Tufts University Friedman School of Nutrition Science and Policy Food Policy and Applied Nutrition Program Dissertation Proposal

In partial fulfillment of the requirements for the Degree of Doctor of Philosophy

Mycotoxin Exposure among Pregnant Women: Examining Knowledge, Practices, Diet Quality and Effects on Birth Outcomes in Banke, Nepal

Doctoral Candidate: Johanna Yvonne Andrews Chavez

Thesis Committee: Patrick Webb, PhD (Chair) Shibani Ghosh, PhD Beatrice Rogers, PhD Gerald Shively, PhD

16 January 2015

Abstract Previous cross-sectional studies examining mycotoxins (particularly aflatoxins) and child linear growth yielded suggestive but inadequately powered results about the factors associated with maternal mycotoxin exposure and the association between maternal mycotoxin exposure and child health and stunting. The long-term goal of this proposed research is to better understand the factors associated with maternal aflatoxin exposure and how maternal aflatoxin exposure is associated with birth outcomes. The goal of aim 1 is to qualitatively assess existing agricultural and food storage knowledge and practices and quantitatively assess if knowledge and practices are associated with maternal aflatoxins exposure levels. The qualitative work will entail primary data collection and analysis of focus group data. The focus groups will include female and male respondents ages 18 or older (n=72) while the quantitative research will entail a secondary data analysis of the Nepal Mycotoxin Birth Cohort. This extensive agricultural and consumption questionnaire will include responses from 1,600 pregnant women ages 16-49 residing in the Banke district of Nepal, and will evaluate local knowledge and household storage practices for foods commonly contaminated with mycotoxins (e.g. peanuts, corn, rice). Correlation matrices and multiple linear regressions will model associations between knowledge/practices and maternal mycotoxin exposure. Findings of aim 1 could inform policy makers about the current state of awareness regarding harmful health effects from mycotoxin contamination, current practices for reducing or exacerbating mycotoxin exposure and will be useful in the design of interventions to counteract high levels of mycotoxin exposure, particularly among pregnant women. Aim 2 will quantitatively examine the degree to which diet quality is associated with maternal mycotoxin exposure. Correlation matrices and multiple linear regressions will model associations between diet quality and maternal mycotoxin exposure. While aims 1 and 2 focus on factors associated with maternal mycotoxin exposure, aim 3 will focus on the association between maternal mycotoxin levels and birth outcomes such as low birth length, low birth weight, small for gestational age, stillbirth, head circumference and knee-heel length. Correlation and multiple linear regressions will be used to model associations between maternal mycotoxin exposure and birth outcomes. Understanding the association between these factors and birth outcomes has implications for food safety regulation policies that limit mycotoxins in food, and can help optimize behavior change-based nutrition and agriculture programs designed to reduce mycotoxin consumption among pregnant women and young children.