Although snacks can provide important nutrients for young children during the complementary feeding period, the increasing availability of snack foods and sugar‐sweetened beverages (SSB), often energy‐dense and nutrient‐poor, in low‐ and middle‐income countries (LMIC) is a concern. Such foods may displace consumption of nutritious foods in contexts where diets are often nutritionally inadequate and the burden of childhood malnutrition is high. This systematic review summarizes literature on the contribution of snack food/SSB consumption to total energy intakes (TEI) of children below 23 months of age in LMIC and associations between this consumption and nutritional outcomes. It also identifies areas where further research is needed. A systematic search of Embase, Global Health, and MEDLINE for literature published in January 1990–July 2018 was conducted. This search yielded 8,299 studies, 13 of which met inclusion criteria: Nine studies assessed % TEI from snack foods/SSB, and four studies assessed associations between snack food/SSB consumption and nutritional outcomes. Average % TEI from snack foods/SSB ranged from 13% to 38%. Findings regarding associations with growth were inconclusive, and no studies assessed associations with nutrient intakes. Variation in measurement of consumption and definitions of snack foods and SSB limited study comparisons. Further research is needed to understand how consumption of energy‐dense, nutrient‐poor snack foods and SSB influences undernutrition and overnutrition among young children during the complementary feeding period in settings that are experiencing dietary transitions and the double burden of malnutrition.

Consumption of unhealthy snack foods and beverages (USFBs) in low- and middle-income countries (LMICs) is rising, with global awareness increasing about risks of overnutrition. However, little is known about the relation between USFB consumption and young children's diet/nutritional outcomes in contexts where nutrient density of complementary foods is often low. This study assessed the association of high USFB consumption, compared with low consumption, with nutrient intakes, dietary adequacy, iron status, and growth in young children in Kathmandu Valley, Nepal. A cross-sectional survey was conducted in a representative sample of 745 primary caregivers of children aged 12–23 mo. Food consumption was measured through quantitative 24-h recalls, and child anthropometric measurements and capillary blood samples were collected. Using adjusted linear/logistic regression models, nutrient intakes, dietary adequacy, length-for-age and weight-for-length z-scores (LAZ and WLZ, respectively), and iron status were compared between lowest and highest tertiles of consumption based on the contribution of USFBs to total energy intakes (TEIs). Mediation of the relation between USFB consumption and LAZ via lowered dietary adequacy was explored using structural equations modeling. On average, USFBs contributed 46.9% of TEI among the highest tertile of consumers, compared with 5.2% of TEI among the lowest. Compared with low-USFB consumers, high-USFB consumers had lower nutrient intakes and a greater proportion were at risk of inadequate intakes for 8 nutrients. Mean LAZ was nearly 0.3 SD lower among high-USFB consumers than low consumers (P = 0.003), with this relationship partially mediated through dietary adequacy. No associations were found with stunting prevalence or iron status. Prevalence of overweight/obesity was low. In this LMIC context, high USFB consumption among young children was associated with inadequate micronutrient intakes, which can contribute to poor growth outcomes. Addressing increased availability of USFBs in LMIC food systems should be a priority for policies and programs aiming to safeguard child nutrition.

Poor quality infant and young child (IYC) diets contribute to chronic under‐nutrition. To design effective IYC nutrition interventions, an understanding of the extent to which realistic food‐based strategies can improve dietary adequacy is required. We collected 24‐h dietary recalls from children 6–23 months of age (n = 401) in two rural agro‐ecological zones of Kenya to assess the nutrient adequacy of their diets. Linear programming analysis (LPA) was used to identify realistic food‐based recommendations (FBRs) and to determine the extent to which they could ensure intake adequacy for 12 nutrients. Mean nutrient densities of the IYC diets were below the desired level for four to nine of the 10 nutrients analysed, depending on the age group. Mean dietary diversity scores ranged from 2.1 ± 1.0 among children 6–8 months old in Kitui County to 3.7 ± 1.1 food groups among children 12–23 months old in Vihiga County. LPA confirmed that dietary adequacy for iron, zinc and calcium will be difficult to ensure using only local foods as consumed. FBRs for breastfed children that promote the daily consumption of cows'/goats' milk (added to porridges), fortified cereals, green leafy vegetables, legumes, and meat, fish or eggs, 3–5 times per week can ensure dietary adequacy for nine and seven of 12 nutrients for children 6–11 and 12–23 months old, respectively. For these rural Kenyan children, even though dietary adequacy could be improved via realistic changes in habitual food consumption practices, alternative interventions are needed to ensure dietary adequacy at the population level.

When food is available, the main obstacle to access is usually economic: people may not be able to afford a nutritious diet, even if they know what foods to eat. The Cost of the Diet method and software was developed to apply linear programming to better understand the extent to which poverty may affect people’s ability to meet their nutritional specifications. This paper describes the principles of the method; the mathematics underlying the linear programming; the parameters and assumptions on which the calculations are based; and then illustrates the output of the software using examples taken from assessments. The software contains five databases: the energy and nutrient content of foods; the energy and nutrient specifications of individuals; predefined groups of individuals in typical households; the portion sizes of foods; and currency conversion factors. Data are collected during a market survey to calculate the average cost of foods per 100 g while focus group discussions are used to assess local dietary habits and preferences. These data are presented to a linear programming solver within the software which selects the least expensive combination of local foods for four standard diets that meet specifications for: energy only; energy and macronutrients; energy, macronutrients and micronutrients; and energy, macronutrients and micronutrients but with constraints on the amounts per meal that are consistent with typical dietary habits. Most parameters in the software can be modified by users to examine the potential impact of a wide range of theoretical interventions. The output summarises for each diet the costs, quantity and proportion of energy and nutrient specifications provided by all the foods selected for a given individual or household by day, week, season and year. When the cost is expressed as a percentage of income, the affordability of the diet can be estimated. The Cost of the Diet method and software could be used to inform programme design and behaviour change communication in the fields of nutrition, food security, livelihoods and social protection as well as to influence policies and advocacy debates on the financial cost of meeting energy and nutrient specifications.

Objectives Micronutrient deficiencies, in southeast Asia (SE Asia), remain a public health challenge. We evaluated whether promoting the consumption of locally available nutritious foods, which is a low-risk micronutrient intervention, alone can ensure dietary adequacy, for women of reproductive age and 6–23 m old children. Methods Representative dietary data from Cambodia, Indonesia, Lao PDR, Thailand and Vietnam were analysed using linear programming analysis to identify nutrients that are likely low in personal food environments (problem nutrients), and to formulate food-based recommendations (FBRs) for three to six target populations per country. Results The number of problem nutrients ranged from zero for 12–23 m olds in Indonesia, Thailand and Vietnam to six for pregnant women in Cambodia. The FBRs selected for each target population, if adopted, would ensure a low percentage of the population was at risk of inadequate intakes for five to ten micronutrients, depending on the country and target population. Of the 11 micronutrients modelled, requirements for iron, calcium and folate were most difficult to meet (≥ 10 of the 24 target populations), using FBRs alone. The number of individual FBRs selected per set, for each target population, ranged from three to eight; and often included meat, fish or eggs, liver/organ meats, vegetables and fruits. Conclusions for practice Intervention strategies need to increase access to nutritious foods, including products fortified with micronutrients, in SE Asia, when aiming to ensure dietary adequacy for most individuals in the population.

Background: Despite the increasing rate of exclusive breastfeeding in Indonesia, there is still a need for supportive interventions. The breastfeeding self-efficacy of mothers is a key factor positively associated with optimum breastfeeding practices. Our analysis aims to assess the determinants of low breastfeeding self-efficacy amongst a sample of women with children aged under 6 months in Malang and Sidoarjo Districts, East Java, Indonesia. Methods: We used information from 1210 mothers of children aged < 6 months recruited in the BADUTA study conducted in 2015–2016 in Malang and Sidoarjo Districts. The outcome variable in this analysis was mothers’ self-efficacy for breastfeeding using the 14 statements in the Breastfeeding Self-Efficacy-Short Form. We evaluated 17 potential predictors of breastfeeding self-efficacy, organized into six sub-groups of variables: (1) context/demographic; (2) household factors; (3) maternal characteristics; (4) child characteristics; (5) breastfeeding practices; and (6) antenatal and delivery care. Logistic regression analyses were employed to examine factors associated with mothers’ self-efficacy with breastfeeding. Results: More than half of the women in this study had a low level of self-efficacy. One of the factors associated with low breastfeeding self-efficacy found in this study was mothers’ problems related to breastfeeding. Mothers who had problems with breastfeeding not related to illness (adjusted odds ratio [aOR] 3.27; 95% CI 2.45, 4.36) or problems related to both illness and non-illness conditions (aOR 3.57; 95% CI 1.37, 9.33) had higher odds of low breastfeeding self-efficacy than those who did not have any problems. Compared to mothers who completed university education, there was a significantly higher odds of low breastfeeding self-efficacy in mothers who completed primary school or lower (aOR 1.88; 95% CI 1.16, 3.05); completed junior high school (aOR 2.27; 95% CI 1.42, 3.63); and completed senior high school (aOR 1.94; 95% CI 1.29, 2.91). Other significant predictors of low breastfeeding self-efficacy were mothers not exposed to any breastfeeding interventions (aOR 1.87; 95% CI 1.09, 3.22); working outside the house (aOR 1.69; 95% CI 1.23, 2.32); not obtaining any advice on breastfeeding (aOR 1.40; 95% CI 1.08, 1.82); with low knowledge of breastfeeding (aOR 1.38; 95% CI 1.03, 1.84); and delivered by Caesarean section (aOR 1.34; 95% CI 1.05, 1.70). Conclusions: Multipronged breastfeeding education programs and support are required to improve women’s self-efficacy with breastfeeding. Improved access to breastfeeding counselors, active support for mothers following cesarean delivery, and increased supporting facilities at workplaces are essential to improve self-efficacy with breastfeeding.