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Background: Limited research exists on the relationship between food insecurity and children's adiposity and diet and how it varies by demographic characteristics in the United States., Objective: The aim of this study was to assess the relationship between household food insecurity and child adiposity-related outcomes, measured as BMI (kg/m2) z score (BMI-z), weight status, and waist circumference, and diet outcomes, and examined if the associations differ by age, sex, and race/ethnicity., Methods: Data collected in 2013-2015 from 5138 US schoolchildren ages 4-15 y from 130 communities in the cross-sectional Healthy Communities Study were analyzed. Household food insecurity was self-reported using a validated 2-item screener. Dietary intake was assessed using the 26-item National Cancer Institute's Dietary Screener Questionnaire, and dietary behaviors were assessed using a household survey. Data were analyzed using multilevel statistical models, including tests for interaction by age, sex, and race/ethnicity., Results: Children from food-insecure households had higher BMI-z (β: 0.14; 95% CI: 0.06, 0.21), waist circumference (β: 0.91 cm; 95% CI: 0.18, 1.63), odds of being overweight or obese (OR: 1.17; 95% CI: 1.02, 1.34), consumed more sugar from sugar-sweetened beverages (β: 1.44 g/d; 95% CI: 0.35, 2.54), and less frequently ate breakfast (β: -0.28 d/wk; 95% CI: -0.39, -0.17) and dinner with family (β: -0.22 d/wk; 95% CI: -0.37, -0.06) compared to children from food-secure households. When examined by age groups (4-9 and 10-15 y), significant relationships were observed only for older children. There were no significant interactions by sex or race/ethnicity., Conclusions: Household food insecurity was associated with higher child adiposity-related outcomes and several nutrition behaviors, particularly among older children, 10-15 y old., (Copyright © American Society for Nutrition 2019.)

Background: Appropriate infant and young child feeding practices are critical for optimal child growth and development, but in Ethiopia, complementary feeding (CF) practices are very poor. Alive & Thrive (A&T) provided intensive behavior change interventions through 4 platforms: interpersonal communication (IPC), nutrition-sensitive agricultural activities (AG), community mobilization (CM), and mass media (MM)., Objectives: The aim of this study was to evaluate the impact of A&T intensive compared with nonintensive interventions (standard nutrition counseling and agricultural extension service and less intensive CM and MM) on CF practices and knowledge and child anthropometric outcomes., Methods: We used a cluster-randomized evaluation design with cross-sectional surveys among households with children aged 6-23.9 mo [n = 2646 at baseline (2015) and n = 2720 at endline (2017)]. We derived difference-in-difference impact estimates (DDEs) and conducted dose-response and path analyses to document plausibility of impacts., Results: At endline, exposure to IPC was 17.8-32.3%, exposure to AG was 22.7-36.0%, exposure to CM was 18.6-54.3%, and exposure to MM was 35.4% in the intensive group. Minimum dietary diversity and minimum acceptable diet increased significantly in the intensive group but remained low at endline (24.9% and 18.2%, respectively). Significant differential declines in stunting prevalence were observed (DDE: -5.6 percentage points; P < 0.05) in children aged 6-23.9 mo, decreasing from 36.3% to 22.8% in the intensive group. Dose-response analyses showed higher odds of minimum dietary diversity (OR: 3.3; 95% CI: 2.2, 4.8) and minimum meal frequency (OR: 1.9; 95% CI: 1.4, 2.6) and higher height-for-age z score (HAZ) (β: 0.24; 95% CI: 0.04, 0.4) among women exposed to 3 or 4 platforms. Path analyses showed a strong relation between AG and egg consumption, which led to increased child dietary diversity and HAZ., Conclusions: Delivery of social and behavior change interventions using multiple platforms was feasible and effective, resulting in improvements in CF practices and child stunting within a 2-y period. There is a need for continued efforts, however, to expand intervention coverage and to improve CF practices in Ethiopia. This trial was registered at clinicaltrials.gov as NCT02775552., (Copyright © American Society for Nutrition 2019.)

Background: Food insecurity, which disproportionately affects marginalized women in the United States, is associated with depressive symptoms. Few studies have examined relations of food insecurity with other mental health outcomes., Objective: The aim of this study was to investigate the associations of food insecurity with symptoms of generalized anxiety disorder (GAD), stress, and posttraumatic stress disorder (PTSD) in the Women's Interagency HIV Study (WIHS), a prospective cohort study of women with or at risk of HIV in the United States., Methods: Participants were 2553 women with or at risk of HIV, predominantly African American/black (71.6%). Structured questionnaires were conducted during April 2013-March 2016 every 6 mo. Food security (FS) was the primary predictor, measured using the Household Food Security Survey Module. We measured longitudinal outcomes for GAD (GAD-7 score and a binary GAD-7 screener for moderate-to-severe GAD). Only cross-sectional data were available for outcomes measuring perceived stress (PSS-10 score) and PTSD (PCL-C score and a binary PCL-C screener for PTSD). We examined associations of FS with the outcomes through use of multivariable linear and logistic regression, including lagged associations with GAD outcomes., Results: After adjusting for sociodemographic and health-related factors including HIV serostatus, current marginal, low, and very low FS were associated with increasingly higher GAD-7 scores, and with 1.41 (95% CI: 1.10, 1.80; P < 0.01), 2.03 (95% CI: 1.59, 2.61; P < 0.001), and 3.23 (95% CI: 2.43, 4.29; P < 0.001) times higher odds of screening positive for moderate-to-severe GAD, respectively. Low and very low FS at the previous visit (6 mo earlier) were independently associated with GAD outcomes at current visit. Associations of FS with PSS-10 and PCL-C scores exhibited similar dose-response relations. Very low FS was associated with 1.93 (95% CI: 1.15, 3.24; P < 0.05) times higher odds of screening positive for PTSD., Conclusions: Food insecurity may be associated with a range of poor mental health outcomes among women in the United States with or at risk of HIV., (Copyright © American Society for Nutrition 2019.)

Background: Frontline health workers (FLWs) are needed for delivering interventions at scale to reduce maternal and child undernutrition, but low- and middle-income countries often face inadequate FLW performance., Objectives: We examined whether and how intervention design elements such as training, supervision, and mass media improved FLW performance in delivering nutrition services., Methods: Survey data were collected in 2010 and 2014 as part of impact evaluations of Alive & Thrive (A&T) interventions to improve infant and young child feeding (IYCF) practices in Bangladesh and Vietnam. FLWs in A&T intensive (A&T-I) areas received specialized IYCF training, job aids, and regular supportive supervision. Those in non-intensive (A&T-NI) areas received standard government training and supervision. There was mass media exposure in both areas. Multiple regression was used to test differences in exposure to intervention design elements and performance outcomes between the 2 program areas. Path analyses were conducted to examine the paths from exposure to performance outcomes measured at FLW and end-user levels., Results: Compared to FLWs in A&T-NI areas, those in A&T-I areas had higher scores in training (by 1.3-3.6 of 10 points), supportive supervision (0.3-3.5 points), and mass media exposure (0.3-3.5 points). These intervention design elements were significantly associated with FLW knowledge and motivation, which in turn improved service delivery. FLW-level performance outcomes contributed to improving end-user-level outcomes such as higher service received (β = 0.12-1.04 in Bangladesh and 0.11-0.96 in Vietnam) and maternal knowledge (β = 0.12-0.17 in Bangladesh and 0.04-0.21 in Vietnam)., Conclusions: Training, supervision, and mass media exposure can be implemented at large scale and contribute to improved FLW service delivery by enhancing knowledge and motivation, which in turn positively influence mother's service utilization and IYCF knowledge. Training, supervision, and mass media to enhance service provision should be considered when designing interventions. This trial was registered at clinicaltrials.gov as NCT01678716 (Bangladesh) and NCT01676623 (Vietnam).

Improving nutritional status during adolescence is an opportunity to improve the lives of this generation and the next. Estimating the burden of malnutrition at a population level is fundamental to targeting interventions and measuring progress over time, and for adolescents, we usually depend on survey data and the 2007 WHO Growth Reference to do so. There is substantial risk of misguided conclusions regarding adolescent prevalence estimates, however, when underlying methodological limitations of the indicators and reference are not adequately considered. We use national prevalence estimates among girls and young women 10-22 y of age from the 2014 State of Food Security and Nutrition in Bangladesh report as an example to demonstrate that determining the true prevalence of undernutrition, overweight, and obesity is complicated by racial/ethnic variation across populations in timing of the adolescent growth spurt, growth potential, and body build. Further challenging the task are inherent limitations of the body mass index as an indicator of thinness and adiposity, and cutoffs that poorly distinguish a well-nourished population from a malnourished one. We provide recommendations for adolescent nutrition policy and program decision-making, emphasizing the importance of 1) critically interpreting indicators and distributions by age when using the 2007 WHO Growth Reference; 2) examining what is happening before and after adolescence, when interpretation of anthropometry is more straightforward, as well as trends over time; and 3) complementing anthropometry with other information, particularly dietary intake. Finally, we advocate that nutrition researchers prioritize exploration of better methods to predict peak height velocity, for development of standardized indicators to measure dietary quality among adolescents, and for studies that will illuminate causal paths so that we can effectively improve adolescent dietary intake and nutritional status., (Copyright © American Society for Nutrition 2019.)

The Global Burden of Disease study (GBD) is an ambitious effort to estimate the disease burden attributable to various risk factors. The results from the GBD are used around the world to monitor the UN established Sustainable Development Goals, set health policies and research strategies, among others. The GBD along with other studies, such as those from the Maternal Child Epidemiology Estimation Group and the Lancet Breastfeeding Series Group, produce estimates of the nutrition-related global burden of disease that exhibit considerable differences. These differences are difficult to reconcile due to the estimation methods, which in recent years have substantially increased in complexity. In this paper, we give a detailed review of the methods used by GBD and other entities to estimate the global burden of disease that is attributable to undernutrition and suboptimal breastfeeding. Further, we compare the methods to determine causes for differences in estimates. We find that the main determinant of differences in estimates is what causes of death are linked to each risk factor. Methods used to estimate nutrition-related disease burden need to be more clearly documented to foster discussion and collaboration on the important assumptions required to produce estimates., (Copyright © American Society for Nutrition 2019.)

Linear growth is increasingly used as the sole or primary outcome for evaluating interventions, but impact is often not seen. Sometimes there is interest in whether children catch up to where they otherwise would have been had detrimental conditions not occurred, but the literature is confusing because of claims for evidence of catch-up growth based on inappropriate methods. This article examines the use of linear growth measures to evaluate intervention impact and catch-up. Focus on linear growth as a measure of impact has resulted in a lack of demonstrable intervention effects, evaluations that do not use measures responsive to nutrition-sensitive and integrated interventions, insufficient emphasis on adolescent girls and women before conception and children after the first 1000 d, and insufficient investment in developing other measures. Nutrition interventions may benefit children but may not discernibly affect linear growth deficits in immediate or intermediate periods. Interventions intended to affect one domain may have positive or negative impacts on others. Child nutrition and growth are part of early childhood development; the focus should be on improving conditions in which children grow and develop throughout childhood and adolescence because poor conditions in a population affect all children. To assess the impact of nutrition interventions, it is important to use a broad set of measures and indicators of outcomes and immediate and underlying determinants. The 4 criteria for demonstrating catch-up in growth, which are much more stringent than those for demonstrating intervention impact, require demonstration of the following: 1) an inhibiting condition and 2) reduced velocity during 1 period, 3) followed by alleviation of or compensation for the inhibiting condition, and 4) higher-than-normal velocity during a subsequent period. Partial catch-up growth is sometimes possible when constraints are removed, but whether it is beneficial to the child is not clear. Research is needed to develop, refine, and validate measures and indicators for the purposes intended., (Copyright © American Society for Nutrition 2019.)

Purpose: We examined the association of meeting the 2009 Institute of Medicine gestational weight gain (GWG) guidelines with offspring obesity and body mass index Z score (BMIZ) at age six overall and by maternal weight status., Methods: Data were from the Infant Feeding Practices Survey II Study (2005-2007) and their Year Six Follow-Up Study (2012). Logistic regression and quantile regression models were used., Results: Eleven percent of children were obese. Children born to mothers who gained excessive weight during pregnancy had an increased risk of obesity as compared with those born to mothers who gained adequate weight (adjusted odds ratio: 1.67). The association was stronger among normal-weight mothers (adjusted odds ratio: 3.50). Inadequate GWG was not associated with offspring obesity overall or in subsamples by maternal prepregnancy BMI. Children born to mothers who gained excessive weight had higher BMIZ. This distributional association was more pronounced among normal-weight mothers. Children born to obese mothers who gained inadequate weight had lower BMIZ at some percentiles of the BMIZ distribution., Conclusions: Excessive GWG was associated with increased risk of offspring obesity and higher BMIZ at age six, whereas inadequate GWG was protective of high BMIZ among children born to obese mothers., (Copyright © 2019 Elsevier Inc. All rights reserved.)

In many global health analyses, it is of interest to examine countries' progress using indicators of socio-economic conditions based on national surveys from varying sources. This results in longitudinal data where heteroscedastic summary measures, rather than individual level data, are available. Administration of national surveys can be sporadic, resulting in sparse data measurements for some countries. Furthermore, the trend of the indicators over time is usually nonlinear and varies by country. It is of interest to track the current level of indicators to determine if countries are meeting certain thresholds, such as those indicated in the United Nations Sustainable Development Goals. In addition, estimation of confidence and prediction intervals are vital to determine true changes in prevalence and where data is low in quantity and/or quality. In this article, we use heteroscedastic penalized longitudinal models with survey summary data to estimate yearly prevalence of malnutrition quantities. We develop and compare methods to estimate confidence and prediction intervals using asymptotic and parametric bootstrap techniques. The intervals can incorporate data from multiple sources or other general data-smoothing steps. The methods are applied to African countries in the UNICEF-WHO-The World Bank joint child malnutrition data set. The properties of the intervals are demonstrated through simulation studies and cross-validation of real data., (© 2018 John Wiley & Sons, Ltd.)

Background: Food insecurity and violence are two major public health issues facing U.S. women. The link between food insecurity and violence has received little attention, particularly regarding the temporal ordering of events. The present study used data from the Women's Interagency Human Immunodeficiency Virus Study to investigate the longitudinal association of food insecurity and violence in a cohort of women at risk for or living with HIV., Methods: Study participants completed six assessments from 2013-16 on food insecurity (operationalized as marginal, low, and very low food security) and violence (sexual or physical, and psychological). We used multi-level logistic regression, controlling for visits (level 1) nested within individuals (level 2), to estimate the association of experiencing violence., Results: Among 2,343 women (8,528 visits), we found that victims of sexual or physical violence (odds ratio = 3.10; 95% confidence interval: 1.88, 5.19) and psychological violence (odds ratio = 3.00; 95% confidence interval: 1.67, 5.50) were more likely to report very low food security. The odds of experiencing violence were higher for women with very low food security at both the current and previous visit as compared to only the current visit. HIV status did not modify these associations., Conclusions: Food insecurity was strongly associated with violence, and women exposed to persistent food insecurity were even more likely to experience violence. Food programs and policy must consider persistent exposure to food insecurity, and interpersonal harms faced by food insecure women, such as violence., Competing Interests: The authors have declared that no competing interests exists.

The past decade has seen an unprecedented increase in attention to undernutrition, and drastically reducing child stunting has become a global development objective. The strong focus on linear growth retardation and stunting has enabled successful advocacy for nutrition, but with this focus has come some confusion and misunderstanding about the meaning of linear growth retardation and stunting among researchers, donors, and agencies active in nutrition. Motivated by the belief that a sharp focus will further accelerate progress in reducing undernutrition, we critically reviewed the evidence. The global attention to stunting is based on the premise that any intervention aimed at improving linear growth will subsequently lead to improvements in the correlates of linear growth retardation and stunting. Current evidence and understanding of mechanisms does not support this causal thinking, with 2 exceptions: linear growth retardation is a cause of difficult births and poor birth outcomes. Linear growth retardation is associated with (but does not cause) delayed child development, reduced earnings in adulthood, and chronic diseases. We thus propose distinguishing 2 distinctly different meanings of linear growth retardation and stunting. First, the association between linear growth retardation (or stunting) and other outcomes makes it a useful marker. Second, the causal links with difficult births and poor birth outcomes make linear growth retardation and stunting outcomes of intrinsic value. In many cases a focus on linear growth retardation and stunting is not necessary to improve the well-being of children; in many other cases, it is not sufficient to reach that goal; and for some outcomes, promoting linear growth is not the most cost-efficient strategy. We appeal to donors, program planners, and researchers to be specific in selecting nutrition outcomes and to target those outcomes directly., (© 2019 American Society for Nutrition.)

Establishing the shape and determinants of trajectories of body mass index (BMI) among Soldiers is critical given the importance of weight management to military service requirements. To establish the shape and determinants of BMI trajectories among Soldiers, we aimed to (1) model the overall BMI trajectory of Soldiers, (2) find the most common trajectory groups among Soldiers, (3) investigate the relationship between BMI trajectories and sociodemographic and military-specific characteristics, and (4) determine if there were Soldiers with large fluctuations in BMI. The study population included all US Army Soldiers on active-duty between 2011 and 2014 who were age 17-62 ( n  = 827,126). With longitudinal data from the Stanford Military Data Repository, we used group-based trajectory modeling to identify the BMI trajectories of Soldiers and multinomial logistic regression to estimate associations between Soldier characteristics and trajectory membership. Four distinct BMI trajectory groups were found: increasing, decreasing, constant, and inconstant. The constant, increasing, and decreasing trajectories were similar in shape and percentage between men and women. The constant trajectory had the fewest Soldiers who exceeded weight standards or had duty limitations. The increasing trajectory was associated with marriage and fewer service years. The decreasing trajectory was associated with more service years and higher educational attainment. The inconstant trajectory differed in shape between men and women. Over 6% of men and 12% of women had fluctuations in BMI indicative of weight cycling. Understanding the characteristics associated with BMI trends may assist the Army in targeting resources aimed to improve Soldier health and combat readiness.

Background: Food insecurity and mental health negatively affect the lives of women in the United States. Participants in the Women's Interagency HIV Study (WIHS) provided the opportunity to understand the association of food insecurity with depression and mental well-being over time., Objective: We investigated the association between current and persistent food insecurity and depression among women at risk of or living with HIV in the United States., Methods: We used longitudinal data from the WIHS, a prospective cohort study in women at risk of or living with HIV from multiple sites in the United States. Participants completed 6 semiannual assessments from 2013 to 2016 on food security (FS; high, marginal, low, and very low) and mental health (i.e., depressive symptoms and mental well-being). We used multiple regression analysis to estimate the association between these variables., Results: Among 2551 participants, 44% were food insecure and 35% reported depressive symptoms indicative of probable depression. Current marginal, low, and very low FS were associated with 2.1-, 3.5-, and 5.5-point (all P < 0.001) higher depression scores, respectively. In models adjusting for both current and previous FS, previous marginal, low, and very low FS were associated with 0.2-, 0.93-, and 1.52-point higher scores, respectively (all P < 0.001). Women with very low FS at both time points (persistent food insecurity) had a 6.86-point higher depression score (P < 0.001). In the mental health models, there was a dose-response relation between current FS and worse mental health even when controlling for previous FS (all P < 0.001). Previous low FS was associated with worse mental health. These associations did not differ by HIV status., Conclusions: Food insecurity placed women at risk of depression and poor mental well-being, but the risk was substantially higher for women experiencing persistent food insecurity. Future interventions to improve women's mental health call for multilevel components that include addressing food insecurity., (© 2019 American Society for Nutrition.)

Background: Food insecurity is strongly associated with subjective well-being. People compare their well-being to a subjective reference that adjusts over time, which is called hedonic adaptation., Objective: We aimed to deepen understanding of the relation between food insecurity and subjective well-being among countries from the perspective of possible hedonic adaptation between food insecurity and subjective well-being., Methods: Global data from the Gallup World Poll 2014 were collected from 152,206 individuals in 147 countries. Telephone and face-to-face surveys were conducted in 37 and 111 countries, respectively, collecting data on law and order; food and shelter; institutions and infrastructure; job climate; and financial, social, physical, and evaluative well-being, including the Food Insecurity Experience Scale. Data were aggregated to country level and merged with economic and social measures from World Bank and United Nations sources: infant mortality, gross domestic product, economic inequality, agricultural value added, fertility, maternal mortality, female schooling, and female participation in the labor force. Multilevel linear regression was used to examine associations between well-being and food insecurity., Results: Experiencing moderate or severe food insecurity was prevalent among countries, with a mean probability of 0.273 ± 0.220. Countries that were less developed economically and socially had a higher probability of experiencing food insecurity, lower subjective well-being as measured by the daily experience index, and less negative slopes for the relation between daily experience index and food insecurity. Food insecurity was the strongest predictor of daily experience from among the measures of economic and social development., Conclusions: The prevalence of food insecurity was strongly and negatively associated with subjective well-being across 147 countries. The association between food insecurity and poor subjective well-being within countries was stronger for more-developed countries, providing evidence of hedonic adaptation between food insecurity and subjective well-being. Food insecurity explained substantial variation in subjective well-being both among and within countries., (© 2018 American Society for Nutrition.)

Introduction: A wide range of water-related problems contribute to the global burden of disease. Despite the many plausible consequences for health and well-being, there is no validated tool to measure individual- or household-level water insecurity equivalently across varying cultural and ecological settings. Accordingly, we are developing the Household Water Insecurity Experiences (HWISE) Scale to measure household-level water insecurity in multiple contexts., Methods and Analysis: After domain specification and item development, items were assessed for both content and face validity. Retained items are being asked in surveys in 28 sites globally in which water-related problems have been reported (eg, shortages, excess water and issues with quality), with a target of at least 250 participants from each site. Scale development will draw on analytic methods from both classical test and item response theories and include item reduction and factor structure identification. Scale evaluation will entail assessments of reliability, and predictive, convergent, and discriminant validity, as well as the assessment of differentiation between known groups., Ethics and Dissemination: Study activities received necessary ethical approvals from institutional review bodies relevant to each site. We anticipate that the final HWISE Scale will be completed by late 2018 and made available through open-access publication. Associated findings will be disseminated to public health professionals, scientists, practitioners and policymakers through peer-reviewed journals, scientific presentations and meetings with various stakeholders. Measures to quantify household food insecurity have transformed policy, research and humanitarian aid efforts globally, and we expect that an analogous measure for household water insecurity will be similarly impactful., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background: Chronic inflammation is associated with AIDS-defining and non-AIDS-defining conditions. Limited research has considered how food insecurity influences chronic inflammation among people living with human immunodeficiency virus (HIV). We examined whether food insecurity was associated with higher levels of inflammation among women living with HIV (WWH) in the United States., Methods: We analyzed cross-sectional data collected in 2015 from 421 participants on antiretroviral therapy from the Women's Interagency HIV Study. The exposure was any food insecurity. The outcome was inflammation, measured by proinflammatory cytokine interleukin-6 (IL-6) and tumor necroses factor receptor 1 (TNFR1) levels. We conducted multivariable linear regressions, adjusting for sociodemographic, clinical, and nutritional factors., Results: Nearly one-third of participants (31%) were food insecure and 79% were virally suppressed (<20 copies/mL). In adjusted analyses, food insecurity was associated with 1.23 times the level of IL-6 (95% confidence interval [CI], 1.06-1.44) and 1.13 times the level of TNFR1 (95% CI, 1.05-1.21). Findings did not differ by HIV control (virally suppressed with CD4 counts ≥500 cells/mm3 or not) in adjusted stratified analyses., Conclusion: Food insecurity was associated with elevated inflammation among WWH regardless of HIV control. Findings support the need for programs that address food insecurity among WWH.

Objective: The purpose of this study was to examine the trajectories of body mass index (BMI) in the first year of life and their determining factors., Methods: We used data from the Infant Feeding Practices Survey II restricted to children with 2 or more time points of BMI data during follow-up visits within the first year of life (n = 2320). Latent class growth analysis was used to identify distinct BMI trajectories. Using multinomial logistic regression, we examined the prenatal and early life determinants of the identified trajectories., Results: Three BMI trajectories were identified during the first year of life: "low-stable" (81.6%), "high-stable" (15.6%), and "rising" (2.8%) trajectories. Boys, preterm infants, infants born to overweight mothers, Hispanic mothers, non-Hispanic Black mothers, and mothers who smoked during pregnancy were significantly more likely to have high-stable versus low-stable trajectories. Infants born to non-Hispanic Black mothers were more likely to have a rising versus a low-stable trajectory. Household income ≥350% of the federal poverty level and full adherence to the guidelines of the American Academy of Pediatrics for both breastfeeding exclusivity and duration reduced the likelihood of infants being in the rising versus the low-stable trajectory., Conclusion: Distinct BMI trajectories were evident as early as infancy. The predictors of these trajectories offer information about high-risk groups, and important and preventable prenatal and postnatal risk factors for future intervention programs., (© 2018 Wiley Periodicals, Inc.)

Background: Antenatal care may be a means to reduce food insecurity in pregnancy and postpartum periods., Objective: With the use of a cluster-randomized design, we tested whether participation in nutrition-focused antenatal care intending to improve household knowledge about the importance of nutrition for pregnant and lactating women and encourage allocation of household resources to ensure sufficient quality and quantity of foods, without providing food assistance, would reduce household food insecurity., Methods: Alive & Thrive integrated nutrition interventions into an existing Maternal, Neonatal, and Child Health (MNCH) program in Bangladesh. The nutrition-focused MNCH package was delivered in 10 subdistricts through antenatal care visits with the use of interpersonal communication, community mobilization, and monitoring of weight gain, aiming to improve maternal diet quality, quantity, and micronutrient intake during pregnancy and breastfeeding. The package included components that could reduce food insecurity, measured using the Household Food Insecurity Access Scale. To examine the impact of the nutrition-focused MNCH package compared with the standard MNCH package, we used linear and multinomial logit regression models, adjusted for subdistrict clustering, to test differences at endline in items, domains, and categories of food insecurity, after first confirming no differences at baseline., Results: At baseline, nearly half of households were food insecure. At endline, the groups differed in food insecurity, whether expressed as items, domains, or categories, with food insecurity in the nutrition-focused MNCH group 22 percentage points lower than in the standard MNCH group and 20 percentage points lower than at baseline., Conclusions: Participation in nutrition-focused antenatal care reduced household food insecurity among recently delivered and pregnant women. Integration of social and behavioral nutrition interventions into antenatal care with components that promote food security provides a potentially effective means to reduce food insecurity, without incurring high costs of providing supplemental food, in populations where limited resources can be directed towards accessing adequate and appropriate foods. Registered at clinicaltrials.gov as NCT02745249.

Background and Aims: Few longitudinal studies have examined the relationship between food insecurity and substance use. We aimed to investigate this relationship using longitudinal data among women with or at risk for HIV in the United States., Design: Women's Interagency HIV Study (WIHS), a prospective cohort study., Setting: Nine sites across the United States., Participants: A total of 2553 women with or at risk for HIV., Measurements: Semi-annual structured interviews were conducted during April 2013-March 2016. Food security (FS) was the primary predictor, measured using the Household Food Security Survey Module. Outcomes were: any illicit substance use except cannabis; licit or illicit cannabis use; stimulant use (crack, cocaine, or methamphetamine); opioid use (heroin or methadone in a non-prescribed way); and prescription drug misuse (prescription narcotics, amphetamines, or tranquilizers in a non-prescribed way) since the last visit. We used multivariable logistic regression with random effects to examine longitudinal associations of current and previous FS with the outcomes simultaneously, adjusting for socio-demographic factors, HIV serostatus, physical health and health insurance., Findings: Average number of visits was 4.6. At baseline, 71% of participants were HIV-seropositive, 44% reported marginal, low, or very low FS, and 13% were using illicit substances. In adjusted analyses, current low and very low FS were significantly associated with 1.59 [95% confidence interval (CI) = 1.02, 2.46; P = 0.039] and 2.48 (95% CI = 1.52, 4.04; P < 0.001) higher odds of any illicit substance use, compared to high FS, and also with higher odds of cannabis, stimulant and opioid use, exhibiting a consistent dose-response relationship. Marginal, low, and very low FS at the previous visit were associated with 1.66 (95% CI = 1.08, 2.54; P = 0.020), 1.77 (95% CI = 1.14, 2.74; P = 0.011), and 2.28 (95% CI = 1.43, 3.64; P < 0.001) higher odds of current illicit substance use., Conclusions: Food insecurity appears to be longitudinally associated with substance use among US women with or at risk for HIV., (© 2018 Society for the Study of Addiction.)

Background: In the US Army, soldiers' nutrition behaviors have a direct impact on their performance. The emphasis in basic combat training is on "soldierization" (transforming a civilian into a soldier), and drill sergeants are instrumental in this process. Limited information about how drill sergeants use their influence to have an impact on nutrition behaviors of new soldiers is available., Objective: This study aimed to determine nutrition attitudes, beliefs, and knowledge of drill sergeants; the ways drill sergeants instill new soldiers with an army identity (eg, warrior athlete, army strong); and how healthy eating is perceived to fit with this new identity., Design: This qualitative, phenomenological study used in-depth interviews conducted with army drill sergeants at two southeast US Army posts between July and August 2011 (n=30)., Main Outcome Measures: Interviews emphasized drill sergeants' perceptions of the eating environment during basic training, the drill sergeant role, and drill sergeants' main duties., Data Analysis: An iterative process of group coding using a constant comparative method was used to find distinct themes. Data were analyzed using qualitative data analysis software., Results: Drill sergeants described their main duty as training new soldiers. Drill sergeants identified the ideal soldier as lean and physically fit but did not identify training soldiers how to eat to become the ideal soldier as part of their duties. Confusion about nutrition concepts was common. Overall, drill sergeants recognized that what soldiers eat affects their physical performance and appearance, but they did not see helping soldiers establish healthy eating behaviors as one of their duties or responsibilities during basic combat training., Conclusions: Drill sergeants are key individuals in the process by which new recruits develop a soldier identity. Additional resources are necessary to help drill sergeants emphasize nutrition and health during basic combat training and help them guide soldiers toward adopting healthy eating as part of their soldier identity to improve weight management, health, and performance., (Copyright © 2019 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: food insecurity occurs when quality and quantity of food is insufficient for maintaining healthy nutritional and food profiles., Objectives: to determine if food insecurity is associated with dietary and biochemical measures in mothers of the northwest of Mexico, which relies primarily on fisheries for livelihood., Methods: a cross-sectional study was conducted with 116 mothers of the Northwest of Mexico. A socioeconomic survey, food security scale, andtwo non-consecutive 24-hour recalls were applied. Anthropometric  measurements were made and hemoglobin, glucose and cholesterol levelswere measured. The association between key measures and food insecurity was assessed using logistic and linear regression., Results: two-thirds (68%) of households experienced food insecurity. Mothers with mild insecurity had 3.7 and 3.2 times higher odds of not consuming fruits and vegetables, respectively, and 4.9 times higher odds of consuming sweetened non-dairy drinks (p = 0.04; 0.04 and 0.05, respectively). In addition, they consumed less protein (β = -3.22%; p < 0.01) and more carbohydrates (β = 6.04%; p = 0.02) compared with mothers with food security. Mothers with severe insecurity consumed less iodine (β = -24.41 μg; p = 0.03) and had lower levels of HDL cholesterol (β = -12.01 mg/dl; p = 0.03) than mothers with food security., Conclusions: food insecurity was associated with low quality diet and low levels of HDL cholesterol in mothers of Northwest Mexico relying on fisheries for livelihood.

Food insecurity, internalized HIV stigma, and depressive symptoms are independently associated with poor HIV outcomes. Food insecurity, stigma, and depression may be interrelated among women living with HIV (WLHIV). We hypothesized that food insecurity would be independently associated with internalized stigma and depressive symptoms among WLHIV in the United States (US), and would partially account for associations between stigma and depressive symptoms. We tested hypotheses using regression models and partial correlation analysis with cross-sectional data among 1317 WLHIV from the Women's Interagency HIV Study. In adjusted models, greater food insecurity was associated with internalized HIV stigma and depressive symptoms (all p < 0.05), exhibiting dose-response relationships. Food insecurity accounted for 23.2% of the total shared variance between depressive symptoms and internalized stigma. Food insecurity is associated with depressive symptoms and internalized HIV stigma among US WLHIV, and may play a role in the negative cycle of depression and internalized stigma.

Introduction: Promoting healthy eating among Soldiers is a priority to the Army due to the link between nutrition and performance. The Army typically uses nutrition education to encourage Soldiers to make healthier food choices with low emphasis on other psychosocial determinants of food choice behaviors., Materials and Methods: Drill Sergeant Candidates (n = 575) completed surveys assessing nutrition knowledge, eating identity type, and food choice behaviors including fruit and vegetable intake, skipping meals, and eating out frequency. In multiple linear regression models using full-information maximum likelihood estimation while controlling for race/ethnicity, education, and marital status, we examined relationships between nutrition knowledge, a healthy eating identity, and Soldiers' food choice behaviors. The study was approved by the Department of Defense and University of South Carolina's Institutional Review Boards., Results: A healthy eating identity was positively associated with greater fruit and vegetable consumption (p < 0.05), and negatively associated with skipping meals and eating out frequency (p < 0.05). Nutrition knowledge was negatively associated with skipping meals (p < 0.05)., Conclusions: Findings suggest that fostering a healthy eating identity may be more effective for promoting healthy food choice behaviors than nutrition education alone. Determining if various points in a Soldier's career could be leveraged to influence a healthy eating identity and behaviors could be an important strategy to improve compliance with health promotion programs.

Background: The impact of community-based obesity prevention efforts on child nutrition has not been adequately studied., Objective: Examine relationships between number, type and intensity of community programs and policies (CPPs) and child nutrition., Methods: An observational study of 5138 children (grades K-8) in 130 U.S. communities was conducted in 2013-2015. CPPs were identified by 10-14 key informant interviews per community. CPPs were characterized based on: count, intensity, number of different strategies used and number of different behaviours targeted. Scores for the prior 6 years were calculated separately for CPPs that addressed primarily nutrition, primarily physical activity (PA) or total combined. Child intakes were calculated from a dietary screener and dietary behaviours were based on survey responses. Multi-level statistical models assessed associations between CPP indices and nutrition measures, adjusting for child and community-level covariates., Results: Implementing more types of strategies across all CPPs was related to lower intakes of total added sugar (when CPPs addressed primarily PA), sugar-sweetened beverages (for nutrition and PA CPPs) and energy-dense foods of minimal nutritional value (for total CPPs). Addressing more behaviours was related to higher intakes of fruit and vegetables (for nutrition and total CPPs) and fibre (total CPPs). Higher count and intensity (PA and total CPPs) were related to more consumption of lower fat compared with higher fat milk. A higher count (PA CPPs) was related to fewer energy-dense foods and whole grains. No other relationships were significant at P < 0.05., Conclusion: Multiple characteristics of CPPs to prevent obesity appear important to improve children's diets., (© 2018 World Obesity Federation.)

Understanding implementation of interventions is critical to illuminate if, how, and why the interventions achieve impact. Alive & Thrive integrated a nutrition intervention into an existing maternal, neonatal, and child health (MNCH) programme in Bangladesh, documenting improvements in women's micronutrient supplement intake and dietary diversity. Here, we examined how well the nutrition intervention was implemented and which elements of implementation explained intervention impact. Survey data were collected in 2015 and 2016 from frontline health workers (FLW) and households in areas randomized to nutrition-focused MNCH (intensified interpersonal counselling, community mobilization, distribution of free micronutrient supplements, and weight-gain monitoring) or standard MNCH (antenatal care with standard nutrition counselling). Seven intervention elements were measured: time commitment, training quality, knowledge, coverage, counselling quality, supervision, and incentives. Multiple regression was used to derive difference-in-differences (DID) estimates. Using village-level endline data, path analysis was used to determine which elements most explained intervention impacts. FLWs in both areas were highly committed and well supervised. Coverage was high (>90%) for counselling, supplement provision, and weight-gain monitoring. Improvements were significantly greater for nutrition-focused MNCH, versus standard MNCH, for training quality (DID: 2.42 points of 10), knowledge (DID: 1.20 points), delivery coverage (DID: 4.16 points), and counselling quality (DID: 1.60 points). Impact was substantially explained by coverage and delivery quality. In conclusion, integration nutrition intervention into the MNCH programme was feasible and well-implemented. Although differences in coverage and counselling quality most explained impacts, all intervention elements-particularly FLW training and performance-were likely important to achieving impact., (© 2018 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

Background: Although a national epidemic of childhood obesity is apparent, how community-based programmes and policies (CPPs) affect this outcome is not well understood., Objectives: This study examined the longitudinal relationship between the intensity of CPPs in 130 communities over 10 years and body mass index (BMI) of resident children. We also examined whether these relationships differ by key family or community characteristics., Methods: Five thousand one hundred thirty-eight children in grades K-8 were recruited through 436 schools located within 130 diverse US communities. Measures of height, weight, nutrition, physical activity and behavioural and demographic family characteristics were obtained during in-home visits. A subsample of families consented to medical record review; these weight and height measures were used to calculate BMI over time for 3227 children. A total of 9681 CPPs were reported during structured interviews of 1421 community key informants, and used to calculate a time series of CPP intensity scores within each community over the previous decade. Linear mixed effect models were used to assess longitudinal relationships between childhood BMI and CPP intensity., Results: An average BMI difference of 1.4 kg/m 2 (p-value < 0.01) was observed between communities with the highest and lowest observed CPP intensity scores, after adjusting for community and child level covariates. BMI/CPP relationships differed significantly by child grade, race/ethnicity, family income and parental education; as well as community-level race/ethnicity., Conclusions: These results indicate that, over time, more intense CPP interventions are related to lower childhood BMI, and that there are disparities in this association by sociodemographic characteristics of families and communities., (© 2018 World Obesity Federation.)

Background: Sustained improvements in infant and young child feeding (IYCF) require continued implementation of effective interventions. From 2010-2014, Alive & Thrive (A&T) provided intensive interpersonal counseling (IPC), community mobilization (CM), and mass media (MM) in Bangladesh, demonstrating impact on IYCF practices. Since 2014, implementation has been continued and scaled up by national partners with support from other donors and with modifications such as added focus on maternal nutrition and reduced program intensity., Objective: We assessed changes in intervention exposure and IYCF knowledge and practices in the intensive (IPC + CM + MM) compared with nonintensive areas (standard nutrition counseling + less intensive CM and MM) 2 y after termination of initial external donor support., Methods: We used a cluster-randomized design with repeated cross-sectional surveys at baseline (2010, n = 2188), endline (2014, n = 2001), and follow-up (2016, n = 2400) in the same communities, among households with children 0-23.9 mo of age. Within-group differences over time and differences between groups in changes were tested., Results: In intensive areas, exposure to IPC decreased slightly between endline and follow-up (88.9% to 77.2%); exposure to CM activities decreased significantly (29.3% to 3.6%); and MM exposure was mostly unchanged (28.1-69.1% across 7 TV spots). Exposure to interventions did not expand in nonintensive areas. Most IYCF indicators in intensive areas declined from endline to follow-up, but remained higher than at baseline. Large differential improvements of 12-17 percentage points in intensive, compared with nonintensive areas, between baseline and follow-up remained for early initiation of and exclusive breastfeeding, timely introduction of foods, and consumption of iron-rich foods. Differential impact in breastfeeding knowledge remained between baseline and follow-up; complementary feeding knowledge increased similarly in both groups., Conclusions: Continued IPC exposure and sustained impacts on IYCF knowledge and practices in intensive areas indicated lasting benefits from A&T's interventions as they underwent major scale-up with reduced intensity. This trial was registered at clinicaltrials.gov as NCT02740842.

Introduction: Efforts to address the critical public health problem of childhood obesity are occurring across the USA; however, little is known about how to characterize the intensity of these efforts., Objectives: The purposes of this study are to describe the intensity of community programs and policies (CPPs) to address childhood obesity in 130 US communities and to examine the extent to which observed CPPs targeted multiple behaviours and employed a comprehensive array of strategies., Methods: To document CPPs occurring over a 10-year period, key informants were interviewed using a semi-structured interview protocol. Staff coded CPPs for key characteristics related to intensity, including reach, duration and strategy. Three types of CPP scores were calculated for intensity of CPPs, targeting of CPPs towards multiple behaviours and strategies used., Results: Nine thousand six hundred eighty-one CPPs were identified. On average, communities had 74 different CPPs in place (standard deviation 30), with variation in documented CPPs (range 25-295). Most communities experienced a steady, modest increase in intensity scores over 10 years. CPP targeting scores suggested that communities expanded the focus of their efforts over time to include more behaviours and strategies., Conclusions: Findings of this large-scale study indicate that great variation exists across communities in the intensity and focus of community interventions being implemented to address childhood obesity., (© 2018 World Obesity Federation.)

Background: Although husbands may provide support during pregnancy, limited evidence exists on how to promote husbands' engagement and what impact it has. Alive & Thrive integrated nutrition-focused interventions, targeting both wives and husbands, through an existing Maternal, Neonatal, and Child Health (MNCH) platform in Bangladesh., Objectives: We evaluated 1) the impact of a nutrition-focused MNCH program, compared with the standard MNCH program, on husbands' behavioral determinants (i.e., awareness, knowledge, self-efficacy) and support to wives to adopt optimal nutrition practices and 2) how much of the previously documented impact on women's supplement intake and dietary diversity was explained by husbands' behavioral determinants and support., Methods: We used a cluster-randomized design with cross-sectional surveys at baseline (2015) and endline (2016) (n = ∼1000 women and ∼700 husbands/survey). We used mixed linear regression accounting for clustering to estimate difference-in-differences (DIDs) for impact on husbands' behavioral determinants and path analysis to examine how much these determinants explained the impact on women's nutrition behaviors., Results: Of husbands in the nutrition-focused MNCH group, 62% were counseled by health workers, 66% attended a husbands' forum, and 34% saw video shows. The nutrition-focused MNCH, compared with the standard MNCH group, resulted in greater husbands' awareness (DID: 2.74 of 10 points), knowledge (DID: 1.31), self-efficacy and social norms with regard to optimal nutrition practices (difference: 1.08), and support to their wives (DID: 1.86). Husbands' behavioral determinants and support explained nearly half of the program impact for maternal supplement intake and one-quarter for dietary diversity., Conclusions: A nutrition-focused MNCH program that promoted and facilitated husbands' engagement during their wives' pregnancies significantly improved husbands' awareness, knowledge, self-efficacy, and support. These improvements substantially explained the program's impact on women's intake of micronutrient supplements and dietary diversity. Targeting wives and husbands and designing activities to engage men in maternal nutrition programs are important to maximize impact. This trial was registered at www.clinicaltrials.gov as NCT02745249.

Zimbabwe has one of the highest rates of maternal mortality, yet little is understood about adolescent girls' and young women's perspectives on pregnancy or planning for pregnancy. The research study took an emic approach to understand and describe how adolescent girls and young women (14-24 years) in Harare, Zimbabwe, conceptualize pregnancy and planning for pregnancy and how these conceptualizations inform pregnancy decisions. Semi-structured, in-depth, qualitative interviews were conducted with adolescent girls and young women ( N = 48) and data were analyzed thematically using NVivo 10. Pregnancy was conceptualized across nine themes: carrying a child and oneself, growing a family, motherhood, the best time for pregnancy, pregnancy decision makers, who is responsible for the pregnancy, pregnancy burden, pregnancy dangers, and increase in social status with pregnancy. Planning for pregnancy was conceptualized during the prepregnancy, pregnancy, and postpregnancy phases. Findings emphasize considering sociocultural views concerning pregnancy and including social networks in maternal health efforts.

Scale development and validation are critical to much of the work in the health, social, and behavioral sciences. However, the constellation of techniques required for scale development and evaluation can be onerous, jargon-filled, unfamiliar, and resource-intensive. Further, it is often not a part of graduate training. Therefore, our goal was to concisely review the process of scale development in as straightforward a manner as possible, both to facilitate the development of new, valid, and reliable scales, and to help improve existing ones. To do this, we have created a primer for best practices for scale development in measuring complex phenomena. This is not a systematic review, but rather the amalgamation of technical literature and lessons learned from our experiences spent creating or adapting a number of scales over the past several decades. We identified three phases that span nine steps. In the first phase, items are generated and the validity of their content is assessed. In the second phase, the scale is constructed. Steps in scale construction include pre-testing the questions, administering the survey, reducing the number of items, and understanding how many factors the scale captures. In the third phase, scale evaluation, the number of dimensions is tested, reliability is tested, and validity is assessed. We have also added examples of best practices to each step. In sum, this primer will equip both scientists and practitioners to understand the ontology and methodology of scale development and validation, thereby facilitating the advancement of our understanding of a range of health, social, and behavioral outcomes.

Background: The Minimum Dietary Diversity for Women (MDD-W) indicator based on a 10-food group women dietary diversity score (WDDS-10) has been validated to assess dietary quality in nonpregnant women. Little is known about its applicability in pregnant women, and specifically pregnant adolescent girls with higher nutrient requirements., Objectives: This study aimed to 1) compare the adequacy of micronutrient intakes between pregnant adolescent girls and women, 2) examine the performance of WDDS-10 in predicting the mean probability of adequacy (MPA) of 11 micronutrients, and 3) assess how well the MDD-W cutoff of 5 groups performed in pregnant adolescent girls and women., Methods: We used data from a 2015 household survey in Bangladesh (n = 600). Nutrient intakes were estimated with a multiple-pass 24-h recall and WDDS-10 was assessed through the use of a list-based method. Multiple linear regression models adjusted for geographical clustering assessed the association between WDDS-10 and MPA. Sensitivity and specificity analysis assessed the accuracy of MDD-W in correctly classifying individuals into high (MPA >0.6) or low MPA., Results: Dietary intakes of pregnant adolescent girls and women were similar in energy intake, WDDS-10 (5.1 ± 1.4), MPA (0.40 ± 0.12), and micronutrient intakes. Probabilities of adequacy were ∼0.30 for riboflavin, vitamin B-12, calcium, and zinc; 0.12-0.15 for folate; 0.16-0.19 for vitamin A; and extremely low for iron at 0.01. The WDDS-10 was significantly associated with MPA in both groups and predicted MPA equally well at population level (SD of residuals 0.11 for both). Use of the 5-food groups cutoff for MDD-W to classify individuals' diets into MPA >0.6, however, resulted in a low correct classification (∼40%). A cutoff of 6 food groups markedly improved correct classification., Conclusions: The WDDS-10 predicted MPA equally well for pregnant adolescent girls and women at population level. The MDD-W indicator performed poorly in classifying individuals with MPA >0.6.

Aims: Household food insecurity (FI), i.e., limited availability of nutritionally adequate foods, is associated with poor glycemic control among adults with type 2 diabetes. We evaluated the association of FI among youth and young adults (YYA) with type 1 diabetes to inform recent clinical recommendations from the American Diabetes Association for providers to screen all patients with diabetes for FI., Methods: Using data from the Washington and South Carolina SEARCH for Diabetes in Youth Study sites, we conducted an observational, cross-sectional evaluation of associations between FI and glycemic control, hospitalizations, and emergency department (ED) visits among YYA with type 1 diabetes. FI was assessed using the Household Food Security Survey Module, which queries conditions and behaviors typical of households unable to meet basic food needs. Participants' HbA 1c were measured from blood drawn at the research visit; socio-demographics and medical history were collected by survey., Results: The prevalence of FI was 19.5%. In adjusted logistic regression analysis, YYAs from food-insecure households had 2.37 higher odds (95% CI: 1.10, 5.09) of high risk glycemic control, i.e., HbA 1c >9.0%, vs. peers from food-secure households. In adjusted binomial regression analysis for ED visits, YYAs from food-insecure households had an adjusted prevalence rate that was 2.95 times (95% CI [1.17, 7.45]) as great as those from food secure households., Conclusions: FI was associated with high risk glycemic control and more ED visits. Targeted efforts should be developed and tested to alleviate FI among YYA with type 1 diabetes., (Copyright © 2018 Elsevier B.V. All rights reserved.)

The effectiveness of salt iodisation in improving the mental development of young children has not been assessed. We implemented a community-based cluster-randomised effectiveness trial in sixty randomly selected districts in the Amhara region of Ethiopia. We randomly allocated each district to treatment and randomly selected one of its villages. In parallel to national salt iodisation efforts, iodised salt was brought early into the markets of the thirty intervention villages before it became widely available in the thirty control villages 4-6 months later. The primary outcome was children's mental development scores on the Bayley Scales. This was an intention-to-treat analysis using mixed linear models adjusted for covariates and clusters. The trial was registered at ClinicalTrials.gov, NCT013496. We assessed 1835 infants aged 5-11 months at baseline. The same children (85 % of the sample) were re-assessed at 20-29 months when all villages had iodised salt. At endline, urinary iodine concentration was higher in children in the intervention group compared with those in the control group (median 228·0 v. 155·1 µg/l, P=0·001). The intervention group had higher scores compared with the control group on the Bayley composite score (raw scores:130·60 v. 128·51; standardised scores: 27·8 v. 26·9; d=0·13; 95 % CI 0·02, 0·23) and three of the four subscales: cognitive (53·27 v. 52·54, d=0·13; 95 % CI 0·03, 0·23), receptive language (20·71 v. 20·18, d=0·13; 95 % CI 0·03, 0·24) and fine motor (35·45 v. 34·94, d=0·15; 95 % CI 0·04, 0·25). The introduction of iodised salt contributes to children's higher urinary iodine concentration and mental development.

Objectives: In 2014, 30% of African-American households with children had low or very low food security, a rate double that of white households with children. A household has low food security if its members experience food shortages and reductions in food quality attributable to a lack of household resources or access and very low food security if its members also experience reductions in food intake and disrupted eating patterns. Households that are either low or very low food secure are known collectively as food insecure. We examined the association between the severity of household food insecurity and reports of lifetime racial discrimination among a sample of food-insecure African-American households in South Carolina., Design: Data were collected from 154 African-American respondents. Food insecurity was measured using the US Department of Agriculture's Household Food Security Survey Module. Lifetime racial discrimination was measured using the Perceived Ethnic Discrimination Questionnaire-Community Version (PEDQ-CV). We used logistic regression to test the association between severity of food insecurity (low vs. very low food secure), PEDQ-CV score and PEDQ-CV subscales. All models were adjusted for demographic and socioeconomic variables., Results: A one-unit increase in the frequency of lifetime racial discrimination was associated with a 5% increase in the odds of being very low food secure (odds ratio (OR) 1.05, P < .05). More reports of discrimination that were stigmatizing or devaluing (OR 1.16, P < .05), took place at a workplace or school (OR 1.15, P < .05) or were threatening or aggressive (OR 1.39, P < .05) increased the odds of being very low food secure. More reports of racial discrimination that were excluding or rejecting did not significantly increase the odds of being very low food secure (OR 1.07, P > .05)., Conclusions: Severity of household food insecurity is associated with lifetime racial discrimination among African-American households in South Carolina.

Maternal undernutrition and mortality remain high in several African countries. Key nutrition and health interventions improve maternal and birth outcomes. Evidence is scarce on how to strengthen health systems to ensure pregnant women and newborns are reached with these interventions. We conducted three quasi-experimental nonrandomized Community Based Maternal and Neonatal Health and Nutrition projects in regions of Ethiopia, Senegal, and Kenya to demonstrate how proven nutrition interventions could be integrated into health programs to improve knowledge and practices during pregnancy, birth, and postpartum. We evaluated impact on knowledge and practices related to maternal and neonatal care using logistic regression and repeated-measures models with districts as a fixed variable and adjusted for covariates. Combined country analyses show significant positive effects of the intervention on women receiving first antenatal care visit (ANC) during first trimester (OR = 1.44; p < .001), those consuming any iron and folic acid supplement during their latest pregnancy (OR = 1.60; p = .005), those whose <6 months infants were exclusively breastfed (OR = 2.01; p=.003), those whose delivery was facility based (OR = 1.48; p=.031), and those whose postnatal care was facility based (OR = 2.15; p<.001). There was no significant differences between intervention and control groups regarding one or more and four or more ANC visits, women consuming iron and folic acid for ≥90 days, and early initiation of breastfeeding. We conclude that integrating proven nutrition interventions into health programs at community level improved components of access to and use of ANC, delivery services, and postnatal care by women in three African countries., (© 2018 John Wiley & Sons Ltd.)

In recent years, school-based food backpack programs (BPPs) have come into national prominence as a response to a perceived crisis of child hunger in America. Distributing bags of free food directly to schoolchildren for their own personal consumption each weekend, BPPs bring together private donors, faith communities, and public schools around an intuitively appealing project: children are hungry, and so we give them food. Perhaps because of their intuitive appeal, BPPs have expanded rapidly, without rigorous evaluation to determine their impacts on children, families, and schools. This Perspective aims to open up thinking about BPPs, first articulating the implicit conceptual model that undergirds BPPs, drawing on documentation offered by major program providers and on our own experience working with several schools implementing BPPs, to provide a window into what BPPs do and how and why they do it. We focus in particular on how the crisis narrative of child hunger has shaped the BPP model and on the related interplay between public sympathy and the neoliberal climate in which structural solutions to family poverty are eschewed. We then assess the BPP model in light of existing knowledge, concluding that BPPs fit poorly with the needs of the majority of children living in food-insecure households in the United States and consequently put children at risk of negative consequences associated with worry, shame, stigma, and disruptions to family functioning. Finally, we provide recommendations for practice and research, emphasizing the importance of 1) responding to children's actual needs throughout program implementation, 2) avoiding unnecessary risks by effective targeting of services to only those children who need them, and 3) rigorously evaluating program outcomes and unintended consequences to determine whether, even for the small number of US children who experience hunger, the benefits of the BPP model outweigh its psychosocial costs., (© 2018 American Society for Nutrition. All rights reserved.)

Women in the general population experience more food insecurity than men. Few studies have examined food insecurity's impact on HIV treatment outcomes among women. We examined the association between food insecurity and HIV outcomes in a multi-site sample of HIV-infected women in the United States (n = 1154). Two-fifths (40%) of participants reported food insecurity. In an adjusted multivariable Tobit regression model, food insecurity was associated with 2.08 times higher viral load (95% confidence interval (CI): 1.04, 4.15) and lower CD4+ counts (- 42.10, CI: - 81.16, - 3.03). Integration of food insecurity alleviation into HIV programs may improve HIV outcomes in women.

Background: Maternal undernutrition is a major concern globally, contributing to poor birth outcomes. Limited evidence exists on delivering multiple interventions for maternal nutrition simultaneously. Alive & Thrive addressed this gap by integrating nutrition-focused interpersonal counseling, community mobilization, distribution of free micronutrient supplements, and weight-gain monitoring through an existing Maternal, Neonatal, and Child Health (MNCH) program in Bangladesh. Objectives: We evaluated the effect of providing nutrition-focused MNCH compared with standard MNCH (antenatal care with standard nutrition counseling) on coverage of nutrition interventions, maternal dietary diversity, micronutrient supplement intake, and early breastfeeding practices. Methods: We used a cluster-randomized design with cross-sectional surveys at baseline (2015) and endline (2016) ( n ∼ 300 and 1000 pregnant or recently delivered women, respectively, per survey round). We derived difference-in-difference effect estimates, adjusted for geographic clustering and infant age and sex. Results: Coverage of interpersonal counseling was high; >90% of women in the nutrition-focused MNCH group were visited at home by health workers for maternal nutrition and breastfeeding counseling. The coverage of community mobilization activities was ∼50%. Improvements were significantly greater in the nutrition-focused MNCH group than in the standard MNCH group for consumption of iron and folic acid [effect: 9.8 percentage points (pp); 46 tablets] and calcium supplements (effect: 12.8 pp; 50 tablets). Significant impacts were observed for the number of food groups consumed (effect: 1.6 food groups), percentage of women who consumed ≥5 food groups/d (effect: 30.0 pp), and daily intakes of several micronutrients. A significant impact was also observed for exclusive breastfeeding (EBF; effect: 31 pp) but not for early initiation of breastfeeding. Conclusions: Addressing nutrition during pregnancy by delivering interpersonal counseling and community mobilization, providing free supplements, and ensuring weight-gain monitoring through an existing MNCH program improved maternal dietary diversity, micronutrient supplement consumption, and EBF practices. This trial was registered at clinicaltrials.gov as NCT02745249., Competing Interests: Author disclosures: PHN, SSK, TS, ZM, LMT, SS, BA, RH, KA, EAF, MTR, and PM, no conflicts of interest. TS, ZM, SS, BA, and KA were members of the program implementation team that designed and implemented the interventions studied and reported on in this article. They reviewed the manuscript and provided contextual interpretation of the results, but final decisions on the manuscript content lay with the primary authors from the evaluation team (PHN, SSK, EAF, MTR, and PM). Alive & Thrive provided specific inputs to the manuscript regarding intervention design and provided feedback on the interpretation of results. Freedom to publish the study findings was protected contractually in the agreement between the respective funding sources and the International Food Policy Research Institute. This is an open access article distributed under the CC-BY license (http://creativecommons.org/licenses/by/3.0/).

Purpose: The purpose of the article was to examine the relationship between body mass index (BMI) trajectories during infancy and risk of obesity at the age of 6 years., Methods: We used data on 1169 children with at least two BMI measures during their first year of life from the Infant Feeding Practices Survey II and its Year 6 Follow-Up. Latent class growth analysis was used to identify distinct trajectories of BMI, and multiple logistic regression analyses were used to assess the association of the identified trajectories with obesity at the age of 6 years., Results: Three trajectories of BMI were identified during the first year of life: low stable (80.2%), high stable (16.9%), and rising (2.8%). Obesity at the age of 6 years was highest among children with a high-stable trajectory (17.2%), followed by the low-stable (9.6%) and rising (9.1%) groups. Compared with those in the low-stable trajectory, the adjusted odds ratio for obesity at the age of 6 years was 1.79 (95% confidence interval 1.13-2.84) in children with the high-stable growth trajectory and 0.84 (0.26-2.72) in children with the rising growth trajectory., Conclusions: High-stable BMI trajectory in infancy resulted in a higher risk for obesity at the age of 6 years, but had low accuracy for identifying obese children at the age of 6 years., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Evidence regarding impact of community policies and programs (CPPs) to prevent child obesity is limited, and which combinations of strategies and components are most important is not understood. The Healthy Communities Study was an observational study to assess relationships of characteristics and intensity of CPPs with adiposity, diet, and physical activity in children, taking advantage of variation across the U.S. in community actions to prevent child obesity. The study examined the association of CPPs to prevent child obesity with measured BMI and waist circumference, hypothesizing that communities with more-comprehensive CPPs would have children with lower adiposity., Methods: The study included 130 communities selected by probability-based sampling or because of known CPPs targeting child obesity. Data were collected at home visits on 5,138 children during 2013-2015. CPPs were scored for multiple attributes to create a CPP intensity score. A CPP target behavior score reflected the number of distinct target behaviors addressed. Scores were standardized with the smallest observed score across communities being 0 and the largest 1. Multilevel regression analysis in 2016 adjusted for community, household, and individual characteristics., Results: Higher CPP target behavior score was significantly associated with lower BMI and waist circumference in a dose-response relationship, with magnitude for the past 3 years of CPPs of 0.843 (p=0.013) for BMI and 1.783 cm (p=0.020) for waist circumference., Conclusions: This study provides plausible evidence that comprehensive CPPs targeting a greater number of distinct physical activity and nutrition behaviors were associated with lower child adiposity., (Copyright © 2017 American Journal of Preventive Medicine. All rights reserved.)

Age-appropriate complementary feeding practices are far from optimal among low- and middle-income countries with available data. The evidence on the association between feeding practices and linear growth is mixed. We sought to systematically examine the association between two indictors of dietary quality-dietary diversity and animal source food (ASF) consumption (WHO, 2008)-and stunting (length-for-age z-score) employing existing data from 39 Demographic and Health Surveys. Data on 74,548 children aged 6-23 months were pooled and multiple logistic regression models, adjusting for child, maternal, and household characteristics, employed to assess the association between dietary quality and stunting. Stratified models by child age and by World Bank country-income classifications (World Bank, 2015) were also applied. Children aged 6-23 months consuming zero food groups in the previous day had a 1.345 higher odds of being stunted when compared to the reference group (≥5 food groups); those who did not consume any ASF in the previous day had a 1.436 higher odds of being stunted compared to children consuming all three types of ASF (egg, meat, and dairy). We estimated that 2,629 cases of stunting would have been averted (12.6% of those stunted) among the population studied if all children had consumed five or more food groups. Outcomes by country-income groupings showed larger associations of diet diversity and ASF consumption for upper- and lower-middle income countries compared to low-income countries. In summary, dietary diversity and ASF consumption were associated with stunting, with associations varying by stratified groups., (© 2017 John Wiley & Sons Ltd.)

Evaluation of complementary feeding programs is needed to enhance knowledge on what works, to document responsible use of resources, and for advocacy. Evaluation is done during program conceptualization and design, implementation, and determination of effectiveness. This paper explains the role of evaluation in the advancement of complementary feeding programs, presenting concepts and methods and illustrating them through examples. Planning and investments for evaluations should occur from the beginning of the project life cycle. Essential to evaluation is articulation of a program theory on how change would occur and what program actions are required for change. Analysis of program impact pathways makes explicit the dynamic connections in the program theory and accounts for contextual factors that could influence program effectiveness. Evaluating implementation functioning is done through addressing questions about needs, coverage, provision, and utilization using information obtained from process evaluation, operations research, and monitoring. Evaluating effectiveness is done through assessing impact, efficiency, coverage, process, and causality. Plausibility designs ask whether the program seemed to have an effect above and beyond external influences, often using a nonrandomized control group and baseline and end line measures. Probability designs ask whether there was an effect using a randomized control group. Evaluations may not be able to use randomization, particularly for programs implemented at a large scale. Plausibility designs, innovative designs, or innovative combinations of designs sometimes are best able to provide useful information. Further work is needed to develop practical designs for evaluation of large-scale country programs on complementary feeding., (© 2017 John Wiley & Sons Ltd.)

Background: Very low food security (VLFS) happens at the intersection of nuanced and complex patterns of risk characteristics across multiple domains. Little is known about the idiosyncratic situations that lead households to experience VLFS. Objective: We used classification and regression tree (CART) analysis, which can handle complex combinations of predictors, to identify patterns of characteristics that distinguish VLFS households in the United States from other households. Methods: Data came from 3 surveys, the 2011-2014 National Health Interview Survey (NHIS), the 2005-2012 NHANES, and the 2002-2012 Current Population Survey (CPS), with sample participants aged ≥18 y and households with income <300% of the federal poverty line. Survey participants were stratified into households with children, adult-only households, and older-adult households (NHIS, CPS) or individuals aged 18-64 y and individuals aged ≥65 y (NHANES). Household food security was measured with the use of the 10-item US Adult Food Security Scale. Variables from multiple domains, including sociodemographic characteristics, health, health care, and participation in social welfare and food assistance programs, were considered as predictors. The 3 data sources were analyzed separately with the use of CART analysis. Results: Household experiences of VLFS were associated with different predictors for different types of households and often occurred at the intersection of multiple characteristics spanning unmet medical needs, poor health, disability, limitation, depressive symptoms, low income, and food assistance program participation. These predictors built complex trees with various combinations in different types of households. Conclusions: This study showed that multiple characteristics across multiple domains distinguished VLFS households. Flexible and nonlinear methods focusing on a wide range of risk characteristics should be used to identify VLFS households and to inform policies and programs that can address VLFS households' various needs., Competing Interests: Author disclosures: SKC, MSF, and EAF, no conflicts of interest., (© 2017 American Society for Nutrition.)

Background: A low proportion of CD28CD8 T cells that express CD57 is associated with increased mortality in HIV infection. The effect of increasing body mass index (BMI) changes in the proportion of CD57CD28CD8 T cells among HIV-infected individuals on antiretroviral therapy is unknown., Setting: In a US cohort of HIV-infected women, we evaluated associations of BMI and waist circumference with 3 distinct CD8 T cell phenotypes: % CD28CD57CD8 T cells, % CD57 of CD28CD8 T cells, and % CD28 of all CD8 T cells., Methods: Multivariable linear regression analysis was used to estimate beta coefficients for each of 3 T-cell phenotypes. Covariates included HIV parameters (current and nadir CD4, current viral load), demographics (age, race, income, and study site), and lifestyle (tobacco and alcohol use) factors., Results: Of 225 participants, the median age was 46 years and 50% were obese (BMI >30 m/kg). Greater BMI and waist circumference were both associated with higher % CD28CD57CD8 T cells and % CD57 of all CD28CD8 T cells in multivariable analysis, including adjustment for HIV viral load (all P < 0.05). The association between greater BMI and the overall proportion of CD28 CD8 cells in fully adjusted models (0.078, 95% confidence interval: -0.053 to 0.209) was not significant., Conclusions: In this analysis, greater BMI and waist circumference are associated with greater expression of CD57 on CD28CD8 T cells and a greater proportion of CD57CD28 CD8 T cells. These findings may indicate that increasing BMI is immunologically protective in HIV-infected women. Future research is needed to understand the prognostic importance of these associations on clinical outcomes.

We aimed to estimate the population fraction of poor early child health and developmental outcomes attributable to maternal depressive symptoms (DS) contrasting it between low- and middle/high-income households. We used a nationally representative probabilistic sample of 4240 children younger than 5 years old and their mothers, derived from the Mexican National Health and Nutrition Survey Data (ENSANUT 2012). Complex survey design, sampling, and analytic weights were taken into account in analyses. DS was measured by CESD-7. Child outcomes were as follows: breastfeeding, attending well-child check-ups, respiratory disease, diarrhea and general health problems, immunization, accidents, growth, obesity, and food insecurity. Prevalence of DS among mothers was 21.36%. In low-SES households, DS was associated with higher risk of never being breastfed (RR = 1.77; p < .05), health problems (RR = 1.37; p < .05), acute respiratory disease (RR = 1.51; p < .05), accidents requiring child hospitalization (RR = 2.16; p < .01), and moderate or severe food insecurity (RR = 1.58; p < .001). In medium- or high-SES households, DS was associated with higher risk of never attending a developmental check-up (RR = 2.14; p < .05) and moderate or severe food insecurity (RR = 1.75; p < .01). Population risks attributable to DS ranged from 2.30 to 17.45%. Prevention of DS could lead to reduction of problematic early childhood outcomes in both low and medium/high SES.

Background: To improve school store food environments, the South Korean government implemented 2 policies restricting unhealthy food sales in school stores. A food-based policy enacted in 2007 restricts specific food sales (soft drinks); and a nutrient-based policy enacted in 2009 restricts energy-dense and nutrient-poor (EDNP) food sales. The purpose of the study was to assess how the 2 policies have changed the school store food environment., Methods: Foods sold in school stores in Seoul, South Korea were observed before (2006, 15 stores) and after (2013, 12 stores) implementation of the school store policies. Food availability in school stores in 2006 and 2013 was compared and EDNP food availability in 2013 was examined., Results: When controlling the total number of foods sold in school stores and school characteristics, the mean number of soft drinks sold in a school store in 2013 (0.3 items) was significantly lower than in 2006 (1.9 items, p = .032). Soft drinks were still available in 50% of school stores observed in 2013, with all school stores selling EDNP foods in 2013., Conclusions: South Korean policies have had a modest influence on availability of unhealthy school store foods. Alternative strategies to improve school store food environments are needed., (© 2017, American School Health Association.)

Micronutrient deficiencies are prevalent among Zimbabweans with serious health and social implications. Due to a lack of a national micronutrient food fortification policy, the Zimbabwe Ministry of Health and Child Care established a policy for the prevention of maternal micronutrient deficiencies, which centres on pregnant women receiving daily iron and folic acid (IFA) at their first antenatal care visit and throughout pregnancy. Despite these efforts, utilization of IFA supplementation in pregnancy in Zimbabwe is low. This study aimed to understand the experiences and knowledge of IFA supplementation among pregnant women and healthcare workers in Harare, Zimbabwe, and the influence of health-service and social environments on utilization. Semi-structured in-depth interviews were conducted in Shona and English, with pregnant women (n = 24) and healthcare workers (n = 14) providing direct antenatal care services to pregnant women in two high-density community clinics. Data were analysed thematically using NVivo 10. Influences on utilization were at the individual and structural environmental levels. Reasons for low utilization of IFA supplementation included forgetting to take IFA, side effects, misconceptions about IFA, limited access to nutrition information, delayed entry or non-uptake of antenatal care and social norms of pregnant women for IFA supplementation. Utilization was enhanced by knowledge of risks and benefits of supplementation, fear of negative health complications with non-utilization, family support and healthcare worker recommendation for supplementation. Study findings can inform approaches to strengthen micronutrient supplementation utilization to improve the micronutrient status of pregnant women to decrease maternal mortality and improve overall maternal and child health in Zimbabwe. © 2016 John Wiley & Sons Ltd., (© 2016 John Wiley & Sons Ltd.)