The main objectives were to assess the adequacy of the micronutrient intakes of lactating women in a peri-urban area in Nepal and to describe the relationships between micronutrient intake adequacy, ...dietary diversity and sociodemographic variables.
A cross-sectional survey was performed during 2008-2009. We used 24 h dietary recall to assess dietary intake on three non-consecutive days and calculated the probability of adequacy (PA) of the usual intake of eleven micronutrients and the overall mean probability of adequacy (MPA). A mean dietary diversity score (MDDS) was calculated of eight food groups averaged over 3 d. Multiple linear regression was used to identify the determinants of the MPA.
Bhaktapur municipality, Nepal.
Lactating women (n 500), 17-44 years old, randomly selected.
The mean usual energy intake was 8464 (sd 1305) kJ/d (2023 (sd 312) kcal/d), while the percentage of energy from protein, fat and carbohydrates was 11 %, 13 % and 76 %, respectively. The mean usual micronutrient intakes were below the estimated average requirements for all micronutrients, with the exception of vitamin C and Zn. The MPA across eleven micronutrients was 0·19 (sd 0·16). The diet was found to be monotonous (MDDS was 3·9 (sd 1·0)) and rice contributed to about 60 % of the energy intake. The multiple regression analyses showed that MPA was positively associated with energy intake, dietary diversity, women's educational level and socio-economic status, and was higher in the winter.
The low micronutrient intakes are probably explained by low dietary diversity and a low intake of micronutrient-rich foods.
Abstract
Balanced energy protein (BEP) supplementation in pregnancy is recommended in the context of undernutrition for the reduction of small‐for‐gestational age neonates and stillbirths. To inform ...an effectiveness trial, we evaluated the acceptability of a packaged, ready‐to‐eat fortified BEP product among women of reproductive age and their health care providers (HCPs) in rural Bangladesh and explored the feasibility of adhering to daily supplementation. We implemented a formative study using focus groups discussions with women (
n
= 29) and HCPs (
n
= 17) to introduce the product and investigate components of acceptability. A “trials of improved practice” activity was conducted in subset of women (
n
= 16) to evaluate adherence to BEP over a 2‐week period, followed by focus group discussions to identify challenges with adherence and strategies employed. Contributors to BEP acceptability included the product's sensory attributes, such as taste, smell and texture; the attractive packaging and informative labelling; and the perceived benefits of use. Participants also identified household and community level factors influencing the adoption of BEP, such as trust in the provider, cultural beliefs on supplement use in pregnancy, and family member tasting and approval. Over the 2‐week period, women consumed over 80% of the supplements provided to them and identified strategies for adherence, including visual aids and reminders from family members or providers. HCPs recommended targeted communication messages for mothers‐in‐law to foster a supportive home environment. Findings informed changes to the BEP product to improve acceptability and shaped the content of communication messages to optimise adherence in a forthcoming effectiveness trial.
Key messages
The balanced energy protein (BEP) product introduced in this formative study was well accepted by women of reproductive age and their health care providers (HCPs), especially with regards to the overall taste, product packaging and labelling, and perceived benefits. Acceptability may be influenced by cultural beliefs around nutritional supplement use during pregnancy, and factors such as family members' approval of the product, and trust in the provider of BEP supplements.
Women who consumed the product over 2 weeks had high daily adherence and identified strategies such as reminders from family members and/or providers and visual aids in the home to enhance regular use. HCPs recommended communication messages that encouraged buy in from husbands and mothers‐in‐law.
Findings from this study informed changes to the BEP product format to improve acceptability and shaped the content of communication messages to encourage adherence in a forthcoming effectiveness trial.
Poor vitamin B-12 (cobalamin) status is widespread in South Asia. Insufficient vitamin B-12 status has been linked to poor neurodevelopment in young children.
We measured the associations between ...vitamin B-12 status in infancy (2-12 mo) and the development and cognitive functioning in Nepalese children 5 y later.
Vitamin B-12 status was assessed in infancy with the use of plasma cobalamin, total homocysteine (tHcy), and methylmalonic acid (MMA). At 5 y of age, we measured development with the use of the Ages and Stages Questionnaire, 3rd edition (ASQ-3), and cognitive functioning by using the Developmental Neuropsychological Assessment, 2nd edition (NEPSY II), in 320 children. In regression models, we estimated the associations between vitamin B-12 status, including a combined indicator of vitamin B-12 status (3cB12) and scores on the ASQ-3 and NEPSY II subtests.
All markers of vitamin B-12 status with the exception of plasma cobalamin were significantly associated with the total ASQ-3 scores in the multiple regression models. A 1-unit increase in the 3cB12 score was associated with an increase in the total ASQ-3 score of 4.88 (95% CI: 2.09, 7.68;
= 0.001). Increases in both plasma tHcy and MMA (indicating poorer status) were associated with a decrease in scores on the NEPSY II affect recognition and geometric puzzle subtests. Each unit increment in 3cB12 scores was associated with increases of 0.82 (95% CI: 0.49, 1.14;
< 0.0005), 0.59 (95% CI: 0.10, 1.09;
= 0.020), and 0.24 (95% CI: 0.02, 0.47;
= 0.035) in the affect recognition, geometric puzzle, and block construction scores, respectively.
Vitamin B-12 status in infancy is associated with development and performance on social perception tasks and visuospatial abilities at 5 y of age. The long-term effects of poor vitamin B-12 status in infancy need further investigation in randomized controlled trials.
Social desirability bias is often speculated to influence survey responses but seldom studied in healthcare. The objective was to explore whether social desirability scores (SDS) or the presence of ...interview observers is associated with inaccurate recall and overestimation of antenatal care (ANC) services.
Longitudinal validation study comparing recalled receipt of ANC services and nutrition components of ANC against direct observations of care. An adapted short form Marlowe-Crowne questionnaire was used to generate an SDS, and the presence of interview observers was treated as a separate exposure. We assessed accuracy and overestimation of recalled receipt of ANC services against observed receipt using log-binomial regression, adjusting for age, education, first-pregnancy and socioeconomic status.
Rural Southern Nepal with recruitment from five government health posts.
401 pregnant women.
Social desirability scores did not significantly predict accuracy or overestimation of most types of ANC care except counselling on nausea. Higher SDS was associated with more accurate recall (adjusted RR, aRR 1.08 (95% CI 1.03, 1.12)) and less overestimation (aRR 0.85 (0.80, 0.91)). The presence of mothers-in-law or husbands during interviews was associated with greater overestimation of the number of ANC visits received by more than three visits (aRR 2.07 (1.11, 3.84)) and (aRR 4.19 (2.17, 8.10)), respectively. Those interviewed with friends present tended to overestimate the receipt of counselling on nausea, avoiding alcohol and not smoking.
The presence of observers can lead to overestimation of the receipt of ANC care and support the conduct of interviews in private settings despite challenges of doing so in village contexts. Findings that the SDS did not predict the accuracy of most types of ANC care might reflect a reality that such questions may not be sensitive from a social-norms perspective. Additional local adaptation of SDS is recommended.
The World Health Organization (WHO) recommends balanced energy and protein (BEP) supplementation be provided to all pregnant women living in undernourished populations, usually defined as having a ...prevalence > 20% of underweight women, to reduce the risk of stillbirths and small-for-gestational-age neonates. Few geographies meet this threshold, however, and a large proportion of undernourished women and those with inadequate gestational weight gain could miss benefiting from BEP. This study compares the effectiveness of individual targeting approaches for supplementation with micronutrient-fortified BEP vs. multiple micronutrient supplements (MMS) alone as control in pregnancy in improving birth outcomes.
The TARGET-BEP study is a four-arm, cluster-randomized controlled trial conducted in rural northwestern Bangladesh. Eligible participants are married women aged 15-35 years old identified early in pregnancy using a community-wide, monthly, urine-test-based pregnancy detection system. Beginning at 12-14 weeks of gestation, women in the study area comprising 240 predefined sectors are randomly assigned to one of four intervention arms, with sector serving as the unit of randomization. The interventions involving daily supplementation through end of pregnancy are as follows: (1) MMS (control); (2) BEP; (3) targeted BEP for those with pre-pregnancy body mass index (BMI) < 18.5 kg/m
and MMS for others; (4) targeted BEP for those with pre-pregnancy BMI < 18.5 kg/m
, MMS for others, and women with inadequate gestational weight gain switched from MMS to BEP until the end of pregnancy. Primary outcomes include birth weight, low birth weight (< 2500 g), and small for gestational age, defined using the 10
percentile of the INTERGROWTH-21st reference, for live-born infants measured within 72 h of birth. Project-hired local female staff visit pregnant women monthly to deliver the assigned supplements, monitor adherence biweekly, and assess weight regularly during pregnancy. Trained data collectors conduct pregnancy outcome assessment and measure newborn anthropometry in the facility or home depending on the place of birth.
This study will assess the effectiveness of targeted balanced energy and protein supplementation to improve birth outcomes among pregnant women in rural Bangladesh and similar settings.
ClinicalTrials.gov NCT05576207. Registered on October 5th, 2022.
The specific aim was to characterize retail purchases of red and processed meat and other major protein-rich foods in the U.S. and by state. Supermarket scanner data from grocery stores, ...supermarkets, and big box stores collected from 2017-2019 (NielsenIQ, New York, NY) was used to characterize retail purchases of red meat, processed meat, and other protein-rich foods in thirty-one states representative of US retail food sales. Red meat, processed meat, poultry, seafood, eggs, other meats, and non-meat foods (beans, nuts, seeds, meat alternatives) by weight accounted for 25.9%, 20.4%, 25.8%, 5.9%, 12.6%, 1.3%, and 10.1%, respectively of total sales in 2017-2019. Mean per capita purchases of red meat by weight was 30.1 g/d, ranging from 45.4 g/d in Mississippi to 21.9 g/d in New York. Mean per capita purchases of processed meat by weight was 23.8 g/d, ranging from 36.6 g/d in Mississippi to 15.2 g/d in California. We observed statistically significant correlations between red and processed meat purchases with cardiovascular mortality and colorectal cancer by state. Per capita retail purchases of red and processed meat appear to reflect a dietary pattern that is not consistent with current national and international dietary recommendations.
Background
Vitamin D deficiency in pregnancy may be a risk factor for child allergic disease. However, less is known about disease risk across different levels of vitamin D.
Objective
We aimed to ...examine the relation between a maternal vitamin D prediction score and child allergic disease.
Methods
A total of 32,456 pregnant women were enrolled in the Danish National Birth Cohort (1996–2003) and had data on a validated vitamin D prediction score based on 1497 mid‐pregnancy plasma 25(OH)D samples. Child allergic disease was assessed at 18 months and at 7 years using questionnaire data and national registry extracts. We used multivariable log‐binomial models to quantify risk ratios (RR) and 95% CI. Plasma 25(OH)D was examined in a stability analysis.
Results
Median (IQR) vitamin D prediction score was 58.7 (49.2–69.0) nmol/l. In main analysis, there was no association between vitamin D prediction score examined in quintiles or by restricted categories (≥75 nmol/l and <25 nmol/l vs. 25–74.9 nmol/l) and child allergic disease. However, maternal vitamin D prediction score ≥100 nmol/l(vs. 50–79.9 nmol/l) was associated with increased risks of child asthma at 18 months (RR: 1.36, 95% CI: 1.02, 1.80) and asthma by hospital admission (RR: 1.65, 95% CI: 1.04, 2.62). For vitamin D prediction score <25–30 nmol/l, there were increased risks of child asthma at 18 months and by hospital admission and medication prescription at age 7, although these findings were not robust to covariate adjustment. Similar results were found for plasma 25(OH)D.
Conclusions
Our study provided little evidence for an association between maternal vitamin D prediction score and child allergic disease for scores ≥75 nmol/l. However, increased risks were observed for vitamin D prediction score ≥100 nmol/l. These associations are hypothesis generating and would need to be replicated in other cohorts.
In Bangladesh, rice prices are known to be positively associated with the prevalence of child underweight and inversely associated with household nongrain food expenditures, an indicator of dietary ...quality. The collection of reliable data on household expenditures is relatively time consuming and requires extensive training. Simple dietary diversity scores are increasingly used as measures of food security and as proxies for nutrient adequacy. This study examines associations between a simple dietary diversity score and commonly used indicators of socioeconomic status in Bangladesh. Data representative of rural Bangladesh was collected from 188,835 households over 18 rounds of bi-monthly data collection from 2003-2005. A simple household dietary diversity score was developed by summing the number of days each household consumed an item from each of 7 food groups over a 7-d period. The dietary diversity score was associated with per capita nongrain food expenditures (r = 0.415), total food expenditures (r = 0.327), and total household expenditures (r = 0.332) using Spearman correlations (all P < 0.0001). The frequency of meat and egg consumption showed greater variation across quintiles of total monthly expenditure than other items contributing to the dietary diversity score. After controlling for other measures of socioeconomic status in multiple linear regression models, the dietary diversity score was significantly associated with monthly per capita food and total expenditures. Low dietary diversity during the period prior to major food price increases indicates potential risk for worsening of micronutrient deficiencies and child malnutrition in Bangladesh.
Animal source foods (ASF) provide nutrients essential to child growth and development yet remain infrequently consumed in rural Nepal. Agriculture and nutrition programs aim to increase ASF intake ...among children through small-scale animal husbandry projects. The relationship between livestock ownership and children's consumption of ASF, however, is not well established. This study examined associations between livestock ownership and the frequency with which Nepali children consume eggs, dairy, and meat. We analyzed longitudinal 7-day food frequency data from sentinel surveillance sites of the Policy and Science of Health, Agriculture and Nutrition (PoSHAN) study. Data consisted of surveys from 485 Nepali farming households conducted twice per year for two years (a total of 1449 surveys). We used negative binomial regression analysis to examine the association between the number of cattle, poultry, and meat animals (small livestock) owned and children's weekly dairy, egg, and meat intakes, respectively, adjusting for household expenditure on each food type, mother's education level, caste/ethnicity, agroecological region, season, and child age and sex. We calculated predicted marginal values based on model estimates. Children consumed dairy 1.4 (95% CI 1.1-2.0), 2.3 (1.7-3.0) and 3.0 (2.1-4.2) more times per week in households owning 1, 2-4 and >4 cattle, respectively, compared to children in households without cattle. Children consumed eggs 2.8 (2.1-3.7) more times per week in households owning 1 or 2 chickens compared to children in households without chickens. Child intake of meat was higher only in households owning more than seven meat animals. Children's intakes of dairy, eggs, and meat rose with household expenditure on these foods. Small-scale animal production may be an effective strategy for increasing children's consumption of eggs and dairy, but not meat. Increasing household ability to access ASF via purchasing appears to be an important approach for raising children's intakes of all three food types.
Optimal breastfeeding practices, reflected by early initiation and feeding of colostrum, avoidance of prelacteal feeds, and continued exclusivity or predominance of breastfeeding, are critical for ...assuring proper infant nutrition, growth and development.
We used data from a nationally representative survey in 21 district sites across the Mountains, Hills and Terai (southern plains) of Nepal in 2013. Determinants of early initiation of breastfeeding, feeding of colostrum, prelacteal feeding and predominant breastfeeding were explored in 1015 infants < 12 months of age. Prelacteal feeds were defined as food/drink other than breast milk given to newborns in first 3 days. Predominant breastfeeding was defined as a child < 6 months of age is mainly breastfed, not fed solid/semi-solid foods, infant formula or non-human milk, in the past 7 days. Adjusted prevalence ratios (APR) and 95% confidence intervals (CI) were estimated, using log Poisson regression models with robust variance for clustering.
The prevalence of breastfeeding within an hour of birth, colostrum feeding, prelacteal feeding and predominant breastfeeding was 41.8, 83.5, 32.7 and 57.2% respectively. Compared to infants not fed prelacteal feeds, infants given prelacteal feeds were 51% less likely to be breastfed within the first hour of birth (APR 0.49; 95% CI 0.36, 0.66) and 55% less likely to be predominantly breastfed (APR 0.45; 95% CI 0.32, 0.62). Infants reported to have received colostrum were more likely to have begun breastfeeding within an hour of birth (APR 1.26; 95% CI 1.04, 1.54) compared to those who did not receive colostrum. Infants born to mothers ≥ 20 years of age were less likely than adolescent mothers to initiate breastfeeding within 1 hour of birth. Infants in the Terai were 10% less likely to have received colostrum (APR 0.90; 95% CI 0.83, 0.97) and 2.72 times more likely to have received prelacteal feeds (APR 2.72; 95% CI 1.67, 4.45) than those in the Mountains.
Most infants in Nepal receive colostrum but less than half initiate breastfeeding within an hour of birth and one-third are fed prelacteal feeds, which may negatively affect breastfeeding and health throughout early infancy.
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