Showing papers in "Maternal and Child Nutrition in 2011"

Long-term consequences of stunting in early life.

Abstract: This review summarizes the impact of stunting, highlights recent research findings, discusses policy and programme implications and identifies research priorities. There is growing evidence of the connections between slow growth in height early in life and impaired health and educational and economic performance later in life. Recent research findings, including follow-up of an intervention trial in Guatemala, indicate that stunting can have long-term effects on cognitive development, school achievement, economic productivity in adulthood and maternal reproductive outcomes. This evidence has contributed to the growing scientific consensus that tackling childhood stunting is a high priority for reducing the global burden of disease and for fostering economic development. Follow-up of randomized intervention trials is needed in other regions to add to the findings of the Guatemala trial. Further research is also needed to: understand the pathways by which prevention of stunting can have long-term effects; identify the pathways through which the non-genetic transmission of nutritional effects is mediated in future generations; and determine the impact of interventions focused on linear growth in early life on chronic disease risk in adulthood.

Early child growth: How do nutrition and infection interact?

Abstract: It is well known that the relationship between child nutrition and infection is bidirectional, i.e. frequent illness can impair nutritional status and poor nutrition can increase the risk of infection. What is less clear is whether infection reduces the effectiveness of nutrition interventions or, vice versa, whether malnutrition lessens the impact of infection control strategies. The objective of this paper is to review the evidence regarding this interaction between nutrition and infection with respect to child growth in low-income populations. Even when there are no obvious symptoms, physiological conditions associated with infections can impair growth by suppressing appetite, impairing absorption of nutrients, increasing nutrient losses and diverting nutrients away from growth. However, there is little direct evidence that nutrition interventions are less effective when infection is common; more research is needed on this question. On the other hand, evidence from four intervention trials suggests that the adverse effects of certain infections (e.g. diarrhoea) on growth can be reduced or eliminated by improving nutrition. Interventions that combine improved nutrition with prevention and control of infections are likely to be most effective for enhancing child growth and development.

Conversion of linoleic acid and alpha-linolenic acid to long chain polyunsaturated fatty acids (LCPUFAs), with a focus on pregnancy, lactation and the first 2 years of life

Abstract: Over the past two decades, there has been a marked shift in the fatty acid composition of the diets of industrialized nations towards increased intake of the n-6 fatty acid linoleic acid (LA, 18:2n-6), largely as a result of the replacement of saturated fats with plant-based polyunsaturated fatty acid (PUFA). While health agencies internationally continue to advocate for high n-6 PUFA intake combined with increased intakes of preformed n-3 long-chain PUFAs (LCPUFA) docosahexaenoic acid (DHA, 22:6n-3) and eicosapentaenoic acid (EPA, 20:5n-3) to reduce the incidence of cardiovascular disease (CVD), there are questions as to whether this is the best approach. LA competes with alpha-linolenic acid (18:3n-3) for endogenous conversion to the LC derivatives EPA and DHA, and LA also inhibits incorporation of DHA and EPA into tissues. Thus, high-LA levels in the diet generally result in low n-3 LCPUFA status. Pregnancy and infancy are developmental periods during which the fatty acid supply is particularly critical. The importance of an adequate supply of n-3 LCPUFA for ensuring optimal development of infant brain and visual systems is well established, and there is now evidence that the supply of n-3 LCPUFA also influences a range of growth, metabolic and immune outcomes in childhood. This review will re-evaluate the health benefits of modern Western diets and pose the question of whether the introduction of similar diets to nations with emerging economies is the most prudent public health strategy for improving health in these populations.

Association between timing of introducing solid foods and obesity in infancy and childhood: A systematic review

Abstract: Determining early-life risk factors for obesity in later life is essential in order to effectively target preventative interventions to reduce obesity. The aim of this systematic review was to investigate current evidence to determine whether the timing of introducing solid foods is associated with obesity in infancy and childhood. Relevant randomized and observational studies from developed countries were identified by searching the following six bio-medical databases (Medline, Embase, British Nursing Index, CINAHL, Maternity and Infant Care, and PsycINFO) and hand-searching reference lists. Studies of pre-term or low birthweight infants were excluded. Twenty-four studies met the inclusion criteria for the systematic review. Data from over 34,000 participants were available for interpretative analysis. No clear association between the age of introduction of solid foods and obesity was found. It is likely that a whole family approach to obesity prevention will be most effective and health professionals should continue to promote healthy infant feeding in line with national recommendations.

Essential fats: how do they affect growth and development of infants and young children in developing countries? A literature review.

Abstract: Omega-3 and omega-6 fatty acids, particularly docosahexaenoic acid (DHA), are known to play an essential role in the development of the brain and retina. Intakes in pregnancy and early life affect growth and cognitive performance later in childhood. However, total fat intake, alpha-linolenic acid (ALA) and DHA intakes are often low among pregnant and lactating women, infants and young children in developing countries. As breast milk is one of the best sources of ALA and DHA, breastfed infants are less likely to be at risk of insufficient intakes than those not breastfed. Enhancing intake of ALA through plant food products (soy beans and oil, canola oil, and foods containing these products such as lipid-based nutrient supplements) has been shown to be feasible. However, because of the low conversion rates of ALA to DHA, it may be more efficient to increase DHA status through increasing fish consumption or DHA fortification, but these approaches may be more costly. In addition, breastfeeding up to 2 years and beyond is recommended to ensure an adequate essential fat intake in early life. Data from developing countries have shown that a higher omega-3 fatty acid intake or supplementation during pregnancy may result in small improvements in birthweight, length and gestational age based on two randomized controlled trials and one cross-sectional study. More rigorous randomized controlled trials are needed to confirm this effect. Limited data from developing countries suggest that ALA or DHA supplementation during lactation and in infants may be beneficial for growth and development of young children 6-24 months of age in these settings. These benefits are more pronounced in undernourished children. However, there is no evidence for improvements in growth following omega-3 fatty acid supplementation in children >2 years of age.

Genetic variation in polyunsaturated fatty acid metabolism and its potential relevance for human development and health.

Abstract: Blood and tissue contents of polyunsaturated fatty acid (PUFA) and long-chain PUFA (LC-PUFA) are related to numerous health outcomes including cardiovascular health, allergies, mental health and cognitive development. Evidence has accumulated to show that in addition to diet, common polymorphisms in the fatty acid desaturase (FADS) gene cluster have very marked effects on human PUFA and LC-PUFA status. Recent results suggest that in addition to fatty acid desaturase 1 and fatty acid desaturase 2, the gene product of fatty acid desaturase 3 is associated with desaturating activity. New data have become available to show that FADS single nucleotide polymorphisms (SNPs) also modulate docosahexaenoic acid status in pregnancy as well as LC-PUFA levels in children and in human milk. There are indications that FADS SNPs modulate the risk for allergic disorders and eczema, and the effect of breastfeeding on later cognitive development. Mechanisms by which FADS SNPs modulate PUFA levels in blood, breast milk and tissues should be explored further. More studies are required to explore the effects of FADS gene variants in populations with different ethnic backgrounds, lifestyles and dietary habits, and to investigate in greater depth the interaction of gene variants, diet and clinical end points, including immune response and developmental outcomes. Analyses of FADS gene variants should be included into all sizeable cohort and intervention studies addressing biological effects of PUFA and LC-PUFA in order to consider these important confounders, and to enhance study sensitivity and precision.

Impact of early and concurrent stunting on cognition.

Abstract: Undernutrition is associated with poor cognitive development, late entry into school, decreased years of schooling, reduced productivity and smaller adult stature. We use longitudinal data from 1674 Peruvian children participating in the Young Lives study to assess the relative impact of early stunting (stunted at 6-18 months of age) and concurrent stunting (stunted at 4.5-6 years of age) on cognitive ability. Anthropometric data were longitudinally collected for children at 6-18 months of age and 4.5-6 years of age at which time verbal and quantitative ability were also assessed. We estimate that an increase in concurrent height-for-age z-scores (HAZ) by one standard deviation was associated with an increase in a child's score on the Peabody Picture Vocabulary Test (PPVT) by 2.35 points [confidence interval (CI): 1.55-3.15] and a 0.16 point increase on the cognitive development assessment (CDA) (CI: 0.05-0.27). Furthermore, we report that the estimate for concurrent HAZ and PPVT is significantly higher than the estimate for early stunting and PPVT. We found no significant difference between early and concurrent estimates for HAZ and CDA. Children from older mothers, children whose mothers had higher education levels, children living in urban areas, children who attended pre-school, children with fewer siblings and children from wealthier backgrounds scored higher on both assessments. Cognitive skills of children entering school were associated with early stunting but the strongest association was found with concurrent stunting suggesting that interventions preventing linear growth faltering should not only focus on the under 2s but include children up to 5 years of age.

Energy intake misreporting among children and adolescents: a literature review

Abstract: While adults' energy intake misreporting is a well-documented phenomenon, relatively little is known about the nature and extent of misreporting among children and adolescents. Children's and adolescents' dietary reporting patterns are likely to be distinct because of their ongoing cognitive and social development. These developmental differences present unique challenges to aspects of dietary reporting, such as food knowledge, portion size estimation and response editing. This review of 28 articles describes energy intake misreporting among children and adolescents. Like adults, children and adolescents tended to underreport energy, with the largest biases observed with food records. Even when mean reported energy intake was close to its expected value, approximately half of all individuals were classified as misreporters, and overreporting appeared to be more common than it is among adults. Associations between numerous characteristics and misreporting were explored in the literature, with the most consistent findings for age and adiposity. Two predictors for adults, gender and social desirability, were not consistent factors among children and adolescents. The review concludes by highlighting knowledge gaps and recommendations for future research and practice.

Metabolic programming of long-term outcomes due to fatty acid nutrition in early life.

Abstract: Understanding of the importance of dietary fatty acids has grown beyond a simple source of energy to complex roles in regulating gene expression and cell and intracellular communication. This is important because the metabolic and neuroendocrine environment of the fetus and infant plays a key role in guiding the set point of neural receptors that regulate energy homeostasis and expression of genes that control energy storage and oxidation. Early deviations in these pathways have the potential to lead to lasting adaptations, termed metabolic programming, which may combine to increase the risk of metabolic syndrome in later life. The quality of fatty acids in human diets has undergone major changes in the last 50 years, characterized by an increase in ω-6 and decrease in ω-3 fatty acids. Evidence is accumulating to support the concept that the maternal intake of ω-6 and ω-3 fatty acids in gestation and lactation, possibly involving both excess ω-6 and inadequate ω-3 fatty acids, can impact the developing infant tissue lipids and neuroendocrine and metabolic pathways relevant to metabolic programming. Further work is needed to understand the needs for different ω-6 and ω-3 fatty acids during fetal and infant life, and their roles with respect to development of energy homeostasis and metabolism.

Food sources and intake of n-6 and n-3 fatty acids in low-income countries with emphasis on infants young children (6-24 months) and pregnant and lactating women.

Abstract: With increasing interest in the potential effects of n-6 and n-3 fatty acids in early life, there is a need for data on the dietary intake of polyunsaturated fatty acids (PUFA) in low-income countries. This review compiles information on the content in breast milk and in foods that are important in the diets of low-income countries from the few studies available. We also estimate the availability of fat and fatty acids in 13 low-income and middle-income countries based on national food balance sheets from the United Nations' Food and Agriculture Organization Statistical Database (FOASTAT). Breast milk docosahexaenoic acid content is very low in populations living mainly on a plant-based diet, but higher in fish-eating countries. Per capita supply of fat and n-3 fatty acids increases markedly with increasing gross domestic product (GDP). In most of the 13 countries, 70-80% of the supply of PUFA comes from cereals and vegetable oils, some of which have very low α-linolenic acid (ALA) content. The total n-3 fatty acid supply is below or close to the lower end of the recommended intake range [0.4%E (percentage of energy supply)] for infants and young children, and below the minimum recommended level (0.5%E) for pregnant and lactating women in the nine countries with the lowest GDP. Fish is important as a source of long-chain n-3 fatty acids, but intake is low in many countries. The supply of n-3 fatty acids can be increased by using vegetable oils with higher ALA content (e.g. soybean or rapeseed oil) and by increasing fish production (e.g. through fish farming).

A descriptive study investigating the use and nature of baby-led weaning in a UK sample of mothers.

Abstract: An alternative to traditional weaning methods known as baby-led weaning (BLW) appears to be emerging in the UK. This approach advocates bypassing typical weaning practices of spoon-feeding pureed foods or baby rice, encouraging instead the introduction of foods in their whole form to the infant from 6 months old. A key tenet of BLW is self-feeding. Anecdotally, the practice of BLW appears to be gaining in popularity. However, research evidence is scant, and little is known about the nature of BLW and the demography of those who utilize it. This study aimed to characterize a sample of women who have chosen to adopt the BLW method and to describe associated attitudes and behaviours. Six hundred and fifty five mothers with a child between 6 months and 12 months of age provided information about timing of weaning onset, use of spoon-feeding and purees, and experiences of weaning and mealtimes. Those participants who used a BLW method reported little use of spoon-feeding and purees and were more likely to have a higher education, higher occupation, be married and have breastfed their infant. BLW was associated with a later introduction of complementary foods, greater participation in meal times and exposure to family foods. Levels of anxiety about weaning and feeding were lower in mothers who adopted a BLW approach. These findings provide an insight into BLW practices and the characteristics of a small population of users.

Maternal fatty acid status during pregnancy and lactation and relation to newborn and infant status

Abstract: The present review of determinants of infant fatty acid status was undertaken as part of a conference on 'Fatty acid status in early life in low-income countries: determinants and consequences'. Emphasis is placed on the essential fatty acids, and particularly the physiologically important long chain polyunsaturated fatty acids (LCPUFAs) of 20 and 22 carbons. We are unaware of any studies of determinants of infant fatty acid status in populations with a cultural dietary pattern with low amounts of linoleic acid (LA, 18:2n-6) and α-linolenic acid (ALA,18:3n-3). Many reports suggest that there may be adverse health effects related to the increased proportion of LA in relation to ALA, which have occurred worldwide due to the increased availability of vegetable oils high in LA. The issue of dietary n-6 to n-3 balance may apply to infant fatty acid status both during fetal and post-natal life; however, this review focuses on the n-3 and n-6 LCPUFA, in particular, docosahexaenoic acid (DHA, 22:6n-3) and arachidonic acid (AA, 20:4n-6), which are the predominant n-3 and n-6 LCPUFA found in cell membranes. The evidence that these fatty acids are preferentially transferred from maternal to fetal circulation across the placenta, and the sources and mechanisms for this transfer, are reviewed. We also address the sources of DHA and AA for the newborn including human milk DHA and AA and the factors that influence maternal DHA status and consequently the amount of DHA available for transfer to the fetus and infant via human milk.

Household food insecurity is associated with depressive symptoms among low-income pregnant Latinas.

Abstract: Latinas experience high rates of poverty, household food insecurity and prenatal depression. To date, only one USA study has examined the relationship between household food insecurity and prenatal depression, yet it focused primarily on non-Latina white and non-Latina black populations. Therefore, this study examined the independent association of household food insecurity with depressive symptoms among low-income pregnant Latinas. This cross-sectional study included 135 low income pregnant Latinas living in Hartford, Connecticut. Women were assessed at enrolment for household food security during pregnancy using an adapted and validated version of the US Household Food Security Survey Module. Prenatal depressive symptoms were assessed using the Center for Epidemiological Studies Depression Scale. A cut-off of ≥21 was used to indicate elevated levels of prenatal depressive symptoms (EPDS). Multivariate backwards stepwise logistic regression was used to identify risk factors for EPDS. Almost one third of participants had EPDS. Women who were food insecure were more likely to experience EPDS compared to food secure women (OR = 2.59; 95% CI = 1.03-6.52). Being primiparous, experiencing heartburn and reporting poor/fair health during pregnancy, as well as having a history of depression were also independent risk factors for experiencing EPDS. Findings from this study suggest the importance of assessing household food insecurity when evaluating depression risk among pregnant Latinas.

Impact of fatty acid status on growth and neurobehavioural development in humans

Abstract: Many studies have been conducted to investigate the effect of n-3 long-chain polyunsaturated fatty acid (LCPUFA) supplementation during the perinatal period on the growth and neurobehavioural development of young children. Most of these intervention trials have involved infants from high-income countries, and a significant proportion have investigated supplementation of infant formulas. Generally, supplementation of infant formula for preterm rather than term infants has demonstrated more consistent, positive effects on aspects of neurobehavioural development, while the growth of both term and preterm infants appears unaffected by LCPUFA supplementation. Maternal n-3 LCPUFA supplementation during pregnancy has consistently resulted in modest increases in birth size, and the most recent study suggests that this is also true from women from low-income environments. The effect of maternal supplementation on global neurobehavioural outcomes for children born at term remains unclear, although n-3 LCPUFA supplementation of women expressing milk for their preterm infants does improve their performance on tests of global neurodevelopment. Further work is required to determine whether dietary n-3 LCPUFA is neuroprotective for children from disadvantaged or low-income backgrounds.

Is baby-led weaning feasible? When do babies first reach out for and eat finger foods?

Abstract: The baby-led weaning philosophy proposes that when solids are introduced, infants should be encouraged to self-feed with solid food, as opposed to spoon-feeding purees. We used data from the Gateshead Millennium Study (GMS) to define the range of ages at which infants reach out for and eat finger foods and related this to developmental status. GMS recruited infants shortly after birth and followed them prospectively using postal questionnaires. Of the 923 eligible children, 602 had data on when they first reached out for food, and 340 (56%) had done so before age 6 months, but 36 (6%) were still not reaching for food at age 8 months. Infants who had not reached out for food by 6 months were less likely to be walking unaided at age 1 year (85 out of 224, 38%) compared with those who did (155 out of 286, 54%; P < 0.001). For the 447 parents who completed a diary of the first five occasions when their child ate finger foods, the first finger food eaten was before age 6 months for 170 (40%) and before age 8 months for 383 (90%); foods offered were mainly bread, rusks or biscuits. Of the 604 with information at age 8 months about current intake, all but 58 (9.6%) were having some finger foods at least daily, but only 309 (51%) were having them more than once per day. Baby-led weaning is probably feasible for a majority of infants, but could lead to nutritional problems for infants who are relatively developmentally delayed.

Acceptability of lipid-based nutrient supplements (LNS) among Ghanaian infants and pregnant or lactating women.

Abstract: Inadequate micronutrient intake during pregnancy, lactation and infancy is a major problem in many developing countries. Lipid-based nutrient supplements (LNS) can improve micronutrient status, growth and development of infants, and also have potential to improve nutritional status of pregnant and lactating women. The objective of the study was to test the acceptability of LNS designed for infants (LNS-20gM) and pregnant or lactating women (LNS-P&L). Participants were infants (n = 22, mean age = 8 months) and pregnant or lactating women (n = 24) attending routine services at a hospital in Ghana. Infants consumed 45 g of a test meal consisting of one part LNS-20gM and three parts fermented maize porridge, while women consumed 50 g of a similar test meal containing LNS-P&L instead. Participants also used their respective LNS at home for 14 days. Primary outcome was the proportion of the test meal consumed. On average, infants consumed 76.2% of the test meal [95% (confidence interval) CI: 65.7, 86.7], while women consumed 87.1% (95% CI: 82.6, 91.6). During the 14-day period, median daily consumption of LNS-20gM was 19.3 g, very close to the recommended 20 g d(-1), while that of LNS-P&L was one sachet, as recommended. We conclude that LNS-20gM and LNS-P&L were well accepted.

Animal studies of the functional consequences of suboptimal polyunsaturated fatty acid status during pregnancy, lactation and early post‐natal life

Abstract: Scores of animal studies demonstrate that seed oils replete with linoleic acid and very low in linolenic acid fed as the exclusive source of fat through pregnancy and lactation result in visual, cognitive, and behavioural deficits in the offspring. Commodity peanut, sunflower, and safflower oils fed to mother rats, guinea pigs, rhesus monkeys, and baboons induce predictable changes in tissue polyunsaturated fatty acid composition that are abnormal in free-living land mammals as well as changes in neurotransmitter levels, catecholamines, and signalling compounds compared with animals with a supply of ω3 polyunsaturated fatty acid. These diets consistently induce functional deficits in electroretinograms, reflex responses, reward or avoidance induced learning, maze learning, behaviour, and motor development compared with ω3 replete groups. Boosting neural tissue docosahexaenoic acid (DHA) by feeding preformed DHA enhances visual and cognitive function. Though no human randomized controlled trials on minimal ω3 requirements in pregnancy and lactation have been conducted, the weight of animal evidence compellingly shows that randomizing pregnant or lactating humans to diets that include high linoleate oils as the sole source of fat would be frankly unethical because they would result in suboptimal child development. Increasing use of commodity ω3-deficient oils in developing countries, many in the name of heart health, will limit brain development of the next generation and can be easily corrected at minimal expense by substituting high oleic acid versions of these same oils, in many cases blended with small amounts of α-linolenic acid oils like flax or perilla oil. Inclusion of DHA in these diets is likely to further enhance visual and neural development.

Infant feeding choices: experience, self‐identity and lifestyle

Abstract: In England, 78% of mothers initiate breastfeeding and, in the UK, less than 1% exclusively breastfeed until 6 months, despite World Health Organization (WHO) recommendations to do so. This study investigated women's infant feeding choices using in-depth interviews with 12 mothers of infants aged 7–18 weeks. Using content analysis, four themes emerged: (1) information, knowledge and decision making, (2) physical capability, (3) family and social influences, (4) lifestyle, independence and self-identity. While women were aware of the ‘Breast is Best’ message, some expressed distrust in this information if they had not been breastfed themselves. Women felt their own infant feeding choice was influenced by the perceived norm among family and friends. Women described how breastfeeding hindered their ability to retain their self-identities beyond motherhood as it limited their independence. Several second-time mothers felt they lacked support from health professionals when breastfeeding their second baby, even if they had previously encountered breastfeeding difficulties. The study indicates that experience of breastfeeding and belief in the health benefits associated with it are important factors for initiation of breastfeeding, while decreased independence and self-identity may influence duration of breastfeeding. Intervention and support schemes should tackle all mothers, not just first-time mothers.

Breastfeeding and reported morbidity during infancy: findings from the Southampton Women's Survey

Abstract: A number of studies in developed countries suggest that breastfeeding protects against infections in infancy. However, the choice to breastfeed is often related to maternal characteristics, and many of these studies are limited in the extent to which they can take account of confounding influences. In a prospective birth cohort study, we assessed the relationship between the duration of breastfeeding and the prevalence of lower respiratory tract infections, ear infections and gastrointestinal morbidity during the first year of life in 1764 infants. We considered the duration of all breastfeeding, including mixed feeding. Eighty-one per cent of the infants were breastfed initially, and 25% were breastfed up to 6 months. There were graded decreases in the prevalence of respiratory and gastrointestinal symptoms between birth and 6 months as breastfeeding duration increased; these were robust to adjustment for a number of confounding factors. The adjusted relative risks (95% confidence interval) for infants breastfed for six or more months compared with infants who were never breastfed were 0.72 (0.58-0.89), 0.43 (0.30-0.61) and 0.60 (0.39-0.92) for general respiratory morbidity, diarrhoea and vomiting, respectively. Duration of breastfeeding in the second half of infancy was less strongly related to diagnosed respiratory tract infections and gastrointestinal morbidity, although important benefits of breastfeeding were still seen. Our data provide strong support for a protective role of breastfeeding against respiratory and gastrointestinal infections in infancy. The graded inverse associations with breastfeeding duration suggest that current efforts to promote breastfeeding and increase duration will have important effects in reducing morbidity in infancy.

Dietary lipids from an evolutionary perspective: sources, structures and functions.

Abstract: Lipids are a complex group of biomolecules whose precise functions remain poorly understood. As a result of this poor understanding, it is difficult to make mechanistically based recommendations for appropriate dietary intakes. It is equally difficult to develop methods that are capable of diagnosing functional impairments because of insufficiencies or excesses in particular fatty acids. Lipids are abundant building blocks of cellular membranes, supply components for lipid particle assembly and substrates for metabolic fuel, and provide a precursor pool for an astonishingly diverse range of signalling molecules. In each of these broad functions, the functional consequences of different structures of fatty acids are not fully understood. According to research on membrane functions through early evolution, docosahexaenoic acid provides two biophysical properties to membranes - accelerating the lateral motion of lipids and proteins within the plane of the membrane and simultaneously slowing the rate of diffusion/leakage of charged species across the plane of the membrane. The range of fatty acid structures used as substrates for assembly of either lipoproteins or milk fat globules is broad, yet the functional consequences of differences are not known. Different lipids signal into a remarkable range of biological processes. Saturated and monounsaturated fatty acids are becoming recognized as signal molecules in their own right. The complex composition of human milk lipids implies that diets with a diversity of fatty acids in complex lipid forms and structures is more beneficial than a narrow range of any particular group of fatty acids.

Balancing nurturance, cost and time: complementary feeding in Accra, Ghana

Abstract: This paper presents a picture of the general patterns of complementary feeding behaviours in urban Ghana. A focused ethnographic study protocol for assessing complementary feeding developed for the Global Alliance for Improved Nutrition was used to collect data from caregivers of children 6-24 months of age. We examined the multiple factors that influence the selection of foods for infants and young children in this urban setting, and found that economic factors, health beliefs and other nurturing-related values, access to food and issues of convenience all play important roles. We conclude that the interactions of nurturance, cost and time are vectors that affect feeding decisions.

Review of fortified food and beverage products for pregnant and lactating women and their impact on nutritional status

Abstract: Fortified beverages and supplementary foods, when given during pregnancy, have been shown to have positive effects on preventing maternal anaemia and iron deficiency. Studies show that use of micronutrient fortified supplementary foods, especially those containing milk and/or essential fatty acids during pregnancy, increase mean birthweight by around 60-73 g. A few studies have also shown that fortified supplementary foods have impacts on increasing birth length and reducing preterm delivery. Fortification levels have ranged generally from 50% to 100% of the recommended nutrient intake (RNI). Iron, zinc, copper, iodine, selenium, vitamins A, D, E, C, B1, B2, B6, and B12, folic acid, niacin and pantothenic acid are important nutrients that have been included in fortified beverages and supplemental foods for pregnant and lactating women. While calcium has been shown to reduce the risk of pre-eclampsia and maternal mortality, calcium, phosphorus, potassium, magnesium and manganese can have negative impacts on organoleptic properties, so many products tested have not included these nutrients or have done so in a limited way. Fortified food supplements containing milk and essential fatty acids offer benefits to improving maternal status and pregnancy outcome. Fortified beverages containing only multiple micronutrients have been shown to reduce micronutrient deficiencies such as anaemia and iron deficiency.

Women's Sense of Coherence related to their infant feeding experiences

Abstract: Given the overwhelming evidence for the benefits of breastfeeding, and yet the low prevalence rates in the UK, it is crucial to understand the influences on women's infant feeding experiences to target and promote effective support. As part of an evaluation study of the implementation of the UNICEF UK Baby Friendly Initiative (BFI) Community Award within two primary (community-based) care trusts in North West England, 15 women took part in an in-depth interview to explore their experiences, opinions and perceptions of infant feeding. In this paper, we have provided a theoretical interpretation of these women's experiences by drawing upon Aaron Antonovsky's Sense of Coherence (SOC) theory. The SOC is a global orientation to how people are able to cope with stressors and maintain a sense of well-being. The three constructs that underpin the SOC are 'comprehensibility' (one must believe that one understands the life challenge), 'manageability' (one has sufficient resources at one's disposal) and 'meaningfulness' (one must want to cope with the life challenge). In this paper, our interpretations explore how infant feeding is influenced by the 'comprehensibility', 'manageability' and 'meaningfulness' of this event; contextualized within a wider socio-cultural perspective. The findings of this paper offer a unique means through which the influences on women's experiences of infant feeding may be considered. Recommendations and suggestions for practice in relation to the implementation of the BFI have also been presented.

Acceptability of three novel lipid-based nutrient supplements among Malawian infants and their caregivers.

Abstract: We tested the acceptability of three new lipid-based nutrient supplements (LNSs) in two independent phases among 18 8-12-month-old healthy rural Malawians and their caregivers. In phase 1, acceptability was assessed by offering three new LNSs in random order, and an LNS already determined to be acceptable, Nutributter(®), each added to 30 g of warm maize porridge over three consecutive days. In phase 2, infants from each village were provided one of the new supplements for a 2-week home-use trial. Outcome measures included the amount consumed, time completion of the dose and the maternal rating of likeability on a 5-point scale. The supplements were rated acceptable if consumption was over 50% of the offered dose in phase 1. The mean (95% confidence interval) proportion of the LNS test meals consumed under direct observation was 88% (82-94%) for LNS-10gM, 90% (84-95%) for LNS-20gM, 87% (79-95%) for LNS-20gNoM, and 86% (83-90%) for Nutributter. The median (25th and 75th centile) time (minutes) for completing the offered test meal was 4 (2, 7) for LNS-10gM, 5 (3, 6) for LNS-20gM, 4 (3, 8) for LNS-20gNoM and 4 (2, 6) for Nutributter. During both phases, almost all caregivers rated all study foods very likeable for themselves and their children, with mean scores slightly lower among the caregivers than among the infants. In the home-use phase, the test foods were almost exclusively used by the study participants with minimal sharing with siblings and other household members. Some infants were reported to prefer the new investigational products over traditional complementary food. Considering that the novel LNS was largely acceptable. Efficacy trials are now needed to assess their impact on child growth and development.

Acceptability of zinc-fortified, lipid-based nutrient supplements (LNS) prepared for young children in Burkina Faso.

Abstract: Micronutrient deficiencies are a public health concern among young children in low-income countries,and novel strategies are needed to improve the nutritional status of children at risk. One promising approach is the use of lipid-based nutrient supplements (LNS),which can be added to complementary food at the time of consumption. The optimal amount of zinc to include in LNS is uncertain, and concerns have been expressed about possible adverse effects of zinc on sensory characteristics of LNS.We conducted a series of acceptability studies of LNS containing either 0 or 10 mg of zinc per daily 20 g LNS dose among Burkinabe children 9-15 months old and their mothers.These acceptability studies included observations of children's consumption, maternal and child sensory reaction to the products using a 5-unit hedonic scale, a triangle test for detection of differences and a review of maternal reports of their child-feeding experiences during a 2-week home-feeding trial. The LNS products were well appreciated by the mothers and children during the sensory trials and the 2-week home- feeding trial. The addition of 10 mg zinc to LNS did not affect the consumed proportion of the offered porridge-LNS-mixture (P = 0.43). Results of the triangle test with mothers confirmed that there was no detect- able difference between products containing 0 or 10 mg zinc per 20 g LNS dose.Most importantly,interviews and focus groups following the 2-week home-feeding trial indicated good acceptability of the products by mothers and their children.

Implementation of a programme to market a complementary food supplement (Ying Yang Bao) and impacts on anaemia and feeding practices in Shanxi, China.

Abstract: In China, a full fat soy powder mixed with multiple micronutrient powders (Ying Yang Bao (YYB)) was developed, and the efficacy of YYB was shown in controlling anaemia and improving child growth and development. However, prior to 2008, there was no sustainable way to provide YYB to vulnerable populations, except through free distribution by the government. This study was to test the concept of public-private partnership (PPP) to deliver YYB and to evaluate the effectiveness of marketing YYB through PPP. Programme activities included development of a complementary food supplement (CFS) national standard, product concept test, product development and marketing, behavior change communication, monitoring and evaluation. Baseline and end-line surveys were used to evaluate product awareness, purchasing and the impacts of the project on anaemia and feeding practices. A Chinese CFS standard was approved. Caregivers and their 6- to-24-month-old children participated in the baseline (n=226) and the end-line survey (n=221). A concept test at the baseline survey showed that 78% of caregivers were willing to buy YYB at 0.1 USD. After developing the product and implementing the intervention for 8 months, 59.6% of surveyed caregivers purchased YYB. While not significant, the prevalence of anaemia was marginally lower at the end line (28.8%) than at the baseline (36.2%). For those purchasing YYB, the risk of anaemia was significantly reduced by 87% of odds (P<0.009). The end-line survey found that feeding practices had improved significantly following the intervention. An enabling policy and regulatory environment in which CFSs are defined and parameters for appropriate marketing are identified as a prerequisite for marketing YYB or other nutritious CFS. Public and private advocacy and marketing could successfully increase awareness of YYB and access and use through market channels. The YYB project may be effective for reducing anaemia and improving feeding practices.

The use of TeleMedicine in the treatment of paediatric obesity: feasibility and acceptability

Abstract: To assess the feasibility of conducting empirically supported family-based paediatric obesity group treatment via TeleMedicine. Seventeen families were randomly assigned to one of two conditions (physician visit, TeleMedicine). Measures included feasibility, satisfaction and intervention outcome measures such as BMI percentile, and nutrition and activity behaviours. Measures were completed at baseline, post-treatment and at 1-year follow-up. Analyses indicate that both feasibility and satisfaction data regarding the TeleMedicine intervention were positive. Intervention outcome indicates no change in BMI percentile or nutrition and activity behaviours for either treatment group. A behavioural family-based weight loss intervention delivered via TeleMedicine was well received by both parents and providers. Due to the small sample size, null findings regarding intervention outcome should be interpreted with caution. Future research should focus on methods to increase the impact of this intervention on key outcome variables.

Relationship of social cognitive theory concepts to mothers' dietary intake and BMI

Abstract: Women tend to have the greatest responsibility for and influence on the home food environment. Understanding theoretical concepts as they pertain to mothers' food-related behaviours could inform the development of interventions that enhance mothers' ability to create healthy family food environments that support optimal child development and help attenuate obesity rates. Likert scales assessed Social Cognitive Theory concepts [i.e. self-efficacy, self-regulation (sets goals, self-reward, self-monitoring, environmental structuring), outcome expectations] and coping of 201 mothers in the context food-related activities. ANOVA determined whether diet and BMI differed among mothers scoring in the highest, middle, and lowest tertiles on the Likert scales. For self-efficacy, coping, sets goals, and outcome expectations scales, lowest tertile mothers had significantly higher BMIs than highest tertile mothers. The lowest tertile for self-efficacy, self-reward, and self-monitoring consumed significantly less fibre, vitamin C, magnesium, potassium, and fruit and vegetables than upper tertiles. On the self-efficacy scale, the lowest tertile consumed significantly more calories, fat, and cholesterol than higher tertiles. Environmental structuring scale findings indicate users of television during dinner had significantly lower intakes of fibre, vitamin C, magnesium, potassium, and fruits and vegetables than those almost never using TV during dinner. Stepwise regression revealed self-monitoring, environmental structuring, self-reward, and outcome expectations were significant positive predictors of self-efficacy. Self-monitoring was a significant positive predictor of outcome expectations. Associations between theoretical concepts, mothers' dietary intakes, and BMIs point to the need to incorporate components that build self-efficacy, self-regulation, outcome expectations, and coping skills into health promotion interventions.

Formative research for the development of a market-based home fortification programme for young children in Niger

Abstract: The objective of this formative research was to assess the acceptability of a micronutrient powder (Sprinkles®) and a lipid-based nutrient supplement (Nutributter®), and to explore people's willingness to pay for these products in a resource-poor context like Niger. In four sites, 84 focus group discussions among mothers, fathers and grandmothers of children 6–23 months were conducted, as well as 80 key informant interviews of mothers who participated in a home study where their children 6–23 months were given either Sprinkles® or Nutributter® to use either for a period of 4 weeks, or they were given both products over the 4-week period, i.e. Sprinkles® for 2 weeks and Nutributter® for an additional 2 weeks. The mothers understood how to use the products and generally used the products correctly. Both products were highly acceptable to adults and most children. In Niamey, where the 4-week home study used both products for 2 weeks each, the mothers tended to prefer Nutributter®. The mothers who used either product were pleased with the improvements they saw in their children's health, including increased appetite, weight gain and increased energy and activity. A few mothers were concerned with how they would be able to provide for their child's increased appetite. Most participants across all four sites reported that they would be willing and able to afford to buy a single sachet of either Sprinkles® at a cost of US$0.03 or Nutributter® at a cost of US$0.08 several times a week. This study provides evidence that both of these products were are highly acceptable in different settings in Niger and suggests that delivery of Nutributter® or Sprinkles® at a low or subsidized cost through a market-based system may be possible in Niger, if an appropriate distribution system can be identified.