Effect of nutrition counselling with a digital job aid on child dietary diversity: Analysis of secondary outcomes from a cluster randomised controlled trial in rural Bangladesh

Adequate dietary diversity among infants is often suboptimal in developing countries. We assessed the impact of nutrition counselling using a digital job aid on dietary diversity of children aged 6–23 months using data from a cluster randomised controlled trial in Bangladesh. The trial had five arms, each with 25 clusters. The four intervention arms provided counselling using a digital job aid and different prenatal and post-natal combinations of lipid-based supplements and the comparison arm with usual practice. We enrolled 1500 pregnant women and followed them until the children reached their second birthday. We developed a tablet-based system for intervention delivery, data collection and project supervision. We combined the four intervention arms (n = 855), in which community health workers (CHWs) provided age-appropriate complementary feeding counselling, to compare against the comparison arm (n = 403). We calculated the outcome indicators from the children's 24-h dietary recalls. Overall, the intervention increased the mean dietary diversity score by 0.09 (95% confidence interval [CI]: 0.2–0.16) and odds of minimum dietary diversity by 18% (95% CI: 0.99–1.40). However, there was a significant interaction on the effect of the intervention on dietary diversity by age. The mean dietary diversity score was 0.24 (95% CI: 0.11–0.37) higher in the intervention than in the comparison arm at 9 months and 0.14 (95% CI: 0.01–27) at 12 months of age. The intervention effect was non-significant at an older age. Overall, consumption of flesh food was 1.32 times higher in the intervention arm (odds ratio [OR] 1.32, 95% CI: 1.11–1.57) in 6–23 months of age. The intervention significantly improved child dietary diversity score in households with mild and moderate food insecurity by 0.27 (95% CI: 0.06–0.49) and 0.16 (0.05–27), respectively, but not with food-secure and severely food-insecure households. Although the study did not evaluate the impact of digital job aid alone, the findings indicate the utility of nutrition counselling by CHWs using a digital job aid to improve child feeding practices in broader programmes.     

Methodological development of an exploratory randomised controlled trial of an early years' nutrition intervention: the CHERRY programme (Choosing Healthy Eating when Really Young)

Good nutrition in the early years of life is vitally important for a child's development, growth and health. Children's diets in the United Kingdom are known to be poor, particularly among socially disadvantaged groups, and there is a need for timely and appropriate interventions that support parents to improve the diets of young children. The Medical Research Council has highlighted the importance of conducting developmental and exploratory research prior to undertaking full‐scale trials to evaluate complex interventions, but have provided very limited detailed guidance on the conduct of these initial phases of research. This paper describes the initial developmental stage and the conduct of an exploratory randomised controlled trial undertaken to determine the feasibility and acceptability of a family‐centred early years' nutrition intervention. Choosing Healthy Eating when Really Young (CHERRY) is a programme for families with children aged 18 months to 5 years, delivered in children's centres in one urban (Islington) and one rural (Cornwall) location in the United Kingdom. In the development stage, a mixed‐methods approach was used to investigate the nature of the problem and options for support. A detailed review of the evidence informed the theoretical basis of the study and the creation of a logic model. In the feasibility and pilot testing stage of the exploratory trial, 16 children's centres, with a sample of 394 families were recruited onto the study. We hope that the methodology, which we present in this paper, will inform and assist other researchers in conducting community‐based, exploratory nutrition research in early years settings.     

Be Healthy in Pregnancy: Exploring factors that impact pregnant women's nutrition and exercise behaviours

Excess gestational weight gain is associated with short‐ and long‐term pregnancy complications. Although a healthy diet and physical activity during pregnancy are recommended and shown to reduce the risk of complications and improve outcomes, adherence to these recommendations is low. The aims of this study were to explore women's view of nutrition and physical activity during pregnancy and to describe barriers and facilitators experienced in implementing physical activity and nutrition recommendations. In a substudy of the Be Healthy in Pregnancy randomized trial, 20 semistructured focus groups were conducted with 66 women randomized to the control group when they were between 16 and 24 weeks gestation. Focus groups were recorded, transcribed verbatim, coded and thematically analysed. The results indicate that women felt motivated to be healthy for their baby, but competing priorities may take precedence. Participants described limited knowledge and access to information on safe physical activity in pregnancy and lacked the skills needed to operationalize both physical activity and dietary recommendations. Women's behaviours regarding diet and physical activity in pregnancy were highly influenced by their own and their peers' beliefs and values regarding how weight gain impacted their health during pregnancy. Pregnancy symptoms beyond women's control such as fatigue and nausea made physical activity and healthy eating more challenging. Counselling from care providers about nutrition and physical activity was perceived as minimal and ineffective. Future interventions should address improving counselling strategies and address individual's beliefs around nutrition and activity in pregnancy.     

Understanding the effects of nutrition‐sensitive agriculture interventions with participatory videos and women's group meetings on maternal and child nutrition in rural Odisha,India: A mixed‐methods process evaluation

A trial of three nutrition‐sensitive agriculture interventions with participatory videos and women''s group meetings in rural Odisha, India, found improvements in maternal and child dietary diversity, limited effects on agricultural production, and no effects on women and children''s nutritional status. Our process evaluation explored fidelity, reach, and mechanisms behind interventions'' effects. We also examined how context affected implementation, mechanisms, and outcomes. We used data from intervention monitoring systems, review notes, trial surveys, 32 case studies with families (n = 91 family members), and 20 group discussions with women''s group members and intervention workers (n = 181 and 32, respectively). We found that interventions were implemented with high fidelity. Groups reached around half of the mothers of children under 2 years. Videos and meetings increased women''s knowledge, motivation and confidence to suggest or make changes to their diets and agricultural production. Families responded in diverse ways. Many adopted or improved rainfed homestead garden cultivation for consumption, which could explain gains in maternal and child dietary diversity seen in the impact evaluation. Cultivation for income was less common. This was often due to small landholdings, poor access to irrigation and decision‐making dominated by men. Interventions helped change norms about heavy work during pregnancy, but young women with little family support still did considerable work. Women''s ability to shape cultivation, income and workload decisions was strongly influenced by support from male relatives. Future nutrition‐sensitive agriculture interventions could include additional flexibility to address families’ land, water, labour and time constraints, as well as actively engage with spouses and in‐laws.     

Efficacy of small group reading intervention for beginning readers with reading-delay: a randomised controlled trial

BACKGROUND: This study evaluated the effectiveness of an intervention for reading-delayed children in Year-1 classes. METHODS: A sample (N = 77) of children drawn from 14 schools representing those with the weakest reading skills were randomly allocated to one of two groups. A 20-week intervention group received the intervention for two consecutive 10-week periods, while a 10-week intervention group only received the intervention for the second 10 weeks of the study. The programme was delivered in daily 20-minute sessions that alternated between small group (N = 3) and individual teaching. The programme combined phoneme awareness training, word and text reading, and phonological linkage exercises. RESULTS: The children receiving the intervention during the first 10-week period made significantly more progress on measures of letter knowledge, single word reading, and phoneme awareness than children not receiving the intervention. However, the children who only received the intervention during the second 10-week period made rapid progress and appeared to catch up with the children who had been given the more prolonged intervention. Failure to respond to the intervention was predicted by poor initial literacy skills and being in receipt of free school meals. CONCLUSION: A reading intervention programme delivered on a daily basis by trained teaching assistants is an effective intervention for children who show reading delays at the end of their first year in school. However, around one-quarter of the children did not respond to this intervention and these children would appear to need more intensive or more prolonged help to improve their reading skills.     

Text messages to improve child diets: Formative research findings and protocol of a randomised controlled trial in Nepal

Given the role of malnutrition in childhood morbidity and mortality, the prioritisation of maternal and child nutrition programmes has grown significantly in the 21st century. Policies and programmes aim to improve infant and young child feeding, but questions persist about the most effective combination of interventions to achieve desired behaviour change. There is increasing interest in mobile-based interventions globally, but scant evidence exists to guide donors, policymakers and programme implementers on their effectiveness. Formative research was conducted to assess the feasibility and acceptance of text message-based interventions and to guide the final design of the text message intervention. This protocol is for a cluster-randomised controlled trial to test the effectiveness of adding text messaging to other ongoing SBC interventions to promote egg consumption, dietary diversity and other ideal dietary practices, particularly among children 12–23 months of age in Kanchanpur, Nepal. The trial findings will contribute to the emerging body of evidence on the effectiveness of using text messages for behaviour change, specifically for young child dietary outcomes in South Asia. Recent studies have suggested that mobile-based interventions alone may be insufficient but valuable when added to other social and behavioural interventions; this trial will help to provide evidence for or against this emerging theory. This trial was registered at ClinicalTrials.gov on 11 March 2019 (ID: NCT03926689) and has been updated twice.     

Toddler obesity prevention: A two‐generation randomized attention‐controlled trial

Rapid weight gain increases risks of obesity and associated co‐morbidities. The objective was to reduce the rate of body mass index (BMI) growth (BMI z score), relative to control. Secondary outcomes were toddler–mother physical activity, mealtime interactions and fruit/vegetable intake. The randomized three‐arm, eight‐session, 4‐month trial, conducted 2009–2013, included two intervention arms (responsive parenting and maternal lifestyle) and an attention control (home safety). Baseline and 6‐ and 12‐month follow‐up evaluations included weight and length/height, ankle accelerometry, video‐recorded mealtime interactions (Emotional Availability Scales) and 24‐h diet recalls (Healthy Eating Index‐2015 [HEI‐2015]). Analyses used linear mixed‐effects models with repeated measures comparing intervention versus control changes in BMI z score. We recruited 277 racially mixed (70% African American) toddler–mother dyads (mean ages 20.1 months and 27.3 years) from US WIC and primary care clinics and randomized them into intervention versus control; 31% toddlers and 73% mothers were overweight/obese. At follow‐up, changes in the rate of toddler BMI z score and maternal BMI were non‐significant. Maternal lifestyle group toddlers and mothers spent 24.43 and 11.01 more minutes in physical activity (95% confidence interval [CI]: 2.55, 46.32, and 95% CI: 1.48, 20.54, respectively). Fruit intake increased in both intervention groups. Hostile mealtime interactions increased in the maternal lifestyle group, and in supplementary analyses, mealtime interactions were significantly higher in the responsive parenting group than in the maternal lifestyles group, suggesting that toddler dietary interventions include responsive parenting. Intervention effects were stronger among older versus younger toddlers. Despite no impact on weight gain, additional research should examine integrated two‐generation responsive parenting and maternal lifestyle interventions among toddler–mother dyads.     

The impact of maternal diet fortification with lipid‐based nutrient supplements on postpartum depression in rural Malawi: a randomised‐controlled trial

Perinatal depression is highly prevalent in low‐and‐middle‐income countries and has been linked to poor child health. Suboptimal maternal nutrition may be a risk factor for perinatal depression. In this randomised‐controlled trial conducted in rural Malawi, we set out to test the hypothesis that women taking a fatty acid‐rich lipid‐based nutrient supplement (LNS) would have fewer depressive symptoms postpartum than those taking iron‐folate (IFA) or multiple‐micronutrient (MMN) capsules. Women were recruited from antenatal clinics and randomised to receive LNS or MMN during pregnancy and for 6 months postpartum, or IFA during pregnancy only. Maternal depressive symptoms were measured using validated translations of the Self Reporting Questionnaire (SRQ) and Edinburgh Postnatal Depression Scale (EPDS), antenatally (SRQ only) and at 6 months postpartum (SRQ and EPDS). Analysis was by modified intention to treat. One thousand three hundred and ninety one women were randomised (LNS = 462, MMN = 466, IFA = 463). The groups were similar across a range of baseline variables. At 6 months postpartum, 1078 (77.5%) had SRQ completed; mean (SD) scores were LNS 1.76(2.73), MMN 1.92(2.75), IFA 1.71(2.66), P = 0.541. One thousand and fifty seven (76.0%) had EPDS completed; mean (SD) scores were LNS 5.77(5.53), MMN 5.43(4.97), IFA 5.52(5.18), P = 0.676. There were no statistically significant differences between the groups on SRQ or EPDS scores (continuous or dichotomised) in unadjusted or adjusted models. In conclusion, fortification of maternal diet with LNS compared with MMN or IFA did not reduce postnatal depressive symptoms in this study.     

Supplemental iron intake and the risk of glucose intolerance in pregnancy: re‐analysis of a randomised controlled trial in Finland

Observational studies suggest that high iron intake during pregnancy is associated with the risk of gestational diabetes. As such studies are prone to bias, we re‐analysed data from a randomised controlled trial of iron supplementation to see whether it supports the risk found in observational studies. The trial was conducted in primary health care setting in five municipalities in Finland in 1985–1986. The participants were 2944 women (95% of pregnant women in the area) who were randomly allocated either to (1) the selective iron group (elemental iron 50 mg twice a day only if diagnosed as anaemic, continuing until their haemoglobin increased to 110 g L^?1) or (2) the routine iron group (elemental iron 100 mg day^?1 throughout the pregnancy regardless of haemoglobin level). The numbers of women in the analyses were 1358 and 1336, respectively. The main outcome measure was a composite variable including any glucose intolerance‐related outcome (e.g. glucosuria, gestational diabetes, large‐for‐gestational‐age child) in mothers' or children's patient records during pregnancy and post‐partum. There were no statistically significant differences in the incidence of the primary outcome between the selective iron and the routine iron groups (13.0 vs. 11.0%, P = 0.12). The most common outcome was large‐for‐gestational‐age calculated from children's hospital data (8.3 vs. 8.2%, P = 0.95). The results were mainly similar when stratified by the mothers' baseline haemoglobin level, body mass index or gestational weight gain. Routine iron supplementation throughout pregnancy did not increase the risk of glucose intolerance during pregnancy. The results need to be confirmed in future trials.     

Healthier diet associated with reduced risk of excessive gestational weight gain: A Chinese prospective cohort study

Limited studies have examined the associations between diet quality and gestational weight gain (GWG) among Chinese pregnant women, adopting Chinese GWG guidelines. We prospectively investigate the associations of diet quality, using the Chinese Healthy Diet Index for Pregnancy (CHDI-P), which assessed diet quality from ‘Diversity’, ‘Adequacy’ and ‘Limitation’ dimensions with overall 100 points, with GWG among participants enroled in Southwest China. Food consumption was collected by 24 h dietary recalls for three consecutive days and CHDI-P scores were divided into tertiles. GWG was calculated according to the weight measured before delivery and classified into adequate weight gain (AWG), insufficient weight gain (IWG) and excessive weight gain(EWG) following Chinese GWG guidelines. Multinomial regression analyses and stratified analyses by pre-pregnancy body mass index were performed to estimate the association between CHDI-P and GWG. A total of 1416 participants were recruited in early pregnancy, and 971 and 997 participants were respectively followed up in middle and late pregnancy. The mean CHDI-P score was 56.44 ± 6.74, 57.07 ± 7.44 and 57.38 ± 7.94 points in early, middle and late pregnancy, respectively. Women in the lowest CHDI-P scores group had an increased risk of EWG in middle (OR = 1.53, 95% confidence interval [CI] = 1.08–2.17) and late pregnancy (OR = 1.71, 95% CI = 1.21–2.41) than women in the highest group, while overweight/obese women had a greater risk of EWG in late pregnancy (OR = 4.25, 95% CI = 1.30–13.90). No association was found between the CHDI-P scores and IWG. Poor diet quality in middle and late pregnancy was associated with a higher risk of EWG.     

The effect of tailor-made information on vitamin D status of immigrant mothers in Norway: a cluster randomized controlled trial

A high prevalence of vitamin D deficiency has been reported in non-Western immigrants in Norway. Our objective was to test whether written information about how to improve vitamin D status could improve the vitamin D status in immigrants mothers attending child health clinics. In this cluster randomized controlled trial in eight child health clinics in Oslo, mothers aged 18-43 years with Pakistani, Turkish, or Somali background were included when their infants were 6 weeks old. The public health nurses gave the intervention group a brochure with information on how to improve vitamin D status, written in their native language. They were compared with a control group receiving usual care, consisting of oral information only. The principal outcome measure was increase in serum 25-hydroxyvitamin D [s-25(OH) D] in mothers 7 weeks later. Forty-four mothers completed the study. Mean baseline s-25(OH) D was 29.1 (14.8) nmol l(-1) in the intervention and 19.4 (9.2) in the control group. There was no significant increase in s-25(OH) D from baseline to follow-up in the intervention [6.3 (95%CI: -1.9, 14.4) nmol l(-1) )] or in the control group [2.9 (95% CI [confidence interval]: -1.2, 7.0) nmol l(-1) ]. When adjusting for baseline s-25(OH) D concentration the mean difference in increase between the intervention and control group was 1.4 (95% CI: -18.7, 21.4) nmol l(-1) (P = 0.87). Adjustment for ethnicity, season and mother's educational background did not alter the results. In sum, providing immigrant mothers with written information about how to improve their vitamin D status did not have an effect on the mothers' vitamin D status.     

Effects of dietary interventions on pregnancy outcomes: a systematic review and meta‐analysis

Dietary intake during pregnancy influences maternal health. Poor dietary practices during pregnancy have been linked to maternal complications. The objective was to determine the effect of dietary intervention before or during pregnancy on pregnancy outcomes. A systematic review was conducted without date restrictions. Randomised controlled trials (RCTs) evaluating whole diet or dietary components and pregnancy outcomes were included. Two authors independently identified papers for inclusion and assessed methodological quality. Meta‐analysis was conducted separately for each outcome using random effects models. Results were reported by type of dietary intervention: (1) counselling; (2) food and fortified food products; or (3) combination (counselling + food); and collectively for all dietary interventions. Results were further grouped by trimester when the intervention commenced, nutrient of interest, country income and body mass index. Of 2326 screened abstracts, a total of 28 RCTs were included in this review. Dietary counselling during pregnancy was effective in reducing systolic [standardised mean difference (SMD) ?0.26, 95% confidence interval (CI) ?0.45 to ?0.07; P < 0.001] and diastolic blood pressure (SMD ?0.57, 95% CI ?0.75 to ?0.38; P < 0.001). Macronutrient dietary interventions were effective in reducing the incidence of preterm delivery (SMD ?0.19, 95% CI ?0.34 to ?0.04; P = 0.01). No effects were seen for other outcomes. Dietary interventions showed some small, but significant differences in pregnancy outcomes including a reduction in the incidence of preterm birth. Further high‐quality RCTs, investigating micronutrient provision from food, and combination dietary intervention, are required to identify maternal diet intakes that optimise pregnancy outcomes.     

Smartphone applications available to pregnant women in the United Kingdom: An assessment of nutritional information

The importance of diet during pregnancy is critically important for the short‐ and long‐term health of both mother and child. The number of apps targeting pregnant women is rapidly increasing, yet the nutritional content of these tools remains largely unexplored. This review aimed to evaluate the coverage and content of nutrition information in smartphone apps available to U.K. pregnant women. Keyword searches were conducted in iTunes and Google Play stores in November 2018. Candidate apps were included if they targeted pregnant women, provided pregnancy‐specific nutritional information, had a user rating of at least 4+ based on at least 20 ratings, and were available in English. Nutritional content was assessed for accuracy against U.K. recommendations. Behaviour change techniques (BCTs) were also evaluated. Twenty‐nine apps were included, seven of which originated in the United Kingdom. There was a large variability in the quality of smartphone app nutritional information. The accuracy of nutrition information varied, and several apps conveyed inappropriate information for pregnancy. On average, 10 BCTs were identified per app (range 2–15). Overall, smartphone apps do not consistently provide accurate and useful nutritional information to pregnant women. This study highlights the need for the integration of evidence‐based nutritional information during app development and for increased regulatory oversight. App developers should also make it clear that nutritional content is intended for a specific geographical region or population or modify for the intended audience. These are important considerations for the design of future apps, which are increasingly used to complement existing maternity services.     

Effects of dietary counselling on food habits and dietary intake of Finnish pregnant women at increased risk for gestational diabetes – a secondary analysis of a cluster‐randomized controlled trial

The incidence of gestational diabetes mellitus (GDM) is increasing and GDM might be prevented by improving diet. Few interventions have assessed the effects of dietary counselling on dietary intake of pregnant women. This study examined the effects of dietary counselling on food habits and dietary intake of Finnish pregnant women as secondary outcomes of a trial primarily aiming at preventing GDM. A cluster‐randomized controlled trial was conducted in 14 municipalities in Finland, including 399 pregnant women at increased risk for developing GDM. The intervention consisted of dietary counselling focusing on dietary fat, fibre and saccharose intake at four routine maternity clinic visits. Usual counselling practices were continued in the usual care municipalities. A validated 181‐item food frequency questionnaire was used to assess changes in diet from baseline to 26–28 and 36–37 weeks gestation. The data were analysed using multilevel mixed‐effects linear regression models. By 36–37 weeks gestation, the intervention had beneficial effects on total intake of vegetables, fruits and berries (coefficient for between‐group difference in change 61.6 g day^?1, 95% confidence interval 25.7–97.6), the proportions of high‐fibre bread of all bread (7.2% units, 2.5–11.9), low‐fat cheeses of all cheeses (10.7% units, 2.6–18.9) and vegetable fats of all dietary fats (6.1% ‐units, 2.0–10.3), and the intake of saturated fatty acids (?0.67 energy‐%‐units, ?1.16 to ?0.19), polyunsaturated fatty acids (0.38 energy‐%‐units, 0.18–0.58), linoleic acid (764 mg day^?1, 173–1354) and fibre (2.07 g day^?1, 0.39–3.75). The intervention improved diet towards the recommendations in pregnant women at increased risk for GDM suggesting the counselling methods could be implemented in maternity care.     

Validity and reproducibility of a semi‐quantitative food frequency questionnaire for use among Portuguese pregnant women

This study aimed to evaluate the validity and reproducibility of a semi‐quantitative food frequency questionnaire (FFQ) to estimate nutrient intake among Portuguese pregnant women. A sample of 101 pregnant women completed a 3‐day food diary (FD) in each pregnancy trimester (reference method) and an interviewer‐administered FFQ in the immediate post‐partum period. Ranking women according to their usual intake showed that, on average, 65% were classified into the same ±1 quintile and 2.4% into opposite quintiles by the two methods. Energy‐adjusted and de‐attenuated correlation coefficients ranged from 0.20 (protein) to 0.58 (riboflavin). Similar results were obtained when the FFQ was compared to each trimester‐specific FD. To assess the FFQ reproducibility, 70 women in their third pregnancy trimester were interviewed twice within a 2‐week interval. The level of agreement was high, with ≥75% of the participants being classified into the same ±1 quintile by the two administrations for 13 of the 15 nutrients examined. A review of the published literature revealed that this is the first FFQ to take the whole pregnancy as its reference time window. Our findings showed that a single administration of this FFQ in the immediate post‐partum period is a valid tool to rank Portuguese pregnant women according to their intakes.