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1.  Blood folate concentrations among women of childbearing age by race/ethnicity and acculturation, NHANES 2001–20101 
Maternal & child nutrition  2014;12(1):39-50.
Hispanic women have higher rates of neural tube defects and report lower total folic acid intakes than non-Hispanic white (NHW) women. Total folic acid intake, which is associated with neural tube defect risk reduction, has been found to vary by acculturation factors (i.e. language preference, country of origin, or time spent in the United States) among Hispanic women. It is unknown whether this same association is present for blood folate status. The objective of this research was to assess the differences in serum and red blood cell (RBC) folate concentrations between NHW women and Mexican American (MA) women and among MA women by acculturation factors. Cross-sectional data from the 2001–2010 National Health and Nutrition Examination Survey (NHANES) were used to investigate how blood folate concentrations differ among NHW or MA women of childbearing age. The impact of folic acid supplement use on blood folate concentrations was also examined. MA women with lower acculturation factors had lower serum and RBC folate concentrations compared with NHW women and to their more acculturated MA counterparts. Consuming a folic acid supplement can minimize these disparities, but MA women, especially lower acculturated MA women, were less likely to report using supplements. Public health efforts to increase blood folate concentrations among MA women should consider acculturation factors when identifying appropriate interventions.
PMCID: PMC4514562  PMID: 24934272
acculturation; folate biomarkers; Mexican Americans; NHANES; red blood cell folate; serum folate
2.  Predictors of micronutrient powder sachet coverage in Nepal 
Maternal & child nutrition  2015;11(0 4):77-89.
Many countries implement micronutrient powder (MNP) programmes to improve the nutritional status of young children. Little is known about the predictors of MNP coverage for different delivery models. We describe MNP coverage of an infant and young child feeding and MNP intervention for children aged 6–23 months comparing two delivery models piloted in rural Nepal: distributing MNPs either by female community health volunteers (FCHVs) or at health facilities (HFs). Cross-sectional household cluster surveys were conducted in four pilot districts among mothers of children 6–23 months after starting MNP distribution. FCHVs in each cluster were also surveyed. We used logistic regression to describe predictors of initial coverage (obtaining a batch of 60 MNP sachets) at 3 months and repeat coverage (≥2 times coverage among eligible children) at 15 months after project launch. At 15 months, initial and repeat coverage were higher in the FCHV model, although no differences were observed at 3 months. Attending an FCHV-led mothers’ group meeting where MNP was discussed increased odds of any coverage in both models at 3 months and of repeat coverage in the HF model at 15 months. Perceiving ≥1 positive effects in the child increased odds of repeat coverage in both delivery models. A greater portion of FCHV volunteers from the FCHV model vs. the HF model reported increased burden at 3 and 15 months (not statistically significant). Designing MNP programmes that maximise coverage without overburdening the system can be challenging and more than one delivery model may be needed.
PMCID: PMC4762178  PMID: 26332845
coverage; micronutrient powder; nutritional supplementation; monitoring; delivery models; children’s nutrition; anaemia; iron deficiency
3.  Adolescent girls' infant and young child nutrition knowledge levels and sources differ among rural and urban samples in Bangladesh 
Maternal & Child Nutrition  2016;12(4):885-897.
In many low‐income countries, girls marry early and have children very soon after marriage. Although conveying infant and young child nutrition (IYCN) knowledge to adolescent girls in time is important to ensure the well‐being of their children, little is known about the best ways to convey these messages. This study examines the extent of, and sources from which adolescent girls derive IYCN knowledge in order to inform the design of programmes that convey such information. Data on adolescent girls aged 12–18 was collected in 2013 in 140 clusters of villages in rural areas (n = 436), and 70 clusters of slums in urban areas (n = 345) in Bangladesh. Data were analysed using multivariable Poisson regression models. In both the urban and rural samples, girls' schooling is positively and significantly associated with IYCN knowledge (P < 0.01 and P < 0.10, respectively). IYCN knowledge of adolescent girls' mothers is also associated with adolescents' IYCN knowledge in both urban and rural samples, but the magnitude of association in the urban sample is only half that of the rural sample (P < 0.01 and P < 0.10, respectively). In Bangladesh, efforts to improve knowledge regarding IYCN are typically focused on mothers of young children. Only some of this knowledge is passed onto adolescent girls living in the same household. As other messaging efforts directed towards mothers have only small, or no association with adolescent girls' knowledge of IYCN, improving adolescent girls' IYCN knowledge may require information and messaging specifically directed towards them. © 2016 John Wiley & Sons Ltd
PMCID: PMC5095776  PMID: 27515279
adolescent girls; child feeding knowledge; nutrition knowledge; Bangladesh
4.  How multiple episodes of exclusive breastfeeding impact estimates of exclusive breastfeeding duration: report from the eight‐site MAL‐ED birth cohort study 
Maternal & Child Nutrition  2016;12(4):740-756.
The duration of exclusive breastfeeding (EBF) is often defined as the time from birth to the first non‐breast milk food/liquid fed (EBFLONG), or it is estimated by calculating the proportion of women at a given infant age who EBF in the previous 24 h (EBFDHS). Others have measured the total days or personal prevalence of EBF (EBFPREV), recognizing that although non‐EBF days may occur, EBF can be re‐initiated for extended periods. We compared breastfeeding metrics in the MAL‐ED study; infants' breastfeeding trajectories were characterized from enrollment (median 7 days, IQR: 4, 12) to 180 days at eight sites. During twice‐weekly surveillance, caretakers were queried about infant feeding the prior day. Overall, 101 833 visits and 356 764 child days of data were collected from 1957 infants. Median duration of EBFLONG was 33 days (95% CI: 32–36), compared to 49 days based on the EBFDHS. Median EBFPREV was 66 days (95% CI: 62–70). Differences were because of the return to EBF after a non‐EBF period. The median number of returns to EBF was 2 (IQR: 1, 3). When mothers re‐initiated EBF (second episode), infants gained an additional 18.8 days (SD: 25.1) of EBF, and gained 13.7 days (SD: 18.1) (third episode). In settings where women report short gaps in EBF, programmes should work with women to return to EBF. Interventions could positively influence the duration of these additional periods of EBF and their quantification should be considered in impact evaluation studies. © 2016 John Wiley & Sons Ltd
PMCID: PMC5095788  PMID: 27500709
exclusive breastfeeding; duration; DHS; prevalence; metrics; MAL‐ED; Nepal; Bangladesh; Pakistan; India; Brazil; Peru; Tanzania; South Africa
5.  Maximizing the benefits and minimizing the risks of intervention programs to address micronutrient malnutrition: symposium report 
Maternal & Child Nutrition  2016;12(4):940-948.
Interventions to address micronutrient deficiencies have large potential to reduce the related disease and economic burden. However, the potential risks of excessive micronutrient intakes are often not well determined. During the Global Summit on Food Fortification, 9–11 September 2015, in Arusha, a symposium was organized on micronutrient risk–benefit assessments. Using case studies on folic acid, iodine and vitamin A, the presenters discussed how to maximize the benefits and minimize the risks of intervention programs to address micronutrient malnutrition. Pre‐implementation assessment of dietary intake, and/or biomarkers of micronutrient exposure, status and morbidity/mortality is critical in identifying the population segments at risk of inadequate and excessive intake. Dietary intake models allow to predict the effect of micronutrient interventions and their combinations, e.g. fortified food and supplements, on the proportion of the population with intakes below adequate and above safe thresholds. Continuous monitoring of micronutrient intake and biomarkers is critical to identify whether the target population is actually reached, whether subgroups receive excessive amounts, and inform program adjustments. However, the relation between regular high intake and adverse health consequences is neither well understood for many micronutrients, nor do biomarkers exist that can detect them. More accurate and reliable biomarkers predictive of micronutrient exposure, status and function are needed to ensure effective and safe intake ranges for vulnerable population groups such as young children and pregnant women. Modelling tools that integrate information on program coverage, dietary intake distribution and biomarkers will further enable program makers to design effective, efficient and safe programs.
PMCID: PMC5095875  PMID: 27501994
micronutrient malnutrition; public health; nutritional interventions; food fortification; nutritional supplements; risk–benefit assessment
6.  Breast pumps as an incentive for breastfeeding: a mixed methods study of acceptability 
Maternal & Child Nutrition  2016;12(4):726-739.
Increasing breastfeeding rates would improve maternal and child health, but multiple barriers to breastfeeding persist. Breast pump provision has been used as an incentive for breastfeeding, although effectiveness is unclear. Women's use of breast pumps is increasing and a high proportion of mothers express breastmilk. No research has yet reported women's and health professionals' perspectives on breast pumps as an incentive for breastfeeding. In the Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS) study, mixed methods research explored women's and professionals' views of breast pumps as an incentive for breastfeeding. A survey of health professionals across Scotland and North West England measured agreement with ‘a breast pump costing around £40 provided for free on the NHS’ as an incentive strategy. Qualitative interviews and focus groups were conducted in two UK regions with a total of 68 participants (pregnant women, new mothers, and their significant others and health professionals) and thematic analysis undertaken. The survey of 497 health professionals found net agreement of 67.8% (337/497) with the breast pump incentive strategy, with no predictors of agreement shown by a multiple ordered logistic regression model. Qualitative research found interrelated themes of the ‘appeal and value of breast pumps’, ‘sharing the load’, ‘perceived benefits’, ‘perceived risks’ and issues related to ‘timing’. Qualitative participants expressed mixed views on the acceptability of breast pumps as an incentive for breastfeeding. Understanding the mechanisms of action for pump type, timing and additional support required for effectiveness is required to underpin trials of breast pump provision as an incentive for improving breastfeeding outcomes. © 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.
PMCID: PMC5096021  PMID: 27502101
Incentives; breastfeeding; breast milk expression; breast pump; acceptability
7.  Exposure to mass media and interpersonal counseling has additive effects on exclusive breastfeeding and its psychosocial determinants among Vietnamese mothers 
Maternal & Child Nutrition  2016;12(4):713-725.
The pathways through which behavior change interventions impact breastfeeding practices have not been well studied. This study aimed to examine: (1) the effects of exposure to mass media and interpersonal counseling on exclusive breastfeeding (EBF) and hypothesized psychosocial determinants (i.e. knowledge, intention, beliefs, social norms, and self‐efficacy); and (2) the pathways through which exposure to mass media and interpersonal counseling are associated with EBF. We used survey data from mothers with children < 2 year (n = 2045) from the 2013 process evaluation of Alive & Thrive's program in Viet Nam. Multiple linear regression analyses and structural equation modeling were used to estimate effects. Exposure to mass media only, interpersonal counseling only, both or neither was 51%, 5%, 19% and 25%, respectively. Exposure to both mass media and interpersonal counseling had additive effects on EBF as well as on related psychosocial factors, compared with no exposure. For example, EBF prevalence was 26.1 percentage points (pp) higher in the group that received interpersonal counseling only, 3.9 pp higher in the mass media group and 31.8 pp higher in the group that received both interventions. As hypothesized, more than 90% of the total effect of the two interventions on EBF was explained by the psychosocial factors measured. Our findings suggest that combining different behavior change interventions leads to greater changes in psychosocial factors, which in turn positively affects breastfeeding behaviors.
PMCID: PMC5094561  PMID: 27334544
breastfeeding; interpersonal counseling; mass media; psychosocial determinants; Viet Nam
8.  Breastfeeding and child development outcomes: an investigation of the nurturing hypothesis 
Maternal & child nutrition  2015;12(4):757-767.
This study investigated whether the nurturing hypothesis – that breastfeeding serves as a proxy for family socio-economic characteristics and parenting behaviours – accounts for the association of breastfeeding with children’s academic abilities. Data used were from the Child Development Supplement of the Panel Study of Income Dynamics, which followed up a cohort of 3563 children aged 0–12 in 1997. Structural equation modelling simultaneously regressed outcome variables, including three test scores of academic ability and two subscales of behaviour problems, on the presence and duration of breastfeeding, family socio-economic characteristics, parenting behaviours and covariates. Breastfeeding was strongly related to all three tests scores but had no relationships with behaviour problems. The adjusted mean differences in the Letter–Word Identification, Passage Comprehension) and Applied Problems test scores between breastfed and non-breastfed children were 5.14 [95% confidence interval (CI): 3.14, 7.14], 3.46 (95% CI: 1.67, 5.26) and 4.24 (95% CI: 2.43, 6.04), respectively. Both socio-economic characteristics and parenting behaviours were related to higher academic test scores and were associated with a lower prevalence of externalising and internalising behaviour problems. The associations of breastfeeding with behaviour problems are divergent from those of socio-economic characteristics and parenting behaviours. The divergence suggests that breastfeeding may not be a proxy of socio-economic characteristics and parenting behaviours, as proposed by the nurturing hypothesis. The mechanism of breastfeeding benefits is likely to be different from those by which family socio-economic background and parenting practices exert their effects. Greater clarity in understanding the mechanisms behind breastfeeding benefits will facilitate the development of policies and programs that maximise breastfeeding’s impact.
PMCID: PMC5087141  PMID: 26194444
academic ability; breastfeeding; behaviour problems; child development
9.  Stop stunting: Pakistan perspective on how this could be realized†  
Maternal & Child Nutrition  2016;12(Suppl Suppl 1):253-256.
PMCID: PMC5084728  PMID: 27187923
10.  Stunting in Nepal: looking back, looking ahead†  
Maternal & Child Nutrition  2016;12(Suppl Suppl 1):257-259.
PMCID: PMC5084730  PMID: 27187924
11.  Reducing stunting by improving maternal, infant and young child nutrition in regions such as South Asia: evidence, challenges and opportunities 
Maternal & Child Nutrition  2016;12(Suppl Suppl 1):27-38.
Meeting the high nutrient needs of pregnant and lactating women and their young children in regions such as South Asia is challenging because diets are dominated by staple foods with low nutrient density and poor mineral bioavailability. Gaps in nutritional adequacy in such populations probably date back to the agricultural revolution ~10 000 years ago. Options for improving diets during the first 1000 days include dietary diversification and increased intake of nutrient‐rich foods, improved complementary feeding practices, micronutrient supplements and fortified foods or products specifically designed for these target groups. Evidence from intervention trials indicates that several of these strategies, both prenatal and post‐natal, can have a positive impact on child growth, but results are mixed and a growth response is not always observed. Nutrition interventions, by themselves, may not result in the desired impact if the target population suffers from frequent infection, both clinical and subclinical. Further research is needed to understand the mechanisms underlying both prenatal and post‐natal growth restriction. In the meantime, implementation and rigorous evaluation of integrated interventions that address the multiple causes of stunting is a high priority. These intervention packages should ideally include improved nutrition during both pregnancy and the post‐natal period, prevention and control of prenatal and post‐natal infection and subclinical conditions that restrict growth, care for women and children and stimulation of early child development. In regions such as South Asia, such strategies hold great promise for reducing stunting and enhancing human capital formation.
PMCID: PMC5084734  PMID: 27187908
child growth; complementary feeding; maternal nutrition; micronutrient malnutrition; nutritional interventions; stunting
12.  Understanding the null‐to‐small association between increased macroeconomic growth and reducing child undernutrition in India: role of development expenditures and poverty alleviation 
Maternal & Child Nutrition  2016;12(Suppl Suppl 1):196-209.
Empirical evidence suggests that macroeconomic growth in India is not correlated with any substantial reductions in the prevalence of child undernutrition over time. This study investigates the two commonly hypothesized pathways through which macroeconomic growth is expected to reduce child undernutrition: (1) an increase in public developmental expenditure and (2) a reduction in aggregate income‐poverty levels. For the anthropometric data on children, we draw on the data from two cross‐sectional waves of National Family Health Survey conducted in 1992–1993 and 2005–2006, while the data for per capita net state domestic product and per capita public spending on developmental expenditure and headcount ratio of poverty were obtained from the Reserve Bank of India and the Government of India expert committee reports. We find that between 1992–1993 and 2005–2006, state‐level macroeconomic growth was not associated with any substantial increases in public development expenditure or substantial reductions in poverty at the aggregate level. Furthermore, the association between changes in public development expenditure or aggregate poverty and changes in undernutrition was small. In summary, it appears that the inability of macroeconomic growth to translate into reductions in child undernutrition in India is likely a consequence of the macroeconomic growth not translating into substantial investments in development expenditure that could matter for children's nutritional status and neither did it substantially improve incomes of the poor, a group where undernutrition is also the highest. The findings here build a case to advocate a ‘support‐led’ strategy for reducing undernutrition rather than simply relying on a ‘growth‐mediated’ strategy.
Key messages Increases in macroeconomic growth have not been accompanied by substantial increases in public developmental spending or reduction in aggregate poverty headcount ratio in India.Association between increases in public development expenditure or poverty headcount ratios and changes in child undernutrition, in particular, child stunting, is small to null.Reducing the burden of undernutrition in India cannot be accomplished solely relying on a growth‐mediated strategy, and a concerted support‐led strategy is required.
PMCID: PMC5084736  PMID: 27187916
stunting; undernutrition; economic growth; poverty; development expenditure; growth‐mediated strategy; support‐led strategy; India
13.  Rethinking policy perspectives on childhood stunting: time to formulate a structural and multifactorial strategy 
Maternal & Child Nutrition  2016;12(Suppl Suppl 1):219-236.
Stunting and chronic undernutrition among children in South Asia remain a major unresolved global health issue. There are compelling intrinsic and moral reasons to ensure that children attain their optimal growth potential facilitated via promotion of healthy living conditions. Investments in efforts to ensure that children's growth is not faltered also have substantial instrumental benefits in terms of cognitive and economic development. Using the case of India, we critique three prevailing approaches to reducing undernutrition among children: an over‐reliance on macroeconomic growth as a potent policy instrument, a disproportionate focus on interpreting undernutrition as a demand‐side problem and an over‐reliance on unintegrated single‐factorial (one at a time) approaches to policy and research. Using existing evidence, we develop a case for support‐led policy approach with a focus on integrated and structural factors to addressing the problem of undernutrition among children in India. Key messages Eliminating child undernutrition is important from an intrinsic perspective and offers considerable instrumental benefits to individual and society.Evidence suggests that an exclusive reliance on a growth‐mediated strategy to eliminate stunting needs to be reconsidered, suggesting the need for a substantial support‐led strategy.Interpreting and addressing undernutrition as a demand‐side problem with proximal single‐factorial interventions is futile.There is an urgent need to develop interventions that address the broader structural and upstream causes of child undernutrition.
PMCID: PMC5084745  PMID: 27187918
stunting; undernutrition; childhood; cognition; economic growth; support‐led strategy; social determinants; upstream interventions; multifactorial; India
14.  Improving women's nutrition imperative for rapid reduction of childhood stunting in South Asia: coupling of nutrition specific interventions with nutrition sensitive measures essential 
Maternal & Child Nutrition  2016;12(Suppl Suppl 1):72-90.
The implications of direct nutrition interventions on women's nutrition, birth outcome and stunting rates in children in South Asia are indisputable and well documented. In the last decade, a number of studies present evidence of the role of non‐nutritional factors impacting on women's nutrition, birth outcome, caring practices and nutritional status of children. The implications of various dimensions of women's empowerment and gender inequality on child stunting is being increasingly recognised. Evidence reveals the crucial role of early age of marriage and conception, poor secondary education, domestic violence, inadequate decision‐making power, poor control over resources, strenuous agriculture activities, and increasing employment of women and of interventions such as cash transfer scheme and microfinance programme on undernutrition in children. Analysis of the nutrition situation of women and children in South Asia and programme findings emphasise the significance of reaching women during adolescence, pre‐conception and pregnancy stage. Ensuring women enter pregnancy with adequate height and weight and free from being anemic is crucial. Combining nutrition‐specific interventions with measures for empowerment of women is essential. Improvement in dietary intake and health services of women, prevention of early age marriage and conception, completion of secondary education, enhancement in purchasing power of women, reduction of work drudgery and elimination of domestic violence deserve special attention. A range of programme platforms dealing with health, education and empowerment of women could be strategically used for effectively reaching women prior to and during pregnancy to accelerate reduction in stunting rates in children in South Asia.
PMCID: PMC5084747  PMID: 27187909
women's nutrition and anthropometry; low birth weight; IUGR; stunting; women's empowerment; nutrition specific; nutrition‐influencing factors
16.  Reducing stunting in Bhutan: an achievable national goal†  
Maternal & Child Nutrition  2016;12(Suppl Suppl 1):246-248.
PMCID: PMC5084760  PMID: 27187921
17.  Childhood stunting: a global perspective 
Maternal & Child Nutrition  2016;12(Suppl Suppl 1):12-26.
Childhood stunting is the best overall indicator of children's well‐being and an accurate reflection of social inequalities. Stunting is the most prevalent form of child malnutrition with an estimated 161 million children worldwide in 2013 falling below −2 SD from the length‐for‐age/height‐for‐age World Health Organization Child Growth Standards median. Many more millions suffer from some degree of growth faltering as the entire length‐for‐age/height‐for‐age z‐score distribution is shifted to the left indicating that all children, and not only those falling below a specific cutoff, are affected. Despite global consensus on how to define and measure it, stunting often goes unrecognized in communities where short stature is the norm as linear growth is not routinely assessed in primary health care settings and it is difficult to visually recognize it. Growth faltering often begins in utero and continues for at least the first 2 years of post‐natal life. Linear growth failure serves as a marker of multiple pathological disorders associated with increased morbidity and mortality, loss of physical growth potential, reduced neurodevelopmental and cognitive function and an elevated risk of chronic disease in adulthood. The severe irreversible physical and neurocognitive damage that accompanies stunted growth poses a major threat to human development. Increased awareness of stunting's magnitude and devastating consequences has resulted in its being identified as a major global health priority and the focus of international attention at the highest levels with global targets set for 2025 and beyond. The challenge is to prevent linear growth failure while keeping child overweight and obesity at bay.
PMCID: PMC5084763  PMID: 27187907
stunting; malnutrition; infant and child growth; child development; healthy growth
18.  Imperatives for reducing child stunting in Bangladesh†  
Maternal & Child Nutrition  2016;12(Suppl Suppl 1):242-245.
PMCID: PMC5084789  PMID: 27187920
19.  Stop stunting: improving child feeding, women's nutrition and household sanitation in South Asia 
Maternal & Child Nutrition  2016;12(Suppl Suppl 1):3-11.
The latest available data indicate that 38% of South Asia's children aged 0–59 months are stunted. Such high prevalence combined with the region's large child population explain why South Asia bears about 40% of the global burden of stunting. Recent analyses indicate that the poor diets of children in the first years of life, the poor nutrition of women before and during pregnancy and the prevailing poor sanitation practices in households and communities are important drivers of stunting, most likely because of underlying conditions of women's status, food insecurity, poverty, and social inequalities. With this evidence in mind, UNICEF Regional Office for South Asia convened the Regional Conference: Stop Stunting: Improving Child Feeding, Women's Nutrition, and Household Sanitation in South Asia (New Delhi, November 10–12, 2014). The Conference provided a knowledge‐for‐action platform with three objectives: (1) share state‐of‐the‐art research findings on the causes of child stunting and its consequences for child growth and development and the sustainable growth and development of nations; (2) discuss better practices and the cost and benefits of scaling up programmes to improve child feeding, women's nutrition, and household sanitation in South Asia; and (3) identify implications for sectoral and cross‐sectoral policy, programme, advocacy and research to accelerate progress in reducing child stunting in South Asia. This overview paper summarizes the rationale for the focus on improving child feeding, women's nutrition, and household sanitation as priority areas for investment to prevent child stunting in South Asia. It builds on the invited papers presented at or developed as a follow on to the Stop Stunting Conference.
PMCID: PMC5084809  PMID: 27187906
stunting; child feeding; women's nutrition; household sanitation; South Asia
20.  Reducing stunting in India: what investments are needed?*  
Maternal & Child Nutrition  2016;12(Suppl Suppl 1):249-252.
PMCID: PMC5084813  PMID: 27187922
21.  Evidence‐based evolution of an integrated nutrition‐focused agriculture approach to address the underlying determinants of stunting 
Maternal & Child Nutrition  2016;12(Suppl Suppl 1):155-168.
Despite progress in reducing hunger and malnutrition since the 1990s, many still suffer from undernutrition and food insecurity, particularly women and young children, resulting in preterm birth, low birthweight and stunting, among other conditions. Helen Keller International (HKI) has addressed malnutrition and household food insecurity through implementation of an Enhanced Homestead Food Production (EHFP) programme that increases year‐round availability and intake of diverse micronutrient‐rich foods and promotes optimal nutrition and hygiene practices among poor households. This paper reviews the evolution and impact of HKI's EHFP programme and identifies core components of the model that address the underlying determinants of stunting. To date, evaluations of EHFP have shown impact on food production, consumption by women and children and household food security. Sale of surplus produce has increased household income, and the use of a transformative gender approach has empowered women. EHFP has also realized nutrition improvements in many project sites. Results from a randomized control trial (RCT) in Baitadi district, Nepal showed a significant improvement in a range of practices known to impact child growth, although no impact on stunting. Additional non‐RCT evaluations in Kailali district of Nepal, demonstrated a 10.5% reduction in stunting and in the Chittagong Hill Tracts in Bangladesh, revealed an 18% decrease in stunting. Based on evidence, the EHFP has evolved into an integrated package that includes agriculture, nutrition, water/hygiene/sanitation, linkages to health care, women's empowerment, income generation and advocacy. Closing the stunting gap requires long‐term exposure to targeted multi‐sectoral solutions and rigorous evaluation to optimize impact.
PMCID: PMC5084820  PMID: 27187913
stunting; nutrition‐sensitive agriculture; homestead food production
22.  Determinants of stunting and poor linear growth in children under 2 years of age in India: an in‐depth analysis of Maharashtra's comprehensive nutrition survey 
Maternal & Child Nutrition  2016;12(Suppl Suppl 1):121-140.
We use a representative sample of 2561 children 0–23 months old to identify the factors most significantly associated with child stunting in the state of Maharashtra, India. We find that 22.7% of children were stunted, with one‐third (7.4%) of the stunted children severely stunted. Multivariate regression analyses indicate that children born with low birthweight had a 2.5‐fold higher odds of being stunted [odds ratio (OR) 2.49; 95% confidence interval (CI) 1.96–3.27]; children 6–23 months old who were not fed a minimum number of times/day had a 63% higher odds of being stunted (OR 1.63; 95% CI 1.24–2.14); and lower consumption of eggs was associated with a two‐fold increased odds of stunting in children 6–23 months old (OR 2.07; 95% CI 1.19–3.61); children whose mother's height was < 145 cm, had two‐fold higher odds of being stunted (OR 2.04; 95% CI 1.46–2.81); lastly, children of households without access to improved sanitation had 88% higher odds of being severely stunted (OR 1.88; 95% CI 1.17–3.02). Attained linear growth (height‐for‐age z‐score) was significantly lower in children from households without access to improved sanitation, children of mothers without access to electronic media, without decision making power regarding food or whose height was < 145 cm, children born with a low birthweight and children 6–23 months old who were not fed dairy products, fruits and vegetables. In Maharashtra children's birthweight and feeding practices, women's nutrition and status and household sanitation and poverty are the most significant predictors of stunting and poor linear growth in children under 2 years.
Key messages One in five (22.7%) of children 0–23 months old in the state of Maharashtra were stunted, and one‐third (7.4%) of the stunted children were severely stunted.Birthweight, child feeding, women's nutrition and household sanitation were the most significant predictors of stunting and poor linear growth in children under 2 years.Children born to mothers whose height was below 145 cm, had two‐fold higher odds of being stunted; children born with a low birthweight had a 2.5‐fold higher odds of being stunted.Low feeding frequency and low consumption of eggs, dairy products, fruits and vegetables were associated with stunting and poor linear growth in children 6–23 months old.Children of households without access to improved sanitation had 88% higher odds of being severely stunted.
PMCID: PMC5084823  PMID: 27187911
stunting; linear growth; children; Maharashtra; India
23.  Can water, sanitation and hygiene help eliminate stunting? Current evidence and policy implications 
Maternal & Child Nutrition  2016;12(Suppl Suppl 1):91-105.
Stunting is a complex and enduring challenge with far‐reaching consequences for those affected and society as a whole. To accelerate progress in eliminating stunting, broader efforts are needed that reach beyond the nutrition sector to tackle the underlying determinants of undernutrition. There is growing interest in how water, sanitation and hygiene (WASH) interventions might support strategies to reduce stunting in high‐burden settings, such as South Asia and sub‐Saharan Africa. This review article considers two broad questions: (1) can WASH interventions make a significant contribution to reducing the global prevalence of childhood stunting, and (2) how can WASH interventions be delivered to optimize their effect on stunting and accelerate progress? The evidence reviewed suggests that poor WASH conditions have a significant detrimental effect on child growth and development resulting from sustained exposure to enteric pathogens but also due to wider social and economic mechanisms. Realizing the potential of WASH to reduce stunting requires a redoubling of efforts to achieve universal access to these services as envisaged under the Sustainable Development Goals. It may also require new or modified WASH strategies that go beyond the scope of traditional interventions to specifically address exposure pathways in the first 2 years of life when the process of stunting is concentrated.
PMCID: PMC5084825  PMID: 27187910
sanitation; water; stunting; child nutrition; child public health; early growth
24.  Drivers of nutritional change in four South Asian countries: a dynamic observational analysis 
Maternal & Child Nutrition  2016;12(Suppl Suppl 1):210-218.
This paper quantifies the factors explaining long‐term improvements in child height for age z‐scores in Bangladesh (1996/1997–2011), India (1992/1993–2005/2006), Nepal (1997–2011) and Pakistan (1991–2013). We apply the same statistical techniques to data from a common data source from which we have extracted a set of common explanatory variables that capture ‘nutrition‐sensitive’ factors. Three are particularly important in explaining height for age z‐score changes over these timeframes: improvements in material well‐being; increases in female education; and improvements in sanitation. These factors have comparable associations across all four countries.
PMCID: PMC5084796  PMID: 27187917
chronic malnutrition; economics constraints; infant and child nutrition; international child health nutrition; low income countries; socioeconomic factors
25.  Promotion and consumption of commercially produced foods among children: situation analysis in an urban setting in Senegal 
Maternal & Child Nutrition  2016;12(Suppl Suppl 2):64-76.
This study assessed the promotion of commercially produced foods and consumption of these products by children less than 24 months of age in Dakar Department, Senegal. Interviews with 293 mothers of children attending child health clinics assessed maternal exposure to promotion and maternal recall of foods consumed by the child on the preceding day. Promotion of breastmilk substitutes and commercially produced complementary foods outside health facilities was common with 41.0% and 37.2% of mothers, respectively, reporting product promotions since the birth of their youngest child. Promotion of commercially produced snack food products was more prevalent, observed by 93.5% of mothers. While all mothers reported having breastfed their child, only 20.8% of mothers breastfed their newborn within the first hour after delivery, and 44.7% fed pre‐lacteal feeds in the first 3 days after delivery. Of children 6–23 months of age, 20.2% had consumed a breastmilk substitute; 49.1% ate a commercially produced complementary food, and 58.7% ate a commercially produced snack food product on the previous day. There is a need to stop the promotion of breastmilk substitutes, including infant formula, follow‐up formula, and growing‐up milks. More stringent regulations and enforcement could help to eliminate such promotion to the public through the media and in stores. Promotion of commercial snack foods is concerning, given the high rates of consumption of such foods by children under the age of 2 years. Efforts are needed to determine how best to reduce such promotion and encourage replacement of these products with more nutritious foods.
PMCID: PMC5071683  PMID: 27061957
complementary foods; complementary feeding; breast milk substitutes; infant feeding; infant and child nutrition; child feeding

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