Abu Ahmed Shamim

Assess association between mid-gestation weight gain and birth size by maternal nutritional status and season. During an antenatal micronutrient trial in 2008–12, 14,801 rural Bangladeshi mothers were measured for wt (kg) and ht (cm) < 12 wk gestation [median (IQR): 9 (7–10) wk] and at 32 (32–33) wk, with single, term (37–42 wk gestational age, GA) newborns measured for wt < 72 hours of birth (BW, kg). Mid-gestation rate of wt gain (GWG) per wk was calculated as the difference between maternal wt measures divided by interval length in wk. Initially, BW was modeled as a function of GWG, adjusted for maternal age, body mass index (BMI), parity, height, newborn sex, GA at birth, birth month and wealth index to yield adjusted increments in BW (in kg) per kg of GWG (β^). This outcome was then analyzed and compared between mothers with low (2, n = 4008) vs normal (18.5–24.9, n = 4770) BMI, across seasons of birth [Sep-Nov (season 1, post-monsoon), Dec-Feb (2, winter) and Mar-May (3, hot/dry) and Jun-Aug (4, monsoon)], and between mothers by BMI in each season of birth. 46% of mothers had a BMI < 18.5 and 53% were < 150 cm in ht. Mean GWG per wk was 0.28 kg for thin, and 0.21 kg for normal BMI mothers. Overall, BW was positively associated with GWG per wk [β^ = 0.87 kg; 95% CI: 0.80–0.94], being greater for mothers of low [β^ = 0.84: 0.74–0.94] vs normal [0.68: 0.59–0.77] 1^st trimester BMI, and varying by season (β^₁ = 0.74, β^₂ = 1.06, β^₃ = 0.86 and β^₄ = 0.78, with 95% CI excluding the average (0.87) for seasons 1 and 2). Comparing β^i between mothers with low vs normal BMI, GWG per wk was associated with a (a) lower mean BW increment in season 1 (0.59 vs 0.82 kg), (b) comparable BW increment in season 2 (β^₂ = 1.08 vs 0.99 kg), (c) greater BW increment in season 3 (β^₃ = 1 vs 0.68 kg) and the largest incremental difference in season 4 (β^₄ = 0.99 vs 0.56 kg) when 95% CIs were exclusive. Birth weight increased with rate of mid-gestation wt gain, especially for thin vs normal wt mothers. Season of birth modified the association, most clearly during monsoon when food is more secure, aligning with mid-gestation intervals spanning the winter season. Maternal nutritional status and season may alter efficiencies of materno-fetal nutrient/energy transfer reflected by birth weight. The Gates Foundation (GH614), Sight and Life and Broadhurst Career Development Professorship.

Infant and young child feeding (IYCF) practices directly impact the health of <2-y-old children. Minimum dietary diversity (MDD) is an IYCF indicator to assess feeding practices of children aged 6–23 mo. The definition of MDD has recently been updated by the WHO and UNICEF, substituting “≥4 out of 7 food groups” (MDD-7FG) with “≥5 out of 8 food groups” (MDD-8FG). The goals of this study were to estimate the prevalence of IYCF indicators and identify the implications of the change in the prevalence of MDD at the national and regional levels of Bangladesh. This study used data from the National Food Security and Nutrition Surveillance 2018–2019 round. A total of 1992 children aged 0–23 mo were included in this analysis. IYCF indicators and MDD were calculated according to the WHO-UNICEF guidelines. The difference between the prevalence of MDD-7FG and MDD-8FG is presented as percentage points. The prevalence of early initiation of breastfeeding was 43.8%, and exclusive breastfeeding was 56.2%. Approximately 55% of children maintained MDD (MDD-7FG), 48% received minimum meal frequency, and 28% received a minimum acceptable diet. Compared with MDD-7FG, the prevalence of MDD-8FG was lower among 6–23-mo-old children. The difference between MDD prevalence (MDD-8FG vs. MDD-7FG) was high for boys (44.0% vs. 53.2%), children aged 12–23 mo (53.4% vs. 63.4%), in urban areas (30.2% vs. 42.4%), in the Dhaka administrative division (42.0% vs. 56.3%), among uneducated mothers (37.1% vs. 47.1%), in households with ≤4 members (44.3% vs. 55%), and for middle-class households (40.3% vs. 57.6%). The new method led to a decrease in the prevalence of MDD in Bangladesh. As the country prepares to implement the new indicator, it is critical to disseminate the new knowledge and its positive implication for improved child feeding and nutrition.

To assess the prevalence of noncommunicable disease (NCD) risk factors and the factors associated with the coexistence of multiple risk factors (≥ 2 risk factors) among adolescent boys and girls in Bangladesh. Data on selected NCD risk factors collected from face to face interviews of 4,907 boys and 4,865 girls in the national Nutrition Surveillance round 2018–2019, was used. Descriptive analysis and multivariable logistic regression were performed. The prevalence of insufficient fruit and vegetable intake, inadequate physical activity, tobacco use, and being overweight/obese was 90.72%, 29.03%, 4.57%, and 6.04%, respectively among boys; and 94.32%, 50.33%, 0.43%, and 8.03%, respectively among girls. Multiple risk factors were present among 34.87% of boys and 51.74% of girls. Younger age (p < 0.001), non-slum urban (p < 0.001) and slum residence (p < 0.001), higher paternal education (p = 0.001), and depression (p < 0.001) were associated with the coexistence of multiple risk factors in both boys and girls. Additionally, higher maternal education (p < 0.001) and richest wealth quintile (p = 0.023) were associated with the coexistence of multiple risk factors in girls. The government should integrate specific services into the existing health and non-health programs which are aimed at reducing the burden of NCD risk factors.

Complementary food supplementation enhances linear growth and may affect body composition in children. We aimed to determine the effect of complementary food supplements provided from the age of 6 to 18 mo on fat-free mass (FFM) and fat mass (FM) gain among children in rural Bangladesh. In an unblinded, cluster-randomized, controlled trial we tested the effects of 4 complementary food supplements for 1 y [chickpea, rice lentil, Plumpy'doz, and wheat-soy-blend++ (WSB++)] compared with no supplements on linear growth. Body composition was estimated using weight-length-based, age- and sex-specific equations at 6, 9, 12, 15, and 18 mo and postintervention aged 24 mo. Generalized estimating equations (GEEs) were applied to estimate the effect of each complementary food on mean FFM and FM from 9 to 18 and 24 mo compared with the control, adjusting for baseline measures. Sex interactions were also explored. In total, 3592 (65.9% of enrolled) children completed all anthropometric assessments. Estimated FFM and FM (mean ± SD) were 5.3 ± 0.6 kg and 1.4 ± 0.4 kg, respectively, at the age of 6 mo. Mean ± SE FFM and FM from 9 to 18 mo were 75.4 ± 14.0 g and 32.9 ± 7.1 g, and 61.0 ± 16.6 g and 30.0 ± 8.4 g, higher with Plumpy'doz and chickpea foods, respectively, than the control (P < 0.001). Estimated FFM was 41.5 ± 16.6 g higher in rice-lentil-fed versus control (P < 0.05) children. WSB++ had no impact on FFM or FM. A group-sex interaction (P < 0.1) was apparent with Plumpy'doz and rice-lentil foods, with girls involved in the intervention having higher estimated FFM and FM than control girls compared with no significant effect in boys. At 24 mo, FFM and FM remained higher only in girls eating Plumpy'doz compared with the controls (P < 0.01). In this randomized trial, supplementation effected small shifts in apparent body composition in rural Bangladeshi children. Where seen, FFM increments were twice that of FM, in proportion to these compartments, and more pronounced in girls. FFM increased in line with reported improvements in length. This trial was registered at clinicaltrials.gov as NCT01562379.

Household food insecurity (HFI) is a major concern in South Asia. The pathways by which HFI may reduce child growth remain inadequately understood. In a cohort study of 12 693 maternal-infant dyads in rural Bangladesh, we examined association and likely explanatory pathways linking HFI, assessed using a validated nine-item perception-based index, to infant size at 6 months. Mothers were assessed early in pregnancy for anthropometric status, dietary diversity and socio-economic status. Infants were assessed for weight, length, and arm, chest and head circumferences and breast and complementary feeding status at birth and 6 months of age. Extent of HFI shared a negative, dose-response association with all measures of infant size at 6 months and odds of wasting and stunting; 57-89 % of variances in the unadjusted models were explained by prenatal factors (maternal nutritional status and dietary diversity), and birth size adjusted for gestational age. Postnatal infant breast and complementary feeding and morbidity exposures explained the remaining fraction of the significant association between HFI and differences in infant arm and chest circumferences and odds of underweight. Contextual (i.e. socio-economic) factors finally brought remaining non-significant fractions of the food insecurity-related mid-infancy growth deficit to practically zero. Improving food security prior to pregnancy and during gestation would likely improve infant growth the most in rural Bangladesh.

Undernutrition may affect fecundability, but few studies have quantified this relationship. In rural Bangladesh, where newlywed couples face strong pressures to become pregnant, we assessed fecundability, estimated by time to pregnancy (TTP), and its association with preconceptional thinness among nulligravid, newlywed female adolescents. During 2001–2002, 5,516 newlywed women aged 12–19 years participated in a home‐based, 5‐weekly surveillance system for 5–6 years to enrol pregnant women into an antenatal vitamin A or β‐carotene supplementation trial. Thinness was defined as a left mid‐upper arm circumference (MUAC) ≤21.5 versus >21.5 cm. At each visit, staff obtained a monthly history of menstruation. Report of amenorrhea prompted a human chorionic gonadotropin urine test to confirm pregnancy. We derived hazard ratios (with 95% confidence intervals [CI]) for pregnancy and Kaplan–Meier curves for TTP. Ages of women at marriage and pregnancy detection (mean ± standard deviation) were 15.3 ± 1.9 and 17.0 ± 1.9 years, respectively. A total of 82.7% of thinner and 87.3% of better nourished women became pregnant. The unadjusted and multivariable relative hazard of ever becoming pregnant was 0.84 (95% CI [0.78, 0.89]) and 0.86 (95% CI [0.81, 0.92]), respectively, and TTP was 12 weeks longer (median [95% CI]: 63 [58–68] vs. 51 [49–54]) in women whose MUAC was ≤21.5 versus >21.5 cm. In rural Bangladesh, thin adolescent newlywed girls have a lower probability of becoming pregnant and experience a longer time to pregnancy.

Antenatal multiple micronutrient (MM) supplementation improves birth outcomes relative to iron–folic acid (IFA) in developing countries, but limited data exist on its impact on pregnancy micronutrient status. We assessed the efficacy of a daily MM (15 nutrients) compared with IFA supplement, each providing approximately 1 RDA of nutrients and given beginning at pregnancy ascertainment, on late pregnancy micronutrient status of women in rural Bangladesh. Secondarily, we explored other contributors to pregnancy micronutrient status. Within a double-masked trial (JiVitA-3) among 44,500 pregnant women, micronutrient status indicators were assessed in n = 1526 women, allocated by cluster to receive daily MM (n = 749) or IFA (n = 777), at 10 wk (baseline: before supplementation) and 32 wk (during supplementation) gestation. Efficacy of MM supplementation on micronutrient status indicators at 32 wk was assessed, controlling for baseline status and other covariates (e.g., inflammation and season), in regression models. Baseline status was comparable by intervention. Prevalence of deficiency among all participants was as follows: anemia, 20.6%; iron by ferritin, 4.0%; iron by transferrin receptor, 4.7%; folate, 2.5%; vitamin B-12, 35.4%; vitamin A, 6.7%; vitamin E, 57.7%; vitamin D, 64.0%; zinc, 13.4%; and iodine, 2.6%. At 32 wk gestation, vitamin B-12, A, and D and zinc status indicators were 3.7–13.7% higher, and ferritin, γ-tocopherol, and thyroglobulin indicators were 8.7–16.6% lower, for the MM group compared with the IFA group, with a 15–38% lower prevalence of deficiencies of vitamins B-12, A, and D and zinc (all P < 0.05). However, indicators typically suggested worsening status during pregnancy, even with supplementation, and baseline status or other covariates were more strongly associated with late pregnancy indicators than was MM supplementation. Rural Bangladeshi women commonly entered pregnancy deficient in micronutrients other than iron and folic acid. Supplementation with MM improved micronutrient status, although deficiencies persisted. Preconception supplementation or higher nutrient doses may be warranted to support nutritional demands of pregnancy in undernourished populations. This trial was registered at clinicaltrials.gov as NCT00860470.

Little is known about the relation between unwanted pregnancy and intention discordance and maternal mental health in low-income countries. The study aim was to evaluate maternal and paternal pregnancy intentions (and intention discordance) in relation to perinatal depressive symptoms among rural Bangladeshi women. Data come from a population-based, community trial of married rural Bangladeshi women aged 13–44. We examined pregnancy intentions among couples and pregnancy-intention discordance, as reported by women at enrollment soon after pregnancy ascertainment, in relation to depressive symptoms in the third trimester of pregnancy (N = 14,629) and six months postpartum (N = 31,422). We calculated crude and adjusted risk ratios for prenatal and postnatal depressive symptoms by pregnancy intentions. In multivariable analyses, women with unwanted pregnancies were at higher risk of prenatal (Adj. RR = 1.60, 95% CI: 1.37–1.87) and postnatal depressive symptoms (Adj. RR = 1.32, 95% CI: 1.21–1.44) than women with wanted pregnancies. Women who perceived their husbands did not want the pregnancy also were at higher risk for prenatal (Adj. RR = 1.42, 95% CI: 1.22–1.65) and postnatal depressive symptoms (Adj. RR = 1.30, 95% CI: 1.19–1.41). Both parents not wanting the pregnancy was associated with prenatal and postnatal depressive symptoms (Adj. RR = 1.34, 95% CI: 1.19–1.52; Adj. RR = 1.13, 95% CI: 1.06–1.21, respectively), compared to when both parents wanted it. Adjusting for socio-demographic and pregnancy intention variables simultaneously, maternal intentions and pregnancy discordance were significantly related to prenatal depressive symptoms, and perception of paternal pregnancy unwantedness and couple pregnancy discordance, with postnatal depressive symptoms. Maternal, paternal and discordant couple pregnancy intentions, as perceived by rural Bangladeshi women, are important risk factors for perinatal maternal depressive symptoms.

Inadequate complementary feeding is common in low- and middle-income countries, contributing to growth deficits. Complementary food supplements (CFSs) aim to fill dietary gaps, but few CFS studies have measured nutrient intake. In a community-based, randomized CFS trial in Bangladesh, we previously reported poor dietary diversity in 6-18-mo-old participants. We investigated, in a secondary analysis in the same trial, micronutrient intake adequacy in supplemented compared with control-arm children. At age 6 mo, children were assigned to 1 y of child-feeding counseling for mothers (control) or counseling plus 1 of 4 CFS formulations. Mothers were administered quantitative past 24-h diet questionnaires for their children at ages 6, 9, 12, 15, and 18 mo. Nutrient intakes were estimated with local recipes and food composition tables assuming average age-specific breastmilk intake. Adequacy was evaluated relative to estimated average requirements or adequate intakes. Multivariate analysis of variance and generalized estimating equation (GEE) regression models estimated the effect of each CFS on nutrient adequacy. GEE models tested dietary predictors of nutrient adequacy in the control arm. A total of 25,964 dietary modules across 5 interviews were completed. Nutrient adequacy from home foods combined with assumed breastmilk intake was low. Only 5 of 16 micronutrients were adequately consumed by >60% of children at 18 mo of age. Daily CFSs did not affect energy-adjusted micronutrient intake from home foods at any follow-up age (P > 0.05). CFSs increased the mean adequacy ratio for all micronutrients (P < 0.001 at all ages), to ≥1 for 14 of 16 micronutrients at 18 mo. Dietary diversity predicted adequate iron, zinc and calcium intake at 15 mo in unsupplemented controls. Home foods did not meet the estimated micronutrient needs of 9-18-mo-old children in rural Bangladesh. Daily supplementation with fortified complementary foods filled many micronutrient intake gaps and did not displace home foods. Previously, CFSs were shown to also improve linear growth and reduce stunting in this cohort. Findings support the need for CFSs in similar settings to promote nutritional well being and growth. This trial was registered at clinicaltrials.gov as NCT01562379.