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Aspects of human anatomy, digestion, and metabolism diverged from other primates, indicating evolutionary reliance on, and compatibility with, substantial meat intake. Implications of a disconnect from evolutionary dietary patterns may contribute to today’s burden of disease, increasing the risk for both nutrient deficiencies and chronic diseases. Meat supplies high-quality protein and various nutrients, some of which are not always easily obtained with meat-free diets and are often already suboptimal or deficient in global populations. Removal of meat comes with implications for a broad spectrum of nutrients that need to be accounted for, whereas compensatory dietary strategies must factor in physiological and practical constraints. Although meat makes up a small part (

Andean-based archeological evidence suggests the existence of heterarchical pre-Columbian societies organized as egalitarian and resource-specialized communities with the capacity to create and maintain intensive productive systems. Using Stark’s analytical framework, we explore the current heterarchical organization of the indigenous Ecuadorian community of Caliata in the context of local cosmovision, identity, and customary institutions. Caliata’s heterarchy is expressed by distributed intelligence through diverse and specialized organizational units that are in constant negotiation in order to reach consensus and to procure optimal responses to uncertainty. The organizational factors at play in mobilizing agri-food systems are key to understanding ancient technologies currently used to support sustainable food security.

Background To achieve a healthy sustainable food system globally, it is imperative to understand how local food systems can provide healthy and sustainable conditions. Objective To explore, through the indigenous community of Caliata in the Ecuadorian highlands, the factors that support or hinder sustainable Andean food systems. Methods We designed a participatory mixed-methods study in Caliata (Chimborazo, Ecuador) and an inclusive and transdisciplinary research process with constant member checking. The study combined culturally validated qualitative methods (n = 49), agroecology-based site analysis, and household surveys (n = 57), including a modified 48-h recall. We used the NOVA food classification system to categorize the diet according to levels of processing and analyzed categorical and numeric data to understand the interplay of parcel size, agrodiversity, and diet diversity. Results First, the agroecological space is defined by the stewardship of Pachamama (Mother Nature), a central role in Andean cosmovision, leading to trophic interactions and cycles characterized by a diversity of heterarchical social organizations and agroecologically useful species. Second, consistency was found in dietary patterns; all respondents consume their produce, fruits being the most popular snack (in a 24-h period, 70% reported an average of 2.2 servings), and two-thirds of households' consumption represent unprocessed or minimally processed foods. Third, gendered agriculture and population aging represent demographic challenges, while chronic health problems remain relatively infrequent compared with the general population. Fourth, food sovereignty is an ecocentric concept based on production, exchanges of seeds and produce, consumption of produce, and knowledge of how agroecological space is treated. This system represents a nutrient loop tied to a system of knowledge about how to care for soil, land, and the ecological community. Conclusions Caliata provides important perspectives on linkages between diet, biodiversity, use of agroecological space, and rural–urban dynamics. This small indigenous community offers lessons for achieving both healthy ecosystems and food security.

This study assesses the perspectives and experiences of Vodou priests (ougan) in the treatment of mental illness in northern Haiti. Our goal is to explore the etiology and popular nosologies of mental illness in the context of Haitian Vodou, through understandings of illness and misfortune which are often viewed as a result of sent spirits-or spirits sent supernaturally by others with the intent to cause harm. Using a qualitative approach, this study conducted semi-structured in-depth interviews with 20 ougan living near the city of Cap-Haïtien. Interviews highlight a sample of healers with little formal training who maintain beliefs and practices that differ significantly from current biomedical models. Ougan treat mental illness through a variety of means including prayer and conjuring of spirits, leaves for teas and baths, as well as combinations of perfumes, rum, human remains, and other powdered concoctions that are either imbibed or rubbed on the skin. The primary purpose of these treatments is to expel the spirit causing harm, yet they can often result in additional harm to the patient. Findings suggest that while ougan are willing to collaborate with biomedical practitioners, significant barriers remain preventing cooperation between these two groups.

Background One in five young children globally suffer the consequences of stunted growth and development and millions experience deficiencies in zinc, iron, iodine, vitamins A and B12, nutrients found bioavailable in fish foods. Small-scale fisheries have the potential to generate income and augment fish consumption while being environmentally sustainable if appropriately managed. However, those engaged in small-scale fisheries are often marginalized, poor, and malnourished. The Samaki Salama project seeks to better understand and address these challenges through a three-arm, longitudinal matched cluster study which evaluates the impact of an integrated nutrition social marketing and modified fishing trap intervention. Methods There will be 400 small-scale fisher households enrolled from Kilifi county, Kenya and residing in communities matched on location (rural), livelihoods, and child nutritional status. The sample will include mothers and other caregivers, children 6–60 months, and fishers in the family. Applying a cluster design, the matched communities will be divided into three groups: (1) control; (2) multi-tiered nutrition social marketing intervention to fishers, mothers, and health workers; and (3) multi-tiered nutrition social marketing intervention plus modified fishing traps and training. Primary outcomes include child growth, fish food intakes, and fisheries yield of mature fish. Secondary outcomes are diet diversity, child diarrheal morbidity, and fisheries revenue. A process evaluation will be used to monitor and ensure fidelity of intervention delivery. Discussion This study builds on a growing body of literature illustrating the effectiveness of nutrition focused social marketing campaigns to promote active engagement of participants, high compliance to the intervention, and sustained behavior change. The second intervention element of modified fishing traps that allow immature fish to escape enables participants to act on the messaging they receive and promotes sustainable fishing through increased harvest efficiency and reduced catch of immature fish. Samaki Salama’s integrated approach provides an example of how to leverage multiple disciplines to address key challenges to human and environmental health and illustrates a pathway for scaling study innovations to other small-scale fisheries systems.

As part of the growing movement of transnational educational partnerships, Washington University in St. Louis (WUSTL) partnered with the Universite Publique du Nord au Cap-Haitien (UPNCH) in Januar...

Background Stunted growth and development is a serious global public health problem. A limited number of field measures exist that can be used to evaluate stunting and its underlying biologic mechanisms. Purpose To assess bone age using tablet-based US in young children living in a rural community in Ecuador, where stunting is prevalent, and to evaluate the associations between bone age, anthropometry, and diet. Materials and Methods From June through August 2017, tablet-based US was used to assess bone age in young children within their homes in rural Cotopaxi, Ecuador. Bone age z scores (BAZs) were assigned using the standards of Greulich and Pyle. Anthropometric data were collected using international protocols; z scores were generated from World Health Organization Child Growth Standards. Groups were compared using the Student t test. Univariate analyses and generalized linear regression modeling were applied to test the association between bone age and anthropometry, adjusting for covariates including age, sex, dietary intake, and morbidities. Results A total of 128 children (mean age, 33.9 months ± 1.8 [standard deviation]; 59 girls, 69 boys) were evaluated. Mean BAZ was -1.20 ± 1.16. Mean BAZ was lower in children with stunted growth (-1.42 ± 1.18) than in children without stunted growth (-0.98 ± 1.10, P = .04). In adjusted analysis, BAZ was associated with the following variables: height-for-age z score (β coefficient, 0.26; 95% confidence interval [CI]: 0.05, 0.46; P = .01), female sex (β coefficient, 0.51; 95% CI: 0.15, 0.88; P = .006), number of times eggs were consumed in the previous 24 hours (β coefficient, 0.22; 95% CI: 0.05, 0.38; P = .009), number of times savory or salty snacks were consumed in the previous 24 hours (β coefficient, 0.42; 95% CI: 0.15, 0.68; P = .002), and ownership of pig livestock, which was a binary variable (β coefficient, -0.46; 95% CI: -0.82, -0.09; P = .01). Conclusion Bone age determined using tablet-based US was lower in children who had stunted growth and was associated with diet in a cohort of children living in rural Ecuador. © RSNA, 2020 See also the editorial by Dillman and Ayyala in this issue.

Objectives: To measure heavy metal concentrations among Kenyan youth and quantify associations with sociocultural, demographic, and health factors as well as anthropometry. Methods: Using data from a study of semi-nomadic pastoralists in Samburu County, Kenya, we measured blood concentrations of lead (Pb), mercury (Hg), and cadmium (Cd) in 161 adolescents. We identified sociocultural, demographic and health characteristics associated with each metal and quantified the association between metals and adolescent anthropometry. Results: Median blood concentrations of Pb, Cd, and Hg were 1.82 µg/dL, 0.24 µg/L and 0.16 µg/L, respectively. Place of residence (highlands vs lowlands) was a determinant of metal concentrations. Hg was inversely related to anemia, and metals were not associated with anthropometry. Conclusions: In this population of Samburu adolescents, median Pb and Cd blood concentrations were higher than other North American or European biomonitoring studies. These findings motivate further investigation into the environmental sources of metals in this community.

OBJECTIVES: This study aimed to characterize mineral nutrition (copper, magnesium, selenium, and zinc) in Samburu pastoralist youth, in the context of differential cultural transitions due to uneven changes in educational access, herding intensity, polygyny, and access to wild, domesticated, and market-sourced foods. MATERIALS AND METHODS: Whole dried blood spots were collected in a total of 161 youth (highlands, n = 97; lowlands, n = 64) to assess concentrations of: cadmium, copper, lead, magnesium, mercury, selenium, and zinc. Concentrations were determined through Inductively Coupled Mass Spectrometry. Dietary intakes were assessed by 24-hour recall method and calculation of probability of inadequate intakes. WHO protocols were applied to collect anthropometric measures in the youth. RESULTS: Nearly half of the adolescents (47.8%) fell below the reference range for zinc status, and 88.2% had low zinc-to-copper ratios. High probability of nutrient inadequacies were evident for protein, fat, vitamins A, B(12), C, and E. In generalized linear modeling, lowland residence was negatively associated with zinc status and the zinc-to-copper ratio, and positively correlated with selenium and copper status. Other significant correlates were: dairy livestock ownership; wife number of the youth’s mother; meat consumption; vegetable consumption; protein intake; infectious disease morbidities; BMI; and hemoglobin concentrations. DISCUSSION: In recent decades, Samburu pastoralists of northern Kenya have experienced marked dietary changes in the context of market integration, extreme drought, diminishing pasture availability, and violent civil conflict. Some children (particularly boys) successfully supplement their diets by foraging for wild foods, while others (particularly actively herding girls) may be more vulnerable.

Author(s): Dewey, Kathryn G; Wessells, K Ryan; Arnold, Charles D; Prado, Elizabeth L; Abbeddou, Souheila; Adu-Afarwuah, Seth; Ali, Hasmot; Arnold, Benjamin F; Ashorn, Per; Ashorn, Ulla; Ashraf, Sania; Becquey, Elodie; Bendabenda, Jaden; Brown, Kenneth H; Christian, Parul; Colford, John M; Dulience, Sherlie JL; Fernald, Lia CH; Galasso, Emanuela; Hallamaa, Lotta; Hess, Sonja Y; Humphrey, Jean H; Huybregts, Lieven; Iannotti, Lora L; Jannat, Kaniz; Lartey, Anna; Port, Agnes Le; Leroy, Jef L; Luby, Stephen P; Maleta, Kenneth; Matias, Susana L; Mbuya, Mduduzi NN; Mridha, Malay K; Nkhoma, Minyanga; Null, Clair; Paul, Rina R; Okronipa, Harriet; Ouedraogo, Jean-Bosco; Pickering, Amy J; Prendergast, Andrew J; Ruel, Marie; Shaikh, Saijuddin; Weber, Ann M; Wolff, Patricia; Zongrone, Amanda; Stewart, Christine P | Abstract: ABSTRACTBackgroundMeta-analyses have demonstrated that small-quantity lipid-based nutrient supplements (SQ-LNS) reduce stunting and wasting prevalence among infants and young children. Identification of subgroups who benefit most from SQ-LNS may facilitate program design.ObjectiveOur objective was to identify study-level and individual-level modifiers of the effect of SQ-LNS on child growth outcomes.MethodsWe conducted a two-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNS provided to children 6 to 24 months of age in low- and middle-income countries (n=37,066). We generated study-specific and subgroup estimates of SQ-LNS vs. control and pooled the estimates using fixed-effects models, with random-effects models as sensitivity analyses. We used random effects meta-regression to examine study-level effect modifiers. Heterogeneity was assessed using I2 and Tau2 statistics. Sensitivity analyses were conducted to examine whether results differed depending on inclusion criteria for arms within trials and types of comparisons.ResultsSQ-LNS provision decreased stunting (length-for-age z-score l −2) by 12% (relative reduction), wasting (weight-for-length (WLZ) z-score l −2) by 14%, low mid-upper arm circumference (MUAC l 125 mm or MUACZ l −2) by 18%, acute malnutrition (WLZ l −2 or MUAC l 125 mm) by 14%, underweight (weight-for-age z-score l −2) by 13%, and small head size (head-circumference z-score l −2) by 9%. Effects of SQ-LNS on growth outcomes generally did not differ by study-level characteristics including region, stunting burden, malaria prevalence, sanitation, water quality, duration of supplementation, frequency of contact or average reported compliance with SQ-LNS. Effects of SQ-LNS on stunting, wasting, low MUAC and small head size were greater among girls than among boys; effects on stunting, underweight and low MUAC were greater among later-born (vs. first-born) children; and effects on wasting and acute malnutrition were greater among children in households with improved (vs. unimproved) sanitation. Results were similar across sensitivity analyses.ConclusionsThe positive impact of SQ-LNS on growth is apparent across a wide variety of study-level contexts. Policy-makers and program planners should consider including SQ-LNS in the mix of interventions to prevent both stunting and wasting. This study was registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592.

Eggs are a rich source of multiple nutrients that support child growth and development. Provision of eggs as a complementary food may improve dietary adequacy among young children at risk for undernutrition. Our objective was to test the impact of an egg intervention on the adequacy of total nutrient intakes and micronutrient density among 6‐ to 15‐month‐old Malawian children. Children 6 to 9 months old, living in Mangochi District, Malawi, were randomly assigned to the intervention group (n = 331) receiving an egg per day or a control group (n = 329) consuming their usual diet. Dietary intakes of macronutrients, vitamins and minerals were assessed using 24‐h recalls at baseline, 3‐month midline and 6‐month endline, with repeat recalls in a subsample. Usual nutrient intake and micronutrient density distributions were modelled to estimate group means and prevalence of inadequacy. Group differences at midline and endline were tested using unequal variance t tests with bootstrapped standard errors. The egg intervention resulted in higher intakes of fat and protein and lower intakes of carbohydrates. The egg group had lower prevalence of inadequacy for selenium, vitamin A, riboflavin, vitamin B5, vitamin B12 and choline. Micronutrient density inadequacy was lower in the egg group for vitamin A and choline at midline and endline, riboflavin at midline and vitamin B5 at endline. Inadequacy of nutrient intakes or density remained highly prevalent in both groups for multiple micronutrients. Though the egg intervention increased intakes of protein and several micronutrients, total intakes and micronutrient density of multiple micronutrients remained far below recommendations.

OBJECTIVES: The purpose of the study was to assess the safety of using eggs as a nutritional intervention for stunting in infants living in a rural indigenous community in Ecuador and to further understand the prevalence of egg allergy in this population. METHODS: The Lulun Project was a randomized controlled trial conducted in a rural indigenous population in Ecuador. Infants age 6–9 months were recruited and randomly assigned to the intervention (1 egg/day; n = 80) or control (no intervention, n = 83) group. At baseline and end line, enumerators collected anthropometric, dietary intake, morbidity, and sociodemographic data along with blood samples. Symptoms of allergies were assessed, including rash, congestion, coughing or wheezing, and diarrhea. Children in the intervention group were monitored by the study team for allergy symptoms during consumption of the first study egg. All children were monitored for illness and allergy symptoms throughout the study. We used ELISA assays to determine serum anti-ovomucoid and ovalbumin IgE levels, a validated approach to identify “risk of” egg allergy. RESULTS: 131 of the children had a sufficient serum sample to be analyzed for IgE levels. Ovomucoid levels were

OBJECTIVES: To assess the potential barriers and facilitators to fish consumption during the complementary feeding period in two coastal counties of Kenya with high rates of child malnutrition. METHODS: This qualitative study was part of a mixed-methods formative research investigation to examine the role of sustainable fish production and access to fish foods in coastal communities in Kenya. Twenty in-depth interviews were conducted with primary caregivers of children less than five years (n = 12) and community health workers and nutritionists (n = 8) in Kilifi County and Kwale County. Interviews were transcribed, translated and analyzed. A conceptual framework was developed based on the analysis to illustrate major factors and pathways influencing decisions to feed fish in the complementary feeding period. RESULTS: Complementary feeding practices reported by caregivers showed a low level of fish consumption in young children and delayed introduction of fish to the diet. Findings indicate that fish consumption was impacted by factors related to accessibility, food preferences, and caregiver's knowledge and beliefs. Access to fish was driven primarily by cost, proximity to locations where different fish types were sold, gendered purchasing behavior and the seasonal availability of fish foods. In some cases, the high cost of fish outweighed positive associations or perceived nutritional benefits when deciding whether to feed fish to children. Caregivers’ knowledge, beliefs, and food preferences also impacted consumption, with mixed perceptions regarding the importance of fish as a source of protein and other nutrients. These direct factors were influenced by prominent community figures such as elder women and health workers, whose own beliefs and understandings were impacted by underlying cultural norms, potentially limiting fish consumption. CONCLUSIONS: Understanding current attitudes and beliefs toward fish consumption during the complementary feeding phase is a critical first step towards the creation of more effective policies and interventions that incorporate sustainable fish foods to address significant nutritional disparities that exist in the study population. FUNDING SOURCES: This study was supported by the United States Agency for International Development (USAID) Feed the Future Innovation Lab for Fish.

OBJECTIVES: We evaluated the availability of workplace breastfeeding (BF) supports, and the associations between these supports and BF practices among formally employed mothers in Kenya – where many women work in horticulture farms and legislation requiring workplace BF supports is being implemented. We hypothesized that the availability of supports would be associated with a higher prevalence and greater odds of exclusive breastfeeding (EBF). METHODS: We conducted repeated cross-sectional surveys among formally employed mothers at 1–4 days, 6 weeks, 14 weeks, and 36 weeks (to estimate 24 weeks) postpartum at 3 health facilities in Naivasha from Sept. 2018 to Oct. 2019, 13 months after the 2017 Kenyan Health Act, which requires workplace BF support, was passed. We evaluated the associations of workplace BF supports with EBF practices using tests of proportions and adjusted logistic regression. RESULTS: Among formally employed mothers (n = 564), reported workplace supports included on-site housing (16.8%), on-site daycare (9.4%), and private lactation spaces (2.8%). Mothers who used workplace on-site childcare were more likely to practice EBF than mothers who used community- or home-based childcare at both 6 weeks (95.7% versus 82.4%, p = 0.030) and 14 weeks (60.6% versus 22.2%, p

OBJECTIVES: Eggs are a rich source of bioavailable nutrients for children, yet have been underutilized in school feeding programs in low- and middle-income countries. The purpose of the Ze Lekòl Project was to identify contextual facilitators, barriers, and resources needed at both the school and food system levels to link local egg value chains to school feeding programs in Cap-Haïtien, Haiti. METHODS: Key stakeholder interviews (n = 23) were conducted with school principals, representatives from the Ministry of Health and Ministry of Agriculture, domestic egg producers, and egg vendors. Focus groups (n = 4) were conducted with school staff and child caregivers. Interviews and focus groups were transcribed into Haitian Creole or French, and translated into English. Using inductive and deductive coding, interviews were analyzed for factors that facilitate or hinder the potential for incorporating locally produced eggs in school feeding programs. The approach to data collection and analysis was informed by the EPIS Implementation Science framework. RESULTS: School administrators and staff described facilitators (i.e., desire for nutritious foods, acceptability of eggs), barriers (i.e., preparation methods, national school feeding program structure) and potential benefits (i.e., improved student focus, reduced caregiver burden) for including eggs in school feeding programs. Local egg producers and vendors expressed facilitators (bulk purchases, customer preference for domestic eggs) and barriers (local availability of supplies, veterinary care, political disruption) to producing and selling locally produced eggs in Cap-Haïtien. CONCLUSIONS: Locally produced eggs are an acceptable food to include in school feeding programs in Cap-Haïtien, Haiti. However, lack of sufficient infrastructure for domestic egg production prevents the ability to consistently provide the quantity of eggs needed for such programs without additional investments in domestic agriculture and school feeding programs. Findings from this study will inform interventions aimed at linking local agriculture to school feeding programs in low and middle-income countries. FUNDING SOURCES: The Washington University in St. Louis Institute for Public Health–Center for Dissemination and Implementation funded this study.

Exclusive breastfeeding (EBF) for the first 6 months of life improves survival, growth and development. In Kenya, recent legislation and policies advocate for maternity leave and workplace support for breastfeeding and breast milk expression. We conducted a qualitative study to describe factors influencing EBF for 6 months among mothers employed in commercial agriculture and tourism. We interviewed employed mothers (n = 42), alternate caregivers and employed mothers' husbands (n = 20), healthcare providers (n = 21), daycare directors (n = 22) and commercial flower farm and hotel managers (n = 16) in Naivasha, Kenya. Despite recognizing the recommended duration for EBF, employed mothers describe the early cessation of EBF in preparation for their return to work. Managers reported supporting mothers through flexible work hours and duties. Yet, few workplaces have lactation spaces, and most considered adjusting schedules more feasible than breastfeeding during work. Managers and healthcare providers believed milk expression could prolong EBF but thought mothers lack experience with pumping. The most frequently suggested interventions for improving EBF duration were to expand schedule flexibility (100% of groups), provide on‐site daycare (80% of groups) and workplace lactation rooms (60% of groups), improve milk expression education and increase maternity leave length (60% of groups). Returning to work corresponds with numerous challenges including lack of proximate or on‐site childcare and low support for and experience with milk expression. These factors currently make EBF for 6 months unattainable for most mothers in these industries. Interventions and supports to improve breastfeeding upon return to work are recommended to strengthen employed mothers' opportunity for EBF.

BackgroundSmall-quantity lipid-based nutrient supplements (SQ-LNS) reduce child stunting and provide many of the fatty acids and micronutrients that are necessary for rapid brain development that occurs during infancy and early childhood. Positive effects of SQ-LNS on developmental outcomes have been found in some trials, but not others.ObjectivesOur objectives were to generate pooled estimates of the effect of SQ-LNS, compared to control groups that received no intervention or an intervention without any nutritional supplement, on developmental outcomes (language, social-emotional, motor, and executive function), and to identify study-level and individual-level modifiers of these effects.MethodsWe conducted a two-stage meta-analysis of individual participant data from 14 intervention versus control group comparisons in 13 randomized trials of SQ-LNS provided to infants and young children age 6 to 24 months in 9 low- or middle-income countries (total n=30,024). We generated study-specific estimates of SQ-LNS vs. control groups (including main effects and subgroup estimates for individual-level effect modifiers) and pooled the estimates using fixed-effects models. We used random effects meta-regression to examine potential study-level effect modifiers.ResultsIn 11-13 intervention versus control group comparisons (n=23,588-24,561), SQ-LNS increased mean language (mean difference: 0.07 standard deviations; 95% CI: 0.04, 0.10), social-emotional (0.08; 0.05, 0.11), and motor scores (0.08; 0.05, 0.11) and reduced the prevalence of children in the lowest decile of these scores by 17% (prevalence ratio: 0.83, 95% CI 0.76, 0.91), 19% (0.81; 0.74, 0.90), and 16% (0.84; 0.77, 0.92), respectively. SQ-LNS also increased the prevalence of children walking without support at 12 months by 9% (1.09; 1.05, 1.14). Effects of SQ-LNS on language, social-emotional, and motor outcomes were larger among study populations with a higher burden (≥ 35%) of child stunting at 18 months (mean difference 0.11-0.13 SD; 8-9 comparisons) than in populations with lower stunting burden (estimates near zero). At the individual level, greater effects of SQ-LNS were found on language among children who were acutely malnourished (mean difference: 0.31) at baseline; on language (0.12), motor (0.11), and executive function (0.06) among children in households with lower socio-economic status; and on motor development among later-born children (0.11), children of older mothers (0.10), and children of mothers with lower education (0.11).ConclusionsSQ-LNS provided daily to children in the range of 6-24 months of age can be expected to result in modest, but potentially important, developmental gains, particularly in populations with high child stunting burden. Certain groups of children who experience higher risk environments, such as those from poor households or with poor baseline nutritional status, have greater potential to benefit from SQ-LNS in developmental outcomes. This study was registered at www.crd.york.ac.uk/PROSPERO as CRD42020159971.

Author(s): Prado, Elizabeth L; Maleta, Kenneth; Caswell, Bess L; George, Matthews; Oakes, Lisa M; DeBolt, Michaela C; Bragg, Megan G; Arnold, Charles D; Iannotti, Lora L; Lutter, Chessa K; Stewart, Christine P | Abstract: BACKGROUND:Eggs are a rich source of nutrients important for brain development, including choline, riboflavin, vitamins B-6 and B-12, folate, zinc, protein, and DHA. OBJECTIVE:Our objective was to evaluate the effect of the consumption of 1 egg per day over a 6-mo period on child development. METHODS:In the Mazira Project randomized controlled trial, 660 children aged 6-9 mo were randomly allocated into an intervention or control group. Eggs were provided to intervention households during twice-weekly home visits for 6 mo. Control households were visited at the same frequency. At enrollment, blinded assessors administered the Malawi Developmental Assessment Tool (MDAT), and 2 eye-tracking tasks using a Tobii-Pro X2-60 eye tracker: a visual paired comparison memory task and an Infant Orienting with Attention task. At endline, 6-mo later, blinded assessors administered the MDAT and eye-tracking tasks plus an additional elicited imitation memory task. RESULTS:At endline, intervention and control groups did not significantly differ in any developmental score, with the exception that a smaller percentage of children were delayed in fine motor development in the intervention group (10.6%) compared with the control group (16.5%; prevalence ratio: 0.59, 95% CI: 0.38-0.91). Among 10 prespecified effect modifiers for the 8 primary developmental outcomes, we found 7 significant interactions demonstrating a consistent pattern that children who were less vulnerable, for example, those with higher household wealth and maternal education, showed positive effects of the intervention. Given multiple hypothesis testing, some findings may have been due to chance. CONCLUSION:The provision of 1 egg per day had no overall effect on child development in this population of children, however, some benefits may be seen among children in less vulnerable circumstances. This trial was registered at clinicaltrials.gov as NCT03385252.

Background In many low- and middle-income countries, improvements in exclusive breastfeeding (EBF) have stalled, delaying reductions in child mortality. Maternal employment is a potential barrier to EBF. Objectives We evaluated associations between maternal employment and breastfeeding (BF) status. We compared formally and non-formally employed mothers in Naivasha, Kenya, where commercial floriculture and hospitality industries employ many women. Methods We conducted a cross-sectional survey among mothers (n = 1186) from September 2018 to October 2019 at 4 postpartum time points: at hospital discharge (n = 296) and at 6 wk (n = 298), 14 wk (n = 295), and 36 wk (to estimate BF at 24 wk; n = 297) postpartum. Mothers reported their BF status and reasons for EBF cessation. We used multivariable logistic regression models to test the association between formal maternal employment and 3 outcomes: early BF initiation (within 1 h of birth), EBF at each time point, and continued BF at 9 mo. Models were informed by a directed acyclic graph: a causal diagram used to characterize the relationship among variables that influence the independent (employment) and dependent (BF status) variables. Results EBF did not differ by employment status at hospital discharge or at 6 wk postpartum. However, formally employed mothers were less likely than those not formally employed to report EBF at 14 wk (59.0% compared with 95.4%, respectively; AOR: 0.19; 95% CI: 0.10, 0.34) and at 24 wk (19.0% compared with 49.6%, respectively; AOR: 0.25; 95% CI: 0.14, 0.44). The prevalence of continued BF at 36 wk did not differ by group (98.1% for formally employed compared with 98.5% for non-formally employed women; AOR: 0.80; 95% CI: 0.10, 6.08). The primary reasons reported for early EBF cessation were returning to work (46.5%), introducing other foods based on the child's age (33.5%), or perceived milk insufficiency (13.7%). Conclusions As more women engage in formal employment in low- and middle-income countries, additional supports to help prolong the period of EBF may be beneficial for formally employed mothers and their children.

OBJECTIVE Nutrition during pregnancy is an important modifiable determinant of fetal growth and development. This pilot study aimed to characterize the association between fetal anthropometry, fetal brain development, and maternal diet among women in Ecuador using portable ultrasound in resource-limited clinics, including measurements of brain structures not typically imaged in this setting. METHODS Pregnant women (n = 47) from four resource-limited health centers were surveyed on demographic, socioeconomic, morbidity, and dietary information. Maternal height, weight, and blood pressure were taken. A sonographer took 15 images per participant, including those standardly assessed during the fetal survey and additional brain structures identified as potentially responsive to maternal nutrition, but not part of the standard fetal survey. RESULTS Mean percentiles for all standard fetal survey measurements generated from WHO Fetal Growth Curves fell below 50%, and negative mean Z scores were found for biparietal diameter (-0.95 ± 1.11) and femur length (-0.22 ± 1.10). Generalized linear modeling adjusting for gestational age and other covariates showed frequency of seafood consumption was positively associated with fetal biparietal diameter Z score (P = 0.005), beans and legumes positively associated with femur length (P = 0.006), and a negative association was found for soda consumption and fetal head circumference (P = 0.013). CONCLUSIONS This pilot study demonstrated the feasibility of capturing images of nutrition-relevant fetal brain structures not part of the standard fetal survey in resource-limited settings using portable ultrasound. Our study revealed associations between anthropometry, brain structure size, and maternal diet demonstrating potential for prenatal nutrition research using ultrasound in the field.

The Lulun Project, a randomized controlled trial conducted in 2015, found that one egg per day for 6 months during early complementary feeding reduced stunting by 47% and increased linear growth by 0.63 length‐for‐age Z (LAZ). This follow‐up cohort study (Lulun Project II) aimed to test whether the growth effect remained in the egg intervention group compared with the control group after approximately 2 years. Mothers or caregivers from the Lulun Project were recontacted and recruited for this study. Enumerators collected data on socio‐economic and demographic factors, 24‐hr frequency of dietary intakes, morbidities, and anthropometric measures of height, weight, and head circumference using World Health Organization protocols. Statistical analyses followed the same analytical plan as Lulun Project, applying generalized linear models and regression modelling to test group differences in height‐for‐age z (HAZ) from LAZ at Lulun Project endline, and structural equation modelling for mediation. One hundred thirty‐five mother–child dyads were included in Lulun II, with 11% losses to follow‐up from endline Lulun Project. Growth faltering across all children was evident with HAZ −2.07 ± 0.91 and a stunting prevelance of 50%. Regression modelling showed no difference between egg and control groups for the HAZ outcome and other anthropometric outcomes, and significant declines in HAZ from endline Lulun Project in the egg intervention are compared with control groups. Current dietary egg intake, however, was associated with reduced growth faltering in HAZ from Lulun Project endline to Lulun Project II, independent of group assignment and through mediation, explaining 8.8% of the total effect. Findings suggest the need for a longer intervention period and ongoing nutrition support to young children during early childhood.

Background In Haiti, differences in the prevalence of anemia between urban and rural areas have been observed. Objective To identify moderating factors that may help explain the difference in the prevalence of anemia in children from poor urban vs. rural areas of Haiti. Methods This cross-sectional study used secondary data from urban and rural school-based trials that assessed the effectiveness of a nutrition intervention. The study was registered at ClinicalTrials.gov as NCT02747524. A total of 300 rural- and 981 urban- children between 2.5–13 years of age were included in this analysis. Effect modification in a binary logistic generalized linear mixed model was conducted using sample weights in SPSS® version 26. Models were adjusted for age and income. School cluster was included as random effect. Results In rural areas, stunting was more prevalent in children with anemia vs. no anemia, (16.6%, and 6.3%, P = 0.008), respectively. Also, rural children with anemia lived with fewer adults vs. rural children with no anemia, (x¯ = 2.83±1.29, and 3.30±1.54, P = 0.005), respectively. In poor urban areas, helminth morbidities were more frequent in children with anemia vs. no anemia, (21.9% vs. 13.9, P = 0.011), respectively. In the combined sample, stunting, [AOR = 2.05; 95%CI (1.32–3.18)], age [AOR = 0.89; 95%CI (0.85–0.93)], and households with more adults [AOR = 0.77; 95%CI (0.67–0.87)] were associated with anemia. Effect modification by place of residence was observed in households with more adults (t = 3.83, P Conclusions In this sample, factors associated with anemia differed in poor urban and rural children from Haiti including family structure and helminth morbidities. Stunting and lower age increased the odds of anemia in the combined sample. Family structure appears to have an important role in anemia, and further research understanding the influence of family structures in anemia is needed.

This best practice article explains a Public Health Seminar course that represents an innovative approach to public health pedagogy with demonstrated learning impacts. Reflecting many of the new Council on Education for Public Health competencies, this required course introduces incoming MPH students to the field of public health using a series of classic and contemporary cases, critically analyzed in a small group discussion format. Other modalities include succinct weekly written reflection critiques, rotating faculty discussion leaders, and a final project using various media platforms to communicate case narratives. Key pedagogical elements support students’ knowledge and skill acquisition: (1) small group discussion format, (2) case-based learning, (3) integration across MPH curriculum, and (4) communication skill building. The Public Health Seminar course offers the opportunity to motivate students early in a program, engaging them in relevant issues and providing insight into the importance of their MPH learning and public health professional practice.

This study aimed to characterize metal contaminant concentrations and assess temporal and spatial variability in the main drinking water sources of Cap-Haïtien, Haiti. Water sources from five communities were sampled in two seasons, June (2014) and October (2014), and analysed for a suite of metals. A geographic information system was used to examine the spatial distribution of sampling points. Metal concentrations were below the US Environmental Protection Agency (USEPA) primary drinking water standards. Mean manganese concentrations were comparatively higher in wells (254.5 µg/L), exceeding the USEPA secondary drinking water standard (50 µg/L). Higher mean Mg/Ca and Ba/Ca ratios (range 2.3-3.4) may indicate different interactions between seawater and groundwater throughout the year. Although metal concentrations were within the limits of the USEPA drinking water standards, emerging contaminants, such as manganese, showed concentrations in excess of recommended limits. These metals may interact with background nutritional status with potential implications for growth and development.

Objective: A matched, case–control study was conducted to examine the association between development of low birth weight (LBW) and maternal factors, including dietary intake, comorbidities, and socioeconomic factors, among women in Cap Haitien, Haiti. Design: Mothers who delivered LBW babies; defined as ≤2.5 kg, were identified by review of the medical record and matched to mothers of similar age, parity, with normal birth weight (NBW) babies. A survey was administered consisting of Women's Dietary Diversity Score (WDDS), maternal reporting of comorbidities, income, and educational level. Subjects: Women were eligible if they delivered and had newborns weighed within the last 2 years. Total study participants consisted of 32 cases and 34 controls matched for age, parity, and month of delivery. Results: Mothers who consume eggs were 78% less likely to have given birth to a LBW infant (OR 0.22 (95% CI: 0.05–0.87). Mothers with NBW babies had a nonsignificant trend towards higher WDDS. The prevalence of hypertension in mothers who were seen in the clinic at least once over the past 2 years was found to be 27%, and 78% of mothers were not aware of their diagnosis. Conclusion: Enhancing maternal nutrition during pregnancy has broad implications for reducing LBW, improving fetal health and reducing fetal predilection for chronic diseases in adulthood. Longitudinal prospective studies are needed to evaluate the selective benefit of eggs and other high-quality foods in protecting fetal growth. Efforts to improve knowledge and awareness of hypertension in Haiti should be undertaken.

ObjectiveWe aimed to assess the maternal and family determinants of four anthropometric typologies at the household level in Colombia for the years 2000, 2005 and 2010.DesignWe classified children Z-score (Z-score (>2) to assess stunting and overweight/obesity, respectively; mothers were categorized according to BMI to assess underweight (2) and overweight/obesity (≥25·0 kg/m2). At the household level, we established four final anthropometric typologies: normal, underweight, overweight and dual-burden households. Separate polytomous logistic regression models for each of the surveyed years were developed to examine several maternal and familial determinants of the different anthropometric typologies.SettingNational and sub-regional (urban and rural) representative samples from Colombia, South America.SubjectsDrawing on data from three waves of Colombia’s Demographic and Health Survey/Encuesta Nacional de Salud (DHS/ENDS), we examined individual and household information from mothers (18–49 years) and their children (birth–5 years).ResultsHigher parity was associated with an increased likelihood of overweight and dual burden. Higher levels of maternal education were correlated with lower prevalence of overweight, underweight and dual burden of malnutrition in all data collection waves. In 2010, participation in nutrition programmes for children ConclusionsResults suggest that maternal and family correlates of certain anthropometric typologies at the household level may be used to better frame policies aimed at improving social conditions and nutrition outcomes.

One in five children across the globe experience stunted growth and underdevelopment due to malnutrition. Animal-source foods (ASFs) offer the opportunity to address this problem and make significant progress towards achieving the World Health Assembly nutrition targets. Eggs and milk are among nature's first foods, providing holistic packages of nutrients and bioactive factors to support healthy growth. They are also affordable and accessible to lowresource, vulnerable populations. Biological and evolutionary rationale argues for the use of ASFs during the complementary feeding period when children are most at risk from infectious diseases and malnutrition. Dietary patterns in the evolutionary history of hominids point to the importance of ASFs for increased brain size and function. Studies also demonstrate high bioavailability of limiting nutrients, such as vitamin A, iron, zinc and fatty acids in the ASF matrix, ensuring efficient absorption and metabolism. The empirical evidence for intervention using eggs, milk and fish, however, remains somewhat limited. One recent trial in Ecuador, the Lulun Project, demonstrated that one egg per day for six months, beginning early in complementary feeding, produced a large effect on linear growth and reduced stunting risk by 47%. To sustainably build systems that support equitable and adequate ASFs in the diets of all children globally, consideration should be given to microeconomic and macroeconomic factors, 'One Health', and maintaining balance in the ecosystem. Important contributions may then be achieved through ASFs for the well-being of populations worldwide.

Small livestock and aquaculture production is thought to positively impact the livelihood security of poor rural households in low-income economies. A systematic narrative review conducted for evid...

Background: Food-based interventions can reduce the prevalence of undernutrition and improve household food security, but nutritious and accessible foods may be underutilized. In Ecuador, eggs are inexpensive and widely available, but while they are a valuable source of essential nutrients for infants and young children, medical advice and community-based information have limited their inclusion in infants' diets. Objective: A qualitative component was conducted to understand local perceptions, knowledge, and practices to complement a randomized control trial that studied the effect of introducing eggs on nutritional status and growth in infants from 6 to 9 months in rural communities in the highland province of Cotopaxi, Ecuador. Methods: The qualitative inquiry consisted of key informant interviews, focus group discussions (FGDs), and structured observations in order to understand perceptions, knowledge, and practices related to household egg consumption and to the introduction of eggs in infants’ diets. Results: The two principal findings were that: (i) eggs are an available and culturally acceptable food source although they are not always a part of the diet; and (ii) perceptions and practices related to household consumption and the introduction of eggs into the diet of infants are shaped by local knowledge and practices, which are shaped by biomedical information and advice provided by public health professionals. Conclusion: Through an effective food-based intervention that includes qualitative research and a social marketing component, the behaviors of mothers and other caregivers can be modified, enabling children to realize the nutritional advantages of early introduction of eggs into their diet.

There is a long history of oppression, poverty, and struggle for survival among the indigenous populations of the Ecuadorian Sierra. Using mixed methods, this article examines the natural resource trends creating livelihood challenges for three rural communities in the Andes of Ecuador and how those challenges are impacting the population’s livelihood security and resilience. Study results indicate that soil degradation linked to land overuse and erosion have led to decreasing agriculture production and economic hardship. This challenging dynamic has led many community members to migrate to cities in search of work and negatively impacted the health of young children and their mothers. The high prevalence of low height-for-age (59.5%), low weight-for-age (26.1%), and anaemia (78%) in children under 5 and an anaemia prevalence of 30% among mothers highlights the severity of malnutrition among the population. These results suggest the need for an intervention that sustainably addresses the agricultural production and consumption challenges faced by the three communities.

OBJECTIVES: We previously demonstrated that formal employment among mothers in Kenya is associated with a lower prevalence and odds of exclusive breastfeeding (EBF). This study evaluated the influence of maternal social support, agency, postnatal depression, and domestic violence on the association between formal employment and EBF in Naivasha, Kenya, where many women work in agricultural labor. METHODS: Using cross-sectional data (n = 1,186), we examined validated scales of social support, agency, domestic violence, and postnatal depression as effect modifiers in adjusted, stratified models of the association between employment and EBF. We hypothesized that higher social support and agency would attenuate the odds ratios that evaluated employment and EBF, and domestic violence and depression would further decrease the odds of EBF based on employment. RESULTS: Comparing formally employed to non-formally employed mothers, women with higher social support were more likely to practice EBF at 14 weeks: OR high (95%CI) = 0.22 (0.09, 0.51) and OR low = 0.12 (0.05, 0.29). The same trend was observed at 24 weeks. Among mothers with higher maternal agency compared to those with lower agency, the negative association between formal and EBF was decreased at both 14 weeks [OR high = 0.21 (0.09, 0.47) versus OR low = 0.16 (0.06, 0.44)] and 24 weeks. Comparing mothers who reported experiencing domestic violence to those who had not, the negative association between formal and EBF was increased at both 14 weeks [OR = 0.06 (0.01, 0.31) versus OR No violence = 0.18 (0.09, 0.36)] and 24 weeks. At 14 weeks, mothers with depression decreased the association between employment and EBF: [OR dep = 0.11 (0.03,0.45) versus OR no depression = 0.16 (0.08, 0.33). At 24 weeks, the employment-EBF relationship was non-significant among mothers with depression: [OR dep = 0.31 (0.08, 1.30) but remained significant among mothers without depression: OR no dep = 0.22 (0.12, 0.40). CONCLUSIONS: Among formally employed mothers, maternal social support and agency improve the employment-breastfeeding relationship, while women exposed to domestic violence or postnatal depression experienced a further decrease in the likelihood of EBF. Supportive interventions to improve EBF and other maternal health factors are needed in the postpartum period for employed mothers. FUNDING SOURCES: NIH Fogarty International Center

OBJECTIVES: Young children with complementary feeding diets that lack diversity and have low micronutrient density are at risk of iron deficiency anemia. Our objectives were to determine the impact of supplementing diets with 1 egg/day on: (1) plasma ferritin, soluble transferrin receptor (sTfR), and hemoglobin (Hb) concentrations; and (2) the prevalence of iron deficiency (ID), anemia, and iron deficiency anemia (IDA). METHODS: Children age 6–9mo in the Mangochi District of Malawi were individually randomized to receive 1 egg/day for 6mo (n = 331) or continue their usual diet (n = 329). Venous blood samples were collected at enrollment and a 6mo follow-up by assessors masked to group assignment. Plasma ferritin, sTfR, c-reactive protein (CRP), and α1-acid glycoprotein (AGP) were assessed using ELISA and hemoglobin was measured using Hemocue analyzers. Ferritin and sTfR were corrected for inflammation using CRP and AGP in linear regression models. Ferritin, sTfR, and hemoglobin concentrations were compared between groups using linear regression models, adjusting for baseline values. The prevalence ratios (PR) of ID (fer 8.3mg/L, or total body iron

Background: Obesity is rising in developing countries like India and is associated with an increase in cardiometabolic problems. Rising incomes, rapid urbanization, and mechanization have induced lifestyle changes like consumption of more obesogenic foods and sedentary habits at work and leisure, contributing to a transition from under- to over-nutrition. This study maps the prevalence of adult (15-49 years) overweight and obesity across regions and socioeconomic groups in India, and estimates its association with lifestyle, health environment, dietary patterns, diabetes, and hypertension.Methods: We employ a combination of 3 latest nationally representative datasets with over 700,000 adults. We use a linear probability regression model to identify the correlates of overweight/obesity and their relative magnitudes. We use intra-household regression to identify differences between men and women and coarsened exact matching to causally estimate the impact of obesity on diabetes and hypertension.Results: Overweight/obesity rates have increased across all states, in rural and urban areas, and for all wealth levels. Women are more likely to be overweight/obese than men, even in the same household. Improved health environment (toilets, piped water, clean cooking fuel), urban jobs, television watching, and processed snacks increase the risk of overweight/obesity. Adults who are overweight/obese have a 5.6% higher risk of diabetes and a 9.7% higher risk of hypertension.Conclusions: Our results underscore the need for policy intervention to reduce the burden of obesity and NCD’s in India.

Author(s): Stewart, Christine P; Caswell, Bess; Iannotti, Lora; Lutter, Chessa; Arnold, Charles D; Chipatala, Raphael; Prado, Elizabeth L; Maleta, Kenneth | Abstract: BackgroundStunted growth is a significant public health problem in many low-income countries.ObjectiveThe aim of this study was to evaluate the impact of 1 egg per day on child growth in rural Malawi.DesignWe conducted an individually randomized controlled trial in which 660 children aged 6-9 mo were equally allocated into an intervention (1 egg/d) or control group. Eggs were provided during twice-weekly home visits for 6 mo. Control households were visited at the same frequency. Assessors blinded to intervention group measured length, weight, head circumference, and midupper arm circumference at baseline and the 6-mo follow-up visit. To assess adherence, multipass 24-h dietary recalls were administered at baseline, 3-mo, and 6-mo visits.ResultsBetween February and July 2018, 660 children were randomly assigned into the intervention (n = 331) and control (n = 329) groups. Losses to follow-up totaled 10%. In the intervention group, egg consumption increased from 3.9% at baseline to 84.5% and 70.3% at the 3-mo and 6-mo visits, whereas in the control group, it remained below 8% at all study visits. The baseline prevalence of stunting was 14%, underweight was 8%, and wasting was 1% and did not differ by group. There was no intervention effect on length-for-age, weight-for-age, or weight-for-length z scores. There was a significantly higher head circumference for age z score of 0.18 (95% CI: 0.01, 0.34) in the egg group compared with the control group. There was a significant interaction with maternal education (P = 0.024), with an effect on length-for-age z score only among children whose mothers had higher education.ConclusionsThe provision of 1 egg per day to children in rural Malawi had no overall effect on linear growth. A background diet rich in animal source foods and low prevalence of stunting at baseline may have limited the potential impact. This trial was registered at clinicaltrials.gov as NCT03385252.