumption through their mothers in the 24 h recall method. Multiple logistic regression models were used to assess the relationship between socioeconomic status and geographical location with food consumption and adequate dietary diversity after adjusting for control variables. The study revealed an association between specific food item consumption, food groups, and dietary diversity by socioeconomic and geographic characteristics. However, dairy consumption increased faster than other nutritional foods when socioeconomic status increased. Furthermore, the study revealed that children’s chances of consuming particular food items and food groups differed across Ghana’s 10 regions. The average probabilities of consuming adequate dietary diversity between the Greater Accra region and Ashanti region were 43% vs. 8% (p < 0.001). Consumption of grains, root, and tubers were relatively higher but low for Vitamin A-rich fruits and vegetables and legumes and nuts for children aged 6–23 months in Ghana. Overall, the mean dietary diversity score was low (3.39; 95% CI: 3.30–3.49) out of eight food groups, and the prevalence of adequate dietary diversity was 22% only. There is a need for policy interventions to ensure appropriate dietary practices to promote healthy growth of children.

Refrigeration and child growth: What is the connection?

Child stunting in Latin America and the Caribbean (LAC) decreased from 22.9% in 1990 to 9.6% in 2017. While stunting rates in the region were falling, access to electricity and refrigeration were on the rise. Despite a large body of evidence surrounding the effects of refrigeration on food consumption, and separately of the importance of food consumption for child health and nutrition, surprisingly few studies explore the potential effects of refrigeration on child nutrition. We studied the relationship between refrigeration and child nutrition outcomes using rich panel data for 1298 low-income households with children younger than 12 months at baseline in El Alto, Bolivia. We estimated the effects of refrigerator ownership on diet and nutrition outcomes using a difference-in-difference approach. Owning a refrigerator was associated with increased food expenditures and improved child nutrition. We found evidence that households that acquired a refrigerator were more likely to buy food that requires refrigeration, and children in households that acquired refrigerators were 0.17 standard deviations taller for their age after 2 years. We also found that refrigeration was associated with a 0.26 standard deviation decline in BMI-for-age, an effect driven by increased height rather than lower weight. These results suggest that refrigeration may play a role in explaining reductions in undernutrition observed in low- and middle-income countries in recent decades.

The role of piped water supplies in advancing health, economic development, and gender equality in rural communities

In rural areas of sub-Saharan Africa, one in eight households obtain drinking water from a piped system; the rest fetch water from improved and unimproved sources located at some distance from their homes. This task falls primarily to women and girls, creating time poverty and risks to safety and health. In this paper, we present a conceptual model that elaborates the mechanisms linking access to piped water with food security and long-term economic impacts. These hypotheses were tested in a quasi-experimental study of four villages in rural Zambia using a combination of household surveys, Global Positioning System transponders, and water meters to measure time spent fetching water, water consumption, and how water was being utilized for domestic and productive activities. Households receiving the piped water intervention spent a median of 3.8 h per week less fetching water, savings that accrued primarily to women and girls. Household water consumption increased 32%, which was used for both domestic and productive uses. Increases in the frequency of gardening and the size of garden plots in treatment households were observed. Households receiving piped water reported being happier, healthier, and having more time to participate in work inside or outside the home. We find that piped water supplies can promote the economic development and well-being of rural households, with particular benefits to women and girls, conditional upon pricing and management models that ensure sustainable service.

Qualitative, longitudinal exploration of coping strategies and factors facilitating infant and young child feeding practices among mothers in rural Rwanda

Background

Mothers in low-income countries face many challenges to appropriately feed their children in the first year such as poverty, food insecurity and high workloads. However, even in the lowest income families there are mothers who succeed to feed their children according to the recommendations. In this paper, we explored the coping strategies that facilitate appropriate breastfeeding and complementary feeding practices among rural Rwandan mothers from birth to one year of a child’s life.

Methods

This qualitative longitudinal study recruited a purposive sample of 17 mothers who followed the infant and young child feeding recommendations (IYCF). They were selected from a larger study of 36 mothers. In-depth interviews were conducted with mothers of the total group (36 mothers) within the first week, at 4^th, 6^th, 9^th and 12^th months postpartum. Interviews were audio-recorded, transcribed verbatim and analyzed thematically.

Results

Coping strategies included improving mothers’ own diet for adequate breastmilk production, prioritizing child feeding over livelihood chores, livelihood diversification and mothers’ anticipatory behaviors such as preparing child’s food in advance. Some of those coping strategies were shifting overtime depending on the development of the children. Personal factors such as breastfeeding self-efficacy, religious beliefs and perceived benefits of breastfeeding were among the facilitating factors. Additionally, social support that mothers received from family members, other mothers in the community, Community Health Workers (CHWs) and health professionals played an important role.

Conclusion

In challenging contextual conditions, mothers manage to follow the recommended breastfeeding and complementary feeding practices through the interplay of active coping strategies, feeling to be in control and social support. Nutrition promotion interventions that aim to improve IYCF should consider strengthening mothers’ capability in gaining greater control of their IYCF practices and the factors facilitating their appropriate IYCF practices.

Dietary condition and feeding practices of children aged 6-23 months in Ethiopia: analysis of 2005-2016 demographic and health survey

BACKGROUND

Childhood malnutrition is well estimated as the major underlying risk factor for morbidity and mortality in children under 5 years. Feeding practices greatly influence the dietary condition of children aged 6-23 months in developing countries. Therefore, this study was performed to determine the association between infant young children feeding (IYCF) practices and the dietary conditions of children aged 6-23 months in Ethiopia.

METHOD

A cross-sectional study was conducted based on data on 5638 children aged 6-23 months from three Ethiopia Demographic and Health Surveys (EDHS) (2005, 2011, 2016). Multivariable logistic regression was performed to estimate the odd ratios (ORs) and 95% confidence intervals (CIs) of stunting and anaemia with IYCF practices.

RESULT

The prevalence of stunting among children aged 6-23 months in Ethiopia decreased greatly from 49% in 2005 to 32% in 2016. Among the IYCF practices, consumption of iron-rich foods, minimum dietary diversity (MDD), and minimum acceptable diet (MAD) were significant predictors of stunting. In addition, the prevalence of anaemia declined significantly from 26% in 2005 to 16% in 2011, but increased to 29% in 2016. Among the IYCF practices, breastfeeding and minimum meal frequency (MMF) had lower odds of childhood anaemia.

CONCLUSIONS

The present study showed that anaemia and stunting among children aged 6-23 months in Ethiopia is critical public health problems that need urgent attention.

Maternal diets matter for children's dietary quality: Seasonal dietary diversity and animal-source foods consumption in rural Timor-Leste

Improving the dietary quality of women and children is essential to reduce all forms of malnutrition. In this study, we assessed seasonal child and maternal dietary diversity and consumption of animal-source foods (ASF), using 1,236 observations from combined data collected among 167 mother-child dyads in rural Timor-Leste. We used generalized linear and logistic mixed-effects models to examine the dietary differentials of mothers and children in two agricultural livelihood zones and across the seasons, as well as to identify household and agroecological characteristics associated with children's dietary quality in relation to their mothers'. We found dietary quality to be marginally better in coastal than in mid-altitude zones. However, women's diets were strikingly poor, and their intake of ASF was lower than among children. Mothers exhibited preferential allocation patterns of specific ASF, dairy products and eggs, to children. The intake of ASF was predicted by seasonality. Flesh foods and red meat were much more likely to be consumed during the dry season, when cultural ceremonies are often performed. We found a positive and strongly significant association between children's dietary indicators-dietary diversity score, minimum dietary diversity and ASF consumption, and those of their mothers'. Maternal dietary quality and educational attainment, more so than agroecological characteristics, were explanatory factors of children's diet. Our study highlights that addressing the dietary quality of children in Timor-Leste would benefit from improving women's diets through better access to nutritious foods and to secondary education.

Determinants of infant and young complementary feeding practices among children 6-23 months of age in urban Pakistan: a multicenter longitudinal study

BACKGROUND

Suboptimal feeding practices have a negative impact on children's health and growth in the first 2 years of life and increase their risk of undernutrition, morbidity, and mortality. The aim of the study was to assess the factors that influence infant and young child feeding practices among urban mothers in a hospital setting at Karachi, Pakistan.

METHODS

A longitudinal multi-center cohort study was conducted in four countries, MULTICENTER BODY COMPOSITION REFERENCE STUDY (MBCRS) to produce normal body composition reference data in healthy infants from 3 months to 24 months of age. Repeated anthropometric (weight, length and head circumference) and body composition measurements using "deuterium dilution method" along with 24-h dietary recall questionnaires were performed on 250 healthy term infants at 3, 6, 9, 12, 18, and 24 months of age. The 24-h dietary recall data from this study was used to assess the breastfeeding and complementary feeding practices in children aged 6-24 months.

RESULTS

A total of 250 healthy infants were enrolled in the study. A majority of newborns (75.4%) were exclusively breastfed till 3 months of age; however, by 6 months of age, only 30.2% of infants were exclusively breastfed. Only 44.1% of children aged 6-24 months achieved minimum dietary diversity (MDD), 84.7% achieved minimum meal frequency (MMF), and 44.1% achieved a minimum acceptable diet (MAD). 71.4% achieved MDD and MAD and 100% achieved MMF at 24 months. The bivariate analysis found that breastfed children (OR 3.93, 95% CI 2.72-5.68), with employed mothers (OR 1.55, 95% CI 1.06-2.27) who had graduated from secondary school (OR 1.45, 95% CI 1.08-1.94) were more likely to meet minimum dietary diversity. The multivariable analysis showed that only the child's age was significantly associated with MDD (p value< 0.0001), with the likelihood of meeting MDD increasing as the children aged; 9 months (OR 18.96, 95% CI 6.63-54.19), 12 months (OR 40.25, 95% CI 14.14-114.58), 18 months (OR 90.02, 95% CI 30.84-262.77) and 24 months (OR 82.14, 95% CI 27.23-247.83).

CONCLUSION

Our study revealed that Infant and young child feeding practices are significantly associated with maternal education, employment, and the child's age. Therefore, it is essential that investments be made towards protective breastfeeding and complementary feeding policies and legislations, emphasis on female education and ensuring the availability of affordable nutritious and diverse foods.

Examining the Effect of Geographic Region of Residence on Childhood Malnutrition in Uganda

OBJECTIVES

In our study, we examine how geographic region of residence may predict childhood malnutrition, expressed as stunting, wasting and underweight, among children under the age of 5 years in Uganda.

METHODS

Using data from the 2016 Uganda Demographic and Health Survey, we performed an incremental multivariate multilevel mixed-effect modelling to examine the effect of a child, parental and household factors on the association between region of residence and each indicator of childhood malnutrition.

RESULTS

Approximately 28%, 3% and 9% of children under age 5 suffered from stunting, wasting and underweight, respectively. The bivariate result shows that the proportion of children suffering from stunting and underweight was relatively lower in the Kampala region compared with the other regions. With the exception of the Northern region (6.44%), wasting was higher (4.12%) among children in the Kampala region. Children in the other regions were more likely to experience stunting and underweight. When controlling for child, parent and household factors, children in the other regions were less likely to suffer from underweight and stunting, compared with those in Kampala region. Children in the other regions, except the Northern region, were less likely to be wasted compared with those in Kampala region.

CONCLUSION

Our finding suggests that child, parental and household characteristics have effects on the association between region of residence and childhood malnutrition. Addressing individual and household socioeconomic disparities may be vital in tackling regional differences in childhood malnutrition.

Plasma Kynurenine to Tryptophan Ratio Is Negatively Associated with Linear Growth of Children Living in a Slum of Bangladesh: Results from a Community-Based Intervention Study

Chronic exposure to infectious agents results in environmental enteric dysfunction-a significant contributor to childhood stunting. Low plasma tryptophan (TRP), increased kynurenine (KYN), and KYN-TRP (KT) ratio are associated with infections and chronic immune activation. We postulated that both these conditions are interlinked, and therefore aimed to identify the association between KT ratio and the linear growth of Bangladeshi children. A total of 480 stunted and at risk of being stunted children aged 12-18 months were enrolled and provided nutrition intervention for 90 days. Plasma samples were assessed using liquid chromatography tandem mass spectrometry to measure TRP and KYN concentrations. Multivariable linear regression with generalized estimating equations was applied to analyze association between the KT ratio and linear growth. Tryptophan, KYN, and KT ratio were significantly higher in stunted children than in children at risk of being stunted both at baseline and at the end of nutrition intervention. Following intervention, the median (interquartile range [IQR]) KYN concentration was significantly reduced from 4.6 (3.6, 5.4) µmol/L to 3.9 (0.3, 7.6) µmol/L, and median (IQR) KT ratio decreased from 104 (80.9, 131) to 92.8 (6.6, 247) in stunted children. We also found KT ratio to be negatively associated (coefficient = -0.7; 95% CI = -1.13, -0.26; P-value = 0.002) with linear growth. In addition, KYN and KT ratio were positively correlated with fecal neopterin and plasma C-reactive protein, whereas TRP was negatively correlated with both of these biomarkers and alpha-1-acid glycoprotein. Our findings imply that KT ratio is associated in the pathophysiology of stunting as well as with biomarkers of inflammation in Bangladeshi children.

Who lacks and who benefits from diet diversity: evidence from (impact) profiling for children in Zimbabwe

BACKGROUND

The impact of diet diversity-defined as the number of different foods or food groups consumed over a given reference period-on child nutrition outcomes strongly interacts with agro-ecological, institutional, and socio-economic drivers of child food and nutrition security. Yet, the literature on the impact of diet diversity typically estimates average treatment effects, largely ignoring impact heterogeneity among different groups.

METHODS

In this paper, we introduce a new method of profiling to identify groups of treatment units that stand to gain the most from a given intervention. We start from the 'polling approach' which provides a fully flexible (non-parametric) method to profile vulnerability patterns (patterns in 'needs') across highly heterogeneous environments [35]. Here we combine this polling methodology with matching techniques to identify 'impact profiles' showing how impact varies across non-parametric profiles. We use this method to explore the potential for improving child nutrition outcomes, in particular stunting, through targeted improvements in dietary diversity in a physically and socio-economically diverse country, namely Zimbabwe. Complex interaction effects with agro-ecological, institutional and socio-economic conditions are accounted for. Finally, we analyze whether targeting interventions at the neediest (as identified by the polling approach) will also create the largest benefits.

RESULTS

The dominant profile for stunted children is that they are young (6-12 months), live in poorer/poorest households, in rural areas characterized by significant sloping of the terrain and with one-sided emphasis on maize cultivation and medium dry conditions. When moving from "need" to "maximal impact", we calculate both the coverage in "need" as well as the impact coverage, and find that targeting on need does not always provide the largest impact.

CONCLUSIONS

Policy-makers need to remain alert that targeting on need is not always the same as targeting on impact. Estimation of heterogeneous treatment effects allows for more efficient targeting. It also enhances the external validity of the estimated impact findings, as the impact of child diet diversity on stunting depends on various agro-ecological variables, and policy-makers can relate these findings to areas outside our study area with similar agro-ecological conditions.

Improvement of Dietary Diversity and Attitude toward Recommended Feeding through Novel Community Based Nutritional Education Program in Coastal Kenya-An Intervention Study

Community-based nutritional intervention to improve the practice of dietary diversity and child nutrition by community health workers (CHWs) involving Nyumba Kumi as small neighborhood units (SNUs) in communities has not yet been explored. This study was conducted in two villages in rural Kenya between 2018 and 2019. In total, 662 participants (control vs. intervention: n = 339 vs. n = 323) were recruited. The intervention group received education on maternal and child nutrition and follow-up consultations. The custom-tailored educational guidelines were made based on Infant and Young Child Feeding and the mother and child health booklet. The educational effects on household caregivers’ feeding practice attitude and child nutritional status were analyzed using multiple linear regression. After the intervention, a total of 368 household caregivers (187 vs. 181) and 180 children (113 vs. 67) were analyzed separately. Between the groups, no significant difference was found in their background characteristics. This study successfully improved the dietary diversity score (β = 0.54; p < 0.01) and attitude score (β = 0.29; p < 0.01). The results revealed that the interventions using CHWs and SNUs were useful to improve dietary diversity and caregivers’ attitudes toward recommended feeding. This research has the potential to be successfully applied in other regions where child undernutrition remains.

Are Women in Rural India Really Consuming a Less Diverse Diet?

BACKGROUND

It is widely considered that women have less diverse diets than other household members. However, it has been challenging to establish this empirically since women's diet diversity is measured differently from that of other household members.

OBJECTIVE

In this article, we compare women's dietary diversity with that of their respective households and thereby generate a measure of "dietary gap."

METHODS

We measure women's "dietary gap" by using the difference of homogenized household and woman dietary scores (using the same scales). This is done using primary data on 3600 households from 4 districts in India. Additionally, we show the robustness of our results to variations in scale and recall periods used to construct the diet diversity scores.

RESULTS

Mean difference tests indicate that women consistently consume 0.1 to 0.5 fewer food groups relative to other household members, with the results being statistically significant at the 1% level. The food groups driving this dietary gap are nonstaples like Vitamin A-rich fruits and vegetables, meat/fish/poultry, and dairy.

CONCLUSIONS

Results point toward the discrimination faced by women in the variety of the food consumed, the importance of considering comparability in creating indices of diet diversity, and the need to collect more detailed information on diets. To our knowledge, this is one of the first studies to examine dietary discrimination faced by women using common scales.

Stunting Was Associated with Reported Morbidity, Parental Education and Socioeconomic Status in 0.5-12-Year-Old Indonesian Children

Stunting is highly prevalent in Indonesian children. The objective of this study was to identify the associations of stunting with morbidity, parental education and socioeconomic status (SES) in Indonesian children. The study population was part of the South East Asian Nutrition Surveys (SEANUTS). A total of 2236 Indonesian children aged 0.5 to 12 years, who had participated in the SEANUTS, were included in this study. Stunting was defined as height for age Z-score (HAZ) ≤ −2 using WHO criteria and severe stunting as HAZ ≤ −3. Information on morbidity, parental education and family SES were collected by structured questionnaires. ANOVA was used for evaluating differences across groups, with or without correction for confounders. The results showed that the overall prevalence of stunting was 31.4%. HAZ in stunted children was associated with disease incidence, including frequency, parental education and family income. There were no significant differences in HAZ values in stunted children with one or more bouts of infectious, digestive tract or respiratory tract illnesses compared to stunted children with no reported illness. The prevalence of stunting in Indonesian children was high and was strongly associated with child morbidity, parental education and SES.

High double burden of child stunting and maternal overweight in the Republic of the Marshall Islands

Many low‐ and middle‐income countries are faced with a double burden of malnutrition characterized by a stagnating burden of undernutrition and an increasing prevalence of overweight and obesity often observed both at population and household levels. We used data from the 2017 National Integrated Child Health and Nutrition Survey in the Republic of the Marshall Islands to explore the prevalence of overweight mother‐stunted child pairs (mother–child double burden, MCDB). We used bivariate analysis, multivariate logistic regression, and multinomial logistic regression analysis to explore associations between child‐, maternal‐, and household‐level variables and both stunting and MCDB and other types of maternal–child pairs. Our results indicate that nearly three out of four mothers were overweight or obese and one in four households is home to an overweight mother with a stunted child. The risk of child stunting and of MCDB were largely associated with maternal characteristics of lower maternal height, maternal age at birth, years of education, and marital status and household economic status as measured by wealth index and number of household members. These findings support the growing body of evidence showing that the coexistence of high maternal overweight and child stunting (MCDB) has linked root causes to early life undernutrition that are exacerbated by the nutrition transition.

Are Household Expenditures on Food Groups Associated with Children's Future Heights in Ethiopia, India, Peru, and Vietnam?

Household expenditure surveys, routinely conducted in low-and middle-income countries (LMICs), usually include questions pertaining to recent household expenditures on key food groups. When child anthropometrics are also available, such expenditure data can provide insights into household food purchasing patterns that are associated with subsequent child growth measures. We used data from 6993 children, born around 2001, from Ethiopia, India, Peru, and Vietnam, from the Young Lives younger cohort. We compared associations between two weeks of household food expenditures (in PPP-Purchasing Power Parity adjusted dollars) on food groups and child height-for-age-Z score (HAZ) at subsequent time points to assess longitudinal associations. Total food expenditures, rural/urban residence, maternal and paternal schooling, and child sex were included in our adjusted models because they may affect the relations between household food group expenditures and future child HAZ. In Ethiopia, India, and Peru every extra PPP$ spent on fats was associated with 0.02-0.07 higher future HAZ. In Vietnam every extra PPP$ spent on starches, was significantly associated with a 0.01 lower future HAZ. Across countries, different patterns of food expenditure and procurement may be differentially critical for predicting child HAZ. Our results demonstrate how expenditures on specific food groups can be associated with children's linear growth. This study provides additional evidence of the utility of longitudinal household food expenditure data in understanding child nutritional status.

Dietary Diversity Practice and Associated Factors among Children Aged 6-23 Months in Robe Town, Bale Zone, Ethiopia

Background

Diet diversification is essential to prepare adequate food that is useful for children's physical and cognitive development. Despite the limited studies performed in different parts of Ethiopia, the information about the feeding practice of children in the current study area is not documented. Thus, this study intended to assess the dietary diversity practices and associated factors among children aged 6-23 months.

Methods

Community-based cross-sectional study was conducted on 517 children aged 6-23 months paired with their mothers in Robe town. Systematic sampling technique was applied to select a child-mother pair. Data were collected using a pretested and structured questionnaire. Multivariate logistic regression analyses were used to identify the factors associated with the dependent variable. Adjusted odds ratios with 95% confidence interval were used to assess the strength of association and level of significance.

Results

From a total of 508 children included, making a 98% response rate, 77% of them did not meet the minimum dietary diversity. Children aged 12-23 months were more likely fed diversified food when compared with those aged 6-11 months (AOR = 2.99). Mothers whose educational level was secondary and above (AOR = 3.21), had media exposure (AOR = 3.99), and were knowledgeable about diet diversification (AOR = 8.5) were more likely to feed their child diversified food than their counterpart. Children whose father was a merchant were more likely to receive a diversified diet compared to those whose fathers were daily laborers.

Conclusions

Inadequate practices of minimum dietary diversity observed in the current study area were mainly associated with the child's age, maternal education, mothers' knowledge on diet diversification, and media exposure. Improving knowledge of mothers, increasing their education, and promoting appropriate infant and child feeding practices through media are an important intervention to improve dietary diversity practices.

Infant and young child feeding practice, dietary diversity, associated predictors, and child health outcomes in Bangladesh

The aim of this study was to explore the association of Infant and Young Child Feeding (IYCF) practices with health and nutritional status among children aged 0-23 months and to investigate the predictors of minimum acceptable diets (MADs) using Bangladesh Demographic and Health Survey (BDHS) data. Binary logistic regression models were performed to assess the association between IYCF and child health and to determine the influential predictors for MAD. About 55% mothers reported exclusive breastfeeding; 65% introduced solid, semisolid, or soft foods for their child; and 27% maintained minimum dietary diversity (MDD). About 64% children received recommended minimum meal frequency (MMF) and 23% received recommended MAD. The likelihood of having wasting was .22 times lower for the child who received MDD and MMF, respectively. MDD and MAD were associated with lower probability of experiencing underweight among children (Adjusted odds ratio [AOR] = .73 and AOR= .81, respectively). Early initiation and continuation of breastfeeding were significantly associated with reduction in diarrhea prevalence among young children. The findings of the study generated imperative evidence related to dietary diversity, associated factors, and child health outcomes. Policy should focus on the improvement of IYCF practices and complimentary food diversity by taking initiatives for designing and implementing effective interventions to tackle childhood morbidity.

Dietary diversity and food intake of urban preschool children in North-Western Sri Lanka

Childhood malnutrition, associated with poor diet, is a clear public health threat in Sri Lanka, with high rates of under‐nutrition and micronutrient deficiencies coupled with the growing risk of overweight/obesity in urban locations. This study explored the dietary diversity and food intake of urban living Sri Lankan preschool children. A cross‐sectional analysis of the baseline data from a cohort study was conducted with parents/caregivers of children aged 2–6 years, from 21 preschool centres in Kurunegala District, Sri Lanka. Demographic and socio‐economic factors, dietary diversity score (DDS) (n = 597) and food intake (n = 458) (using a food frequency questionnaire) were assessed. Children had a mean DDS of 4.56 ± 0·85 out of 9, with most (91.1%) in the medium DDS category (DDS of 3.1–6.0), consuming rice as most common food. Lentils were consumed more than any meat or alternative food groups at all DDS levels. Child DDS differs with parent/caregiver age and ethnicity. Mean daily intakes of fruit (1.02) and vegetables (0.84) servings align with approximately half of national recommendations, with less than 20% of children meeting daily recommendations. More than one‐third consumed sugary snacks and confectionaries daily and 1 in 10 had them twice a day. Around 40% reported watching television while eating the evening meal. Despite the majority having reasonable DDSs (medium category), findings highlighted inadequate intakes of fruits and vegetables, excessive intakes of sugary snacks and unhealthy dietary and social behaviours, suggests the need for population‐based interventions to promote healthier dietary habits.

Factors Associated With Child Stunting, Wasting, and Underweight in 35 Low- and Middle-Income Countries

IMPORTANCE

Evidence on the relative importance of various factors associated with child anthropometric failures (ie, stunting, underweight, and wasting) and their heterogeneity across countries can inform global and national health agendas.

OBJECTIVE

To assess the relative significance of factors associated with child anthropometric failures in 35 low- and middle-income countries (LMICs).

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of 299 353 children who were born singleton and aged 12 to 59 months with nonpregnant mothers and valid anthropometric measures assessed the strengths of associations of 26 factors with child stunting, underweight, and wasting, using Demographic and Health Surveys (2007-2018) from 35 LMICs. Data analysis was conducted from July 2019 to February 2020.

EXPOSURES

A total of 9 direct factors (ie, dietary diversity score; breastfeeding initiation; vitamin A supplements; use of iodized salt; infectious disease in past 2 weeks; oral rehydration therapy for children with diarrhea; care seeking for suspected pneumonia; full vaccination; and indoor pollution) and 17 indirect factors (household wealth; maternal and paternal education; maternal and paternal height and body mass index; maternal autonomy for health care, movement, and money; water source; sanitation facility; stool disposal; antenatal care; skilled birth attendant at delivery; family planning needs; and maternal marriage age) were assessed.

MAIN OUTCOMES AND MEASURES

Three anthropometric failure outcomes were constructed based on the 2006 World Health Organization child growth standards: stunting (height-for-age z score less than -2 standard deviations [SDs]), underweight (weight-for-age z score less than -2 SDs), and wasting (weight-for-height z score less than -2 SDs).

RESULTS

Among the 299 353 children aged 12 to 59 months included in the analysis, 38.8% (95% CI, 38.6%-38.9%) had stunting, 27.5% (95% CI, 27.3%-27.6%) had underweight, and 12.9% (95% CI, 12.8%-13.0%) had wasting. In the pooled sample, short maternal height was the strongest factor associated with child stunting (odds ratio [OR], 4.7; 95% CI, 4.5-5.0; P < .001), followed by lack of maternal education (OR, 1.9; 95% CI, 1.8-2.0; P < .001), poorest household wealth (OR, 1.7; 95% CI,1.6-1.8; P < .001), and low maternal body mass index (OR, 1.6; 95% CI, 1.6-1.7; P < .001). Short paternal height was also significantly associated with higher odds of stunting (OR, 1.9; 95% CI, 1.7-2.2; P < .001). Consistent results were found for underweight (eg, short maternal height: OR, 3.5; 95% CI, 3.3-3.7; P < .001; lack of maternal education: OR, 1.8; 95% CI, 1.7-2.0; P < .001) and wasting (eg, low maternal body mass index: OR, 2.3; 95% CI, 2.1-2,4; P < .001; poorest household wealth: OR, 1.2; 95% CI, 1.1-1.3; P < .001). Parental nutritional status and household socioeconomic conditions ranked the strongest (1st to 4th) for most countries, with a few exceptions (eg, lack of maternal education ranked 18th-20th in 8 countries for child wasting). Other factors were not associated with anthropometric failures in pooled analysis and had large country-level heterogeneity; for example, unsafe water was not associated with child underweight in the pooled analysis (OR, 0.97; 95% CI, 0.95-1.00; P < .001), and it ranked from 4th to 20th across countries.

CONCLUSIONS AND RELEVANCE

In this study, socioeconomic conditions and parental nutritional status were the strongest factors associated with child anthropometric failures. Poverty reduction, women's education, and nutrition programs for households could be important strategies for reducing child undernutrition; however, country-specific contexts should be considered in national policy discussions.

Level of Undernutrition and Its Determinants Among Children Aged 12-59 Months in Wolaita District, Ethiopia

Background

Undernutrition remains one of the most common causes of morbidity and mortality among children throughout the world particularly in developing countries. The present study aimed to assess the magnitude and associated factors of undernutrition among children aged 12–59 months.

Methods

A community-based cross-sectional study was conducted in Wolaita district from May to June 2015. Multi-stage stratified systematic random sampling procedure was used. Data were collected using a pretested interviewer-administered questionnaire from 626 children aged 12–59 months. Height and weight were measured by trained data collectors and WHO Anthro version 3.2.2 software was used. Data were entered into Epi Info version 3.3.5 and were exported and analyzed using SPSS version 21. Multivariable logistic regression model with a step-wise method was used to determine the predictors of undernutrition.

Results

One third (34.1%; 95% CI 30.4–37.9%) of children were stunted while 6.9% and 11.9% of them were wasted and underweight, respectively, based on WHO Z score <-2. Children live in mother-headed households which often use unprotected sources of water and children who did not get minimum dietary diversity were more likely to be stunted compared to their counterparts. Children residing in rural residences, being a male child, having less power for mother decision-making, presence of diarrhea in the last 2 weeks of the survey and who did not get the minimum dietary diversity were found to be significant determinants of underweight. Children living rural, male sex, their order of birth being 5th and above and who had not got the minimum meal frequency were more likely to be wasted than their counterparts.

Conclusion and Recommendation

Undernutrition has a high prevalence in under-5-year-old children of Wolaita district. Under nutrition was associated with female-headed households, unprotected sources of water, below the minimum dietary diversity, rural residence, participation of mother in decision-making, presence of diarrhea, and minimum meal frequency. Thus, nutritional intervention programs in Wolaita district in Ethiopia should focus on these factors.

Determinants of age-appropriate breastfeeding, dietary diversity, and consumption of animal source foods among Indonesian children

Global child feeding practices remain suboptimal. In this study, we assess the determinants of age-inappropriate breastfeeding, dietary diversity, and consumption of 3+ types of animal source foods (ASFs) using 11,687 observations from combined data from the Indonesian Demographic Health Survey of 2012 and 2017. We used linear and logistic regression after adjusting for the complex sampling design. Child's age and quality of antenatal care (ANC) were associated with all outcomes. Socio-economic status and labour force participation were positively associated with higher dietary diversity score, ASF consumption, and age-inappropriate breastfeeding. More ANC visits and having consultation at ANC were associated with more dietary diversity. Higher women's knowledge level was associated with more dietary diversity and consuming more ASF. Compared with western Indonesia, more children in eastern Indonesia were age-inappropriately breastfed and had lower dietary diversity. The Indonesian government needs to develop programmes to improve child feeding particularly in eastern Indonesia, focusing on improving dietary diversity and ASF consumption in poorer households and on prolonging breastfeeding in richer households. Women's labour force participation should be encouraged, but programmes for working mothers are also needed to support continued breastfeeding and to express breast milk. ANC and postnatal programmes need improved consultation sessions for child feeding.

The influence of dietary diversity on the nutritional status of children between 6 and 23 months of age in Tanzania

BACKGROUND

Undernutrition poses a serious health challenge in developing countries and Tanzania has the highest undernutrition burden of Eastern and Southern Africa. Poor infant and young child feeding practices have been identified as the main causes for undernutrition. As dietary diversity is a major requirement if children are to get all essential nutrients, it can thus be used as one of the core indicators when assessing feeding practices and nutrition of children. Therefore, adequate information on the association between dietary diversity and undernutrition to identify potential strategies for the prevention of undernutrition is critical. Here we examined to what extent dietary diversity is associated with undernutrition among children of 6 to 23 months in Tanzania.

METHODS

Using existing data from the Tanzania Demographic and Health Survey of 2015-2016, we carried out secondary data analysis. Stunting, Wasting and Underweight of the surveyed children were calculated from Z-scores of Height-for-age (HAZ), Weight-for-height (WHZ) and Weight-for-age (WAZ) based on 2006 WHO standards. A composite dietary diversity score was created by summing the number of food groups eaten the previous day as reported for each child by the mother ranging from 0 to 7. Then, minimum dietary diversity (MDD) of 4 food groups out of seven was used to assess the diversity of the diet given to children. Bivariate and multivariate logistic regression techniques were used to assess the crude and adjusted odds ratios of stunting, wasting and being underweight.

RESULTS

A total of 2960 children were enrolled in this study. The prevalence of stunting was 31%, wasting 6% and underweight 14%. Among all children, 51% were female and 49% male. The majority (74%) of children did not reach the MDD. The most commonly consumed types of foods were grains, roots and tubers (91%), and Vitamin A containing fruits and vegetables (65%). The remaining food groups were reported to be consumed by a much lower proportion of children, including eggs (7%), meat and fish (36%), milk and dairy products (22%), as well as legumes and nuts (35%), and other vegetables (21%). Consumption of a diverse diet was significantly associated with a reduction of stunting, wasting and being underweight in children. The likelihood of being stunted, wasted and underweight was found to decrease as the number of food groups consumed increased. Children who did not receive the MDD had a significantly higher likelihood of being stunted (AOR = 1.37, 95% CI; 1.13-1.65) and underweight (AOR = 1.49, 95% CI; 1.15-1.92), but this was not the case for wasting. Consumption of animal-source foods has been found to be associated with reduced stunting among children.

CONCLUSION

Consumption of a diverse diet is associated with a reduction in undernutrition among children of 6 to 23 months in Tanzania. Measures to improve the type of complementary foods in order to meet the energy and nutritional demands of children should be considered in Tanzania.

Determinants of Household Food Insecurity and Its Association with Child Malnutrition in Sub-Saharan Africa: A Review of the Literature

Food insecurity is a global public health challenge. Household food insecurity is the leading risk factor of malnutrition, claiming approximately 300,000 deaths each year. Whether directly or indirectly, due to inadequate food consumption and poor diet quality, it is also accountable for over half of all deaths among children in Sub-Saharan Africa. It is estimated that the prevalence of food-insecure individuals in the area will reach 17 million by the year 2021. Inadequate nutrition may result in low immunity, impaired physical and mental development and reduced productivity among children under five years and throughout the life course. This review article attempts to discuss the various household food insecurity determinants and their association with child malnutrition in a Sub-Saharan Africa context. The purposes of this article are to inform governments, policymakers and service providers regarding the importance of household food security and its determinants on child malnutrition, and to plan strategies to improve the household food security status in Sub-Saharan Africa.

Dietary Diversity, Social Support and Stunting among Children Aged 6-59 Months in an Internally Displaced Persons Camp in Kayin State, Myanmar

Children living in the internally displaced person (IDP) camp are at higher risk of stunting. This cross-sectional study aimed to assess the prevalence and to identify the associated factors of stunting among children aged 6–59 months at Myaing-Gyi-Ngu IDP camp in Kayin State, Myanmar. According to the World Health Organization Child Growth Standards, children with a height-for-age Z-scores below −2 standard deviation of the reference median (HAZ ≤ −2) were classified as stunted. Multiple logistic regression analysis was performed to identify the strong predictors. Prevalence of stunting has been found very high (59.4%). Adjusted model revealed that children living with illiterate mothers (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.07–3.24), being third/later-birth child (OR, 1.88; 95% CI, 1.13–3.14), consuming less than 4 food groups (OR, 4.22; 95% CI, 1.94–9.16), and older age of child (OR, 6.36 for 13–24 months; 95% CI, 2.74–14.74, 7.45 for 25–36 months; 95% CI, 3.21–17.25 and 12.75 for 37–59 months; 95% CI, 5.51–29.52) had higher odds of becoming stunted. The levels of support availability, presumed support and support received of mothers were generally low, but no significant associations were observed. In conclusion, this study showed high prevalence of stunting, but low dietary diversity and social support in the IDP camp. Due to the significant association of dietary diversity scores with stunting, interventions aiming at improving dietary diversity should be taken to reduce the stunting among children in the IDPs camp.

Diet Diversity and Micronutrient Adequacy among Filipino School-Age Children

Previous studies have shown that the dietary diversity of young Filipino children to be limited and that the prevalence of nutrient inadequacies is high. This study extends the current knowledge to examine the relationship between diet diversity and the probability of adequacy of micronutrients among Filipino schoolchildren (aged 6 to 12 years), by the wealth status and dwelling location. The dietary intake data were collected using a single 24-h recall from 6460 children in the Filipino National Nutrition Survey 2013. The diet diversity score (DDS) and the probability of adequacies (PA) of 11 micronutrients were calculated, and further stratified by socio-economic status (SES) and dwelling location. The diet diversity was generally low (mean DDS = 4 out of 9). Children from the lowest SES, and living in rural areas, tended to have a lower DDS. Children with a DDS of 1 were likely to be inadequate in all 11 micronutrients. The higher DDS (≥6) was associated with higher PAs for the B vitamins but not for calcium, folate, iron, vitamin A and to large extent, vitamin C. This suggests that it was difficult for this population to achieve adequacy in these 5 micronutrients. More rigorous research on the topic is needed. Better access to nutrient-rich or fortified staple foods, in tandem with increased education on the importance of dietary diversity, are potential strategies to support children in achieving adequate micronutrient intakes.

Parent's food preference and its implication for child malnutrition in Dabat health and demographic surveillance system; community-based survey using multinomial logistic regression model: North West Ethiopia; December 2017

BACKGROUND

A Shortage or excessive intake of the nutrient is malnutrition; affecting every aspect of human beings. Malnutrition at childhood has long-lasting and multiple effects. In Ethiopia significant numbers of children were suffering from malnutrition that might be associated with parents' food preference; the fact not yet investigated. Therefore the aim of this study was to assess parents' food preferences and its implication for child malnutrition.

METHODS

The study was conducted among 7150 mothers/caretakers in Dabat demographic and health surveillance site. Data were collected by experienced data collectors working for the surveillance centers after extensive training. A multinomial logistic regression model was fitted to determine the effect of factors on the dependent variable and model fitness was checked using a likelihood ratio test.

RESULTS

About 62.55% of mothers/caretakers prefer to feed children with a family and 16.45% of them prefer to feed children with a specific type of food. Mothers/caretakers who introduce semisolid food after 6 months 2.34(1.50-3.96) were times more likely prefer to feed with family food for their children than a balanced diet. Regarding the specific type of food preference mothers who introduce semisolid food after 6 months and those obtain food from the market were 6.53(3.80-11.24) and 4.38(3.45-5.56) times more likely to prefer to feed specific types of than balanced diet respectively.

CONCLUSION

Food preference had contributed to the increased and persistent magnitude of child malnutrition as 62.55% of mothers prefer to feed children with family and only 21% of them prefer to feed a balanced diet for under-five children. Therefore we recommended integration of child dietary diversity, acceptability and safety counseling session for mothers visiting health institutions for child vaccination, ANC and PNC services.

A framework for targeting water, sanitation and hygiene interventions in pastoralist populations in the Afar region of Ethiopia

Globally, many populations face structural and environmental barriers to access safe water, sanitation and hygiene (WASH) services. Among these populations are many of the 200 million pastoralists whose livelihood patterns and extreme environmental settings challenge conventional WASH programming approaches. In this paper, we studied the Afar pastoralists in Ethiopia to identify WASH interventions that can mostly alleviate public health risks, within the population's structural and environmental living constraints. Surveys were carried out with 148 individuals and observational assessments made in 12 households as part of a Pastoralist Community WASH Risk Assessment. The results show that low levels of access to infrastructure are further compounded by risky behaviours related to water containment, storage and transportation. Additional behavioural risk factors were identified related to sanitation, hygiene and animal husbandry. The Pastoralist Community WASH Risk Assessment visually interprets the seriousness of the risks against the difficulty of addressing the problem. The assessment recommends interventions on household behaviours, environmental cleanliness, water storage, treatment and hand hygiene via small-scale educational interventions. The framework provides an approach for assessing risks in other marginal populations that are poorly understood and served through conventional approaches.

Dietary patterns of >30,000 adolescents 9-15 years of age in rural Bangladesh

Little is known of the usual food intakes of rural adolescents in South Asia. This study describes dietary patterns, based on >91,000 7‐day food frequencies among 30,702 girls and boys, aged 9–15 years in rural northwest Bangladesh. Three intake assessments per child, taken across a calendar year, were averaged to represent individual annual intake patterns for 22 food groups. Latent class analysis was used to assign individuals to dietary patterns based on class membership probabilities. The following five dietary patterns (class membership probabilities) were identified: (1) “least diverse” (0.20); (2) “traditional” (0.28); (3) “low vegetable/low fish” (0.23), (4) “moderately high meat” (0.20); and (5) “most diverse” (0.09). The least diverse pattern had the lowest median consumption of most foods and traditional had a relatively higher intake of most vegetables and fish. The most diverse pattern consumed both healthy and processed foods much more often than other patterns. The two most diverse patterns (4 and 5) were associated with higher socioeconomic status, body mass index, height‐for‐age Z‐score, and male gender, and the least diverse pattern showed inverse associations with these characteristics. The most diverse pattern may represent an early wave of the nutrition transition in rural Bangladesh.

Mapping the effects of drought on child stunting

As climate change continues, it is expected to have increasingly adverse impacts on child nutrition outcomes, and these impacts will be moderated by a variety of governmental, economic, infrastructural, and environmental factors. To date, attempts to map the vulnerability of food systems to climate change and drought have focused on mapping these factors but have not incorporated observations of historic climate shocks and nutrition outcomes. We significantly improve on these approaches by using over 580,000 observations of children from 53 countries to examine how precipitation extremes since 1990 have affected nutrition outcomes. We show that precipitation extremes and drought in particular are associated with worse child nutrition. We further show that the effects of drought on child undernutrition are mitigated or amplified by a variety of factors that affect both the adaptive capacity and sensitivity of local food systems with respect to shocks. Finally, we estimate a model drawing on historical observations of drought, geographic conditions, and nutrition outcomes to make a global map of where child stunting would be expected to increase under drought based on current conditions. As climate change makes drought more commonplace and more severe, these results will aid policymakers by highlighting which areas are most vulnerable as well as which factors contribute the most to creating resilient food systems.

Predictors of complementary feeding practices in Afghanistan: Analysis of the 2015 Demographic and Health Survey

Despite improvements over the past 20 years, high burdens of child mortality and undernutrition still coexist in Afghanistan. Global evidence indicates that complementary feeding (CF) practices predict child survival and nutritional status. Our study aims to describe CF practices in Afghanistan and to discern underlying predictors of CF by analysing data from Afghanistan's 2015 Demographic and Healthy Survey. Multilevel models were constructed comprising potential predictors at individual, household, and community levels and four CF indicators: timely introduction of solid, semi-solid, or soft foods (INTRO), minimum meal frequency (MMF), minimum dietary diversity (MDD), and minimum acceptable diet (MAD) among breastfed children. INTRO prevalence among children aged 6-8 months was 56%, whereas the prevalence of MMF, MDD, and MAD among children aged 6-23 months was 55%, 23%, and 18%, respectively. Of the seven food groups considered, four were consumed by 20% or fewer children: eggs (20%), legumes and nuts (18%), fruits and vegetables (15%), and flesh foods (14%). Increasing child age and more antenatal care visits were significantly and positively associated with greater odds of meeting all CF indicators. Lower household wealth and lower community-level access to health care services were associated with lower odds of MDD and MAD. Disparities in achieving recommended CF practices were observed by region. CF practices in Afghanistan are poor and significant socioeconomic inequities in CF are observed across the country. Our study calls for urgent policy and programme attention to improve complementary feeding practices as an intrinsic part of the national development agenda.

Stunting, food security, markets and food policy in Rwanda

BACKGROUND

Over the past two decades, Rwanda has experienced impressive economic growth, resulting in considerable improvements in living standards and poverty reduction. Despite these gains, progress on reducing the level of stunting in smallholder rural children, particularly boys, continues to be a serious concern.

METHODS

Policies, dietary diversity and socio-economic factors that may influence stunting in rural Rwandan children were evaluated using a logit model with clustered variance-covariance estimators based on village membership of the household.

RESULTS

Stunting of rural children was found to be multidimensionally related to the child's gender, weight and age; the dietary diversity, marriage status and education level of the head of household; mother's height; presence of a family garden or if they owned livestock; environmental factors such as altitude and soil fertility and location relative to a main road en route to a market; and a policy that promoted food production.

CONCLUSIONS

Findings suggest that agricultural policies may be subsidizing poor dietary behavior in that the aggregation of production encourages households to sell high quality nutritious food such as fruit and vegetables, for more voluminous amounts of nutritionally substandard goods, hence low dietary diversity. However, it is less clear if rural food markets are capable of supplying diverse and nutritious foods at affordable prices on a consistent basis, resulting in a lack of diversity and hence, low nutrient quality diets. Rwanda's next round of food security policies should focus on nutrition insecurity with special emphasis on the lack of protein, micronutrients and calories. Multipronged policies and programs focused on income growth, food security, enhanced access to markets and gender-related nutrition risks from inception through 2 years of age in the rural areas are required to improve rural household health outcomes, stunting in particular.