By: Mary Scourboutakos

Presently in America breastfeeding rates are sub-par.

While the World Health Organization recommends exclusive breastfeeding for up to six months of age, with continued breastfeeding alongside complementary foods up to two years of age or beyond—in the US 79% of mothers initiate breastfeeding, but only 22% exclusively breastfeed to six months and only 27% are still breastfeeding (non-exclusively) at two years postpartum.1 Meanwhile in countries like Sri Lanka, 83.1% of mothers are still breastfeeding their children two years post-partum.2

So the question is…how do we get women in America to breastfeed longer?
Traditionally, when trying to promote breastfeeding, people have focused on the benefits for infants, such as improved cognitive development,3 fewer childhood infections,4 and decreased risk for obesity and chronic disease later in life.5

But when you consider current rates of breastfeeding (see above!), clearly this approach isn’t working. Nevertheless, there may be a presently unexplored way to promote breastfeeding…

Emerging research suggests that in fact, the benefits of breastfeeding for the mother may surpass the benefits of breastfeeding for the infant.6-8
In fact, research has shown that long-term breastfeeding is associated with decreased maternal risk for breast cancer,9-11 ovarian cancer,12, 13 endometrial cancer,14 diabetes,15 heart disease,16 as well as greater postpartum weight-loss,17, 18 and mental health benefits.19, 20

But how long is long? And by how much does risk decrease? In terms of breast cancer, research from China has shown that women who breastfeed for more than 24 months per child cut their risk for breast cancer in half, compared to women who breastfed for only one to six months.10 Furthermore, dose-response curves for risk of diabetes show an inverse relationship with lifetime duration of breastfeeding, which suggests that the longer you breastfeed for, the lower your risk is.15

So, my unsolicited piece of advice for public health agencies is…if you’re trying to improve rates of breastfeeding, never mind touting the benefits for the baby, maybe try promoting the benefits for the Mom!

REFERENCES

1.National Center for Chronic Disease Prevention and Health Promotion. Breastfeeding – Report Card. 2014; Available at:https://www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf(Accessed: 7 February 2016).
2.Ministry of Health Care and Nutrition. Sri Lanka – Demographic and Health Survey. 2006; Available at: https://www.statistics.gov.lk/social/DHS%20200607%20FinalReport.pdf (Accessed: 2016 February).
3.Quigley MA, Hockley C, Carson C, Kelly Y, Renfrew MJ, and Sacker A. Breastfeeding is associated with improved child cognitive development: a population-based cohort study. J Pediatr, 2012. 160(1):25-32.
4.Li R, Dee D, Li CM, Hoffman HJ, and Grummer-Strawn LM. Breastfeeding and risk of infections at 6 years. Pediatrics, 2014. 134 Suppl 1:S13-20.
5.Yan J, Liu L, Zhu Y, Huang G, and Wang PP. The association between breastfeeding and childhood obesity: a meta-analysis. BMC Public Health, 2014. 14:1267.
6.Schwarz EB. Infant feeding in America: enough to break a mother’s heart? Breastfeed Med, 2013. 8(5):454-7.
7.Bartick MC, Stuebe AM, Schwarz EB, Luongo C, Reinhold AG, and Foster EM. Cost analysis of maternal disease associated with suboptimal breastfeeding. Obstet Gynecol, 2013. 122(1):111-9.
8.Bartick M and Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics, 2010. 125(5):e1048-56.
9.Zhou Y, Chen J, Li Q, Huang W, Lan H, and Jiang H. Association between breastfeeding and breast cancer risk: evidence from a meta-analysis. Breastfeed Med, 2015. 10(3):175-82.
10.Zheng T, Duan L, Liu Y, Zhang B, Wang Y, Chen Y, et al. Lactation reduces breast cancer risk in Shandong Province, China. Am J Epidemiol, 2000. 152(12):1129-35.
11.De Silva M, Senarath U, Gunatilake M, and Lokuhetty D. Prolonged breastfeeding reduces risk of breast cancer in Sri Lankan women: a case-control study. Cancer Epidemiol, 2010. 34(3):267-73.
12.Luan NN, Wu QJ, Gong TT, Vogtmann E, Wang YL, and Lin B. Breastfeeding and ovarian cancer risk: a meta-analysis of epidemiologic studies. Am J Clin Nutr, 2013. 98(4):1020-31.
13.Li DP, Du C, Zhang ZM, Li GX, Yu ZF, Wang X, et al. Breastfeeding and ovarian cancer risk: a systematic review and meta-analysis of 40 epidemiological studies. Asian Pac J Cancer Prev, 2014. 15(12):4829-37.
14.Jordan SJ, Cushing-Haugen KL, Wicklund KG, Doherty JA, and Rossing MA. Breast-feeding and risk of epithelial ovarian cancer. Cancer Causes Control, 2012. 23(6):919-27.
15.Aune D, Norat T, Romundstad P, and Vatten LJ. Breastfeeding and the maternal risk of type 2 diabetes: a systematic review and dose-response meta-analysis of cohort studies. Nutr Metab Cardiovasc Dis, 2014. 24(2):107-15.
16.Schwarz EB, Ray RM, Stuebe AM, Allison MA, Ness RB, Freiberg MS, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol, 2009. 113(5):974-82.
17.Jarlenski MP, Bennett WL, Bleich SN, Barry CL, and Stuart EA. Effects of breastfeeding on postpartum weight loss among U.S. women. Prev Med, 2014. 69:146-50.
18.Baker JL, Gamborg M, Heitmann BL, Lissner L, Sorensen TI, and Rasmussen KM. Breastfeeding reduces postpartum weight retention. Am J Clin Nutr, 2008. 88(6):1543-51.
19.Groer MW. Differences between exclusive breastfeeders, formula-feeders, and controls: a study of stress, mood, and endocrine variables. Biol Res Nurs, 2005. 7(2):106-17.
20.Groer MW and Davis MW. Cytokines, infections, stress, and dysphoric moods in breastfeeders and formula feeders. J Obstet Gynecol Neonatal Nurs, 2006. 35(5):599-607.

By Emily Roberts

The Mediterranean Diet is based on the eating patterns in the Mediterranean region and focuses on fruits, vegetables, fish, whole grains and healthy fats (1).  A diet not invented, but discovered, is now recognized as one of the healthiest dietary patterns (2). UNESO defines it as “a social practice based on all the “savoir-faire”, knowledge, traditions ranging from the landscape to the table and covering the Mediterranean Basin, cultures, harvesting, fishing, conservation, processing, preparation, cooking and in particular the way we consume” (3). The Mediterranean region is considered the Mediterranean Basin that borders the Mediterranean Sea and includes parts of seven countries: France, Portugal, Italy, Spain, Greece, Malta and Cyprus (4). There have been foreseen health benefits of consuming this diet, classifying it as “heart healthy” due to its likelihood to reduce the risk for heart disease (5,6). Living on the southern coast of France, I not only experience the Mediterranean lifestyle, but I have the opportunity to consume a Mediterranean Diet.

The Discovery

The Mediterranean Diet was discovered to have particular health benefits by Ancel Keys of the University of Minnesota in the 1950’s. He happened upon this discovery while studying the health of poor populations in Southern Italy in comparison to the wealthy in New York. He found the Italian populations had lower levels of cholesterol and a low rate of coronary heart disease (1).

Typical Foods

The diet is full of fresh foods including fruits, vegetables, herbs, fish, olive oil, breads, nuts and pastas (1). There is a very low consumption of red meats, poultry, butter, refined grains and processed foods. The diet is rich in fiber, monounsaturated fats and polyunsaturated fats, antioxidant compounds, and essential vitamins and minerals; conversely, it is very low in saturated fats. Given the diet’s composition of nutrient dense foods, strong adherence to this diet is associated with improved nutritional adequacy (2).

The Benefits

A strong adherence to the Mediterranean Diet enhances the chances of improving your health status. It has been found to reduce the risk for mortality, especially due to cardiovascular disease (7). There have been many cohort studies conducted in the Mediterranean Basin often showing good adherence to the diet and resulting in reduced incidence for cardiovascular events (6). The benefits of the diet are likely to improve with physical activity as well, such as decreased blood levels of LDL (1).

My observations

During my time in the south of France I have noticed the influence the agriculture and natural resources of the Mediterranean Basin has on the cuisine. This area is rich in olive groves, offering a plentiful supply of fresh olive products. The sea offers fresh fish, shellfish and other seafood, while local markets sell fresh fruits and vegetables. Cattle farms are not as populous in this area, so the consumption of red meat and butter is not as high as other European regions (such as Northern France). However, considering I am still residing in France, pastries, baguettes, and of course cheese are a typical part of the French dietary meal pattern. This differentiates my diet somewhat from other Mediterranean regions. Thankfully, walking as a means of transport is very common if not necessary, offering an efficient form of daily exercise. Fresh and homemade are the two words that best describe home cooking near the Mediterranean.  While residing with a local French family, I ate many freshly prepared meals. Everything made from scratch from salad dressings to whole grain bread.

The Mediterranean Diet is not an effort, rather a daily practice for many Europeans. As Americans, we may recommend it as a diet intervention or integrate it into our own eating habits for health reasons. This diet is seen to be successful by offering significant health benefits. This encourages me to try various diets from around the world that could potentially provide various health benefits for Americans, as well as a taste of a new culture.

1.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684452/

3.La DiÈte MÉditerranÉenne 2010. Candidature transnationale en vue de l’inscription sur la Liste ReprÉsentative du Patrimoine Culturel ImmatÉriel de l’HumanitÉ. Espagne / GrÈce / Italie/Maroc, Version Informations Additionnelles.

By Mary Scourboutakos

Living in Canada, I was never worried about recombinant bovine somatotropin hormone, aka rBST. This synthetic hormone, which mimics a natural hormone that causes cows to produce more milk, was banned in Canada in the 1990s. So North of the 49th parallel, most people have never heard of it.

Meanwhile in the United States, the situation is a little different. rBST is legal in the US because technically, there’s no evidence that it causes harm to humans. Meanwhile in Canada, the rationale for its ban is that it may pose risks for the cows that are treated with it.

With that in mind, whenever I visit the US, I always explore the milk on grocery store shelves to see if it contains rBST. To my surprise, on nearly every occasion, I’ve been hard pressed to find a jug of milk that didn’t say “from cows not treated with rBST”.

This was reassuring. But then I noticed something…while every jug of milk said “no rBST” I couldn’t find a single block of cheese, or container of yogurt declaring this.

This got me thinking…are they using the rBST-treated milk in yogurt and cheese? Could it be that consumers are so far removed from the food chain that they would think to look for “no rBST” on their milk, but wouldn’t think to look for it on their cheese?

It didn’t make sense…were the labels missing? Or was the industry using rBST milk in places where people would be less likely to look for it? I wanted to get to the bottom of this, so I started asking people about it. No one really knew the answer until I spoke with a representative from the food industry who told me that it takes so much effort to change labels, the industry won’t label something unless there is extremely consumer demand. She predicted that the yogurts and cheese are probably made with rBST-free milk, they’re just not advertising it.

Lo and behold, after doing some reading I found that in fact, many brands have removed rBST from ALL of their products, they’re just not stating it on their label, or they’re doing so haphazardly on some products but not others.

Perhaps I’m an over informed consumer who is paying attention to details that nearly no one else even knows or cares about, nevertheless, it’s interesting to consider that a product could in fact be potentially healthier—or at least kinder to the animal it’s coming from—than expected. I guess sometimes the food industry doesn’t show off everything it could.

By John E. Courtney, PhD

As a society, ASN highlights the very best scientific research that promotes healthy people and communities; we recognize that nutrition research is conducted within and across the public, private and government sectors of our society. ASN members understand that the nutrition challenges facing the world are multi-faceted and require research-based solutions. The Society also understands that public confidence in scientific research and integrity is essential to translate scientific evidence into improved dietary practices by consumers.

ASN’s professional activities allow members to come together and share information and research findings that accelerates discoveries that allow us to better understand the connections among diets and health. As a broad member-based organization, we are transparent about the fact that industry, government, trade groups and other scientific organizations contribute funding to help our society support the research enterprise for all of our members. ASN is committed to openness, objective science, and disclosure of potential conflicts. The Society’s Conflict of Interest attestation and “guiding principles for working with external groups and addressing COI” can be found on our website. All of the Editors for ASN’s three journals have publicly-available conflict of interest statements, which is not a required process and is an example of our commitment to transparency.

ASN promotes rigorous research that highlights the very best dietary practices, policies and guidance. Because issues of nutrition impact virtually every aspect of the food supply chain, involvement of all informed stakeholders in the scientific enterprise is essential. Furthermore, in today’s extremely competitive research environment, industry support helps progress research that might otherwise be impossible due to limited federal funding. ASN, like all scientific societies, remains vigilant in safeguarding the integrity of the scientific process from the biases and influences that can be associated with research funding from all sources. Without scientific integrity, there can be no public trust.

ASN does not have small goals, and therefore we cannot work in a vacuum. We believe that scientists in academia, government, and industry can partner to solve the world’s nutrition challenges. Our members work with moms and dads, children, the elderly, the sick, the under- and over- nourished, foundations, companies, governments, and media. We look forward to continuing to work with all stakeholders who are passionate about nutrition and committed to the highest ethical standards for research that advances the public health to achieve a healthier world.

ASN welcomes all to the table to learn from one other and to make progress on continuing to solve today’s complex nutrition challenges. These challenges include improving mechanisms and processes to fund, conduct and review nutrition research that improves global health.

By Brett Loman

Americans are more aware of what we are eating than ever before, but how we choose to track this information varies quite a lot. Some simply choose to eat more or less of a specific type of food while others record every single thing that they consume. In light of this, I decided to give a few programs a test run. I’ve rated them with 3 stars being the highest.

SuperTracker **½ overall
(free online tool, part of the MyPlate website published by the USDA)
At first impression I was overwhelmed by the multitude of –initially- empty tables and graphs. Once I got into the swing of things, however, my concerns transformed into amusement.
Ease of Use – **
While only be accessed through a web browser, the mobile site is an apt adaptation of the desktop version. Searching for each food is simple enough, but things get cumbersome when selecting the number of units. There is a multitude of units to choose from (e.g. fluid ounces, grams, slices, etc) but the number of those units is limited to a select few choices in a drop down menu.
Foods Available – **
Only some name brands and restaurants are available as choices. However, I could build the majority of complex foods using the basic selections that were available.
Nutrient Information ***
I was surprised by how much detailed information this program offers. Nearly every macronutrient, vitamin, and mineral was addressed in the “Nutrients Report”. This report offers target and average intake side-by-side plus expandable menus that explain which foods contributed (and by what percentage) to that nutrient’s intake.
Recommendation Information – ***
This is where the graphics are exceptionally helpful. They compare my intake to recommendations on the basis of food groups (broken down into things such as refined versus whole grains), empty calories, and individual nutrients.

MyDietAnalysis **overall
(subscription-based website provided by Pearson)
It happens to be the tracker utilized by my university’s introductory nutrition course, so naturally I had to give it a try.
Ease of Use – *
It is only available through a web browser, and the mobile site was not very user-friendly. Commonly chosen foods were under a completely separate menu unhelpfully named “Fast Entry” and only 7 days of intake could be store at one time.
Foods Available – ***
This program has the most specific food items I have seen in a tracker program. Most of the major chain restaurant and grocery brands are represented, cutting out the guesswork involved when building an item from scratch.
Nutrient Information – **
They come awfully close to matching SuperTracker in this respect, but MyDietAnalysis falls short since nearly the same information is presented… on several different pages.
Recommendation Information – **
The “Actual Intakes –vs- Recommended Intakes” report shows you just that for all of the nutrients side-by-side. The bar graph is a nice touch, but the scale for percent of goal met could use a little help, given that I didn’t even realize that it was there at first.

MyFitnessPal *½ overall
(free website and mobile application)
Definitely the app most-mentioned by patients and friends who claim to track their eating habits, tempting me to give it a go.
Ease of Use – ***
By far the greatest strength of this program is its availability as a mobile app. Eating lunch out? Just whip out your phone and track it on the spot. Another handy feature puts the foods you eat most often in a checklist immediately under the search box.
Foods Available – *
What I see as both a major weakness and strength of this app is the ability of any user to create foods, which can then be shared community wide. Sure, it’s great for the company, but the problem lies in the room for inaccuracies and errors.
Nutrient Information – *
Disappointingly, only nutrients routinely found on the nutrition facts panel were available. Again accuracy depends upon who actually entered the food into the database.
Recommendations Information – *
Only 6 of the nutrients could be displayed on my homepage at a time, and the printable report doesn’t even include all nutrients available, nor any averages of my intake compared to recommendations.

Final Thoughts
So are any of these inaccuracies, shortcomings, or lack of information harmful? I’d say probably not. The important thing here is that any of these tools can get people aware of what they are eating so that healthy changes can be made. With that I say happy tracking and please discuss in the comment section below.

By Marion L. Roche, PhD, Micronutrient Initiative

An estimated 42% of pregnant women are anemic. Anaemia in pregnancy is associated with increased mortality for mothers and infants, low birth weight in infants and increased risk of premature delivery. Iron Folic Acid (IFA) supplementation is recommended where anaemia is a public health concern. Many in the global nutrition research community have been anxiously awaiting the JiVitA-3 Randomized Trial in Bangladesh. This study has been looking at the comparative effectiveness of iron folic acid (IFA) supplements vs. multiple micronutrient supplements for pregnant women and one month postpartum.

This recent research in Bangladesh, which shows potential to reduce preterm births and low birth weight, holds promise for contributing to global reductions in neonatal mortality, although reductions in infant mortality were not found to be significant in this study. Low birth weight puts infants at risk of neonatal mortality and developmental consequences later in life. The risks of neonatal deaths for preemies and the critical importance of addressing preterm births has gained increasing recognition through the “Born too Soon” Global Action Report.

These results are exciting and will be balanced with the costs of transitioning from IFA to multiple micronutrients as countries decide how, when, and if to transition to “multis.” For many countries, the multiple micronutrients will be an added cost, and will come with substantial implications for procurement and supply management. They will also be a new product for many of the physicians, nurses, health workers and family members that have a role of supporting and encouraging pregnant women, and most importantly for pregnant women themselves.

Multiple micronutrient supplements will only have benefits if pregnant women have access to the supplements, receive them early enough in pregnancy to consume the recommended dose, and be supported, motivated and encouraged to consume the supplements daily. Global experiences with IFA supplementation would suggest that adherence has been one of the greatest challenges to behaviour change. Supporting adherence requires a reliable supply, encouraging counseling for pregnant women and improving a women’s access to IFA and related ante natal care services.

Nepal’s national iron intensification project is an example of a project that, for over eight years, was able to increase iron coverage from 23% to 80% and increase adherence of 90 tablets from 6% to 56%. This was largely achieved through the integration of a community based delivery system of female community health volunteers (FCHVs) who delivered the IFA supplements to women in their community and also encouraged them and restocked their IFA supply when needed. The FCHVs also received participatory training and provided practical advice on how to support and encourage women. Additional strategies will be needed to further increase adherence and maintain the motivation of the FCHVs.

As the global nutrition community reflects on the implications of the evidence from this new study, they will also be looking to learn from IFA programs and the successes and challenges. Whether IFA or multis are selected as part of the strategy for anemia reduction and improving maternal and newborn health, innovative approaches and replication of best practices and promising strategies for increasing adherence and coverage are needed to reduce maternal anaemia and benefit infants.

By Debbie Fetter

“Wow! I had no idea there was so many calories in that,” a family friend exclaimed at a baseball game. The menu labeling regulations would be pleased. “I was going to get the peanuts, but now I’m getting the hot dog because it has less calories.” Now we have a problem–if only he knew that a portion size of peanuts would be more nutritious than the hot dog.

The U.S. Food and Drug Administration recently released the highly anticipated menu and vending machine calorie labeling requirements. These rules, as part of the 2010 Patient Protection and Affordable Care Act, require calorie information to be labeled on menus, including menu boards, in chain restaurants, similar retail food establishments, and vending machines, that have 20 or more locations. The hope is the nutritional information displays will help consumers make more healthful choices. The question is, do consumers actually modify their food choices when presented with the calorie information? Or, are these menu-labeling laws just an unsuccessful battle on the fight against obesity? The LEAN Act, introduced in 2008 by Congress, has already spearheaded posting calorie content information on menus in several major US cities (1). Since there already has been exposure to menu labeling, let’s take a look at some of the evidence so far.

Ideally, customers will order less caloric meals once they know the true calorie contents. Realizing some customers may be alarmed at the high calorie content, restaurants may even choose to reduce the calorie content of their items by using healthier ingredients (2). Almost half of American’s food expenditures and calories come from quick and table service restaurants. Consumers also tend to underestimate the calorie content, and this underestimation increases as the meal calorie levels increase. Burton and colleagues conducted a consumer diary study to examine how accurately consumers estimate the calorie content of their food. Nutrition information estimates for calorie, fat, and sodium were all underestimated (p<0.001). After exposure to the nutrition information, meals lower in calories (less than 720 cal) had a significant increase in attractiveness (p<0.01), whereas meals higher in calories (greater than 1,030 cal) had a significant decrease in attractiveness (p<0.001). These findings suggest that providing the nutrition information on the menus may cause customers to purchase less caloric meals, and could even cause restaurants to reformulate higher calorie foods because of the decline in sales. There are barriers to consumers' understanding and use of this nutrition information, such as price, time constraints, confusion or lack of understanding about nutrition information, personal preference, hunger, and purchasing habits. Among five fast-food restaurant studies that have been conducted, only one study found a significant association between menu labeling and choosing a purchase with fewer calories. This calorie reduction was equal to only 14.4 (5.8%) fewer calories. Further, calorie reductions have been shown to be greater in areas where the people had more education and higher incomes (4). Harnack and colleagues conducted a randomized 2x2 factorial experiment to test the effects of calorie labeling and value size pricing on fast food meal choices. Participants were adolescents and adults who regularly ate fast food (n=594) and were randomly placed in one of four groups. The “control menu” had value pricing, but didn't list the calorie content. The “calorie menu” had both the listed calorie content and value pricing. The “price menu” didn't list the calorie content or have value pricing. The “calorie plus price menu” listed the calorie content, but didn't have value pricing. Participants were instructed to order individually from their assigned menu with a staff member. When participants finished eating, the remaining food was covertly measured using a digital food scale. A final interview was conducted upon leaving where the staff member asked questions about nutrition knowledge and beliefs, and recorded self-reported height and weight. The average energy and nutrient composition of the meals were similar (p=0.25), regardless of the experimental condition. This suggests that providing calorie information may have little effect on food choices on people who already regularly consume fast food. Also, when asked to rate the importance of price, taste, nutrition, and convenience when buying food from either a fast food restaurant or a grocery store, taste was the highest rated answer for each scenario (97.6% and 98.5%, respectively). Nutrition was the least likely to be ranked as number 1 out of these factors. These findings indicate that provision of calorie information may not have much effect on regular fast food customers. Results from a systematic review and meta-analysis found that menu labeling, with calories alone, did not have the desired effect of consumers choosing and consuming fewer calories (4). Additional contextual or interpretive nutrition information on menus seemed to help consumers in the selection and consumption of fewer calories. Further research needs to be done to find the most successful approach for providing menu-based nutrition information, especially for consumers who may be limited in their food and health literacy skills. References 1. Burton S, Howlett E, Heintz Tangari A. Food for thought: How will the nutrition labeling of quick service restaurant menu items influence consumers' product evaluations, purchase intentions, and choices? J of Retailing. 2009;85(3):258-273. doi:10.1016/j.jretai.2009.04.007 2. Farley TA, Caffarelli A, Bassett MT, Silver L, Frieden TR. New York City's fight over calorie labeling. Health Aff. 2009;28(6):w1098-1109. doi:10.1377/hlthaff.28.6.w1098 3. Harnack LJ, French SA, Oakes JM, Story MT, Jeffery RW, Rydell SA. Effects of calorie labeling and value size pricing on fast food meal choices: results from an experimental trial. Int J Behav Nutr Phys Act. 2008;5:63. doi:10.1186/1479-5868-5-63 4. Sinclair SE, Cooper M, Mansfield ED. The influence of menu labeling on calories selected or consumed: A systematic review and meta-analysis. J Acad Nutr Diet. 2014;114(9):1375-1388. doi:10.1016/j.jand.2014.05.014

By Sheela Sinharoy

When people think of nutrition, they probably do not think immediately of toilets. However, there is growing interest within the global public health community in the relationship between sanitation and nutrition. A group of researchers led by Dr. Tom Clasen of Emory University and the London School of Hygiene and Tropical Medicine has been studying this topic. They recently published findings from a study examining the effectiveness of a rural sanitation program on several outcomes, including child malnutrition, in The Lancet.

The intervention took place in Odisha, India, in the context of the national Total Sanitation Campaign, through which the government of India promotes latrine construction. The campaign focuses on households below the poverty line; it provides them with a latrine but requires that they contribute materials and labor for construction. For this study, the researchers selected 100 rural villages and enrolled households with pregnant women or children under age four. The study took place between May 2010 and December 2013.

Malnutrition was measured in two ways, through height-for-age z-score (HAZ) in children under two and weight-for-age z-score (WAZ) in children under five. The intervention had no effect on mean HAZ. Intention-to-treat analysis also showed no effect on mean WAZ, but per-protocol analysis showed a modest effect size of 0.10 (95% CI: 0.003-0.20). In other words, among the households that were compliant with the intervention, the children had slightly better WAZ scores. The absence of a stronger effect was surprising enough to garner attention from The New York Times, which published an article titled, “Latrines May Not Improve Health of Poor Children.”

I wanted to learn more, so I spoke with Dr. Clasen about the findings. He explained that while latrine coverage increased through the intervention, latrine use remained sub-optimal. While it may seem counter-intuitive, many community members chose not to use their new latrines, preferring instead the culturally accepted practice of open defecation. In particular, the study found that “latrine use was nearly five times higher for women than for men or children.” The reasons behind these gender and age differences are not clear, but Dr. Clasen emphasized the need to increase latrine use, aiming for “everybody, all the time.”

Researchers are examining other potential factors influencing latrine compliance. For example, what role do women play in deciding whether a household invests the resources necessary to build a latrine? If this decision is in the hands of men, and men are less likely to use a latrine, what are the implications for sanitation coverage and compliance? The study team is carrying out analyses on these and many other questions.

Ultimately, Dr. Clasen explained, this was an isolated intervention that could not address the multitude of issues that might affect the study outcomes. Factors such as poor disposal of child feces, the close proximity of livestock, poor water quality, and other forms of contamination likely play an important role in determining child nutrition outcomes. As always, more research is needed to better understand the complicated relationship between sanitation and nutrition.

Reference
Clasen T, Boisson S, Routray P, Torondel B, Bell M, Cumming O, et al. Effectiveness of a rural sanitation programme on diarrhea, soil-transmitted helminth infection, and child malnutrition in Odisha, India: a cluster-randomised trial. Lancet. 2014 [cited 2014 Nov 3]. https://www.thelancet.com/journals/langlo/article/PIIS2214-109X%2814%2970307-9/abstract

By Marion Roche, PhD

At the 2014 Clinton Global Initiative in late September, former President Bill Clinton remarked that a Masaai Warrior has better access to mobile communications today using a small cell phone than he had during his presidency 25 years ago. This access to technology is providing a wealth of opportunities, including in nutrition research and programming. Cell phones are ubiquitous across the African continent and are being used increasingly as an essential part of health community plans: in the area of emergency maternal health, such as when labour stops progressing; for improving supply demands, such as when rural clinics run low on zinc and oral rehydration salts (ORS). The use of cell phones has been at the forefront of the emergence of an entire field of mobile health, known as m-health. One of the most popular uses is probably communications messaging, such as sending regular SMS reminders to parents for growth monitoring visits.

Mobile technologies also offer innovations in global nutrition research. As cell phone use across Africa increases, it becomes easier and easier to train field workers in the use of personal data assistants (PDAs), as people are more familiar with the technology from having their own cell phones. One such example from the Micronutrient Initiative (MI) is the use of PDAs for data collection in our field surveys evaluating a mass media intervention to improve zinc and ORS for the treatment of diarrhea in Senegal. Interviewers carried a PDA with questionnaires loaded onto their device. Text-prompts guided them through the questionnaire, eliminating the need for paper surveys and the logistical complications of storage and transportation that paper surveys add. In the case of our Senegal survey, the PDAs connected to the mobile network daily and sent the interviews to a central server, eliminating the step of manual data entry, as PDAs are configured to send the data directly into the digital database. Anyone who has done data entry can appreciate the extreme benefit of being able to skip this time-consuming and high-risk-for-errors step. Further, the study supervisor can check for concerns in data quality from multiple study sites on a daily basis and follow up with interviewers the next day, potentially increasing overall data quality. And just as important, the issue of lost or damaged paper questionnaires is greatly reduced.

Using PDAs for field surveys opens up other new opportunities, such as incorporating visual media into questionnaires. We were able to provide caregivers in our Senegal zinc and ORS study with pictures of the different brands of products available, giving programmers important insights. The use of images can also be helpful in surveys with dietary recalls, although this option would require preparation of uploading photos and knowing the foods and supplements available to the targeted audience in advance. After a media campaign, we could include images from television spots or radio segments to see if parents recall the ads.

Global Positioning System (GPS) is now offered with some PDAs, which can help in monitoring data quality, survey implementation, and new ways for interpreting data. For example, with the Senegal project, we have the GPS coordinates for households and a visual map of clusters, or hot spots, for diarrhea infections, enabling us to prioritize these areas for intervention. We were also able to ask families about radio stations they listened to and create a map of radio stations reaching the communities in order to develop a national mass media campaign using local radio stations. With traditional surveys it could be months before this type of information would be available.

Despite the advances in using PDAs for data gathering, there are downsides, the biggest being initial purchase costs, related software, as well as having the training and expertise to support surveys in-country. Other challenges are short battery life, theft, connectivity issues, and, in some cases, the need for accompanying paper consent forms. At MI we are fortunate to work with Canadian partner Health Bridge whose expertise and equipment support our local partners and the MI office in Senegal. Innovations in enabling access to these new technologies may be the next challenge in m-health for nutrition surveys, as we work towards systems that provide greater access to larger segments of populations in low to middle income countries.

The May and September issues of Advances in Nutrition (AN) will feature selected proceedings from the 20th International Congress of Nutrition, held in Granada, Spain in September 2013. The proceedings are being published in supplements to AN; supplement coordinators were Angel Gil, Ibrahim Elmadfa, and Alfredo Martinez.

According to Dr. Gil, “For 2014 we planned a comprehensive Congress under the theme Joining Cultures through Nutrition to promote nutrition and healthy lifestyles to people on a sustainable planet. Hence, the 20th ICN offered a modern and attractive Congress, joining different cultures, traditions, and knowledge with respect to new aspects of nutrition research, development, and innovation around the world.”

The scientific program included 6 plenary lectures, 32 special lectures, 4 debates, 90 parallel symposia, 38 sponsored symposia, and 16 satellite symposia. A special effort was made to ensure the involvement of speakers and participants from all continents and countries, including nutrition and food specialists in research, academia, and industry, as well as policy makers, with a gender balance and applicability for all societies. During the 6-day meeting of the ICN, more than 4,000 delegates and 650 internationally renowned nutrition scientists, researchers, and clinicians from 120 countries were actively engaged in discussions, attended sessions and joined networking events. This year the planning committee was especially pleased with the participation of young investigators and nutrition professionals from developing countries.

The IUNS and the 20th ICN wish to thank the California Walnut Commission and Mead Johnson Nutrition for generously providing educational grants to support the publication and distribution of proceedings from the 20th ICN. The contents of this supplement are solely the responsibility of the authors and do not necessarily represent official views of the IUNS.