Differences in dietary acceptability, restraint, disinhibition, and hunger among African American participants randomized to either a vegan or omnivorous soul food diet

The Nutritious Eating with Soul study was a 24-month, randomized behavioral nutrition intervention among African American adults. This present study, which is a secondary analysis of the NEW Soul study, examined changes in dietary acceptability, restraint, disinhibition, and hunger. Participants (n = 159; 79% female, 74% with ≥ college degree, mean age 48.4 y) were randomized to either a soul food vegan (n = 77) or soul food omnivorous (n = 82) diet and participated in a two-year behavioral nutrition intervention. Questionnaires assessing dietary acceptability (Food Acceptability Questionnaire; FAQ) and dietary restraint, disinhibition, and hunger (Three-Factor Eating Questionnaire; TFEQ) were completed at baseline, 3, 6, 12, and 24 months. Mixed models were specified with main effects (group and time) and interaction effects (group by time) to estimate mean differences in FAQ and TFEQ scores using intent-to-treat analysis. After adjusting for employment, education, food security status, sex, and age, there were no differences in any of the FAQ items, total FAQ score, dietary restraint, disinhibition, and hunger at any timepoint except for one item of the FAQ at 12 months. Participants in the vegan group reported a greater increase in satisfaction after eating a meal than the omnivorous group (mean difference 0.80 ± 0.32, 95% CI 0.18, 1.42; P = 0.01). This is one of the first studies to examine differences in dietary acceptability, hunger, and other eating factors among African American adults randomized to either a vegan or omnivorous soul food diet. The findings highlight that plant-based eating styles are equally acceptable to omnivorous eating patterns and have similar changes in hunger, restraint, and disinhibition. These results suggest that plant-based eating styles can be an acceptable dietary pattern to recommend for cardiovascular disease prevention and may result in greater post-meal satisfaction.

Household food insecurity and associations with hemoglobin A1c and acute diabetes-related complications in youth and young adults with type 1 diabetes: The SEARCH for diabetes in youth study

AIMS

To examine, among youth and young adults (YYA) with type 1 diabetes (T1D), the association of household food insecurity (HFI) with: 1) HbA1c and 2) episodes of diabetic ketoacidosis (DKA) and severe hypoglycemia.

METHODS

HFI was assessed using the U.S. Household Food Security Survey Module in SEARCH for Diabetes in Youth participants with T1D between 2016 and 2019. Linear and logistic regression models adjusted for age, diabetes duration, sex, race, ethnicity, clinic site, parent/participant education, household income, health insurance, and diabetes technology use.

RESULTS

Of 1830 participants (mean age 20.8 ± 5.0 years, 70.0 % non-Hispanic White), HbA1c was collected for 1060 individuals (mean HbA1c 9.2 % ± 2.0 %). The prevalence of HFI was 16.4 %. In the past 12 months, 18.2 % and 9.9 % reported an episode of DKA or severe hypoglycemia, respectively. Compared to participants who were food secure, HFI was associated with a 0.33 % (95 % CI 0.003, 0.657) higher HbA1c level. Those with HFI had 1.58 (95 % CI 1.13, 2.21) times the adjusted odds of an episode of DKA and 1.53 (95 % CI 0.99, 2.37) times the adjusted odds of an episode of severe hypoglycemia as those without HFI.

CONCLUSIONS

HFI is associated with higher HbA1c levels and increased odds of DKA in YYA with T1D.

Testing the Effectiveness of a Community-Based Peer Support Intervention to Mitigate Social Isolation and Stigma of Adolescent Motherhood in Zimbabwe

OBJECTIVES

Social isolation and stigma contribute to poor mental health outcomes. Adolescent mothers in Zimbabwe often experience isolation and stigma, lacking social support and resources to navigate motherhood. The study tested the effectiveness of a community-based peer support intervention to mitigate social isolation and stigma of adolescent motherhood in Harare, Zimbabwe.

METHODS

Community health workers (n = 12) and peer educators (n = 12) in the intervention arm were recruited and trained on co-facilitating peer support groups. Adolescent mothers aged 15-18 years from two low-income high-density communities in Harare were recruited, using a quasi-experimental design. The intervention arm (n = 104) participated in the peer support groups and both arms completed sociodemographic, base-, mid-, and end-line surveys (control arm n = 79). Peer support groups (12 groups with 6-12 participants in each) met in-person twice a month and completed 12 sessions from May to August 2019 addressing participant-identified topics such as income generation and depression. WhatsApp Messenger was used for training and implementation support. Key community stakeholders discussed project progress and recommendations to improve adolescent mothers' health. Data were analyzed using Stata 15.

RESULTS

The intervention arm reported lower depressive symptoms and common mental disorders and higher overall, family, friends, and significant-other support, compared to control. The intervention arm felt more engaged with peers, knew who and where to turn to for help, and had coping, parenting and communication strategies to manage life challenges.

CONCLUSIONS FOR PRACTICE

The intervention mitigated social isolation and stigma and thereby improved mental health and social support among adolescent mothers in Harare. Trial Registration This trial is registered at Clinical Trials.gov, NCT05213182 https://clinicaltrials.gov/ct2/show/NCT05213182 .

Complementing the United States Household Food Security Survey Module with Items Reflecting Social Unacceptability

BACKGROUND

Social unacceptability of food access is part of the lived experience of food insecurity but is not assessed as part of the United States Household Food Security Survey Module (HFSSM).

OBJECTIVES

The objectives were as follows: 1) to determine the psychometric properties of 2 additional items on social unacceptability in relation to the HFSSM items and 2) to test whether these 2 items provided added predictive accuracy to that of the HFSSM items for mental health outcomes.

METHODS

Cross-sectional data used were from the Intersection of Material-Need Insecurities and HIV and Cardiovascular Health substudy of the Multicenter AIDS Cohort Study/Women's Interagency HIV Study Combined Cohort Study. Data on the 10-item HFSSM and 2 new items reflecting social unacceptability were collected between Fall 2020 and Fall 2021 from 1342 participants from 10 United States cities. The 2 social unacceptability items were examined psychometrically in relation to the HFSSM-10 items using models from item response theory. Linear and logistic regression was used to examine prediction of mental health measured by the 20-item Center for Epidemiologic Studies Depression scale and the 10-item Perceived Stress Scale.

RESULTS

The social unacceptability items were affirmed throughout the range of severity of food insecurity but with increasing frequency at higher severity of food insecurity. From item response theory models, the subconstructs reflected in the HFSSM-10 and the subconstruct of social unacceptability were distinct, not falling into one dimension. Regression models confirmed that social unacceptability was distinct from the subconstructs reflected in the HFSSM-10. The social unacceptability items as a separate scale explained more (∼1%) variation in mental health than when combined with the HFSSM-10 items in a single scale, and the social unacceptability subconstruct explained more (∼1%) variation in mental health not explained by the HFSSM-10.

CONCLUSIONS

Two social unacceptability items used as a separate scale along with the HFSSM-10 predicted mental health more accurately than did the HFSSM-10 alone.

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.

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.

Properties of the Household Food Security Survey Module Scale in Young Adults with Diabetes

BACKGROUND

The Household Food Security Survey Module (HFSSM) was not tailored to people with chronic diseases or young adults (YAs).

OBJECTIVES

We aim to evaluate whether the 18-item HFSSM meets assumptions underlying the scale among YAs with diabetes.

METHODS

Data from 1887 YAs with youth-onset type 1 diabetes or type 2 diabetes were used from the SEARCH for Diabetes in Youth Study, 2016-2019, and on 925 who returned for the SEARCH Food Security Cohort Study, 2018-2021, all of whom had completed the HFSSM. Guttman scaling properties (affirmation of preceding less severe items) and Rasch model properties (probability to answer an item based on difficulty level) were assessed.

RESULTS

Items 3 (balanced meals) and 6 (eating less than one should) were affirmed more frequently than expected (nonmonotonic response pattern). At 1.2%-3.5%, item nonresponse was rare among type 1 diabetes but higher among type 2 diabetes (range: 3.1%-10.6%). Items 9 (not eating the whole day) and 3 did not meet the Guttman scaling properties. Rasch modeling revealed that item 3 had the smallest difficulty parameter. INFIT indices suggested that some responses to item 3 did not match the pattern in the rest of the sample. Classifying household food insecurity (HFI) based on items 1 and 2 compared with other 2-item combinations, including item 3, revealed a substantial undercount of HFI ranging from 5% to 8% points.

CONCLUSIONS

Use of the HFSSM among YAs with diabetes could potentially result in biased HFI reporting and affect estimates of HFI prevalence in this population.

Impact of Suaahara, an integrated nutrition programme, on maternal and child nutrition at scale in Nepal

Suaahara was an innovative, complex, multi-sectoral, large-scale, nutrition programme in Nepal to increase exposure to nutrition-related information and services, improve nutrition-related knowledge and practices among pregnant women and mothers of infants and young children, and improve their nutrition. This study evaluated the effectiveness of Suaahara to improve nutrition and nutrition-related practices by comparing changes over 10 years between intervention and comparison districts. The samples of households at baseline in 2012 and endline in 2022 were 2040 and 2480, respectively, from 120 old wards. The impact was estimated using intent-to-treat regression models in which survey year, arm and their interaction were fixed effects, accounting for district clustering, with the interaction estimating differences between arms in changes over time. The intervention, relative to comparison, reduced maternal underweight by 8.43 percentage points (p < 0.001), consistent with improved maternal and fetal condition that was manifested as the greater length of 0.761 z-scores (p = 0.004) of infants 0-5.9 months. Complementary feeding practices with children between 6 and 23.9 months of age improved more in the intervention than comparison districts: child dietary diversity by 0.294 food groups (p = 0.072) and minimum dietary diversity by 9.51 percentage points (p = 0.028), feeding sick child more (p = 0.002) and administering oral rehydration solution and zinc for diarrhoea (p = 0.057) by about 17 percentage points each, and minimum meal frequency (p = 0.004) and minimum acceptable diet (p = 0.022) by about 15 percentage points each. Substantial impacts were demonstrated despite political restructuring, earthquakes, and other major challenges that Nepal and Suaahara faced and limitations in statistical power because of the reduced number of districts that then could be included in the study. Registered at clinicaltrials.gov with identifier NCT05448287.

Self-Reported Food Security in Adolescents with Type 1 Diabetes: Association with Hemoglobin A1c and Mental Health Symptoms Independent of Household Food Security

BACKGROUND

Typically, child exposure to food insecurity is assessed by caregiver reports of household food security. Child report has the potential for greater accuracy because it pertains only to the child whose experiences may differ from caregiver reports.

OBJECTIVE

We assessed if adolescent-reported food insecurity was associated with levels of hemoglobin A1c (HbA1c), acute diabetes-related complications, depressive symptoms, and disordered eating behaviors in adolescents with type 1 diabetes, independently from household food security.

METHODS

In a cross-sectional analysis of the multicenter SEARCH for Diabetes in Youth Cohort Study (phase 4, 2016-2019) including 601 adolescents aged 10-17 y with type 1 diabetes and their caregivers, household food security, and adolescent-reported food security were assessed using the 18-item Household Food Security Survey Module and the 6-item Child Food Security Assessment questionnaire. Age-stratified (10-13 and 14-17) regression models were performed to estimate independent associations, adjusting for sociodemographics, clinical factors, and household food security.

RESULTS

Food insecurity was reported by 13.1% (n = 79) of adolescents and 15.6% (n = 94) of caregivers. Among adolescent-caregiver dyads, 82.5% (n = 496) of reports were concordant and 17.5% (n = 105) discordant, Cohen's κ= 0.3. Adolescent-reported food insecurity was not independently associated with HbA1c, diabetic ketoacidosis, and severe hypoglycemia, including in age-stratified analyses. Adolescent-reported food insecurity was independently associated with elevated odds of depressive symptoms [odds ratio (OR): 3.6; 95% confidence interval (CI): 1.3, 10.3] and disordered eating behaviors (OR: 2.5, 95% CI: 1.4, 4.6) compared with adolescents reporting food security; these associations remained in both age groups for disordered eating behaviors and in the older group for depressive symptoms.

CONCLUSIONS

Adolescents with type 1 diabetes may experience food insecurity differently than caregivers. Adolescent-reported food insecurity was independently associated with depressive symptoms and disordered eating behaviors and thus may be an important attribute to assess in addition to household food security in adolescents with type 1 diabetes.

Impact of a livelihood intervention on gender roles and relationship power among people with HIV

OBJECTIVE

To evaluate the impact of an agricultural livelihood intervention on gender role conflict and sexual relationship power among people with HIV (PWH) in western Kenya.

DESIGN

Study participants were enrolled in Shamba Maisha , a cluster randomized controlled trial of an agricultural intervention conducted among PWH across 16 health facilities during 2016-2020. Intervention participants received a water pump, seeds, and agricultural and financial training; control participants received standard of HIV care.

METHODS

We assessed men's views on masculinity and gender roles via the validated gender role conflict score (GRCS; range 18-78, higher = greater gender role conflict). We measured gender power imbalances among women via the validated Sexual Relationship Power Scale (SRPS), which combines subscales of relationship control and decision-making dominance (range 1-4, higher = female holds more power). We compared changes over the study period by arm using longitudinal multilevel difference-in-difference linear regression models accounting for clustering of facilities using the intention-to-treat cohort.

RESULTS

We enrolled 720 participants (366 intervention, 354 control); 2-year retention was 94%. Median age was 40 and approximately 55% of participants were female. Among men, after 24-months the decrease in GRCS scores was 4.3 points greater in the intervention than the control arm ( P  < 0.001). Among women, the intervention resulted in 0.25 points greater increase in the SRPS compared to the control arm ( P  < 0.001).

CONCLUSIONS

Shamba Maisha resulted in less gender role conflict in men and greater sexual relationship power for women. Agricultural livelihood interventions may be a powerful tool to improve gender power imbalances, which may subsequently mitigate poverty and food insecurity.

Links between Household-Level Income-Generating Agricultural Intervention and the Psychological Well-Being of Adolescent Girls in Human Immunodeficiency Virus-Affected Households in Southwestern Kenya: A Qualitative Inquiry

BACKGROUND

Adolescent girls may experience poor psychological well-being, such as social isolation, shame, anxiety, hopelessness, and despair linked to food insecurity.

OBJECTIVES

This study aimed to investigate the experiences with and perceived effects of a household-level income-generating agricultural intervention on the psychological well-being of adolescent girls in human immunodeficiency virus (HIV)-affected households in southwestern Kenya.

METHODS

We conducted 62 in-depth interviews with HIV-affected adolescent girls and caregiver dyads in Adolescent Shamba Maisha (NCT03741634), a sub-study of adolescent girls and caregivers with a household member participating in Shamba Maisha (NCT01548599), a multisectoral agricultural and finance intervention trial aimed to improve food security and HIV health indicators. Participants were purposively sampled to ensure diversity in terms of age and location. Data were audiotaped, transcribed, translated, and uploaded into Dedoose (Sociocultural Research Consultants, LLC) software for management. Data were analyzed thematically based on reports from Dedoose.

RESULTS

We found evidence that a household-level structural intervention aimed at increasing food and financial security among persons living with HIV can contribute to better psychological well-being among adolescent girls residing in these households. The intervention also affected: 1) reduction of social isolation, 2) reduction of shame and stigma, 3) increased attendance and concentration in school, 4) improved caregiver mental health, and 5) reduced parental aggression and improved household communication. These associations were reported more commonly among those in the intervention arm than the control arm.

CONCLUSIONS

This study extends existing research by demonstrating how multisectoral structural interventions delivered at a household level can improve the psychological well-being of adolescents. We recommend that future research test livelihood interventions designed specifically for adolescent girls that integrate food-security interventions with other elements to address the social and psychological consequences of food insecurity holistically. This trial was registered at clinicaltrials.gov as NCT03741634.

Differences in Infant Diet Quality Index by Race and Ethnicity Predict Differences in Later Diet Quality

BACKGROUND

Racial and ethnic disparities in infant-feeding practices may negatively influence diet quality and health.

OBJECTIVES

This study investigated the racial, ethnic, and language (English or Spanish) differences in infant diet quality, later diet quality, and weight status at 2-5 y, and whether these differences were explained through infant diet quality among participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

METHODS

Using the WIC Infant and Toddler Feeding Practices Study-2 (unweighted n = 2663; weighted n = 362,712), relationships between the Infant Dietary Quality Index (IDQI; range 0-1) and Healthy Eating Index-2020 (HEI-2020; range 0-100) and BMI z-score (BMIz) at 2-5 y were analyzed by race, ethnicity, and language preference [Hispanic Spanish-speaking, Hispanic English-speaking, non-Hispanic (NH) White, and NH Black participants]. Statistical interaction between IDQI and each group was evaluated in multivariable models. The mediation of each group through the IDQI was assessed using causal mediation methods.

RESULTS

Differences in IDQI [mean (standard deviation)] were observed between Hispanic Spanish-speaking participants [0.41 (0.10)], Hispanic English-speaking participants [0.37 (0.10)], NH White participants [0.36 (0.10)], and NH Black participants [0.35 (0.09)], P < 0.001. Differences in HEI-2020 occurred at 2-5 y, with the Hispanic Spanish-speaking participants having consistently higher HEI-2020 scores. Differences in BMIz were observed at 5 y, with higher scores among Hispanic Spanish-speaking participants. Interaction between race, ethnicity, and IDQI was observed for all outcomes except for BMIz at 3 y. Through mediation, IDQI explained 13%-20% of the difference in HEI-2020 scores between Hispanic Spanish-speaking and NH White participants at 2-5 y. IDQI explained 22%-25% of the difference in HEI-2020 scores between the Hispanic Spanish-speaking and NH Black participants at 4 y and 5 y.

CONCLUSIONS

Higher infant diet quality scores observed in Hispanic Spanish-speaking participants explain some of the racial and ethnic differences observed in later diet quality, suggesting that improving infant diet quality may help reduce diet disparities during early childhood.

Association of Higher Intake of Plant-Based Foods and Protein With Slower Kidney Function Decline in Women With HIV

BACKGROUND

We investigated whether there exists an association between dietary acid load and kidney function decline in women living with HIV (WLWH) receiving antiretroviral therapy (ART).

SETTING

One thousand six hundred eight WLWH receiving ART in the WIHS cohort with available diet data and a baseline estimated glomerular filtration rate (eGFR) ≥15 mL/minute/1.73 m2.

METHODS

A brief dietary instrument conducted from 2013 to 2016 under the Food Insecurity Sub-Study was used for assessing fruits and vegetables (FV) and protein intake. A mixed-effects model with random intercept and slope was used to estimate subjects' annual decline rate in eGFR and the association between FV intake and eGFR decline, adjusting for sociodemographics, serum albumin, comorbidities, time on ART, ART drugs, HIV markers, and baseline eGFR. We evaluated whether markers of inflammation mediated the effect of FV intake on decline in eGFR, using causal mediation analysis.

RESULTS

We found a dose-response relationship for the association of FV intake and eGFR decline, with lesser annual decline in eGFR in the middle and highest tertiles of FV intake. An increase of 5 servings of FV intake per day was associated with a lower annual eGFR decline (-1.18 [-1.43, -0.94]). On average, 39% of the association between higher FV intake and slower eGFR decline was explained by decreased levels of inflammation.

CONCLUSIONS

Plant-rich diet was associated with slower decline in kidney function. Inflammation is a potential path through which diet may affect kidney function. The findings support an emerging body of literature on the potential benefits of plant-rich diets for prevention of chronic kidney disease.

Feasibility and impact of school-based nutrition education interventions on the diets of adolescent girls in Ethiopia: a non-masked, cluster-randomised, controlled trial

BACKGROUND

Adolescence is a critical period of physical and psychological development, especially for girls, because poor nutrition can affect their wellbeing as well as that of their children. We aimed to assess the feasibility and impact of a package of nutrition education interventions delivered through public primary schools on the diets of adolescent girls in Ethiopia.

METHODS

In this non-masked, cluster-randomised, controlled trial, primary schools (clusters) in the Southern Nations, Nationalities, and People's Region and Somali region of Ethiopia were randomly allocated to the intervention group (nutrition information provided during flag ceremonies, classroom lessons, school club meetings, peer group mentoring, BMI measurement and counselling, and parent-teacher meetings) or the control group (standard academic curriculum on health and nutrition) by use of computer-generated pseudo-random numbers. Duration of the school-based interventions was 4 months, and the key messages were related to dietary diversity (eating a variety of foods), energy adequacy (eating breakfast and healthy snacks), and healthy food choices (avoiding junk foods). Adolescent girls were eligible for participation if aged 10-14 years and enrolled in grades 4-8 in a study school. Data were collected with two independent cross-sectional surveys: baseline before the start of implementation and endline 1·5 years later. The primary outcome of impact was dietary diversity score, defined as the number of food groups (out of ten) consumed over the previous 24 h using a list-based method, and minimum dietary diversity, defined as the proportion of girls who consumed foods from at least five of the ten food groups, in the intention-to-treat population. We also assessed intervention exposure as a measure of feasibility. We estimated intervention effects using linear regression models for mean differences at endline, with SEs clustered at the school level, and controlled for adolescent age, region, household food security, and wealth. The trial is registered with ClinicalTrials.Gov, NCT04121559, and is complete.

FINDINGS

27 primary schools were randomly allocated to the intervention group and 27 to the control group. Between March 22 and April 29, 2021, 536 adolescent girls participated in the endline survey (270 in the intervention group and 266 in the control group), with median age of 13·3 years (IQR 12·1-14·0). At endline, the dietary diversity score was 5·37 (SD 1·66) food groups in the intervention group and 3·98 (1·43) food groups in the control group (adjusted mean difference 1·33, 95% CI 0·90-1·75, p<0·0001). Increased minimum dietary diversity was also associated with the intervention (182 [67%] of 270 in the intervention group vs 76 [29%] of 266 in the control group; adjusted odds ratio 5·37 [95% CI 3·04-9·50], p<0·0001). 256 (95%) of 270 adolescent girls in the intervention group were exposed to at least one of the five in-school intervention components.

INTERPRETATION

Integrating nutrition interventions into primary schools in Ethiopia was feasible and increased dietary diversity incrementally among adolescent girls, but could be limited in changing other food choice behaviours, such as junk food consumption, based on nutrition education alone.

FUNDING

Bill & Melinda Gates Foundation.

Understanding Commitment of Local Food Banks, Faith-Based Organizations, and Schools to Provide Nongovernment Food Programs

Background

Nongovernment food assistance is typically provided to families by faith-based organizations, schools, and food banks. Community organizations appear to be strongly committed to these programs, but little is known about the basis for this commitment.

Objectives

The aim of this study was to examine the values and identities of community organizations to understand the reasons for their commitment to providing nongovernment food assistance.

Methods

Thirty-three in-depth interviews were conducted with 36 leaders at faith-based organizations (19 participants), schools (14 participants), and a local food bank (3 participants) in South Carolina. Observations were made, and informational documents (e.g., flyers and pamphlets) were reviewed. Thematic coding using the constant comparative method was guided by the policy concepts of organizational perspectives, values, and identities.

Results

Nongovernment food programs offered participants volunteering opportunities to become involved with community organizations, which in turn increased financial support for the sustainability of these programs. School participants regarded themselves as a mechanism through which food programs were provided because of their commitment to students and believed they have limited capacity to make proposals to influence the food programs. Seeking to improve the well-being of the community by ending hunger was not the primary value on which organizations focused; instead, it was the process of fulfilling other values (e.g., forming or maintaining relationships within the community), maintaining identity, and appealing to their participants that strengthened their commitment to nongovernment food programs.

Conclusion

Nongovernment programs are meant to be a solution to food insecurity complementary to government programs. Commitment to nongovernment programs fulfills organizational identities, wants, and assumptions, but a consequence of commitment to food programs, derived from fulfilling other values, is that the roots of hunger in a community become obscured and alternative solutions are ignored or rejected.

Strategies elementary school children use to influence mothers' food purchasing decisions

This study aimed to understand the strategies elementary-school-aged children used to influence mothers' food purchasing decisions. Semi-structured qualitative interviews were conducted with 40 children aged 6-11 years and their mothers living in South Carolina. Strategies to influence mothers' food purchases were collected from children and their mothers separately. The interviews were audio-recorded, transcribed verbatim, and open-coded. The constant comparative method was used for data analysis. Coding matrices were used to compare children's and mothers' responses on the children's strategies. Children reported 157 instances of 25 distinct strategies to influence mothers' purchasing decisions. Mothers had concordance with 83 instances of these strategies. Mothers were more concordant with sons than daughters. The most common and successful strategies reported by children and mothers were repeated polite requests, reasoned requests and referencing friends. Other strategies included offers to contribute money or service, using other family members to pursue mothers for the item, writing a list and grabbing desired items. Mothers perceived that children had a large influence on food purchasing decisions. Children were aware of the strategies that would get positive reactions from mothers. They (children) could get their desired items a lot of times, often, or several times in a month from their mothers irrespective of the healthfulness of the items. Children's influence can be used as a change agent for improving mothers' food purchases if children prefer healthy foods. Efforts are needed for mothers and children to help address children's strategies to influence mothers to purchase unhealthy foods and make healthy foods more appealing to children.

Longitudinal Relationship Between Food Insecurity, Engagement in Care, and ART Adherence Among US Women Living with HIV

Food insecurity disproportionately affects people with HIV and women in the United States (US). More evidence is needed to understand the interplay between levels of food insecurity and levels of antiretroviral therapy (ART) adherence over time, as well as how food insecurity relates to engagement in HIV care. We used random effects models with longitudinal data from the US Women's Interagency HIV Study to estimate the (1) adjusted associations of current and 6-month lagged food security with ART adherence categories (n = 1646), and (2) adjusted associations of food security with engagement-in-care (n = 1733). Very low food security was associated with a higher relative risk of ART non-adherence at prior and current visits compared with food security, and this association increased across non-adherence categories. Very low food security was associated with lower odds of receiving HIV care and higher odds of a missed visit. Food insecurity among US women with HIV is associated with poorer engagement in care and degree of ART non-adherence over time.

Strengthening Nutrition Interventions during Antenatal Care Improved Maternal Dietary Diversity and Child Feeding Practices in Urban Bangladesh: Results of a Quasi-Experimental Evaluation Study

BACKGROUND

Bangladesh is urbanizing rapidly, facing challenges of malnutrition, low coverage and poor quality of urban nutrition services.

OBJECTIVES

We assessed the effect of integrating maternal, infant, and young child nutrition interventions, delivered at urban Maternal Neonatal and Child Health facilities, on maternal dietary diversity, iron and folic acid (IFA) and calcium consumption, and child feeding practices.

METHODS

We used a quasi-experimental design with a nonrandom assignment of 20 health care facilities in Dhaka to intensive and standard service arms. We conducted facility-based observations and community-based surveys at baseline (2020) and endline (2022) (n = 2455 observations and surveys with 1678 pregnant women [PW] or recently delivered women [RDW] at endline). We derived difference-in-difference (DID) estimates, adjusted for characteristics that differed at baseline or endline, and accounted for clustering.

RESULTS

Exposure to antenatal care (ANC) was similar in both arms: two-thirds of RDW received ANC during the first trimester and three-fourths received ≥4 ANC checkups. Compared to the standard arm, a higher proportion of PW in the intensive arm received counseling on dietary diversity (DID: 45 percentage points [pp]), and a higher proportion of RDW received IFA (25 pp) and calcium supplementation (19 pp), showed adequate weight gain (44 pp), and recorded appropriate child feeding (27 pp). Improvements were greater in the intensive than the standard arm for the number of food groups consumed (DID: 1.1 food groups) and minimum dietary diversity (23 pp); no effect was observed for IFA and calcium consumption during pregnancy. However, effects were observed for early initiation of (20 pp) and exclusive breastfeeding (45 pp), introduction of solid or semisolid foods (28 pp), and egg and/or flesh food consumption (33 pp) among children. Minimum dietary diversity and acceptable diet remained low in both arms.

CONCLUSIONS

Intensifying nutrition in government-aligned health care services delivered by experienced nongovernmental organization-run facilities is a feasible model to address the urban health gap, nutrition services coverage, and improve practices. The trial was registered at clinicaltrials.gov as NCT03882268.

Changing maternal, infant and young child nutrition practices through social and behaviour change interventions implemented at scale: Lessons learned from Alive & Thrive

Alive & Thrive (A&T) is an initiative designed to advance the implementation of maternal, infant and young child nutrition (MIYCN) social and behaviour change (SBC) at a large scale. The aims of this research were to: (1) describe A&T's SBC implementation processes and their impact based on a review of programme documents and peer-reviewed publications and (2) gather lessons learned from key informant interviews (N = 23) with A&T staff and stakeholders in Bangladesh, Burkina Faso, Ethiopia, India, Nigeria and Vietnam. A&T's SBC approach used interpersonal communication, community mobilization and mass media to address knowledge gaps, strengthen self-efficacy and shift social norms. The initiative used data for design and evaluation and facilitated scale and sustainability through close collaboration with governments and other stakeholders. A&T's approach increased exclusive breastfeeding, minimum meal frequency of children and use of iron and folic acid tablets by pregnant women, but had mixed impacts on early initiation of breastfeeding and maternal and child dietary diversity. Multiple SBC channels and frequent contacts strengthened the impact of SBC on MIYCN practices. Lessons learned included: using existing large-scale platforms for interpersonal communication, improving counselling skills of health workers, delivering timely tailored messages, engaging key influencers to take specific actions, using research to address underlying behavioural concerns and maximize mass media reach and frequency, using simple memorable messages and employing additional channels to reach low media coverage areas. A&T developed and implemented at-scale MIYCN SBC in multiple countries, providing lessons learned about intervention strategies, engagement of influencers and mass media campaign development, which governments and other implementers can adapt and replicate.

Basic human values drive food choice decision-making in different food environments of Kenya and Tanzania

Increased access to a variety of foods in low-and-middle-income countries (LMICs) has led to greater autonomy in food choice decision-making. Autonomy allows individuals to make decisions through negotiation of considerations in ways that are consistent with basic values. The aim of this study was to identify and describe how basic human values drive food choice in two diverse populations with transitioning food environments living in the neighboring East African countries of Kenya and Tanzania. Secondary data analysis was carried out on focus group discussions conducted with men and women in Kenya (n = 28) and Tanzania (n = 28) as part of prior studies on food choice. A priori coding based on Schwartz's theory of basic human values was conducted, followed by a narrative comparative analysis, which included review by original principal investigators. Values of conservation (security, conformity, tradition), openness to change (self-directed thought and action, stimulation, indulgence), self-enhancement (achievement, power, face), and self-transcendence (benevolence-dependability and -caring) were prominent drivers of food choice in both settings. Participants described how values were negotiated and highlighted existing tensions. For example, the value of tradition was cited as important in both settings but changing food contexts (e.g., new foods, diverse neighborhoods) increased prioritization of values like stimulation, indulgence, and self-directed thought and action. The application of a basic values framework was useful for understanding food choice in both settings. A focused understanding of how values drive food choice decision-making in the context of changing food availability in LMICs is essential for the promotion of sustainable healthy diets.

Assessing and Monitoring Nutrition Security to Promote Healthy Dietary Intake and Outcomes in the United States

The US Department of Agriculture's Economic Research Service leads the federal government in data development and research on food security in US households. Nutrition security is an emerging concept that, although closely related, is distinct from food security. No standard conceptualization or measure of nutrition security currently exists. We review the existing research on nutrition security and how it is informed by the more robust literature on food security and diet quality. Based on this review, we propose a conceptual framework for understanding nutrition security and its relationship to food security. We identify two constructs (healthy diets and nutritional status) and multiple subconstructs that form the basis of nutrition security. The proposed framework and corresponding constructs are intended to provide (a) understanding of how nutrition security arises and how it differs from food security, (b) background on why assessment and monitoring of nutrition security is important, and (c) guidance for a research agenda that will further clarify the meaning of nutrition security and its measurement.

Comparing the effect of a multisectoral agricultural intervention on HIV-related health outcomes between widowed and married women

INTRODUCTION

Widowed women make up 18-40% of the 12 million women living with HIV in eastern and southern Africa. Widowhood has also been associated with greater HIV morbidity and mortality. We compared the effectiveness of a multisectoral climate adaptive agricultural livelihood intervention (called Shamba Maisha) on food insecurity, and HIV related health outcomes among widowed and married women living with HIV in western Kenya.

METHODS

We implemented Shamba Maisha (NCT02815579) using a cluster-randomized control trial design. The intervention arm received an US$175 in-kind loan to purchase a micro-irrigation pump, seeds, and fertilizer, and received eight training sessions on sustainable agriculture and financial management. Study outcomes were measured every 6 months over a 24-month follow-up period and trends in outcomes assessed using multilevel mixed-effects models.

RESULTS

The trial enrolled 232 (61.5%) married and 145 (38.5%) widowed women. Widowed women (mean age 42.8 ± 8.4 years) were older than married women (35.8 ± 9.0 years) (p < 0.01). Almost all widowed women (97.2%) self-identified as household heads compared to 10.8% of married women. Comparing widowed vs married women, reduction in food insecurity (-3.13, 95%CI -4.42, -1.84 vs. -3.08, 95%CI -4.15, -2.02), depressive symptoms (-0.21, 95%CI -0.36, -0.07 vs. -0.19, 95%CI -0.29, -0.08), internalized stigma (-0.33, 95%CI -0.55, -0.11 vs. -0.38, 95%CI -0.57, -0.19), and anticipated stigma (-0.46 95%CI -0.65, -0.28 vs. -0.35, 95%CI -0.50, -0.21) was similar for both groups. In contrast, improvements in social support (-2.22, 95%CI -3.85, -0.59 vs. -4.00, 95%CI -5.16, -2.84; p = 0.08) and reduction in enacted stigma (0.01, 95%CI -0.06, 0.08 vs. -0.14, 95%CI -0.20, -0.09; p < 0.01) were weaker for widowed than married women.

CONCLUSIONS

Our study is among the first comparing the effect of a livelihood intervention on HIV health outcomes among widowed and married women. Widowed women experienced similar benefits as married women on individual-level outcomes, but weaker benefit on outcomes dependent on their external environment like enacted stigma and social support. Future trials and programs targeting widowed women should bolster stigma reduction and social support.

Food Insecurity and Adequacy of Dietary Intake in Youth and Young Adults With Youth-Onset Type 1 and Type 2 Diabetes

BACKGROUND

Household food insecurity is associated with poor dietary intake in the general population, but little is known about this association in persons with diabetes.

OBJECTIVE

We examined the degree of adherence to the dietary reference intakes and 2020-2025 Dietary Guidelines for Americans overall and according to food security status and diabetes type among youth and young adults (YYA) with youth-onset diabetes.

DESIGN, PARTICIPANTS, AND SETTING

The SEARCH for Diabetes in Youth study includes 1,197 YYA with type 1 diabetes (mean age = 21 ± 5 years) and 319 YYA with type 2 diabetes (25 ± 4 years). Participants (or parents if younger than age 18 years) completed the US Department of Agriculture Household Food Security Survey Module, wherein ≥3 affirmations indicate food insecurity.

MAIN OUTCOME MEASURES

Diet was assessed via food frequency questionnaire and compared with age- and sex-specific dietary reference intakes for 10 nutrients and dietary components (calcium; fiber; magnesium; potassium; sodium; vitamins C, D, and E; added sugar; and saturated fat).

STATISTICAL ANALYSES PERFORMED

Median regression models controlled for sex- and type-specific means for age, diabetes duration, and daily energy intake.

RESULTS

Prevalence of guideline adherence was overarchingly poor, with <40% of participants meeting recommendations for eight of 10 nutrients and dietary components; however, higher adherence (>47%) was observed for vitamin C and added sugars. YYA with type 1 diabetes who were food insecure were more likely to meet recommendations for calcium, magnesium, and vitamin E (P < 0.05), and less likely for sodium (P < 0.05) than those with food security. In adjusted models, YYA with type 1 diabetes who were food secure had closer median adherence to sodium (P = 0.002) and fiber (P = 0.042) guidelines than those food insecure. No associations were observed in YYA with type 2 diabetes.

CONCLUSIONS

Food insecurity is associated with lesser adherence to fiber and sodium guidelines in YYA with type 1 diabetes, which may lead to diabetes complications and other chronic diseases.

Why understanding food choice is crucial to transform food systems for human and planetary health

What, how and why people eat has long been understood to be important for human health, but until recently, has not been recognised as an essential facet of climate change and its effects on planetary health. The global climate change and diet-related health crises occurring are connected to food systems, food environments and consumer food choices. Calls to transform food systems for human and planetary health highlight the importance of understanding individual food choice. Understanding what, how and why people eat the way they do is crucial to successful food systems transformations that achieve both human and planetary health goals. Little is known about how food choice relates to climate. To clarify potential paths for action, we propose that individual food choice relates to climate change through three key mechanisms. First, the sum of individual food choices influences the supply and demand of foods produced and sold in the marketplace. Second, individual food decisions affect type and quantity of food waste at the retail and household level. Third, individual food choices serve as a symbolic expression of concern for human and planetary health, which can individually and collectively stimulate social movements and behaviour change. To meet the dietary needs of the 2050 global population projection of 10 billion, food systems must transform. Understanding what, how and why people eat the way they do, as well as the mechanisms by which these choices affect climate change, is essential for designing actions conducive to the protection of both human and planetary health.

Viabilidad de una escala de experiencias de inseguridad del agua en hogares mexicanos

OBJETIVO

Identificar la viabilidad de la Escala de Experiencias de Inseguridad del Agua en el Hogar (Household Water Insecurity Experiences Scale, HWISE, por sus siglas en inglés) como herramienta para evaluar las experiencias de hogares mexicanos en relación con la inseguridad en el acceso al agua. Material y métodos. La escala fue integrada en la Encuesta Nacional de Salud y Nutrición Continua 2021 (Ensanut Continua 2021) y se utilizaron tres criterios para evaluar su viabilidad: 1) Consistencia interna: Se aplicó la prueba Alfa de Cronbach para estimar la correlación entre los ítems de la escala. Se consideró un punto de corte de al menos 0.80 como criterio de confiabilidad; 2) Equivalencia de los ítems para distintos indicadores sociodemográficos; y 3) Variables asociadas con inseguridad del agua.

RESULTADOS

La escala HWISE mostró: 1) Buena confiabilidad o consistencia interna (Alfa de Cronbach de 0.928); 2) comportamiento equivalente de los ítems en los contextos urbano y rural, en nueve regiones del país y por terciles de condiciones de bienestar; y 3) asociación significativa con variables predictoras de inseguridad del agua.

CONCLUSIONES

La escala HWIS, adaptada para México, es apropiada para su uso en evaluar la condición de inseguridad del agua en hogares mexicanos.

Text messages to improve child diets: Formative research findings and protocol of a randomised controlled trial in Nepal

Given the role of malnutrition in childhood morbidity and mortality, the prioritisation of maternal and child nutrition programmes has grown significantly in the 21st century. Policies and programmes aim to improve infant and young child feeding, but questions persist about the most effective combination of interventions to achieve desired behaviour change. There is increasing interest in mobile-based interventions globally, but scant evidence exists to guide donors, policymakers and programme implementers on their effectiveness. Formative research was conducted to assess the feasibility and acceptance of text message-based interventions and to guide the final design of the text message intervention. This protocol is for a cluster-randomised controlled trial to test the effectiveness of adding text messaging to other ongoing SBC interventions to promote egg consumption, dietary diversity and other ideal dietary practices, particularly among children 12-23 months of age in Kanchanpur, Nepal. The trial findings will contribute to the emerging body of evidence on the effectiveness of using text messages for behaviour change, specifically for young child dietary outcomes in South Asia. Recent studies have suggested that mobile-based interventions alone may be insufficient but valuable when added to other social and behavioural interventions; this trial will help to provide evidence for or against this emerging theory. This trial was registered at ClinicalTrials.gov on 11 March 2019 (ID: NCT03926689) and has been updated twice.

The Infant Diet Quality Index Predicts Dietary and Adiposity Outcomes in US Children 2 to 4 years old

BACKGROUND

Healthy nutrition during the first year of life is critical for optimal growth and development. Limited techniques are available to assess diet quality in infancy, and few have been shown to be predictive of dietary and adiposity outcomes in low-income children.

OBJECTIVE

The objectives of this study were to construct an Infant Diet Quality Index (IDQI) to assess the diet quality from birth to 12 mo and to determine whether the IDQI exhibits predictive validity by estimating the longitudinal associations of IDQI scores with diet quality and weight status at 2 to 4 y.

DESIGN

Data were analyzed from the longitudinal Women, Infants, and Children Infant and Toddler Feeding Practices Study-2 (unweighted, n = 2858; weighted. N = 392,439) using one 24-h dietary recall and survey responses during infancy. The newly constructed IDQI consists of 16 equally-weighted components: 1) breastfeeding duration; 2) exclusive breastfeeding; age of first introduction of: 3) solids, 4) iron-rich cereals, 5) cow milk, 6) sugar-sweetened beverages, 7) salty/sweet snacks, 8) other drinks/liquids, and 9) textured foods; frequency of consuming 10) fruit or 11) vegetables; frequency of consuming different 12) fruit or 13) vegetables; 14) nonrecommended bottle-feeding practices; 15) use of commercial baby foods; and 16) number of meals and snacks. Regression analysis was used to estimate associations between the total IDQI score (range, 0-1) and Healthy Eating Index-2015 (HEI-2015) scores and body mass index z-scores (BMIz) at 2 to 4 y of age, adjusted for covariates (e.g., child age, sex and race/ethnicity; maternal education level, etc.) RESULTS: The total IDQI score was positively associated with HEI-2015 at the age of 2 y (β = 16.7; 95% CI: 12.6, 20.9; P < 0.001), 3 y (β = 14.5; 95% CI: 8.1, 21.0; P < 0.001), and 4 y (β = 15.4; 95% CI: 8.4, 22.4; P < 0.001); and negatively associated with BMIz at the age of 2 y (β = -1.24; 95% CI: -2.01, -0.47; P = 0.002) and 4 y (β = -0.92; 95% CI: -1.53, -0.30; P = 0.003).

CONCLUSIONS

The IDQI has predictive validity for diet quality and weight status in low-income US children.

Prevalence and Predictors of Household Food Insecurity and Supplemental Nutrition Assistance Program Use in Youth and Young Adults With Diabetes: The SEARCH for Diabetes in Youth Study

OBJECTIVE

To assess the prevalence of household food insecurity (HFI) and Supplemental Nutrition Assistance Program (SNAP) participation among youth and young adults (YYA) with diabetes overall and by type, and sociodemographic characteristics.

RESEARCH DESIGN AND METHODS

The study included participants with youth-onset type 1 diabetes and type 2 diabetes from the SEARCH for Diabetes in Youth study. HFI was assessed using the 18-item U.S. Household Food Security Survey Module (HFSSM) administered from 2016 to 2019; three or more affirmations on the HFSSM were considered indicative of HFI. Participants were asked about SNAP participation. We used χ2 tests to assess whether the prevalence of HFI and SNAP participation differed by diabetes type. Multivariable logistic regression models were used to examine differences in HFI by participant characteristics.

RESULTS

Of 2,561 respondents (age range, 10-35 years; 79.6% ≤25 years), 2,177 had type 1 diabetes (mean age, 21.0 years; 71.8% non-Hispanic White, 11.8% non-Hispanic Black, 13.3% Hispanic, and 3.1% other) and 384 had type 2 diabetes (mean age, 24.7 years; 18.8% non-Hispanic White, 45.8% non-Hispanic Black, 23.7% Hispanic, and 18.7% other). The overall prevalence of HFI was 19.7% (95% CI 18.1, 21.2). HFI was more prevalent in type 2 diabetes than type 1 diabetes (30.7% vs. 17.7%; P <  0.01). In multivariable regression models, YYA receiving Medicaid or Medicare or without insurance, whose parents had lower levels of education, and with lower household income had greater odds of experiencing HFI. SNAP participation was 14.1% (95% CI 12.7, 15.5), with greater participation among those with type 2 diabetes compared with those with type 1 diabetes (34.8% vs. 10.7%; P < 0.001).

CONCLUSIONS

Almost one in three YYA with type 2 diabetes and more than one in six with type 1 diabetes reported HFI in the past year-a significantly higher prevalence than in the general U.S. population.

Relationship Power, Antiretroviral Adherence, and Physical and Mental Health Among Women Living with HIV in Rural Kenya

Little is known about the association of gender-based power imbalances and health and health behaviors among women with HIV (WWH). We examined cross-sectional baseline data among WWH in a cluster-randomized control trial (NCT02815579) in rural Kenya. We assessed associations between the Sexual Relationship Power Scale (SRPS) and ART adherence, physical and mental health, adjusting for sociodemographic and social factors. SRPS consists of two subscales: relationship control (RC) and decision-making dominance. Women in the highest and middle tertiles for RC had a 7.49 point and 8.88 point greater Medical Outcomes Study-HIV mental health score, and a 0.27 and 0.29 lower odds of depression, respectively, compared to women in the lowest tertile. We did not find associations between SPRS or its subscales and ART adherence. Low sexual relationship power, specifically low RC, may be associated with poor mental health among WWH. Intervention studies aimed to improve RC among WWH should be studied to determine their effect on improving mental health.

Concurrence of water and food insecurities, 25 low- and middle-income countries

Objective

To investigate how water and food insecurity were associated in nationally representative samples of individuals from 25 low- and middle-income countries.

Methods

We used data from the 2020 World Gallup Poll in which the Individual Water Insecurity Experiences Scale and the Food Insecurity Experience Scale had been administered to 31 755 respondents. These scales measure insecurity experiences in the previous 12 months. We classified individuals as water insecure if their score was ≥ 12 and food insecure if the Rasch probability parameter was ≥ 0.5. For estimating the proportions, we used projection weights. We estimated the relationships between binary and continuous measures of water insecurity and food insecurity for individuals within each country and region using multivariable logistic and linear regression models, adjusting for key socioeconomic characteristics including income, gender, age and education.

Findings

Among the 18.3% of respondents who experienced water insecurity, 66.8% also experienced food insecurity. The likelihood of experiencing moderate-to-severe food insecurity was higher among respondents also experiencing water insecurity (adjusted odds ratio, aOR: 2.69; 95% confidence interval, CI: 2.43 to 2.98). Similar odds were found in Asia (aOR: 2.95; 95% CI: 2.04 to 4.25), Latin America (aOR: 2.17; 95% CI: 1.62 to 2.89), North Africa (aOR: 2.92; 95% CI: 2.17 to 3.93) and sub-Saharan Africa (aOR: 2.71; 95% CI: 2.40 to 3.06).

Conclusion

Our results suggest that water insecurity should be considered when developing food and nutrition policies and interventions. However, more research is needed to understand the paths between these insecurities.

Prevalence and Severity of Food Insecurity Before and During the Coronavirus Disease 2019 Pandemic Among Adults and Youth in Australia, Canada, Chile, Mexico, the United Kingdom, and the United States

BACKGROUND

Disruptions from the coronavirus disease 2019 (COVID-19) pandemic potentially exacerbated food insecurity among adults and youth.

OBJECTIVES

The objective was to examine changes in the prevalence and severity of food insecurity among adults and youth from before (2019) to during (2020) the pandemic in multiple countries.

METHODS

Repeated cross-sectional data were collected among adults aged 18-100 y (n = 63,278) in 5 countries in November to December in 2018-2020 and among youth aged 10-17 y (n = 23,107) in 6 countries in November to December in 2019 and 2020. Food insecurity in the past year was captured using the Household Food Security Survey Module and the Child Food Insecurity Experiences Scale. Changes in the prevalence and severity of food insecurity were examined using logistic and generalized logit regression models, respectively. Models included age, gender, racial-ethnic identity, and other sociodemographic characteristics associated with food insecurity to adjust for possible sample differences across waves. Models were weighted to reflect each country's population.

RESULTS

Adults [adjusted OR (AOR): 1.15; 95% CI: 1.02, 1.31] and youth (AOR: 1.43; 95% CI: 1.19, 1.71) in Mexico were more likely to live in food-insecure households in 2020 compared to 2019. Adults in Australia (AOR: 0.81; 95% CI: 0.72, 0.92) and Canada (AOR: 0.87; 95% CI: 0.77, 0.99) were less likely to live in food-insecure households in 2020. Trends in severity aligned with changes in prevalence, with some exceptions. Youth in Australia (AOR: 2.24; 95% CI: 1.65, 3.02) and the United States (AOR: 1.39; 95% CI: 1.04, 1.86) were more likely to have many compared with no experiences of food insecurity in 2020 compared to 2019. There was no evidence of change among adults and youth in the remaining countries.

CONCLUSIONS

Except for Mexico, few changes in food insecurity among adults and youth were observed from before to during the COVID-19 pandemic. Action is needed to support households at risk of food insecurity. J Nutr 20XX;xx:xx-xx.

Effect of a Plant-Based vs Omnivorous Soul Food Diet on Weight and Lipid Levels Among African American Adults: A Randomized Clinical Trial

IMPORTANCE

More African American individuals die from cardiovascular disease (CVD) than any other chronic disease condition. Despite this disparity, African American individuals are underrepresented in nutrition and CVD interventions.

OBJECTIVE

To compare the effects of an entirely plant-based (vegan) or low-fat omnivorous (omni) diet on change in body weight and lipids during a 2-year intervention.

DESIGN, SETTING, AND PARTICIPANTS

The Nutritious Eating With Soul (NEW Soul) study was a 2-year, randomized clinical trial conducted in 2 cohorts (2018-2020 and 2019-2021) that took place in a university teaching kitchen in Columbia, South Carolina (before March 2020), and via online videoconference sessions (after March 2020). Participants included African American adults aged 18 to 65 years with overweight or obesity (body mass index of 25.0-49.9) and without type 2 diabetes, uncontrolled thyroid disease, recent weight loss, or pregnancy. Data assessors and statisticians were blinded to study condition. Data analysis was performed from March to June 2022.

INTERVENTIONS

The intervention included weekly nutrition classes for 6 months biweekly classes for 6 months, and monthly classes for 12 months. Dietary interventions either emphasized no animal product intake (vegan) or a low-fat omnivorous diet (omni). Both dietary patterns emphasized soul food cuisine (traditional African American southern foodways).

MAIN OUTCOMES AND MEASURES

Primary outcomes included change in body weight and lipid measures at 12 months.

RESULTS

There were 568 participants who completed an online screening questionnaire; 409 were excluded and 159 were randomized (77 to the vegan group and 82 to the omni group). Of the 159 participants (mean [SD] age, 48.4 [10.6] years; 126 female [79%]) who began the study, the main outcome of body weight was obtained for 121 participants (76%) at 12 months. There were no differences in outcomes between groups, including 12-month changes in weight (mean, -2.39 kg [95% CI, -3.48 to -1.30 kg] for the vegan group vs -2.03 kg [95% CI, -3.07 to -1.00 kg] for the omni group; P = .64), total cholesterol (-1.05 mg/dL [95% CI, -9.60 to 7.50 mg/dL] for the vegan group vs 1.66 mg/dL [95% CI, -7.20 to 10.50 mg/dL] for the omni group; P = .67), or low-density lipoprotein cholesterol (mean, -2.56 mg/dL [95% CI, -9.52 to 4.40 mg/dL] for the vegan group vs -0.79 mg/dL [95% CI, -7.98 to 6.40 mg/dL] for the omni group; P = .73). Weight loss at 12 months among cohort 1, whose weight was assessed in 2019 before the COVID-19 pandemic, was significantly greater than that for cohort 2, whose weight was assessed summer 2020 during COVID-19 (-3.45 kg [95% CI, -4.67 to -2.22 kg] vs -1.24 kg [95% CI, -2.24 to -0.25 kg]; P = .01).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial examining weight loss and CVD risk factor reduction among African American adults, there were no differences between the groups, and the magnitude of changes overall was small.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03354377.

How Perspectives on Food Safety of Vendors and Consumers Translate into Food-Choice Behaviors in 6 African and Asian Countries

Background

Consumption of unsafe foods increases morbidity and mortality and is currently an issue, particularly in low- and middle-income countries. Policy actions to ensure food safety are dominated by mitigation of biological and chemical hazards through supply-side risk management, lessening the degree to which consumer perspectives of food safety are considered.

Objectives

This study aimed to provide an in-depth understanding, from vendor and consumer perspectives, of how food-safety concerns of consumers translate into their subsequent food-choice behaviors in 6 diverse low- and middle-income countries.

Methods

Six Drivers of Food Choice projects (2016-2022) provided transcripts from 17 focus group discussions and 343 interviews conducted in Ghana, Guinea, India, Kenya, Tanzania, and Vietnam. Qualitative thematic analysis was used to identify emerging themes important to food safety.

Results

The analysis suggests that consumers constructed meaning about food safety through personal lived experience and social influences. Community and family members contributed knowledge about food safety. Concerns about food safety were influenced by reputations of and relationships with food vendors. Consumers' mistrust of food vendors was amplified by purposeful adulteration or unsafe selling practices and new methods used to produce food. Moreover, consumers were reassured of food safety by positive relationships with vendors; meals cooked at home; implementation of policies and following regulations; vendor adherence to environmental sanitation and food-hygiene practices; cleanliness of vendors' appearance; and vendors' or producers' agency to use risk mitigation strategies in production, processing, and distribution of food.

Conclusions

Consumers integrated their meanings, knowledge, and concerns about food safety to achieve assurance about the safety of their foods when making food-choice decisions. The success of food-safety policies hinges on consideration of consumers' food-safety concerns in their design and implementation, alongside actions to reduce risk in food supply.

Self-efficacy and Social Settings Matter for Fostering Healthy Eating in Mexican Schoolchildren

OBJECTIVE

To identify differences in schoolchildren's self-efficacy for eating behaviors across social settings and self-efficacy sources favoring healthy and unhealthy eating.

DESIGN

A cross-sectional, mixed-methods study using self-efficacy and demographic surveys, focus groups, and school environment semistructured observations.

SETTING

Morelos, Mexico, Cuernavaca City school district, public elementary schools in the National School Lunch Program.

PARTICIPANTS AND RECRUITMENT

We studied 274 fifth- and sixth-grade children from 8 elementary schools during the 2016-2017 school year.

VARIABLES MEASURED

Children's self-efficacy for healthy and unhealthy eating across 3 settings (school cafeteria, recess, and home). Children's perceptions about sources of self-efficacy, which favor their healthy or unhealthy eating (performance accomplishments, behavior modeling, verbal persuasion, and emotional or physiological states). Sociodemographic information was obtained from parents.

ANALYSIS

We performed a variance components analysis with school and students within schools as random effects with paired t tests (quantitative data) and content analysis on the basis of the Social Cognitive Theory (qualitative data).

RESULTS

Schoolchildren's self-efficacy for healthy eating differed across social settings, being greater in the school cafeteria than at recess or home, except for drinking water. On average, self-efficacy for unhealthy eating was lower in the cafeteria than in other studied settings. Performance achievements and behavior modeling were key sources of self-efficacy for healthy and unhealthy eating.

CONCLUSION AND IMPLICATIONS

Sources of self-efficacy and social settings matter to understanding schoolchildren's healthy and unhealthy eating. Future interventions might consider developing collective efficacy among the school community and boosting children's participation in home meal planning. Further research could explore locus of control and other intrapersonal dimensions influencing self-efficacy.

Effect of a Multisectoral Agricultural Intervention on HIV Health Outcomes Among Adults in Kenya: A Cluster Randomized Clinical Trial

Importance

Food insecurity and HIV health outcomes are linked through nutritional, mental health, and health behavior pathways.

Objective

To examine the effects of a multisectoral agriculture and livelihood intervention on HIV viral suppression and nutritional, mental health, and behavioral outcomes among HIV-positive adults prescribed antiretroviral therapy (ART).

Design, Setting, and Participants

This cluster randomized clinical trial was performed in 8 pairs of health facilities in Kenya. Participants were 18 years or older, living with HIV, and receiving ART for longer than 6 months; had moderate to severe food insecurity; and had access to arable land and surface water and/or shallow aquifers. Participants were followed up every 6 months for 24 months. Data were collected from June 23, 2016, to June 13, 2017, with follow-up completed by December 16, 2019. Data were analyzed from June 25 to August 31, 2020, using intention-to-treat and per-protocol methods.

Interventions

A loan to purchase a human-powered irrigation pump, fertilizer, seeds, and pesticides combined with the provision of training in sustainable agriculture and financial literacy.

Main Outcomes and Measures

The primary outcome was the relative change from baseline to the end of follow-up in viral load suppression (≤200 copies/mL) compared between study groups using difference-in-differences analyses. Secondary outcomes included clinic attendance, ART adherence, food insecurity, depression, self-confidence, and social support.

Results

A total of 720 participants were enrolled (396 women [55.0%]; mean [SD] age, 40.38 [9.12] years), including 366 in the intervention group and 354 in the control group. Retention included 677 (94.0%) at the 24-month visit. HIV viral suppression improved in both groups from baseline to end of follow-up from 314 of 366 (85.8%) to 327 of 344 (95.1%) in the intervention group and from 291 of 353 (82.4%) to 314 of 333 (94.3%) in the control group (P = .86). Food insecurity decreased more in the intervention than the control group (difference in linear trend, -3.54 [95% CI, -4.16 to -2.92]). Proportions of those with depression during the 24-month follow-up period declined more in the intervention group (from 169 of 365 [46.3%] to 36 of 344 [10.5%]) than the control group (106 of 354 [29.9%] to 41 of 333 [12.3%]; difference in trend, -0.83 [95% CI, -1.45 to -0.20]). Self-confidence improved more in the intervention than control group (difference in trend, -0.37 [95% CI, -0.59 to -0.15]; P = .001), as did social support (difference in trend, -3.63 [95% CI, -4.30 to -2.95]; P < .001).

Conclusions and Relevance

In this cluster randomized trial, the multisectoral agricultural intervention led to demonstrable health and other benefits; however, it was not possible to detect additional effects of the intervention on HIV clinical indicators. Agricultural interventions that improve productivity and livelihoods hold promise as a way of addressing food insecurity and the underpinnings of poor health among people living with HIV in resource-limited settings.

Trial Registration

ClinicalTrials.gov Identifier: NCT02815579.

Sustaining Agriculture and Nutrition Interventions: Continued Engagement of Village Model Farmers in Nepal

BACKGROUND

In homestead food production (HFP) programs, village model farmers (VMFs), after training, implement agriculture and nutrition activities to improve household knowledge and practices. Little evidence exists on what enables VMFs to remain actively engaged and for impacts to be sustained.

OBJECTIVE

To examine variables explaining active engagement of VMFs, at least 4 years post-training, in an HFP program in Nepal.

METHODS

We used cross-sectional data, collected from 2018 to 2019, among 4750 VMFs of Suaahara, a multisectoral nutrition program. We assessed whether respondents registered their HFP group with the local government, conducted regular group meetings, discussed vegetable growing and chicken rearing practices with group members, or engaged in saving and credit activities in their HFP group. Outcome variable was a count of these 4 activities in which the VMF engaged. Socioeconomic, demographic, and programmatic explanatory variables were identified a priori and by bivariate analysis and were adjusted in ordinal regression models accounting for clusters.

RESULTS

On average, VMFs engaged in 1.4 activities. Having attended primary or secondary school (adjusted odds ratios [AOR] = 1.39), being a female community health volunteer (AOR = 1.27), being from an advantaged caste/ethnic group (AOR = 1.34), receiving additional trainings (AOR = 1.56) and inputs (AOR = 1.31) were associated with more active engagement of VMFs.

CONCLUSION

Village model farmers receiving more training and inputs were more likely to remain actively engaged. Female community health workers, people from higher caste/ethnic groups, and those with primary or secondary education were more likely to remain active VMFs and could be targeted for this role in HFP programs leading to sustained impact.

Effectiveness of the Eggs Make Kids demand-creation campaign at improving household availability of eggs and egg consumption by young children in Nigeria: A quasi-experimental study

Using a quasi-experimental design, our study aimed to determine the effectiveness of the 'Eggs Make Kids Sharp & Bright and Strong & Active' demand-creation campaign in Nigeria. The intervention arm received emotionally compelling radio and television advertisements about eggs, and was exposed to promotional activities and advertising about eggs at points of purchase, schools and health facilities; the comparison arm received no intervention. Children 6-59 months of age (intervention: n = 1359; comparison: n = 1485) were assessed 14 months apart. Intent-to-treat analyses with analysis of covariance method assessed the impact of the intervention on caregivers' behaviour towards eggs, caregivers' willingness to pay for eggs, availability of eggs in households, and consumption of eggs by children 6-59 months of age. Analyses were adjusted for possible confounders and perceived effects of COVID-19 on finances and food consumption. Compared to the comparison arm, the intervention arm showed a greater prevalence of household egg acquisition (odds ratio = 1.34, p < 0.0001), and larger improvements in caregiver self-efficacy (β = 0.242, p = 0.004) and intent to feed eggs to children (β = 0.080, p = 0.021). No effects were found on children's egg consumption or caregivers' reported willingness to pay for eggs. The lack of impact on child egg consumption despite increased acquisition of eggs and caregiver self-efficacy suggests that other barriers to child consumption may exist. Additional research should further investigate factors that may influence intrahousehold distribution of eggs and whether these may also influence other nutritious foods.

Mechanisms linking gender-based violence to worse HIV treatment and care outcomes among women in the United States

OBJECTIVE

To test whether substance use mediates the associations between gender-based violence (GBV) and suboptimal adherence to antiretroviral therapy (ART), and GBV and poor engagement in care, among women living with HIV (WLHIV) in the United States (US).

DESIGN

We analyzed longitudinal data collected among 1717 WLHIV in the Women's Interagency HIV Study (WIHS).

METHODS

From 2013 to 2017, WLHIV completed semi-annual assessments on GBV, substance use, and HIV treatment and care. Adjusted multilevel logistic regression models were built to estimate the impact of GBV on; suboptimal (<95%) adherence and at least one missed HIV care appointment without rescheduling in the past 6 months. Mediation analyses were performed to test whether heavy drinking and illicit drug use mediated the associations between GBV and the two HIV outcomes.

RESULTS

The mean age was 47 (standard deviation = 9), 5% reported experiencing GBV, 17% reported suboptimal adherence and 15% reported at least one missed appointment in the past 6 months. Women who experienced GBV had a significantly higher odds of suboptimal adherence [adjusted odds ratio (aOR) = 1.99; 95% confidence interval (CI) = 1.40-2.83] and missed appointments (aOR = 1.92, 95% CI = 1.32-2.33). Heavy drinking and illicit drug use mediated 36 and 73% of the association between GBV and suboptimal adherence and 29 and 65% of the association between GBV and missed appointments, respectively.

CONCLUSIONS

Substance use is an underlying mechanism through which GBV affects outcomes along the HIV care continuum among WLHIV in the US. To optimize HIV treatment and care among women, interventions should address the combined epidemics of substance use, violence, and HIV.

Estimating national, demographic, and socioeconomic disparities in water insecurity experiences in low-income and middle-income countries in 2020-21: a cross-sectional, observational study using nationally representative survey data

BACKGROUND

We are facing a global water crisis. However, because most water indicators assess physical availability or infrastructure in aggregate, knowing which sociodemographic groups experience water insecurity is difficult. We aimed to assess the prevalence of water insecurity across low-income and middle-income countries (LMICs) and examine how it varies by sociodemographic characteristics and exposure to life disruptions due to the COVID-19 pandemic across and within countries.

METHODS

In this observational study, we used Individual Water Insecurity Experiences (IWISE) scale data from a cross-sectional, nationally representative sample of individuals aged 15 years and older (defined as adults) in 31 LMICs. The IWISE scale range is 0-36, and water insecurity was defined as a score of 12 or higher. We used multivariable linear regression models to assess how individual-level experiences with water insecurity related to sociodemographic characteristics in each country, region, and the pooled sample.

FINDINGS

45 555 individuals from 31 LMICs completed the IWISE module between Sept 4, 2020, and Feb 24, 2021, and were included in the 2020 Gallup World Poll (GWP) database; 45 365 individuals had sufficient data to estimate the prevalence of water insecurity. 42 918 individuals from 30 LMICs had sufficient data to assess sociodemographic characteristics associated with water insecurity, and 39 161 individuals in 29 countries had sufficient data to assess how IWISE scale scores covaried with life disruptions due to the COVID-19 pandemic. The overall prevalence of water insecurity in 2020 was 14·2%, ranging by region from 36·1% in the sub-Saharan Africa region to 9·1% in the Asia region, and by country from 63·9% in Cameroon to 3·6% in China. In the pooled model including sociodemographic and COVID-19 factors, difficulty getting by on household income (vs no difficulty getting by: β 2·76 [95% CI 2·45-3·07]), living in the outskirts of a city (vs living in a large city: 0·85 [0·29-1·41]), and being greatly affected by the COVID-19 pandemic (vs not being affected: 2·36 [1·96-2·77]) were strongly associated with higher IWISE scores. In country and regional models, the sociodemographic factors most consistently associated with higher IWISE scores were difficulty getting by on household income and life disruptions due to the COVID-19 pandemic, but the strength of these associations varied across countries and regions.

INTERPRETATION

Through extrapolation of these nationally representative data, we estimate that hundreds of millions of people had life-altering experiences with water insecurity globally in 2020, and that their sociodemographic characteristics vary by country and region. Additional individual-level measurements globally could help pinpoint the characteristics of those who are most water insecure, thereby guiding the development of context-specific policy and interventions that will best serve those most affected.

FUNDING

Carnegie Corporation, Northwestern University, and USAID.

Alternative caregivers` role in food choices for young children in semi-urban and urban Mexico

Alternative caregivers (i.e., someone besides the primary caregiver who also takes care of children) make food choices for children. This study investigated what alternative caregivers consider when making food choices for children and their perspectives on their role in making food choices to feed children. In-depth interviews were conducted with 16 alternative caregivers of children aged 1-5 years old in semi-urban and urban areas of the State of Mexico in Mexico. Interviews were recorded, transcribed, coded, and analyzed using constant comparative method. Alternative caregivers described spaces and situations that exposed children to food while under their care. Alternative caregivers who spent longer periods of time with the child described more involvement in what the child ate. Healthy or nutritious food, cost of food and affection for children were important considerations for alternative caregivers when deciding what to feed the child. Alternative caregivers had a substantial role in child feeding, decisions about cooking, and advising mothers on how to feed their children. Efforts to promote healthy food choices for children should include targeting of alternative caregivers.

Towards standardised and valid anthropometric indicators of nutritional status in middle childhood and adolescence

Recognition of the importance of nutrition during middle childhood (age 5-9 years) and adolescence (age 10-19 years) is increasing, particularly in the context of global food insecurity and rising overweight and obesity rates. Until now, policy makers have been slow to respond to rapidly changing patterns of malnutrition across these age groups. One barrier has been a scarcity of consistent and regular nutrition surveillance systems for these age groups. What should be measured, and how best to operationalise anthropometric indicators that have been the cornerstone of nutrition surveillance in younger children and in adults, has been the topic of ongoing debate. Even with consensus on the importance of a given anthropometric indicator, difficulties arise in interpreting trends over time and between countries owing to the use of different terminologies, reference data, and cutoff points. In this Viewpoint we highlight the need to revisit anthropometric indicators across middle childhood and adolescence, a process that will require WHO and UNICEF coordination, the engagement of national implementors and policy makers, and partnership with research communities and donors.

Adolescent-Reported Household Food Insecurity and Adolescents' Poor Mental and Physical Health and Food Insufficiency in Kenya

Background

Assessing adolescents' experiences of food insecurity in households is important for promoting healthy development. Although parental reports have been traditionally used, emerging research highlights the importance of child and adolescent reports of the household food environment.

Objectives

Extending research from high- and upper-middle-income countries, this study of adolescent compared with adult reports of household food insecurity in Kenya, a lower-middle-income country, examined 1) prevalence of and correspondence between adolescent and adult reports of household food insecurity, and 2) associations of adolescent and adult reports of household food insecurity with adolescent nonnutritional and nutritional outcomes.

Methods

Using data from the Kenya Violence Against Children Surveys (n = 1182), we assessed prevalence of household food insecurity reported by adolescents (ages 13-17 y) and adults, with McNemar χ2 and κ analysis of correspondence between reports. Ordinal and binary logistic regression assessed associations between adolescent and adult reports and adolescent mental health and self-rated physical health and food sufficiency outcomes.

Results

Household food insecurity was reported by 36% of adolescents and 63% of adults; 36% of adult reports were discordant with adolescent reports (κ = 0.333). Odds of adolescent mental health difficulties were highest with adolescent-only report (OR = 2.11, P = 0.02), followed by adult and adolescent (OR = 1.83, P = 0.001) and adult-only (OR = 1.06, P = 0.77) report. Odds of poor adolescent self-rated physical health were highest with adult and adolescent report (OR = 2.47, P < 0.001) followed by adolescent-only (OR = 2.04, P = 0.08) and adult-only (OR = 1.37, P = 0.20) report. Odds of adolescents eating ≤1 meals the previous day were highest with adult and adolescent (OR = 21.38, P < 0.001) followed by adult-only (OR = 7.44, P = 0.01) and adolescent-only (OR = 2.31, P = 0.34) report.

Conclusions

Measuring household food insecurity with both adolescent report and adult report is important for having a comprehensive understanding of household resources and needs and of the nonnutritional (mental and physical health) and nutritional (diet and food) outcomes of household food insecurity for adolescents.

Development, Validity, and Cross-Context Equivalence of the Child Food Insecurity Experiences Scale for Assessing Food Insecurity of School-Age Children and Adolescents

BACKGROUND

Children ages 6 to 17 years can accurately assess their own food insecurity, whereas parents are inaccurate reporters of their children's experiences of food insecurity. No globally applicable scale to assess the food insecurity of children has been developed and validated.

OBJECTIVES

We aimed to develop a globally applicable, experience-based measure of child and adolescent food insecurity and establish the validity and cross-contextual equivalence of the measure.

METHODS

The 10-item Child Food Insecurity Experiences Scale (CFIES) was based on items previously validated from questionnaires from the United States, Venezuela, and Lebanon. Cognitive interviews were conducted to check understanding of the items. The questionnaire then was administered in 15 surveys in 13 countries. Other items in each survey that assessed the household socioeconomic status, household food security, or child psychological functioning were selected as criterion variables to compare to the scores from the CFIES. To investigate accuracy (i.e., criterion validity), linear regression estimated the associations of the CFIES scores with the criterion variables. To investigate the cross-contextual equivalence (i.e., measurement invariance), the alignment method was used based on classical measurement theory.

RESULTS

Across the 15 surveys, the mean scale scores for the CFIES ranged from 1.65 to 5.86 (possible range of 0 to 20) and the Cronbach alpha ranged from 0.88 to 0.94. The variance explained by a 1-factor model ranged from 0.92 to 0.99. Accuracy was demonstrated by expected associations with criterion variables. The percentages of equivalent thresholds and loadings across the 15 surveys were 28.0 and 5.33, respectively, for a total percentage of nonequivalent thresholds and loadings of 16.7, well below the guideline of <25%. That is, 83.3% of thresholds and loadings were equivalent across these surveys.

CONCLUSIONS

The CFIES provides a globally applicable, valid, and cross-contextually equivalent measure of the experiences of food insecurity of school-aged children and adolescents, as reported by them.

Strengthening causal inference from randomised controlled trials of complex interventions

Researchers conducting randomised controlled trials (RCTs) of complex interventions face design and analytical challenges that are not fully addressed in existing guidelines. Further guidance is needed to help ensure that these trials of complex interventions are conducted to the highest scientific standards while maximising the evidence that can be extracted from each trial. The key challenge is how to manage the multiplicity of outcomes required for the trial while minimising false positive and false negative findings. To address this challenge, we formulate three principles to conduct RCTs: (1) outcomes chosen should be driven by the intent and programme theory of the intervention and should thus be linked to testable hypotheses; (2) outcomes should be adequately powered and (3) researchers must be explicit and fully transparent about all outcomes and hypotheses before the trial is started and when the results are reported. Multiplicity in trials of complex interventions should be managed through careful planning and interpretation rather than through post hoc analytical adjustment. For trials of complex interventions, the distinction between primary and secondary outcomes as defined in current guidelines does not adequately protect against false positive and negative findings. Primary outcomes should be defined as outcomes that are relevant based on the intervention intent and programme theory, declared (ie, registered), and adequately powered. The possibility of confirmatory causal inference is limited to these outcomes. All other outcomes (either undeclared and/or inadequately powered) are secondary and inference relative to these outcomes will be exploratory.

"They Eat What They Eat, I Eat What I Eat": Examining the Perspectives and Experiences of African Americans Who Adopt Plant-Based Diets

Adopting a plant-rich or plant-based diet is one of the major recommendations for addressing obesity, overweight, and related health conditions in the United States. Currently, research on African Americans' food choices in the context of plant-based diets is limited. The primary aim of this study was to understand food-related experiences and perceptions of African Americans who were participating in the Nutritious Eating with Soul (NEW Soul) study, a culturally tailored dietary intervention focused on increasing the consumption of plant-based foods. The roles of gender and ethnicity were also examined to identify how eating patterns were chosen or maintained. Twenty-one African American adults in South Carolina, who were randomly assigned to either a vegan diet (n = 11) or a low-fat omnivorous diet (n = 10) in the NEW Soul study, completed one-on-one, qualitative interviews. Emerging themes included awareness, being in control, and identity. The study revealed that access to social support and coping strategies for addressing negative comments about plant-based food choices may be important components to include in future nutrition interventions focused on African Americans.

Estimating Childhood Stunting and Overweight Trends in the European Region from Sparse Longitudinal Data

BACKGROUND

Monitoring countries' progress toward the achievement of their nutrition targets is an important task, but data sparsity makes monitoring trends challenging. Childhood stunting and overweight data in the European region over the last 30 y have had low coverage and frequency, with most data only covering a portion of the complete age interval of 0-59 mo.

OBJECTIVES

We implemented a statistical method to extract useful information on child malnutrition trends from sparse longitudinal data for these indicators.

METHODS

Heteroscedastic penalized longitudinal mixed models were used to accommodate data sparsity and predict region-wide, country-level trends over time. We leveraged prevalence estimates stratified by sex and partial age intervals (i.e., intervals that do not cover the complete 0-59 mo), which expanded the available data (for stunting: from 84 sources and 428 prevalence estimates to 99 sources and 1786 estimates), improving the robustness of our analysis.

RESULTS

Results indicated a generally decreasing trend in stunting and a stable, slightly diminishing rate for overweight, with large differences in trends between low- and middle-income countries compared with high-income countries. No differences were found between age groups and between sexes. Cross-validation results indicated that both stunting and overweight models were robust in estimating the indicators for our data (root mean squared error: 0.061 and 0.056; median absolute deviation: 0.045 and 0.042; for stunting and overweight, respectively).

CONCLUSIONS

These statistical methods can provide useful and robust information on child malnutrition trends over time, even when data are sparse.

Translation of policy for reducing undernutrition from national to sub-national levels in Rwanda

Understanding how countries improve children’s nutrition can inform policies and contribute to further improvements. We examined the relationship between improvements in nutrition in Rwanda (1992–2017) and political commitment to- and policy coherence in- nutrition. We reviewed nutrition-relevant Rwandan policies and programs (2000–2018) and conducted 90 semi-structured interviews with national (n = 32), mid-level (n = 38), and community (n = 20) nutrition stakeholders and 40 community-level focus group discussions (FGDs). FGDs and sub-national interviews were conducted in ten purposefully selected districts, five each in which stunting decreased (reduced) and increased or stagnated (non-reduced) between the 2010 and 2014/15 Rwanda Demographic and Health Surveys. Analysis consisted of thematic analysis and the assessment of events, policy developments, and strategies that influenced nutrition in Rwanda, including operationalization of political commitment and policy coherence for nutrition. Political and institutional commitment to nutrition increased in Rwanda as evidenced by the adoption of a multisectoral nutrition policy that was reinforced with national and subnational horizontal coordination platforms. These platforms strengthened multisectoral strategies to address nutrition and supported operational and institutional commitment. The role of mid-level actors in nutrition governance increased as responsibilities for planning, implementing, and monitoring nutrition programs were increasingly delegated to sub-national administrative levels. Variations in policy implementation existed between reduced and non-reduced districts. Despite improvements, challenges remained in coordination, financial commitment, and capacity to address, monitor, and evaluate nutrition. Political commitment to- and policy coherence in- nutrition at the national level are important for improving nutrition, and when reinforced institutionally, can be translated to sub-national levels where implementation occurs.