REVIEW OF LITERATURE
Definitions
Nutrition refers to the consumption of food in relation to the body's dietary requirements A well-balanced diet, along with regular physical activity, is essential for maintaining good health In contrast, poor nutrition can weaken the immune system, heighten the risk of diseases, hinder physical and mental development, and decrease overall productivity (WHO, 2017a).
Food is a vital substance that provides nutritional support to organisms, typically derived from plants or animals It contains essential nutrients, including carbohydrates, fats, proteins, vitamins, and minerals, which are ingested and assimilated by cells to generate energy, sustain life, and promote growth (Rosenthal, 1999).
Food security encompasses the essential pillars of availability, accessibility, utilization, and stability of food throughout the year for everyone The United Nations defines food security as a condition where all individuals, at all times, have both physical and economic access to adequate, safe, and nutritious food that satisfies their dietary needs and preferences, ensuring an active and healthy lifestyle (Acharya, 2017).
Diet refers to the total food intake of an individual or organism, often associated with specific nutritional choices for health or weight management While humans are omnivores, cultural influences and personal preferences shape individual food choices, which can be affected by tastes or ethical beliefs Consequently, dietary selections can vary in their healthiness, as noted by the World Health Organization (2017).
- Healthy food is food believed to be highly beneficial to health, especially food grown organically and free of chemical additives, including fiber,
6 natural vitamins, and fructose, for example, animal products (meat, fish, eggs, and dairy products), green leafy vegetables and fruits, various legumes, and dried fruits (Acharya, 2017)
- Dietary practice is defined as observable actions or behavior of dietary habits that can be classified as good or poor dietary practices (Nnam, 2015)
- Good dietary practices relate to the parental knowledge and practices in choosing and preparing the right food for 3-5-year-olds.
Proper dietary practices for children aged 3-5 years old
Micronutrient deficiency remains a global health challenge, significantly contributing to morbidity and mortality, particularly in low-income and developing countries, where over two billion people lack essential vitamins and minerals This deficiency often arises from limited access to micronutrient-rich foods, such as fruits, vegetables, and fortified products, which are frequently too costly or unavailable As a result, individuals face an increased risk of infectious diseases and mortality from conditions like diarrhea, measles, malaria, and pneumonia, which rank among the top ten global health threats (WHO, 2002).
Adequate nutrition in early childhood is crucial for healthy growth, organ development, immune function, and cognitive advancement (UNICEF, 2012) Malnutrition, which encompasses deficiencies, excesses, or imbalances in nutrient intake, can occur even when children consume enough food (WHO, 2018) It is essential that the food provided meets daily micronutrient requirements to prevent malnutrition (WFP, 2015).
The human diet at all life stages is mainly based on cereals, meats, and vegetables Rice (glutinous, polished, and steamed rice) is the staple food of most
In the Lao PDR, rice is a staple food, consumed more than any other item, with individuals averaging two servings daily, approximately 130g per meal (Douangvichit, 2017) However, poor quality diets, characterized by low calorie and nutrient content, along with infections, are significant contributors to childhood malnutrition Nutritionists emphasize the importance of a diverse range of foods for a high-quality diet (Ruel, 2003) The state of child nutrition in the Lao PDR reflects broader health issues, with malnutrition rates among children under five showing a stunting prevalence of 33%, underweight prevalence of 21%, and wasting at 9% (LSB, 2018).
1.2.1 Food consumption patterns influence a child's normal growth and development The daily food intake should provide a child with adequate energy and meet or exceed the recommended daily allowances for all nutrients For children these are shown as follows:
1.2.1.1 Energy (calories) should be sufficient for growth and development, and for maintenance of the appropriate body weight The required energy consumption of children is 100 calories per 1 kg of weight or approximately 1000-
Children aged 3-5 years require approximately 1200 calories per day to support their rapid growth (Walsh et al, 2015) This energy is sourced from the five essential food groups: carbohydrates (like rice, maize, and wheat), proteins (including milk, fish, pork, and chicken), vitamins and minerals (found in vegetables and fruits), and fats.
1.2.1.2 Fat (Lipids): Children should eat foods low in poly-saturated fat and trans-fat; however, the total fat intake must not exceed 30 to 35%of the total calorie intake Most fats come from sources of poly-unsaturated and mono-unsaturated fatty acids, such as fish, nuts and vegetable oils It is estimated that female under fives need to absorb 30-35% or 1000-1100 kilocalories per day (kcal/d) as opposed to 1000-1200 kilocalories for the male under fives
1.2.1.3 Calcium has an important role in muscle contraction, transmitting messages through the nerves, and the release of hormones If people are not getting
Ensuring adequate calcium intake is crucial for maintaining strong bones and normal cell function When the body lacks sufficient calcium, it may draw from the bones, leading to potential weakening For optimal health, it is recommended that children under five consume between 700 to 800 mg of calcium daily (Steffen et al).
1.2.1.4 Iron is an important component of hemoglobin, the substance in red blood cells, that carries oxygen from the lungs throughout the body Hemoglobin represents about two-thirds of the body's iron If one does not have enough iron, the body cannot make enough healthy oxygen-carrying red blood cells Therefore, a lack of iron eventually results in iron-deficiency anemia
1.2.1.5 Iodine is a mineral found in some foods The body needs iodine to make thyroid hormones These hormones control the body's metabolism and many other important functions The body also needs thyroid hormones for proper bone and brain development during pregnancy and infancy
1.2.1.6 Carbohydrates Children need to eat a wide variety of nutritious carbohydrates for a healthy and balanced diet It is beneficial to eat more of the lower glycemic index foods such as legumes, fruits, and vegetables, dairy foods, and to choose whole-grain cereals as these provide more fiber, vitamins and minerals and contain more natural sugars Therefore, it is recommended that children under five receive 19-22 g of carbohydrates per day Steinmuller et al.,
1.2.1.7 Protein is required to synthesize enzymes and hormones that regulate body processes and stimulate growth There is protein in fish, pork, chicken, eggs and animal livers, but eggs are an especially good source of protein
A recommended protein intake is approximately 4 g per 1kg of weight or around 60-85 g per day for children aged 3-5 years (Walsh et al, 2015)
1.2.1.8 Grains:Whole grains likebrown rice, buckwheat, bulgur (cracked wheat) and refined oatmeal are recommended with an intake of approximately 4-5 ounces or 110-140 g per day for children aged 3-5 years
1.2.1.9 Vegetables include dark green vegetables such as broccoli, collard greens and spinach; red and orange vegetables such as carrots, pumpkins, potatoes
9 and tomatoes; and other vegetables likeartichokes, asparagus, avocados, bean sprouts, beets, Brussels sprouts, cabbages, cauliflowers, celery, cucumbers, eggplants, mushrooms, onions, beans and tomatoes
1.2.1.10 Milk / Dairy: 1ẵ-2 servings of dairy is recommended for children aged 3-5 years; for example, 1 serving = 1 cup of milk, or yogurt or a slice of cheese Calcium-fortified soymilk (soy beverage) is also part of the dairy group (along with almonds and hazelnuts)
1.2.1.11 Fruit: These include apples, bananas, berries, figs, fruit juices
(unsweetened), grapefruit, grapes, kiwi fruits, mangoes, watermelons and oranges Many of these can be offered as dried fruits as well (Serrano & Powwell, 2013).
Overview of the problems caused by inadequate parental dietary practices for their
Dietary quality has gained significant attention in the global food market due to its impact on health, especially concerning chronic diseases like cardiovascular disease (CVD) and cancer (Wong et al, 2017) A poor diet is linked to a higher risk of obesity, diabetes, and other life-threatening conditions (Adams et al, 2016).
A study conducted in Bahir Dar town, Northwest Ethiopia, revealed that 39.3% of participants exhibited good dietary practices, while 60.7% reported poor practices Additionally, 61.4% demonstrated good dietary knowledge, contrasting with 38.6% who had poor knowledge A significant association (P < 0.05) was found between husbands' income and dietary knowledge, with 378 participants (61.4%) showing good knowledge Participants scored above 75% in most dietary knowledge areas, except for iodine (48.7%), vitamin A (64.1%), and iron sources (60.4%) (Nana & Zema, 2018) Furthermore, a multivariate analysis in Madagascar's Amoron'i Mania region indicated that low education levels were significantly linked to reduced dietary diversity (AOR=3.80 [1.58-9.02]).
A study conducted in Kajiado County, Kenya, revealed that 92.7% of parents had low nutritional knowledge, with less than 40% awareness Additionally, children's dietary practices were inadequate, as 76.1% consumed fewer than three meals per day, and 95.7% had a low dietary diversity of fewer than six food groups daily These poor dietary habits adversely affect the nutritional status of household members, particularly preschool children, who are at a heightened risk of malnutrition.
Parents play a crucial role in shaping their children's health, behavior, and education by influencing their food environments and initial experiences with food Their beliefs, practices, and knowledge about nutrition significantly impact children's understanding of healthy eating Research indicates that parental nutrition knowledge and attitudes are vital for fostering children's healthy food choices Additionally, these factors affect the variety and quality of foods available at home, ultimately influencing children's diets Studies have shown a significant association between maternal education and children's nutritional outcomes, such as underweight and wasting.
Deficiencies in essential nutrients such as vitamin A, iron, iodine, zinc, and thiamine significantly elevate the risk of morbidity and mortality in infants and young children Vitamin A deficiency can result in blindness and increases the likelihood of death before the age of five Iron deficiency leads to anemia and exacerbates the severity of infectious diseases like malaria Iodine deficiency is linked to goiter and cretinism, which severely impairs physical and mental development Zinc deficiency contributes to stunted growth and higher mortality rates from diarrhea, while thiamine deficiency can cause infantile beriberi, potentially leading to fatal cardiac failure.
A good diet is crucial for the growth and development of children (Karkee et al, 2014), whereas a poor diet can delay fetal growth resulting in low birth weight,
11 and -at a later stage- the child‟s development may be stunted (Paudel et al, 2012)
One in four children under the age of five suffers from stunting due to inadequate nutrition, with malnutrition responsible for 45% of global child deaths in this age group (WHO, 2018) Research in Hebei Province, China, identified poor feeding practices and the caregivers' knowledge as significant contributors to undernutrition (Mutorwa, 2018).
A lack of adequate knowledge among mothers significantly contributes to poor feeding practices, as highlighted by the United States Agency for International Development (USAID, 2011) Many mothers and caregivers are often unaware of essential aspects such as the appropriate duration of breastfeeding, the right time to introduce complementary feeding, and the types of food that are suitable for children (Mulenga, 2018; Nabugoomu, 2015).
Dietary intake among young children is significantly influenced by caregivers, particularly parents, who control the type, quantity, and quality of food provided (Kourlaba et al, 2009) Parents play a crucial role in determining food availability, preparation methods, and consumption patterns (Татаркин, 2012) Their behaviors serve as role models, greatly impacting children's eating habits (Татаркин, 2012) Additionally, caregivers' feeding, caregiving, and healthcare-seeking practices profoundly affect children's food intake and vulnerability to diseases (Hoddinott et al, 2013) A factor analysis of the Comprehensive Feeding Practices Questionnaire has identified key feeding practices, which are influenced by demographic variables such as ethnicity, socioeconomic status, sex, maternal education, and weight status (Faber, 2010).
Factors associated with dietary practices
social, economic and demographic charateristics of parents
Research indicates a significant relationship between socio-economic factors, such as maternal education, family size, and a child's nutritional status Malambugi (2010) found no notable differences in stunting rates among children of mothers with varying levels of education, including informal and primary schooling In Tanzania, Kassa et al (2016) revealed that maternal education and household size influenced parental feeding practices, with educated mothers more likely to adopt diversified feeding strategies Similarly, Kimani-Murage et al (2011) identified a strong association between parents' education and income levels and their children's nutritional outcomes Additionally, parental feeding practices, including modeling, food restrictions, and pressure to eat, play a crucial role in shaping children's food preferences and intake patterns (Gregory et al.).
The family context significantly impacts the development of children's eating behaviors, as they spend most of their time with family members Parents, caregivers, and siblings all play a crucial role in shaping young children's habits Given this strong influence, targeting the family unit presents an effective opportunity to enhance children's health behaviors.
Dietary behavior among various ethnic minority groups is influenced by both common and distinct factors Key issues such as limited access to traditional foods, religious dietary restrictions, and specific food preferences were observed across all populations studied, regardless of their geographic origin or settlement country Notably, religious beliefs significantly impacted dietary choices among South Asians (including Pakistanis, Bangladeshis, and Indians), as well as African, Middle Eastern, and Eastern European immigrants (Osei-Kwasi et al., 2016).
1.4.1 Knowledge of dietary recommendations, sources of nutrients, choosing foods and food preparation
Parents‟ nutritional knowledge and attitudes may influence the variety of foods available in the household and the quality of children‟s diets (Christian et al,
Parents play a crucial role in shaping their children's eating behaviors and food preferences, as their knowledge and attitudes towards nutrition significantly impact childhood growth A study in Mashonaland, Zimbabwe, revealed that parents had poor to moderate nutrition knowledge and a limited understanding of the causes of overweight in preschool children, with a notable link between parental education level and nutrition knowledge (Mushonga et al, 2017) Additionally, research by Inayati's team on caregivers of mildly wasted children in Nias Island, Indonesia, found no significant association between parental practices and nutrition knowledge, indicating that improved education alone may not lead to changes in behavior (Inayati et al, 2012).
Parents play a crucial role in shaping their children's dietary habits by controlling the availability, preparation, and portion sizes of food (Nyathela, 2017) It is essential for parents to recognize that children need both stimulation and attention to optimize their dietary intake (Wardlaw & Smith) Being responsive to a child's hunger and fullness cues is vital for meeting their physiological and psychological feeding needs Additionally, parents must ensure that their children receive adequate nutrients from a variety of food sources, necessitating careful monitoring of food intake frequency, quality, and quantity Various factors can influence how parents impact their young children's eating patterns and food consumption (Lande, 2014).
Most studies have found a positive correlation between education levels of parents and their knowledge of healthy eating behaviors Two family factors that
Research indicates that parental education and household income significantly influence children's healthy eating habits (Valentin et al., 2016) Mothers with higher nutritional knowledge tend to provide their children with more fruits, vegetables, and legumes while limiting sugary drinks and fast food Additionally, these mothers are more likely to avoid artificial substances in food and recognize the connection between nutrition and health Ultimately, a mother's level of nutritional knowledge plays a crucial role in shaping her children's eating behaviors (Yabancı et al., 2014).
In 2011, only 13% of the poorest households had access to improved sanitation, with rural children from these households facing a higher risk of stunting—49% of rural children compared to 27% of urban children, and 61% among the poorest While 89% of the population exhibited acceptable food consumption patterns, about 11% of rural households had poor to borderline consumption The 2017 Laos Social Indicator Survey revealed that 61% of households identified unaffordability as a significant barrier to dietary diversity.
Access to diverse diets in households is notably low, particularly in rural areas of Laos, where many families consume only three out of the nine recommended food groups, as highlighted by the 2012-2013 Laos Consumption Survey Additionally, there exists a significant gender gap in accessing health and nutrition services, with distance to health facilities posing a major barrier for the rural poor living in remote areas The limited nutrition-related knowledge among parents is exacerbated by supply-side challenges, such as the inadequate capacity of health facilities and staff to deliver essential services Furthermore, even in the absence of financial constraints, religious beliefs often promoted and enforced by influential family members, including grandmothers and husbands, contribute to these challenges These underlying factors at the household level significantly impact children's nutrition and health outcomes.
Inadequate food intake, disease, insufficient care, and poor feeding practices pose significant risks to health To mitigate these risks, nutrition-sensitive interventions are essential These programs focus on enhancing food security, providing adequate caregiving resources at the maternal, household, and community levels, and ensuring access to health services and safe, hygienic environments (Higuera et al.).
Insufficient access to safe water, sanitation, and hygiene practices leads to repeated water-related diseases, such as enteric and helminthic infections, which are linked to stunting in early childhood A significant portion of child wasting is caused by diarrhea resulting from inadequate water, sanitation, and hygiene Environmental factors, including these practices, account for an estimated 50% of the disease burden related to undernutrition Additionally, the diet of preschool children plays a crucial role in their nutritional status.
Healthy eating behaviors are fostered through a balanced and varied diet, supportive food environments, and parental guidance in child food choices These practices contribute to positive outcomes for children, such as optimal growth and development, higher intake of nutritious foods, and reduced risk of obesity (Marshall et al, 2011).
Parental influences significantly shape children's eating behaviors, particularly during infancy and early childhood (Ainuki & Akamatsu, 2011) Strategies employed by parents to manage their children's diets, known as parental child feeding practices, dictate what, when, and how much children eat, both at mealtimes and beyond (Blissett, 2011; Hetherington et al., 2011) These practices are closely associated with the dietary quality of preschool children (Unicef, 2014) However, there is limited research on the factors influencing parental dietary practices for preschoolers in Lao PDR It is important to note that food intake habits established during preschool years tend to persist into later life.
Early unhealthy food patterns can have lasting implications for health throughout life, influenced by both internal factors like a child's taste preferences and external factors such as peers, media, and parents Parents are particularly crucial in shaping early food practices, serving as providers, enforcers, and role models for their children, who rely heavily on them for guidance (Warkentin et al., 2018).
Parental feeding practices are significantly affected by the availability of food at home Although numerous studies have measured food availability, only a limited number have explored its relationship with parental practices, including modeling, support, and the encouragement of healthy eating habits (Haszard, 2013).
Overview of areas intended to implement research
Vientiane Province has 11 districts spread over a total land area of 15,927 km 2 The population was about 419,090 as of the 1 st March 2015 census (Census,
The research area is situated in the northwest of Laos, bordered by Sayabouli to the west, Luang Prabang to the north, Xiangkhoang to the northeast, Bolikhamxay to the east, and Vientiane capital and Thailand to the south It encompasses four districts: Phonhong, Viengkham, Toulakhome, and Keo Oudom, comprising 144 villages and 32,100 households, with an average of 4-5 members per household The total population is approximately 154,900, including 77,200 women and an estimated 4,871 children under five years old (MPI, 2015).
Overview of methods
A Food Frequency Questionnaire (FFQ) is a concise list of foods and beverages that allows individuals to indicate how frequently they consume each item over a designated timeframe Semi-quantitative FFQs gather data on portion sizes, either through standardized portions or by offering a selection of portion sizes, while non-quantitative FFQs do not collect portion size information.
Nutrient intake can be assessed using computerized software that calculates the frequency of food consumption multiplied by the nutrient content per serving Common reference databases for Food Frequency Questionnaires (FFQs) include the USDA food and nutrient database and the University of Minnesota's NCCN nutrient database Additionally, some programs leverage data from the National Health and Nutrition Examination Survey (NHANES) for nationwide comparisons (Rodrigo et al., 2015).
Food security ensures that all individuals have consistent physical and economic access to sufficient food for a healthy life Measuring food insecurity is complex and has posed challenges for researchers due to the technical difficulties and costs associated with data collection The U.S Household Food Security Survey Module (US HFSSM) employs an eighteen-question format to assess behaviors and attitudes related to food insecurity It includes questions about perceptions of food quantity and concerns about food availability Responses are summarized on a scale that categorizes households as food secure or insecure, providing essential data for monitoring food assistance programs and reporting national food insecurity prevalence (Coates, 2007).
Social, economic and demographic charateristics of parents
Parental dietary practices among parents having children 3-5 years old
SUBJECTS AND METHODS
Subjects
The subjects of this study were parents who had children aged between 36 and 60 months old
- All parents (a mother or father per preschool child) who is taking care of their children aged 3-5 years old and who can answer questions and inform consent
- Parents who do not take care of children aged 3-5 years old
Study site and duration
The research was carried out in four of the eleven districts in Vientiane Province, Lao PDR, with a total population of 154,900, including 77,200 women Notably, there were an estimated 4,871 children under the age of five in the study area, according to the MPI report from 2015.
This study was conducted from January to December 2019 Data collection was carried out from 1 st - 31 st August 2019 (4 weeks).
Study design
This study utilized a quantitative approach with a cross-sectional design, conducting face-to-face interviews using structured questionnaires The research aimed to gather insights into the dietary practices of parents with children aged 3-5 years in the rural districts of Vientiane Province, Lao PDR, in 2019.
Sample size
The sample size formula for deriving the population size for the study was as follows n = the number of respondents required for the study
Za = Reliability range from Z-statistics ((Z = 1.96; = 0.05)
P = Partial percentage (%) from previous studies (P = 50%) e = Estimates from the p we allowed (e = 0.05)
Information was to be collected from 400 parents.
Sampling method
A probability multistage sampling method in three stages was applied:
Stage 1: Four districts were randomly selected from the total of 11 districts
Stage 2: Systematic random sampling was employed to create a sampling frame from which to choosethree villages per district
Stage 3: Households were selected by applying the systematic random sampling method based on the size of the population
First four districts (Phonhong, Viengkham, Toulakhom and Keoudom) were randomly selected out of the eleven possible districts (Vangvieng, Sanakham, Hinherb, Kasi, Meuane, Viengkham, Toulakhom, Phonhong, Mad, Feuang, and Sanakham)
Systematic random sampling was employed to choose a total of 12 villages across four districts, selecting three villages from each district In Phonhong district, the selected villages were Phonkham, Hongleui, and Nongnark from a total of 17 villages In Viengkham district, the chosen villages were MeungKao, Veunsan, and Nakeuan from a pool of 9 villages In Toulakhom district, three villages were also randomly selected.
33 villages (Souksala, Phonyeng, and Napheiu), and in Keoudom district, we randomly selected three out of 11 villages (Phonyeng, Dansavanh, and Mai)
Systematic random sampling was employed to select households for the survey, targeting a sample size of 400 parents with children aged 3 to 5 years Participants were drawn from four districts and 12 villages, with recruitment taking place from January to April 2019.
2020 The 400 parents who were eligible for the study were selected as follows:
The list of parents who were eligible for the study was obtained from the community health centers‟ logbooks in the 12 villages
From these eligible parents, 400 parents were selected using a simple random sampling technique.
Data collection method
- After obtaining the permission of the head of each household, each subject was interviewed face to face
- A self-administrated questionnaire translated into the Lao language was used for collecting data
The assessment of parental dietary practices focused on meals prepared the previous day for children, utilizing indicators of minimally acceptable dietary practices To ensure appropriate dietary practices, parents needed to provide meals that met the required daily food intake and frequency Minimum dietary diversity was evaluated based on five food groups and the necessary amounts for adequate feeding Additionally, appropriate frequency was determined by the preparation of meals for children three or more times the previous day.
The questionnaire consisted of four parts, the first three for the independent variables and the fourth for the dependent variable as follows:
Part I: General characteristics of parents
The section included nine key items regarding parents' general information, such as their age, ethnicity, religion, marital status, household size, number of children, education level, occupation, and monthly income.
Part II: Knowledge of parents
The study utilized questionnaires to assess parents' understanding of dietary recommendations, nutrient sources, food selection, and preparation methods (Peters et al., 2013) Comprising 10 True or False items, the questionnaire assigned 1 point for each "True" response and 0 points for "False," resulting in a maximum possible score of 10 points.
The level of that knowledge was categorized as “High” or “Low” as determined by the percentage of the knowledge score:
- High level of knowledge: ≥80% or ≥ 8 of the total score
- Low level of knowledge: