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Background: Solomon Islands (SI) mandated wheat flour fortification in 2010. Rice is a key staple food in SI, and its fortification may provide an opportunity to deliver additional micronutrients to the population., Objective: To determine whether fortified rice (proposed) and fortified wheat flour potentially benefit women of reproductive age (WRA)., Methods: We analyzed data from the 2012-2013 Household Income and Expenditure Survey to quantify food purchases, which served as a proxy for food consumption. We accounted for varied household composition by using adult male equivalent (AME) adjustments., Results: Among 4478 households, 95.6% purchased rice and 86.6% purchased at least 1 food containing fortified wheat flour in the previous 14 days. Median apparent intake of rice among WRA was 205 g/d/AME. If fortified according to proposed standards, this apparent intake could result in the consumption of 12.3 mg iron/d, fulfilling 44% of the estimated average requirement (EAR), and 226 µg folic acid/d, satisfying 57% of World Health Organization's recommended intake of 400 µg/d. Overall, apparent rice consumption could fulfill 113%, 114%, and 131% of the EAR for WRA for zinc, thiamin, and niacin, respectively. Fortified wheat flour was consumed in much lower quantities, with an estimated apparent median intake of 22 g/d/AME among WRA and 78 g/d/AME among women in urban populations., Conclusions: The potential benefit of fortified wheat flour in SI is likely limited to urban populations. Apparent consumption of fortified rice in SI could contribute considerably to daily intake of iron, B vitamins including folic acid, and zinc among WRA.

Background: Fortification of cereal grains with at least iron or folic acid is legislated in 85 countries worldwide. Relative to wheat and maize flour, rice fortification is relatively new and provides an opportunity to deliver essential micronutrients to populations that consume rice as a dietary staple., Objective: To describe miller and public sector experiences and perspectives on rice fortification with micronutrients in Colombia and offer recommendations for policy makers., Methods: Interviews with Colombian rice millers, research and development personnel, and public sector leaders; desk review of key documents., Results: In Colombia, rice fortified with micronutrients is market driven and a few very large rice millers, currently representing about 35% of the market, have voluntarily fortified rice since 2002. The technology used (spraying) is unique to Colombia and to date there is no independent verification of nutrient retention after washing and cooking rice fortified through this technology. Millers are unwilling to switch to more proven methods, such as extrusion or coating, which will incur higher capital investment and recurring costs. Despite interest from multiple stakeholders between 2002 and 2011, mandatory rice fortification is not part of the Colombian government policy as of July 2015., Conclusion: Rice fortified with micronutrients through spraying technology has achieved moderate coverage in Colombia, but the technology is unproven, its effectiveness unknown, and public health impact likely limited. For rice fortification to be an effective nutrition intervention to improve micronutrient status, policy makers should explore standards to guide industry and improvements to regulatory capacity.

Background: Child undernutrition remains high in South Asian and sub-Saharan African countries. Rapid declines in nutritional status occur before the age of 2 years, particularly during the period of complementary feeding. Improving complementary feeding practices is a neglected area in nutrition programs., Objective: To understand community perspectives on complementary feeding practices in order to inform the design of future interventions for improved complementary feeding., Methods: From May through August 2009, data were collected in two rural locations and one urban location in Bangladesh through semistructured interviews, food attributes exercises, 24-hour dietary recalls, opportunistic observations, and trials of improved practices (TIPs). Key informant interviews and focus group discussions were also carried out among family members and community opinion leaders., Results: Lay perceptions about complementary feeding differ substantially from international complementary feeding recommendations. A large proportion of children do not consume sufficient amounts of complementary foods to meet their energy and micronutrient needs. There was a gap in knowledge about appropriate complementary foods in terms of quality and quantity and strategies to convert family foods to make them suitable for children. Complementary feeding advice from family members, peers, and health workers, the importance given to feeding young children, and time spent by caregivers in feeding influenced the timing, frequency, types of food given, and ways in which complementary feeding occurred., Conclusions: Perceptions and practices related to complementary feeding need to be effectively addressed to improve the levels of child undernutrition. Lack of understanding of children's nutritional needs and insufficient time for feeding children are key barriers to complementary feeding.

Unlabelled: BACKGROUND. Optimal feeding of infants and young children in developing countries includes daily feeding of animal-source foods. OBJECTIVE. To evaluate constraints on the availability of animal-source foods at the community level, access to animal-source foods at the household level, and intake of animal-source foods at the individual level among children under 3 years of age in case studies in five developing countries: Mexico, Peru, Haiti, Senegal, and Ethiopia., Methods: Data were obtained from published and unpublished research and from program experiences of health and agriculture specialists., Results: In Ethiopia, 27% to 51% of case-study children had consumed an animal-source food on the previous day; from 56% to 87% of children in the other case-study sites had consumed an animal-source food on the previous day. Data on intake of animal-source foods in grams were only available for the Latin American case-study sites, where daily milk intake was high in Mexico and Peru (195 and 180 g/day, respectively) and the intakes of meat, fish, and poultry (MFP) (29.0 and 13.6 g/day) and of egg (18.4 and 4.9 g/day) were low. The conceptual model guiding this work identified more constraining factors at the community and household levels than at the individual level. The most common constraints on feeding animal-source foods to young children were poverty, animal health, and land degradation at the community level; cost of animal-source foods and limited livestock holdings at the household level; and caregivers' perceptions of giving animal-source foods to children at the individual level., Conclusions: For program planning, it is useful to simultaneously consider factors that affect community availability of household access to, and children's intake of animal-source foods. Efforts to overcome individual-level constraints on intake of animal-source foods should be coupled with activities to address community and household constraints.

Background: Lyophilized meat powder with iron-fortified wheat flour can be used to produce an infant porridge with bioavailable iron, but its acceptability and safety are unknown., Objective: To evaluate the acceptability and safety of porridges containing lyophilized meat powder and iron-fortified wheat flour., Methods: Peruvian mothers' input was used to develop porridges without (no meat) and with meat powder (low or high chicken liver, low or high chicken thigh). Acceptability was determined by maternal hedonic scoring, 9-day infant intake, and videotape analysis of how well infants liked each porridge. Dry and cooked porridges and meat ingredients were tested for microorganisms; meats were tested for pesticides., Results: Mothers gave higher acceptability scores to the no-meat porridge, followed in order by low and high quantities of meat powder (e.g., mean +/- SD "taste"scores were 4.5 +/- 0.9 for the no-meat, 3.7 +/- 1.1 for the low-liver, and 3.3 +/- 1.1 for the high-liver porridges, p = .0001). Infants' porridge intake did not differ: 61.4 +/- 47.1 g of no-meat, 62.1 +/- 44.9 g of low-thigh, and 67.5 +/- 42.0 g of low-liver (p = .7), as supported by the video analysis. Microbiologic safety was acceptable except for marginally acceptable molds and yeasts in dry ingredients. No pesticide residues were detected., Conclusions: Despite mothers' clear preference for no-meat porridges, infants consumed equal amounts of porridges with and without meat. Thus, if mothers can be convinced to feed the meat-containing porridges to the infants despite their own preferences, the infants will consume these porridges. The mold and yeast content of the porridge ingredients must be reduced.

This study assessed barriers to exclusive breastfeeding in rural Viet Nam and identified how a few mothers were able to exclusively breastfeed despite barriers. A cross-sectional quantitative and qualitative assessment was carried out among 120 mothers of infants less than six months old in northern Viet Nam. Only 24% of the mothers exclusively breastfed. Adjusting for infant's age and who attended delivery, the risk of not exclusively breastfeeding was 14.0 times greater for women who had returned to work than for women who had not. Exclusively breastfeeding mothers (n = 4) who worked differed from other mothers in important ways. They all felt they had enough milk, all knew the appropriate time to introduce foods and liquids, and most were supported in their breastfeeding decisions by commune health workers and family members. This research suggests strategies that can be implemented now to increase exclusive breastfeeding in rural work environments. These include improving knowledge about the introduction of water and semi-solids, addressing perceptions of milk insufficiency, securing support from others, and presenting mothers with options for exclusively breastfeeding, even when they work outside the home.

Rigorous assessments of program quality are uncommon in developing countries. We evaluated the quality of the two-week, volunteer-facilitated, caregiver-child rehabilitation "hearth," or nutrition education and rehabilitation program (NERP), sessions in Save the Children's integrated nutrition program in Viet Nam. Field workers observed attendance, food contribution, food preparation, meal consumption, health message delivery, hygiene, and weighing at 240 NERP days at 59 NERP centers during seven months of implementation. Participation in cooking NERP meals (75.8%), washing mothers' and children's hands (75.7% and 81.6%, respectively), and weighing (74.5% on days 1 and 12) were high, but attendance rates (50.3%), food contributions (20.3%), and health message delivery (20.0%) were lower than expected, all with wide variation among communes, ecology, NERP day, and NERP round. Contrary to protocol, food was often delivered to malnourished children who stayed at home to accommodate caregivers' workloads and other constraints. While home-delivery of food prevented caregivers from learning from each other in a group, it did bring "tangible messages" (i.e., a large serving size of a new food) to the doorstep. Health volunteers were wise to stress active learning over repetitive message delivery. In summary, these NERPs were probably typical of previous NERPs although comparable quality measures are lacking. Despite imperfect implementation, the NERP's active-learning and local problem-solving helped achieve measurable impact on growth, diet, morbidity, and empowerment despite uncommon program challenges, such as uncharacteristically low baseline levels of malnutrition and high population dispersion. Regular quality monitoring may enhance impact even further.

Forty-two percent of Vietnamese children are stunted by two years of age. Since 1990, Save the Children Federation/US (SC) has implemented integrated nutrition programs targeting young children. We evaluated the effect of SC's nutrition program on the complementary food intake of young rural Vietnamese children. Using a longitudinal, prospective, randomized design, we followed 238 children (119 each from intervention and comparison communes) age 5 to 25 months old for six months with a re-survey at 12 months. We gathered 24-hour recall data at baseline and at months 2, 4, 6, and 12. Dietary energy intake was calculated using the 1972 Vietnamese food composition table. Key outcomes were daily frequency of consuming intervention-promoted food and non-breastmilk liquids and food, daily quantity of non-breastmilk liquids and food consumed, daily energy intake, and proportion of children meeting daily median energy requirements. Young rural children exposed to SC's program consumed intervention-promoted, and any, foods more frequently, ate a greater quantity of any food, consumed more energy, and were more likely to meet their daily energy requirements than comparison children. Some effects were only observed during the intensive intervention period; others persisted into or were evident only at the 12-month follow-up, approximately four months after program completion. Based on the mothers' reports, the intervention did not apparently compromise breastfeeding prevalence or frequency. The intervention improved children's food and energy intake and protected them from declining as rapidly as comparison children in meeting their energy requirements.

Few prospective studies of child growth and its determinants take place in programmatic contexts. We evaluated the effect of Save the Children's (SC) community empowerment and nutrition program (CENP) on child growth, care, morbidity, empowerment, and behavioral determinants. This paper describes the research methods of this community-based study. We used a longitudinal, prospective, randomized design. We selected 12 impoverished communes with documented child malnutrition, three comparison, and three intervention communes in each of two districts in Phu Tho Province, west of Hanoi. SC taught district trainers in November 1999 to train local health volunteers to implement the 10-month CENP, including situation analysis, positive deviance (PD) inquiry, growth monitoring and promotion, nutrition education and rehabilitation program (NERP), deworming, and monitoring. PD inquiries aim to discover successful care practices in poor households that likely promote well-nourished children. NERPs are neighborhood-based, facilitated group learning sessions where caregivers of malnourished children learn and practice PD and other healthy behaviors. We dewormed all intervention and comparison children. We randomly selected 240 children 5 to 25 months of age (120 intervention and 120 comparison). We gathered information on nutritional status, diet, illness, care, behavioral determinants, empowerment, and program quality, monthly for six months with a re-survey at 12 months. We collected most information through maternal interview but also observed hygiene and program quality, and videotaped feedings at home. Some implementation and research limitations will attenuate CENP impact and measurement of its effectiveness.

Globally, the caregiving behaviors that contribute to good nutritional status are well understood; but it is not clear why some caregivers perform these behaviors while others do not. This formative qualitative research was designed to improve understanding about what distinguishes caregivers who practice optimal behaviors from those who do not. This study is a one-time, cross-sectional baseline assessment of factors that affect nutrition-related behavior change. It took place in a rural northern province in Viet Nam. One hundred caregivers of children 6 to 17.9 months of age from five communes were interviewed. None of the five communes were included in the larger prospective study designed to test the impact of the Community Empowerment and Nutrition Program (CENP). Four behaviors were examined: feeding the child "positive deviant" foods, feeding the child during diarrheal episodes, washing the child's hands, and taking the child to the health center when ill. Results indicate that for all four behaviors, favorable social norms distinguished those who practiced each behavior from those who did not. Positive, reinforcing beliefs and attitudes were important determinants of every behavior except handwashing Likewise, self-efficacy differentiated doers from non-doers for all behaviors except feeding during diarrheal episodes. Findings from this research suggest that fathers and in-laws of non-doers are more likely to fail to advise mothers about infant feeding and health than they are to provide negative advice. By discovering what distinguishes those who practice optimal behaviors from those who do not, researchers, program planners, and others are better equipped to develop targeted interventions that lead to positive behavior change.

Infectious disease and poor diet are the two proximal causes of malnutrition in children. During the 1990s, integrated nutrition programs implemented by Save the Children (SC) in Viet Nam reduced severe child malnutrition, but it has not been clear if this impact was due primarily to improved diet or reduced disease. The aim of this study was to determine whether a community-based, integrated nutrition program in Viet Nam reduced child morbidity due to diarrhea or acute respiratory infections. Children 5 to 25 months old were randomly selected from randomly assigned intervention and comparison communes. Caregivers of children from the intervention and comparison groups (n = 119 per group) were interviewed about their child's morbidity at program baseline and at study months 2, 4, 6, and 12. Multiple logistic regression and general estimating equations (GEE) were used to evaluate the effect of the intervention on the occurrence of any diarrhea and respiratory illness in the preceding two weeks. Respiratory illness, mainly upper respiratory illness, was more common than diarrheal disease at baseline (54% vs. 6%, respectively). During follow-up, children in the intervention communes had approximately half the respiratory illness experienced by those in comparison communes (AOR = 0.5; p = .001). Diarrheal disease was also lower in the intervention group, although differences were not statistically significant. We conclude that SC's integrated nutrition program was associated with reduced upper respiratory illness, perhaps due to improved hygiene practices and/or improved micronutrient intakes.

Style of child feeding may be an important determinant of child nutrition and health outcomes. Responsive feeding refers to the level and kind of interaction between caregiver and child that lead to a positive feeding experience, adequate dietary intake, and enhanced developmental opportunities. Responsive feeding behaviors may include active physical help and verbalization during feeding, role-playing, persistence, and positive feeding strategies. The aim of this study was to investigate styles of feeding among Vietnamese children 12 or 17 months of age from a rural province in northern Viet Nam. Forty child/mother pairs were videotaped during two, two-hour feeding episodes. Caregiver and child behaviors were coded at the level of the "intended bite" as observed through the videotape analysis of feeding episodes to assess caregiver behavior and the child's interest and acceptance of food. We found it feasible to use videotape and the modified coding and analysis scheme, originally developed for work in Peru, in Viet Nam. In Viet Nam, caregivers provided physical help to eat nearly all of the time for the younger children, and about 70% of the time among 17 month olds. Caregivers verbalized during only 30% of intended bites, and only half of these verbalizations were responsive in tone or words. Positive caregiver behaviors were significantly associated with higher child acceptance of food, while non-responsive feeding behaviors were associated with child rejection of food. Future analyses of this data set will evaluate the degree to which an integrated nutrition program positively modified caretaker behaviors. More research is needed to demonstrate the relationships among the promotion of responsive feeding behaviors, acceptance of food, and improved nutrition and health status of children.

Integrated nutrition programs are widely used to prevent and/or reverse childhood malnutrition, but rarely rigorously evaluated. The impact of such a program on the physical growth of young rural Vietnamese children was measured. We randomized six communes to receive an integrated nutrition program implemented by Save the Children. We matched six communes to serve as controls. Our sample consisted of 238 children (n = 119 per group) who were 5 to 25 months old on entry. Between December 1999 and December 2000, we measured weight and height monthly for seven months and again at month 12. Principle outcomes were weight-for-age Z score (WAZ), height-for-age Z score (HAZ), and weight-for-height Z score (WHZ), and the changes among these measures. As expected, anthropometric indicators relative to international references worsened as the children aged. Overall, children in the intervention communes who were exposed to the integrated nutrition program did not show statistically significant better growth than comparison children. Intervention children who were younger (15 months or less) and more malnourished (less than-2 Z) at baseline, however, deteriorated significantly less than their comparable counterparts. Between baseline and month four, for example, intervention children who were malnourished and less than 15 months old at entry lost on average 0.05 WAZ while similar comparison children lost 0.25 WAZ (p = .02). Lack of overall impact on growth may be due to a lower than expected prevalence of malnutrition at baseline and/or deworming of comparison children. Targeting nutrition interventions at very young children will have the maximum impact on growth.

Empowerment is often cited as a fundamental component of health promotion strategies. Anecdotes suggest that Save the Children's integrated nutrition project empowers local women and health volunteers. The aim of this research was to document the degree to which this is being accomplished. Using qualitative methodologies, we conducted a cross-sectional assessment to compare self-reported changes in identified empowerment domains among 17 program health volunteers and 20 mothers involved in a child nutrition intervention and among five Women's Union leaders and five mothers in a non-intervention comparison commune. Intervention mothers reported increased knowledge, confidence, and information sharing about child-care and feeding, while non-intervention mothers reported minimal changes in these domains. Both intervention health volunteers and non-intervention Women's Union leaders expressed improvements in knowledge, confidence, and relationships with community members. In this study we found that the relative increases in empowerment were greater for mothers than for health volunteers. Intervention mothers reported more sharing of information on child care with neighbors. Health volunteers developed closer relationships with community members than Women's Union leaders. The increased information sharing has positive implications for spread of key messages to families that did not directly participate in intensive feeding and the sustainability of the intervention's impact. Future research should focus on developing culturally specific concepts of empowerment to better understand the effects of empowerment efforts. This study's identification of empowerment domains will inform future empowerment studies in Vietnam.