Alissa Pries, Senior Research Advisor, ARCH Project

Helen Keller International

October 30, 2019

Unhealthy snack foods, diets, and nutritional status

during the complementary feeding period: a study

among young children in Kathmandu Valley, Nepal

CHANGING FOOD ENVIRONMENTS AND

DIETS

• Rapid growth in availability of processed foods worldwide with ‘nutrition transitions’ occurring in many LMIC1,2

• Shift in diet patterns increases risk of overweight/obesity in countries with concurrent high rates of undernutrition3

• Increased consumption of snack foods and sugar-sweetened beverages (SSB) among adults and children

EVOLVING FOOD SYSTEMS:TREND FROM GLOBAL NUTRITION REPORT

PREVALENCE OF SUGARY SNACK

CONSUMPTION AMONG CHILDREN 6-23

MONTHS IN LMIC4

0 20 40 60 80 100

Zimbabwe

Uganda

Zambia

Tanzania

Sierra Leone

Madagascar

Cameroon

Swaziland

Nigeria

Liberia

Ghana

Timor-Leste

Namibia

Malawi

Maldives

Cambodia

Nepal

Philippines

% of children 12-23 months

26.4

7.6

57.7

38.4

74.7

31.3

82.7

63.1

0

20

40

60

80

100

Dakar Dar es Salaam Kathmandu Phnom Penh

% o

f ch

ildre

n

6-11 mths

12-23 mths

PROPORTION OF CHILDREN CONSUMING ANY COMMERCIAL SNACK FOOD IN THE LAST 24 HRS5

SNACKS DURING THE COMPLEMENTARY

FEEDING PERIOD: A CONCERN?

• Snacks not necessarily negative; but, snack foods are often energy-dense,

high in trans fats/added sugar/salt

• Overconsumption of unhealthy foods could displace consumption of other

important micronutrients

– Could be a particular concern in LMIC

• Excessive energy intakes; impact on food preferences potential

pathway to obesity and NCDs later in life

• No prior research in LMIC among childern below 2 years...

STUDY OBJECTIVES

1. To describe reasons for use and perceptions of commercial snack foods

and beverages

2. To assess the nutrient profiles and describe the consumption patterns

of unhealthy snack foods/beverages (USFB) consumed

3. To investigate the socio-economic characteristics associated with high

consumption of USFB

4. To describe children’s dietary outcomes (nutrient intakes and dietary

adequacy) and nutritional status (anthropometric and iron status)

5. To assess associations between high consumption of USFB and these

nutritional outcomes

STUDY POPULATION & SAMPLING

DESIGN

Children 12-23 months and their primary

caregivers living in Kathmandu Valley

Two-stage cluster sampling procedure:

1. 78 clusters randomly assigned to municipality

wards based on probability-proportional-to-

size

2. In each cluster, 12 caregivers/children

recruited 2-3 days in advance of data

collection

– 9-10 caregivers/children randomly sampled from

this list for interview

SAMPLE SIZE

Outcomes Measurement Power

Difference

between low/high

USFB consumers

Sample required1

Iron status Hemoglobin 90% 1.0 g/dl516

(n=172 per tercile)

Linear growth LAZ 80% 0.5 LAZ666

(n=222 per tercile)

Ponderal growth WLZ 80% 0.5 WLZ666

(n=222 per tercile)

Dietary adequacy Mean nutrient intake 90% 0.3 SD702

(n=234 per tercile)

1α = 0.05 for all calculations; assumed design effect = 2

Households approached

n=18,300

Household with child 12-23 mths

n=1,129

No child 12-23 mths

n=17,171

Caregiver refused

n=114

Caregiver not resident of

Kathmandu Valley

n=111

Child sick on day of interview

n=47

Eligible children 12-23 mths

n=1,018

Recruited children 12-23 mths

n=904

Completed interviews among children

12-23 mths

n=745

Child not sampled for interview

n=82

Caregiver not available on day of

interview

n=30Children 12-23 mths available on day

of interview

n=827

QUANTITATIVE SURVEY METHODS

Gathered quantitative data through:

1. Structured interview with caregivers

2. Dietary assessment

3. Anthropometric measurements

4. Capillary blood sample

CAREGIVER QUESTIONNAIRE

• Interviewer-administered; ~ 1 hour per interview

• Electronic data collection on tablets

• Survey modules gathered data on:

– Caregiver/child demographic and socio-economic characteristics

– Secondary caregivers and their involvement in child care

DIETARY ASSESSMENT

• 4-pass 24 hour dietary recalls with caregiver of

all food/beverages consumed by child

– Weighed measurement with scales of estimated

portion sizes of all foods/beverages consumed

• Used this data to calculate energy and

nutrient intakes for each child

– Food composition table compiled specifically for this

study

– Label information used for commercial products

• Repeat 24HR for 10% of sample on non-

consecutive day

ANTHROPOMETRIC MEASUREMENTS

• Length (cm) and weight (kg)

measurements for children

– Height and weight also measured for primary

caregivers who were mothers of the child

• 2 repeated measures were taken in serial

BIOCHEMICAL MEASUREMENTS

• 150 μL capillary blood samples taken

• HemoCue use for on-site haemoglobin measurements

• Iron status was assessed through – haemoglobin, serum ferritin

and transferrin receptor

• Two markers of inflammation (AGP and CRP)

EXPOSURE OF INTEREST

High consumption of unhealthy snack foods or beverages (USFB)

Snack foods/beverages: focus on food types, not the act/behaviour of

snacking

• Foods: biscuits, chips/cheeseballs, instant noodles, fruit, jaulo, lito

• Beverages: soft drinks, commercial fruit drinks, and chocolate/malt-based

drinks, milk

Unhealthy: nutrient profiling (United Kingdom FSA model)

High consumption: terciles of USFB consumption based on % of TEI

• low consumers

• moderate consumers

• high consumers

PRIMARY OUTCOMES (LOW VERSUS

HIGH USFB CONSUMERS)

Dietary: total median nutrient intakes; prevalence of risk of inadequate

nutrient intakes

• Ca, Fe, Zn, vitamins – A, C, thiamin, riboflavin, niacin, B6, B12,

folate

Anthropometrics: length-for-age z-scores (LAZ); weight-for-length (WLZ)

Biochemical: iron deficiency anemia

• Low hemoglobin (Hb<11.0 g/dL) and low serum ferritin (<12.0

μg/L)/high transferrin receptor (>8.3 mg/L)

• Adjustment for elevation and presence of infection

RESULTS: USFB CONSUMPTION

239 unique snack foods or beverages

consumed75.3% (n=180) of these were profiled as

‘unhealthy’

87.8% (n=158) of these unhealthy foods were

commercially packaged and branded

USFB contributed one-quarter (24.5%) TEI

Comparable to rates among school-age children in places like the

US or UK

Contribution by consumption tercile:

• Low consumers: 5.2% TEI

• Moderate consumers: 21.5% TEI

• High consumers: 46.9% TEI

RESULTS: CONSUMPTION OF USFB AND

CONTRIBUTION TO TOTAL ENERGY INTAKE

FOOD CATEGORIES % TEI

USFB 24.5 ± 0.7

FOODS 22.5 ± 0.7

Biscuits 10.8 ± 0.5

Candy/chocolates 3.5 ± 0.2

Savory snacks 3.4 ± 0.3

Instant noodles 2.2 ± 0.2

Sweet bread/bakery 2.0 ± 0.2

Traditional savory snacks 0.2 ± 0.04

Processed dairy 0.2 ± 0.09

Sugary breakfast cereal 0.1 ± 0.03

Traditional sweet snacks 0.1 ± 0.04

BEVERAGES 2.0 ± 0.2

Sweetened tea/water 0.8 ± 0.08

Fruit juice drinks 1.0 ± 0.1

Soft drinks 0.1 ± 0.04

Chocolate-powder drinks 0.1 ± 0.04

RESULTS: MEDIAN NUTRIENT INTAKES

Low

(n=249)

Moderate

(n=248)

High

(n=248)P

Energy, kcal/d 666 (459 – 875) 613 (462 – 802) 594 (385 – 833) 0.10

Total fat, g/d 20.8 (13.3 – 33.0) 20.0 (12.6 – 31.6) 19.3 (11.8 – 32.2) 0.98

Protein, g/d 23.5 (15.6 – 33.5)a 18.9 (13.0 – 27.8)b 15.7 (10.2 – 23.2)c <0.001

Calcium, mg/d 353 (184 – 566)a 252 (112 – 455)b 161 (67 – 314)c <0.001

Iron, mg/d 4.0 (2.6 – 6.6)a 3.3 (2.3 – 5.0)b 3.0 (1.7 – 5.0)b <0.001

Zinc, mg/d 3.3 (2.2 – 5.0)a 2.5 (1.7 – 4.0)b 1.8 (1.2 – 3.1)c <0.001

Vitamin C, mg/d 17.1 (6.3 – 34.6)a 15.1 (5.6 – 34.3)a,b 9.5 (3.4 – 25.6)b 0.004

Vitamin A (RAE), μg/d 170 (88 – 301)a 116 (54 – 226)b 81 (31 – 171)c <0.001

Thiamin, mg/d 0.4 (0.3 – 0.7)a 0.3 (0.2 – 0.5)b 0.3 (0.2 – 0.5)b 0.054

Riboflavin, mg/d 0.8 (0.4 – 1.3)a 0.6 (0.3 – 1.1)b 0.5 (0.2 – 0.8)b <0.001

Niacin, mg/d 4.8 (2.9 – 7.4)a 4.2 (2.5 – 6.7)b 3.4 (2.1 – 5.8)b 0.005

Vitamin B-6, mg/d 0.4 (0.3 – 0.7)a 0.4 (0.3 – 0.6)a 0.3 (0.2 – 0.5)b <0.001

Vitamin B-12, μg/d 0.9 (0.5 – 1.5)a 0.7 (0.3 – 1.3)b 0.6 (0.2 – 1.0)b <0.001

Folate, μg/d 72.0 (43.3 – 120.9)a 57.4 (34.1 – 90.6)b 47.6 (25.2 – 71.2)c <0.0011ANOVA of log transformed data with cluster adjustment used and Bonferroni post-hoc tests conducted to compare between groups;

labeled medians in a row without a common letter differ, P<0.05

RESULTS: % AT RISK OF INADEQUATE NUTRIENT

INTAKES

5.7

49.1

97.2

15.7

3.012.1

39.8

14.7

51.2

39.1

21.6

70.5

10.2

78.8

100.0

39.1

4.9

21.3

50.4

28.9

58.2 56.8

30.3

89.1

0

20

40

60

80

100

% o

f chi

ldre

n

Low USF/SSB consumers (n=249) High USF/SSB consumers (n=248)

– High USFB consumer LAZ: -1.12 ± 1.06

– Moderate USFB consumer LAZ: -0.93 ± 1.04

– Low USFB consumer LAZ: -0.75 ± 1.15

Mean length-for-age z-scores (LAZ) was 0.3 SD lower among high snack food consumers,

as compared to low consumers

ASSOCIATION WITH GROWTH

Unadjusted1 Adjusted2

n β

(95% CI) p n

β (95% CI)

p

Length-for-age z-score (LAZ) 733 -0.37

(-0.56 – -0.18) <0.001 684

-0.29

(-0.49 – -0.10) 0.003

Weight-for-length z-score (WLZ)7 732 0.03

(-0.15 – 0.21) 0.77 683

-0.09

(-0.28 – 0.10) 0.37

n OR

(95% CI) p n

OR

(95% CI) p

Stunting (LAZ < -2) 733 1.51

(0.95 – 2.39) 0.08 684

1.25

(0.70 – 2.24) 0.45

Wasting5 (WLZ < -2) 732 0.65

(0.29 – 1.48) 0.31 683

1.11

(0.40 – 3.04) 0.84

1Comparisons between high and low snack consumers made using random-effects linear and logistic regression with cluster adjustment 2Adjusted for: child age, sex, morbidity, deworming, immunization status, vitamin A supplementation, birthweight, breastfeeding status,

caste/ethnicity, caregiver education, household food security and wealth status

Reference: Pries et al. (2019)

ARCH NEPAL STUDY: PRODUCT

LABELS

The nutrient content of the 15 most commonly consumed products from

several categories were analysed:

– Infant cereal: N = 3 products

– Biscuits: N = 4 products

– Chocolates: N = 2 products

– Instant noodles: N = 2 products

– Savory snacks: N = 2 products

– Sugar sweetened beverages: N = 2 products

NUTRIENT COMPOSITION

RESULTS

VS. LABEL – INFANT CEREALS

Iron Calcium ZincTotal

sugar

Total

sodium

Infant

cereal A48% 34% 36% 116% 42%

Infant

cereal B-80%

Not on

label

Not on

label

Not on

label

Not on

label

Infant

cereal C-83% -85%

Not on

label

Not on

label

NOTE: = if percent difference <10%

NUTRIENT COMPOSITION RESULTS

VS. LABEL– INSTANT NOODLES

Iron Calcium ZincTotal

sugar

Total

sodium

Noodle A -17% 27%Not on

label

Not on

label200%

Noodle B -23%Not on

label13% 37%

NOTE: = if percent difference <10%

How can we protect young children’s diets in changing

food environments?

• Listening to caregivers’ reasons for use

• Marketing regulations

• Product standards

POLICY SOLUTIONS

GLOBAL GUIDANCE FOR MARKETING

REGULATIONS CHILDREN < 2 YEARSBreast-milk

substitutes

Commercial

complementary

foods

Other commercial

processed foods

(ex. junk food)

???

MARKETING: PRODUCT CLAIMS

“G for

Genius”

“Enriched

with vitamins

+ minerals”

“So

healthy”

“Packed

with fruit

goodness”

“Contains

protein,

calcium,

vitamin D”

SOLUTION: MARKETING

REGULATION

Example: Front of pack labeling regulations in Chile

HOW CAN WE PROTECT YOUNG

CHILDREN’S DIETS: PRODUCT

STANDARDS

• Standards for food fortification and corporate

accountability

– Often what is actually in a package does not match

what is on label

– Consideration for fortified complementary foods as

well

HOW CAN WE PROTECT YOUNG

CHILDREN’S DIETS: PRODUCT

STANDARDS

Reference: Changing Markets Foundation, Cereal offender: is Kellogg’s breaking its breakfast promise? (2019)

HOW CAN WE PROTECT YOUNG

CHILDREN’S DIETS: PRODUCT

STANDARDS

• Standards for food fortification and corporate

accountability

– Often what is actually in a package does not match what

is on label

– Consideration for fortified complementary foods as well

• Fortification of junk foods

– Does this make a product “healthy”?? reformulation

is necessary

CONCLUSIONS

• Consumption of unhealthy processed foods during the complementary

feeding period can contribute to both overnutrition and undernutrition.

• Caregivers often know these foods are unhealthy, but turn to them for young

child feeding because they are convenient and tasty.

• Given changing food system, how to protect young children’s diets:

– Marketing/labeling regulations to improve caregiver awareness

– Reformulation and fortification standards

– Consider the drivers of these food choices

REFERENCES

1. Monteiro CA, Moubarac JC, Cannon G, Ng SW, Popkin B. Ultra-processed products are becoming dominant in the global food system.

Obes. Rev. 14, 21–28 (2013).

2. Popkin BM, Adair LS, Ng SW. Global nutrition transition and the pandemic of obesity in developing countries. Nutr. Rev. 70, 3–21 (2012).

3. Popkin BM. The nutrition transition and its health implications in lower-income countries. Public Health Nutr. 1, 5–21 (1998).

4. Huffman S, Piwoz E, Vosti S, Dewey K. Babies, soft drinks and snacks: a concern in low-and middle-income countries? Maternal & Child

Nutrition 10, 562–574 (2014) .

5. Pries AM, Huffman SL, Champeny M, Adhikary I, Benjamin M, Coly AN, Diop EHI, Mengkheang K, Sy NY, Dhungel S, Feeley A, Vitta B,

Zehner E. Consumption of commercially produced snack foods and sugar-sweetened beverages during the complementary feeding period in

four African and Asian urban contexts. Maternal and Child Nutrition, 13(Suppl 2): DOI: 10.1111/mcn.12412 (2017).

6. Ministry of Health and Population (MOHP) Nepal, New ERA & ICF International Inc. Nepal Demographic and Health Survey 2016.

Kathmandu, Nepal: Ministry of Health, Nepal (2017).

7. Pries AM, Rehman AM, Filteau S, Sharma N, Upadhyay A, Ferguson EL. Unhealthy snack food and beverage consumption is associated

with lower dietary adequacy and length-for-age z-scores among 12-23 month-olds in Kathmandu Valley, Nepal. Journal of Nutrition.

DOI:10.1093/jn.nxz140 (2019).

8. Pries AM, Sharma N, Upadhyay A, Rehman AM, Filteau S, Ferguson EL. Energy intake from unhealthy snack food/beverage among 12-23-

month-old children in urban Nepal. Maternal and Child Nutrition, 15(Suppl 4): DOI: 10.1111/mcn.12775 (2019).

9. Pries AM, Filteau S, Ferguson EF. Snack food and beverage consumption in low- and middle-income countries: a systematic review.

Maternal and Child Nutrition, 15(Suppl 4): DOI: 10.1111/mcn.12729 (2019).

10. Sharma N, Ferguson EF, Upadhyay A, Zehner E, Filteau S, Pries AM. Perceptions of commercial snack food and beverages for infant and

young child feeding: a mixed-methods study among caregivers in Kathmandu Valley, Nepal. Maternal and Child Nutrition, 15(Suppl 4): DOI:

10.1111/mcn.12711 (2019).

THANK YOU!

THANK YOU!

HKI: Nisha Sharma, Atul Upadhyay, Babita Adhikari, Anushka

Thapa, Pratik Niraula, Sonia Thebe, Dale Davis, Elizabeth Zehner,

Mary Champeny, Mackenzie Green, Rolf Klemm, Gary Mundy

LSTHM : Elaine Ferguson, Suzanne Filteau, Andrea Rehman