Scott B. Ickes

Poor Nutritional Habits: A Modifiable Predecessor of Chronic Illness? A North Carolina Family Medicine Research Network (NC-FM-RN) Study

Purpose: To examine associations between personal nutritional patterns and various indicators of health, disease risk, and chronic illness in a diverse, representative sample of adult patients from primary care settings. Methods: As part of a survey of adult patients conducted in the waiting rooms of 4 primary care practices in North Carolina (recruitment rate 74.8%), a 7-item nutrition screen was administered to 1788 study participants. Other questionnaire items addressed disease and functional status, race/ethnicity, health habits, and demographic factors. Results: Respondents included 292 African Americans (17.3%), 1004 non-Hispanic whites (59.4%), 255 Hispanics (15.1%), and 126 American Indians (7.4%); mean age 47.5 years. Thirty percent reported eating 3 or more fast food meals weekly, 29% drank 3 or more high-sugar beverages weekly, 22% ate 3 or more high-fat snacks weekly, 36% ate 3 or more desserts weekly, 11% reported eating “a lot” of margarine, butter, or meat fat; 62% ate 2 or fewer fruits or vegetables daily; and 42% reported consuming protein less than 3 times a week. Scores on a summary measure were worse for prediabetics than for diabetics, for young adults compared with older persons, and for persons reporting good/excellent health versus fair/poor health. Conclusions: People at high risk for developing chronic illnesses later in life reported poorer diets in comparison with people who are already ill. This probably represents increased nutritional awareness and motivation among people with chronic diseases. Because primary care patients have a high prevalence of chronic disease risk factors, the primary care office setting may constitute a particularly appropriate location for nutrition education.

Maternal Literacy, Facility Birth, and Education Are Positively Associated with Better Infant and Young Child Feeding Practices and Nutritional Status among Ugandan Children

BACKGROUND Understanding maternal factors that influence child feeding is necessary to inform intervention planning in settings in which mothers experience substantial social vulnerabilities. OBJECTIVE The purpose of this study was to assess maternal sociodemographic factors that may constrain womens caring capabilities and subsequent child nutrition in Uganda. METHODS We analyzed data from the 2006 and 2011 Uganda Demographic and Health Surveys to model the associations between maternal sociodemographic factors, child feeding practices, and anthropometry with multivariate logistic regression models. RESULTS The proportion of children fed according to recommended guidelines declined in Uganda from 2006 to 2011. Mothers who lacked literacy skills were less likely to achieve recommended complementary feeding indicators; however, literacy was not associated with breastfeeding practices. Mothers in the upper 60% wealth percentile were more likely to meet minimum meal frequency, diversity, and adequacy indicators. Mothers who gave birth at health facilities (2006 OR: 0.49; 95% CI: 0.26, 0.91; P < 0.05) and who were in the upper 60% wealth percentile (2011 OR: 0.43; 95% CI: 0.21, 0.69) were less likely to exclusively breastfeed until 6 mo. There were no significant associations between age at first pregnancy, maternal education, and infant and young child feeding practices. Women with a formal education had children with lower stunting and underweight probabilities in both time periods (OR range: 0.43-0.74). Women who delivered in childbirth facilities were less likely to have a child with low weight-for-age, length-for-age, or weight-for-length z scores (OR range: 0.59-0.82). Marital status, the age at first child birth, not accepting domestic violence, freedom to travel away from home, and involvement in household and reproductive decisions were not associated with child anthropometry in either time period. CONCLUSIONS Mothers with low literacy skills, who deliver their children at home, and who lack formal education are particularly at risk of poor child feeding and represent a group that may benefit from enhanced interventions that address their particular vulnerabilities. Factors that contribute to improved maternal feeding capabilities but may impair breastfeeding practices need to be better understood.

Examination of facilitators and barriers to home-based supplemental feeding with ready-to-use food for underweight children in western Uganda

Poor complementary feeding practices and low-quality complementary foods are significant causes of growth faltering and child mortality throughout the developing world. Ready-to-use foods (RUF) are energy-dense, lipid-based products that do not require cooking or refrigeration that have been used to prevent and treat malnutrition among vulnerable children. The effectiveness of these products in improving child nutritional status depends on household use by caregivers. To identify the key facilitators and barriers that influence appropriate in-home RUF consumption by supplemental feeding program beneficiaries, we conducted individual interviews among caregivers (n = 80), RUF producers (n = 8) and program staff (n = 10) involved in the Byokulia Bisemeye mu Bantu supplemental feeding program in Bundibugyo, Uganda. By documenting caregiver perceptions and feeding practices related to RUF, we developed a conceptual framework of factors that affect appropriate feeding with RUF. Findings suggest that locally produced RUF is well received by caregivers and children, and is perceived by caregivers and the community to be a healthy supplemental food for malnourished children. However, child feeding practices, including sharing of RUF within households, compromise the nutrient delivery to the intended child. Interventions and educational messages informed by this study can help to improve RUF delivery to targeted beneficiaries.

Health Economics in Public Health

BACKGROUND Economic analysis is an important tool in deciding how to allocate scarce public health resources; however, there is currently a dearth of such analysis by public health researchers. METHODS Public health researchers and practitioners were surveyed to determine their current use of health economics and to identify barriers to use as well as potential strategies to decrease those barriers in order to allow them to more effectively incorporate economic analyses into their work. Data collected from five focus groups informed survey development. The survey included a demographic section and 14 multi-part questions. Participants were recruited in 2006 from three national public health organizations through e-mail; 294 academicians, practitioners, and community representatives answered the survey. RESULTS Survey data were analyzed in 2007. Despite an expressed belief in the importance of health economics, more than half of the respondents reported very little or no current use of health economics in their work. Of those using health economics, cost-benefit and cost-effectiveness analysis and determination of public health costs were cited as the measures used most frequently. The most important barriers were lack of expertise, funding, time, tools, and data, as well as discomfort with economic theory. The resource deemed most important to using health economics was collaboration with economists or those with economic training. Respondents indicated a desire to learn more about health economics and tools for performing economic analysis. CONCLUSIONS Given the importance of incorporating economic analysis into public health interventions, and the desire of survey respondents for more collaboration with health economists, opportunities for such collaborations should be increased.

Parental Involvement in a School-Based Child Physical Activity and Nutrition Program in Southeastern United States: A Qualitative Analysis of Parenting Capacities.

Background. Parent involvement varies widely in school-based programs designed to promote physical activity and healthy nutrition, yet the underlying factors that may limit parent’s participation and support of learned behaviors at home are not well understood. Method. We conducted a qualitative study that consisted of one focus group (n = 5) and 52 in-depth interviews among parents whose children participated in a school-based physical activity and nutrition (PAN) promotion program in Williamsburg, Virginia, United States. We sought to identify factors that enabled or constrained parent’s support of and involvement in children’s programs and to understand the underlying factors that contribute to family success in making dietary and physical activity changes at home. Results. Parents identified their physical and mental health, self-confidence, time, and decision making as underlying “capacities” in the family health pattern. When strengthened, these capacities encourage healthful family behavior and support of school-based PAN programs. Families that succeeded in adopting lessons learned from school-based PAN programs identified four primary strategies for success: shared goals, meal planning, modeling of good behaviors, and collective activities. Conclusions. Interventions that aim to improve child nutrition and physical activity and the broader family health environment should consider underlying capacities of parents and the importance of joint goals and activities.

Impact of lipid-based nutrient supplementation (LNS) on children's diet adequacy in Western Uganda

Lipid-based nutrient supplements (LNS) can help treat undernutrition; however, the dietary adequacy of children supplemented with LNS, and household utilisation patterns are not well understood. We assessed diet adequacy and the quality of complementary foods by conducting a diet assessment of 128 Ugandan children, ages 6-59 months, who participated in a 10-week programme for children with moderate acute malnutrition (MAM, defined as weight-for-age z-score < -2). Caregivers were given a weekly ration of 650 kcal day(-1) (126 g day(-1) ) of a peanut/soy LNS. Two 24-h dietary recalls were administered per child. LNS was offered to 86% of targeted children at least once. Among non-breastfed children, over 90% met their estimated average requirement (EAR) cut-points for all examined nutrients. Over 90% of breastfed children met EAR cut-points for nutrient density for most nutrients, except for zinc where 11.7% met cut-points. A lower proportion of both breastfed and non-breastfed children met adjusted EARs for the specific nutritional needs of MAM. Fewer than 20% of breastfed children met EAR nutrient-density guidelines for MAM for zinc, vitamin C, vitamin A and folate. Underweight status, the presence of a father in the childs home, and higher programme attendance were all associated with greater odds of feeding LNS to targeted children. Children in this community-based supplemental feeding programme who received a locally produced LNS exhibited substantial micronutrient deficiencies given the special dietary needs of this population. These results can help inform programme strategies to improve LNS targeting, and highlight potential nutrient inadequacies for consumers of LNS in community-based settings.

Reply to Correspondence: is the strength of association between indicators of dietary quality and the nutritional status of children being underestimated?

To the Editors, We are grateful to Thorne-Lyman et al. (2014) for the insightful comments in response to the Jones et al. (2014) article. We largely agree with observations highlighting important limitations of dietary data drawn from 24-h recall methods and take the opportunity to augment the discussion of the important question posed regarding the potential underestimation of the associations between indicators of dietary quality and child nutritional status. Thorne-Lyman et al. (2014) suggest in particular that low statistical power resulting from random within-person error introduced through the use of single pass 24-h recall data may explain the statistically non-significant relationships observed between the World Health Organization (WHO) minimum dietary diversity (MDD) indicator and child stunting in the recent article by Jones et al. (2014). They further suggest that this within-person error could be corrected for in analyses if at least one additional day of data on the food group diversity of young child diets were collected. We agree with this assertion and suggest also that these challenges are not limited to random withinperson error associated with data derived from 24-h recalls. Taking the MDD indicator as an example, we highlight in the Jones et al. (2014) article that this indicator lacks specificity with respect to the micronutrient adequacy of diets (i.e. it may commonly misclassify adequate diets as inadequate). Therefore, even with sufficient statistical power, classifying the adequacy of diets using a binary categorical variable may not allow for sufficient accuracy when using regression analysis to examine the relationship between diet diversity and nutrition-related health outcomes (Royston et al. 2006). Investing the effort and expense to collect replicate measurements of child dietary diversity will reduce within-person error and can provide a more accurate exposure assessment. Having done this, however, it would be disadvantageous to limit the analysis by using an indicator that lacks specificity and therefore cannot take full advantage of the additional information collected from those replicate measurements. While the WHO indicators provide practitioners, researchers and decision-makers with easy-to-use metrics to draw attention to disparities in child feeding practices, they have specific limitations in assessing diet-health relationships. In highlighting the need to be clear about the use of data, Beaton (1994), in the article cited by Thorne-Lyman et al. (2014), points out that error in dietary assessment may have different consequences depending on the analytic question at hand. In regression analyses, for example, random error resulting from within-person variation may alter both the intercept of an observed relationship and the slope (Beaton 1994). However, if one is only interested in comparing group means (e.g. comparing dietary diversity across countries or subgroups within countries), random error will not bias the relationship, but will rather simply decrease statistical power to detect a difference (Beaton 1994). The WHO infant and young child feeding (IYCF) indicators are especially well suited for this latter purpose, in which case, the random within-person error introduced through single-day 24-h food group recall is not a serious concern in sufficiently large samples. In examining the relationship between diet and health on the other hand, random error is a threat to the actual observed relationship. It is not clear that the MDD indicator is the appropriate metric for representing dietary data collected using the replicate measurements needed for addressing this withinperson error. Indeed, future research efforts and discussions would be well directed towards identifying the most appropriate indicators, especially those that bs_bs_banner

Building a Stronger System for Tracking Nutrition-Sensitive Spending: A Methodology and Estimate of Global Spending for Nutrition-Sensitive Foreign Aid.

Background: There is growing awareness that the necessary solutions for improving nutrition outcomes are multisectorial. As such, investments are increasingly directed toward “nutrition-sensitive” approaches that not only address an underlying or basic determinant of nutrition but also seek to achieve an explicit nutrition goal or outcome. Understanding how and where official development assistance (ODA) for nutrition is invested remains an important but complex challenge, as development projects components vary in their application to nutrition outcomes. Currently, no systematic method exists for tracking nutrition-sensitive ODA. Objective: To develop a methodology for classifying and tracking nutrition-sensitive ODA and to produce estimates of the amount of nutrition-sensitive aid received by countries with a high burden of undernutrition. Methods: We analyzed all financial flows reported to the Organization for Economic Co-Operation and Development’s Development Assistance Committee Creditor Reporting Service in 2010 to estimate these investments. We assessed the relationships between national stunting prevalence, stunting burden, under-5 mortality, and the amount of nutrition-specific and nutrition-sensitive ODA. Results: We estimate that, in 2010, a total of

An Assessment of Perceived Barriers to Farmers’ Market Access

379·4 million (M) US dollars (USD) was committed to nutrition-specific projects and programs of which 25 designated beneficiaries (countries and regions) accounted for nearly 85% (

Understanding barriers and facilitators of fruit and vegetable consumption among a diverse multi-ethnic population in the USA

320 M). A total of