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.
Evaluating the impact of advocacy for policy change presents many challenges. Recent advances in the field of evaluation, such as contribution analysis (CA), offer guidance on how to make credible claims regarding such impact. The purposes of this article are (a) to detail the application of CA to assess the contribution of an advocacy initiative to improve infant and young child feeding policies and (b) to present the emergent theory of change and contribution story of how progress was achieved. An evaluation applying developmental evaluation and CA was conducted on the Alive & Thrive (A&T)–UNICEF initiative in seven Southeast Asian countries to document the extent to which policy objectives were achieved and identify key drivers of policy change. A contribution story was developed based on these experiences. The advocacy approach, which involved a four‐part process, contributed directly to (a) set the agenda of various actors and (b) create a strategic group; and indirectly to (a) set and maintain the issue on the agenda at all stages of the policy cycle, (b) support the government to carry out a set of critical tasks, and (c) extend commitment. All of this helped to achieve progress towards policy change. External influences were at play. The flexibility of A&T allowed key actors to utilize the positive external influences and address some of the negative ones through developing responsive strategies mitigating their effects. The emerging contribution story supports that A&T–UNICEF initiative contributed to the progress achieved in the participating countries.
Child undernutrition continues to be a national concern in Indonesia, whereas childhood overweight/obesity rises. Economic development has led to wide availability of highly processed foods and beverages, with growing evidence that children are consuming commercial snack products during the critical complementary feeding period. This study assessed the prevalence and patterns of consumption of commercially produced snack foods and sugar‐sweetened beverages among Indonesian children. A cross‐sectional survey was conducted with 495 mothers of children aged 6–35 months living in Bandung City, Indonesia. Among all children, 81.6% consumed a commercial snack food and 40.0% consumed a sugar‐sweetened beverage in the day preceding the interview. At 6–11 months, 46.5% of children consumed a snack food and 2.0% consumed a sugar‐sweetened beverage. Snack foods were consumed 3 or more times a day by 60.0% of children 24–35 months of age. Sweet biscuits and savory snacks were the most commonly consumed snack foods; sweetened milks and sweetened teas were the most common beverages. Maternal education, child age, and consumption of a commercially produced complementary food were associated with snack food consumption. Factors associated with sugar‐sweetened beverage consumption were child age and consumption of a commercially produced complementary food or breastmilk substitute. These findings reflect a high presence of processed, high‐sugar/salt commercial snack products in the diets of children 6–35 months. National attention should focus on interventions to reduce reliance on processed snack products and increase consumption of nutrient‐rich, locally available foods during the complementary feeding period.
The objective of this study was to assess plasma fatty acid (FA) patterns of 6‐month‐old South African infants and to determine their association with feeding practices, growth, and psychomotor development. Plasma total phospholipid FA composition (% of total FAs) of 6‐month‐old infants (n = 353) from a peri‐urban township was analysed, and principal component and factor analysis were performed to identify plasma FA patterns. Feeding practices, anthropometric measurements, and psychomotor development scores were determined. Four major plasma phospholipid FA patterns were identified: A plant‐based C18 FA, a high n‐6 long‐chain polyunsaturated fatty acids (LCPUFA), a C16:1 and long‐chain saturated fatty acid (SFA), and a high n‐3 and low n‐6 LCPUFA pattern. Formula feeding was associated with higher, whereas breastfeeding was associated with lower scores for the plant‐based C18 FA and C16:1 and long‐chain SFA patterns. On the other hand, breastfeeding, the consumption of cow's milk, and the consumption of semisolid foods were associated with higher scores, whereas formula feeding was associated with lower scores for the high n‐6 LCPUFA pattern. Breastfeeding and the consumption of semisolids were also associated with higher high n‐3 and low n‐6 LCPUFA pattern scores. The C16:1 and long‐chain SFA and high n‐3 and low n‐6 LCPUFA patterns were positively associated with psychomotor development scores. In 6‐month‐old South African infants, we identified distinct plasma FA patterns that presumably represent the FA quality of their diet and that are associated with psychomotor development. Our results suggest that breast milk is an important source of n‐6 LCPUFAs and formula‐fed infants may be at risk of inadequate LCPUFA intake.
Smartphone apps for use in pregnancy are common and could influence lifestyle behaviours, but they have not been evaluated. This review aimed to assess the quality of iPhone pregnancy apps and whether they included behaviour change techniques (BCTs) and/or pregnancy‐specific nutrition information. A keyword search of the Australian iTunes app store was conducted. For inclusion, apps had to be available at no cost, in English, intended for use by pregnant women, and contain nutrition information. App quality was assessed using the Mobile Application Rating Scale (MARS). Absence or presence of BCTs was assessed using the CALO‐RE taxonomy, with type of nutrition information included also reported. The initial key word search identified 607 apps, with 51 iPhone apps included in final evaluation. Mean overall MARS quality rating score was 3.05 out of 5 (1 = inadequate; 5 = excellent). The functionality subscale scored highest (mean = 3.32), and aesthetics scored lowest (mean = 2.87). Out of a possible 40 BCTs, 11 were present across the apps with a median of three BCTs (range: 0–6) identified per app. The median number of pregnancy‐specific nutrition topics per app was three (range 0 to 7). Despite the availability of a large number of iPhone pregnancy apps, few are of high quality, with only a small number of BCTs used and limited inclusion of pregnancy‐specific nutrition information. It is important to be aware of limitations within current pregnancy apps before recommending usage during this key life stage.
The International Code of Marketing of Breast‐milk Substitutes (the Code) adopted by the World Health Assembly (WHA) in 1981 and regularly updated through subsequent WHA resolutions, represents the international policy framework for protecting breastfeeding against inappropriate marketing practices. By March 2016, at least 135 countries had some measures covering provisions of the Code in their legislation. The translation of the International Code into national measures was investigated in the context of the advocacy efforts undertaken by the Alive & Thrive (A&T) initiative with UNICEF and partners. A real‐time evaluation was carried out over 22 months in seven Southeast Asian countries (Cambodia, Indonesia, Lao People's Democratic Republic [Lao PDR], Myanmar, Thailand, Vietnam, and Timor‐Leste) and two African countries (Burkina Faso and Ethiopia). Drivers of policy change and progress were examined. Two theory‐based approaches were used: developmental evaluation and contribution analysis. Data collection methods included participant observation, key informant meetings, in‐depth interviews, reflective practice, and desk review. Overall, countries made significant progress in translating the International Code into national measures and in moving forward throughout the policy cycle. The main driver of policy change was the creation of a strategic group, which engaged key relevant actors and supported the government in the performance of 15 critical tasks, which the analysis reveals is a second driver. Those critical tasks are described in this paper and could help public health advocates to anticipate the stages and challenges of policy change and develop more effective strategies to translate the Code into their legal framework.
An uncontrolled study with process evaluation was conducted in three U.K. community maternity sites to establish the feasibility and acceptability of delivering a novel breastfeeding peer‐support intervention informed by motivational interviewing (MI; Mam‐Kind). Peer‐supporters were trained to deliver the Mam‐Kind intervention that provided intensive one‐to‐one peer‐support, including (a) antenatal contact, (b) face‐to‐face contact within 48 hr of birth, (c) proactive (peer‐supporter led) alternate day contact for 2 weeks after birth, and (d) mother‐led contact for a further 6 weeks. Peer‐supporters completed structured diaries and audio‐recorded face‐to‐face sessions with mothers. Semistructured interviews were conducted with a purposive sample of mothers, health professionals, and all peer‐supporters. Interview data were analysed thematically to assess intervention acceptability. Audio‐recorded peer‐support sessions were assessed for intervention fidelity and the use of MI techniques, using the MITI 4.2 tool. Eight peer‐supporters delivered the Mam‐Kind intervention to 70 mothers in three National Health Service maternity services. Qualitative interviews with mothers (n = 28), peer‐supporters (n = 8), and health professionals (n = 12) indicated that the intervention was acceptable, and health professionals felt it could be integrated with existing services. There was high fidelity to intervention content; 93% of intervention objectives were met during sessions. However, peer‐supporters reported difficulties in adapting from an expert‐by‐experience role to a collaborative role. We have established the feasibility and acceptability of providing breastfeeding peer‐support using a MI‐informed approach. Refinement of the intervention is needed to further develop peer‐supporters' skills in providing mother‐centred support. The refined intervention should be tested for effectiveness in a randomised controlled trial.
The consumption of free sugars is directly associated with adiposity and dental caries in early childhood; however, intake data in the first 2 years of life are limited. This cross‐sectional analysis aims to identify major food sources of free sugars for Australian children aged 12–14 months and investigate factors associated with meeting the World Health Organisation (WHO) Guideline for sugars intake. Three days of nonconsecutive dietary data were collected via a 24‐hr recall and 2‐day food record for 828 participants. Usual intake of energy, total sugars, and free sugars were estimated, along with food group contributions to free sugars. Multiple logistic regression analysis was used to investigate factors associated with exceeding the WHO conservative recommendation that <5% of energy should come from free sugars. Mean free sugars intake was 8.8 (SD 7.7, IQR 3.7–11.6) g/day, contributing 3.6% (SD 2.8, IQR 1.6–4.8) of energy. Only 2.4% of participants exceeded the WHO recommendation that <10% of energy should come from free sugars, with 22.8% of participants exceeding the <5% recommendation. Children from households with greater socio‐economic disadvantage (IRSAD <5, OR = 1.94) and in the lowest income bracket (OR = 2.10) were more likely to have intakes ≥5% of energy. Major food sources of free sugars were commercial infant foods (26.6%), cereal‐based products (19.7%), namely, sweet biscuits (8.3%) and cakes (7.6%), followed by yoghurt (9.6%), and fruit and vegetable beverages (7.4%). These findings highlight the substantial contribution of infant foods to free sugars intakes and provide further evidence that dietary intakes are influenced by social determinants.
Maternal vitamin D deficiency during pregnancy may have persistent adverse effects on childhood growth and development. We examined whether 25‐hydroxyvitamin D (25(OH)D) concentrations during pregnancy and at cord blood were associated with childhood body composition and cardiovascular outcomes. This study was embedded in a population‐based prospective cohort in Rotterdam, The Netherlands, among 4,903 mothers and their offspring. We measured 25(OH)D concentrations at a median gestational age of 20.4 weeks (95% range 18.5–23.4 weeks) and at birth (40.1 weeks [95% range 35.8–42.3 weeks]). 25(OH)D concentrations were categorized into severely deficient (<25.0 nmol/L); deficient (25.0 to 49.9 nmol/L); sufficient (50.0 to 74.9 nmol/L) and optimal (≥75.0 nmol/L). At 6 years, we measured childhood body mass index; fat and lean mass by Dual‐energy X‐ray Absorptiometry; blood pressure; and serum cholesterol, triglycerides, and insulin concentrations. Compared with children from mothers with optimal 25(OH)D concentrations (≥75.0 nmol/L), those of severely deficient vitamin D (<25.0 nmol/L) mothers had a 0.12 standard deviation score (SDS); (95% Confidence Interval (CI) [0.03, 0.21]) higher fat mass percentage and a 0.13 SDS (95% CI [−0.22, −0.04]) lower lean mass percentage. These associations remained after adjustment for current child vitamin D status. Maternal and cord blood 25(OH)D concentrations were not associated with cardiovascular risk factors in childhood. In conclusion, severe maternal 25(OH)D deficiency (<25.0 nmol/L) during pregnancy is associated with an adverse childhood body composition profile, but we did not observe evidence for an association with childhood cardiovascular risk factors. Further studies are needed to replicate our findings, to examine the underlying mechanisms, the causality of the associations, and the potential for public health interventions.
Promotion of breast milk substitutes (BMS) and inappropriate marketing of commercially produced complementary foods (CPCF), including through television, can negatively influence infant and young child feeding. The World Health Organization International Code of Marketing of Breast‐milk Substitutes and subsequent relevant World Health Assembly (WHA) resolutions prohibit such advertising and require manufacturers and distributors to comply with its provisions; however, such regulations at national level may vary. Advertisements require Ministry of Health approval in Cambodia but are not regulated in Senegal. Television stations were monitored for 13 months in Phnom Penh and for 3 months in Dakar to assess advertisements for BMS and CPCF. Ten television channels (out of 16) in Phnom Penh and four (out of 20) in Dakar aired advertisements for BMS. Three and five channels, respectively, aired advertisements for CPCF. All BMS advertised in Phnom Penh were for children over 1 year of age. BMS products for children 6+ months of age and 1+ years of age were advertised in Dakar. Average air time for BMS advertisements was 189.5 min per month in Phnom Penh and 29.7 min in Dakar. Air time for CPCF advertisements averaged 3.2 min per month and 13.6 min, respectively. Fewer than half of BMS advertisements and three quarters of CPCF advertisements explicitly stated an age of use for products. Nutrition and health claims were common across BMS advertisements. This study illustrates the need to adopt, regulate, monitor, and enforce legislation prohibiting BMS promotion, as well as to implement regulations to prevent inappropriate promotion of CPCF.
Commercially produced complementary foods (CPCF) that are iron fortified can help improve iron status of young children. We conducted a review of 217 CPCF sold in 42 stores in Bandung, Indonesia, in 2017. There were 95 (44%) infant cereals, 71 (33%) snacks or finger foods (biscuits or cookies, puffs, and noodles or crackers), 35 (16%) purees, and 16 (7%) other foods for which we obtained label information. Nearly 70% of CPCF reported iron content on their labels, but only 58% of products were reported to be fortified with iron according to ingredient lists. Among iron‐fortified products, only one fifth indicated a specific type of iron used as the fortificant, but all of these were recommended by the World Health Organization for fortifying complementary foods. Infant cereal was more likely to contain added iron (81%) compared with snacks or finger food (58%) and purees (14%) and had higher iron content per median serving size (cereal = 3.8 mg, snacks or finger food = 1.3 mg, mixed meals = 2.7 mg, and purees = 0.9 mg). Infant cereal was most likely to meet the recommended daily intakes for iron (41% for infants 6–12 months of age and 66% for children 12–36 months) compared with snacks or finger food (infants = 14%, children = 22%), mixed meals (infants = 28%, children = 46%), or purees (infants = 9%, children = 15%). Regulations on fortification of complementary foods need to specify minimum levels and forms of iron and require reporting in relation to requirements by child age and serving size. Monitoring and enforcement of regulations will be essential to ensure compliance.
Ensuring nutritious complementary feeding is vital for child nutrition. Prior research in Kathmandu Valley found high consumption rates of commercially produced snack foods among young children, which are often energy‐dense/nutrient poor. This mixed‐methods study was conducted to elicit Nepali caregivers' perceptions of commercial snack foods and beverages and factors influencing their use for young child feeding. Seven facilitated focus group discussions (FGD) were conducted with Kathmandu Valley caregivers of children 12–23 months, and a survey of 745 primary caregivers of children 12–23 months of age was then conducted. During the FGD, caregivers reported commonly providing commercial food and beverage products to their children as snacks, and 98.6% of caregivers participating in the survey reported feeding their child such a food in the previous week. Because of processing and packaging, snack foods were not trusted by many FGD participants and considered as “junk foods” and not healthy for children. However, commercial snack foods were consistently ranked highly on convenience, both because of minimal preparation and ease of feeding; 48.5% of all surveyed caregivers reported providing a snack food because of convenience. Other family members' diets or provision of snack foods as treats also influenced children's consumption of these snack foods and beverages. This study indicates that caregivers of young children prefer snack options that are nutrient rich; however, this may conflict with preferences for foods that require minimal preparation and are appealing to young children. Such findings carry programmatic implications for interventions aiming to address children's diet quality in urban Nepal.
Few studies have documented the marketing of commercial foods and beverages for infants and young children in West Java, Indonesia. To assess the prevalence of promotions at points‐of‐sale for commercially produced products commonly fed to young children in Bandung City, 43 small and large stores were visited in 2017. Promotions for breastmilk substitutes (BMS), commercially produced complementary foods (CPCF), and select types of commercial snack products were photographed and information recorded on promotion characteristics. There were 402 and 206 promotions observed with BMS and CPCF products, respectively. Sixteen promotions with BMS products for infants under 12 months were found in 42.9% of stores selling BMS, violating national regulations. Almost all BMS promotions (98.3%) included BMS products for ages 1 year and above (“growing‐up milks”). Of all BMS products available for sale, half of all infant/follow‐up formula and 77.2% of growing‐up milks were promoted. CPCF were found in 97.7% of stores, and 81.0% of these stores had promotions; 70.5% of all available CPCF products were promoted. Of the 2,451 promotions observed for commercial snack products, 17.3% used promotional techniques targeting young children or caregivers. Joint‐promotions were common, with BMS and CPCF marketed in combination with commercial snack products; 49.0% of BMS promotions were joint BMS‐snack promotions, and 80.0% or more of infant/follow‐up formula promotions included a commercial snack. Revising and enforcing infant food and beverage marketing regulations to ensure consistency with global standards are necessary to protect and promote optimal infant and young child feeding in Indonesia.
Scaling up breastfeeding programmes has not been highly prioritized despite overwhelming evidence that breastfeeding benefits the health of mothers and children. Lack of evidence‐based tools for scaling up may deter countries from prioritizing breastfeeding. To fill this gap, Becoming Breastfeeding Friendly (BBF) was developed to guide countries in effectively scaling up programmes to protect, promote, and support breastfeeding. BBF includes an evidence‐based toolbox that consists of a BBF Index, case studies, and a 5‐meeting process. These three interrelated components enable countries to assess their breastfeeding scaling up environment, identify gaps, propose policy recommendations, develop a scaling up plan, and track progress. The toolbox was developed based on current evidence and expert guidance from a Technical Advisory Group, which was composed of global breastfeeding and metric experts with experience in the scaling up of health and nutrition programmes in low‐, middle‐, and high‐income countries. The BBF toolbox required a step‐by‐step iterative approach to describe and systematize each component, thus an operational manual was developed. The BBF toolbox and BBF operational manual underwent intensive pretesting in two countries, Ghana and Mexico, resulting in the modification of each component plus the operational manual. Pretesting continues in six additional countries demonstrating that BBF is a robust and dynamic multi‐sectoral process that, with relatively minor adaptations, can be successfully implemented in countries across world regions.
Sudden unexpected infant death (SUID) and sudden infant death syndrome (SIDS) prevention has focused on modifying individual behavioural risk factors, especially bedsharing. Yet these deaths are most common among poor and marginalized people in wealthy countries, including U.S. Blacks, American Indians/Alaskan Natives, New Zealand Māori, Australian Aborigines, indigenous Canadians, and low‐income British people. The United States now has the world's highest prevalence of SUID/SIDS, where even Whites' SIDS prevalence now approaches that of the Māori. Using public databases and the literature, we examine SUID/SIDS prevalence and the following risk factors in selected world populations: maternal smoking, preterm birth, alcohol use, poor prenatal care, sleep position, bedsharing, and formula feeding. Our findings suggest that risk factors cluster in high‐prevalence populations, many are linked to poverty and discrimination and have independent effects on perinatal outcomes. Moreover, populations with the world's lowest rates of SUID/SIDS have low income‐inequality or high relative wealth, yet have high to moderate rates of bedsharing. Employing syndemics theory, we suggest that disproportionately high prevalence of SUID/SIDS is primarily the result of socially driven, co‐occurring epidemics that may act synergistically to amplify risk. SUID must be examined through the lens of structural inequity and the legacy of historical trauma. Emphasis on bedsharing may divert attention from risk reduction from structural interventions, breastfeeding, prenatal care, and tobacco cessation. Medical organizations play an important role in advocating for policies that address the root causes of infant mortality via poverty and discrimination interventions, tobacco control, and culturally appropriate support to families.
Burden and risk factors for wasting in the first 6 months of life among Indian children are not well documented. We used data from India's National Family Health Survey 4 to estimate the prevalence of severe wasting (weight for length < ‐3 SD) among 18,898 infants under 6 months of age. We also examined the association of severe wasting with household, maternal, and child‐related factors using multivariable logistic regression analysis. Prevalence of severe wasting among infants less than 6 months of age was 14.8%, ranging from 3.5 to 21% across states. Low birth weight (<2,500 g; adjusted odds ratio [AOR] 1.40, 95% CI [1.19, 1.65]), nonutilization of supplementary nutrition by mother during lactation (AOR 1.23, 95% CI [1.05, 1.43]), and anthropometric assessment during summer (AOR 1.37, 95% CI [1.13, 1.65]) and monsoon months (AOR 1.53, 95% CI [1.20, 1.95]) were associated with higher odds of severe wasting. Infants aged 2 to 3 months (AOR 0.78, 95% CI [0.66, 0.93]) and 4 to 5 months (AOR 0.65, 95% CI [0.55, 0.73]) had lower odds of severe wasting as compared with the 0‐ to 1‐month category. This analysis reveals a high burden of severe wasting in infants less than 6 months in India. Preventive interventions must be targeted at reducing low birth weight due to fatal growth restriction and prematurity. Appropriate care practices at facilities and postdischarge with extra attention to those born small and sick can prevent further deterioration in nutritional status.
This study aimed to assess the association between watching TV whilst eating and consumption of ultraprocessed foods amongst children aged 4–10 years old in the United Kingdom. Cross‐sectional data from the UK National Diet and Nutrition Survey (NDNS 2008–2012) were analysed. Dietary data were derived from 4‐day food diaries of 1,277 children, and the dietary contribution of ultraprocessed foods was assessed. Meals were classified based on time of day in which foods were consumed (lunch: 11 pm–3 pm and dinner: 6 pm–9 pm). Crude and adjusted linear regression models were employed to verify the effect of watching TV during meals on dietary contribution of ultraprocessed foods (% of total energy intake). More than 70% of the children watched TV during meals, and 31.4% presented the behaviour on both “lunch and dinner.” Children's mean total energy intake was 1,532.3 kcal/day, of which 65.8% came from ultraprocessed foods. Findings indicated that children who watched TV whilst having both meals (lunch and dinner) consumed on average 85.5 kcal/day and 6.1% more energy from ultraprocessed foods than those who did not. Children who watched TV only during dinner consumed on average 37.1 kcal/day and 3.4% more energy from ultraprocessed foods than those who did not. The behaviour of watching TV whilst eating meals was associated with higher total daily consumption of ultraprocessed foods by children in the United Kingdom. Therefore, interventions designed to promote healthy eating habits should include aspects related to the context of meals.
The prevalence of childhood stunting in Myanmar is one of the highest among the countries of Southeast Asia. Cross‐sectional data from the Myanmar Demographic Health Survey 2015–2016 were used to examine risk factors for stunting, wasting, and underweight among children aged 0–59 months. The prevalence of stunting, wasting, and underweight was 29.0%, 7.3%, and 19.2%, respectively. Accounting for sampling design and weights, multivariable logistic regression was conducted with 35 household, maternal, and child characteristics. Current pregnancy and maternal height <145 cm, home delivery, child's small birth size recalled by mother, and older age (ref: 0–5 months) predicted both stunting and underweight. Larger than average birth size was protective for all stunting, wasting, and underweight. Maternal body mass index <18.5 kg m−2 was a common risk factor for wasting and underweight. Lower wealth quintiles, maternal engagement in nonagricultural occupation, and male child predicted stunting only. Younger child age and not receiving vitamin A supplementation in the previous 6 months were risk factors for wasting only. Regional variation was also seen, with a higher odds of stunting in the West‐South Region, North‐East States, and West States, compared with the Central Regions. In Myanmar, socio‐economic and demographic factors, poor maternal nutritional status, and living in certain geographical locations are affecting children's undernutrition. It is recommended that interventions for growth faltering focus on the first 1,000 days of life; optimum maternal nutrition be ensured during and before pregnancy and at adolescence; societal support be provided for mothers in poverty or engaged in nonagriculture; and region‐specific undernutrition pathways be understood.