Food environment and child diet quality in Vietnam and Cambodia Restricted; Files Only

Duong, Cam (Fall 2022)

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Objective: Ensuring a healthy, diverse diet in early life is critical to optimal nutrition during childhood and through the life course. However, most studies of child diet quality in resource-constrained settings are cross-sectional, which limit our understanding of dietary changes in the early childhood. Furthermore, few studies have used a food system approach to understand how food environment influences parental food choice and child diet quality. The objective of this dissertation is to characterize temporal dietary patterns in the early childhood and assess the linkage between food environment and child diet quality.

Methods: In Aim 1, we empirically constructed temporal patterns of minimum dietary diversity using prospectively collected data between 6 and 24 months in a birth cohort (n = 781) from rural Vietnam. The associations between the temporal dietary patterns and conditional growth outcomes measured during the same period were then evaluated. In Aim 2, we assessed whether better access to fresh food markets was associated with better dietary diversity in children aged 6 to 24 months in rural Cambodia by combining Cambodia Demographic and Health Survey data (n = 1594) with a national listing of fresh food markets (n = 485). In Aim 3, we carried out 24 in-depth interviews and 2 focus group discussions with mothers of preschool children across the rural-urban spectrum in Vietnam to understand children’s eating patterns, mothers’ perception of food environment and mothers’ food choice behaviors.   

Results: In Aim 1, we identified two key aspects of diet quality in early childhood, including the initiation of diverse diet and the stability of diverse diet over time. The optimal dietary pattern included children who started a diverse diet between 6 and 8 months and maintained this diet afterwards. However, less than a third of our sample followed this optimal diet and children deviating from the optimal diet experienced a slower growth in first two years of life. For example, compared to children with optimal dietary pattern, children who started diverse diet after their first birthday experienced 0.25 z-score lower gain in conditional HAZ (β: -0.25; 95% CI: -0.49, -0.02). In Aim 2, we found that longer distance to nearest fresh food markets was modestly associated with lower children’s dietary diversity score (β: -0.16; 95% CI: -0.28, -0.05, but this association was non-significant among the low-income households. In Aim 3, we found that children’s eating patterns indeed changed over time, which were likely to due to the seasonality of household food availability and the changes in child eating behaviors. We also found that most mothers expressed intentions to feed children nutritious fresh food for healthy growth, but some mothers face difficulties in securing sufficient food for families during lean season or in managing food refusal and fussiness in children.  

Conclusions: Many children did not start diverse diet at the recommended time between 6 and 8 months or maintain the diverse diet afterwards. These children may experience slower linear growth and weight gain during the first 2 years of life. Possible reasons for delayed, unstable diverse diet are the poor accessibility to food markets, the seasonality of fresh food supply, the presence of packaged foods and beverages to replace nutritious fresh food, the lack of household resources for food acquisition and difficulties in managing child eating behaviors. Ensuring timely, stable diverse diet requires both behavioral change programs to improve caregivers’ responsive feeding practices and policies to promote healthy, diverse and resilient food environment. 

Table of Contents

Chapter 1: Introduction. 1

1.1      References. 3

Chapter 2: Background and literature review.. 5

2.1      Child nutrition. 7

2.2      Child diet diversity. 10

2.3      Parental food choice behaviors. 11

2.4      Food environment 14

2.5      Knowledge gaps. 15

2.6      References. 15

Chapter 3: Temporal dietary diversity patterns and child growth in rural Vietnam. 23

3.1      Abstract 24

3.2      Introduction. 25

3.3      Method. 26

Data source. 26

Sample selection. 27

Variables. 27

Statistical analysis. 29

3.4      Results. 30

Temporal dietary diversity patterns. 30

Associations between growth measures and temporal dietary diversity patterns. 32

3.5      Discussion. 32

3.6      References. 37

3.7      Figures & tables. 45

Chapter 4: Access to food markets, household wealth and child nutrition in rural Cambodia. 52

4.1      Abstract 53

4.2      Introduction. 53

4.3      Methods. 56

Study context 56

Data sources. 56

Data processing. 58

Measurement of key variables. 59

Statistical strategies. 60

4.4      Results. 61

Food market distribution in Cambodia. 61

Children characteristics. 62

Associations between distance to markets and child nutrition indicators. 62

Effect modifications of market access with child diet by household wealth. 62

Food consumptions by wealth and distance to markets. 63

4.5      Discussion. 63

Child diet and market access. 64

Child height and market access. 66

Policy implications. 66

Strengths and limitations. 67

4.6      Conclusions. 68

4.7      References. 69

4.8      Figures & tables. 77

Chapter 5: Maternal food choice for preschool children across urban-rural settings in Vietnam.. 82

5.1      Abstract 83

5.2      Introduction. 83

5.3      Methods. 85

Study settings and design. 85

Recruitment and participants selection. 86

Data collection. 86

Data analysis. 87

5.4      Results. 88

Contextual influencers. 88

Maternal food choice intentions. 91

Maternal food choice constraints. 94

5.5      Discussion. 97

5.6      Conclusion. 101

5.7      References. 102

5.8      Figures & tables. 108

Chapter 6: Discussion & Conclusion. 110

6.1      Summary of key findings. 110

6.2      Strengths and limitations. 113

6.3      Public health implications. 117

6.4      Future research. 119

6.5      Conclusions. 121

6.6       References 121

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