A sex- and gender-based analysis of factors associated with linear growth in infants in Ecuadorian Andes.

Although female infants may have an early life biological advantage over males, gendered treatment can alter health outcomes. Ecuador has an unusually high ratio of male to female infant mortality, but gender norms have been reported to favor boys. This analysis of baseline data from the Lulun Project, a randomized controlled trial conducted in rural Andean communities of Ecuador, investigates the roles of sex and gender in undernutrition among infants 6 to 9 months of age. Twenty-four-hour recall frequencies were used to assess dietary intake. Food outcome models were analyzed as prevalence ratios calculated using a binomial distribution with a log link or robust Poisson regression. Linear regression was used to analyze the continuous growth outcome length-for-age z score. Socioeconomic and health history variables were comparable between male and female infants. Boys were more often fed liquids other than breastmilk within their first 3 days of life (17.1% vs. 5.2%, P = 0.026). Compared with girls, boys were less likely to be fed eggs by 33% (95% CI 0.46, 0.96), cheese, yogurt, or other milk products by 40% (95% CI 0.39, 0.92), yellow fruit by 44% (95% CI 0.33, 0.97), water by 37% (95% CI 0.45, 0.88), thin porridge by 29% (95% CI 0.56, 0.92), and tea without milk by 67% (95% CI 0.11, 0.99). Prevalence of boys with an adequate dietary diversity score (≥ 4) was reduced by 27% relative to girls (95% CI 0.54, 0.99). Males fared worse in length-for-age z scores (- 2.16 vs. - 1.56, P = 0.000), weight-for-age z scores (- 0.86 vs. - 0.33, P = 0.002), prevalence of stunting (50.6% vs. 23.4%, P = 0.000), and plasma concentrations of dimethylglycine (1.25 vs. 1.65 µg/mL, P = 0.021). After adjusting for demographic, caregiver perceptions of appetite, and biological factors, length-for-age z score for a male child was 0.62 units lower than for a female (95% CI - 0.98, - 0.26). Male infants were shown to receive lower quality complementary foods and have worse anthropometric measures than female infants.Trial registration clinicaltrials.gov, NCT02446873. Registered February 28, 2015, https://clinicaltrials.gov/ct2/show/NCT02446873 .

Maternal education and equity in breastfeeding: trends and patterns in 81 low- and middle-income countries between 2000 and 2019.

BACKGROUND: In low- and middle-income countries (LMICs), low levels of formal maternal educational are positively associated with breastfeeding whereas the reverse is true among women with higher levels of formal education. As such, breastfeeding has helped to reduce health equity gaps between rich and poor children. Our paper examines trends in breastfeeding and formula consumption by maternal educational in LMICs over nearly two decades. METHODS: We used 319 nationally representative surveys from 81 countries. We used WHO definitions for breastfeeding indicators and categorized maternal education into three categories: none, primary, and secondary or higher. We grouped countries according to the World Bank income groups and UNICEF regions classifications. The trend analyses were performed through multilevel linear regression to obtain average absolute annual changes in percentage points. RESULTS: Significant increases in prevalence were observed for early initiation and exclusive breastfeeding across all education categories, but more prominently in women with no formal education for early breastfeeding and in higher level educated women for exclusive breastfeeding. Small decreases in prevalence were seen mostly for women with no formal education for continued breastfeeding at 1 and 2 years. Among formula indicators, only formula consumption between 6 and 23 months decreased significantly over the period for women with primary education. Analysis by world regions demonstrated that gains in early and exclusive breastfeeding were almost universally distributed among education categories, except in the Middle East and North Africa where they decreased throughout education categories. Continued breastfeeding at 1 and 2 years increased in South Asia, Latin America and the Caribbean, and Eastern Europe and Central Asia for primary or higher education categories. Declines occurred for the group of no formal education in South Asia and nearly all education categories in the Middle East and North Africa with a decline steeper for continued breastfeeding at 2 years. With a few exceptions, the use of formula is higher among children of women at the highest education level in all regions. CONCLUSIONS: Over the course of our study, women with no formal education have worsening breastfeeding indicators compared to women with primary and secondary or higher education.

Egg intervention effect on linear growth no longer present after two years.

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.

Anemia in Bolivian children: a comparative analysis among three regions of different altitudes.

Here, we analyzed four population-based demographic and health surveys conducted in Bolivia between 1998 and 2016 to understand trends in anemia in children from 6 to 59 months of age by selected sociodemographic characteristics and three categories of altitude: low, medium, and high. Over the 18-year period, the prevalence of anemia was virtually unchanged while that in children living at high altitude increased. Anemia in children living at all three altitude categories is more than 40% and a severe public health problem according to the World Health Organization. We did not identify a single consistent risk factor for anemia in children living at high altitude compared with those living at medium or low altitude. The most consistent characteristic associated with childhood anemia across the three altitude categories was diarrhea in the last 2 weeks. Low length/height for age, an adolescent or anemic mother, a mother with no or little education, and a mother who speaks Quechua or Aymara were also risk factors. We conclude that it is necessary to review anemia policies and programs and prioritize children who are at greatest risk of developing anemia, particularly those living at high altitude. As iron deficiency appears to explain only a small part of childhood anemia, there is also a need to better understand its other causes and develop appropriate interventions.

The Lulun Project's social marketing strategy in a trial to introduce eggs during complementary feeding in Ecuador.

The Lulun Project incorporated a social marketing strategy that accompanied a randomized controlled trial (RCT) of a food-based intervention that introduced eggs into the complementary feeding diet of Ecuadorian infants. This strategy was designed to promote behaviour change, in this case, egg consumption, through voluntary prosocial behaviour, empowerment, and brand loyalty. A three-phase social marketing strategy (design, campaigns, and evaluation) contributed to our successful RTC by applying techniques drawn from marketing, publicity, design, and communications. To develop the strategy, we conducted (a) market research focused on culturally based norms, values, and local expectations; (b) a situational assessment based on the four Ps of social marketing (people, product, place, and price); and (c) fostered a creative process to develop the project's brand and communication plan. The strategy combined a communication plan, brand, and activities that were implemented in four campaigns: outreach, recruitment, promotion, and closing. Our evaluation showed that the social marketing strategy was instrumental in promoting the RCT's objectives and responding to unforeseen events and community concerns regarding the RCT. The strategy resulted in high compliance, low attrition, and infant feeding policy change, including Ecuador's Ministry of Public Health new complementary feeding guidelines for introducing eggs early in complementary feeding. Use of social marketing techniques, like those in our study, could be key for scaling up this food-based intervention-or others like it-in Ecuador and beyond.

Eggs early in complementary feeding increase choline pathway biomarkers and DHA: a randomized controlled trial in Ecuador.

Background: Choline status has been associated with stunting among young children. Findings from this study showed that an egg intervention improved linear growth by a length-for-age z score of 0.63.Objective: We aimed to test the efficacy of eggs introduced early in complementary feeding on plasma concentrations of biomarkers in choline pathways, vitamins B-12 and A, and essential fatty acids.Design: A randomized controlled trial, the Lulun ("egg" in Kichwa) Project, was conducted in a rural indigenous population of Ecuador. Infants aged 6-9 mo were randomly assigned to treatment (1 egg/d for 6 mo; n = 80) and control (no intervention; n = 83) groups. Socioeconomic data, anthropometric measures, and blood samples were collected at baseline and endline. Household visits were made weekly for morbidity surveillance. We tested vitamin B-12 plasma concentrations by using chemiluminescent competitive immunoassay and plasma concentrations of choline, betaine, dimethylglycine, retinol, essential fatty acids, methionine, dimethylamine (DMA), trimethylamine, and trimethylamine-N-oxide (TMAO) with the use of liquid chromatography-tandem mass spectrometry.Results: Socioeconomic factors and biomarker concentrations were comparable at baseline. Of infants, 11.4% were vitamin B-12 deficient and 31.7% marginally deficient at baseline. In adjusted generalized linear regression modeling, the egg intervention increased plasma concentrations compared with control by the following effect sizes: choline, 0.35 (95% CI: 0.12, 0.57); betaine, 0.29 (95% CI: 0.01, 0.58); methionine, 0.31 (95% CI: 0.03, 0.60); docosahexaenoic acid, 0.43 (95% CI: 0.13, 0.73); DMA, 0.37 (95% CI: 0.37, 0.69); and TMAO, 0.33 (95% CI: 0.08, 0.58). No significant group differences were found for vitamin B-12, retinol, linoleic acid (LA), α-linolenic acid (ALA), or ratios of betaine to choline and LA to ALA.Conclusion: The findings supported our hypothesis that early introduction of eggs significantly improved choline and other markers in its methyl group metabolism pathway. This trial was registered at clinicaltrials.gov as NCT02446873.

Eggs in Early Complementary Feeding and Child Growth: A Randomized Controlled Trial.

BACKGROUND: Eggs are a good source of nutrients for growth and development. We hypothesized that introducing eggs early during complementary feeding would improve child nutrition. METHODS: A randomized controlled trial was conducted in Cotopaxi Province, Ecuador, from March to December 2015. Children ages 6 to 9 months were randomly assigned to treatment (1 egg per day for 6 months [n = 83]) and control (no intervention [n = 80]) groups. Both arms received social marketing messages to encourage participation in the Lulun Project (lulun meaning "egg" in Kichwa). All households were visited once per week to monitor morbidity symptoms, distribute eggs, and monitor egg intakes (for egg group only). Baseline and end point outcome measures included anthropometry, dietary intake frequencies, and morbidity symptoms. RESULTS: Mothers or other caregivers reported no allergic reactions to the eggs. Generalized linear regression modeling showed the egg intervention increased length-for-age z score by 0.63 (95% confidence interval [CI], 0.38-0.88) and weight-for-age z score by 0.61 (95% CI, 0.45-0.77). Log-binomial models with robust Poisson indicated a reduced prevalence of stunting by 47% (prevalence ratio [PR], 0.53; 95% CI, 0.37-0.77) and underweight by 74% (PR, 0.26; 95% CI, 0.10-0.70). Children in the treatment group had higher dietary intakes of eggs (PR, 1.57; 95% CI, 1.28-1.92) and reduced intake of sugar-sweetened foods (PR, 0.71; 95% CI, 0.51-0.97) compared with control. CONCLUSIONS: The findings supported our hypothesis that early introduction of eggs significantly improved growth in young children. Generally accessible to vulnerable groups, eggs have the potential to contribute to global targets to reduce stunting.

Sugar-Sweetened Beverages Are the Main Sources of Added Sugar Intake in the Mexican Population.

BACKGROUND: Sugar intake has been associated with an increased prevalence of obesity, other noncommunicable diseases, and dental caries. The WHO recommends that free sugars should be <10% of total energy intake (TEI) and that additional health benefits could be obtained with a reduction below 5% of TEI. OBJECTIVE: The objective of this study was to estimate the total, intrinsic, and added sugar intake in the Mexican diet and to identify the food groups that are the main sources of these sugars. METHODS: We used data from a national probabilistic survey [ENSANUT (National Health and Nutrition Survey) 2012], which represents 3 geographic regions and urban and rural areas. Dietary information was obtained by administering a 24-h recall questionnaire to 10,096 participants. Total sugar intake was estimated by using the National Institute of Public Health (INSP) food-composition table and an established method to estimate added sugars. RESULTS: The mean intakes of total, intrinsic, and added sugars were 365, 127, and 238 kcal/d, respectively. Added sugars contributed 13% of TEI. Sugar-sweetened beverages (SSBs) were the main source of sugars, contributing 69% of added sugars. Food products high in saturated fat and/or added sugar (HSFAS) were the second main sources of added sugars, contributing 25% of added sugars. CONCLUSIONS: The average intake of added sugars in the Mexican diet is higher than WHO recommendations, which may partly explain the high prevalence of obesity and diabetes in Mexico. Because SSBs and HSFAS contribute >94% of total added sugars, strategies to reduce their intake should be strengthened. This includes stronger food labels to warn the consumer about the content of added sugars in foods and beverages.

Por que investir e o que será necessário para melhorar as práticas de amamentação? / Why invest, and what it will take to improve breastfeeding practices?

Apesar de seus benefícios estabelecidos, a amamentação não é mais uma norma em muitas comunidades. Os determinantes multifatoriais da amamentação necessitam de medidas de suporte em diversos níveis, de legislações e políticas a atitudes e valores sociais, condições de trabalho e emprego para mulheres, e serviços de saúde para possibilitar que as mulheres amamentem. Quando intervenções relevantes são oferecidas adequadamente, as práticas de amamentação são responsivas e podem melhorar rapidamente. Os melhores resultados são obtidos quando intervenções são implementadas concomitantemente por diversos canais. A propaganda de substitutos ao leite materno afeta negativamente a amamentação: as vendas em todo o mundo em 2014 de 44,8 bilhões de dólares demonstram a grande ambição competitiva da indústria com a alimentação infantil. Não amamentar está associado com menor inteligência e perdas econômicas de aproximadamente 302 bilhões de dólares anualmente ou 0,49% do produto nacional bruto mundial. A amamentação fornece, em curto e longo prazos, vantagens para a saúde, econômicas e ambientais para as crianças, mulheres e para a sociedade. Para alcançar estes ganhos, suporte político e investimento financeiro são necessários para proteger, promover e dar suporte à amamentação.

Key principles to improve programmes and interventions in complementary feeding.

Although there are some examples of successful complementary feeding programmes to promote healthy growth and prevent stunting at the community level, to date there are few, if any, examples of successful programmes at scale. A lack of systematic process and impact evaluations on pilot projects to generate lessons learned has precluded scaling up of effective programmes. Programmes to effect positive change in nutrition rarely follow systematic planning, implementation, and evaluation (PIE) processes to enhance effectiveness over the long term. As a result a set of programme-oriented key principles to promote healthy growth remains elusive. The purpose of this paper is to fill this gap by proposing a set of principles to improve programmes and interventions to promote healthy growth and development. Identifying such principles for programme success has three requirements: rethinking traditional paradigms used to promote improved infant and young child feeding; ensuring better linkages to delivery platforms; and, improving programming. Following the PIE model for programmes and learning from experiences from four relatively large-scale programmes described in this paper, 10 key principles are identified in the areas of programme planning, programme implementation, programme evaluation, and dissemination, replication, and scaling up. Nonetheless, numerous operational research questions remain, some of which are highlighted in this paper.

Characteristics attributed to complementary foods by caregivers in four countries of Latin America and the Caribbean.

BACKGROUND: Attributes that caregivers assign to complementary foods have been primarily described in the context of illness, but attributes assigned to foods in everyday circumstances must be understood to effectively promote good complementary feeding. OBJECTIVE: This study aimed to understand how mothers judge complementary foods to be appropriate by cross-cultural examination of food perceptions in four different Latin American and Caribbean countries. METHODS: We used semistructured interviews to assess attributes that mothers ascribed to a list of key foods, both home-made and manufactured, and reasons for feeding or not feeding them. We elicited attributes from 79 caregivers with children 6 to 24 months of age from two urban and perirban sites each in Brazil, Jamaica, Mexico, and Panama. RESULTS: Textual analysis based on six home foods common to the four countries and manufactured foods resulted in six attribute categories, five of which could be positive or negative (Nutrient Content, Effects on Child, Child's Response, Availability and Accessibility, and Other Food Attributes); one (Food Quality and Safety) was only negative. Analysis of attributes of home foods (chicken, eggs, beans, carrots, bananas or plantains, and oranges) revealed many beliefs that were common within and across countries, whereas analysis of the attributes of manufactured foods revealed that these foods were less known. CONCLUSIONS: The consistency of the attribute categories across countries and across home and manufactured foods suggests their relevance to planning programs to improve complementary feeding in Latin America and the Caribbean and possibly other developing countries. These results can be used programmatically to assess the need for and the focus of food education programs, and to indicate which countries will be more receptive to certain foods as a means of improving complementary feeding.

Interacción de la ingesta dietética y la enfermedad diarreica en el crecimiento de los niños / Interaction of dietary intake and diarrheal disease in the growth of children

Existe evidencia en la literatura acerca de los efectos negativos de la enfermedad diarreica, y de los efectos positivos que la suplementación alimentaria tienen en el crecimiento postnatal. En el presente estudio se analiza la naturaleza de la relación entre los efectos de la enfermedad diarreica y la suplementación alimentaria en el crecimiento de niños del medio rural de Guatemala. Los datos al respecto, aquí analizados, provienen de un estudio longitudinal de suplementación alimentaria, que el INCAP llevó a cabo en el período compreendido entre 1969 y 1977. Se encontró un efecto negativo importante de la enfermedad diarreica en el crecimiento de niños con baja ingesta dietética, de tres a 36 meses de edad. En cambio, según se constató, el efecto negativo de la enfermedad diarreica en el crecimiento fue menor en un grupo cuya dieta tuvo incrementos improtantes. A diferencia de un estudio realizado en Colombia - en el que el efecto de la suplementación alimentaria se restringe a los grupos con mayor prevalencia de diarrea - el efecto de la suplementación en el crecimiento de los niños guatemaltecos estaba presente en todos los niveles de prevalencia de enfermedad diarreica. El artículo comenta las posibles causas de los diferentes resultados encontrados en el estudio de Colombia y los del estudio aquí descrito