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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. Key messages: Optimal breastfeeding practices during the first few months of life were positively associated with cognitive development in early childhood and school‐aged children.While exclusive breastfeeding was directly associated with child cognition at 6–7 years, cognitive development at 2 years mediated the association of early initiation of breastfeeding on cognition at 6–7 years. More research is needed to replicate these findings, explore mechanisms and evaluate the causal relationship.Child linear growth in early childhood mediated the association of minimum dietary diversity at 1 year on child height‐for‐age z‐score at 6–7 years. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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), Author(s): Purnima Menon 1, Phuong Hong Nguyen 1,*, Kuntal Kumar Saha 1, Adiba Khaled 1, Andrew Kennedy 1, Lan Mai Tran 2, Tina Sanghvi 2, Nemat Hajeebhoy 2, Jean Baker [...]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Abstract: 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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). [ABSTRACT FROM AUTHOR]