Nutritional epidemiology aims to link dietary exposures to chronic disease, but the instruments for evaluating dietary intake are inaccurate. One way to identify unreliable data and the sources of errors is to compare estimated intakes with the total energy expenditure (TEE). In this study, we used the International Atomic Energy Agency Doubly Labeled Water Database to derive a predictive equation for TEE using 6,497 measures of TEE in individuals aged 4 to 96years. The resultant regression equation predicts expected TEE from easily acquired variables, such as body weight, age and sex, with 95% predictive limits that can be used to screen for misreporting by participants in dietary studies. We applied the equation to two large datasets (National Diet and Nutrition Survey and National Health and Nutrition Examination Survey) and found that the level of misreporting was >50%. The macronutrient composition from dietary reports in these studies was systematically biased as the level of misreporting increased, leading to potentially spurious associations between diet components and body mass index.

Linear growth faltering remains a pervasive public health concern that affects many children worldwide. This study aimed to investigate possible maternal factors promoting normal linear growth among children aged 6–23 months of age from impoverished Rwandan households. We used a three-stage cluster sampling procedure. The study population consisted of children aged six to 23 months and their mothers who lived in the study districts. A structured questionnaire helped to collect data from 807 selected mother-child dyads. The primary outcome variable was height-for-age Z scores. The main predictors were maternal income-generating activity, maternal education, maternal depression, household decision making, number of ANC visits, use of family planning method, types of family planning, and mode of delivery. We used univariate analysis to establish median, frequencies, and percentages. Furthermore, we used the Kruskal-Wallis, Mann-Whitney U, and Spearman rank correlation tests for bivariate analysis. We included in the final model of robust linear regression for multivariate analysis the potential confounding variables identified as significantly associated with the outcome (child age, participation in works for both parents, good handwashing practice, owning a vegetable garden, and the total number of livestock) along with maternal factors. Maternal factors that promoted normal linear growth of children were the presence of maternal income generation activity (β= 0.640 [0.0269 1.253], p value = 0.041), the participation of the mother in the decision-making process of the household (β=0.147 [0.080 0.214], p-value < 0.001), and the higher frequency of consultations with ANC (β=0.189 [0.025 0.354], p-value = 0.024). Additionally, a combination of household decision-making with the number of ANC visits predicted an increase in the linear growth of the child (β=0.032 [0.019 0.045], p-value < 0.001). Maternal factors such as maternal income-generating activity, maternal participation in household decision making, and increased number of ANC visits were found to promote normal child linear growth. These results contribute valuable information to the formulation of interventions and policies to improve child nutrition and growth in the community studied.

ABSTRACTBackgroundResponsive feeding among infants and young children (IYC) determines their food acceptance and adequate dietary intake, which enhances growth and developmental opportunities. However, little is known about responsive feeding practices among IYC in Rwanda. This study explored the status and barriers of responsive feeding practices among mothers from rural areas of Muhanga District in Rwanda.MethodThis descriptive longitudinal and exploratory mixed methods study was conducted among 29 mothers from 2 rural health centers in Muhanga District. Mothers were interviewed, and their interactions with children during lunch meals at 6, 9, and 12 months were observed. The interviews were recorded, transcribed, and thematically analyzed using Atlas.ti software.ResultsThe study shows that the number of mothers who reported to verbally encourage their children to eat during feeding increased with the child's age. Less than half of mothers, at all three time points of data collection (at 6, 9, and 12 months), reported and were observed allowing their children to self‐feed, smiling and talking to them during feeding. The perceived major barriers to mother–child interaction during feeding were lack of time due to the burden of other responsibilities, and poverty. In addition, fear of messing up and food waste were barriers to child self‐feeding opportunities.ConclusionFindings indicate that responsive feeding was less practiced among study mothers due to lack of time, poverty, and fear of food waste during child self‐feeding. Nutrition interventions in this community should consider raising awareness of responsive feeding practices through education and encouraging mothers to devote sufficient time to interact with their children during feeding episodes.

Introduction: Malnutrition is a leading cause of mortality among children around the world, with over 6 million deaths occurring each year and an estimated 144 million worldwide being stunted in 2020. Rwanda has one the highest rates of child stunting in the world at 33%. We identified factors associated with stunting among children in Nyabihu district, Rwanda. Methods: A matched case-control study was conducted among children aged 6 to 59 months who attended health centres in Nyabihu district from March to April 2023. A total of 136 cases and 266 controls were included in the study. Cases were selected based on WHO anthropometric measurements and matched with children of the same age and residence. Primary data on sociodemographics, hygiene and sanitation, feeding practices and clinical characteristics were collected using a structured questionnaire. Multivariate logistic regression analysis was performed to identify independent associated factors. Results: The following factors were significant to child’s stunting: being in socio-economic category 1 (aOR 11.1; 95%CI: 4.3- 28.4), non-parental caregivers (aOR 3.8; 95% CI: 2-7.4) and having more than one under-five children at household with odds increasing with increasing number of children: 2 under-five children (aOR 3; 95%CI 1.05-8.6), 3 underfive children (aOR; 5; 95%CI: 1.5-6.2), mostly of the agriculture produce was sold (aOR 4.3; 95%CI: 2.3-7.9), not treating drinking water (AOR 2.4; 95% CI 1.3- 4.5), washing hands before feeding a child (aOR 0.08; 95%CI: 0.04- 0.1), not attending ANC (aOR 8; 95%CI: 1.8- 34.7), and attending mass campaign (aOR 0.34; 95%CI: 0.1-0.6). Conclusion: The findings show that the first/lowest socio-economic category, washing hands before child feeding, treating drinking water, a greater number of underfive children in the household, attending ANC and vaccination campaigns were associated with stunting. Mitigating poverty, strengthening antenatal care attendance, child vaccination and improving hygiene and sanitation can help to reduce stunting.

Abstract Background The global population is increasingly aging, imposing a substantial burden on social and healthcare systems as aging is associated with gradual muscle wasting and functional decline. Consumption of protein-rich foods, such as livestock-based meat, providing high-quality proteins can prevent muscle wasting and related functional decline in older adults. However, there is a lack of data on the older adults’ perceptions about meat consumption, particularly in Sub-Saharan Africa. Objective To explore the perceptions about dietary meat consumption among older adults in Gasabo district, Kigali, Rwanda. Methods We conducted a descriptive qualitative study, using focus group discussions. A total of eight FGDs, lasting between 55 and 80 min, were conducted with gender-mixed groups, including 31 men and 33 women aged ≥ 55 years old. Eight older adults participated in each FGD session, and all discussions were conducted in the local language (Kinyarwanda) using a pre-designed interview guide. The discussions were audio-recorded and transcribed verbatim and translated into English. The transcript was inductively analyzed using thematic analytical process. Results Three themes were identified from the data, predominantly related to motives and barriers of meat consumption. The motives of meat consumption included improved quality and taste of the diet, improving own health, and having a social function. Barriers of meat consumption were perceived to be related to health risks, sustainability concerns (depletion of resources), and religious beliefs. Lastly, it was widely perceived that meat was unavailable and economically inaccessible, thus meat consumption was perceived to be associated with improved wealth. Conclusion The findings revealed a low and declining meat consumption among older adults due to poverty. Improving financial capacity or strategic public health work to improve protein consumption in the elderly is necessary to meet nutritional needs and facilitate healthy aging.

Obesity is caused by a prolonged positive energy balance 1 , 2 . Whether reduced energy expenditure stemming from reduced activity levels contributes is debated 3 , 4 . Here we show that in both sexes, total energy expenditure (TEE) adjusted for body composition and age declined since the late 1980s, while adjusted activity energy expenditure increased over time. We use the International Atomic Energy Agency Doubly Labelled Water database on energy expenditure of adults in the United States and Europe ( n = 4,799) to explore patterns in total (TEE: n = 4,799), basal (BEE: n = 1,432) and physical activity energy expenditure ( n = 1,432) over time. In males, adjusted BEE decreased significantly, but in females this did not reach significance. A larger dataset of basal metabolic rate (equivalent to BEE) measurements of 9,912 adults across 163 studies spanning 100 years replicates the decline in BEE in both sexes. We conclude that increasing obesity in the United States/Europe has probably not been fuelled by reduced physical activity leading to lowered TEE. We identify here a decline in adjusted BEE as a previously unrecognized factor.

There is considerably greater variation in metabolic rates between men than between women, in terms of basal, activity and total (daily) energy expenditure (EE). One possible explanation is that EE is associated with male sexual characteristics (which are known to vary more than other traits) such as musculature and athletic capacity. Such traits might be predicted to be most prominent during periods of adolescence and young adulthood, when sexual behaviour develops and peaks. We tested this hypothesis on a large dataset by comparing the amount of male variation and female variation in total EE, activity EE and basal EE, at different life stages, along with several morphological traits: height, fat free mass and fat mass. Total EE, and to some degree also activity EE, exhibit considerable greater male variation (GMV) in young adults, and then a decrease in the degree of GMV in progressively older individuals. Arguably, basal EE, and also morphometrics, do not exhibit this pattern. These findings suggest that single male sexual characteristics may not exhibit peak GMV in young adulthood, however total and perhaps also activity EE, associated with many morphological and physiological traits combined, do exhibit GMV most prominently during the reproductive life stages.

Abstract At 33% of under‐5s, stunting rates in Rwanda remain stubbornly high, as do figures for maternal (25% of pregnant women) and childhood anaemia (37%). Intensive communication and education campaigns have provided caregivers with high levels of knowledge about best practices in Maternal, Infant and Young Child Nutrition (MIYCN), but this is not translating into the improved diets which could contribute to reducing rates of stunting. Deploying an anthropological approach via multi‐module Focused Ethnographic Studies carried out within household case studies, the research team sought to understand drivers of suboptimal feeding practices in a sample of 30 households across all of Rwanda's districts. The sample included households with pregnant women as well as children in the 6–60 month age range. Analysed against a framework of proximal and underlying causes of under‐nutrition, our results reveal gaps in the knowledge‐capability‐practice chain resulting from decisions and prioritisations taken by caregivers and heads‐of‐household. Pregnant women and mothers of young children possess high levels of knowledge about feeding themselves and their young children, but this is not reflected in decision‐making and prioritisation around the acquisition and feeding of animal source foods, whose consumption is low among both groups. This was found to be true even in households which own and raise livestock. Turning to policy and programmes, we argue for a move towards incentivized human capital programming focusing on the ‘last mile’ behaviour change which is needed to translate knowledge and capability into better dietary choices.

Saliva and urine are the two main body fluids sampled when breast milk intake is measured with the 2H oxide dose-to-mother technique. However, these two body fluids may generate different estimates of breast milk intake due to differences in isotope enrichment. Therefore, we aimed to assess how the estimated amount of breast milk intake differs when based on saliva and urine samples and to explore whether the total energy expenditure of the mothers is related to breast milk output. We used a convenience sample of thirteen pairs of mothers and babies aged 2-4 months, who were exclusively breastfed and apparently healthy. To assess breast milk intake, we administered doubly labelled water to the mothers and collected saliva samples from them, while simultaneously collecting both saliva and urine from their babies over a 14-d period. Isotope ratio MS was used to analyse the samples for 2H and 18O enrichments. Mean breast milk intake based on saliva samples was significantly higher than that based on urine samples (854·5 v. 812·8 g/d, P = 0·029). This can be attributed to slightly higher isotope enrichments in saliva and to a poorer model fit for urine samples as indicated by a higher square root of the mean square error (14·6 v. 10·4 mg/kg, P = 0·001). Maternal energy expenditure was not correlated with breast milk output. Our study suggests that saliva sampling generates slightly higher estimates of breast milk intake and is more precise as compared with urine and that maternal energy expenditure does not influence breast milk output.

ObjectivesIn Rwanda, anemia affects 38% of all under five and 61% of those aged 9-11 months old; however, the contribution of diet to anemia remains less known. This study aimed to assess if dietary iron intake predicts the risk of anemia and iron deficiency among Rwandan children of 12 months old.MethodsA longitudinal study of 192 children was conducted in 2016-2018 in a rural setting in Rwanda. We measured hemoglobin concentration, and collected blood samples from the infant-mother pairs at birth, 4 and 12 months post-partum. Plasma or serum ferritin, soluble transferrin receptors (sTfR), C-reactive protein (CRP), and α-Acid Glycoprotein (AGP) concentrations were measured using sandwich ELISA technique. Body iron stores were calculated from the sTfR/Ferritin ratio. Hemoglobin and ferritin values were adjusted for altitude and infection, respectively. Dietary iron intake data were collected using a full 24-hour recall, and the intake of iron from micronutrient powders was captured by questionnaire. Predictors of anemia, iron deficiency, and iron deficiency anemia at 12 months of age were modelled using Cox proportional hazard regression with robust variance.ResultsAnemia, iron deficiency (ID), and iron deficiency anemia (IDA) occurred in 73%, 56%, and 44% of the infants at 4 months, and 48%, 88% and 45% of the children at 12 months, respectively. For their mothers, anemia, ID, and IDA occurred in 12%, 59%, and 9% at 4 months, and 12%, 49%, and 8% at 12 months. Child's dietary iron intake did not significantly predict anemia [PR = 1.00 (0.96-1.04)], ID [PR = 0.99 (0.98-1.01)], or IDA [PR = 0.99 (0.95-1.03)] at 12 months. However, this study revealed that the child's hemoglobin concentration at birth was inversely associated with anemia at 12 months [PR = 0.92 (0.86-0.99)], whereas inflammation [PR = 1.23 (1.03-1.46)] and IDA at 4 months [PR = 1.44 (1.04-1.99)] increased the risk of anemia at 12 months. Presence of inflammation additionally predicted risk of IDA at 12 months [PR = 1.27 (1.05-1.54)].ConclusionsWhile dietary iron intake is not a significant predictor of anemia, 94% of anemia cases coincide with ID at 12 months of age. In addition, inflammation is the most important predictor of anemia and IDA at this age. Therefore, prevention of inflammation is crucial to make dietary measures effective.Funding SourcesEmbassy of the Kingdom of the Netherlands in Rwanda; UNICEF Rwanda; Nuffic.

Blood hemoglobin (Hb) is a common indicator for diagnosing anemia and is often determined through laboratory analysis of venous samples. One alternative to laboratory-based methods is the handheld HemoCue® Hb 201+ device, which requires a finger prick and wicking of blood into a pretreated cuvette for analysis. An alternative HemoCue® gravity method is being investigated for improved accuracy. Further, recent developments in noninvasive technologies could provide an accurate, rapid, safe, point-of-care option for hemoglobin estimation while addressing some limitations of current tools, but device performance must be assessed in low-resource settings. This study evaluated the performance of two HemoCue® Hb 201+ blood sampling methods and a noninvasive device (Pronto® with DCI-mini™ sensors) in a Rwandan pediatric clinic. Reference hemoglobin values were determined in 132 children 6 to 59 months of age by using a standard hematology analyzer (Sysmex KN21TM). Half were tested using the HemoCue® wicking method; half were tested using the HemoCue® gravity method; and 112 had successful hemoglobin readings with Pronto® DCI-mini™. Statistical analysis was used to assess the level of bias generated by each method and the key drivers of bias. The HemoCue® gravity method was the least biased. The HemoCue® wicking and Pronto® methods biases were inversely related to the Sysmex KN21TM results. Both HemoCue® sampling methods correctly classified patients’ anemic status in 80% or more of instances, whereas the Pronto® device had a correct classification rate of only 69%. The HemoCue® gravity method was more accurate than the traditional HemoCue® wicking method in this study, but its accuracy and operational feasibility should be confirmed by future studies. The Pronto® DCI-mini™ devices showed considerable promise but require further improvements in sensitivity and specificity before wider adoption.