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Background: Children born preterm and/or small for gestational age (SGA) are at increased risk of poor cognitive outcomes, particularly in low and middle-income countries (LMICs)., Objectives: This study aimed to examine the cognitive and academic deficits during the school-age years in children born preterm or SGA compared with those in children born term adequate for gestational age (AGA) in rural Vietnam., Methods: Children born to women in a preconception micronutrient supplementation trial in Vietnam were classified into 3 groups: preterm AGA (n =138), term SGA (n =169), and term AGA (n = 1134). Cognitive abilities were assessed using the Wechsler Intelligence Scale for Children, measuring 4 domains [verbal comprehension index (VCI), perceptual reasoning index (PRI), working memory index (WMI), and processing speed index (PSI) scores] and full-scale intelligence quotient (FSIQ) at 6-7 and 10-11 y. Academic achievement was assessed with mathematic and language tests. Analysis of variance and multiple regression models were used to analyze differences in cognitive function and academic achievement at 6-7 and 10-11 y by birth phenotypes., Results: Compared with term AGA children, those born SGA had lower cognitive scores at both 6-7 y (VCI, -2.3; PRI, -3.7; PSI -2.1; and FSIQ, -2.9) and 10-11 y (VCI, -3.7; PRI, -3.5; WMI, -2.7; PSI, -1.9; and FSIQ, -3.9). Children born SGA also had poorer academic achievement with lower language (5.3) and mathematic (2.5) scores. Adjustments for maternal factors and home environment attenuated the associations, but the differences in VCI, PRI, FSIQ, and language at 10-11 y remained significant. There were no differences in cognitive function and academic achievement between children born preterm and AGA., Conclusions: Our findings highlight the enduring association of birth phenotype on cognitive functioning and academic achievement during the school years, despite adjustments for maternal education and family environment. Further research is needed to implement effective interventions to improve birth outcomes and optimize child health and development in LMICs. The trial was registered at clinicaltrials.gov as NCT01665378 (URL: https://clinicaltrials.gov/ct2/show/NCT01665378)., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Limited evidence exists on the long-term effects of early feeding practices on child growth and development. We examined the relationships between infant feeding practices and child height and development at ages 2 and 6-7 years. We studied 885 mother-child dyads from a randomized controlled trial of preconception supplementation in Vietnam. Early initiation of breastfeeding (EIBF), exclusive breastfeeding (EBF), breastfeeding (BF) duration and minimum dietary diversity (MDD) were assessed using World Health Organization (WHO) guidelines. Child development was assessed by the Bayley Scales of Infant Development-III at 2 years and the Wechsler Intelligence Scale for Children® - IV at 6-7 years. Child height-for-age z-score (HAZ) was calculated from child height and age. Multivariable regression and structural equation models were used in analyses that controlled for confounding. EIBF and EBF at 6 months occurred in 52% and 62% of children, respectively. Mean breastfeeding duration was 18 months and 83% achieved MDD at 1 year. EIBF was associated with motor (β = 0.13, 95% confidence interval [CI]: 0.00, 0.28) and cognitive development at 2 years (β = 0.12, 95% CI: -0.01, 0.26), which in turn were positively associated with cognitive development at 6-7 years. EBF was directly associated with development at 6-7 years (β = 0.21, 95% CI:0.08, 0.34) whereas motor and cognitive development at 2 years explained 41%-75% of the relationship between EIBF and development at 6-7 years. HAZ at 2 years also mediated 70% of the association between MDD at 1 year and HAZ at 6-7 years. BF duration was not associated with child development and HAZ. Early infant feeding practices, especially EIBF and EBF, have important long-term implications for optimizing child linear growth and cognition as they begin school., (© 2024 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Background: Preterm and small for gestational age (SGA) remain significant public health concerns worldwide. Yet limited evidence exists on their growth patterns during childhood from low-or middle-income countries., Objectives: We investigated the postnatal growth patterns of preterm and SGA compared to term appropriate for gestational age (AGA) children from birth to 10-11y, and examined the impact of birth status on child nutritional status during the school age years., Methods: Children born to women who participated in a double-blinded randomized controlled trial of preconception micronutrient supplementation in Vietnam were classified into three groups: preterm AGA ( n  = 130), full-term SGA ( n  = 165) and full-term AGA ( n  = 1,072). Anthropometric data (weight and height) were collected prospectively at birth, 3, 6, 12, 18, 24 months and at 6-7 and 10-11y. We used ANOVA and multiple regression models to examine the differences in growth patterns from birth to 10-11y as well as child undernutrition and overnutrition by birth status., Results: Children who were born preterm exhibited rapid postnatal growth, but still had lower HAZ at 1y and 2y and showed catch up to the AGA group at 6y. Compared to those born AGA, SGA infants had higher risk of thinness (BMIZ < -2) at 2y and 6y (adjusted Odds Ratio, AOR [95% CI] 2.5 [1.0, 6.1] and 2.6 [1.4, 4.6], respectively); this risk reduced at 10-11y (1.6 [0.9, 2.8]). The risk of stunting (HAZ < -2) was also 2.4 [1.5, 3.8] and 2.3 times [1.2, 4.1] higher in SGA than AGA group at ages 2y and 6-7y, respectively, with no differences at 10y. Although preterm children had higher rates of thinness and stunting at 2y compared to AGA children, these differences were not statistically significant. No associations were found between preterm or SGA and overweight /obesity at age 10-11y., Conclusion: Children who were born term-SGA continued to demonstrate deficits in weight and height during childhood whereas those born preterm showed catch-up growth by age 6-7y. Additional efforts to reduce the burden of these conditions are needed, particularly during school-age and early adolescents when children are exposed to challenging environments and have higher demands for nutrition., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Nguyen, Nguyen, Tran, Khuong, Nguyen, Young and Ramakrishnan.)

Background: Adolescent nutrition has faced a policy neglect, partly owing to the gaps in dietary intake data for this age group. The Food Recognition Assistance and Nudging Insights (FRANI) is a smartphone application validated for dietary assessment and to influence users toward healthy food choices., Objectives: This study aimed to assess the feasibility (adherence, acceptability, and usability) of FRANI and its effects on food choices and diet quality in female adolescents in Vietnam., Methods: Adolescents ( N = 36) were randomly selected from a public school and allocated into 2 groups. The control group received smartphones with a version of FRANI limited to dietary assessment, whereas the intervention received smartphones with gamified FRANI. After the first 4 wk, both groups used gamified FRANI for further 2 wk. The primary outcome was the feasibility of using FRANI as measured by adherence (the proportion of completed food records), acceptability and usability (the proportion of participants who considered FRANI acceptable and usable according to answers of a Likert questionnaire). Secondary outcomes included the percentage of meals recorded, the Minimum Dietary Diversity for Women (MDDW) and the Eat-Lancet Diet Score (ELDS). Dietary diversity is important for dietary quality, and sustainable healthy diets are important to reduce carbon emissions. Poisson regression models were used to estimate the effect of gamified FRANI on the MDDW and ELDS., Results: Adherence to the application was 82% and the percentage of meals recorded was 97%. Acceptability and usability were 97%. MDDW in the intervention group was 1.07 points (95% CI: 0.98, 1.18; P = 0.13) greater than that in the control (constant = 4.68); however, the difference was not statistically significant. Moreover, ELDS in the intervention was 1.09 (95% CI: 1.01, 1.18; P = 0.03) points greater than in the control (constant = 3.67)., Conclusions: FRANI was feasible and may be effective to influence users toward healthy food choices. Research is needed for FRANI in different contexts and at scale.The trial was registered at the International Standard Randomized Controlled Trial Number as ISRCTN 10681553., (© 2023 The Authors.)

Background: The Minimum Dietary Diversity for Women of Reproductive Age (MDD-W) indicator was validated as a proxy of micronutrient adequacy among nonpregnant women in low- and middle-income countries (LMICs). At that time, indeed, there was insufficient data to validate the indicator among pregnant women, who face higher micronutrient requirements., Objective: This study aimed to validate a minimum food group consumption threshold, out of the 10 food groups used to construct MDD-W, to be used as a population-level indicator of higher micronutrient adequacy among pregnant women aged 15-49 y in LMICs., Methods: We used secondary quantitative 24-h recall data from 6 surveys in 4 LMICs (Bangladesh, Burkina Faso, India, and Nepal, total n  = 4909). We computed the 10-food group Women's Dietary Diversity Score (WDDS-10) and calculated the mean probability of adequacy (MPA) of 11 micronutrients. Linear regression models were fitted to assess the associations between WDDS-10 and MPA. Sensitivity, specificity, and proportion of individuals correctly classified were used to assess the performance of MDD-W in predicting an MPA of >0.60., Results: In the pooled sample, median values (interquartile range) of WDDS-10 and MPA were 3 (1) and 0.20 (0.34), respectively, whereas the proportion of pregnant women with an MPA of >0.60 was 9.6%. The WDDS-10 was significantly positively associated with MPA in each survey. Although the acceptable food group consumption threshold varied between 4 and 6 food groups across surveys, the threshold of 5 showed the highest performance in the pooled sample with good sensitivity (62%), very good specificity (81%), and percentage of correctly classified individuals (79%)., Conclusions: The WDDS-10 is a good predictor of dietary micronutrient adequacy among pregnant women aged 15-49 y in LMICs. Moreover, the threshold of 5 or more food groups for the MDD-W indicator may be extended to all women of reproductive age, regardless of their physiologic status., (© 2023 The Authors.)

Adolescent and young women face grave nutrition challenges, but limited evidence exists on solutions to improve their diets. Action-research was done over 3 years (2020-2022) in secondary cities of Colombia (Medellin) and Vietnam (Thai Nguyen) to identify nutrient deficits in adolescent and young women diets; elaborate food-based recommendations to improve their nutritional status using Optifood linear programming; and engage respondents in incorporating suggested recommendations to their diet using a Social Innovation Challenge approach. A total of 1001 respondents were interviewed in Vietnam, 793 in Colombia. The probability of nutrient inadequacy in both locations was highest for iron and calcium, followed by the risk of deficiency for several other vitamins and minerals. Social Innovation Challenge teams (11 in Vietnam, 9 in Colombia) were created and supported in developing solutions to improve diets and tackle those deficiencies. Awards and resources were transferred to the most promising solutions to enable their implementation. Pre/post measurements of the interventions' impact using the Global Diet Quality Score as outcome metric showed significant improvement in the diets of Challenge participants. After introducing a series of companion articles that offer detailed results on those various steps, this paper draws strategic lessons from an action-research perspective., (© 2023 The Authors. Annals of the New York Academy of Sciences published by Wiley Periodicals LLC on behalf of New York Academy of Sciences.)

The Global Diet Quality Score (GDQS) has been recommended as a simple diet quality metric that is reflective of both nutrient adequacy and noncommunicable disease outcomes. It has been validated among women of reproductive age (15-49 years) in diverse settings but not specifically among younger women. This paper examines the relationship between the GDQS and nutrient adequacy, anthropometric outcomes, and depressive symptoms among 1001 Vietnamese young women aged 16-22 years. In energy-adjusted models, the GDQS was significantly (p < 0.05) and positively correlated with intakes of protein (ρ = 0.23), total fat (ρ = 0.06), nine micronutrients (calcium, iron, zinc, vitamin C, riboflavin, niacin, vitamin B6, folate, and vitamin A) (ρ = 0.12-0.35), and the mean probability of adequacy of micronutrients (ρ = 0.28). Compared to young women with optimal GDQS, those with low and very low GDQS were two to five times more likely to have a mean probability of nutrient adequacy less than 50% and showed two to three times higher odds for depression. No association was observed for GDQS and anthropometric outcomes. In conclusion, the GDQS performed well in capturing nutrient adequacy and depressive symptoms among Vietnamese young women. Further research is warranted to explore the relationship between diet quality and depression in other settings., (© 2023 The Authors. Annals of the New York Academy of Sciences published by Wiley Periodicals LLC on behalf of New York Academy of Sciences.)

Adolescence is a sensitive transition time that affects rights, roles, and responsibilities in food choice, yet limited evidence exists on dietary intakes during this critical period. This study assessed the food consumption pattern and the adequacy of energy, macronutrient, and micronutrient intakes among female youth belonging to three occupational groups in Vietnam. Dietary intakes were measured for 1001 participants aged 16-22 years using INDDEX24's 24-h recall method. Multivariate regression analyses were conducted to examine differences in diet outcomes among the three occupational groups. Dietary diversity was similar across groups but workers, compared to high school and college students, consumed less baked/grain-based sweets and fast foods, and more soft drinks, other sweets, and processed meat. Two-thirds of the sample showed energy intake lower than the estimated energy requirement, while a substantial percentage had insufficient or excessive intake of carbohydrate and fat. The mean probability of adequacy of nutrient intakes was low (0.33) and not different across all three occupational groups except for folate, which favored workers. Our study provides novel evidence supporting the development and implementation of interventions to achieve national targets, with emphasis on female youths who undergo special transitions in education, occupation, and lifestyle., (© 2023 The Authors. Annals of the New York Academy of Sciences published by Wiley Periodicals LLC on behalf of New York Academy of Sciences.)

Unhealthy eating habits are common among adolescents in Vietnam, where transitioning food environments increasingly offer energy-dense micronutrient-poor foods. Successful behavior change approaches must be feasible and acceptable, promoting local foods that are available, accessible, and preferred. Yet, few studies have investigated the potential of food-based approaches for adolescents. We used linear programming to identify problem nutrients, local nutrient sources, and realistic food-based recommendations (FBRs) to improve nutrient intake among girls 16-22 years in Thai Nguyen, Vietnam. We then identified a reduced set of FBRs to prioritize the most critical micronutrient gaps. Calcium and iron targets could not be met in any realistic diet modeling scenario. The best set of FBRs included seven recommendations which could meet intake targets for 9 of 11 modeled micronutrients. The best reduced set of three FBRs targeting iron and calcium only-although more feasible for behavior change-was less effective at improving intake of these nutrients since fewer foods were recommended. Given the difficulty of meeting calcium and iron targets using local foods within acceptable dietary patterns, additional interventions, such as supplementation, staple food fortification, or increasing the availability of affordable calcium- and iron-rich foods, may be necessary to promote dietary adequacy for adolescent girls., (© 2023 The Authors. Annals of the New York Academy of Sciences published by Wiley Periodicals LLC on behalf of New York Academy of Sciences.)

Background: Important gaps exist in the dietary intake of adolescents in low- and middle-income countries (LMICs), partly due to expensive assessment methods and inaccuracy in portion-size estimation. Dietary assessment tools leveraging mobile technologies exist but only a few have been validated in LMICs., Objective: We validated Food Recognition Assistance and Nudging Insights (FRANI), a mobile artificial intelligence (AI) dietary assessment application in adolescent females aged 12-18 y (n = 36) in Ghana, against weighed records (WR), and multipass 24-hour recalls (24HR)., Methods: Dietary intake was assessed during 3 nonconsecutive days using FRANI, WRs, and 24HRs. Equivalence of nutrient intake was tested using mixed-effect models adjusted for repeated measures, by comparing ratios (FRANI/WR and 24HR/WR) with equivalence margins at 10%, 15%, and 20% error bounds. Agreement between methods was assessed using the concordance correlation coefficient (CCC)., Results: Equivalence for FRANI and WR was determined at the 10% bound for energy intake, 15% for 5 nutrients (iron, zinc, folate, niacin, and vitamin B6), and 20% for protein, calcium, riboflavin, and thiamine intakes. Comparisons between 24HR and WR estimated equivalence at the 20% bound for energy, carbohydrate, fiber, calcium, thiamine, and vitamin A intakes. The CCCs by nutrient between FRANI and WR ranged between 0.30 and 0.68, which was similar for CCC between 24HR and WR (ranging between 0.38 and 0.67). Comparisons of food consumption episodes from FRANI and WR found 31% omission and 16% intrusion errors. Omission and intrusion errors were lower when comparing 24HR with WR (21% and 13%, respectively)., Conclusions: FRANI AI-assisted dietary assessment could accurately estimate nutrient intake in adolescent females compared with WR in urban Ghana. FRANI estimates were at least as accurate as those provided through 24HR. Further improvements in food recognition and portion estimation in FRANI could reduce errors and improve overall nutrient intake estimations., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: There is limited evidence from prospective cohorts in low-resource settings on the long-term impact of pre-pregnancy body mass index (PPBMI) and gestational weight gain (GWG) on postpartum weight retention (PPWR) and maternal and child body composition., Objectives: We examined the associations between PPBMI and timing of GWG on PPWR at 1, 2, and 6-7 years and maternal and child percent body fat at 6-7 years., Methods: We used data from the PRECONCEPT study (NCT01665378) that included prospectively collected data on 864 mother-child pairs from preconception through 6-7 years postpartum. The key outcomes were PPWR at 1, 2, and 6-7 years, and maternal and child percent body fat at 6-7 years that was measured using bioelectric impedance. Maternal conditional GWG (CGWG) was defined as window-specific weight gains (< 20wk, 21-29wk, and  ≥ 30wk), uncorrelated with PPBMI and all prior body weights. PPBMI and CGWG were calculated as standardized z-scores to allow for relative comparisons of a 1 standard deviation (SD) increase in weight gain for each window. We used multivariable linear regressions to examine the associations, adjusting for baseline demographic characteristics, intervention, breastfeeding practices, diet and physical activity., Results: Mean (SD) PPBMI and GWG were 19.7 (2.1) kg/m 2 and 10.2 (4.0) kg, respectively. Average PPWR at 1, 2, and 6-7 years was 1.1, 1.5 and 4.3 kg, respectively. A one SD increase in PPBMI was associated with a decrease in PPWR at 1 year (β [95% CI]: -0.21 [-0.37, -0.04]) and 2 years (-0.20 [-0.39, -0.01]); while a one SD in total CGWG was associated with an increase in PPWR at 1 year (1.01 [0.85,1.18]), 2 years (0.95 [0.76, 1.15]) and 6-7 years (1.05 [0.76, 1.34]). Early CGWG (< 20 weeks) had the greatest association with PPWR at each time point as well as with maternal (0.67 [0.07, 0.87]) and child (0.42 [0.15, 0.69]) percent body fat at 6-7 years., Conclusion: Maternal nutrition before and during pregnancy may have long-term implications for PPWR and body composition. Interventions should consider targeting women preconception and early in pregnancy to optimize maternal and child health outcomes., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Young, Nguyen, Tran, Khuong, Hendrix, Martorell and Ramakrishnan.)

Background: The long-term association between preconception maternal hemoglobin (Hb) concentrations and child health and development is unclear., Objectives: We examined associations between maternal preconception Hb concentrations and anemia with 1) birth outcomes (weight, length, preterm, gestational age, small for gestational age); 2) child Hb at 3 mo, 6 mo, 12 mo, and 24 mo; and 3) motor and mental development at 12 mo and 24 mo (Bayley scales for infant development) and cognitive functioning at 6-7 y (Wechsler Intelligence Scale for Children)., Methods: We used data from a randomized controlled trial (PRECONCEPT) conducted in Vietnam. Over 5000 women who were intending to conceive were recruited, and offspring were prospectively followed from birth (n = 1599) through 6-7 y (n = 1318). Multivariable linear and logistic regressions were used to assess the association between preconception Hb or anemia (Hb < 12g/dL) on child health and development outcomes, adjusted by supplementation group (tested for interactions) and confounding at maternal, child, and household levels., Results: At preconception enrollment, 20% of the women were anemic. Maternal preconception Hb was positively associated with child Hb at 3 mo (0.06; 95% CI: 0.01, 0.12), 6 mo (0.08; 95% CI: 0.03, 0.13), 12 mo (0.10; 95% CI: 0.04, 0.15), and 24 mo (0.07; 95% CI: 0.02, 0.12). Likewise, maternal preconception Hb was associated with reduced risk of child anemia at 6 mo (0.89; 95% CI: 0.81, 0.98), 12 mo (0.81; 95% CI: 0.74, 0.89), and 24 mo (0.87; 95% CI: 0.79, 0.95). Maternal preconception anemia was negatively associated with cognition (-1.64; 95% CI: -3.09, -0.19) and language development (-1.61; 95% CI: -3.20, -0.03) at 24 mo. Preconception Hb was not associated with birth outcomes or cognitive outcomes at 6-7 y., Conclusions: Maternal preconception Hb was associated with child Hb across the first 1000 d of life. However, preconception Hb was not a significant predictor of birth outcomes or cognitive outcomes at 6-7 y in this cohort from Vietnam., Clinical Trial Registration: PRECONCEPT study (NCT: 01665378)., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The role of changes in maternal hemoglobin (Hb) across pregnancy on child health and development (CHD) remains unclear., Objective: We examined the association between maternal Hb trajectories and CHD outcomes: (a) birth outcomes (birth weight, length, gestational age, preterm, and small for gestational age); (b) child Hb at 3, 6, 12, and 24 months; and (c) motor and mental development at 12 and 24 months and cognitive functioning at age 6-7 years., Methods: We used data from a randomized controlled trial (PRECONCEPT) conducted in Vietnam ( N = 1,175 women enrolled during preconception with offspring follow-up through 6-7 years). Maternal Hb trajectories were developed using latent class analysis with Hb data at preconception, early (≤20 weeks), mid (21-29 weeks), and late (≥30 weeks) pregnancy. Multivariable linear and logistic regression models were used to assess the association between maternal Hb trajectories on CHD outcomes, adjusting for confounding variables at the maternal, child and household levels., Results: Four distinct maternal Hb trajectories were identified. Track 1 (low initial Hb-decline) was associated with lower child Hb at 3 months (β [95% CI] -0.52 [-0.87, -0.16]), 6 months (-0.36 [-0.68, -0.05]), 12 months (-0.46 [-0.79, -0.13]), and 24 months (-0.44 [-0.72, -0.15]) and motor development at 12 months (-3.58 [-6.76, -0.40]) compared to track 4 (high initial Hb-decline). After adjustment for multiple testing, relationships remained robust with the exception of associations with child Hb at 6 months and motor development at 12 months. Track 2 (low initial Hb-improve) was the only Hb trajectory to increase across pregnancy; however, it was insufficiently powered. Track 3 (mid Hb-decline) was associated with lower child Hb at 12 months (-0.27 [-0.44, -0.10]) and 24 months (-0.20 [-0.34, -0.05]) compared to track 4 (high initial Hb-decline). Maternal Hb trajectories were not associated with birth outcomes or child development at 24 months or 6-7 years., Conclusion: Maternal Hb trajectories during pregnancy are associated with child Hb concentrations across the first 1,000 days, but not with birth outcomes or later cognitive functioning. More work is needed to better understand and interpret changes in Hb levels during pregnancy especially in resource poor settings., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Young, Nguyen, Tran, Khuong, Tandon, Martorell and Ramakrishnan.)

Background: Inequity in child development is found at early age, but limited evidence exists on whether these gaps change over time and what are the mediators., Objective: We aim to (1) quantify wealth related gaps in cognitive and socio-emotional development in early and middle childhood; (2) examine how these gaps were mitigated by maternal, child factors and home environment., Methods: We assessed the offspring of women who participated in a randomized controlled trial of preconception micronutrient supplementation in Vietnam (n = 1599). Child development was measured by the Bayley Scales of Infant Development-III (at 1-2y) and the Wechsler Intelligence Scale for Children®-IV (at 6-7y). We used multivariable regression to estimate the changes in wealth gaps for child development over time, adjusting for potential factors that potentially influence cognitive development., Results: We found significant wealth gaps in cognitive development during early childhood (gaps between top and bottom quintiles: 0.5 SD); these gaps increased substantially in middle childhood (0.9 SD). Wealth disparity in social emotion did not change over time (0.26-0.28 SD). Maternal factors, quality of home environment, and child nutritional status mitigated the wealth gap in cognitive development (7-42%) in early childhood. The contribution of these mitigating factors was smaller in middle childhood (2- 15%). Wealth gap in social emotion reduced by 13% and 43% among children with better nutritional status at 2y and higher quality of home environment at 6-7y, respectively., Conclusion: Interventions focusing on improving quality of home environment, maternal education, wellbeing, and child nutrition status may help reduce developmental deficits associated with poverty., (© 2023. The Author(s).)

Unhealthy diets are a critical global concern while dietary measure methods are time consuming and expensive. There is limited evidence that phone-based interventions can improve nutrition data collection and dietary quality, especially for adolescents in developing countries. We developed an artificial-intelligence-based phone application called Food Recognition Assistance and Nudging Insights (FRANI) to address these problems. FRANI can recognize foods in images, track food consumption, display statistics and use gamified nudges to give positive feedback on healthy food choice. This study protocol describes the design of new pilot studies aimed at measuring the feasibility (acceptability, adherence, and usability) of FRANI and its effects on the quality of food choice of adolescents in Ghana and Vietnam. In each country, 36 adolescents (12-18 years) will be randomly allocated into two groups: The intervention group with the full version of FRANI and the control group with the functionality limited to image recognition and dietary assessment. Participants in both groups will have their food choices tracked for four weeks. The control groups will then switch to the full version of FRANI and both groups will be tracked for a further 2 weeks to assess acceptability, adherence, and usability. Analysis of outcomes will be by intent to treat and differences in outcomes between intervention and control group will use Poisson and odds ratio regression models, accounting for repeated measures at individual levels. If deemed feasible, acceptable and usable, FRANI will address gaps in the literature and advance the nutrition field by potentially improving the quality of food choices of adolescent girls in developing countries. This pilot study will also provide insights on the design of a large randomized controlled trial. The functioning and dissemination of FRANI can be an important step towards highly scalable nutrition data collection and healthier food choices for a population at risk of malnutrition. The study protocol and the methods and materials were approved by the Institutional Review Board (IRB) of the IFPRI on April 29th, 2020 (registration number #00007490), the Thai Nguyen National Hospital on April 14th, 2020 (protocol code 274/ĐĐĐ-BVTWTN) and the University of Ghana on August 10th, 2020 (Federalwide Assurance FWA 00001824; NMIMR-IRB CPN 078-19/20). The study protocol was registered in the International Standard Randomized Controlled Trial Number (ISRCTN 10681553; https://doi.org/10.1186/ISRCTN10681553) on November 12, 2021., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2022 Braga, Arrieta, Bannerman, Doyle, Folson, Gangupantulu, Hoang, Huynh, Koch, McCloskey, Tran, Tran, Truong, Nguyen, Hughes and Gelli.)

Background: There is a gap in data on dietary intake of adolescents in low- and middle-income countries (LMICs). Traditional methods for dietary assessment are resource intensive and lack accuracy with regard to portion-size estimation. Technology-assisted dietary assessment tools have been proposed but few have been validated for feasibility of use in LMICs., Objectives: We assessed the relative validity of FRANI (Food Recognition Assistance and Nudging Insights), a mobile artificial intelligence (AI) application for dietary assessment in adolescent females (n = 36) aged 12-18 y in Vietnam, against a weighed records (WR) standard and compared FRANI performance with a multi-pass 24-h recall (24HR)., Methods: Dietary intake was assessed using 3 methods: FRANI, WR, and 24HRs undertaken on 3 nonconsecutive days. Equivalence of nutrient intakes was tested using mixed-effects models adjusting for repeated measures, using 10%, 15%, and 20% bounds. The concordance correlation coefficient (CCC) was used to assess the agreement between methods. Sources of errors were identified for memory and portion-size estimation bias., Results: Equivalence between the FRANI app and WR was determined at the 10% bound for energy, protein, and fat and 4 nutrients (iron, riboflavin, vitamin B-6, and zinc), and at 15% and 20% bounds for carbohydrate, calcium, vitamin C, thiamin, niacin, and folate. Similar results were observed for differences between 24HRs and WR with a 20% equivalent bound for all nutrients except for vitamin A. The CCCs between FRANI and WR (0.60, 0.81) were slightly lower between 24HRs and WR (0.70, 0.89) for energy and most nutrients. Memory error (food omissions or intrusions) was ∼21%, with no clear pattern apparent on portion-size estimation bias for foods., Conclusions: AI-assisted dietary assessment and 24HRs accurately estimate nutrient intake in adolescent females when compared with WR. Errors could be reduced with further improvements in AI-assisted food recognition and portion estimation., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Background: To address gaps in coverage and quality of nutrition services, Alive & Thrive (A&T) strengthened the delivery of maternal nutrition interventions through government antenatal care (ANC) services in Uttar Pradesh, India. The impact evaluation of the A&T interventions compared intensive ANC (I-ANC) with standard ANC (S-ANC) areas and found modest impacts on micronutrient supplementation, dietary diversity, and weight-gain monitoring., Objectives: This study examined intervention-specific program impact pathways (PIPs) and identified reasons for limited impacts of the A&T maternal nutrition intervention package., Methods: We used mixed methods: frontline worker (FLW) surveys (n = ∼500), counseling observations (n = 407), and qualitative in-depth interviews with FLWs, supervisors, and block-level staff (n = 59). We assessed 7 PIP domains: training and materials, knowledge, supportive supervision, supply chains, data use, service delivery, and counseling., Results: Exposure to training improved in both I-ANC and S-ANC areas with more job aids used in I-ANC compared with S-ANC (90% compared with 70%), but gaps remained for training content and refresher trainings. FLWs' knowledge improvement was higher in I-ANC than S-ANC (22-36 percentage points), but knowledge of micronutrient supplement benefits and recommended foods was insufficient (<50%). Most FLWs received supervision (>90%), but supportive supervision was limited by staff vacancies and competing work priorities. Supplies of iron-folic acid and calcium supplements were low in both areas (30-50% stock-outs). Use of monitoring data during review meetings was higher in I-ANC than S-ANC (52% compared with 36%) but was constrained by time, understanding, and data quality. Service provision improved in both I-ANC and S-ANC areas, but counseling on supplement benefits and weight-gain monitoring was low (30-40%)., Conclusions: Systems-strengthening efforts improved maternal nutrition interventions in ANC, but gaps remained. Taking an intervention-specific perspective to the PIP analysis in this package of services was critical to understand how common and specific barriers influenced overall program impact., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Global success case analyses have identified factors supporting reductions in stunting across countries; less is known about successes at the subnational levels. We studied four states in India, assessing contributors to reductions in stunting between 2006 and 2016. Using public datasets, literature review, policy analyses and stakeholder interviews, we interpreted changes in the context of policies, programs and enabling environment. Primary contributors to stunting reduction were improvements in coverage of health and nutrition interventions (ranged between 11 to 23% among different states), household conditions (22-47%), and maternal factors (15-30%). Political and bureaucratic leadership engaged civil society and development partners facilitated change. Policy and program actions to address the multidimensional determinants of stunting reduction occur in sectors addressing poverty, food security, education, health services and nutrition programs. Therefore, for stunting reduction, focus should be on implementing multisectoral actions with equity, quality, and intensity with assured convergence on the same geographies and households., Supplementary Information: The online version contains supplementary material available at 10.1007/s12571-021-01252-x., Competing Interests: Conflicts of interestThe authors have no relevant financial or non-financial interests to disclose., (© The Author(s) 2022.)

Suboptimal dietary intake is a critical cause of poor maternal nutrition, with several adverse consequences both for mothers and for their children. This study aimed to (1) assess maternal dietary patterns in India; (2) examine enablers and barriers in adopting recommended diets; (3) review current policy and program strategies to improve dietary intakes. We used mixed methods, including empirical analysis, compiling data from available national and subnational surveys, and reviewing literature, policy, and program strategies. Diets among pregnant women are characterized by low energy, macronutrient imbalance, and inadequate micronutrient intake. Supply- and demand-side constraints to healthy diets include food unavailability, poor economic situation, low exposure to nutrition counselling, food restrictions and taboos, adverse family influence and gender norms, and gaps in knowledge. Intervention strategies with potential to improve maternal diets include food-based programs, behavior change communication, and nutrition-sensitive agriculture interventions. However, strategies face implementation bottlenecks and limited effectiveness in real-world at-scale impact evaluations. In conclusion, investments in systems approaches spanning health, nutrition, and agriculture sectors, with evaluation frameworks at subnational levels, are needed to promote healthy diets for women.

Background: Millions of children fail to meet their developmental potential and experience mental health concerns globally. Evidence is mixed on whether growth beyond the first 1000 d of life influences intellectual functioning and mental health in school-age children., Objectives: We examined associations of childhood growth before and after the first 1000 d of life with child intellectual functioning and mental health at age 6-7 y., Methods: We used data from a follow-up of a randomized controlled trial of preconception supplementation (PRECONCEPT study) in Vietnam. A total of 5011 women participated in the study and 1579 children were born during 2012-2014. At age 6-7 y, child intellectual functioning was assessed using the Wechsler Intelligence Scale for Children, and mental health concerns were measured using the Strengths and Difficulties Questionnaire. Multivariable linear models were used to examine the independent association of child size at age 2 y [height-for-age z-score (HAZ) and body-mass-index z-score (BMIZ)] and conditional measures of linear and ponderal growth between the ages of 2 and 7 y., Results: HAZ at 2 y was positively associated with the Full-Scale Intelligence Quotient (β = 1.4; 95% CI: 0.5, 2.2 points) and its subdomains, namely Perceptual Reasoning Index, Working Memory Index, and Processing Speed Index (β = 1.0-1.4 points). Higher HAZ at 2 y was associated with lower overall mental health concerns (β = -0.24; 95% CI: -0.47, -0.01) and peer problems (β = -0.08; 95% CI: -0.17, -0.01). Faster height gain between 2 and 7 y was associated with higher total intellectual functioning (β = 0.9; 95% CI: 0.02, 1.8) and fewer emotional issues (β = -0.09; 95% CI: -0.18, -0.01). BMIZ at 2 y was not associated with intellectual functioning but was marginally associated with higher conduct and peer problems. Conditional weight gain between 2 and 7 y was not associated with child intellectual functioning or mental health in young school-age children., Conclusions: Child linear growth both during and beyond the first 1000 d is positively associated with intellectual functioning and mental health during the early school-age years., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Gender disparities in child undernutrition and mortality in India have been a topic of interest for a long time, but little is known on trends or geographic variability in recent periods. We examined the degree to which historic patterns in gender disparities in child undernutrition and mortality in India have persisted given recent progress in health and nutrition. Using two nationally representative datasets from India between 2006 and 2016, we estimated mortality rates and stunting by gender and by birth order among children under 5 years old. We then tested for differences between boys and girls within each survey round for both national and state levels using bootstrapped standard errors, controlling for cluster and sampling weights. We found striking progress in child mortality and stunting in India between 2006 and 2016 for both boys and girls. Boys were more likely to die than girls during the first year of life. Girls had a higher risk of mortality between age 1 and 5 years than boys in 2006, but the improvements in survival eliminated this gender gap in 2016. For stunting, we found no gender difference in 2006, but girls had higher height-for-age Z-scores (HAZ) and lower stunting than boys in 2016. Trends in gender gaps in mortality and stunting vary substantially by birth order and between states. Our findings indicate that improvements in mortality and nutritional status among girls have started to close gender disparities. Policy efforts to close gaps must stay the course in states that have made progress and be accelerated in states where disparities are still prominent., (© 2021 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Background: Growth faltering is associated with adverse consequences during childhood and later life. However, questions remain on the relative importance of preconception maternal nutritional status (PMNS) and child growth during the first 1000 d of life., Objectives: We examined associations between PMNS, gestational weight gain (GWG), and child growth during the first 1000 d with attained body size at age 6-7 y., Methods: We used data from a follow-up of a double-blinded randomized controlled trial of preconception micronutrient supplementation in Vietnam (n = 5011 women). The outcomes included offspring height-for-age z score (HAZ), BMI-for-age z score (BMIZ), and prevalence of stunting and overweight/obese at age 6-7 y (n = 1579). We used multivariable linear and Poisson regression models to evaluate the relative contributions of PMNS (height and BMI), GWG, and conditional growth in 4 periods: fetal, 0-6 mo, 6-12 mo, and 12-24 mo., Results: PMNS was positively associated with child-attained size at 6-7 y. For each 1-SD higher maternal height and BMI, offspring had 0.28-SD and 0.13-SD higher HAZ at 6-7 y, respectively. Higher maternal BMI and GWG were associated with larger child BMIZ (β: 0.29 and 0.10, respectively). Faster linear growth, especially from 6 to 24 mo, had the strongest association with child HAZ at 6-7 y (β: 0.39-0.42), whereas conditional weight measures in all periods were similarly associated with HAZ (β: 0.10-0.15). For BMIZ at 6-7 y, the magnitude of association was larger and increased with child age for conditional weight gain (β: 0.21-0.41) but smaller for conditional length gain. Faster growth in the first 2 y was associated with reduced risk of stunting and thinness but increased risk of overweight/obese at 6-7 y., Conclusions: Interventions aimed at improving child growth while minimizing the risk of overweight during the school age years should target both women of reproductive age prior to conception through delivery and their offspring during the first 1000 d. The trial was registered at clinicaltrials.gov as NCT01665378., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Background: Although there is growing evidence on the role of preconception nutrition for birth outcomes, very few studies have evaluated the long-term effects of nutrition interventions during the preconception period on offspring cognitive outcomes., Objective: We evaluate the impact of preconception weekly multiple micronutrients (MMs) or iron and folic acid (IFA) supplementation compared with folic acid (FA) alone on offspring intellectual functioning at age 6-7 y., Methods: We followed 1599 offspring born to women who participated in a double-blinded randomized controlled trial of preconception supplementation in Vietnam. Women received weekly supplements containing either 2800 μg FA only, 60 mg iron and 2800 μg FA, or MMs (15 micronutrients including IFA) from baseline until conception, followed by daily prenatal IFA supplements until delivery. We used the Wechsler Intelligence Scale for Children to measure full-scale IQ (FSIQ) and 4 related domains of intellectual functioning [Verbal Comprehension Index (VCI), Perceptual Reasoning Index (PRI), Working Memory Index (WMI), and Processing Speed Index (PSI) scores] at 6-7 y. Group comparisons were done using ANOVA tests for all children and the subgroup born to women who consumed the supplements ≥26 wk before conception (per-protocol analyses)., Results: The final sample with data at 6-7 y (n = 1321) was similar for baseline maternal and offspring birth characteristics and age at follow-up by treatment group. Compared with the offspring in the FA group, those in the MM group had higher FSIQ (β = 1.7; 95% CI: 0.1, 3.3), WMI (β = 1.7; 95% CI: 0.2, 3.2), and PSI (β = 2.5; 95% CI: 0.9, 4.1). Similar findings were observed in the per-protocol analyses. There were no significant differences by treatment group for VCI and PRI., Conclusions: Preconception supplementation with MMs improved certain domains of intellectual functioning at age 6-7 y compared with FA. These findings suggest the potential for preconception micronutrient interventions to have long-term benefits for offspring cognition., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Rapid urban expansion has important health implications. This study examines trends and inequalities in undernutrition and overnutrition by gender, residence (rural, urban slum, urban non-slum), and wealth among children and adults in India. We used National Family Health Survey data from 2006 and 2016 (n = 311,182 children 0-5y and 972,192 adults 15-54y in total). We calculated differences, slope index of inequality (SII) and concentration index to examine changes over time and inequalities in outcomes by gender, residence, and wealth quintile. Between 2006 and 2016, child stunting prevalence dropped from 48% to 38%, with no gender differences in trends, whereas child overweight/obesity remained at ~7-8%. In both years, stunting prevalence was higher in rural and urban slum households compared to urban non-slum households. Within-residence, wealth inequalities were large for stunting (SII: -33 to -19 percentage points, pp) and declined over time only in urban non-slum households. Among adults, underweight prevalence decreased by ~13 pp but overweight/obesity doubled (10% to 21%) between 2006 and 2016. Rises in overweight/obesity among women were greater in rural and urban slum than urban non-slum households. Within-residence, wealth inequalities were large for both underweight (SII -35 to -12pp) and overweight/obesity (+16 to +29pp) for adults, with the former being more concentrated among poorer households and the latter among wealthier households. In conclusion, India experienced a rapid decline in child and adult undernutrition between 2006 and 2016 across genders and areas of residence. Of great concern, however, is the doubling of adult overweight/obesity in all areas during this period and the rise in wealth inequalities in both rural and urban slum households. With the second largest urban population globally, India needs to aggressively tackle the multiple burdens of malnutrition, especially among rural and urban slum households and develop actions to maintain trends in undernutrition reduction without exacerbating the rapidly rising problems of overweight/obesity., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Existing health and community nutrition systems have the potential to deliver many nutrition interventions. However, the coverage of nutrition interventions across the delivery platforms of these systems has not been uniform. We (1) examined the opportunity gaps between delivery platforms and corresponding nutrition interventions through the continuum of care in India between 2006 and 2016 and and (2) assessed inequalities in these opportunity gaps., Methods: We used two rounds of the National Family Health Survey data from 2005 to 2006 and 2015-2016 (n=36 850 and 190 898 mother-child dyads, respectively). We examine the opportunity gaps over time for seven nutrition interventions and their associated delivery platforms at national and state levels. We assessed equality and changes in equality between 2006 and 2016 for opportunity gaps by education, residence, socioeconomic status (SES), public and private platforms., Results: Coverage of nutrition interventions was consistently lower than the reach of their associated delivery platforms; opportunity gaps ranging from 9 to 32 percentage points (pp) during the pregnancy, 17 pp during delivery and 9-26 pp during childhood in 2006. Between 2006 and 2016, coverage improved for most indicators, but coverage increases for nutrition interventions was lower than for associated delivery platforms. The opportunity gaps were larger among women with higher education (22-57 pp in 2016), higher SES status and living in urban areas (23-57 pp), despite higher coverage of most interventions and the delivery platforms among these groups. Opportunity gaps vary tremendously by state with the highest gaps observed in Tripura, Andaman and Nicobar islands, and Punjab for different indicators., Conclusions: India's progress in coverage of health and nutrition interventions in the last decade is promising, but both opportunity and equality gaps remained. It is critical to close these gaps by addressing policy and programmatic delivery systems bottlenecks to achieve universal coverage for both health and nutrition within the delivery system., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Exposure to intimate partner violence (IPV) can have profound adverse consequences on maternal and child health. This study aimed to: (1) identify factors associated with IPV during pregnancy and postpartum in Bangladesh; and (2) assess the associations between IPV and maternal mental health and breastfeeding practices. We used data from a cross-sectional survey of 2000 mothers with children <6 months in four districts in Bangladesh. We applied multivariable logistic regression models to examine factors associated with IPV and structural equation modelling to assess the inter-relationships between IPV, maternal common mental disorders (CMD, measured by Self-reporting Questionnaire ≥7) and breastfeeding practices. Overall, 49.7% of mothers experienced violence during the last 12 months and 28% of mothers had high levels of CMD. Only 54% of women reported early initiation of breastfeeding and 64% reported exclusive breastfeeding. Women were more likely to experience IPV if living in food-insecure households, being of low socio-economic status, having low autonomy or experiencing inequality in education compared with husbands (OR ranged from 1.6 to 2.8). Women exposed to IPV were 2-2.3 times more likely to suffer from high levels of CMD and 28-34% less likely to breastfeed their babies exclusively. The indirect path (the indirect effects of IPV on breastfeeding through CMD) through maternal CMD accounted for 14% of the relationship between IPV on breastfeeding practice. In conclusion, IPV is pervasive in Bangladesh and is linked to increased risks of CMD and poor breastfeeding practices. Integrating effective interventions to mitigate IPV, along with routine maternal and child health services and involving men in counselling services, could help both to reduce exposure to IPV among women and to contribute to better health outcomes for women and children., (© The Author(s) 2020. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Limited evidence exists on the complex relationship among interventions, early initiation of breastfeeding (EIBF), prelacteal feeding and exclusive breastfeeding (EBF). We examined whether early breastfeeding practices are associated with EBF and how much improving EIBF and non-prelacteal feeding contributes to increased prevalence of EBF. Survey data were collected in 2010 and 2014 as part of impact evaluations of Alive & Thrive (A&T) interventions to improve infant and young child feeding (IYCF) practices in Bangladesh, Vietnam and Ethiopia. Multivariable logistic regression analyses were used to examine effects of interventions and early breastfeeding practices on EBF. Structural equation modelling quantified the direct and indirect effects of interventions (via improving EIBF and non-prelacteal feeding) on EBF. Although breastfeeding is nearly universal in all three countries (≥98%), delayed initiation of breastfeeding is prevalent (>60%) and prelacteal feeding is common. EIBF alone was not associated with EBF, whereas non-prelacteal feeding was associated with 1.6-3.5 higher odds of EBF. Intervention exposure affected breastfeeding practices in all three countries; these impacts were amplified among those who practiced EIBF or non-prelacteal feeding [odds ratio (OR) = 11 and 27.5 in Bangladesh and 6.5 and 11.5 in Vietnam, respectively]. The paths through EIBF and non-prelacteal feeding explained 13%-18% of the effect of the interventions on EBF. Early breastfeeding practices influence EBF, but interventions aimed only at the initiation and early days of breastfeeding will be inadequate to promote EBF. Social and behaviour change interventions should simultaneously target EIBF, non-prelacteal feeding and EBF to support optimal breastfeeding practices., (© 2020 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Background: India is facing a dual burden of undernutrition and overweight/obesity, and there are gaps in our understanding of the driving factors over time., Objective: This study examined the national and state trends for BMI and identified the determinants of underweight and overweight/obesity among adolescent girls and women., Methods: We used India's National Family Health Surveys data collected in 2005-2006 (n = 110,887) and 2015-2016 (n = 645,193). We applied multiple regression and decomposition analysis to assess determinants of underweight (BMI z score <  -1 SD; <18.5 kg/m2) and overweight/obesity (BMI z score >1 SD; ≥25 kg/m2)., Results: Over the past decade, the prevalence of underweight decreased (43% to 38% and 33% to 19%) and the prevalence of overweight/obesity increased (3% to 5% and 15% to 24%), among adolescents and women, respectively, with high heterogeneity across states. Factors associated with a lower prevalence of underweight among women included higher socioeconomic status (SES) (OR: 0.35; 95% CI: 0.31, 0.41), urban residence (OR: 0.49; 95% CI: 0.45, 0.54), improved diet diversity (OR: 0.75; 95% CI: 0.69, 0.82), and latrine use (OR: 0.76; 95% CI: 0.70, 0.82). Higher education levels, decision-making, and ownership of money were also associated with a lower prevalence of underweight. Factors positively associated with overweight/obesity among women included SES (OR: 3.24; 95% CI: 2.81, 3.73), urban residence (OR: 2.23; 95% CI: 2.05, 2.42), diet diversity (OR: 1.21; 95% CI: 1.10, 1.32), latrine use (OR: 1.31; 95% CI: 1.21, 1.43), and education (OR: 1.39; 95% CI: 1.24, 1.55). Adolescents shared similar determinants to women. Overall, SES was a key driver of changes in women's BMI, explaining 29% of the reduction in undernutrition and 46% of the increase in overweight/obesity., Conclusions: Despite overall declines, regional and age disparities remain in the overall burden of underweight and the increases in overweight/obesity are concerning. The identified divergent risk factors (SES, residence, diet, education) highlight that simply improving economic status will not ensure healthy BMI status for women and girls. Balanced multidisciplinary approaches are needed to address both undernutrition and overweight., (Copyright © The Author(s) 2019.)

Background: Social and behavior change communication interventions are integral to improving dietary and care practices, but evidence on the impact of the combination and intensity of these interventions in different contexts is scarce., Objectives: We examined the extent of and factors associated with intervention exposure: interpersonal communication (IPC) alone or with other interventions (i.e., mass media, community mobilization, or nutrition-sensitive agricultural activities), number of and factors associated with IPC contacts, and combinations of intervention components and number of contacts associated with infant and young child feeding (IYCF) practices., Methods: We used endline survey data from impact evaluations in Bangladesh, Ethiopia, and Vietnam ( n  = 1001, 1720, and 1001 mothers with children aged <2 y, respectively). Multivariable regression models were used for analyses., Results: Exposure to the interventions varied in all 3 countries. On average, mothers received 8 visits in the last 6 mo in Bangladesh, 2 visits in the last 3 mo in Ethiopia, and 1 visit in the last 6 mo in Vietnam. Across countries, the factors associated with intervention exposure and number of IPC contacts differed. In Ethiopia, exposure to IPC with other interventions was associated with higher odds of achieving minimum meal frequency (OR: 1.6), minimum dietary diversity (OR: 1.8), and consumption of iron-rich foods (OR: 4.7). In Vietnam, exposure to IPC alone or with mass media was associated with higher odds of exclusive breastfeeding (EBF; OR: 2.8-3.7). Near-monthly visits were associated with 2-3 times higher odds of IYCF practices in Bangladesh and Ethiopia. In Vietnam, even 1 IPC visit was associated with 2 times higher odds of EBF., Conclusions: Exposure matters for impact, but the combination of behavior change interventions and number of IPC contacts required to support IYCF behavior change are context specific. This trial was registered at www.clinicaltrials.gov as NCT01678716 (Bangladesh), NCT02775552 (Ethiopia), and NCT01676623 (Vietnam)., (Copyright © The Author(s) 2019.)

Background: The Minimum Dietary Diversity for Women (MMD-W) was validated as a proxy of micronutrient adequacy for nonpregnant women, with proposed data collection being either a list-based or a qualitative open recall method. Few studies have compared the performance of these 2 methods., Objectives: We compared performance in predicting micronutrient adequacy of food group indicators (FGIs) measured by the list-based and the quantitative open recall methods using varying quantity cut-offs. We also examined the agreement between list-based and open recall FGIs., Methods: Data were collected in Bangladesh ( n  = 600 pregnant women) and India ( n  = 655). The performance of different indicators to predict micronutrient adequacy was compared using receiver operating characteristic (ROC) analysis. Correlations between list-based and open recall FGIs were calculated using Spearman's rank test; agreement was assessed by the intraclass correlation coefficient (ICC) and kappa statistics. Food groups that were most often misreported by the list-based method were identified., Results: There were no statistically significant differences in ROC curves between list-based and open recall FGIs in either country. In Bangladesh, correlations between list-based and open recall FGIs varied between 0.6 and 0.8; ICC values were 0.43-0.75; kappa values were 0.51-0.53 when using a cut-off of any quantity or 15 g for open recall, but were lower (k = 0.24) with the cut-off of 1 portion. In India, these values were lower: ∼0.4 for correlation, 0.32-0.37 for ICCs, and 0.17-0.22 for kappas. Food groups most susceptible to misreporting using the list-based method were beans/peas in Bangladesh and other vegetables in India., Conclusions: Our study provides initial support for the use of list-based questionnaires in assessing food group diversity or prevalence of MDD-W in pregnant women. Additional and context-specific work may be required to understand the potential of simple methodologies to assess consumption of specific food groups. This trial was registered at clinicaltrials.gov as NCT02745249 (Bangladesh) and NCT03378141 (India)., (Copyright © The Author(s) 2019.)

Background: Interaction within mothers' social networks can theoretically diffuse messages from interventions and campaigns into norms and practices for infant and young child feeding (IYCF)., Objectives: We hypothesized that mothers' social networks, diffusion of information, and social norms differed in intensive [intensive interpersonal counseling (IPC), community mobilization (CM), and mass media (MM)] compared with nonintensive (standard IPC and less-intensive CM and MM) intervention areas, were associated with IYCF practices, and partly explained practice improvement., Methods: We conducted household surveys at endline in 2014 and follow-up in 2016 (n = ∼2000 each round). We used multiple regression to test differences and changes in networks, diffusion, and norms within intervention areas. We analyzed paths from intervention exposure to IYCF practices through networks, diffusion, and norms., Results: Mothers' networks were larger in intensive than in nonintensive areas in 2014 and increased in both areas over time [25-38 percentage points (pp)]. The prevalence of receipt of IYCF information was high, with no changes over time in intensive areas but an increase in nonintensive areas (8-16 pp). In both areas, more family members and health workers provided IYCF information over time. Sharing of information increased 17-23 pp in intensive and 11-41 pp in nonintensive areas over time. Perceived descriptive norms improved 8-16 pp in intensive and 17-28 pp in nonintensive areas. Perceived injunctive norms were high in both areas. Breastfeeding practices were associated with networks, diffusion, and norms (OR: 1.6-4.4 times larger comparing highest with lowest quartile). Minimum dietary diversity was associated with larger networks and diffusion (OR: 1.5-2.2) but not with social norms. Indirect paths from intervention exposure to practices explained 34-78% of total effects., Conclusions: Diffusion of IYCF information through social networks, reinforced by positive social norms for messages promoted over time, will contribute to positive changes in IYCF practices that may be achieved and sustained through large-scale social and behavior change interventions. This trial was registered at clinicaltrials.gov as NCT0274084., (Copyright © American Society for Nutrition 2019.)

Despite strong policy and program commitment, essential maternal nutrition services are not reaching enough women in many countries. This paper examined multifactorial determinants (personal, family, community, and health services) associated with maternal nutrition practices in Uttar Pradesh, India. Data were from a household survey of pregnant (n = 667) and recently delivered women (n = 1,835). Multivariable regression analyses were conducted to examine the determinants of four outcomes: consumption of diverse diets, consumption of iron folic acid (IFA) and calcium tablets, and weight monitoring during pregnancy. Population attributable risk analysis was used to estimate how much the outcomes can be improved under optimal program implementation. During pregnancy, women consumed 28 IFA and 8 calcium tablets, 18% consumed diverse diet, and 17% were weighed ≥3 times. Nutrition knowledge was associated with consumption of diverse diet (odds ratio [OR] = 2.2 times), IFA (2.3 times), calcium (11.7 times), and weight monitoring (1.3 times). Beliefs and self-efficacy were associated with IFA (OR = 2.0) and calcium consumption (OR = 4.6). Family support and adequate health services were also associated with better nutrition practices. Under optimal program implementation, we estimate that 51% of women would have adequate diet diversity, an average consumption of 98 IFA, and 106 calcium tablets, and women would be weighed 4.9 times during pregnancy. Strengthening existing program operations and increasing demand for services has the potential to result in large improvements in maternal nutrition practices from current baseline levels but may not be sufficient to meet World Health Organization-recommended levels without creating an enabling environment including improvements in education and income levels to support behaviour change., (© 2019 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

Background: Frontline health workers (FLWs) are needed for delivering interventions at scale to reduce maternal and child undernutrition, but low- and middle-income countries often face inadequate FLW performance., Objectives: We examined whether and how intervention design elements such as training, supervision, and mass media improved FLW performance in delivering nutrition services., Methods: Survey data were collected in 2010 and 2014 as part of impact evaluations of Alive & Thrive (A&T) interventions to improve infant and young child feeding (IYCF) practices in Bangladesh and Vietnam. FLWs in A&T intensive (A&T-I) areas received specialized IYCF training, job aids, and regular supportive supervision. Those in non-intensive (A&T-NI) areas received standard government training and supervision. There was mass media exposure in both areas. Multiple regression was used to test differences in exposure to intervention design elements and performance outcomes between the 2 program areas. Path analyses were conducted to examine the paths from exposure to performance outcomes measured at FLW and end-user levels., Results: Compared to FLWs in A&T-NI areas, those in A&T-I areas had higher scores in training (by 1.3-3.6 of 10 points), supportive supervision (0.3-3.5 points), and mass media exposure (0.3-3.5 points). These intervention design elements were significantly associated with FLW knowledge and motivation, which in turn improved service delivery. FLW-level performance outcomes contributed to improving end-user-level outcomes such as higher service received (β = 0.12-1.04 in Bangladesh and 0.11-0.96 in Vietnam) and maternal knowledge (β = 0.12-0.17 in Bangladesh and 0.04-0.21 in Vietnam)., Conclusions: Training, supervision, and mass media exposure can be implemented at large scale and contribute to improved FLW service delivery by enhancing knowledge and motivation, which in turn positively influence mother's service utilization and IYCF knowledge. Training, supervision, and mass media to enhance service provision should be considered when designing interventions. This trial was registered at clinicaltrials.gov as NCT01678716 (Bangladesh) and NCT01676623 (Vietnam).

Background: Adolescent pregnancy and child undernutrition are major social and public health concerns. We aimed to examine associations between adolescent pregnancy and child undernutrition in India, where one in five adolescents live, and one in three of the world's stunted children., Methods: Data were from India's fourth National Family Health Survey, 2015-16. Primiparous women aged 15-49 years who gave birth between 2010 and 2016 were classified on the basis of age at first birth: 10-19 years (adolescence), 20-24 years (young adulthood), and 25 years or older (adulthood). Primary outcomes were anthropometric measures of offspring undernutrition. Multivariable regression and structural equation models were used to understand the extent to which these measures were linked to adolescent pregnancy and the potential social, biological, and programmatic pathways., Findings: Of the 60 096 women in the sample, 14 107 (25%) first gave birth during adolescence. Children born to adolescent mothers had lower Z scores for length or height-for-age (mean difference -0·53 SD), weight-for-age (-0·40 SD), and weight-for-length or height (-0·16 SD) than children born to adult mothers. Compared with adult mothers, adolescent mothers were shorter (-1·21 cm, 95% CI -1·78 to -0·65), more likely to be underweight (18 percentage points, 15-21) and anaemic (8 percentage points, 6-11), less likely to access health services (-4 to -15 percentage points), and had poorer complementary feeding practices (-3 to -9 percentage points). Adolescent mothers also had less education (-3·30 years, 95% CI -3·68 to -2·91), less bargaining power (-7 to -15 percentage points), and lived in poorer households (-0·66 SD, 96% CI -0·82 to -0·50) with poorer sanitation (-28 percentage points, -32 to -24). In the path analysis, these intermediate factors predicted child anthropometry, with the strongest links being mother's education (18%), socioeconomic status (13%), and weight (15%)., Interpretation: Children born to adolescent mothers are at risk of being undernourished. Adolescent pregnancy is related to child undernutrition through poor maternal nutritional status, lower education, less health service access, poor complementary feeding practices, and poor living conditions. Policies and programmes to delay pregnancy and promote women's rights could help break the intergenerational cycle of undernutrition through many routes., Funding: Bill & Melinda Gates Foundation through Partnerships and Opportunities to Strengthen and Harmonize Actions for Nutrition in India, led by the International Food Policy Research Institute., (Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Religious fasting often involves abstention from animal source foods (ASFs). Although children are exempt, their diets are influenced by the widespread fasting practices. This study investigated the factors influencing ASF consumption among young children during the Lent fasting period in western Amhara, Ethiopia. We used baseline survey data from households with children 6-23 months of age (n = 2,646). We conducted regression analysis to examine the maternal and household factors associated with ASF consumption and path analysis to examine the direct and indirect effects of maternal knowledge, beliefs, social norms, and livestock ownership on ASF consumption. Only 24% of children consumed any ASF in the previous day-18% dairy products, 5% eggs, and 2% flesh foods. Mothers with high knowledge, beliefs, and social norms about feeding children ASFs during fasting had higher odds (odds ratio: 1.3-1.4) of children who consumed them. Compared with households with no ASFs, those with ASFs available were 4.8 times more likely to have children who consumed them. Most of the association between knowledge, beliefs and social norms, and ASF consumption was explained by pathways operating through ASF availability (approximately 9, 12, and 8 pp higher availability, respectively), which in turn were associated with higher consumption. Cow ownership was directly and indirectly associated with ASF consumption, whereas having chickens was indirectly associated with consumption via the availability pathway. Our findings corroborate the importance of maternal behavioural determinants related to feeding ASFs to children during fasting on ASF consumption via household availability and the positive influence of livestock ownership., (© 2018 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

Limited evidence exists on socio-economic status (SES) inequalities in infant and young child feeding (IYCF) in India. We examine trends and changes in inequalities for IYCF practices over 2006-2016 and identify factors that may explain differences in IYCF across SES groups. We use data from the 2015-2016 and 2005-2006 National Family Health Surveys (n = 112,133 children < 24 months). We constructed SES quintiles (Q) and assessed inequalities using concentration and slope indices. We applied path analyses to examine the relationship between SES inequalities, intermediate determinants, and IYCF. Breastfeeding improved significantly over 2006-2016: from 23% to 42% for early initiation of breastfeeding (EIBF) and 46% to 55% for exclusive breastfeeding (EBF). Minimum dietary diversity (MDD) improved modestly (15% to 21%), but adequate diet did not change (~9%). Large SES gaps (Q5-Q1) were found for EIBF (8-17%) and EBF (-15% to -10%) in 2006; these gaps closed in 2016. The most inequitable practices in 2006 were MDD and iron-rich foods (Q5 ~ 2-4 times higher than Q1); these gaps narrowed in 2016, but levels are low across SES groups. Factors along the path from SES inequalities to IYCF practices included health and nutrition services, information access, maternal education, number of children < 5 years, and urban/rural residence. The improvements in breastfeeding and narrowing of equity gaps in IYCF practices in India are significant achievements. However, ensuring the health and well-being of India's large birth cohort will require more efforts to further improve breastfeeding, and concerted actions to address all aspects of complementary feeding across SES quintiles., (© 2018 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

Introduction: India carries the largest burden of anaemia globally. Progress to reduce anaemia has been slow despite substantial economic growth and 50 years of programmatic efforts. Identification of the factors that contribute to anaemia reductions is needed to accelerate progress. We examined changes in haemoglobin (Hb) and anaemia among women and children in India from 2006 to 2016 and identified drivers of changes in these outcomes over time., Methods: We used two rounds of National Family Health Survey data collected in 2005-2006 and 2015-2016 (n=245 346 children 6-59 months; 37 165 pregnant women (PW) 15-49 years; 760 460 non-pregnant women (NPW) 15-49 years). We first examined trends in Hb and anaemia, and changes in 30 selected variables (including immediate and underlying determinants, and nutrition and health interventions (NHIs)). We identified drivers of Hb and anaemia using multivariate regression and estimated their contribution to changes in these outcomes over time using regression-based decomposition., Results: Hb and anaemia improved significantly between 2006 and 2016 in children (4.5  g/L and 11 percentage points (pp), respectively) and PW (3.2  g/L and 7.6 pp), but not in NPW. Despite these changes, anaemia is still very high (>50%) and progress varied considerably by state (-33 pp to +16 pp). Most immediate and underlying determinants, and NHIs improved significantly over time. Changes among a set of drivers common to children and PW accounted for the changes in Hb; these included maternal schooling (children, 10%; PW, 24%), coverage of NHIs (children, 18%; PW, 7%), socioeconomic status (children, 7%; PW, 17%), sanitation (children, 3%; PW, 9%), and meat and fish consumption (children, 3%; PW, 1%). The decomposition models moderately explained Hb changes over time (children, 49%; PW, 66%)., Conclusions: Multiple common drivers have contributed to the anaemia changes among children and pregnant women in India. Further improvements in these drivers can have population-level effects by simultaneously influencing both maternal and child anaemia., Competing Interests: Competing interests: None declared.

Understanding implementation of interventions is critical to illuminate if, how, and why the interventions achieve impact. Alive & Thrive integrated a nutrition intervention into an existing maternal, neonatal, and child health (MNCH) programme in Bangladesh, documenting improvements in women's micronutrient supplement intake and dietary diversity. Here, we examined how well the nutrition intervention was implemented and which elements of implementation explained intervention impact. Survey data were collected in 2015 and 2016 from frontline health workers (FLW) and households in areas randomized to nutrition-focused MNCH (intensified interpersonal counselling, community mobilization, distribution of free micronutrient supplements, and weight-gain monitoring) or standard MNCH (antenatal care with standard nutrition counselling). Seven intervention elements were measured: time commitment, training quality, knowledge, coverage, counselling quality, supervision, and incentives. Multiple regression was used to derive difference-in-differences (DID) estimates. Using village-level endline data, path analysis was used to determine which elements most explained intervention impacts. FLWs in both areas were highly committed and well supervised. Coverage was high (>90%) for counselling, supplement provision, and weight-gain monitoring. Improvements were significantly greater for nutrition-focused MNCH, versus standard MNCH, for training quality (DID: 2.42 points of 10), knowledge (DID: 1.20 points), delivery coverage (DID: 4.16 points), and counselling quality (DID: 1.60 points). Impact was substantially explained by coverage and delivery quality. In conclusion, integration nutrition intervention into the MNCH programme was feasible and well-implemented. Although differences in coverage and counselling quality most explained impacts, all intervention elements-particularly FLW training and performance-were likely important to achieving impact., (© 2018 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

Background: Sustained improvements in infant and young child feeding (IYCF) require continued implementation of effective interventions. From 2010-2014, Alive & Thrive (A&T) provided intensive interpersonal counseling (IPC), community mobilization (CM), and mass media (MM) in Bangladesh, demonstrating impact on IYCF practices. Since 2014, implementation has been continued and scaled up by national partners with support from other donors and with modifications such as added focus on maternal nutrition and reduced program intensity., Objective: We assessed changes in intervention exposure and IYCF knowledge and practices in the intensive (IPC + CM + MM) compared with nonintensive areas (standard nutrition counseling + less intensive CM and MM) 2 y after termination of initial external donor support., Methods: We used a cluster-randomized design with repeated cross-sectional surveys at baseline (2010, n = 2188), endline (2014, n = 2001), and follow-up (2016, n = 2400) in the same communities, among households with children 0-23.9 mo of age. Within-group differences over time and differences between groups in changes were tested., Results: In intensive areas, exposure to IPC decreased slightly between endline and follow-up (88.9% to 77.2%); exposure to CM activities decreased significantly (29.3% to 3.6%); and MM exposure was mostly unchanged (28.1-69.1% across 7 TV spots). Exposure to interventions did not expand in nonintensive areas. Most IYCF indicators in intensive areas declined from endline to follow-up, but remained higher than at baseline. Large differential improvements of 12-17 percentage points in intensive, compared with nonintensive areas, between baseline and follow-up remained for early initiation of and exclusive breastfeeding, timely introduction of foods, and consumption of iron-rich foods. Differential impact in breastfeeding knowledge remained between baseline and follow-up; complementary feeding knowledge increased similarly in both groups., Conclusions: Continued IPC exposure and sustained impacts on IYCF knowledge and practices in intensive areas indicated lasting benefits from A&T's interventions as they underwent major scale-up with reduced intensity. This trial was registered at clinicaltrials.gov as NCT02740842.

Growing evidence supports the role of preconception maternal nutritional status (PMNS) on birth outcomes; however, evidence of relationships with child growth are limited. We examined associations between PMNS (height, weight and body mass index- BMI) and offspring growth during the first 1000 days. We used prospective cohort data from a randomized-controlled trial of preconception micronutrient supplementation in Vietnam, PRECONCEPT (n = 1409). Poisson regression models were used to examine associations between PMNS and risk of offspring stunting (<-2 HAZ) at 2 years. We used path analytic models to examine associations with PMNS on fetal growth (ultrasound measurements) and offspring HAZ at birth and 2 years. All models were adjusted for child age, sex, gestational weight gain, education, socioeconomic status and treatment group. A third of women had a preconception height < 150cm or weight < 43 kg. Women with preconception height < 150 cm or a weight < 43 kg were at increased risk of having a stunted child at 2 years (incident risk ratio IRR: 1.85, 95% CI 1.51-2.28; IRR 1.35, 95% CI 1.10-1.65, respectively). While the traditional low BMI cut-off (< 18.5 kg/m2) was not significant, lower BMI cut-offs (< 17.5 kg/m2 or < 18.0 kg/m2) were significantly associated with 1.3 times increased risk of child stunting. In path models, PMNS were positively associated with fetal growth (ultrasound measurements) and offspring HAZ at birth and 2 years. For each 1 standard deviation (SD) increase in maternal height and weight, offspring HAZ at 2 years increased by 0.30 SD and 0.23 SD, respectively. In conclusion, PMNS influences both offspring linear growth and risk of stunting across the first 1000 days. These findings underscore the importance of expanding the scope of current policies and strategies to include the preconception period in order to reduce child stunting., Competing Interests: The authors have declared that no competing interests exist.

Background: Although husbands may provide support during pregnancy, limited evidence exists on how to promote husbands' engagement and what impact it has. Alive & Thrive integrated nutrition-focused interventions, targeting both wives and husbands, through an existing Maternal, Neonatal, and Child Health (MNCH) platform in Bangladesh., Objectives: We evaluated 1) the impact of a nutrition-focused MNCH program, compared with the standard MNCH program, on husbands' behavioral determinants (i.e., awareness, knowledge, self-efficacy) and support to wives to adopt optimal nutrition practices and 2) how much of the previously documented impact on women's supplement intake and dietary diversity was explained by husbands' behavioral determinants and support., Methods: We used a cluster-randomized design with cross-sectional surveys at baseline (2015) and endline (2016) (n = ∼1000 women and ∼700 husbands/survey). We used mixed linear regression accounting for clustering to estimate difference-in-differences (DIDs) for impact on husbands' behavioral determinants and path analysis to examine how much these determinants explained the impact on women's nutrition behaviors., Results: Of husbands in the nutrition-focused MNCH group, 62% were counseled by health workers, 66% attended a husbands' forum, and 34% saw video shows. The nutrition-focused MNCH, compared with the standard MNCH group, resulted in greater husbands' awareness (DID: 2.74 of 10 points), knowledge (DID: 1.31), self-efficacy and social norms with regard to optimal nutrition practices (difference: 1.08), and support to their wives (DID: 1.86). Husbands' behavioral determinants and support explained nearly half of the program impact for maternal supplement intake and one-quarter for dietary diversity., Conclusions: A nutrition-focused MNCH program that promoted and facilitated husbands' engagement during their wives' pregnancies significantly improved husbands' awareness, knowledge, self-efficacy, and support. These improvements substantially explained the program's impact on women's intake of micronutrient supplements and dietary diversity. Targeting wives and husbands and designing activities to engage men in maternal nutrition programs are important to maximize impact. This trial was registered at www.clinicaltrials.gov as NCT02745249.

Background: The Minimum Dietary Diversity for Women (MDD-W) indicator based on a 10-food group women dietary diversity score (WDDS-10) has been validated to assess dietary quality in nonpregnant women. Little is known about its applicability in pregnant women, and specifically pregnant adolescent girls with higher nutrient requirements., Objectives: This study aimed to 1) compare the adequacy of micronutrient intakes between pregnant adolescent girls and women, 2) examine the performance of WDDS-10 in predicting the mean probability of adequacy (MPA) of 11 micronutrients, and 3) assess how well the MDD-W cutoff of 5 groups performed in pregnant adolescent girls and women., Methods: We used data from a 2015 household survey in Bangladesh (n = 600). Nutrient intakes were estimated with a multiple-pass 24-h recall and WDDS-10 was assessed through the use of a list-based method. Multiple linear regression models adjusted for geographical clustering assessed the association between WDDS-10 and MPA. Sensitivity and specificity analysis assessed the accuracy of MDD-W in correctly classifying individuals into high (MPA >0.6) or low MPA., Results: Dietary intakes of pregnant adolescent girls and women were similar in energy intake, WDDS-10 (5.1 ± 1.4), MPA (0.40 ± 0.12), and micronutrient intakes. Probabilities of adequacy were ∼0.30 for riboflavin, vitamin B-12, calcium, and zinc; 0.12-0.15 for folate; 0.16-0.19 for vitamin A; and extremely low for iron at 0.01. The WDDS-10 was significantly associated with MPA in both groups and predicted MPA equally well at population level (SD of residuals 0.11 for both). Use of the 5-food groups cutoff for MDD-W to classify individuals' diets into MPA >0.6, however, resulted in a low correct classification (∼40%). A cutoff of 6 food groups markedly improved correct classification., Conclusions: The WDDS-10 predicted MPA equally well for pregnant adolescent girls and women at population level. The MDD-W indicator performed poorly in classifying individuals with MPA >0.6.

Background: Maternal undernutrition is a major concern globally, contributing to poor birth outcomes. Limited evidence exists on delivering multiple interventions for maternal nutrition simultaneously. Alive & Thrive addressed this gap by integrating nutrition-focused interpersonal counseling, community mobilization, distribution of free micronutrient supplements, and weight-gain monitoring through an existing Maternal, Neonatal, and Child Health (MNCH) program in Bangladesh. Objectives: We evaluated the effect of providing nutrition-focused MNCH compared with standard MNCH (antenatal care with standard nutrition counseling) on coverage of nutrition interventions, maternal dietary diversity, micronutrient supplement intake, and early breastfeeding practices. Methods: We used a cluster-randomized design with cross-sectional surveys at baseline (2015) and endline (2016) ( n ∼ 300 and 1000 pregnant or recently delivered women, respectively, per survey round). We derived difference-in-difference effect estimates, adjusted for geographic clustering and infant age and sex. Results: Coverage of interpersonal counseling was high; >90% of women in the nutrition-focused MNCH group were visited at home by health workers for maternal nutrition and breastfeeding counseling. The coverage of community mobilization activities was ∼50%. Improvements were significantly greater in the nutrition-focused MNCH group than in the standard MNCH group for consumption of iron and folic acid [effect: 9.8 percentage points (pp); 46 tablets] and calcium supplements (effect: 12.8 pp; 50 tablets). Significant impacts were observed for the number of food groups consumed (effect: 1.6 food groups), percentage of women who consumed ≥5 food groups/d (effect: 30.0 pp), and daily intakes of several micronutrients. A significant impact was also observed for exclusive breastfeeding (EBF; effect: 31 pp) but not for early initiation of breastfeeding. Conclusions: Addressing nutrition during pregnancy by delivering interpersonal counseling and community mobilization, providing free supplements, and ensuring weight-gain monitoring through an existing MNCH program improved maternal dietary diversity, micronutrient supplement consumption, and EBF practices. This trial was registered at clinicaltrials.gov as NCT02745249., Competing Interests: Author disclosures: PHN, SSK, TS, ZM, LMT, SS, BA, RH, KA, EAF, MTR, and PM, no conflicts of interest. TS, ZM, SS, BA, and KA were members of the program implementation team that designed and implemented the interventions studied and reported on in this article. They reviewed the manuscript and provided contextual interpretation of the results, but final decisions on the manuscript content lay with the primary authors from the evaluation team (PHN, SSK, EAF, MTR, and PM). Alive & Thrive provided specific inputs to the manuscript regarding intervention design and provided feedback on the interpretation of results. Freedom to publish the study findings was protected contractually in the agreement between the respective funding sources and the International Food Policy Research Institute. This is an open access article distributed under the CC-BY license (http://creativecommons.org/licenses/by/3.0/).

Little is known about nutrition and well-being indicators of pregnant adolescents and the availability and use of nutrition interventions delivered through maternal, newborn, and child health (MNCH) programs. This study compared the differences between pregnant adolescents and adult pregnant women in services received, and in maternal and child nutrition and health conditions. A survey of 2,000 recently delivered women with infants <6 months of age was carried out in 20 sub-districts in Bangladesh where MNCH program is being implemented. Differences in service use and outcomes between pregnant adolescents and adult women were tested using multivariate regression models. The coverage of antenatal care and nutrition services was similar for adolescent and adult mothers. Compared to adult mothers, adolescent mothers had significantly fewer ownership of assets and lower decision making power. Adolescent mothers weighed significantly less than adult women (45.8 vs 47.1 kg, p = 0.001), and their body mass index was significantly lower (19.7 vs 21.3, p = 0.001). Adolescents recovered later and with greater difficulty after childbirth. Infants of adolescent mothers had significant lower height-for-age z-score (-0.89 vs -0.74, p = 0.04), lower weight-for age z-score (-1.21 vs -1.08, p = 0.02) and higher underweight prevalence (22.4% vs 17.9%, p = 0.04) compared to infants of adult women. In conclusion, this study confirms that adolescent pregnancy poses substantial risks for maternal and infant outcomes, and emphasizes that these risks are significant even where services during pregnancy are available and accessed. A focus on preventing adolescent pregnancy is imperative, while also strengthening health and nutrition services for all pregnant women, whether adult or adolescent.

Background: Rigorous evaluations of health system-based interventions in large-scale programs to improve complementary feeding (CF) practices are limited. Alive & Thrive applied principles of social franchising within the government health system in Vietnam to improve the quality of interpersonal counseling (IPC) for infant and young child feeding combined with a national mass media (MM) campaign and community mobilization (CM). Objective: We evaluated the impact of enhanced IPC + MM + CM (intensive) compared with standard IPC + less-intensive MM and CM (nonintensive) on CF practices and anthropometric indicators. Methods: A cluster-randomized, nonblinded evaluation design with cross-sectional surveys ( n = ∼500 children aged 6-23.9 mo and ∼1000 children aged 24-59.9 mo/group) implemented at baseline (2010) and endline (2014) was used. Difference-in-difference estimates (DDEs) of impact were calculated for intent-to-treat (ITT) analyses and modified per-protocol analyses (MPAs; mothers who attended the social franchising at least once: 62%). Results: Groups were similar at baseline. In ITT analyses, there were no significant differences between groups in changes in CF practices over time. In the MPAs, greater improvements in the intensive than in the nonintensive group were seen for minimum dietary diversity [DDE: 6.4 percentage points (pps); P < 0.05] and minimum acceptable diet (8.0 pps; P < 0.05). Significant stunting declines occurred in both intensive (7.1 pps) and nonintensive (5.4 pps) groups among children aged 24-59.9 mo, with no differential decline. Conclusions: When combined with MM and CM, an at-scale social franchising approach to improve IPC, delivered through the existing health care system, significantly improved CF practices, but not child growth, among mothers who used counseling services at least once. A greater impact may be achieved with strategies designed to increase service utilization. This trial was registered at clinicaltrials.gov as NCT01676623.

Background: Child linear growth sometimes improves in both intervention and comparison groups in evaluations of nutrition interventions, possibly because of spillover intervention effects to nonintervention areas or improvements in underlying determinants of nutritional change in both areas. Objective: We aimed to understand what changes in underlying socioeconomic characteristics and behavioral factors are important in explaining improvements in child linear growth. Methods: Baseline (2010) and endline (2014) surveys from the Alive & Thrive impact evaluation were used to identify the underlying determinants of height-for-age z scores (HAZs) among children aged 24-48 mo in Bangladesh ( n = 4311) and 24-59 mo in Vietnam ( n = 4002). Oaxaca-Blinder regression decompositions were used to examine which underlying determinants contributed to HAZ changes over time. Results: HAZs improved significantly between 2010 and 2014 in Bangladesh (∼0.18 SDs) and Vietnam (0.25 SDs). Underlying determinants improved substantially over time and were larger in Vietnam than in Bangladesh. Multiple regression models revealed significant associations between changes in HAZs and socioeconomic status (SES), food security, maternal education, hygiene, and birth weight in both countries. Changes in HAZs were significantly associated with maternal nutrition knowledge and child dietary diversity in Bangladesh, and with prenatal visits in Vietnam. Improvements in maternal nutrition knowledge in Bangladesh accounted for 20% of the total HAZ change, followed by maternal education (13%), SES (12%), hygiene (10%), and food security (9%). HAZ improvements in Vietnam were accounted for by changes in SES (26%), prenatal visits (25%), hygiene (19%), child birth weight (10%), and maternal education (7%). The decomposition models in both countries performed well, explaining >75% of the HAZ changes. Conclusions: Decomposition is a useful and simple technique for analyzing nonintervention drivers of nutritional change in intervention and comparison areas. Improvements in underlying determinants explained rapid improvements in HAZs between 2010 and 2014 in Bangladesh and Vietnam.

Background: Despite recommendations supporting optimal breastfeeding, the number of women practicing exclusive breastfeeding (EBF) remains low, and few interventions have demonstrated implementation and impact at scale. Alive & Thrive was implemented over a period of 6 y (2009-2014) and aimed to improve breastfeeding practices through intensified interpersonal counseling (IPC), mass media (MM), and community mobilization (CM) intervention components delivered at scale in the context of policy advocacy (PA) in Bangladesh and Viet Nam. In Bangladesh, IPC was delivered through a large non-governmental health program; in Viet Nam, it was integrated into government health facilities. This study evaluated the population-level impact of intensified IPC, MM, CM, and PA (intensive) compared to standard nutrition counseling and less intensive MM, CM, and PA (non-intensive) on breastfeeding practices in these two countries., Methods and Findings: A cluster-randomized evaluation design was employed in each country. For the evaluation sample, 20 sub-districts in Bangladesh and 40 communes in Viet Nam were randomized to either the intensive or the non-intensive group. Cross-sectional surveys (n ~ 500 children 0-5.9 mo old per group per country) were implemented at baseline (June 7-August 29, 2010, in Viet Nam; April 28-June 26, 2010, in Bangladesh) and endline (June 16-August 30, 2014, in Viet Nam; April 20-June 23, 2014, in Bangladesh). Difference-in-differences estimates (DDEs) of impact were calculated, adjusting for clustering. In Bangladesh, improvements were significantly greater in the intensive compared to the non-intensive group for the proportion of women who reported practicing EBF in the previous 24 h (DDE 36.2 percentage points [pp], 95% CI 21.0-51.5, p < 0.001; prevalence in intensive group rose from 48.5% to 87.6%) and engaging in early initiation of breastfeeding (EIBF) (16.7 pp, 95% CI 2.8-30.6, p = 0.021; 63.7% to 94.2%). In Viet Nam, EBF increases were greater in the intensive group (27.9 pp, 95% CI 17.7-38.1, p < 0.001; 18.9% to 57.8%); EIBF declined (60.0% to 53.2%) in the intensive group, but less than in the non-intensive group (57.4% to 40.6%; DDE 10.0 pp, 95% CI -1.3 to 21.4, p = 0.072). Our impact estimates may underestimate the full potential of such a multipronged intervention because the evaluation lacked a "pure control" area with no MM or national/provincial PA., Conclusions: At-scale interventions combining intensive IPC with MM, CM, and PA had greater positive impacts on breastfeeding practices in Bangladesh and Viet Nam than standard counseling with less intensive MM, CM, and PA. To our knowledge, this study is the first to document implementation and impacts of breastfeeding promotion at scale using rigorous evaluation designs. Strategies to design and deliver similar programs could improve breastfeeding practices in other contexts., Trial Registration: ClinicalTrials.gov NCT01678716 (Bangladesh) and NCT01676623 (Viet Nam)., Competing Interests: JB, TS, NH, SA, KA and RH are part of the Alive and Thrive implementation team who delivered the interventions described in this paper. They helped conceive and design the study, but played no role in research data collection or data analysis. Their contributions to this manuscript included written inputs to sections on intervention design, critical in-person discussions regarding interpretation of results, and written review of manuscript drafts. Final decisions about results to include, interpretation and conclusions rested with authors from the evaluation team (PM, RR, EAF, MR, PN, KKS, AKh, AKn, LTM).

Dietary diversity (DD) reflects micronutrient adequacy of the diet and is associated with better child growth. Emerging evidence suggests that maternal and child DD are associated. This could have measurement and programmatic implications. Data on mother-child (6-24 mo) dyads in Bangladesh, Vietnam, and Ethiopia were used to examine agreement and association between maternal and child DD and identify determinants of maternal and child DD. The DD scores were derived from a 24-h recall of intake of foods from 7 groups. Multivariable regression was used to examine for the association, adjusting for covariates at child, maternal, and household levels. There was mother/child agreement for staple foods across the 3 countries but disagreement for flesh foods, dairy, fruits, and vegetables. A strong positive association was seen between maternal and child DD; a difference of one food group in mother's consumption was associated with a difference of 0.29, 033, and 0.24 groups in child's consumption in Bangladesh, Vietnam, and Ethiopia, respectively. The odds of achieving minimum DD (≥4 groups) were higher among children whose mother consumed 4 groups compared with ≤3 food groups [Bangladesh: OR = 2.73 (95% CI: 1.76, 4.25); Vietnam: OR = 2.30 (95% CI: 1.45, 3.43); Ethiopia: OR = 5.11 (95% CI: 2.36, 11.04)]. Maternal education was associated with both maternal and child DD; food security and socioeconomic status were associated only with maternal DD. Given the disagreements in mother/child intake for nutrient-rich foods, both maternal and child DD should be measured in surveys. Behavior change communications should focus on promoting both mother and child DD and encouraging mothers to feed young children all family foods, not just a subset.