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Diana A, Mallard SR, Haszard JJ, Purnamasari DM, Nurulazmi I, Herliani PD, Nugraha GI, Gibson RS, Houghton L. Consumption of fortified infant foods reduces dietary diversity but has a positive effect on subsequent growth in infants from Sumedang district, Indonesia. PLoS One 2017; 12:e0175952. [PMID: 28426828 PMCID: PMC5398566 DOI: 10.1371/journal.pone.0175952] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 04/03/2017] [Indexed: 12/30/2022] Open
Abstract
Stunting and underweight among under-five children in Indonesia are common, raising public health concerns. Whether inappropriate complementary feeding (CF) practices compromise optimal growth during late infancy in Indonesia is uncertain. Therefore we characterized and evaluated CF practices in Indonesian infants and investigated their relationship with subsequent growth. We enrolled breastfed infants at 6 months of age (n = 230); and followed them at 9 (n = 202) and 12 months of age (n = 190). We collected socio-demographic and anthropometric data and two-day in-home weighed food records. Relations between WHO CF indicators, sentinel foods, and energy and micronutrient intakes at 9 months and growth at 12 months were explored using multiple linear regression. Stunting and underweight increased from 15.8% and 4.4% at 6 months to 22.6% and 10.5% at 12 months, respectively. Median intakes of calcium, iron, zinc, and riboflavin were below WHO recommendations. Infants consuming fortified infant foods (FIFs) at 9 months had diets with a lower dietary diversity (DD) score (2.3 vs.3.0), energy density, median energy (250 vs. 310 kcal/d) and protein (6.5 vs. 9.1 g/d) intake than non-consumers (p<0.01), despite higher intakes of calcium, iron, and vitamins A and C (p<0.001). Positive relations existed for 9-month consumption of iron-rich/iron fortified infant foods with length-for-age Z-score (LAZ) at 12 months (β = 0.22; 95% CI: 0.01, 0.44; P = 0.04), and for fortified infant foods alone with both LAZ (β = 0.29; 95% CI: 0.09, 0.48; P = 0.04) and weight-for-age Z-score (β = 0.14; 95% CI: 0.02, 0.26; P = 0.02) at 12 months. The positive association of FIFs with subsequent growth may be attributed to their content of both powdered cow's milk and multi-micronutrient fortificants. Nonetheless, mothers should not be encouraged to over-rely on FIFs as they reduce DD.
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Affiliation(s)
- Aly Diana
- Faculty of Medicine, Universitas Padjadjaran, West Java, Indonesia
- Department of Human Nutrition, University of Otago, Otago, New Zealand
| | | | | | | | | | | | - Gaga I. Nugraha
- Faculty of Medicine, Universitas Padjadjaran, West Java, Indonesia
| | | | - Lisa Houghton
- Department of Human Nutrition, University of Otago, Otago, New Zealand
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102
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Ickes S, Baguma C, Brahe CA, Myhre JA, Bentley ME, Adair LS, Ammerman AS. Maternal participation in a nutrition education program in Uganda is associated with improved infant and young child feeding practices and feeding knowledge: a post-program comparison study. BMC Nutr 2017; 3. [PMID: 31354959 PMCID: PMC6660008 DOI: 10.1186/s40795-017-0140-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background Cost-effective approaches to improve feeding practices and to reduce undernutrition are needed in low-income countries. Strategies such as nutritional counseling, food supplements, and cash transfers can substantially reduce undernutrition among food-insecure populations. Lipid-based nutrient supplements (LNS) are an increasingly popular strategy for treating and preventing undernutrition and are often delivered with nutrition education. The post-program effects of participation in a LNS-supported supplemental feeding program on Infant and Young Child Feeding (IYCF) practices and caregiver child feeding knowledge are not well understood. The objective of this study was to understand whether children’s diet quality and caregiver nutrition knowledge was improved after participation in such a program. Methods We conducted a post-program comparison group study to compare feeding practices and caregiver nutrition knowledge among mother-child dyads who completed a nutrition education program and a community comparison group in western Uganda. We administered a feeding practices survey and two 24-h dietary recalls to 61 Post-Program (PP) caregivers and children ages 6 to 59 months (mean age = 25.1 months) who participated in a supplemental feeding program (which included growth monitoring, caregiver nutrition education, and LNS) and a Comparison Group (CG) of 61 children and caregivers. PP caregivers were recruited 4 to 8 weeks after program participation ended. We hypothesized that PP caregivers would report better IYCF practices and greater knowledge of key nutrition education messages related to IYCF. Results PP children had higher dietary diversity scores (3.0 vs 2.1, p =0.001) than CG children, and were more fed more frequently (3.0 vs 2.1 times per day, p = 0.001). IYCF indicators were higher in the PP group for minimum meal frequency (44.8% vs. 37.9%), minimum dietary diversity (10.3 vs. 3.4%), iron-rich complementary foods (17.2 vs. 20.7%), and minimally acceptable diet (10.3% vs 3.6%), but differences were non-significant. Caregivers in the PP group demonstrated greater knowledge of healthful IYCF practices. Conclusions Nutrition education can be effective to improve caregiver feeding practices and children’s dietary diversity and the frequency by which they are fed. A 10-week nutrition education and supplemental feeding program appears to provide some benefit to children in terms of dietary diversity and frequency of meals, and caregiver knowledge of feeding 1 to 2 months after program completion. However, children in this rural Ugandan region have diets that are still largely inadequate, highlighting the need for enhanced interventions and policies to promote diverse and appropriate diets for young children in this region. Future follow-up work in LNS-supported programs is recommended to understand how other similar approaches influence children's diet quality after program completion in other contexts.
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Affiliation(s)
- Scott Ickes
- The University of Washington Department of Health Service and Nutritional Sciences, University of Washington School of Public Health, Raitt Hall Box 353410, Seattle, WA 98195-3410, U.S.A
| | - Charles Baguma
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | | | - Margaret E Bentley
- Department of Nutrition, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Linda S Adair
- Department of Nutrition, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Alice S Ammerman
- Department of Nutrition, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
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103
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Underwood CR, Broaddus ET, Kc S, Thapa RK. Community Theater Participation and Nutrition-Related Practices: Evidence from Nepal. JOURNAL OF HEALTH COMMUNICATION 2017; 22:327-336. [PMID: 28287949 DOI: 10.1080/10810730.2017.1290166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Suaahara, a nutrition-enhancement program in Nepal, conducted participatory community theater (CT) dramas with the goal of improving nutrition-related practices. To evaluate CT, a pre/posttest with randomized intervention and matched control sites was used. Dramas were conducted in Nawalparasi, Bajhang, and Sindhupalchowk Districts to represent the mountain, hill, and terai/plains regions. Within each study district, two intervention sites were randomly selected and two matched comparison sites were identified for inclusion in the study. At both baseline and endline, 600 individuals aged 18-59 (100 men and 100 women/district × 3 districts) were interviewed in the control sites and 600 in the intervention sites (1200 total respondents). Multivariate logistic analysis controlling for background characteristics found that CT attendance was significantly and positively associated with improved nutrition-related knowledge (adjusted odds ratio ratio [aORR] 10.2, p < 0.001) and communication (aORR 2.4, p < 0.001), hand washing after cleaning a defecating child (aORR 1.49, p < 0.05), feeding children eggs (aORR 1.83, p < 0.01), and feeding children meat and/or fish (aORR 2.10, p < 0.01). This is the first study to rely on a pre/post matched intervention-control design to assess CT effects in a low-income setting. By testing the "difference-in-differences"-or the difference between intervention groups at baseline and endline minus that between controls at baseline and endline-the argument that the effects can be causally attributed to the intervention itself is strengthened. These findings support the continued and expanded use of CT to improve nutrition-related knowledge, communication, efficacy, and feeding practices as a valuable community-based, public health approach.
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Affiliation(s)
- Carol R Underwood
- a Department of Health, Behavior & Society, Bloomberg School of Public Health , Johns Hopkins University , Baltimore , Maryland , USA
| | - Elena T Broaddus
- b Department of International Health, Bloomberg School of Public Health , Johns Hopkins University , Baltimore , Maryland , USA
| | - Shreejana Kc
- c Center for Communication Programs, Bloomberg School of Public Health , Johns Hopkins University , Kathmandu , Nepal
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104
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Dewey KG, Mridha MK, Matias SL, Arnold CD, Cummins JR, Khan MSA, Maalouf-Manasseh Z, Siddiqui Z, Ullah MB, Vosti SA. Lipid-based nutrient supplementation in the first 1000 d improves child growth in Bangladesh: a cluster-randomized effectiveness trial. Am J Clin Nutr 2017; 105:944-957. [PMID: 28275125 DOI: 10.3945/ajcn.116.147942] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 02/02/2017] [Indexed: 11/14/2022] Open
Abstract
Background: Stunting in linear growth occurs mainly during the first 1000 d, from conception through 24 mo of age. Despite the recognition of this critical period, there have been few evaluations of the growth impact of interventions that cover most of this window.Objective: We evaluated home fortification approaches for preventing maternal and child undernutrition within a community-based health program. We hypothesized that small-quantity lipid-based nutrient supplements (LNSs) provided to women during pregnancy and the first 6 mo postpartum, LNSs provided to their offspring from 6 to 24 mo of age, or both would result in greater child length-for-age z score (LAZ) at 24 mo than iron and folic acid (IFA) provided to women during pregnancy and postpartum plus micronutrient powder (MNP) or no supplementation for their offspring from 6 to 24 mo.Design: We conducted a cluster-randomized effectiveness trial with 4 arms: 1) women and children both received LNSs (LNS-LNS group), 2) women received IFA and children received LNSs (IFA-LNS group), 3) women received IFA and children received MNP (IFA-MNP group), and 4) women received IFA and children received no supplements (IFA-Control group). We enrolled 4011 women at ≤20 wk of gestation within 64 clusters, each comprising the supervision area of a community health worker. Analyses were primarily performed by using ANCOVA F tests and Tukey-Kramer-corrected pairwise comparisons.Results: At 24 mo, the LNS-LNS group had significantly higher LAZ (+0.13 compared with the IFA-MNP group) and head circumference (+0.15 z score compared with the IFA-Control group); these outcomes did not differ between the other groups. Stunting prevalence (LAZ <-2) was lower in the LNS-LNS group at 18 mo than in the IFA-MNP group (OR: 0.70; 95% CI: 0.53, 0.92), but the difference diminished by 24 mo (OR: 0.81; 95% CI: 0.63, 1.04).Conclusion: Home fortification with small-quantity LNSs, but not MNP, during the first 1000 d improved child linear growth and head size in rural Bangladesh. This trial was registered at clinicaltrials.gov as NCT01715038.
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Affiliation(s)
| | - Malay K Mridha
- Departments of Nutrition and.,Nutrition and Clinical Science Division and
| | | | | | - Joseph R Cummins
- Department of Economics, University of California, Riverside, CA
| | - Md Showkat Ali Khan
- Initiative of Noncommunicable Disease, Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh; and
| | | | | | | | - Stephen A Vosti
- Agricultural and Resource Economics, University of California, Davis, CA
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105
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Campbell RK, Hurley KM, Shamim AA, Shaikh S, Chowdhury ZT, Mehra S, de Pee S, Ahmed T, West KP, Christian P. Effect of complementary food supplementation on breastfeeding and home diet in rural Bangladeshi children. Am J Clin Nutr 2016; 104:1450-1458. [PMID: 27680994 PMCID: PMC5081719 DOI: 10.3945/ajcn.116.135509] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 08/26/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Complementary food supplements (CFSs) can enhance growth where stunting is common, but substitution for the usual diet may reduce observed benefits. OBJECTIVE We aimed to characterize dietary diversity from home foods in a CFS efficacy trial and determine whether supplementation reduced breastfeeding frequency or displaced home foods. DESIGN In a cluster-randomized controlled trial in rural Bangladesh, children (n = 5499) received, for 1 y starting at age 6 mo, periodic child feeding counseling for mothers (control) or counseling plus 1 of 4 CFSs fed as a daily snack. Breastfeeding status and past 24-h diet were assessed at enrollment and every 3 mo thereafter until 18 mo of age. A 7-food group dietary diversity score (DDS) was calculated from home foods only, and a DDS ≥4 constituted minimum dietary diversity (MDD). RESULTS Most children (97%) were breastfed through 18 mo of age, and 24-h breastfeeding frequency did not differ by supplementation group. Child dietary diversity was low; only 51% of children met the MDD by 18 mo. Rice, potatoes, and biscuits (cookies) were the most frequently consumed foods, whereas the legumes, dairy, eggs, and vitamin A-rich fruit and vegetable food groups were each consumed by <50% of children. The odds of meeting the MDD through the consumption of home foods were equal or greater in the supplemented groups compared with the control group at all ages. High socioeconomic status and any maternal education were associated with increased odds of MDD at age 18 mo, whereas child sex and household food security were not associated with MDD. CONCLUSIONS In a setting where daily complementary food supplementation improved linear growth, there was no evidence that supplementation displaced breastfeeding or home foods, and the supplementation may have improved dietary diversity. Pathways by which supplementation with fortified foods may enhance dietary diversity, such as an improved appetite and increased body size, need elucidation. This trial was registered at clinicaltrials.gov as NCT01562379.
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Affiliation(s)
- Rebecca K Campbell
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kristen M Hurley
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Saijuddin Shaikh
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Zaynah T Chowdhury
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Sucheta Mehra
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Saskia de Pee
- Nutrition Division, United Nations World Food Program, Rome, Italy
| | - Tahmeed Ahmed
- Center for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Keith P West
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Parul Christian
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
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106
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Unger HW, Ashorn P, Cates JE, Dewey KG, Rogerson SJ. Undernutrition and malaria in pregnancy - a dangerous dyad? BMC Med 2016; 14:142. [PMID: 27645498 PMCID: PMC5029041 DOI: 10.1186/s12916-016-0695-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 09/15/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In low-resource settings, malaria and macronutrient undernutrition are major health problems in pregnancy, contributing significantly to adverse pregnancy outcomes such as preterm birth and fetal growth restriction. Affected pregnancies may result in stillbirth and neonatal death, and surviving children are at risk of poor growth and infection in infancy, and of non-communicable diseases in adulthood. Populations exposed to macronutrient undernutrition frequently reside in malaria-endemic areas, and seasonal peaks of low food supply and malaria transmission tend to coincide. Despite these geographic and temporal overlaps, integrated approaches to these twin challenges are infrequent. DISCUSSION This opinion article examines the current evidence for malaria-macronutrition interactions and discusses possible mechanisms whereby macronutrient undernutrition and malaria may interact to worsen pregnancy outcomes. Macronutrient undernutrition dysregulates the immune response. In pregnant women, undernutrition may worsen the already increased susceptibility to malarial infection and could impair development of protective immunity to malaria, and is likely to exacerbate the impact of placental malaria on fetal growth. Malarial infection, in turn, can drive nutritional depletion; poor gestational weight gain and weight loss in pregnancy increases the risk of adverse pregnancy outcomes. Despite a commendable number of studies and trials that, in isolation, attempt to address the challenges of malaria and undernutrition in pregnancy, few dare to venture beyond the 'single disease - single solution' paradigm. We believe that this may be a lost opportunity: researching malaria-nutrition interactions, and designing and implementing integrated interventions to prevent and treat these commonly co-existing and intertwining conditions, may markedly reduce the high burden of preterm birth and fetal growth restriction in affected areas. CONCLUSION We call for more collaboration between researchers studying malaria and nutrition in pregnancy, and propose a research agenda to address this important twin health problem.
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Affiliation(s)
- Holger W. Unger
- Department of Medicine at the Doherty Institute, The University of Melbourne, Melbourne, Victoria Australia
- Simpson Centre for Reproductive Health, Edinburgh Royal Infirmary, Edinburgh, UK
| | - Per Ashorn
- Department of Paediatrics, University of Tampere School of Medicine, Tampere, Finland
- Department for International Health, University of Tampere School of Medicine, Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Jordan E. Cates
- Department of Epidemiology, University of North Carolina-Chapel Hill, Chapel Hill, NC USA
| | - Kathryn G. Dewey
- Program in International and Community Nutrition and Department of Nutrition, University of California, Davis, CA USA
| | - Stephen J. Rogerson
- Department of Medicine at the Doherty Institute, The University of Melbourne, Melbourne, Victoria Australia
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