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Additional file 5: Supplementary Annex 5. Menstrual monitoring consent form in English.

Additional file 3: Supplementary Annex 3. Menstrual monitoring participant information sheet in English.

Additional file 8: Supplementary Annex 8. Data Monitoring Committee (DMC) charter.

Additional file 1: Supplementary Annex 1. Trial Steering Monitoring (TSC) charter.

Additional file 4: Supplementary Annex 4. Full Trial participant information sheets in English.

Additional file 7: Supplementary Annex 7. Expected pregnancies to be enrolled and numbers after loss to follow-up.

Additional file 6: Supplementary Annex 6. Full Trial consent form in English.

Additional file 2: Supplementary Annex 2. List of selected study clusters with population and expected pregnancies.

Optimising child feeding behaviours could improve child health in Guatemala, Honduras and El Salvador, where undernutrition rates remain high. However, the design of interventions to improve child feeding behaviours is limited by piecemeal, theoretically underdeveloped evidence on factors that may influence these behaviours. Between July 2018 and January 2020, we systematically searched Cochrane, Medline, EMBASE, Global Health and LILACS databases, grey literature websites and reference lists, for evidence of region-specific causes of child feeding behaviours and the effectiveness of related interventions and policies. The Behaviour Change Wheel was used as a framework to synthesise and map the resulting literature. We identified 2,905 records and included 68 relevant studies of mixed quality, published between 1964 and 2019. Most (n = 50) were quantitative, 15 were qualitative and three used mixed methods. A total of 39 studies described causes of child feeding behaviour; 29 evaluated interventions or policies. Frequently cited barriers to breastfeeding included mothers' beliefs and perceptions of colostrum and breast milk sufficiency; fears around child illness; and familial and societal pressures, particularly from paternal grandmothers. Child diets were influenced by similar beliefs and mothers' lack of money, time and control over household finances and decisions. Interventions (n = 22) primarily provided foods or supplements with education, resulting in mixed effects on breastfeeding and child diets. Policy evaluations (n = 7) showed positive and null effects on child feeding practices. We conclude that interventions should address context-specific barriers to optimal feeding behaviours, use behaviour change theory to apply appropriate techniques and evaluate impact using robust research methods.

Introduction: Undernutrition rates remain high in rural, low-income settings, where large gender-based inequities persist. We hypothesised that increasing gender equity in agriculture could improve nutrition. Methods: We conducted a systematic review to assess the associations between gender-based inequities (in income, land, livestock, and workloads) and nutrition, diets, and food security outcomes in agricultural contexts of low- and middle-income countries. Between 9 March and 7 August 2018, we searched 18 databases and 14 journals, and contacted 27 experts. We included quantitative and qualitative literature from agricultural contexts in low- and middle-income countries, with no date restriction. Outcomes were: women’s and children’s anthropometric status, dietary quality, and household food security. We conducted meta-analyses using random effects models. PROSPERO registration: CRD42018093987. Results: We identified 19,820 records, of which 34 studies (42,809 households) met the inclusion criteria. Most (22/25) quantitative studies had a high risk of bias, and qualitative evidence was mixed-quality. Income, land, and livestock equity had heterogeneous associations with household food security and child anthropometric outcomes. Meta-analyses showed women’s share of household income earned (0.32 (95% CI -4.22, 4.86), 6 results) and women’s share of land owned (2.72 (-0.52, 5.96) 3 results) did not increase the percentage of household budget spent on food. Higher-quality studies showed more consistently positive associations between income equity and food security. Evidence is limited on other exposure-outcome pairings. Conclusion: We find heterogeneous associations between gender equity and household-level food security. High-quality research is needed to establish the impact of gender equity on nutrition outcomes across contexts.

INTRODUCTION: Micronutrient deficiencies are prevalent in Nepal where starchy foods constitute a large proportion of diets and consumption of micronutrient-rich foods is inadequate. We conducted a study to determine whether rice would be an appropriate vehicle for micronutrient fortification in Nepal. MATERIALS AND METHODS: In Bajura in remote rural Nepal, we conducted a household survey to characterize rice intakes in 195 households, and a double-blinded acceptability test with 177 social safety net rice consumers ≥18 years of age. Of these, 168 tasted fortified and unfortified rice to assess whether respondents could differentiate between fortified and non-fortified rice and their sensory properties. Rice was fortified by blending hot extruded kernels containing 6 micronutrients together with non-fortified rice at a 1:99 ratio. We used binomial tests to assess whether participants could correctly differentiate fortified rice, from non-fortified rice and paired t-tests to compare scores for sensory qualities of cooked fortified and non-fortified rice. We used multiple regression to test associations between per capita consumption and age, gender, wealth and food security. RESULTS: Per capita consumption of rice (median 216g/day, IQR 144.0, 288.0) did not vary by wealth but was +52.08g, (95% CI 10.43, 93.72) higher amongst moderately to severely food insecure households compared with food secure / mildly food insecure. Most respondents could not differentiate fortified rice from non-fortified rice: 37.5% identified uncooked fortified rice and 39.3% cooked rice, which was not different from the 33% expected by chance (p = 0.22 and p = 0.09 respectively). The sensory qualities of fortified rice were acceptable (scoring 3.9 out of 5) and did not differ from non-fortified rice (p>0.05). CONCLUSION: A rice fortification programme implemented through the Nepal Food Corporation's social safety nets has potential because purchase and consumption of rice is high and fortified rice is acceptable among consumers in remote food insecure areas of Nepal.

Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 Checklist: recommended items to address in a clinical trial protocol and related documents*. (DOC 122 kb)