Poverty

Assessing calibration and bias of a deployed machine learning malnutrition prediction model within a large healthcare system

Malnutrition is a frequently underdiagnosed condition leading to increased morbidity, mortality, and healthcare costs. The Mount Sinai Health System (MSHS) deployed a machine learning model (MUST-Plus) to detect malnutrition upon hospital admission. However, in diverse patient groups, a poorly calibrated model may lead to misdiagnosis, exacerbating health care disparities. We explored the model's calibration across different variables and methods to improve calibration. Data from adult patients admitted to five MSHS hospitals from January 1, 2021 - December 31, 2022, were analyzed. We compared MUST-Plus prediction to the registered dietitian's formal assessment. Hierarchical calibration was assessed and compared between the recalibration sample (N = 49,562) of patients admitted between January 1, 2021 - December 31, 2022, and the hold-out sample (N = 17,278) of patients admitted between January 1, 2023 - September 30, 2023. Statistical differences in calibration metrics were tested using bootstrapping with replacement. Before recalibration, the overall model calibration intercept was -1.17 (95% CI: -1.20, -1.14), slope was 1.37 (95% CI: 1.34, 1.40), and Brier score was 0.26 (95% CI: 0.25, 0.26). Both weak and moderate measures of calibration were significantly different between White and Black patients and between male and female patients. Logistic recalibration significantly improved calibration of the model across race and gender in the hold-out sample. The original MUST-Plus model showed significant differences in calibration between White vs. Black patients. It also overestimated malnutrition in females compared to males. Logistic recalibration effectively reduced miscalibration across all patient subgroups. Continual monitoring and timely recalibration can improve model accuracy.

No heat, no eat: (Dis)entangling insecurities and their implications for health and well-being

This study explores the associations between energy poverty, food insecurity, and a set of outcomes-including the self-reported burden of chronic illness, physical disabilities, and mental health-among social-aid recipients across Israel. We highlight the socio-demographic characteristics and housing conditions of energy-poor households and analyze the association between energy poverty and health and well-being using multivariate regression models. Of 1390 aid-recipient respondents, more than 85% met the criteria for living in an energy-poor household, and almost all of them also struggled with food insecurity and were raised in poor households as children. In addition, the severity of energy poverty was positively and significantly associated with the occurrence of diabetes, hypertension, and mental illness, and, as compared with energy-secure households, severely energy-poor households were more prone to forgo acquiring prescription medications, medical aid, or required health treatments due to financial hardships. These findings highlight the nuanced negotiation over necessities that aid-supported households make; despite being at greater risk of being sick, energy-poor households are more likely to forgo buying medicines and seeking healthcare so as to pay the electricity bills. Hidden energy poverty, coupled with what might be hidden morbidity, may have significant implications for healthcare systems, and a climate-sensitive health policy at both the municipal and national levels is required to strengthen resilience among low-income households.

Using intersectionality to study gender and antimicrobial resistance in low- and middle-income countries

Different sexes and genders experience differentiated risks of acquiring infections, including drug-resistant infections, and of becoming ill. Different genders also have different health-seeking behaviours that shape their likelihood of having access to and appropriately using and administering antimicrobials. Consequently, they are distinctly affected by antimicrobial resistance (AMR). As such, it is crucial to incorporate perspectives on sex and gender in the study of both AMR and antimicrobial use in order to present a full picture of AMR's drivers and impact. An intersectional approach to understanding gender and AMR can display how gender and other components 'intersect' to shape the experiences of individuals and groups affected by AMR. However, there are insufficient data on the burden of AMR disaggregated by gender and other socio-economic characteristics, and where available, it is fragmented. For example, to date, the best estimate of the global burden of bacterial AMR published in The Lancet does not consider gender or other social stratifiers in its analysis. To address this evidence gap, we undertook a scoping review to examine how sex and gender compounded by other axes of marginalization influence one's vulnerability and exposure to AMR as well as one's access to and use of antimicrobials. We undertook a gendered analysis of AMR, using intersectionality as a concept to help us understand the multiple and overlapping ways in which different people experience exposure vulnerability to AMR. This approach is crucial in informing a more nuanced view of the burden and drivers of AMR. The intersectional gender lens should be taken into account in AMR surveillance, antimicrobial stewardship, infection prevention and control and public and professional awareness efforts, both donor and government funded, as well as national and international policies and programmes tackling AMR such as through national action plans.

Food choice drivers at varying income levels in an emerging economy

The purpose of this work was to explore and compare food choice drivers of low (LI), middle (MI) and high (HI) income urban people in an emerging economy (South Africa). Here, 13 focus group (FG) discussions [six LI, n = 36, 67% women; four MI, n = 22, 100% women and three HI, n = 17, 76% women; total n = 75) were transcribed, coded inductively and deductively and 17 food choice categories emerged. Eight of these, i.e., aspects related to: plant vs animal protein, food waste, food preparation, availability of resources, food exploration, social aspects and food spoilage, are not typically (e.g., sensory appeal, mood, health, convenience etc.) measured with established food choice questionnaires. Economic factors and Availability of food and resources were mentioned the most by LI participants compared to MI and HI. Whereas, Health; Familiarity and Food exploration were mostly mentioned by MI and HI participants. This study yielded a mixture of individual and environment based motives which add to our understanding of the "why" aspects underlying food choice in an urban and emerging economy. The fact that these aspects are compared by income group provides interesting information on the similarities and differences of how the food choice process unfolds across varying income groups. The insights from this study are useful for the development of an updated, quantitative food choice questionnaire for application in this and other emerging economies.

Developing feasible healthy diets for Ethiopian women of reproductive age: a linear goal programming approach

OBJECTIVE

To develop a healthy diet for Ethiopian women closely resembling their current diet and taking fasting periods into account while tracking the cost difference.

DESIGN

Linear goal programming models were built for three scenarios (non-fasting, continuous fasting and intermittent fasting). Each model minimised a function of deviations from nutrient reference values for eleven nutrients (protein, Ca, Fe, Zn, folate, and the vitamins A, B1, B2, B3, B6, and B12). The energy intake in optimised diets could only deviate 5 % from the current diet.

SETTINGS

Five regions are included in the urban and rural areas of Ethiopia.

PARTICIPANTS

Two non-consecutive 24-h dietary recalls (24HDR) were collected from 494 Ethiopian women of reproductive age from November to December 2019.

RESULTS

Women's mean energy intake was well above 2000 kcal across all socio-demographic subgroups. Compared to the current diet, the estimated intake of several food groups was considerably higher in the optimised modelled diets, that is, milk and dairy foods (396 v. 30 g/d), nuts and seeds (20 v. 1 g/d) and fruits (200 v. 7 g/d). Except for Ca and vitamin B12 intake in the continuous fasting diet, the proposed diets provide an adequate intake of the targeted micronutrients. The proposed diets had a maximum cost of 120 Ethiopian birrs ($3·5) per d, twice the current diet's cost.

CONCLUSION

The modelled diets may be feasible for women of reproductive age as they are close to their current diets and fulfil their energy and nutrient demands. However, the costs may be a barrier to implementation.

Spatial-temporal trends in global childhood overweight and obesity from 1975 to 2030: a weight mean center and projection analysis of 191 countries

BACKGROUND

The geographic information science-based interactive map provided good prospects for the public health to study disease prevalence. The purpose of this study is to understand global spatial-temporal trends of childhood overweight and obesity and underlying causes help formulating intervention strategies.

METHODS

This multiple cross-sectional study included data on childhood overweight and obesity prevalence, gross national income per capita, and urbanization rate for 191 countries from 1975-2016. Autoregressive integrated moving average model, standard deviational ellipse model and mixed-effects models were used to explore spatial-temporal trends of childhood overweight and obesity and associations with gross national income per capita and urbanization rate.

RESULTS

Globally, childhood overweight and obesity rate would reach 30.0% in 2030 (boys: 34.2%, girls: 27.4%). By 2030, it would reach 58.3% in middle- and high-income countries and 68.1% in Western Pacific region. Spatial-temporal trendline for childhood overweight and obesity in 1975-2030 exhibited a "C" shape, migrating from 1975 (15.6。E, 24.6。N) to 2005 (10.6。E, 21.7。N), then to 2030 (14.8。E, 17.4。N). The trendline for urbanization rate was also an irregular "C", and the turning point appeared five years earlier than childhood overweight and obesity.

CONCLUSIONS

Globally, childhood overweight and obesity prevalence will continue to increase. Its weight mean center migrated from western countries to Asia and Africa following economic development.

Risk factors for inadequate and excessive gestational weight gain in 25 low- and middle-income countries: An individual-level participant meta-analysis

BACKGROUND

Many women experience suboptimal gestational weight gain (GWG) in low- and middle-income countries (LMICs), but our understanding of risk factors associated with GWG in these settings is limited. We investigated the relationships between demographic, anthropometric, lifestyle, and clinical factors and GWG in prospectively collected data from LMICs.

METHODS AND FINDINGS

We conducted an individual participant-level meta-analysis of risk factors for GWG outcomes among 138,286 pregnant women with singleton pregnancies in 55 studies (27 randomized controlled trials and 28 prospective cohorts from 25 LMICs). Data sources were identified through PubMed, Embase, and Web of Science searches for articles published from January 2000 to March 2019. Titles and abstracts of articles identified in all databases were independently screened by 2 team members according to the following eligibility criteria: following inclusion criteria: (1) GWG data collection took place in an LMIC; (2) the study was a prospective cohort or randomized trial; (3) study participants were pregnant; and (4) the study was not conducted exclusively among human immunodeficiency virus (HIV)-infected women or women with other health conditions that could limit the generalizability of the results. The Institute of Medicine (IOM) body mass index (BMI)-specific guidelines were used to determine the adequacy of GWG, which we calculated as the ratio of the total observed weight gain over the mean recommended weight gain. Study outcomes included severely inadequate GWG (percent adequacy of GWG <70), inadequate GWG (percent adequacy of GWG <90, inclusive of severely inadequate), and excessive GWG (percent adequacy of GWG >125). Multivariable estimates from each study were pooled using fixed-effects meta-analysis. Study-specific regression models for each risk factor included all other demographic risk factors measured in a particular study as potential confounders, as well as BMI, maternal height, pre-pregnancy smoking, and chronic hypertension. Risk factors occurring during pregnancy were further adjusted for receipt of study intervention (if any) and 3-month calendar period. The INTERGROWTH-21st standard was used to define high and low GWG among normal weight women in a sensitivity analysis. The prevalence of inadequate GWG was 54%, while the prevalence of excessive weight gain was 22%. In multivariable models, factors that were associated with a higher risk of inadequate GWG included short maternal stature (<145 cm), tobacco smoking, and HIV infection. A mid-upper arm circumference (MUAC) of ≥28.1 cm was associated with the largest increase in risk for excessive GWG (risk ratio (RR) 3.02, 95% confidence interval (CI) [2.86, 3.19]). The estimated pooled difference in absolute risk between those with MUAC of ≥28.1 cm compared to those with a MUAC of 24 to 28.09 cm was 5.8% (95% CI 3.1% to 8.4%). Higher levels of education and age <20 years were also associated with an increased risk of excessive GWG. Results using the INTERGROWTH-21st standard among normal weight women were similar but attenuated compared to the results using the IOM guidelines among normal weight women. Limitations of the study's methodology include differences in the availability of risk factors and potential confounders measured in each individual dataset; not all risk factors or potential confounders of interest were available across datasets and data on potential confounders collected across studies.

CONCLUSIONS

Inadequate GWG is a significant public health concern in LMICs. We identified diverse nutritional, behavioral, and clinical risk factors for inadequate GWG, highlighting the need for integrated approaches to optimizing GWG in LMICs. The prevalence of excessive GWG suggests that attention to the emerging burden of excessive GWG in LMICs is also warranted.

Double Burden of Malnutrition: A Population Level Comparative Cross-Sectional Study across Three Sub-Saharan African Countries-Malawi, Namibia and Zimbabwe

BACKGROUND

The double burden of malnutrition in sub-Saharan African countries at different levels of economic development was not extensively explored. This study investigated prevalence, trends, and correlates of undernutrition and overnutrition among children under 5 years and women aged 15-49 years in Malawi, Namibia, and Zimbabwe with differing socio- economic status.

METHODS

Prevalence of underweight, overweight, and obesity were determined and compared across the countries using demographic and health surveys data. Multivariable logistic regression was used to ascertain any relationships between selected demographic and socio-economic variables and overnutrition and undernutrition.

RESULTS

An increasing trend in overweight/obesity in children and women was observed across all countries. Zimbabwe had the highest prevalence of overweight/obesity among women (35.13%) and children (5.9%). A decreasing trend in undernutrition among children was observed across all countries, but the prevalence of stunting was still very high compared to the worldwide average level (22%). Malawi had the highest stunting rate (37.1%). Urban residence, maternal age, and household wealth status influenced maternal nutritional status. The likelihood of undernutrition in children was significantly higher with low wealth status, being a boy, and low level of maternal education.

CONCLUSIONS

Economic development and urbanization can result in nutritional status shifts.

Sexual dimorphism in selenium deficiency is associated with metabolic syndrome and prevalence of heart disease

BACKGROUND

Serum selenium levels have been associated with the incidence of heart failure (HF) and signs of the metabolic syndrome. In addition, notable differences have been reported between males and females in food intake and micronutrient metabolism, possibly explaining different health outcomes.

OBJECTIVE

Our objective was to elucidate sex-specific, cross-sectional phenotypic differences in the association of serum selenium concentrations with parameters of metabolic syndrome and HF.

METHODS

We investigated data from individuals from a community-based cohort (PREVEND; N = 4288) and heart failure cohort (BIOSTAT-CHF; N = 1994). In both populations, cross-sectional analyses were performed for potential interaction (p < 0.1) between sex and serum selenium with overlapping signs and clinical parameters of the metabolic syndrome and HF.

RESULTS

Baseline selenium levels of the total cohort were similar between PREVEND (85.7 μg/L) and BIOSTAT-CHF (89.1 μg/L). Females with lower selenium levels had a higher BMI and increased prevalence of diabetes than females with higher selenium, in both PREVEND (p_interaction < 0.001; p_interaction = 0.040, resp.) and BIOSTAT-CHF (p_interaction = 0.021; p_interaction = 0.024, resp.), while opposite associations were observed for males. Additionally, in females, but not in males, lower selenium was associated with a higher prevalence of myocardial infarction (MI) in PREVEND (p_interaction = 0.021) and BIOSTAT-CHF (p_interaction = 0.084).

CONCLUSION

Lower selenium was associated with a higher BMI and increased prevalence of diabetes in females, opposite to males, and was also associated with more MI in females. Interventional studies are needed to validate this observation.

Mother's education and nutritional status as correlates of child stunting, wasting, underweight, and overweight in Nigeria: Evidence from 2018 Demographic and Health Survey

Aim: This study examined the nexus between mother's education and nutritional status and their relationships with child stunting, wasting, underweight, and overweight. Methods: The data of 34,193 under-five (U-5) children from the 2018 Nigeria Demographic and Health Survey (NDHS) were analyzed using descriptive statistics, and binary and complementary log-logistic regression models. Results: The prevalence of child stunting, wasting, underweight, and overweight were 36.51%, 6.92%, 21.73%, and 2.05%, respectively. Compared to children born to mothers with at least secondary education, uneducated women's children (odds ratio (OR) = 1.55; 95% confidence interval (CI) = 1.32-1.82) and those of women with primary education (OR = 1.49; 95% CI = 1.28-1.72) were more likely to be stunted. Similarly, children born to uneducated women (OR = 1.51; 95% CI = 1.24-1.83) were more likely to be underweight than women with at least secondary education. The likelihood of child underweight (OR = 1.71; 95% CI = 1.45-2.01) and wasting (rate ratio (RR) = 1.82; 95% CI = 1.47-2.26) were higher among underweight mothers, respectively, than those with normal body mass index (BMI). The likelihood of child stunting (OR = 0.75; 95% CI = 0.67-0.84) and underweight (OR = 0.66; 95% CI = 0.57-0.77) were lower among obese/overweight mothers compared to those with normal BMI, but their children were more likely to be overweight (RR = 1.77; 95% CI = 1.27-2.48). Conclusion: Attainment of higher education by mothers should be promoted to prevent childhood nutritional imbalances, and sensitization on healthy dietary habits and lifestyles should be promoted among women, especially the overweight/obese, to reduce their risk of having overweight children.

The silent tragic reality of Hidden Hunger, anaemia, and neural-tube defects (NTDs) in India

Hidden Hunger arising from nutritional iron-, folate-, and vitamin-B₁₂-deficiencies is exceedingly common in India and has profound negative impacts on anaemia, on pregnancy, and on embryonic-foetal neurodevelopment in utero, which predisposes to NTDs and psychological-psychiatric manifestations in childhood. Whereas younger-to-middle-aged Indians fail to perform at maximum potential, the elderly are at risk for calamitous neurologic events. However, these micronutrient-deficiencies are eminently correctable through food-fortification. Therefore, the Indian Government can no longer afford the luxury of inaction by either denying or downplaying the gravity of this problem. What is critically needed from India's leaders is an urgent, clear-eyed reappraisal and act of anagnorisis-(an often startling self-recognition and discovery of a profoundly serious error and tragic flaw)-in failing to confront this problem for decades. Only when closely followed by a metanoia-(a transformative change of heart that triggers remedial action)-can they help India avoid a catastrophic tryst with destiny.

Traditional Individual and Environmental Determinants of Healthy Eating in Vihiga County, Western Kenya

Traditional ethnic groups in Kenya are unlikely to eat a healthy and diversified diet due to many individual and environmental factors, which may result in poor health status. Therefore, the determinants of eating behavior need to be identified prior to any public health action. For this study, focus group discussions (15 in total) in a double-layer design were conducted, comprising adult men and women from 5 villages of Vihiga County. Questions explored knowledge; barriers and cues to action toward eating a healthy diet containing a variety of foods; including indigenous food species. We found that healthy eating concepts are known; however, several taboos that restrict food consumption reduce local diet quality in terms of diversity. Nutrition education is a cue to action. We identified several individual and environmental determinants of eating behavior in the studied communities. Public health action should focus on supporting healthy eating behaviors and refining some taboos’ beliefs.

The Targets for Stunting Prevention Policies in Papua, Indonesia: What Mothers' Characteristics Matter?

The study aimed to analyze the most appropriate maternal characteristics for stunting prevention policies. The study employed secondary data from the 2017 Indonesia Nutritional Status Monitoring Survey. The study obtained weighted samples of 11,887 Papuan children under five years of age. On the other hand, the study used the nutritional status as an outcome variable and maternal characteristics as an exposure variable. The research employed the following four control variables: residence, region, under-five age, and gender. The study occupied the binary logistic regression. The results show that mothers who graduated from primary school and under were 1.263 times more likely than mothers with a college education to have stunted children. Mothers who graduated from junior high school are 1.222 times more likely than mothers with a college education to have stunted children. Mothers who graduated from senior high school were 1.122 times more likely than mothers with a college education to have stunted children. Mothers with a never-married status have a 1.138 times greater probability than divorced/widowed mothers to have stunted children. Meanwhile, married mothers are 0.936 times more likely than divorced/widowed mothers to have stunted children. The study concluded that the target group for stunting prevention policies are mothers with poor education and who are single.

Assessing the double burden of malnutrition among Bangladeshi reproductive-aged women: A comparison between unconditional and conditional quantile regression

BACKGROUND AND AIMS

The coexistence of undernutrition and overnutrition creates a double burden of malnutrition (DBM) among women in Bangladesh. This study aimed to assess heterogeneous effects of sociodemographic factors on women's nutritional status using quantile regression (QR) models and to investigate the differences between the results of unconditional QR (UQR) and conditional QR (CQR) models.

METHODS

A sample of 17 285 nonpregnant women aged 15 to 49 years was extracted from the latest Bangladesh Demographic and Health Survey, 2017-2018. Women's nutritional status was determined using body mass index (BMI). The UQR and CQR were used to estimate the heterogeneous effects of sociodemographic factors on women's BMI.

RESULTS

Results show that the estimated effects of sociodemographic factors varied across the BMI distribution. For the same quantile, the effects differed between UQR and CQR. For instance, education was significantly positively associated with BMI. In UQR, secondary educated women achieved an increase of 0.996 and 1.720 in BMI at 10th and 90th quantiles, respectively, compared to noneducated women, whereas conditional effects were 1.336 and 1.492 at 10th and 90th quantiles, respectively, in CQR. These results also indicate secondary education appeared to have a lesser (or higher) impact in the lower (or upper) tail of BMI distribution, and unconditional and conditional effects for the same quantile varied notably. Other factors such as women's age, occupation, household wealth, number of children ever born and household size, religion, and place of residence were significantly associated with BMI and showed heterogeneous effects.

CONCLUSION

Overall, there is a need to focus on heterogeneous effects of factors on women's nutritional status. Patterns of unconditional heterogeneous effects would be more informative than conditional heterogeneous effects while studying factors' effects. These findings may aid in developing strategies targeting high-risk groups to combat the double burden of malnutrition.

Rural and Urban Correlates of Stunting Among Under-Five Children in Sierra Leone: A 2019 Nationwide Cross-Sectional Survey

Background

Undernutrition accounts for at least 50% of the annual global under-five mortality burden. Although disparities in the childhood stunting between urban and rural areas in Sierra Leone have been documented, information on factors associated with these differences is lacking. We aimed to determine rural-urban correlates of stunting among children under the age of 5 in Sierra Leone.

Methods

We analyzed data from 2019 Sierra Leone demographic and health survey (SLDHS) focusing on under-five children. We conducted multivariable logistic regression to examine rural-urban factors associated with childhood stunting.

Results

Prevalence of stunting was 31.6% (95% CI 29.8-33.2) in rural areas and 24.0% (95% CI 21.6-26.1) in urban areas. Within the rural areas, children of stunted mothers (aOR = 2.37; 95% CI 1.07-5.24, P < .05), younger mothers aged 15 to 19 years (aOR = 2.08; 95% CI 1.17-3.69, P < .05), uneducated mothers (aOR = 1.87; 95% CI 1.28-2.71, P < .01), as well as older children (24-59 months) (aOR = 1.83; 95% CI 1.48-2.27, P < .001), and boys (aOR = 1.37; 95% CI 1.12-1.66, P < .01) were more likely to be stunted compared to those of non-stunted, older, post-primary education mothers and those who were less than 24 months and girls respectively. While urban children whose fathers had lower education (aOR = 1.94; 95% CI 1.10-3.42, P < .05), whose mothers were more parous (para 2-4) (aOR = 1.74; 95% CI 1.03-2.95, P < .05), and boys (aOR = 1.48; 95% CI 1.06-2.08, P < .05) were more likely to be stunted compared to their counterparts with fathers that had tertiary education, mothers of low parity and girls, respectively.

Conclusions

Stunting is more prevalent in the rural areas compared to the urban areas. Sex of the child was the only significant factor in both rural and urban areas. Our study findings suggest that programs designed to reduce stunting should aim for integrated yet context specific interventions in rural and urban areas.

Individual- and community-level factors associated with underweight and overweight among women of reproductive age in Bangladesh: a multilevel analysis

The co-existence of under- and overweight at population level around the globe is well documented. However, this has yet to be explored using suitable statistical techniques in the context of Bangladesh. This study aimed to examine the prevalence and risk factors for being underweight and overweight or obese compared with normal weight in ever-married non-pregnant women aged 15-49 years in Bangladesh using data from the most recent Bangladesh Demographic and Health Survey conducted in 2014. Multilevel multinomial logistic regression (MLMLR) and quantile regression models were fitted to examine the associations of socioeconomic and individual-, household- and community-level factors on the nutritional status of women as measured by BMI. Overall, the prevalences of underweight, normal weight, overweight and obese women were 19%, 58%, 19% and 4%, respectively, in 2014. The MLMLR analysis revealed that women of young age, widowed/divorced/separated, having a larger family size and children aged ≤5 years in the household, currently amenorrhoeic and members of non-government organizations were at significantly increased risk of being underweight; those of older age, having higher parity, more educated, frequently watched TV and non-poor were more likely to be overweight or obese relative to normal BMI. Women from more affluent communities and urban areas were more likely to be overweight or obese relative to normal BMI than their counterparts from less-affluent and rural communities. Women's nutritional status was found to be heterogeneous across the regions of the country. The findings indicate that, along with individual-level factors, community-level characteristics are also important in explaining women's BMI in Bangladesh. The issue of under- and overweight or obesity among women in Bangladesh requires the immediate adoption of a public health policy for its mitigation. When developing intervention programmes, important determinants and uniform development of regions should be taken into consideration to combat the dual burden of under- and overweight among women in Bangladesh.

The "Double Burden of Malnutrition" in the Amazon: dietary change and drastic increases in obesity and anemia over 40 years among the Awajún

Undernutrition and overnutrition are interconnected. Yet few studies have examined the "double burden of malnutrition" (DBM) over time in indigenous communities. We investigated changes in the food systems and nutritional health of Awajún communities in the Peruvian Amazon in the 1970s and in 2013. Methods included ethnography, 24 hr food recalls, and biological measures. In 2013, the number of traditional foods consumed decreased to 10% of levels in the 1970s and the number of market foods consumed increased 40-fold. Rates of anemia and obesity were also substantially higher in 2013 compared to the 1970s (23% vs 6% for anemia and 30% vs. 0% for obesity) indicating a DBM has emerged. Examining the predictors of hemoglobin levels and body mass indices in the 2013 sample reveals that this DBM is differentially impacting women and that risk for obesity among the Awajún is associated with multiple proxies of market integration beyond just the consumption of market foods. These findings highlight the complex pathways by which rapid lifestyle changes are creating gendered health inequalities within indigenous communities over time.

The missing focus on women's health in the First 1,000 days approach to nutrition

The First 1,000 Days approach highlights the time between conception and a child’s second birthday as a critical period where adequate nutrition is essential for adequate development and growth throughout the child’s life and potentially onto their own offspring. Based on a review of relevant literature, this commentary explores the First 1,000 Days approach with a maternal lens. While the primary objective of the First 1,000 Days approach to nutrition is to reduce child malnutrition rates, particularly chronic undernutrition in the form of stunting, interventions are facilitated through mothers in terms of promoting healthy behaviours such as exclusive breast-feeding and attention to her nutritional status during pregnancy and lactation. Though these interventions were facilitated through women, women’s health indicators are rarely tracked and measured, which we argue represents a missed opportunity to strengthen the evidence base for associations between maternal nutrition and women’s health outcomes. Limited evidence on the effects of dietary interventions with pregnant and lactating mothers on women’s health outcomes hinders advocacy efforts, which then contributes to lower prioritisation and less research.

The Double Burden of Malnutrition: A Systematic Review of Operational Definitions

BACKGROUND

Despite increasing research on the double burden of malnutrition (DBM; i.e., coexisting over- and undernutrition), there is no global consensus on DBM definitions.

OBJECTIVES

To identify published operational DBM definitions, measure their frequency of use, and discuss implications for future assessment.

METHODS

Following a structured search of peer-reviewed articles with terms describing "overnutrition" [e.g., overweight/obesity (OW/OB)] and "undernutrition" (e.g., stunting, micronutrient deficiency), we screened 1920 abstracts, reviewed 500 full texts, and extracted 623 operational definitions from 239 eligible articles.

RESULTS

We organized three identified DBM dimensions (level of assessment, target population, and forms of malnutrition) into a framework for building operational DBM definitions. Frequently occurring definitions included coexisting: 1) OW/OB and thinness, wasting, or underweight (n = 289 occurrences); 2) OW/OB and stunting (n = 161); 3) OW/OB and anemia (n = 74); and 4) OW/OB and micronutrient deficiency (n = 73).

CONCLUSIONS

Existing DBM definitions vary widely. Putting structure to possible definitions may facilitate selection of fit-for-purpose indicators to meet public health priorities.

High double burden of child stunting and maternal overweight in the Republic of the Marshall Islands

Many low‐ and middle‐income countries are faced with a double burden of malnutrition characterized by a stagnating burden of undernutrition and an increasing prevalence of overweight and obesity often observed both at population and household levels. We used data from the 2017 National Integrated Child Health and Nutrition Survey in the Republic of the Marshall Islands to explore the prevalence of overweight mother‐stunted child pairs (mother–child double burden, MCDB). We used bivariate analysis, multivariate logistic regression, and multinomial logistic regression analysis to explore associations between child‐, maternal‐, and household‐level variables and both stunting and MCDB and other types of maternal–child pairs. Our results indicate that nearly three out of four mothers were overweight or obese and one in four households is home to an overweight mother with a stunted child. The risk of child stunting and of MCDB were largely associated with maternal characteristics of lower maternal height, maternal age at birth, years of education, and marital status and household economic status as measured by wealth index and number of household members. These findings support the growing body of evidence showing that the coexistence of high maternal overweight and child stunting (MCDB) has linked root causes to early life undernutrition that are exacerbated by the nutrition transition.

The double burden of under- and overnutrition among Bangladeshi women: Socioeconomic and community-level inequalities

BACKGROUND

The prevalence of overweightness in Bangladesh is increasing, while underweightness also continues to persist. A better understanding of the patterns and socioeconomic risk factors of both conditions, particularly among women, is critical in order to promote the development of interventions to improve maternal health in Bangladesh. This study therefore sought to assess the patterns of under- and overweightness between 2004 and 2014 and to examine the predictors of individual and community-level inequalities of under- and overnutrition in Bangladesh.

METHODS

Cross-sectional data of 10, 431, and 16,478 ever-married nonpregnant women aged between 15 and 49 years who did not give birth in the two months preceding the survey were extracted from the 2004 and 2014 Bangladesh Demographic and Health Surveys, respectively. Body mass index was used to measure weight status, and underweightness, at-risk for overweightness, overweightness, and obesity were the main outcome variables. Patterns of nutritional change over time was examined by considering the annual average rate of change. Multilevel multinomial logistic regression and quantile regression were used to identify the inequalities.

RESULTS

In 2014, the age-adjusted prevalence values of underweightness, at-risk for overweightness, overweightness, and obesity were 19.7%, 14.9%, 18.1% and 4.0%, respectively. A higher average annual rate of reduction of underweightness was found among wealthier, highly educated, and wealthier community-living women, while a rate of increase of overweightness was found among poorer, uneducated, and poor community-living women. Individual and community-level inequalities of malnutrition were observed among these populations. In comparison with women living in low wealth communities, women from wealthier communities were at an increased risk of being at-risk for overweightness [adjusted odds ratio (AOR): 1.53, 95% confidence interval (CI): 1.23-1.91], overweight (AOR: 1.60, 95% CI: 1.27-2.00), and obese (AOR: 2.12, 95% CI: 1.42-3.18).

CONCLUSIONS

This study suggests the coexistence of a double burden of under- and overnutrition in Bangladesh and that the prevalence of overweightness surpasses that of underweightness. The burdens of under- and overnutrition are strongly associated with women's individual socioeconomic positions and the nature of the community in which they live.

Correlates of the double burden of malnutrition among women: an analysis of cross sectional survey data from sub-Saharan Africa

OBJECTIVE

To investigate the correlates of the double burden of malnutrition (DBM) among women in five sub-Saharan African countries.

DESIGN

Secondary analysis of Demographic and Health Surveys (DHS). The outcome variable was body mass index (BMI), a measure of DBM. The BMI was classified into underweight (BMI <18.50 kg/m²), normal weight (18.50-24.99 kg/m²), overweight (25.0-29.9 kg/m²) and obesity (≥30.0 kg/m²).

SETTINGS

Ghana, Nigeria, Kenya, Mozambique and Democratic Republic of Congo (DRC).

SUBJECTS

Women aged 15-49 years (n=64698).

RESULTS

Compared with normal weight women, number of years of formal education was associated with the likelihood of being overweight and obese in Ghana, Mozambique and Nigeria, while associated with the likelihood of being underweight in Kenya and Nigeria. Older age was associated with the likelihood of being underweight, overweight and obese in all countries. Positive associations were also observed between living in better-off households and overweight and obesity, while a negative association was observed for underweight. Breastfeeding was associated with less likelihood of underweight in DRC and Nigeria, obesity in DRC and Ghana, overweight in Kenya and overweight and obesity in Mozambique and Nigeria relative to normal weight.

CONCLUSIONS

Our analysis reveals that in all the countries, women who are breastfeeding are less likely to be underweight, overweight and obese. Education, age and household wealth index tend to associate with a higher likelihood of DBM among women. Interventions to address DBM should take into account the variations in the effects of these correlates.

Nicotinamide and Demographic and Disease transitions: Moderation is Best

Good health and rapid progress depend on an optimal dose of nicotinamide. Too little meat triggers the neurodegenerative condition pellagra and tolerance of symbionts such as tuberculosis (TB), risking dysbioses and impaired resistance to acute infections. Nicotinamide deficiency is an overlooked diagnosis in poor cereal-dependant economies masquerading as 'environmental enteropathy' or physical and cognitive stunting. Too much meat (and supplements) may precipitate immune intolerance and autoimmune and allergic disease, with relative infertility and longevity, via the tryptophan-nicotinamide pathway. This switch favours a dearth of regulatory T (Treg) and an excess of T helper cells. High nicotinamide intake is implicated in cancer and Parkinson's disease. Pro-fertility genes, evolved to counteract high-nicotinamide-induced infertility, may now be risk factors for degenerative disease. Moderation of the dose of nicotinamide could prevent some common diseases and personalised doses at times of stress or, depending on genetic background or age, may treat some other conditions.

[Coexistence of maternal overweight or obesity and stunted children in south-western Benin households]

INTRODUCTION

To determine the prevalence and determinants of coexistence of maternal overweight or obesity and stunted children (DBM / SCOM) in south-western Benin households.

METHODS

This cross-sectional study was carried out in June 2015 on 357 mother-child pairs randomly selected by a two-stage sampling technique in the city of Comè and its surroundings. Data on socio-economic factors, family, health care, dietary quality were collected by questionnaires, observation and documentary review. Anthropometric measurements were performed in mothers and children. A logistic regression analysis model was used to search for determinants of the coexistence of the two aspects of malnutrition.

RESULTS

19.3% of mothers were overweight and 5.7% were obese. 46% of children were stunted. The prevalence of DBM / SCOM was 11.5%. The main factors associated with DBM/SCOM were the child's age, the mother's occupation, ethnicity, social status and educational level, and the size, economic level, transportation means and food insecurity of the household.

CONCLUSION

A high frequency of the coexistence of maternal overweight or obesity and stunting was observed in Comè households. Interventions based on the identified determinants are needed to act simultaneously on the double burden of malnutrition in Comè.

Subclinical inflammation affects iron and vitamin A but not zinc status assessment in Senegalese children and Cambodian children and women

OBJECTIVE

To assess the impact of the acute-phase response (APR) during inflammation on Fe, Zn and vitamin A biomarkers to allow accurate evaluation of micronutrient status in populations.

DESIGN

Ferritin (FER), soluble transferrin receptor (TfR), retinol-binding protein (RBP), Zn, α1-acid glycoprotein and C-reactive protein concentrations were measured. Correction factors (CF) for each biomarker were calculated as the ratio for groups at different stages of inflammation v. the reference group without inflammation.Setting/SubjectsSenegalese (n 594) and Cambodian schoolchildren (n 2471); Cambodian women of reproductive age (n 2117).

RESULTS

TfR was higher during the incubation phase (CF=1·17) and lower during early and late convalescence (CF=0·87 and 0·78). FER was higher during all phases (CF=0·83, 0·48 and 0·65, respectively). RBP was higher during incubation (CF=0·88) and lower during early convalescence (CF=1·21). No effect of inflammation on Zn status was found.

CONCLUSIONS

Inflammation led to overestimation of Fe status and underestimation of vitamin A status. The response of the biomarker for vitamin A status to inflammation depended on the vitamin A status of the populations. Surprisingly, the assessment of Zn status was hardly affected by inflammation. Different phases of the APR had opposite effects on the assessment of Fe status using TfR. More research is needed to define the correct methods to adjust for inflammation in nutritional studies.

[How to intervene and prevent stunting of children from homes belonging to the Sisbén in Caldas]

INTRODUCTION

Growth retardation or chronic malnutrition (low height for age) indicates a failure in the natural genetic potential that allows us to growth.

OBJECTIVE

To estimate predictive models of growth retardation in households with children younger than five years in the department of Caldas and registered in the identification system of potential beneficiaries of social programs (Sistema de Identificación de Potenciales Beneficiarios de Programas Sociales, Sisbén).

MATERIALS AND METHODS

We conducted an analytical study in all households (N=56,987) included in the Sisbén III database with the presence of children younger than five years (N=33,244). The variables under study were demographic and socioeconomic characteristics, health service access, housing, poverty, education, job market, and growth retardation. The multivariate analysis was done in two phases: first, an exploratory analysis of households using hierarchical classification (cluster), then estimation of a nonlinear predictive model (probit) with growth retardation as the dependent variable.

RESULTS

The largest proportion of growth retardation in children younger than five years was found in southcentral Caldas, in urban centers, and households with monthly income lower than USD$ 65.

CONCLUSION

Poverty in Caldas women-headed households with children younger than five years registered in the Sisbén was the main predictor of growth retardation.

Iron retention in iron-fortified rice and use of iron-fortified rice to treat women with iron deficiency: A pilot study

Objectives

1. Evaluate the effect of washing and cooking iron-fortified rice on iron retention and bioavailability. 2. Evaluate the effect of iron-fortified rice on women with iron deficiency anemia

Methods

1. Iron-fortified rice (18 mg/100 g as FeSO₄) was cooked in Baton Rouge, Louisiana (C), rinsed and cooked (RC), fried and cooked (FC), cooked with extra water (CW), or soaked and cooked with extra water (SCW), and iron retention was determined. 2. Rice samples were cooked in Kampala, Uganda in a lab (C-Uganda) and households using traditional cooking method (TC-Uganda) and iron retention were determined. 3. Seventeen women with iron deficiency (low iron and/or low ferritin) anemia were randomized to 100 g/d of rice (two cooked 0.75 cup servings) for two weeks containing 18 mg/d iron (supplemented) or 0.5 mg/d iron (un-supplemented). Hemoglobin and hematocrit were evaluated at baseline and 2 weeks with other measures of iron metabolism.

Results

1. Iron retention, from highest to lowest, was (C), (RC), (FC), (C-Uganda), (CW), (SCW) and (TC-Uganda). 2. Seventeen women were randomized and 15 completed the study (hemoglobin 10.6 ± 1.6 g, hematocrit 33.7 ± 4.1%), 9 in the iron-fortified rice group and 6 in the un-fortified rice group. The iron-fortified group had a greater increase in hemoglobin (0.82 g, p = 0.0035) and Hematocrit (1.83%, p = 0.0248) with directional differences in other measures of iron metabolism favoring the iron-fortified group.

Conclusions

Iron-fortified rice increased hemoglobin and hematocrit in women with iron-deficient anemia. Iron deficiency and anemia are widespread in Southeast Asia and Africa and undermine development in these regions.

•

Iron deficiency is prevalent engendering poor health and cognitive development.

•

Iron deficiency can be treated effectively with iron fortification.

•

Iron rinses in a rice-based diet have leached reducing fortification.

•

An iron rinse resistant leaching during cooking is described.

•

The leach-resistant iron rinse improved iron deficiency anemia in a clinical trial.

Inventory on the dietary assessment tools available and needed in africa: a prerequisite for setting up a common methodological research infrastructure for nutritional surveillance, research, and prevention of diet-related non-communicable diseases

OBJECTIVE

To carry out an inventory on the availability, challenges, and needs of dietary assessment (DA) methods in Africa as a pre-requisite to provide evidence, and set directions (strategies) for implementing common dietary methods and support web-research infrastructure across countries.

METHODS

The inventory was performed within the framework of the "Africa's Study on Physical Activity and Dietary Assessment Methods" (AS-PADAM) project. It involves international institutional and African networks. An inventory questionnaire was developed and disseminated through the networks. Eighteen countries responded to the dietary inventory questionnaire.

RESULTS

Various DA tools were reported in Africa; 24-Hour Dietary Recall and Food Frequency Questionnaire were the most commonly used tools. Few tools were validated and tested for reliability. Face-to-face interview was the common method of administration. No computerized software or other new (web) technologies were reported. No tools were standardized across countries.

CONCLUSIONS

The lack of comparable DA methods across represented countries is a major obstacle to implement comprehensive and joint nutrition-related programmes for surveillance, programme evaluation, research, and prevention. There is a need to develop new or adapt existing DA methods across countries by employing related research infrastructure that has been validated and standardized in other settings, with the view to standardizing methods for wider use.

A systematic review of the prevalence and predictors of the double burden of malnutrition within households

Recently, increasing attention has been paid to the emergence of the double burden of malnutrition within households. We provide an overview of the literature regarding this phenomenon by reviewing previous studies of the prevalence of double-burden households and associated factors together with the research methods used. Studies were identified from the electronic databases PubMed and Web of Science, using the same search terms for both. A total of thirty-five articles met the eligibility criteria, and 367 sets of prevalence data were extracted. In all, thirty-four articles were published in 2000 or later; twenty-four used secondary data and twenty-five focused on mother-child pairs. The ages of children varied from 0 to 19 years. All the studies used BMI as a nutritional indicator for adults. For children, height-for-age was most frequently used, whereas weight-for-age, weight-for-height and BMI-for-age were also used in multiple studies. The reported national prevalence of double-burden households varied from 0·0 to 26·8 % by country and year; however, few studies were directly comparable, because of differences in the combinations of undernourished and overweight persons, age ranges, nutritional indicators and cut-off points. Whereas many focused on African countries, a few involved Asian countries. Although urban residence, income and education were frequently assessed, the role of intermediate factors in nutritional status, such as diet and physical activity, remains unclear. It is recommended that future studies use comparable indicators and cut-off points, involve Asian countries, and investigate individual diet and physical activity.

A human rights approach to the health implications of food and nutrition insecurity

Food and nutrition insecurity continues to pose a serious global challenge, reflecting government shortcomings in meeting international obligations to ensure the availability, accessibility, and quality of food and to ensure the highest attainable standard of health of their peoples. With global drivers like climate change, urbanization, greater armed conflict, and the globalization of unhealthy diet, particularly in under-resourced countries, food insecurity is rapidly becoming an even greater challenge for those living in poverty. International human rights law can serve a critical role in guiding governments that are struggling to protect the health of their populations, particularly among the most susceptible groups, in responding to food and nutrition insecurity. This article explores and advocates for a human rights approach to food and nutrition security, specifically identifying legal mechanisms to "domesticate" relevant international human rights standards through national policy. Recognizing nutrition security as a determinant of public health, this article recognizes the important links between the four main elements of food security (i.e., availability, stability, utilization, and access) and the normative attributes of the right to health and the right to food (i.e., availability, accessibility, affordability, and quality). In drawing from the evolution of international human rights instruments, official documents issued by international human rights treaty bodies, as well as past scholarship at the intersection of the right to health and right to food, this article interprets and articulates the intersectional rights-based obligations of national governments in the face of food and nutrition insecurity.

Height, BMI, and relative economic standing in children from developing countries

OBJECTIVES

The purpose of this study was to estimate a height-BMI association in child and female adolescent populations in developing countries, and to evaluate the potential role of relative economic status in this association.

METHODS

Flexible structured additive regression models were used to estimate associations between height, BMI, and relative wealth. Linear regression models were used to evaluate height-wealth interactions on BMI outcomes. The models were applied to pooled samples of 971,180 children under 5 years of age and 225,718 adolescent females between 15 and 19 years. Samples were taken from Demographic and Health Surveys from 64 developing countries.

RESULTS

Children exhibited a strong inverse association between height and BMI over the entire distribution of height. Female adolescents showed a weak inverse association. Relative economic status was associated with a stronger height-BMI relationship in early-life (<3 years) and a weaker relationship as children age into their fifth year.

CONCLUSIONS

Relative economic status may protect against consequences of a negative height-BMI association in young children in developing countries, first by promoting higher body weight among shorter children during the risk period for early-life mortality, and afterwards by limiting body weight in shorter children when overweight and obesity become longer-term health issues.

Examining Nutritional Adequacy and Dietary Diversity Among Women in Niger

Objective The purpose of this study was to examine the nutritional adequacy and dietary composition among women residing in Zinder and Maradi of Niger, and the factors that affect the variety of their dietary intake. Methods Data from 3360 women of ages 15-49 were used in the analysis. The variable of interest was the Women Dietary Diversity Score (WDDS), which is the simple sum of scores of the 9 categorized food groups, ranging from 0 to 9. Lower values for WDDS indicate nutritionally inadequate dietary diversity. Analysis included descriptive, Mann-Whitney U test and linear regression. Results The majority of the participants were residing in the Maradi Region (56.7%) and were living in households with both male and female adults (94.9%). The mean WDDS was 3.5 in Zinder compared to 2.5 in Maradi (p < .05). The most frequently consumed food items in both Zinder and Maradi were starchy staple food (98.3%). Region of residence was one of the strong predictor of WDDS. A total number of farmers in the household and Household Dietary Diversity Score (HDDS) had positive and significant effects on WDDS whereas Household Hunger Scale (HHS) had a negative and significant effect on WDDS. Conclusion Niger has one of the highest concentrations of malnutrition in the world. In 2012, approximately 2.5 million Nigeriens were affected by malnutrition. Our study results reinforce the importance to conduct more studies that examine the nutritional intake of women in Niger.

Maternal and early life nutrition and physical activity: setting the research and intervention agenda for addressing the double burden of malnutrition in South African children

Early life is important for later health outcomes, yet there are few studies which adequately address all of the potential early life insults that may affect later life health and growth trajectories. This is particularly evident in low- to middle-income countries such as South Africa, where women of childbearing age are particularly vulnerable to high levels of physical inactivity, malnutrition, and obesity. Pregnancy may therefore be an opportune time to change behaviours and improve maternal and offspring health outcomes, and decrease the inter-generational transfer of risk. We show clear evidence that physical activity and nutrition are important target areas for intervention during pregnancy and in the early years of life, yet that current literature in Africa, and specifically South Africa, is limited. We have outlined the available literature concerning the impact of maternal and early life nutrition and physical activity on the health status of South African children, and have provided some recommendations for future research and policy.

Gender inequalities in excess adiposity and anaemia combine in a large double burden of malnutrition gap detrimental to women in an urban area in North Africa

OBJECTIVE

The nutrition transition has exacerbated the gender gap in health in the Middle East and North Africa region as the increase in excess adiposity has been much higher among women than men. This is not exclusive of the persistence of anaemia, generally also more prevalent among women. We assessed the magnitude and sociodemographic factors associated with gender inequality vis-à-vis the double burden of excess adiposity and anaemia.

DESIGN

Cross-sectional study, stratified two-stage cluster sample. BMI (=weight/height2) ≥25·0 kg/m2 defined overweight and BMI≥30·0 kg/m2 obesity. Anaemia was defined as Hb <120 g/l for women, <130 g/l for men. Gender inequalities vis-à-vis the within-subject coexistence of excess adiposity and anaemia were assessed by women v. men relative prevalence ratios (RPR). Their variation with sociodemographic characteristics used models including gender × covariate interactions.

SETTING

Greater Tunis area in 2009-2010.

SUBJECTS

Adults aged 20-49 years (women, n 1689; men, n 930).

RESULTS

Gender inequalities in excess adiposity were high (e.g. overweight: women 64·9 % v. men 48·4 %; RPR=2·1; 95 % CI 1·6, 2·7) and much higher for anaemia (women 38·0 % v. men 7·2 %; RPR=8·2; 95 % CI 5·5, 12·4). They were striking for overweight and anaemia (women 24·1 % v. men 3·4 %; RPR=16·2; 95 % CI 10·3, 25·4). Gender inequalities in overweight adjusted for covariates increased with age but decreased with professional activity and household wealth score; gender inequality in anaemia or overweight and anaemia was more uniformly distributed.

CONCLUSIONS

Women were much more at risk than men, from both over- and undernutrition perspectives. Both the underlying gender-related and sex-linked biological determinants of this remarkable double burden of malnutrition inequality must be addressed to promote gender equity in health.

The double burden of malnutrition in Indonesia: Social determinants and geographical variations

The presence of simultaneous under- and over-nutrition has been widely documented in low- and middle-income countries, but global nutritional research has seen only a few large-scale population studies from Indonesia. We investigate the social determinants as well as the geographical variations of under- and over-nutrition in Indonesia using the largest public health study ever conducted in the country, the National Basic Health Research 2007 (N=645,032). Multilevel multinomial logistic regression and quantile regression models are fitted to estimate the association between nutritional status and a number of socio-economic indicators at both the individual and district levels. We find that: (1) education and income reduce the odds of being underweight by 10-30% but at the same time increase those of overweight by 10-40%; (2) independent from the compositional effect of poverty, income inequality is detrimental to population health: a 0.1 increase in the Gini coefficient is associated with an 8-12% increase in the odds of an individual׳s being both under- and overweight; and (3) the effects that these determinants have upon nutritional status are not necessarily homogeneous along the continuum of body mass index. Equally important, our analysis reveals that there is substantial spatial clustering of areas with elevated risk of under- or over-nutrition across the 17,000-island archipelago. As of 2007, under-nutrition in Indonesia remains a 'disease of poverty', while over-nutrition is one of affluence. The income inequality accompanying Indonesia׳s economic growth may aggravate the dual burden of under- and over-nutrition. A more equitable economic policy and a policy that improves living standards may be effective for addressing the double burden.

Nutritional status of toddlers and preschoolers according to household income level: overweight tendency and micronutrient deficiencies

BACKGROUNDS/OBJECTIVES

The effects of malnutrition on growth of toddlers and preschoolers by socioeconomic status are not well known. This study aimed to examine the effects of dietary intake on growth outcomes in toddlers and preschoolers by household income level.

SUBJECTS/METHODS

The study population was a total of 1,687 children aged 1 to 5 years that participated in the KNHANES from 2009 to 2011. Growth of children was assessed by height for age (HFA) and weight for height (WFH). Children were classified into three groups according to children's HFA and WFH compared to the 10^th and 90^th percentiles of the 2007 Korean Children and Adolescent Growth Standard. Average monthly household income was divided into quartile groups. Dietary intake data were obtained by using the one day 24-hr recall method. Risks of inadequate intake of nutrients and unfavorable growth were estimated by using a multiple logistic regression model adjusted for sex, age, region, and energy intake.

RESULTS

The low HFA group (< 10^th percentile) had significantly lower intakes of energy, carbohydrate, and thiamin as compared with the high group (≥ 90^th percentile). For WFH status, vitamin C intake was lower in the low group than in the high group. Household income level was related to WFH status but not HFA. Children from lower income households were more likely to have high WFH than those from higher income households (P for trend = 0.038). Household income status was also significantly related with risk of inadequate intake of micronutrients such as thiamin (P for trend = 0.032) and vitamin C (P for trend = 0.002), showing higher odds of inadequate intakes in children from lower income households.

CONCLUSIONS

Children from lower income households were prone to be overweight and to have inadequate intakes of micronutrients such as thiamin and vitamin C. To reduce nutritional and health disparities, collective action in the public sector is required from early life.

The double burden of malnutrition in indigenous and nonindigenous Guatemalan populations

BACKGROUND

As the prevalence of obesity increases in developing countries, the double burden of malnutrition (DBM) has become a public health problem, particularly in countries such as Guatemala with a high concentration of indigenous communities where the prevalence of stunting remains high.

OBJECTIVE

The aim was to describe and analyze the prevalence of DBM over time (1998-2008) in indigenous and nonindigenous Guatemalan populations.

DESIGN

We used 3 National Maternal and Child Health Surveys conducted in Guatemala between 1998 and 2008 that include anthropometric data from children aged 0-60 mo and women of reproductive age (15-49 y). We assessed the prevalence of childhood stunting and both child and adult female overweight and obesity between 1998 and 2008. For the year 2008, we assessed the prevalence of DBM at the household (a stunted child and an overweight mother) and individual (stunting/short stature and overweight or anemia and overweight in the same individual) levels and compared the expected and observed prevalence rates to test if the coexistence of the DBM conditions corresponded to expected values.

RESULTS

Between 1998 and 2008, the prevalence of childhood stunting decreased in both indigenous and nonindigenous populations, whereas overweight and obesity in women increased faster in indigenous populations than in nonindigenous populations (0.91% compared with 0.38%/y; P-trend < 0.01). In 2008, the prevalence of stunted children was 28.8 percentage points higher and of overweight women 4.6 percentage points lower in indigenous compared with nonindigenous populations (63.7% compared with 34.9% and 46.7% compared with 51.3%, respectively). DBM at the household and individual levels was higher in indigenous populations and was higher in geographic areas in which most of the population was indigenous, where there was also a greater prevalence of stunting and DBM at the individual level, both in women and children.

CONCLUSIONS

In Guatemala, DBM is more prevalent in indigenous than in nonindigenous populations at the household and individual levels. To enhance effectiveness, current strategies of national policies and programs should consider DBM and focus on indigenous populations.

Dietary patterns and physical inactivity, two contributing factors to the double burden of malnutrition among adults in Burkina Faso, West Africa

A population-based cross-sectional study was carried out in the northern neighbourhoods of Ouagadougou (Burkina Faso), to examine the relationship of nutritional deficiencies and cardiometabolic risk factors (CMRF) with lifestyle in adults. We randomly selected 330 households stratified by income tertile. In each income stratum, 110 individuals aged 25-60 years and having lived in Ouagadougou for at least 6 months were randomly selected. We performed anthropometric, dietary intake and physical activity measurements, and blood sample collection. Cluster analysis of dietary intake identified two dietary patterns: 'urban' (29 % of subjects) and 'traditional' (71 %). The 'urban' cluster exhibited a higher intake of fat and sugar, whereas a higher intake of plant protein, complex carbohydrate and fibre was observed in the 'traditional' pattern. Female sex, low income and lack of education were associated with the 'traditional' cluster, as well as Fe and vitamin A deficiency. CMRF prevalence (abdominal obesity, hypertension, hyperglycaemia, dyslipidaemia) was similar in both clusters. Subjects in the 'traditional' cluster spent more time in physical activity and had less sedentary time than those in the 'urban' cluster. 'Traditional' dietary pattern, low income, female sex and sedentary time were significant contributing factors to the double burden of malnutrition. The rapid nutrition transition is reflected in this co-occurrence of CMRF and nutritional deficiencies. This stresses the need for prevention strategies addressing both ends of the nutrition spectrum.

Contribution to the development of a food guide in Benin: linear programming for the optimization of local diets

OBJECTIVE

Food guides are important tools for nutrition education. While developing a food guide in Benin, the objective was to determine the daily number of servings per food group and the portion sizes of common foods to be recommended.

DESIGN

Linear programming (LP) was used to determine, for each predefined food group, the optimal number and size of servings of commonly consumed foods. Two types of constraints were introduced into the LP models: (i) WHO/FAO Recommended Nutrient Intakes and dietary guidelines for the prevention of chronic diseases; and (ii) dietary patterns based on local food consumption data recently collected in southern Benin in 541 adults. Dietary intakes of the upper tertile of participants for diet quality based on prevention and micronutrient adequacy scores were used in the LP algorithms.

SETTING

Southern area of the Republic of Benin.

SUBJECTS

Local key-players in nutrition (n 30) from the government, academic institutions, international organizations and civil society were partners in the development of the food guide directed at the population.

RESULTS

The number of servings per food group and the portion size for eight age-sex groups were determined. For four limiting micronutrients (Fe, Ca, folate and Zn), local diets could be optimized to meet only 70 % of the Recommended Nutrient Intakes, not 100 %.

CONCLUSIONS

It was possible to determine the daily number of servings and the portion sizes of common foods that can be recommended in Benin with the help of LP to optimize local diets, although Recommended Nutrient Intakes were not fully met for a few critical micronutrients.

A review on the genetic, environmental, and lifestyle aspects of the early-life origins of cardiovascular disease

This article is a comprehensive review on developmental origins of health and disease regarding various factors related to the origins of cardiovascular diseases from early life. It presents a summary of the impacts of various factors such as epigenetics; gene-environment interaction; ethnic predisposition to cardiovascular diseases and their underlying risk factors; prenatal factors; fetal programming; maternal weight status and weight gain during pregnancy; type of feeding during infancy; growth pattern during childhood; obesity; stunting; socioeconomic status; dietary and physical activity habits; active, secondhand, and thirdhand smoking, as well as environmental factors including air pollution and global climate change on the development and progress of cardiovascular diseases and their risk factors. The importance of early identification of predisposing factors for cardiovascular diseases for primordial and primary prevention of cardiovascular diseases from early life is highlighted.

Dual burden of body weight among Iranian children and adolescents in 2003 and 2010: the CASPIAN-III study

INTRODUCTION

Our aim was to compare changes of body mass index (BMI) and waist circumference (WC) curves of Iranian children by comparing the results of two national surveys of a surveillance program, i.e. CASPIAN-I (2003-2004) and CASPIAN-III (2009-2010). The second objective was to evaluate the prevalence of obesity, overweight and underweight among 10-18-year-old Iranian children and adolescents.

MATERIAL AND METHODS

This study was performed among students who were selected by multistage random cluster sampling from urban and rural areas of 27 provinces of Iran, as part of a national survey of school student high risk behavior entitled CASPIAN-III, conducted in 2009-2010.

RESULTS

We evaluated 5088 school students (50.2% boys). In rural areas, underweight was more common in boys and overweight and obesity in girls. In urban areas underweight and obesity were more common in boys, whereas overweight was more common in girls. The highest prevalence of underweight (23.5%) was seen in students aged 13 years and the lowest (11.4%) in those aged 18 years. Underweight was significantly more common in rural than in urban areas (22.1% vs. 15.8%, respectively, p < 0.0001) and overweight/obesity was more common in urban than in rural areas. Compared with the findings in 2003-2004, the overall prevalence of elevated body mass index (16.6%) including obesity (9.1%) and overweight (7.5%) as well as underweight (17.5%) increased from 2003 to 2010.

CONCLUSIONS

In recent years, the double burden of nutritional disorders has increased among Iranian children and adolescents, especially in rural areas. This change may be related to epidemiologic transition, notably in terms of nutrition transition and rapid changes in lifestyle habits. This finding is an important issue for policy-makers for interventional preventive programs.

A double burden of overall or central adiposity and anemia or iron deficiency is prevalent but with little socioeconomic patterning among Moroccan and Tunisian urban women

In North Africa, overnutrition has dramatically increased with the nutrition transition while micronutrient deficiencies persist, resulting in clustering of opposite types of malnutrition that can present a unique difficulty for public health interventions. We assessed the magnitude of the double burden of malnutrition among urban Moroccan and Tunisian women, as defined by the coexistence of overall or central adiposity and anemia or iron deficiency (ID), and explored the sociodemographic patterning of individual double burden. In cross-sectional surveys representative of the region around the capital city, we randomly selected 811 and 1689 nonpregnant women aged 20-49 y in Morocco and Tunisia, respectively. Four double burdens were analyzed: overweight (body mass index ≥25 kg/m(2)) or increased risk abdominal obesity (waist circumference ≥80 cm) and anemia (blood hemoglobin <120 g/L) or ID (C-reactive protein-corrected serum ferritin <15 μg/L). Adjusted associations with 9 sociodemographic factors were estimated by logistic regression. The prevalence of overweight and ID was 67.0% and 45.2% in Morocco, respectively, and 69.5% and 27.0% in Tunisia, respectively, illustrating the population-level double burden. The coexistence of overall or central adiposity with ID was found in 29.8% and 30.1% of women in Morocco, respectively, and in 18.2% and 18.3% of women in Tunisia, respectively, quite evenly distributed across age, economic, or education groups. Generally, the rare, associated sociodemographic factors varied across the 4 subject-level double burdens and the 2 countries and differed from those usually associated with adiposity, anemia, or ID. Any double burden combining adiposity and anemia or ID should therefore be taken into consideration in all women. This trial was registered at clinicaltrials.gov as NCT01844349.

A narrative review of recent progress in understanding the relationship between tuberculosis and protein energy malnutrition

Protein energy malnutrition (PEM) and tuberculosis (TB) are the major public health issues, particularly in the developing country setting. Malnutrition is an underlying cause of many deaths and when left untreated devastates normal physical and cognitive development. TB continues to gather momentum as a serious infectious killer. They have both rightly been highlighted as important global health issues by their inclusion in the Millennium Development Goals. But what is known of their relationship with one another? It is historically accepted that PEM and TB have a synergistic relationship adversely having an impact on one another. However, researchers have sought to apply this understanding in an examination of the relationship between TB and PEM with often inconclusive results. This narrative review of recently published research and current knowledge may help delineate the association between PEM and TB mortality. Such results will assist future research in this important area of health--an area lacking evidence-based guidance.

Socioeconomic status, body mass index and prevalence of underweight and overweight among Polish girls aged 7-18: a longitudinal study

The aim of this paper was to establish whether the influence of socioeconomic factors on BMI and the prevalence of underweight and overweight changes with age. The data were obtained from 1008 schoolgirls aged 16-18 years for whom earlier data on weight and height were available. Their height and body mass were measured and their BMIs calculated. Height and weight in early life were assessed by medical records review. The girls were measured by trained school nurses at 7, 9, 14 years of age. Socioeconomic differences in BMI were found to increase with age. Parents' higher education and urban environment were associated with smaller BMI gain between the ages of 7 and 18 years. Among subjects whose mother and/or father had higher education the prevalence of underweight increased with age, and in other groups it remained at a similar level. In the younger age categories (7- and 9-year-olds) underweight was less frequent in subjects from towns than those from rural areas, while in the older categories (14, 16-18 years of age) the opposite tendency was found. As subjects grew up, there was a decline in the prevalence of overweight and obesity in all groups. Parental education and place of residence seem to influence weight status in a different way in childhood than during adolescence.