Cyclic Formula Feeding Among Infants Participating in the Special Supplemental Nutrition Program for Women, Infants, and Children.

BACKGROUND: Low-income households often experience a cyclic pattern in food availability, with acute food shortages at month end. Variations in the monthly feeding of infant formula are understudied. OBJECTIVES: This study aimed to compare the amount and frequency of formula consumed at the beginning and end of the monthly Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) assistance cycle and test associations with total energy intake and other feeding practices among infants aged 7-11 mo. METHODS: This study was conducted between May 2020 and April 2021 in the southeastern United States and involved mothers of infants participating in WIC's fully formula package. Mothers were interviewed and 24-h feeding recalls were conducted at the beginning and end of the month. We defined month beginning as 5 d following the first WIC formula purchase and month end as 5 d before the next monthly cycle. Fifty mother-infant dyads participated in single or multiple monthly cycles, totaling 98 monthly cycles. Generalized linear mixed-effects modeling was used to test differences in formula feeding at month beginning and end. RESULTS: Most participants (84%) were African American or Latino and >90% purchased all formula within 2-3 d of the WIC issuance. The energy intake from formula at month beginning was significantly higher than at month end (67.63% and 57.85%, respectively; P = 0.002), with no differences in total energy intake. The odds of infants being fed cow milk and fruit juices/drinks increased from month beginning to end (P < 0.05). CONCLUSIONS: Infants in low-income households are at risk of experiencing a cyclic feeding pattern characterized by higher formula feeding at month beginning and an increase in feeding of nonrecommended drinks at month end. The WIC program policy could review educational and distribution options to reduce cyclic formula feeding and clarify caregivers' understanding of infants' formula needs. Household-level investigations into formula management and determinants of cyclic feeding are warranted.

Es Niño o Niña?: Gender Differences in Feeding Practices and Obesity Risk among Latino Infants.

Background: Obesity prevalence is significantly higher among Latino boys than girls. Weight status at 12 mo, a significant predictor of childhood obesity, is associated with feeding practices during infancy. Objectives: The objectives were to examine breastfeeding and formula-feeding practices overall and by infant gender and to examine relations among infant gender, milk-feeding practices, and obesity risk among Latino infants over the first year of life. Methods: Latino mother-infant dyads (n = 90) were recruited from a pediatric clinic. Mothers were interviewed at regular intervals (infants aged 2, 4, 6, and 9 mo), and 24-h feeding recalls were conducted when infants were aged 6 and 9 mo. Infants' lengths and weights were retrieved from clinic records to calculate weight-for-length percentiles. A bivariate analysis was conducted to compare feeding practices by gender and mediation analysis to test whether feeding practices mediated the relation between gender and obesity risk. Results: The majority (80%) of mothers were born outside the United States. In early infancy, mixed feeding of formula and breastfeeding was common. At 6 and 9 mo of age, milk-feeding practices differed, with formula feeding more common for boys than girls. At 12 mo, 38% of infants experienced obesity risk (≥85th weight-for-length percentile). Infants' obesity risk increased by 18% per 1 oz increase in powdered formula intake. Formula intake among boys was on average 1.42 oz (in dry weight) higher than that among girls, which, in turn, mediated their increased obesity risk (IERR = 1.27, 95% confidence interval: 1.02, 1.90). Conclusions: The increased obesity risk among Latino boys compared with girls at 12 mo was explained by higher rates of formula feeding at 6 and 9 mo of age. Future investigations of cultural values and beliefs in gender-related feeding practices are warranted to understand the differences in obesity risk between Latino boys and girls.

Breastfeeding duration and associations with prevention of accelerated growth among infants from low-income, racially and ethnically diverse backgrounds.

OBJECTIVE: To describe breastfeeding rates from early to late infancy and to examine associations between breastfeeding duration and infant growth, including rapid weight gain (RWG, > 0·67 SD increase in weight-for-age Z-score), among infants from low-income, racially and ethnically diverse backgrounds. DESIGN: A short, prospective cohort study was conducted assessing breastfeeding status at infant ages 2, 4, 6, 9 and 12 months. Infant length and weight measurements were retrieved from electronic health records to calculate weight-for-length Z-scores and the rate of weight gain. SETTING: Pediatric clinic in the Southeastern USA. PARTICIPANTS: Mother-infant dyads (n = 256). RESULTS: Most participants were African American (48 %) or Latina (34 %). Eighty-one per cent were participating in the Special Supplemental Nutrition Program for Women, Infants and Children. Infants were breastfed for a median duration of 4·75 months, with partial more common than exclusive breastfeeding. At 12 months, 28 % of the participants were breastfeeding. Infants breastfed beyond 6 months had significantly lower growth trajectories than infants breastfed for 0-2 months (ß = 0·045, se = 0·013, P = 0·001) or 3-6 months (ß = 0·054, se = 0·016, P = 0·001). Thirty-six per cent of the infants experienced RWG. RWG was more common among infants who were breastfed for 2 months or less than 6+ month breastfed group (relative risk = 1·68, CI95 (1·03, 2·74), P = 0·03). CONCLUSIONS: Breastfeeding beyond 6 months is associated with the prevention of accelerated growth among infants from low-income, racially and ethnically diverse backgrounds, suggesting progress toward health equity.

Formula Feeding Is Associated with Rapid Weight Gain between 6 and 12 Months of Age: Highlighting the Importance of Developing Specific Recommendations to Prevent Overfeeding.

We examined differences in mean daily calorie intake and rapid weight gain risk among 6- to 12-month-old infants by milk feeding status: breastmilk only, breastmilk and formula (combined), or formula only. Another objective was to determine what frequency and amount of formula fed were associated with overfeeding among infants. Mother-infant dyads (n = 240) were recruited from a pediatric clinic mainly serving Medicaid recipients. At 6, 9, and 12 months of infants' age, 24 h feeding recalls were conducted using the multiple-pass method. Infant weight measurements were accessed from clinic records to estimate rapid weight gain between 6 and 12 months. Among the participants, 82% received WIC. More than half of the participants were either African American or Latino by race/ethnicity. Calorie intake among formula-only fed infants was higher than in the other two milk feeding groups. One-fourth of the infants were experiencing rapid weight gain, and the risk was 3-fold higher among formula-only fed infants. Exceeding daily calorie requirements or overfeeding was associated with both formula amount and the frequency of feeding (p < 0.01). Specific guidelines and education on formula feeding practices are critical to prevent accelerated growth among infants. Gaining further understanding on parenting style and formula feeding practices is also warranted.

Associations between early introduction to complementary foods, subsequent cereal-added bottle feeding and daily macronutrient intake among infants.

Introducing complementary foods early during infancy has been associated with an increased risk of overweight later in life, but the pathway is an understudied topic. Hence the study was conducted with low-income and primarily minority mother-infant dyads to: 1) understand how the introduction of complementary foods prior to 4 months was associated with socio-demographic characteristics and food security status; 2) determine the association between early introduction to complementary foods and breastfeeding and adding cereal into the bottle in later infancy (i.e., at 6 and 9 months), and; 3) examine how adding infant cereal into the bottle was related to daily calorie and macronutrient intake in infancy. We conducted interviews with mothers (n = 201) at 4 months of age and 24-h feeding recalls at age 6 and 9 months. Results indicated that 29% of the infants were fed complementary foods before 4 months of age. Introducing complementary foods early was negatively associated with breastfeeding and positively associated with adding cereal into the bottle at 6-months. This practice was more common among those who experienced marginal to very low levels of food security. Comparing by race/ethnicity, Latinx mothers were significantly less likely to introduce solids early. After controlling for sex, infants fed cereal in the bottle were consuming significantly more calories compared to their counterparts. Specifically, adding cereal into the bottle resulted in approximately 10% additional daily calorie intake among infants. Understanding how these feeding practices affect appetite development and weight status during infancy is warranted.

Examination of the Cameroon DHS data to investigate how water access and sanitation services are related to diarrhea and nutrition among infants and toddlers in rural households.

Undernutrition among children is a significant issue in rural areas in Cameroon, with diarrhea being one of the major contributing risk factors. To gain a better understanding of the risk factors of diarrhea, the main objective of this epidemiological study was to examine associations between water access and sanitation service with diarrhea, diet diversity, and anemia among infants and toddlers in rural households in Cameroon. The study involved household- and individual-level data of 2,129 rural-dwelling infants and toddlers from the Demographic and Health Survey database. About one-third of infants and toddlers were experiencing diarrhea, with higher odds among those who lived in households with limited water service (p = 0.028). The odds of having diarrhea were 50% higher among infants and toddlers when households did not have sanitation facilities (p = 0.007). The lack of improved water and sanitation was also associated with a low intake of various food groups among older infants and toddlers. The prevalence of anemia was high, but no significant differences were seen by water and sanitation services. The achievement of SDG #6 will help address undernutrition and achieve other SDGs, including improving health and wellbeing.

Integrated Approach in Addressing Undernutrition in Developing Countries: A Scoping Review of Integrated Water Access, Sanitation, and Hygiene (WASH) + Nutrition Interventions.

A scoping review of integrated water access, sanitation, and hygiene (WASH) plus nutrition interventions was conducted mainly to describe different components of intervention and examine their effectiveness in improving nutritional outcomes among children. Of the 8 small- to large-scale interventions, 6 were conducted in sub-Saharan Africa and the remaining 2 in South Asia. All the interventions were done in rural settings; the majority involved sanitation and hygiene deliverables along with the nutrition strategies, such as distribution of nutrition supplements. In assessing effectiveness, no significant improvements were seen in growth indicators; reduction in diarrheal rate among children was also not universal across interventions. Further strengthening of WASH, especially an improvement in "W", or water access, is warranted to ensure uptake of sanitation and hygiene behaviors and prevent the fecal-oral route among children. Improved water access will also enhance the effectiveness of nutrition initiatives, such as promoting vegetable gardening and utilization of child nutrient supplements.

A Qualitative Examination of Water Access and Related Coping Behaviors to Understand Its Link to Food Insecurity among Rural Households in the West Region in Cameroon.

Food insecurity is a significant public health issue, since it causes malnutrition and engenders millions of deaths every year. A significant association is found between water and food insecurity. However, it remains unclear what are the pathways through which water shortage impacts food insecurity. Hence, a qualitative study was conducted in rural areas in Cameroon to (1) examine water access, its management, and its daily use and (2) investigate common behavior changes and coping strategies adults used in managing limited water availability in their households. Three rounds of focus group discussions and six key informant interviews were conducted with men and women. The results demonstrated that water access was limited, involving long walking distances and making several trips to the water sources. The household size, number of adults vs. children, and presence of storage containers affected water availability and its daily use. To manage limited water, coping behaviors included skipping drinking, changing cooking plans, and recycling water. In conclusion, limited water access increases food insecurity through several pathways. Governments, policy makers, and international organizations should recognize the interwoven link between water and food security. Joint actions and collaborative efforts are needed to improve success and reduce tradeoffs in achieving Sustainable Development Goals # 2 and # 6.

Household Food Insecurity, Breastfeeding, and Related Feeding Practices in US Infants and Toddlers: Results From NHANES 2009-2014.

OBJECTIVE: To examine the relationships among food insecurity, breastfeeding, and other related feeding practices by race/ethnicity among US infants and toddlers. DESIGN: National Health and Nutrition Examination Surveys 2009-2014, a nationally representative cross-sectional survey. PARTICIPANTS: Infants and toddlers aged 0-24 months with complete data on household food security status (n = 2,069). MAIN OUTCOME MEASURES: Initiation of breastfeeding (yes or no), duration of breastfeeding, and age of introduction to foods/drinks. ANALYSIS: Differences in feeding practices by food security status were tested in survey-weighted, stratified multiple regression models. RESULTS: Breastfeeding initiation rates among non-Hispanic whites, Hispanics, and non-Hispanic blacks were estimated at 80.0%, 77.5%, and 57.4%, respectively (P < .001). A total of 43% of infants and toddlers were introduced to foods/drinks before 4 months. After adjusting for household income, education, and other covariates, food insecurity was not a significant predictor of poor feeding behaviors. CONCLUSIONS AND IMPLICATIONS: Racial/ethnic disparities existed, with non-Hispanic black infants at the highest risk for never being breastfed, nor to continue through the recommended period of breastfeeding. Food insecurity was not shown to affect breastfeeding and other infant feeding practices directly. Further investigation is needed to understand whether food insecurity, through stress and other sociostructural pathways, mediates poor infant feeding practices.

Racial/Ethnic Differences in Diet Quality and Eating Habits Among WIC Pregnant Women: Implications for Policy and Practice.

PURPOSE: One of the major federal food assistance programs, the Special Supplemental Program for Women, Infants, and Children (WIC), serves approximately 1.5 million low-income pregnant women per year; however, limited information is available on their dietary habits. This is critical because low-income women are at higher risk of gaining excess weight during pregnancy. Thus, the study objectives were to (1) determine the overall diet quality of WIC pregnant women and (2) examine diet quality and eating behaviors by race/ethnicity and other sociodemographics. DESIGN: This was a cross-sectional study. SETTING: One of the 3 WIC offices in a north-central county in North Carolina, USA. SAMPLE: Pregnant women (n = 198) in the second trimester. MEASURES: Interviews included sociodemographics, food security, diet, and eating behaviors. Diet quality was assessed by the Healthy Eating Index (HEI) 2010 scores. ANALYSIS: Descriptives, bivariate analysis, and multivariate analysis. RESULTS: Average participant age was 26 years, and the mean HEI-2010 score was 56 of maximum score of 100. Specifically, African American women consumed significantly lower servings of whole grains (ß = -1.71; 95% CI: -3.10 to -0.32; P < .05) and dairy (ß = -1.42; 95% CI: -2.51 to -0.33; P < .05) compared with non-Hispanic white women. Hispanic women scored higher in daily intake of fruits (ß = 0.98; 95% CI: 0.17-1.79; P < .05) and for consuming empty calories in moderation (ß = 1.57; 95% CI: 0.06-3.09; P < .05). Frequency of intake of fast foods/outside meals was higher among African American women (57%, P = .025). CONCLUSION: Efforts are warranted to promote optimal nutrition among WIC pregnant women. Specifically, African American women are highly vulnerable to poor dietary habits during pregnancy. Further investigation of barriers/facilitators for healthy eating is necessary to address nutrition disparities among WIC pregnant women.

Status on the Scale Development to Measure Water Insecurity Experiences at the Household Level: A Narrative Review.

Adequate and safe water is critical in promoting all 3 pillars of food security. Hence, ensuring availability of water for all is one of the 2030 Sustainable Development Goals. To monitor progress of this goal and understand the role of water in addressing food insecurity, development of a household-level water insecurity scale has become very critical. As such, using the following concept of water insecurity: inconsistent access to sufficient amount of safe and clean water for active and healthy life, several scale development studies have been conducted to measure water insecurity experiences at the household level. Hence, in this review, the science literature was evaluated to 1) describe the scale development process; 2) assess the validity results by comparing scale measurements results with the established 4 United Nations (UN) water standards on water access; and 3) examine key water- and food-related dimensions covered by the scales in measuring water insecurity at the household level. Eight published studies were identified from the following scientific databases: EBSCO, PubMed, Google Scholar, and JSTOR. Five of the 8 selected studies were conducted in sub-Saharan Africa, 2 were conducted in North and South America, and 1 was conducted in South Asia. A majority of the studies were conducted with women and included preliminary qualitative/ethnographic phases to identify scale items. Of the 4 UN water standards, the amount of water used/stored was commonly used to test the scale results. However, no consistent results were found in its association with water insecurity. In a rural setting, distance to water source was positively associated with water insecurity. Psychosocial distress/anxiety and reduced water use for hygiene were key dimensions of scale in all the studies. Rigorous research is needed to establish various levels of water insecurity, its scoring scheme, and its association with daily intake of water-an essential nutrient.

Interrelationship between food security status, home availability of variety of fruits and vegetables and their dietary intake among low-income pregnant women.

OBJECTIVE: To (i) determine differences in the availability of variety of fruits and vegetables (F&V) at home by food security status; and (ii) examine the inter-associations between food security status, availability of variety of F&V at home and frequency of F&V intake, among low-income pregnant women. Design/Setting Participants were interviewed to collect food security status, home availability of variety of F&V and frequency of F&V intake. Bivariate analyses, multivariate regression and exploratory mediation analyses were conducted using IBM SPSS Statistics version 23.0 and the PROCESS macro. SUBJECTS: Low-income pregnant women (n 198) were interviewed if they were ≥18 years of age, in the second trimester of pregnancy, and spoke English or Spanish. RESULTS: Low/very low food security was found among 43 % of participants. Compared with fully food-secure participants, very low food-secure participants reported a lower variety of fruits (P=0·028) and vegetables (P=0·058) available at home. Mediation analyses indicated that through home availability of variety of fresh F&V, food security status was associated with the daily intake of F&V (indirect effect (95 % CI): fresh fruits, -0·039 (-0·074, -0·013); fresh vegetables, -0·048 (-0·083, -0·023)). As food security worsened, the available variety of fresh F&V decreased, which was associated with lower intake. CONCLUSIONS: The study highlights the interlink between food security, home food environment and diet quality, and the importance of nutrition education intervention to promote a healthy home food environment and improved pregnancy outcomes among low-income women.

What changes upon resettlement: understanding difference in pre- and post-resettlement dietary habits among South-Asian refugees.

This study was conducted with the Montagnard refugee women (n = 42) to understand their pre-resettlement living conditions and estimate pre- and post-resettlement differences in their intake of major food groups. In-depth interviews were conducted with the participants in their homes by multilingual Montagnard women fluent in English and their tribal languages. Most of the participants did not receive education and 39% reported household incomes of $500 or less per month. Participants had a very limited or no experience in weekly food shopping and budgeting before moving to the United States. In comparison of food habits, intake of different types of meat increased upon resettlement (P < .05). Pre-resettlement food shortage experience and receiving ≥ $500 in SNAP increased the odds of high meat intake. Due to a significant shift in food choices and environment, refugees are at a higher risk of experiencing poor health after moving to the United States.

Food insecurity: its relationship to dietary intake and body weight among Somali refugee women in the United States.

OBJECTIVE: To examine the association between food insecurity, dietary intake, and body mass index among Somali refugee women living in the United States. METHODS: Cross-sectional study utilizing the snowball sampling method. RESULTS: Most (67%) participants experienced some level of food insecurity, which was common among recent arrivals and those who spoke only Somali at home (P < .05). Intake of meat and eggs was higher, whereas intake of fruits and vegetables was lower, among food insecure than secure participants. Food insecurity was positively related to overweight and obesity (odds ratio: 2.66; confidence interval: 1.25-5.69; P < .01). CONCLUSIONS AND IMPLICATIONS: Somali refugees experienced high levels of food insecurity upon resettlement. Poor dietary habits and the high overweight/obesity rate among insecure families call for future research in understanding what role family structure, cultural norms, and food preference play in predicting food security and dietary habits among Somali and overall African refugees in the United States.

Development of the Oxford Hills Healthy Moms Project using a social marketing process: a community-based physical activity and nutrition intervention for low-socioeconomic-status mothers in a rural area in Maine.

A physical activity and nutrition community intervention called the Oxford Hills Healthy Moms (OHHM) Project was developed using a multifaceted social marketing process, including review of state surveillance results, key informant interviews, and a survey and focus group discussions with low-socioeconomic-status (low-SES) mothers. This formative work was used to make key decisions on the selection of the intervention region, segmentation of the audience, and design of intervention strategies addressing multiple levels of the socioecological model. The OHHM Project aims to increase fruit and vegetable consumption and physical activity levels among low-SES mothers in the Oxford Hills region of Maine. The OHHM Project includes five components: (a) physical activity buddy program, (b) cooking club with education, (c) fruit and vegetable discount buying club with education, (d) increased access to produce vendors, and (e) increased access to places for physical activity.