Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?

The case for investment in nutritional interventions to prevent and reduce childhood and adolescent overweight and obesity in Peru: a modelling study

BACKGROUND

Between 2006 and 2016 the prevalence of overweight and obesity among children and adolescents aged 5-19 years in Peru increased from 22.7 to 27.0%. This investment case quantifies the economic impacts of childhood and adolescent overweight and obesity in Peru. It identifies and quantifies the potential impact of a set of new or expanded interventions that can strengthen current national efforts to prevent and reduce child and adolescent overweight and obesity.

METHODS

A deterministic Markov cohort model with a societal cost perspective estimated reductions in mortality and morbidity from implementing interventions to prevent and reduce child and adolescent overweight and obesity and the impact in savings in healthcare costs and gains in wages and productivity. Interventions identified through a review of published literature includes a school-based social marketing campaign, exclusive breastfeeding promotion and support, a healthy food and drink policy for school premises, and a 20% subsidy on fruits and vegetables for people living below the national poverty line. The return on investment (ROI) was calculated along with the estimated cost savings associated with the interventions. Analysis was conducted to test ROI sensitivity to changes in the key parameters and assumptions.

RESULTS

Between 2025 and 2092, the expected combined direct and indirect healthcare costs attributable to child and adolescent overweight and obesity in Peru are 210.6 billion USD. The direct healthcare costs are 1.8 billion USD, and the indirect costs are 208.8 billion USD. Expected savings for all interventions combined is 13.9 billion USD with a per-person savings of 12,089.8 USD. The expected ROI of the four interventions combined is 39.3 USD (30-years), 64.6 USD (50-years), and 164.1 USD (66-years) per one USD invested.

CONCLUSIONS

The overweight and obesity epidemic among children and adolescents in Peru requires wide-ranging and expanded implementation of policies to achieve long-term reductions in prevalence. This study's findings show that the four priority interventions have high ROIs and can be used to guide policy to address the complex interplay of factors that contribute to the obesogenic environment.

A quasi-experimental study assessing the effectiveness of a community-based egg intervention in the nutritional and health status of young children from rural Honduras

OBJECTIVE

This community-public-private-academic coalition project implemented and evaluated the effectiveness of a rural, community-based egg intervention that aimed to support the nutrition and health of children living in rural, poor communities from Intibucá, Honduras, during the COVID-19 pandemic.

DESIGN

This investigator-blind, non-randomized, controlled study was informed by a community health improvement process and participatory research. Women from 13 communities were given a microloan to start an egg farm that supplied 1 egg daily to 201 children ages 6-24 months for 1 year (intervention group). Control communities (n = 14) were selected from neighboring municipalities with similar sociodemographic backgrounds based on size. Sociodemographic-, anthropometric-, and morbidity data were collected biannually between January 2021 to January 2022. Outcome changes were compared with linear-, generalized- or Poisson- mixed models adjusted by sex, age, maternal education, breastfeeding status, assets, adults living at home, baseline outcomes, and community-cluster.

RESULTS

Baseline to 6- and 12-month weekly frequency of egg intake significantly increased in the intervention vs. the control group: 6-month change = 1.86; 95%CI (1.61, 2.14); 12-month change = 1.63; 95%CI (1.42, 1.87 p<0.001), respectively. Baseline to 12-month changes in the intervention group were not significant for length/height-for-age-z-scores = 0.12, p = 0.187; weight-for-length/height-z-scores = -0.02, p = 0.78; and diarrhea prevalence, AOR = 1.69; 95%CI (0.53, 5.42), p = 0.378. Lower odds of respiratory infections were observed for the intervention vs. the control group at 6- and 12-month post: AOR = 0.28; 95%CI (0.12, 0.63), p = 0.002; AOR = 0.30; 95%CI (0.12, 0.75), p = 0.010, respectively.

CONCLUSIONS AND RELEVANCE

Children in the intervention group reported consuming eggs more days per week relative to the control group. Lower odds of respiratory infections were observed in the intervention group throughout the study. Ongoing follow-up will offer more insights on the intervention's effectiveness in linear growth, dietary diversity, food security, and other nutritional outcomes.

Income and education disparities in childhood malnutrition: a multi-country decomposition analysis

INTRODUCTION

Childhood malnutrition is a complex issue with a range of contributing factors. The consequences of malnutrition are severe, particularly for children. This study aims to identify the factors contributing to inequality gaps in childhood malnutrition. Our study provides insights into modifiable elements to inform interventions targeted at distinct contexts and populations to improve child nutrition.

METHODS

This study utilized data from the Demographic and Health Surveys (DHS) of 27 countries. First, the risk differences (RDs) between the prevalence of childhood malnutrition among the determinant variables, household income, and maternal education categories were calculated. The Blinder‒Oaxaca decomposition was subsequently used to determine the extent to which the difference in childhood malnutrition prevalence between low-income and high-income groups and maternal education levels results from the contributory effects of the explanatory variables: child and maternal individual-level compositional factors.

RESULTS

We examined data from 138,782 children in 27 countries from 2015 to 2020. The prevalence of childhood malnutrition (10.5%) varied across countries, ranging from 6.5% in Burundi to 29.5% in Timor Leste. On average, the prevalence of childhood malnutrition was 11.0% in low-income households and 10.7% among mothers without education. Some nations had pro-low-income (i.e., malnutrition concentrated among children from poor households) or pro-no-maternal education (i.e., malnutrition concentrated among children from mothers with no formal education) inequality in childhood malnutrition, but most did not. We found a complex interplay of compositional effects, such as the child's age, maternal education, maternal health behavior, and place of residence, that influence the inequality in childhood malnutrition rates across 10 pro-low-income countries. In addition, we also found that a complex mix of compositional effects, such as the household wealth index, maternal health behavior, and maternal age, contribute to childhood malnutrition inequality between educated and uneducated mothers across the 7 pro-no maternal education countries.

CONCLUSION

The prevalence of childhood malnutrition varies among low-income, high-income, and no maternal education-maternal education groups. This study highlights the need for a country-specific approach to addressing childhood malnutrition, with policies and interventions tailored to each country's specific context.

Evaluation of Complementary Feeding Indicators Among Children Aged 6-23 Months According to the Health Literacy Status of Their Mothers

BACKGROUND/OBJECTIVES

Infant and young child feeding (IYCF) practices directly affect child health, development, and survival, especially under 2 years of age and ultimately affect adult life well-being. As the primary caregivers of the children, mothers with higher health literacy may better perceive the benefits of optimal complementary feeding practices, leading to improved health outcomes for their children. In this study, we aimed to assess complementary feeding practices among children aged 6-23 months in Turkey according to 2021 World Health Organization IYCF indicators [minimum dietary diversity (MDD); minimum meal frequency (MMF); minimum acceptable diet (MAD); egg and/or flesh food consumption (EFF); sweet beverage consumption (SwB); unhealthy food consumption (UFC); zero vegetable or fruit consumption (ZVF); and bottle feeding (BoF)] and investigate their associations with sociodemographic characteristics and mothers' health literacy.

METHODS

With a descriptive study design, we reached 572 mothers of children aged 6-23 months from five regions of Turkey. We used the Turkey Health Literacy Scale-32 (TSOY-32) to assess mothers' health literacy.

RESULTS

While maternal and child age are significantly associated with more complementary feeding practices, specifically MDD, MAD, and EFF, having multiple children has negative impacts on several complementary feeding indicators, including MDD, MMF, MAD, UFC, and ZVF. The only indicator associated with mothers' TSOY-32 scores was zero fruit and vegetable consumption.

CONCLUSION

Raising awareness among mothers about the importance of complementary feeding practices and identification of vulnerable groups will guide practitioners and policymakers to improve child health and nutrition.

Changing paradigm of malnutrition among Bangladeshi women of reproductive age and gaps in national Nutrition Policies and Action Plans to tackle the emerging challenge

Objective

The main objective of this paper is to document the changing paradigm of malnutrition in Bangladesh and estimating how this is creating an intergenerational risk. This paper also examines national policy responses to tackle the silent epidemic of double burden of malnutrition.

Methods

Publicly available datasets of five Bangladesh Demographic and Health Surveys were used to see the changing paradigm of malnutrition among Bangladesh women. In addition to that, four national policies concerning, maternal and child health; and nutrition were reviewed using CDC's 2013 Policy Analytical Framework.

Results

In Bangladesh, the share of ever-married women aged 15-49 who were underweight declined sharply between 2007 and 2017-2018, from 30 to 12%. In the same period, the proportion of women who were overweight or obese increased from 12 to 32%. Despite remarkable progress in reducing undernourishment among women, the share of well-nourished remained unchanged: 58% in 2007 and 56% in 2017-2018, mainly due to the shift in the dominant burden from undernutrition to overnutrition. This shift occurred around 2012-2013. Currently, in Bangladesh 0.8 million of births occur to overweight women and 0.5 million births occur to underweight women. If the current trend in malnutrition continues, pregnancies/births among overweight women will increase. Bangladesh's existing relevant policies concerning maternal health and nutrition are inadequate and mostly address the underweight spectrum of malnutrition.

Discussion

Both forms of malnutrition pose a risk for maternal and child health. Underweight mothers are at risk of having anemia, antepartum/postpartum hemorrhage, and premature rupture of membranes. Maternal obesity increases the risk of perinatal complications, such as gestational diabetes, gestational hypertension, and cesarean deliveries. Currently, around 24% of the children are born to overweight/obese mothers and 15% to underweight mothers. Bangladesh should revise its national policies to address the double burden of malnutrition among women of reproductive age across pre-conception, pregnancy, and post-natal stages to ensure optimum maternal and child health.

The economic cost consequences of suboptimal infant and young child feeding practices: a scoping review

Breastfeeding is important for women and children's health, but less than half of infants worldwide begin life with optimal breastfeeding. A growing literature shows consistently large economic costs of not breastfeeding, with global studies showing economic losses of around US$300 billion globally. However, existing studies are highly diverse in approaches, methods, data sources and country results. Building on a landmark 2012 UNICEF UK review focused on high-income countries, we conducted a scoping review to map and characterize the expanding literature and identify future research directions in this research area. We included studies (n = 36) in diverse country settings and outcomes for women and children. We used PubMed, Web of Science, EMBASE, MEDLINE, ProQuest and manual searches of cost of not breastfeeding studies published between 1996 and 2023. Articles were excluded if they were macroeconomic evaluations, did not assign monetary values or only evaluated breastfeeding or formula feeding costs and not outcomes or were cost of programs studies. We found considerable diversity in disciplinary approaches and differences in methodologies. Though there were different cost measurement perspectives (societal, institutional/payer and individual), all but two excluded the costs of unpaid care. Studies typically measured costs of medical treatment, with more recent studies using dynamic simulation models. The largest economic costs were derived from lifetime estimates of human capital losses, namely cost of premature death and loss of intelligence quotient points. Medical and death costs varied widely depending on method of calculation, but total costs consistently exceeded $US100 billion annually for the USA, and around $US300 billion in global studies. Our findings suggest that greater interdisciplinary collaboration is needed particularly to better define infant feeding exposures, and advance comprehensive measurement of costs and outcomes across lifetimes, in order to prioritize breastfeeding as a public health strategy of economic importance.

Feasibility of Employing mHealth in Delivering Preventive Nutrition Interventions Targeting the First 1000 Days of Life: Experiences from a Community-Based Cluster Randomised Trial in Rural Bangladesh

BACKGROUND/OBJECTIVES

An Android platform-based customised app and web-linked system was developed to aid in implementing selected nutrition interventions by community health workers (CHWs) in a community-based cluster randomised trial (c-RCT) in rural Bangladesh.

METHODS

Here, we describe the architecture of the intervention delivery system, and explore feasibility of employing mHealth as CHWs' job aid, employing a mixed-method study design covering 17 visits per mother-child dyad. We analysed CHWs' real-time visit information from monitoring and documentation data, and CHWs' qualitative interviews to explore the advantages and barriers of using mHealth as a job aid.

RESULTS

Intervention coverage was high across the arms (>90%), except around the narrow perinatal period (51%) due to mothers' cultural practice of moving to their parents' homes and/or hospitals for childbirth. CHWs mentioned technical and functional advantages of the job aid including device portability, easy navigability of content, pictorial demonstration that improved communication, easy information entry, and automated daily scheduling of tasks. Technical challenges included charging tablets, especially in power cut-prone areas, deteriorated battery capacity over continuous device usage, unstable internet network in unsupportive weather conditions, and device safety. Nevertheless, onsite supervision and monitoring by expert supervisors remained important to ensure intervention quality.

CONCLUSIONS

With appropriate training and supervision, CHWs utilised the tablet-based app proficiently, attaining high coverage of long-term visits. mHealth was thus useful for designing, planning, scheduling, and delivering nutrition interventions through CHWs, and for monitoring and supervision by supervisors. Therefore, this application and job aid can be adopted or replicated into the currently developing national health systems platform for improving coverage and quality of preventive maternal and child nutrition services. In addition, continuous supportive supervision by skilled supervisors must be accompanied to ensure CHWs' task quality. Finally, future studies should rigorously assess undesirable health and environmental effects of mHealth before and after mainstreaming, effective interventions addressing device-induced health hazards should be designed and scaled up, and effective e-waste management must be ensured.

Iron Deficiency: Global Trends and Projections from 1990 to 2050

BACKGROUND

Iron deficiency (ID) remains the leading cause of anemia, affects a vast number of persons globally, and continues to be a significant global health burden. Comprehending the patterns of ID burden is essential for developing targeted public health policies.

METHODS

Using data from the Global Burden of Disease (GBD) 2021 study for the years 1990-2021, the XGBoost model was constructed to predict prevalence and disability-adjusted life years (DALYs) for the period 2022-2050, based on key demographic variables. Shapley Additive exPlanations (SHAP) values were applied to interpret the contributions of each variable to the model's predictions. Additionally, the Age-Period-Cohort (APC) model was used to evaluate the effects of age, period, and birth cohort on both prevalence and DALYs. The relationship between the Socio-Demographic Index (SDI) and ID's age-standardized prevalence rate (ASPR) as well as the age-standardized DALYs rate (ASDR) was also analyzed to assess the influence of socioeconomic development on disease burden.

RESULTS

The global prevalent cases of ID grew from 984.61 million in 1990 to 1270.64 million in 2021 and are projected to reach 1439.99 million by 2050. Similarly, global DALYs from ID increased from 28.41 million in 1990 to 32.32 million in 2021, with a projected rise to 36.13 million by 2050. The ASPR declined from 18,204/100,000 in 1990 to 16,433/100,000 in 2021, with an estimated annual percentage change (EAPC) of -0.36% over this period. It is expected to decrease further to 15,922 by 2050, with an EAPC of -0.09% between 2021 and 2050. The ASDR was 518/100,000 in 1990 and 424/100,000 in 2021, with an EAPC of -0.68% from 1990 to 2021. It is expected to remain relatively stable at 419/100,000 by 2050, with an EAPC of -0.02% between 2021 and 2050. In 2021, the highest ASPRs were recorded in Senegal (34,421/100,000), Mali (34,233/100,000), and Pakistan (33,942/100,000). By 2050, Mali (35,070/100,000), Senegal (34,132/100,000), and Zambia (33,149/100,000) are projected to lead. For ASDR, Yemen (1405/100,000), Mozambique (1149/100,000), and Mali (1093/100,000) had the highest rates in 2021. By 2050, Yemen (1388/100,000), Mali (1181/100,000), and Mozambique (1177/100,000) are expected to remain the highest. SHAP values demonstrated that gender was the leading predictor of ID, with age and year showing negative contributions. Females aged 10 to 60 consistently showed higher prevalence and DALYs rates compared to males, with the under-5 age group having the highest rates for both. Additionally, men aged 80 and above exhibited a rapid increase in prevalence. Furthermore, the ASPR and ASDR were significantly higher in regions with a lower SDI, highlighting the greater burden of ID in less developed regions.

CONCLUSIONS

ID remains a significant global health concern, with its burden projected to persist through 2050, particularly in lower-SDI regions. Despite declines in ASPR and ASDR, total cases and DALYs are expected to rise. SHAP analysis revealed that gender had the greatest influence on the model's predictions, while both age and year showed overall negative contributions to ID risk. Children under 5, women under 60, and elderly men aged 80+ were the most vulnerable groups. These findings underscore the need for targeted interventions, such as improved nutrition, early screening, and addressing socioeconomic drivers through iron supplementation programs in low-SDI regions.

Global burden and health inequality of nutritional deficiencies from 1990 to 2019

Introduction

Nutritional deficiencies (NDs) manifest in various forms and are widespread globally. However, a systematic evaluation of the epidemiology of NDs across all causes and age groups in different countries and regions has not been conducted.

Materials and methods

This study aimed to utilize data from the 2019 Global Burden of Disease (GBD) study to assess the burden and trends of NDs, including their incidence, prevalence, mortality, and disability-adjusted life years (DALYs). Additionally, the study evaluated health inequalities at global, regional, and national levels from 1990 to 2019.

Result

In 2019, the age-standardized incidence rate of NDs was 2,207.71 per 100,000 individuals (95% UI 1,863.04-2,604.67), and the age-standardized DALYs (ASR-DALYs) was 680.12 per 100,000 individuals (95% UI 507.21-894.89). Among the causes of NDs, dietary iron deficiency had the highest ASR-DALYs and exhibited minimal variation. Children under the age of 5 years faced the greatest risk of NDs. Sex disparity was evident, with males having lower rates than females. Although the gap in the burden of NDs between regions classified as poor and wealthy decreased, disparities persist.

Conclusion

These findings provide critical insights for the development of global health strategies aimed at mitigating NDs and may guide policymakers in implementing effective and economically viable interventions.

The effect of the implementation of the international code of marketing of breast-milk substitutes on child mortality in Ghana and Tanzania

OBJECTIVE

The International Code of Marketing of Breast-Milk Substitutes is an important instrument to protect and promote appropriate infant and young child feeding and the safe use of commercial milk formulas. Ghana and Tanzania implemented the Code into national legislation in 2000 and 1994, respectively. We aimed to estimate the effects of the Code implementation on child mortality (CM) in both countries.

SETTING

The countries analysed were Ghana and Tanzania.

PARTICIPANTS

For CM and HIV rates, data from the Institute for Health Metrics and Evaluation from up to 2019 were used. Data for income and skilled birth rates were retrieved from the World Bank, for fertility from the World Population Prospects, for vaccination from the Global Health Observatory and for employment from the International Labour Organization.

DESIGN

We used the synthetic control group method and performed placebo tests to assess statistical inference. The primary outcomes were CM by lower respiratory infections, mainly pneumonia, and diarrhoea and the secondary outcome was overall CM.

RESULTS

One-sided inference tests showed statistically significant treatment effects for child deaths by lower respiratory infections in Ghana (P = 0·0476) and Tanzania (P = 0·0476) and for diarrhoea in Tanzania (P = 0·0476). More restrictive two-sided inference tests showed a statistically significant treatment effect for child deaths by lower respiratory infections in Ghana (P = 0·0476). No statistically significant results were found for overall CM.

CONCLUSION

The results suggest that the implementation of the Code in both countries had a potentially beneficial effect on CM due to infectious diseases; however, further research is needed to corroborate these findings.

Understanding of Maternal Health Status in Different Social Groups in India Using NFHS Data

Maternal health is a major public health concern in India. MMR of India has declined significantly but maternal health status has not much improved. The prevalence of anemia and low Body Mass Index (BMI) is more severe among the women belonging to the Scheduled Caste (SC) and Scheduled Tribe (ST) categories. In this paper, attempts have been made to examine the maternal health status and to identify the factors responsible for poor health status among SC and ST women. The study is purely based on secondary data taken from latest 3 rounds of NFHS (2005-6, 2015-16 & 2019-21). Multivariate analysis have been carried out using panel regression model to understand the impact of determinants on maternal healthcare. The study found that the SC and ST women are more prone to anemia than others (GENERAL category women). Maternal health status is mostly controlled by per capita health expenditure and health infrastructure variables like no. of hospitals and nurses, irrespective of social class. Thus poor maternal health status in India, especially among socially disadvantaged groups of society, have been major concern. The government should be more focused on existing policies related to maternal healthcare.

Sustainable-use marine protected areas to improve human nutrition

Coral reef fisheries are a vital source of nutrients for thousands of nutritionally vulnerable coastal communities around the world. Marine protected areas are regions of the ocean designed to preserve or rehabilitate marine ecosystems and thereby increase reef fish biomass. Here, we evaluate the potential effects of expanding a subset of marine protected areas that allow some level of fishing within their borders (sustainable-use MPAs) to improve the nutrition of coastal communities. We estimate that, depending on site characteristics, expanding sustainable-use MPAs could increase catch by up to 20%, which could help prevent 0.3-2.85 million cases of inadequate micronutrient intake in coral reef nations. Our study highlights the potential add-on nutritional benefits of expanding sustainable-use MPAs in coral reef regions and pinpoints locations with the greatest potential to reduce inadequate micronutrient intake level. These findings provide critical knowledge given international momentum to cover 30% of the ocean with MPAs by 2030 and eradicate malnutrition in all its forms.

Complementary Feeding in the Clinical Practice: An Exploratory Survey among Italian Primary Care Pediatricians

Introduction: Complementary feeding (CF) is the process of introducing solid or liquid foods (complementary foods, CFs) other than human breast milk (HBM) or infant formula into infants' diet when HBM or infant formula is no longer sufficient to meet infants' nutritional needs. Primary care pediatricians (PCPs) are paramount in guiding and educating infants' families during CF. Materials and Methods: Our exploratory survey aimed to investigate PCPs' current clinical approach to managing CF. From 1 March 2024 to 30 April 2024, a digital questionnaire composed of 32 multiple-choice questions investigating PCPs' attitudes toward CF in healthy, full-term infants was proposed to 1620 PCPs contacted through scientific societies. Results: The questionnaire was completed voluntarily; 707 PCPs (79.5% female, 66.1% aged over 50 years) fully responded to the survey in the proposed timeframe (participation rate 43.6%). Among the responders, 47.5% recommended traditional CF; 42.1% declared to know the baby-led weaning (BLW) approach and on-demand CF (ODCF), but only 32.8% and 12.5% of them recommended these types of CF, respectively. The vast majority (95%) of participants recommended that CF start between 4 to 6 completed months of age. CF routinely based on vegetarian or plant-based diets was supported by 45/707 (6.1%), only if planned by a specialist by 253/707 (35.8%), and only upon request by caregivers by 257/707 (36.3%). Egg and fish introduction was mostly advised in the first year of life, although in case of a positive family history of food allergy, 13.3% of participants recommended the introduction of egg and fish after 12 months. Conclusions: In conclusion, PCPs did not display a homogenous approach to CF; further studies and educational programs are needed to achieve more flexibility and knowledge on this important nutritional issue.

Adolescent pregnancy, maternal and child anaemia: Empirical analysis from India, Bangladesh, and Nigeria

Early childbearing poses several potential risks to maternal and child health. This paper empirically analyses the association between teenage pregnancy and child nutritional status, maternal and child anaemia in three countries (Nigeria, India and Bangladesh) that account for the highest proportion of teenage births and/or total number of malnourished teenage mothers and children. Data were sourced from nine waves of Demographic and Health Surveys conducted in Bangladesh, India, and Nigeria from 2005-2018, covering a sample of 27,705 children from Bangladesh, 266,308 children from India and 54,719 children from Nigeria. Our outcome measures of maternal and child nutrition include (i) a composite measure of anthropometric failure for children (CIAF), (ii) maternal anaemia, (iii) childhood anaemia, and (iv) anaemia in maternal-child pairs. Using multivariate regression analysis, we examine the associations between early childbirth, child nutrition, and maternal and child anaemia, controlling for an array of household-level socioeconomic and demographic characteristics. Across all three countries, the prevalence of CIAF (childhood anthropometric failure) is significantly higher among children born to women aged below 17 at first birth. We further find that early pregnancy and childbearing are associated with significantly higher rates of severe/moderate anaemia among both mothers and children in Bangladesh and Nigeria. In the three countries studied, the proportions of teenage mothers with vulnerable socioeconomic status and suboptimal pre-conception care are relatively high, which raises the risk of maternal and child morbidity as well as mortality.

Understanding the Crisis: Prevalence and Key Determinants of Stunting in Children Aged 2 to 5 Years in an Afghan Refugee Camp in Kohat

BACKGROUND

Stunting, characterized by impaired growth and development due to malnutrition and illness, is a significant public health concern with profound implications for cognitive and physical development. This issue is particularly severe in refugee settings, where food insecurity and limited access to healthcare exacerbate the problem.

OBJECTIVE

This study aimed to evaluate the prevalence and determinants of stunting among children aged 2 to 5 years in an Afghan refugee camp in Kohat, Pakistan.

METHODS

A cross-sectional observational design was employed, collecting data from children aged 2 to 5 years who had resided in the camp for at least six months. A pre-validated, standardized questionnaire was administered to parents or guardians to gather data on socio-demographic factors, dietary intake, and health history. Stunting was defined as a height-for-age Z-score less than -2 SD from the median of the WHO Child Growth Standards. Anthropometric measurements were taken following WHO guidelines. Bivariate and multivariate logistic regression analyses were conducted to identify predictors of stunting.

RESULTS

Out of 384 children, 153 (40%) were found to be stunted. The prevalence was slightly higher among boys (80 out of 153, 52%) compared to girls (73 out of 153, 48%). Significant predictors of stunting included a lack of parental education (adjusted odds ratio (AOR) for fathers 1.8, 95% confidence level (CI) 1.2-2.9; AOR for mothers 2.1, 95% CI 1.3-3.4), a history of infectious diseases (AOR 1.9, 95% CI 1.2-3.0), and low dietary diversity (AOR 2.3, 95% CI 1.4-3.7).

CONCLUSION

The study highlights the high prevalence of stunting among children in the refugee camp, underscoring the need for comprehensive interventions targeting healthcare improvement, parental education, economic support, and dietary diversity to reduce stunting rates and improve children's health outcomes.

Using the Lives Saved Tool to inform global nutrition advocacy

Background

The global nutrition community has been interested in investigating investment strategies that could be used to promote an increased focus and investment in nutrition programming in low- and middle-income countries.

Methods

The Lives Saved Tool (LiST) was used to evaluate lives saved and the costs of nutrition interventions in nine high-burden countries. In this case study, we detail the analyses that were conducted with LiST and how the results were packaged to develop Nourish the Future - a five-year proposal for the US government to scale up lifesaving malnutrition interventions.

Results

Scaling up a proposed package of critical nutrition interventions including micronutrient supplementation for pregnant women, breastfeeding support, Vitamin A supplementation for children, and treatments for moderate and severe acute malnutrition is an effective and cost-effective way to avert millions of child deaths and stillbirths.

Conclusions

This is one of the few case studies that outlines how a nutrition modeling tool (in this case LiST) was used to engage in a prioritisation exercise to inform a US-based advocacy ask. We share reflections and provide practical insights into user motivation and preferences for existing and future modeling tool developers. This case study also emphasises how integral evidence translation and strategic advocacy are to ensure the use of the modeling results.

Food taboos and preferences among adolescent girls, pregnant women, breastfeeding mothers, and children aged 6-23 months in Mainland Tanzania: A qualitative study

Malnutrition is a serious public health problem and has long-lasting economic consequences for individuals and families and, in turn, affects the economic growth of the country. Understanding food taboos and individual preferences for food items is critical to the development of effective nutritional programs and educational messages. The present study aimed to explore food taboos and preferences in food items among breastfeeding mothers, pregnant women, adolescent girls, and their young children aged 6-23 months old. This is a qualitative cross-sectional study employing ethnography. A multistage sampling technique was used to select one region from the seven zones in mainland Tanzania. In each region, we purposively selected one rural ward and one urban ward. We conducted 25 focus group discussions with a total of 208 participants. We also conducted 42 in-depth interviews with nutrition officers, community health workers, religious leaders, influential persons, representatives of civil society organisations, and community leaders in the respective areas. We thematically coded the data and analyzed the narrative. Food taboos and individual preferences in food items continue to be practiced in Tanzania's Mainland despite efforts to educate people on healthy diets. In some regions of Tanzania's Mainland, pregnant women and breastfeeding mothers were prohibited from eating eggs, meat, fish, or vegetables. In Arusha, adolescent girls were prohibited from eating goat meat similar to Singida where adolescent girls were prohibited from eating chicken thighs. It is believed that by feeding a young child with eggs her hair gets plucked. This study underscores that food taboos and preferences still exist in Tanzania Mainland, and implies gaps in the nutrition education. Thus, nutrition education campaigns and programs should address food taboos and preferences for the meaningful tackling of malnutrition.

Elucidating the dynamics and impact of the gut microbiome on maternal nutritional status during pregnancy, effect on pregnancy outcomes and infant health in rural Pakistan: study protocol for a prospective, longitudinal observational study

INTRODUCTION

Undernutrition during pregnancy is linked to adverse pregnancy and birth outcomes and has downstream effects on the growth and development of children. The gut microbiome has a profound influence on the nutritional status of the host. This phenomenon is understudied in settings with a high prevalence of undernutrition, and further investigation is warranted to better understand such interactions.

METHODS AND ANALYSIS

This is a prospective, longitudinal observational study to investigate the relationship between prokaryotic and eukaryotic microbes in the gut and their association with maternal body mass index (BMI), gestational weight gain, and birth and infant outcomes among young mothers (17-24 years) in Matiari District, Pakistan. We aim to enrol 400 pregnant women with low and normal BMIs at the time of recruitment (<16 weeks of gestation). To determine the weight gain during pregnancy, maternal weight is measured in the first and third trimesters. Gut microbiome dynamics (bacterial and eukaryotic) will be assessed using 16S and 18S rDNA surveys applied to the maternal stool samples. Birth outcomes include birth weight, small for gestational age, large for gestational age, preterm birth and mortality. Infant growth and nutritional parameters include WHO z-scores for weight, length and head circumference at birth through infancy. To determine the impact of the maternal microbiome, including exposure to pathogens and parasites on the development of the infant microbiome, we will analyse maternal and infant microbiome composition, micronutrients in serum using metallomics (eg, zinc, magnesium and selenium) and macronutrients in the stool. Metatranscriptomics metabolomics and markers of inflammation will be selectively deployed on stool samples to see the variations in dietary intake and maternal nutritional status. We will also use animal models to explore the bacterial and eukaryotic components of the microbiome.

ETHICS AND DISSEMINATION

The study is approved by the National Bioethics Committee (NBC) in Pakistan, the Ethics Review Committee (ERC) at Aga Khan University and the Research Ethics Board (REB) at the Hospital for Sick Children, and findings will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05108675.

Cerebral palsy in African paediatric populations: A scoping review

AIM

To review the epidemiology and outcomes of African children with cerebral palsy (CP) over a 21-year period.

METHOD

The PubMed, Scopus, and Web of Science online databases were searched for original research on African children with CP aged 18 years and younger published from 2000 to 2021.

RESULTS

A total of 1811 articles underwent review against explicit criteria; 93 articles were selected for inclusion in the scoping review. The reported prevalence of CP ranged from 0.8 to 10 per 1000 children. Almost half had perinatal risk factors, but up to 26% had no identifiable risk factor. At least one-third of children with CP had one or more comorbidities, most commonly epilepsy, intellectual disability, and malnutrition. African children with CP demonstrated excess premature mortality approximately 25 times that of the general population, predominantly from infections. Hospital-based and younger populations had larger proportions of children with severe impairments. African children with CP had inadequate access to care and education, yet showed functional improvements compared to controls for all evaluated interventions.

INTERPRETATION

The prevalence of CP in Africa remains uncertain. African children with CP have different risk profiles, greater premature mortality, and more severe functional impairments and comorbidities compared to the Global North. Several barriers prevent access to optimal care. Larger African studies on validated and effective interventions are needed.

Behaviour change communication influences on food consumption behaviours and the demand for diverse nutritious foods in the Makoni District, Zimbabwe

This study evaluated the effectiveness of nutrition behavioural change communication interventions and food consumption behaviours and demand for nutritious foods in Makoni district, Zimbabwe. The study employed an observational and cross-sectional design using mixed-methods. The population was smallholder farmers' households with children six to twenty-four months old. Secondary data was obtained from the main intervention reports. The total sample size of this project comprised of five personnel participating in the implementation of the intervention for key informant interviews; forty participants for the in-depth interviews; and a total of 81 participants for eight focus group discussions. Participants indicated that the Livelihoods and Food Security Programme intervention successfully increased their nutrition knowledge, enhanced their ability to diversify crop production, and improved their access to varied foods, including some new crops. Local markets had little influence on the demand for nutritious foods by the intervention population. The interventions were effective in stimulating demand for diverse and nutritious foods in Makoni District.

A Systematic Review of Methods and Practice for Integrating Maternal, Fetal, and Child Health Outcomes, and Family Spillover Effects into Cost-Utility Analyses

BACKGROUND

Maternal-perinatal interventions delivered during pregnancy or childbirth have unique characteristics that impact the health-related quality of life (HRQoL) of the mother, fetus, and newborn child. However, maternal-perinatal cost-utility analyses (CUAs) often only consider either maternal or child health outcomes. Challenges include, but are not limited to, measuring fetal, newborn, and infant health outcomes, and assessing their impact on maternal HRQoL. It is also important to recognize the impact of maternal-perinatal health on family members' HRQoL (i.e., family spillover effects) and to incorporate these effects in maternal-perinatal CUAs.

OBJECTIVE

The aim was to systematically review the methods used to include health outcomes of pregnant women, fetuses, and children and to incorporate family spillover effects in maternal-perinatal CUAs.

METHODS

A literature search was conducted in Medline, Embase, EconLit, Cochrane Collection, Cumulative Index to Nursing and Allied Health Literature (CINAHL), International Network of Agencies for Health Technology Assessment (INAHTA), and the Pediatric Economic Database Evaluation (PEDE) databases from inception to 2020 to identify maternal-perinatal CUAs that included health outcomes for pregnant women, fetuses, and/or children. The search was updated to December 2022 using PEDE. Data describing how the health outcomes of mothers, fetuses, and children were measured, incorporated, and reported along with the data on family spillover effects were extracted.

RESULTS

Out of 174 maternal-perinatal CUAs identified, 62 considered the health outcomes of pregnant women, and children. Among the 54 quality-adjusted life year (QALY)-based CUAs, 12 included fetal health outcomes, the impact of fetal loss on mothers' HRQoL, and the impact of neonatal demise on mothers' HRQoL. Four studies considered fetal health outcomes and the effects of fetal loss on mothers' HRQoL. One study included fetal health outcomes and the impact of neonatal demise on maternal HRQoL. Furthermore, six studies considered the impact of neonatal demise on maternal HRQoL, while four included fetal health outcomes. One study included the impact of fetal loss on maternal HRQoL. The remaining 26 only included the health outcomes of pregnant women and children. Among the eight disability-adjusted life year (DALY)-based CUAs, two measured fetal health outcomes. Out of 174 studies, only one study included family spillover effects. The most common measurement approach was to measure the health outcomes of pregnant women and children separately. Various approaches were used to assess fetal losses in terms of QALYs or DALYs and their impact on HRQoL of mothers. The most common integration approach was to sum the QALYs or DALYs for pregnant women and children. Most studies reported combined QALYs and incremental QALYs, or DALYs and incremental DALYs, at the family level for pregnant women and children.

CONCLUSIONS

Approximately one-third of maternal-perinatal CUAs included the health outcomes of pregnant women, fetuses, and/or children. Future CUAs of maternal-perinatal interventions, conducted from a societal perspective, should aim to incorporate health outcomes for mothers, fetuses, and children when appropriate. The various approaches used within these CUAs highlight the need for standardized measurement and integration methods, potentially leading to rigorous and standardized inclusion practices, providing higher-quality evidence to better inform decision-makers about the costs and benefits of maternal-perinatal interventions. Health Technology Assessment agencies may consider providing guidance for interventions affecting future lives in future updates.

Kangaroo mother care prior to clinical stabilisation: Implementation barriers and facilitators reported by caregivers and healthcare providers in Uganda

Kangaroo mother care (KMC) is an evidence-based method to improve newborn survival. However, scale-up even for stable newborns has been slow, with reported barriers to implementation. We examined facilitators and barriers to initiating KMC before stabilisation amongst neonates recruited to the OMWaNA study in Uganda. The OMWaNA study was a randomised controlled trial that examined the mortality effect of KMC prior to stabilisation amongst newborns weighing ≤2000 grams. At the four trial hospitals, we conducted focus group discussions (FGD) separately with caregivers and healthcare providers, in-depth interviews (IDI) with caregivers and key informant interviews (KII) with hospital administrators and healthcare providers. The World Health Organisation (WHO) Health Systems Building Blocks were used to guide thematic analysis. Eight FGDs (4 caregivers, 4 healthcare providers), 41 caregiver IDIs (26 mothers, 8 grandmothers, 7 fathers), and 23 KIIs were conducted. Key themes based on the building blocks were; family and community support/ involvement, health workforce, medical supplies and commodities, infrastructure and design, financing, and health facility leadership. We found that the presence of a family member in the hospital, adequate provision of healthcare workers knowledgeable in supporting KMC prior to stability, and adequate space for KMC beds where neonatal care is being delivered, can enable implementation of KMC before stability. Implementation barriers included fear of inadvertently causing harm to the newborn, inadequate space to practice KMC in the neonatal unit, and a limited number of trained healthcare workers coupled with insufficient medical supplies.

Quantifying the increased risk of illness in malnourished children: a global meta-analysis and propensity score matching approach

BACKGROUND

Childhood morbidity and mortality continue to be major public health challenges. Malnutrition increases the risk of morbidity and mortality from illnesses such as acute respiratory infections, diarrhoea, fever, and perinatal conditions in children. This study explored and estimated the magnitude of the associations between childhood malnutrition forms and child morbidity.

METHODS

We performed an individual participant data (IPD) meta-analysis and employed propensity score matching to examine crude (unadjusted) and adjusted associations. Our analysis utilized demographic and health datasets from surveys conducted between 2015 and 2020 in 27 low- and middle-income countries. Our objective was to quantify the risk of morbidity in malnourished children and estimate the population-attributable fraction (PAF) using a natural experimental design with a propensity score-matched cohort.

RESULTS

The IPD meta-analysis of child morbidity across three childhood malnutrition forms presented nuanced results. Children with double-burden malnutrition had a 5% greater risk of morbidity, which was not statistically significant. In contrast, wasted children had a 28% greater risk of morbidity. Overweight children exhibited a 29% lower risk of morbidity. Using the matched sample, children with double-burden malnutrition and overweight children had lower morbidity risks (1.7%, RR: 0.983 (95% CI, 0.95 to 1.02) and 20%, RR: 0.80 (95% CI, 0.76 to 0.85), respectively), while wasting was associated with a 1.1 times (RR: 1.094 (95% CI, 1.05 to 1.14)) greater risk of morbidity. Eliminating double-burden malnutrition and wasting in the four and seven countries with significant positive risk differences could reduce the child morbidity burden by an estimated average of 2.8% and 3.7%, respectively.

CONCLUSIONS

Our study revealed a correlation between specific childhood malnutrition subtypes-double-burden malnutrition and wasting-and increased risks of morbidity. Conversely, overweight children exhibited a lower risk of immediate morbidity, yet they may face potential long-term health challenges, indicating the necessity for nuanced approaches to childhood nutrition.

Development of a Digital Platform to Promote Mother and Child Health in Underserved Areas of a Lower-Middle-Income Country: Mixed Methods Formative Study

Background

Primary health care (PHC) is the backbone of universal health coverage, with community health workers (CHWs) being one of its critical pillars in lower-middle-income countries. Most CHW functions require them to be an efficient communicator, but their program development has been deficient in this area. Can IT provide some solutions? Moreover, can some IT-based CHW-delivered innovations help mothers and children in areas not covered by PHC services? We explored these questions during the development and feasibility testing of a digital application designed to improve the communication capacity of CHWs in two underserved areas of Islamabad.

Objective

This study aims to explore the perceptions, practices, and related gaps about mother and child health, and child development in an underserved area; develop and deploy a behavior change communication program to address the gaps; and assess the feasibility of the program.

Methods

We carried out a mixed methods study with three steps. First, we conducted 13 in-depth interviews and two focus group discussions with stakeholders to explore the issues faced by mothers living in these underserved areas. To address these barriers, we developed Sehat Ghar, a video-based health education application to demonstrate practices mothers and families needed to adopt. Second, we trained 10 volunteer CHWs from the same community to deliver health education using the application and assessed their pre-post knowledge and skills. Third, these CHWs visited pregnant and lactating mothers in the community with random observation of their work by a supporting supervisor.

Results

Initial exploration revealed a need for health-related knowledge among mothers and suboptimal utilization of public health care. Sehat Ghar used behavior change techniques, including knowledge transfer, enhancing mothers' self-efficacy, and improving family involvement in mother and child care. Volunteer CHWs were identified from the community, who after the training, showed a significant improvement in mean knowledge score (before: mean 8.00, SD 1.49; after: mean 11.40, SD 1.43; P<.001) about health. During supportive supervision, these CHWs were rated as excellent in their interaction with mothers and excellent or very good in using the application. The CHW and her community reported their satisfaction with the application and wanted its delivery regularly.

Conclusions

Sehat Ghar is a simple, easy-to-use digital application for CHWs and is acceptable to the community. Mothers appreciate the content and presentation and are ready to incorporate its messages into their daily practices. The real-world effectiveness of the innovation tested on 250 mother-infant pairs will be important for its proof of effectiveness. With its usefulness and adaptability, and the rapidly spreading use of mobile phones and internet technology, this cost-effective innovation can help in delivering health communications at a large scale in a minimum amount of time.

Protection from environmental enteric dysfunction and growth improvement in malnourished newborns by amplification of secretory IgA

Environmental enteric dysfunction (EED) is a condition associated with malnutrition that can progress to malabsorption and villous atrophy. Severe EED results in linear growth stunting, slowed neurocognitive development, and unresponsiveness to oral vaccines. Prenatal exposure to malnutrition and breast feeding by malnourished mothers replicates EED. Pups are characterized by deprivation of secretory IgA (SIgA) and altered development of the gut immune system and microbiota. Extracellular ATP (eATP) released by microbiota limits T follicular helper (Tfh) cell activity and SIgA generation in Peyer's patches (PPs). Administration of a live biotherapeutic releasing the ATP-degrading enzyme apyrase to malnourished pups restores SIgA levels and ameliorates stunted growth. SIgA is instrumental in improving the growth and intestinal immune competence of mice while they are continuously fed a malnourished diet. The analysis of microbiota composition suggests that amplification of endogenous SIgA may exert a dominant function in correcting malnourishment dysbiosis and its consequences on host organisms, irrespective of the actual microbial ecology.

The Hidden Hunger among Nepalese Non-Pregnant Women Aged 15-49 Years: The Role of Individual, Household, and Community-Level Factors

Micronutrient deficiencies remain a public health burden among non-pregnant women in developing countries, including Nepal. Hence, this study examined micronutrient deficiencies among non-pregnant Nepalese women aged 15-49 using the 2016 Nepal National Micronutrient Status Survey (NNMSS). Data for 2143 non-pregnant women was extracted from the 2016 NNMSS. The study analysed the levels of ferritin, soluble transferrin receptor (sTfR), red blood cell (RBC) folate, and zinc of the participants. Multivariable logistic analysis was carried out to assess factors associated with micronutrient deficiencies. The prevalence of ferritin, sTfR, folate, and zinc was observed to be 19%, 13%, 16%, and 21%, respectively. Non-pregnant women from the Janajati region were significantly less prone to high levels of ferritin [adjusted odds ratio (AOR): 0.45; 95% confidence interval (CI): 0.25, 0.80], and those who had body mass index (BMI) of 25 kg/m2 or higher had significantly elevated ferritin levels [AOR: 2.69; 95% CI: 1.01, 7.17]. Non-pregnant women aged 35-49 years were significantly less predisposed to folate deficiency [AOR: 0.58; 95% CI: 0.40, 0.83], and the odds of zinc deficiency were significantly lower among non-pregnant women from wealthier households [AOR: 0.48; 95% CI: 0.31, 0.76]. This study provides further insight into screening high-risk subgroups and instituting public health interventions to address the prevailing micronutrient deficiencies among non-pregnant Nepalese women.

Co-coverage of reproductive, maternal, newborn and child health interventions shows wide inequalities and is associated with child nutritional outcomes in Ethiopia (2005-2019)

The health system is the primary vehicle for the delivery of nutrition-specific interventions that aim to reduce maternal and child malnutrition. The integration of nutrition interventions into existing health interventions is promising, but to ensure that no one is left behind requires that access to essential health services is equitably distributed. This study aims to assess trends and socioeconomic inequalities in coverage of reproductive, maternal, newborn and child health (RMNCH) and assess its association with child nutritional outcomes in Ethiopia. Using the Ethiopian Demographic and Health Survey (2005, 2011, 2016, and 2019), we estimated the coverage of RMNCH interventions in Ethiopia using the co-coverage index, which is a count of the number of interventions accessed. We assessed the trend and inequalities in co-coverage and evaluated its association with child nutritional outcomes like stunting, wasting, and minimum dietary diversity (MDD). The national co-coverage index has shown a significant increase over the 2005-2019 period. However, all of the RMNCH interventions constituting the co-coverage index showed a pro-rich and pro-urban distribution (p < 0.05). The highest inequality, based on the slope index of inequality (SII), was observed for skilled assistance during delivery (SII: 80.4%), followed by access to an improved source of drinking water (SII: 62.6%), and antenatal care visits (SII: 55.5%). The low coverage in RMNCH and the observed inequality were associated with stunting, wasting, and MDD. Reducing socioeconomic inequality in RMNCH is key to achieve the health, nutrition and equity-related goals of the Sustainable Development Goals.

Understanding differential reductions in undernutrition among districts in Rwanda through the perspectives of mid-level and community actors on policy commitment and policy coherence

Understanding the drivers of improvements in child undernutrition at only the national level can mask subnational differences. This paper aimed to understand the contributions of factors in the enabling environment to observed differences in stunting reduction between districts in Rwanda. In 2017, we conducted 58 semi-structured interviews with mid-level actors (n = 38) and frontline workers (n = 20) implementing Rwanda's multi-sectoral nutrition policy in five districts in which stunting decreased (reduced districts) and five where it increased or stagnated (non-reduced districts) based on Rwanda's 2010 and 2014/15 Demographic and Health Surveys. Mid-level actors are government officials and service providers at the subnational level who represent the frontline of government policy. Interviews focused on political commitment to and policy coherence in nutrition, and contributors to nutrition changes. Responses were coded to capture themes on the changes and challenges of these topics and compared between reduced and non-reduced districts. Descriptive statistics described district characteristics. Political commitment to nutrition was high in both reduced and non-reduced districts. Respondents from reduced districts were more likely to define commitment to nutrition as an optimal implementation of policy, whereas those from non-reduced districts focused more on financial commitment. Regarding coherence, respondents from reduced compared to non-reduced districts were more likely to report the optimal implementation of multi-sectoral nutrition planning meetings, using data to assess plans and progress in nutrition outcomes and integration of nutrition into the agriculture sector. In contrast, respondents from non-reduced districts more often reported challenges in their relationships with national-level stakeholders and nutrition and/or monitoring and evaluation capacities. Enhancing the integration of nutrition in different sectors and improving mid-level actors' capacity to plan and advocate for nutrition programming may contribute to reductions in stunting.

Effects of short birth interval on child malnutrition in the Asia-Pacific region: Evidence from a systematic review and meta-analysis

Child malnutrition remains a significant concern in the Asia-Pacific region, with short birth intervals recognised as a potential risk factor. However, evidence of this association is inconclusive. This study aimed to systematically review the existing evidence and assess the summary effects of short birth interval on child malnutrition in the Asia-Pacific region. Five electronic databases were searched in May 2023 to identify relevant studies reporting the association between short birth interval and child malnutrition, including stunting, wasting, underweight, anaemia and overall malnutrition, in Asia-Pacific region between September 2000 and May 2023. Fixed-effects or random-effects meta-analysis was performed to estimate the summary effects of short birth interval on child malnutrition. Out of 56 studies meeting the inclusion criteria, 48 were included in quantitative synthesis through meta-analysis. We found a slightly higher likelihood of stunting (n = 25, odds ratio [OR] = 1.13; 95% confidence interval [CI]: 0.97-1.32) and overall malnutrition (n = 3, OR = 2.42; 95% CI: 0.88-6.65) among children born in short birth intervals compared to those with nonshort intervals, although the effect was not statistically significant. However, caution is warranted due to identified heterogeneity across studies. Subgroup analysis demonstrated significant effects of short birth intervals on child malnutrition in national-level studies and studies with larger sample sizes. These findings underscore short birth intervals as a significant contributor to child malnutrition in the Asia-Pacific region. Implementing effective policies and programs is vital to alleviate this burden, ultimately reducing child malnutrition and associated adverse outcomes, including child mortality.

Modeled impacts of bouillon fortification with micronutrients on child mortality in Senegal, Burkina Faso, and Nigeria

Micronutrient interventions can reduce child mortality. By applying Micronutrient Intervention Modeling methods in Senegal, Burkina Faso, and Nigeria, we estimated the impacts of bouillon fortification on apparent dietary adequacy of vitamin A and zinc among children and folate among women. We then used the Lives Saved Tool to predict the impacts of bouillon fortification with ranges of vitamin A, zinc, and folic acid concentrations on lives saved among children 6-59 months of age. Fortification at 250 µg vitamin A/g and 120 µg folic acid/g was predicted to substantially reduce vitamin A- and folate-attributable deaths: 65% for vitamin A and 92% for folate (Senegal), 36% for vitamin A and 74% for folate (Burkina Faso), and >95% for both (Nigeria). Zinc fortification at 5 mg/g would avert 48% (Senegal), 31% (Burkina Faso), and 63% (Nigeria) of zinc-attributable deaths. The addition of all three nutrients at 30% of Codex nutrient reference values in 2.5 g bouillon was predicted to save an annual average of 293 child lives in Senegal (3.5% of deaths from all causes among children 6-59 months of age), 933 (2.1%) in Burkina Faso, and 18,362 (3.7%) in Nigeria. These results, along with evidence on program feasibility and costs, can help inform fortification program design discussions.

Lessons for the UK on implementation and evaluation of breastfeeding support: evidence syntheses and stakeholder engagement

Background

Breastfeeding impacts positively on multiple health outcomes, but < 50% of UK women breastfeed at 8 weeks. Women with long-term conditions face additional challenges in breastfeeding.

Objectives

To synthesise global and UK evidence to co-create an implementation and evaluation toolkit for cost-effective breastfeeding support in the NHS.

Design

Evidence syntheses with stakeholder engagement.

Review methods

Systematic reviews examined effectiveness of breastfeeding support for (1) healthy women and (2) women with long-term conditions using Cochrane Pregnancy and Childbirth Group methods. Mixed-methods systematic reviews synthesised process evaluations of effective breastfeeding support interventions for healthy women and experiences of receiving/providing support for breastfeeding women with long-term conditions. Cross-study synthesis integrated qualitative and quantitative findings. Systematic reviews synthesised evidence on the incremental costs and cost-effectiveness of breastfeeding support following National Institute for Health and Care Excellence guidance. All searches were conducted from May 2021 to October 2022. Stakeholder engagement and toolkit development comprised online discussions, a modified Delphi study, focus groups and four workshops. Participants were 23 stakeholders, 16 parents in the parents' panels, 15 women in the focus groups and 87 stakeholders who attended the workshops.

Results

We found considerably more interventions designed for healthy women (review 1) than aimed at women with long-term conditions (reviews 1 and 4); approximately half of the studies were targeted at groups at higher risk of poor breastfeeding outcomes, and the impact of support may be different in these populations. Despite this, studies from review 2 found that women perceived the provision of support as positive, important and needed. Studies from review 5 echoed a range of suggestions from participants regarding potential strategies to improve breastfeeding support, with the most widely reported being the need to acknowledge the role and influence of other sources of support (e.g. partners, family, friends, peers, external professionals, web-based resources) and involving these sources in the provision of breastfeeding support for women with long-term conditions. In reviews 3 and 6, there was uncertainty about the cost-effectiveness of breastfeeding support interventions due to the limited number of studies and lack of good-quality evidence.

Limitations

There was a lack of evidence for the effectiveness and cost-effectiveness of breastfeeding interventions in the UK. There was often insufficient information reported about intervention characteristics.

Conclusions

'Breastfeeding only' support probably reduces the number of women stopping any or exclusive breastfeeding. The evidence for 'breastfeeding plus' interventions is less consistent, but these may reduce the number of women stopping exclusive breastfeeding at 4-6 weeks and at 6 months. We found no evidence of differential intervention effects regarding mode of provision or provider. Cost-effectiveness is uncertain due to the lack of good-quality evidence. Key enablers of successful implementation were responsiveness and tailoring of interventions to both women's and supporters' needs. Breastfeeding support as delivered in the included studies probably has little to no effect on breastfeeding outcomes for women with long-term conditions. The mixed-methods synthesis and stakeholder work identified that existing interventions may not address the complex needs of these women. The main study output is a co-produced toolkit to guide implementation and evaluation of breastfeeding support services in the UK.

Future work

Evaluation of breastfeeding support for all women, particularly those at risk of poor breastfeeding outcomes (e.g. long-term conditions, deprivation). This could involve tailoring the toolkit to local contexts via implementation and effectiveness studies or using quality improvement studies.

Study registration

This study is registered as PROSPERO CRD42022337239, CRD42021229769 and CRD42022374509. The reviews of economic evidence were not registered; however, the review protocol can be accessed via the repository held by Queen's University Belfast Research Portal (https://pure.qub.ac.uk/).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130995) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 20. See the NIHR Funding and Awards website for further award information.

Empowering women can improve child dietary diversity in Ethiopia

Women empowerment is an underlying factor of child feeding and nutrition. However, the lack of standardized measurements has made it difficult to design interventions that embed women empowerment and measure their impacts. This study aimed to assess temporal trends in women empowerment in Ethiopia and evaluate their contribution towards improving dietary diversity in infants and young children. We used women and child data from the Ethiopian Demographic and Health Survey 2005, 2011, and 2016, yielding a total sample of 6113 mother-child pairs. The survey-based women's empowerment index (SWPER) developed and validated for use in Africa was used to assess three dimensions of women empowerment: (i) social autonomy, (ii) decision making; and (iii) attitude to violence. We used multiple-linear and multivariable logistic regression to assess the associations between SWPER and the number of food groups consumed/and the minimum dietary diversity (MDD). To determine drivers of changes over time, a regression decomposition analysis was run. Women empowerment indices have improved over the 2005-2016 period, but a significant proportion of women had low standardized SWPER scores for autonomy/social independence (47%) and attitude to violence (49%) domains in 2016. SWPER autonomy and SWPER decision-making scores were strongly associated with the odds of meeting MDD. Changes in women empowerment accounted for 17% of the improvements in MDD between 2005 and 2016. SWPER was a stronger predictor of the change in MDD, than known predictors like wealth, child age, and urban residence. As a critical underlying driver of child nutrition, women empowerment should be boldly addressed and integrated in nutrition interventions.

Diagnosis, Prevention, and Management of Fetal Growth Restriction (FGR)

Fetal growth restriction (FGR), or intrauterine growth restriction (IUGR), is still the second most common cause of perinatal mortality. The factors that contribute to fetal growth restriction can be categorized into three distinct groups: placental, fetal, and maternal. The prenatal application of various diagnostic methods can, in many cases, detect the deterioration of the fetal condition in time because the nature of the above disorder is thoroughly investigated by applying a combination of biophysical and biochemical methods, which determine the state of the embryo-placenta unit and assess the possible increased risk of perinatal failure outcome and potential for many later health problems. When considering the potential for therapeutic intervention, the key question is whether it can be utilized during pregnancy. Currently, there are no known treatment interventions that effectively enhance placental function and promote fetal weight development. Nevertheless, in cases with fetuses diagnosed with fetal growth restriction, immediate termination of pregnancy may have advantages not only in terms of minimizing perinatal mortality but primarily in terms of reducing long-term morbidity during childhood and maturity.

Time to treatment-seeking by caretakers of children under-five with diarrhea and associated factors in Uganda: a multilevel proportional hazards analysis

BACKGROUND

Diarrhea is considered to be one of the major public health concerns in developing countries. It has a detrimental impact, reflecting one of the highest child mortality rates globally, especially in Sub-Saharan Africa, where 2 out of every 10 children in Uganda under the age of five die. The objective of this study was to investigate the factors associated with time to treatment seeking by caretakers of children under-five with Diarrhea in Uganda.

METHOD

DOVE dataset of 745 caretakers in a prospective and retrospective incidence-based study using multi-stage sampling design was used in the assessment. The analysis was done using a time-to-event approach using life tables, Kaplan Meier survival analysis and multilevel proportional hazards model.

RESULTS

Kaplan-Meier survival analysis indicated the median time to seeking treatment among 745 caretakers of children under-Five after onset of diarrhea was 2 days. The multi-level proportional hazards model of a Weibull distribution showed that the estimated frailty variance was 0.13, indicating heterogeneity of treatment seeking time by caretakers of under-five children with diarrhea across regions in Uganda. Significant factors found to influence time to treatment-seeking by caretakers of children under-five with diarrhea were, male children (HR = 0.82; 95% CI = 0.71-0.95, p = 0.010), belonging to richest wealth quintile (HR = 1.37; 95% CI = 1.05-1.78, p = 0.022), and residing more than 5 km away from a health facility (HR = 0.68; 95% CI = 0.56-0.84, p = 0.000).

CONCLUSIONS

There are delays in seeking diarrhea treatment in Uganda because two days are enough to claim a life after dehydration.The policymakers should pay attention to formulate effective intervention to sensitize caregivers on the importance of early treatment-seeking behavior to avoid severe malnutrition caused by diarrhea. Community awareness program should also be encouraged particularly in areas of more than 5 km from the health facility to make people aware of the necessity to take prompt action to seek care in the early stage.

Maternal dietary diversity increases with women's high decision-making autonomy in Northwest Ethiopia, 2022

Background

Dietary diversification is one of several approaches for improving micronutrient levels in women of reproductive age. Therefore, this study aimed to assess the magnitude of minimum dietary diversity among pregnant women, explore the association between women's decision-making autonomy and dietary diversity, and identify other potential determinants of dietary diversity in Northwest Ethiopia.

Method

A community-based cross-sectional study of 621 pregnant women was conducted from November 2022 to December 2022. A cluster random sampling technique was employed. A binary logistic regression model was used to explore the association between dietary diversity and women's decision-making autonomy. Adjusted odds ratios with 95 % CIs were estimated to identify factors associated with the dietary diversity of pregnant women, and they were considered to be statistically significant at a P-value <0.05.

Results

The minimum dietary diversity among pregnant women was 22.4 %. The study revealed a significant association between dietary diversity and women's decision-making autonomy (AOR: 2.82, 95 % CI: 1.73, 4.59; p value: 0.001). Primary education and above (AOR = 4.0, CI: 2.1, 7.67), monthly income 1000-2000 ETB (AOR = 4.46, CI: 2.53, 7.87) and >2000 ETB (AOR = 6.05, CI: 3.16, 11.59), having nutritional information (AOR = 2.15, CI: 1.32, 3.51), being food secure (AOR = 2.63, CI:1.6, 4.34), morbidity status (AOR: 0.278, CI: 0.14, 0.56), ANC visits one time (AOR = 2.08, CI = 1.003, 4.33) and two or three times (AOR = 2.45, CI: 1.15, 5.24) were potential predictors of pregnant women's dietary diversity.

Conclusion

Maternal dietary diversity was significantly associated with women's decision-making autonomy. Thus, the government should strengthen women's empowerment, rights, access to education, and economic opportunities.

Identifying measures for coverage of nutrition-sensitive social protection programs: Learnings from India

Optimal child growth requires a combination of nutrition-specific and sensitive interventions in the first 1,000 days. There is limited guidance on how to measure the population-level coverage of nutrition-sensitive social protection (NSSP), which is designed with explicit nutrition goals and often provides food or cash transfers and co-coverage with nutrition and health intervention. In this study in India, we designed a questionnaire that captures seven core NSSP program elements (transfer type, size, modality, population, timing, provider, conditionalities), then used cognitive testing to refine the questionnaire, and then implemented the questions as part of a telephone survey. Cognitive testing indicated variability in understanding the terms used to specify NSSP programs, including the need to use regional program names. Respondents also had difficulty recalling the timing of the benefit receipt. We included the refined NSSP coverage questions in a phone-based survey with 6,627 mothers with children <2 years across six states. Coverage of subsidized food was 73% across all households. Women were more likely to report receiving food than cash transfers during pregnancy (89% vs. 60%) and during lactation (75% vs. 13%). Co-coverage of NSSP with nutrition and health interventions during pregnancy (16%) and early childhood (3%) was low. It was feasible to measure coverage of NSSP investments in these populations; however, further research is needed to comprehensively assess all the dimensions of the NSSP benefits, including benefit adequacy and the validity of these questions when administered in person and by phone.

Small Fish Big Impact: Improving Nutrition during Pregnancy and Lactation, and Empowerment for Marginalized Women

Undernutrition and micronutrient deficiencies such as anemia are considered significant public health challenges in Bangladesh, which enhancing fish consumption is a well-established food-based intervention to address these. This paper documents the establishment of community-based fish chutney production and reports the impact of its consumption on mid-upper arm circumference (MUAC) and hemoglobin (Hb) levels among targeted 150 pregnant and lactating women (PLW) in rural Bangladesh. A fish chutney was developed using locally available ingredients followed by a series of laboratory tests, including nutrient composition, shelf-life and food safety. A community-based fish chutney production process was designed to: (1) supply locally available ingredients for processing; (2) establish two fish drying sites; (3) initiate a community-based production site; and (4) distribute fish chutney to PLW for one year by six women nutrition field facilitators. Then a pre- and post-intervention study was designed for a selected 150 PLW to receive 30 g of fish chutney daily for 12 months. Differences in mean MUAC and Hb levels pre- and post-consumption were analyzed using one-way analysis of variance. Consumption of 30 g of fish-chutney resulted in significant increases of the mean values of Hb levels and MUAC among the targeted PLW.

Maternal empowerment, feeding knowledge, and infant nutrition: Evidence from rural China

Background

Maternal empowerment - the capacity to make decisions within households - is linked to better child feeding and nutritional outcomes, but few studies have considered the mediating role of caregiver knowledge. Further, existing literature centres primarily on the husband-wife dyad while overlooking grandmothers as important childcare decision-makers.

Methods

We collected primary data through household surveys in 2019 and 2021 from 1190 households with infants zero to six months living in rural western China. We identified the primary and secondary caregivers for each infant and assessed their feeding knowledge and practices, as well as infant nutritional status. We constructed a maternal empowerment index using a seven-item decision-making questionnaire and examined the relationship between maternal empowerment in childcare and household decisions, caregivers' feeding knowledge, and infant feeding practices and nutritional outcomes.

Results

Mothers had significantly higher levels of feeding knowledge than secondary caregivers (most were grandmothers, 72.7%), with average knowledge scores of 5.4 vs. 4.1, respectively, out of 9. Mothers and secondary caregivers with higher levels of feeding knowledge had significantly higher exclusive breastfeeding rates by 13-15 percentage points (P < 0.01) and 11-13 percentage points (P < 0.01), respectively. The knowledge of secondary caregivers was even more strongly associated with not feeding formula (15 percentage points, P < 0.01). Mothers empowered to make childcare decisions were more likely to exclusively breastfeed (12-13 percentage points, P < 0.01), less likely to formula feed (9-10 percentage points, P < 0.05), and more likely to have children with higher Z-scores for length-for-age (0.32-0.33, P < 0.01) and weight-for-age (0.24-0.25, P < 0.05). Effects remained after controlling for maternal feeding knowledge.

Conclusions

While mothers' and grandmothers' feeding knowledge was both important for optimal infant feeding, grandmothers' knowledge was particularly critical for practicing exclusive breastfeeding. Given the disparity in feeding knowledge between the two caregivers, our study further shows that mothers empowered in childcare decision-making were more likely to exclusively breastfeed their infants. This implies that some mothers with adequate knowledge may not practice optimal feeding because of lower decision-making power. Overall, our study highlights the role of secondary caregivers (grandmothers) in infant care and suggests that future child nutritional interventions may benefit from involving secondary caregivers (grandmothers).

Registration

Parent trial registration: ISRCTN16800789.

Food Systems Interventions for Nutrition: Lessons from 6 Program Evaluations in Africa and South Asia

Although there is growing global momentum behind food systems strategies to improve planetary and human health-including nutrition-there is limited evidence of what types of food systems interventions work. Evaluating these types of interventions is challenging due to their complex and dynamic nature and lack of fit with standard evaluation methods. In this article, we draw on a portfolio of 6 evaluations of food systems interventions in Africa and South Asia that were intended to improve nutrition. We identify key methodological challenges and formulate recommendations to improve the quality of such studies. We highlight 5 challenges: a lack of evidence base to justify the intervention, the dynamic and multifaceted nature of the interventions, addressing attribution, collecting or accessing accurate and timely data, and defining and measuring appropriate outcomes. In addition to more specific guidance, we identify 6 cross-cutting recommendations, including a need to use multiple and diverse methods and flexible designs. We also note that these evaluation challenges present opportunities to develop new methods and highlight several specific needs in this space.

Using Novel Multimethod Evaluation Approaches to Understand Complex Food System Interventions: Insights from a Supply Chain Intervention Intended to Improve Nutrition

Background

A "food system" approach to improve diet quality by intervening within areas such as food supply chains is gaining prominence. However, evidence of such interventions' impact, and understanding of appropriate methods to evaluate them, is lacking.

Objectives

We present an impact evaluation of an intervention that aimed to increase consumption of nutritious foods by supporting food-producing firms in Kenya. In doing so, we demonstrate how multiple methods, including those from other disciplines, can be used to evaluate a complex food systems intervention.

Methods

Four methods focused on food-producing firms and their management, including a survey of intervention participants (n = 83 individuals), a "laboratory-in-the-field" experiment (n = 83 individuals), baseline/endline data on firm performance (n = 71 firms), and semistructured interviews (n = 19 firms). Three methods focused on consumers in neighborhoods targeted by a supported firm: a randomized field experiment tested effects of making a supported product exhaustively available on consumers' purchases and consumption (n = 1295 consumers); 3 discrete choice experiments (n = 1295 consumers) tested factors influencing consumers' willingness to pay for foods with relevant characteristics.

Results

Among firms, we saw suggestive evidence of increased networking and business relationships, while laboratory-in-the-field experiments indicated the intervention might foster cooperation among participants. Qualitative interviews suggested that the intervention enabled firms to increase production, improve management, increase revenues, and lower costs. Baseline/endline data confirmed a positive effect only on the launch of new products and hiring workers. In the field experiment, consumption of the supported product increased in areas where it was made available relative to a control group, but this did not increase overall consumption of the food type or dietary diversity.

Conclusions

Results showed positive signs of the intervention improving firm-level outcomes but limited impact on consumers' diet quality. The evaluation also demonstrates how diverse methods can be used to evaluate complex interventions.

Ready-to-Use Supplementary-Food Biscuit Production with Low-Cost Ingredients for Malnourished Children in Sub-Saharan Africa

In Africa, the number of children under 5 years old who suffer from stunting and wasting are, respectively, 61.4 and 12.1 million, and to manage situations like these, emergency food products like RUTF and RUSF (ready-to-use therapeutic/supplementary food) are very useful. The aim of this study was to develop an RUSF biscuit using the low-cost food resources usually present in Sub-Saharan Africa (Burundi and the DRCongo in our case study); we conducted chemical characterization, nutritional evaluation, and a stability trial simulating the usual storage conditions in a rural context to demonstrate that RUSF can be functional also using low-cost ingredients and a simple method of production. The obtained recipes showed good potential in supplying protein integration-17.81% (BUR) and 16.77% (CON) (% as food) were the protein contents-and the protein digestibility values were very high (BUR: 91.72%; CON: 92.01%). Moreover, 30% of the daily requirement was achieved with less than 50 g of both recipes in all the considered ages. Finally, a good shelf-life was demonstrated during the 35-day testing period at 30 °C, considering moisture, texture, and lipid oxidation evolution. Recipes like these, with appropriate changes, could be very useful in all contexts where child malnutrition is a serious problem.

The effect of dietary diversity on anemia levels among children 6-23 months in sub-Saharan Africa: A multilevel ordinal logistic regression model

BACKGROUND

Anemia is the most common hematologic disorder of children worldwide. Since dietary diversity is a main requirement of children is to get all the essential nutrients, it can thus use as one of the basic indicator when assessing the child's anemia. Although dietary diversity plays a major role in anemia among children in sub-Saharan Africa, there is little evidence of an association between the dietary diversity and anemia level to identified potential strategies for prevention of anemia level in sub-Saharan Africa.

OBJECTIVE

To examine the association between dietary diversity and anemia levels among children aged 6-23 months in sub-Saharan Africa.

METHODS

The most recent Demographic and Health Surveys from 32 countries in SSA were considered for this study, which used pooled data from those surveys. In this study, a total weighted sample of 52,180 children aged 6-23 months was included. The diversity of the diet given to children was assessed using the minimum dietary diversity (MDD), which considers only four of the seven food groups. A multilevel ordinal logistic regression model was applied due to the DHS data's hierarchical structure and the ordinal nature of anemia. With a p-value of 0.08, the Brant test found that the proportional odds assumption was satisfied. In addition, model comparisons were done using deviance. In the bi-variable analysis, variables having a p-value ≤0.2 were taken into account for multivariable analysis. The Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) was presented for potential determinants of levels of anemia in the multivariable multilevel proportional odds model.

RESULTS

The overall prevalence of minimum dietary diversity and anemia among children aged 6-23 months were 43% [95% CI: 42.6%, 43.4%] and 72.0% [95% CI: 70.9%, 72.9%] respectively. Of which, 26.2% had mild anemia, 43.4% had moderate anemia, and 2.4% had severe anemia. MDD, being female child, being 18-23 months age, born from mothers aged ≥25, taking drugs for the intestinal parasite, higher level of maternal education, number of ANC visits, middle and richer household wealth status, distance of health facility and being born in Central and Southern Africa were significantly associated with the lower odds of levels of anemia. Contrarily, being 9-11- and 12-17-months age, size of child, having fever and diarrhea in the last two weeks, higher birth order, stunting, wasting, and underweight and being in West Africa were significantly associated with higher odds of levels of anemia.

CONCLUSION

Anemia was a significant public health issue among children aged 6-23 months in sub-Saharan Africa. Minimum dietary diversity intake is associated with reduced anemia in children aged 6 to 23 months in sub-Saharan Africa. Children should be fed a variety of foods to improve their anemia status. Reducing anemia in children aged 6-23 months can be achieved by raising mother education levels, treating febrile illnesses, and improve the family's financial situation. Finally, iron fortification or vitamin supplementation could help to better reduce the risk of anemia and raise children's hemoglobin levels in order to treat anemia.

'Counselling is not just providing information': perceptions of caregivers and stakeholders on the design of nutrition and health counselling interventions for families with young children in rural Kenya

BACKGROUND

Globally, a fifth of the children continue to face chronic undernutrition with a majority of them situated in the Low- and Middle-Income Countries (LMIC). The rising numbers are attributed to aggravating factors like limited nutrition knowledge, poor feeding practices, seasonal food insecurity, and diseases. Interventions targeting behaviour change may reduce the devastating nutrition situation of children in the LMICs.

OBJECTIVE

For the co-design of a Behaviour Change Communication (BCC) intervention for young children in rural Kenya, we aimed to identify the experiences, barriers, facilitators, and preferences of caregivers and stakeholders regarding nutrition and health counselling.

DESIGN

We employed a qualitative study design and used a semi-structured interview guide. The in-depth interviews were recorded, transcribed, and analysed using content analysis, facilitated by the software NVivo.

SETTING

Health and Demographic Surveillance System (HDSS) area in Siaya County, rural Kenya.

PARTICIPANTS

We interviewed 30 caregivers of children between 6 and 23 months of age and 29 local stakeholders with experience in implementing nutrition projects in Kenya.

RESULTS

Nutrition and health counselling (NHC) was usually conducted in hospital settings with groups of mothers. Barriers to counselling were long queues and delays, long distances and high travel costs, the inapplicability of the counselling content, lack of spousal support, and a high domestic workload. Facilitators included the trust of caregivers in Community Health Volunteers (CHVs) and counselling services offered free of charge. Preferences comprised (1) delivering of counselling by CHVs, (2) offering individual and group counselling, (3) targeting male and female caregivers.

CONCLUSION

There is a disconnect between the caregivers' preferences and the services currently offered. Among these families, a successful BCC strategy that employs nutrition and health counselling should apply a community-based communication channel through trusted CHVs, addressing male and female caregivers, and comprising group and individual sessions.

Induction of social contagion for diverse outcomes in structured experiments in isolated villages

Certain people occupy topological positions within social networks that enhance their effectiveness at inducing spillovers. We mapped face-to-face networks among 24,702 people in 176 isolated villages in Honduras and randomly assigned villages to targeting methods, varying the fraction of households receiving a 22-month health education package and the method by which households were chosen (randomly versus using the friendship-nomination algorithm). We assessed 117 diverse knowledge, attitude, and practice outcomes. Friendship-nomination targeting reduced the number of households needed to attain specified levels of village-wide uptake. Knowledge spread more readily than behavior, and spillovers extended to two degrees of separation. Outcomes that were intrinsically easier to adopt also manifested greater spillovers. Network targeting using friendship nomination effectively promotes population-wide improvements in welfare through social contagion.

Stunting and Gut Microbiota: A Literature Review

Stunting, a condition characterized by impaired growth and development in children, remains a major public health concern worldwide. Over the past decade, emerging evidence has shed light on the potential role of gut microbiota modulation in stunting. Gut microbiota dysbiosis has been linked to impaired nutrient absorption, chronic inflammation, altered short-chain fatty acid production, and perturbed hormonal and signaling pathways, all of which may hinder optimal growth in children. This review aims to provide a comprehensive analysis of existing research exploring the bidirectional relationship between stunting and the gut microbiota. Although stunting can alter the gut microbial community, microbiota dysbiosis may exacerbate it, forming a vicious cycle that sustains the condition. The need for effective preventive and therapeutic strategies targeting the gut microbiota to combat stunting is also discussed. Nutritional interventions, probiotics, and prebiotics are among the most promising approaches to modulate the gut microbiota and potentially ameliorate stunting outcomes. Ultimately, a better understanding of the gut microbiota-stunting nexus is vital for guiding evidence-based interventions that can improve the growth and development trajectory of children worldwide, making substantial strides toward reducing the burden of stunting in vulnerable populations.

How Livelihood Change Affects Food Choice Behaviors in Low- and Middle-Income Countries: A Scoping Review

Livelihoods have changed dramatically over the past decade in low- and middle-income countries (LMIC). These shifts are happening in tandem with shifts in individual and household food choice behaviors. This scoping review aimed to identify and characterize mechanisms through which livelihood changes could affect food choice behaviors in LMIC, including behaviors relating to food production, acquisition, preparation, distribution, and consumption. A literature search was conducted using 4 databases: PubMed, PsycInfo, AGRICOLA, and Embase. The search was further enhanced by expert solicitations. Studies were included if they measured or focused on a livelihood change, described or assessed a change in ≥1 food choice behavior, and focused on LMIC. Studies were excluded if they focused on migration from LMIC to a high-income country. Of the 433 articles that were identified, 53 met the inclusion criteria. Five mechanisms of how livelihood change can affect food choice were identified: occupation, locality, time, income, and social relations. Changes in occupation altered the balance of the availability and affordability of foods in local food environments compared with individual food production. Changes in location, time use, and income influenced where food was purchased, what types of foods were acquired, and how or where foods were prepared. Additionally, changes in social relationships and norms led to expanded food preferences, particularly among urban populations. Time limitations and higher discretionary income were associated with consumption of ultraprocessed foods. Understanding the relationships between the changes in livelihood occuring in LMIC and food choices of households in these countries can inform the development of policies, programs, and other actions to promote sustainable healthy diets and planetary health.

Evidence for Policies and Practices to Address Global Food Insecurity

Food insecurity affects an estimated 691-783 million people globally and is disproportionately high in Africa and Asia. It arises from poverty, armed conflict, and climate change, among other demographic and globalization forces. This review summarizes evidence for policies and practices across five elements of the agrifood system framework and identifies gaps that inform an agenda for future research. Under availability, imbalanced agriculture policies protect primarily staple food producers, and there is limited evidence on food security impacts for smallholder and women food producers. Evidence supports the use of cash transfers and food aid for affordability and school feeding for multiple benefits. Food-based dietary guidelines can improve the nutritional quality of dietary patterns, yet they may not reflect the latest evidence or food supplies. Evidence from the newer food environment elements, promotion and sustainability, while relatively minimal, provides insight into achieving long-term impacts. To eliminate hunger, our global community should embrace integrated approaches and bring evidence-based policies and practices to scale.

Pre-pregnancy body mass index and caesarean section in Andean women in Peru: a prospective cohort study

BACKGROUND

During the last two decades, Caesarean section rates (C-sections), overweight and obesity rates increased in rural Peru. We examined the association between pre-pregnancy body mass index (BMI) and C-section in the province of San Marcos, Northern Andes-Peru.

METHODS

This is a prospective cohort study. Participants were women receiving antenatal care in public health establishments from February 2020 to January 2022, who were recruited and interviewed during pregnancy or shortly after childbirth. They answered a questionnaire, underwent a physical examination and gave access to their antenatal care card information. BMI was calculated using maternal height, measured by the study team and self-reported pre-pregnancy weight measured at the first antenatal care visit. For 348/965 (36%) women, weight information was completed using self-reported data collected during the cohort baseline. Information about birth was obtained from the health centre's pregnancy surveillance system. Regression models were used to assess associations between C-section and BMI. Covariates that changed BMI estimates by at least 5% were included in the multivariable model.

RESULTS

This study found that 121/965 (12.5%) women gave birth by C-section. Out of 495 women with pre-pregnancy normal weight, 46 (9.3%) had C-sections. Among the 335 women with pre-pregnancy overweight, 53 (15.5%) underwent C-sections, while 23 (18.5%) of the 124 with pre-pregnancy obesity had C-sections. After adjusting for age, parity, altitude, food and participation in a cash transfer programme pre-pregnancy overweight and obesity increased the odds of C-section by more than 80% (aOR 1.82; 95% CI 1.16-2.87 and aOR 1.85; 95% CI 1.02-3.38) compared to women with a normal BMI.

CONCLUSIONS

High pre-pregnancy BMI is associated with an increased odds of having a C-section. Furthermore, our results suggest that high BMI is a major risk factor for C-section in this population. The effect of obesity on C-section was partially mediated by the development of preeclampsia, suggesting that C-sections are being performed due to medical reasons.

Examining the relationship between intimate partner violence and child development program attendance in young children: A cross-sectional study

The aim of the present study was to determine the association between different types of intimate partner violence against women and nonattendance at the Growth and Development Control Program (CRED or well-child visits) of their children under 5 years of age. This was an analytical cross-sectional study that comprised a secondary analysis of data from the Demographic and Family Health Survey (ENDES in Spanish) of Peru, 2019. Data from 19,647 mothers (aged 15-49 years) and their children under 5 years were analyzed. The independent variables were the types of intimate partner violence = emotional, physical, and sexual. The outcome variable was nonattendance at CRED in the last 6 months. The mean maternal age was 30.47 ± 6.66 years; 66.1% of children were between 25 and 60 months of age; the prevalence of nonattendance at CRED was 29.9%. A relationship was found between partner violence against the mother and nonattendance at CRED. Specifically, there was a higher probability of nonattendance in the children of women who experienced partner violence (sexual = aPR = 1.25 [95% CI = 1.07-1.44]; physical = aPR = 1.17 [95% CI = 1.08-1.26]; emotional = aPR = 1.12 [95% CI = 1.03-1.21]). This study showed an association indicating that children born to mothers experiencing intimate partner violence exhibit an elevated likelihood of nonattendance at CRED when compared to children of mothers not subjected to such violence. Therefore, emphasizing the promotion and monitoring of child development, especially for those with a history of maternal violence, should be a primary priority, particularly in primary care.