Trade policy reform, retail food prices and access to healthy diets worldwide

Recent use of least-cost diets as a measure of global food security revealed that over 3 billion people are unable to afford sufficient nutritious food for an active and healthy life, driving demand for policy changes to improve access and affordability. This study quantifies the role of imports in consumer prices, matching retail prices in 144 countries to imports by origin of the item or its main ingredient, resulting in a total of 13,846 pairs of a retail price and its import cost in 2017. We find that 55% of retail items had some active imports supplementing domestic production, and of those around 48% have nonzero tariffs whose average effective rate is around 6.7% of the imported commodity price. Over all countries for which data are available, the share of consumer prices for least-cost healthy diets that is attributable to tariffs and non-tariff measures averages 0.67% and 2.45% globally. The highest restrictions are on nutrient-rich vegetables, fruits and animal-sourced foods. Access to bulk commodities from diverse origins is essential for food and nutrition security, providing a greater diversity of foods and food ingredients at lower and more stable prices than can be grown at any one location. On average over all food products that are imported, 83% of the retail price is domestic value added after arrival. We conclude that food imports are best understood as inputs to the domestic production and distribution of retail items, with consumer prices and growth of the food sector dependent on the cost levels, infrastructure and institutions underlying each product's entire value chain.

Peak timing of slowest growth velocity among young children coincides with highest ambient temperatures in Burkina Faso: a longitudinal study

BACKGROUND

Seasonal cycles in climatic factors affect drivers of child growth and contribute to seasonal fluctuations in undernutrition. Current growth seasonality models are limited by categorical definitions of seasons that rely on assumptions about their timing and fail to consider their magnitude.

OBJECTIVE

We disentangle the relationship between climatic factors and growth indicators, using harmonic regression to determine how child growth is related to peaks in temperature, precipitation, and vegetation.

METHODS

Longitudinal anthropometric data collected between August 2014 and December 2016 from 5039 Burkinabè children measured monthly from age 6 to 28 mo (108,580 observations) were linked with remotely sensed daily precipitation, vegetation, and maximum air temperature. Our models parsimoniously extract a cyclic signal with multiple potential peaks, to compare the magnitude and timing of seasonal peaks in climatic factors and morbidity with that of nadirs in growth velocity (cm/mo, kg/mo).

RESULTS

Length and weight velocity were slowest twice a year, coinciding both times with the highest temperatures, and peak fever incidence. Length velocity is slowest 13 d after the first temperature peak in April, and 5 d after the second. Similarly, weight velocity is slowest 13 d before the first temperature peak, and 11 d before the second. The statistical relationship between temperature and anthropometry shows that when the current temperature is higher, weight velocity is lower (β = -0.0048; 95% CI: -0.0059, -0.0038), and length velocity is higher (β = 0.0088; 95% CI: 0.0070, 0.0105).

CONCLUSIONS

Results suggest that child health and development are more affected by high temperatures than by other aspects of climatic seasonality such as rainfall. Emerging shifts in climatic conditions will pose challenges to optimal growth, highlighting the importance of changes that optimize the timing of nutrition interventions and address environmental growth-limiting conditions.

CLINICAL TRIAL REGISTRY

Clinicaltrials.gov: NCT02071563.

COVID-19 mobility restrictions and stay-at-home behaviour in 2020 were associated with higher retail food prices worldwide

COVID-19 policy responses have included mobility restrictions, and many people have chosen to stay at home to avoid exposure. These actions have ambiguous impacts on food prices, lowering demand for food away from home and perishables, while increasing supply costs for items where workers are most affected by the pandemic. We use evidence from 160 countries to identify the net direction and magnitude of association between countries' real cost of all food and mobility restriction stringency. We investigate the deviation of each month's price level in 2020 from that month's average price level during the previous three years and find that an increase in mobility restriction stringency from no restrictions to most restrictive is associated with an increase in the real cost of all food of more than one percentage point across all models. We then examine the relationship between retail food price levels by food group and stay-at-home behaviour around markets in 36 countries and find positive associations for non-perishables, dairy and eggs.

Beyond the Food Systems Summit: Linking Recommendations to Action-The True Cost of Food

A transformation of food systems is needed to achieve the 17 Sustainable Development Goals specified in the 2030 Agenda for Sustainable Development. Recognizing the true costs and benefits of food production and consumption can help guide public policy decisions to effectively transform food systems in support of sustainable healthy diets. A new, expanded framework is presented that allows the quantification of costs and benefits in three domains: health, environmental, and social. The implications for policy makers are discussed. Curr Dev Nutr 2023;x:xx.

Sibling rivalry between twins in utero and childhood: Evidence from birthweight and survival of 95 919 twin pairs in 72 low- and middle-income countries

BACKGROUND

This study explores the magnitude and timing of sex and gender disparities in child development by describing differences in health outcomes for male and female siblings, comparing twins to control for all aspects of life circumstances other than sex and gender.

METHODS

We construct a repeat cross-sectional dataset of 191 838 twins among 1.7 million births recorded in 214 nationally representative household surveys for 72 countries between 1990 and 2016. To test for biological or social mechanisms that might favor the health of male or female infants, we describe differences in birthweights, attained heights, weights, and survival to distinguish gestational health from care practices after each child is born.

RESULTS

We find that male fetuses grow at the expense of their co-twin, significantly reducing their sibling's birthweight and survival probabilities, but only if the other fetus is male. Female fetuses are born significantly heavier when they share the uterus with a male co-twin and have no significant difference in survival probability whether they happen to draw a male or a female co-twin. These findings demonstrate that sex-specific sibling rivalry and male frailty begin in utero, prior to gender bias after birth that typically favors male children.

CONCLUSIONS

Sex differences in child health may have competing effects with gender bias that occurs during childhood. Worse health outcomes for males with a male co-twin could be linked to hormone levels or male frailty, and could lead to underestimates of the effect sizes of later gender bias against girls. Gender bias favoring surviving male children may explain the lack of differences in height and weight observed for twins with either male or female co-twins.

Tracing global flows of bioactive compounds from farm to fork in Nutrient Balance Sheets can help guide intervention towards healthier food supplies

Adequate supplies of healthy foods available in each country are a necessary but not sufficient condition for adequate intake by each individual. This study provides complete Nutrient Balance Sheets that account for all plant-based and animal-sourced food flows from farm production through trade to non-food uses and waste in 173 countries from 1961 to 2018. We track 36 bioactive compounds in all farm commodities recorded by the Food and Agriculture Organization of the United Nations, accounting for nutrient-specific losses in processing and cooking as well as bioavailability. We compare supply to requirements given each country's age-sex distribution and find that the adequacy of food supplies has increased but often remains below total needs, with even faster rise in energy levels and lower density of some nutrients per calorie. We use this nutrient accounting to show how gaps could be filled, either from food production and trade or from selected biofortification, fortification and supplementation scenarios for nutrients of concern such as vitamin A, iron and zinc.

Retail prices of nutritious food rose more in countries with higher COVID-19 case counts

The COVID-19 pandemic has curtailed lives and livelihoods, leading to price spikes for some foods and declines for others. We compare monthly retail food prices in up to 181 countries from January 2019 to June 2021, test for differences over time and find that average prices rose significantly, especially for more nutritious food groups in countries with higher COVID-19 case counts. Analysis of retail prices by food group complements data on farm commodity prices and overall consumer price indexes, helping to guide policy for resilience and response to shocks.

Linear Growth Spurts are Preceded by Higher Weight Gain Velocity and Followed by Weight Slowdowns Among Rural Children in Burkina Faso: A Longitudinal Study

BACKGROUND

The temporal relationship between length (linear) and weight (ponderal) growth in early life is important to support optimal nutrition program design. Studies based on measures of attained size have established that wasting often precedes stunting, but such studies do not capture responsiveness of growth to previous compared with current conditions. As a result, the temporality of linear and ponderal growth relationships remain unclear.

OBJECTIVES

We used growth velocity indicators to assess the temporal bidirectional relationships between linear and ponderal growth in children.

METHODS

Using monthly anthropometric measurements from 5039 Burkinabè children enrolled at 6 months of age and followed until 28 months from August 2014 to December 2016, we employed multilevel mixed-effects models to investigate concurrent and lagged associations between linear and ponderal growth velocity, controlling for time trends, seasonality, and morbidity.

RESULTS

Faster ponderal growth is associated with faster concurrent and subsequent linear growth (0.21-0.72 increase in length velocity z-score per unit increase in weight velocity z-score), while faster linear growth is associated with slower future weight gain (0.009-0.02 decrease in weight velocity z-score per unit increase in length velocity z-score), especially among children 9-14 months. Ponderal growth slows around the same time as peaks in morbidity, followed roughly a month later by slower linear growth.

CONCLUSIONS

Use of velocity measures to assess temporal dependencies between linear and ponderal growth demonstrate that the same growth-limiting conditions likely affect both length and weight velocity, that slow ponderal growth likely limits subsequent linear growth, and that linear growth spurts may not be accompanied by sufficient increases in dietary intake to avoid slowdowns in weight gain.

Global variation in the cost of a nutrient-adequate diet by population group: an observational study

BACKGROUND

Nutrient deficiencies limit human development and could be caused by the high cost of locally available foods needed to meet nutrient requirements. We aimed to identify the populations whose nutrient needs are most difficult to meet with existing global food systems.

METHODS

In this observational study, we used the International Comparison Program 2017 collection of global food prices to measure cost per day and cost per calorie of meeting nutrient needs, based on least-cost diets within upper and lower bounds for energy and 20 nutrients for healthy populations across 20 demographic groups in 172 countries. We then analysed the composition of these least-cost diets by food groups to estimate how the affordability of foods for meeting nutrient needs varied by age, sex, and reproductive status.

FINDINGS

In 2017, the global median of diet costs per day was US$2·32 (IQR 1·95-2·76), with cost highest for adolescent boys aged 14-18 years at $2·72 (2·31-3·15). For females, median cost was highest for adolescents aged 14-18 years during pregnancy and lactation at $2·64 (2·29-3·15), exceeding the cost for adult men aged 19-30 years. The global median of diet cost per 1000 kcal was $0·94 (IQR 0·80-1·12), and was higher for females throughout the life course than for males, peaking for adolescent girls aged 9-13 years ($1·17 [95% CI 1·15-1·19]) and women older than 70 years ($1·18 [1·17-1·19]). Diet costs were most sensitive to requirements for calcium, iron, zinc, and vitamins C and E, as well as the upper bounds on carbohydrates and sodium. Total diet costs per day did not vary significantly with national income; however, in high-income countries, the composition of least-cost diets included more animal-source foods, whereas in low-income countries, diets with more pulses, nuts and seeds, and fruits and vegetables provided the most affordable way to meet nutrient requirements.

INTERPRETATION

Diets with adequate nutrients were unaffordable for many demographic groups, especially women and girls. These results could help to guide agriculture and food policy or transfer programmes to support populations at risk of inadequate intake.

FUNDING

The Bill & Melinda Gates Foundation and UKAid.

Sustainable food systems and nutrition in the 21st century: a report from the 22nd annual Harvard Nutrition Obesity Symposium

Food systems are at the center of a brewing storm consisting of a rapidly changing climate, rising hunger and malnutrition, and significant social inequities. At the same time, there are vast opportunities to ensure that food systems produce healthy and safe food in equitable ways that promote environmental sustainability, especially if the world can come together at the UN Food Systems Summit in late 2021 and make strong and binding commitments toward food system transformation. The NIH-funded Nutrition Obesity Research Center at Harvard and the Harvard Medical School Division of Nutrition held their 22nd annual Harvard Nutrition Obesity Symposium entitled "Global Food Systems and Sustainable Nutrition in the 21st Century" in June 2021. This article presents a synthesis of this symposium and highlights the importance of food systems to addressing the burden of malnutrition and noncommunicable diseases, climate change, and the related economic and social inequities. Transformation of food systems is possible, and the nutrition and health communities have a significant role to play in this transformative process.

Monthly measurement of child lengths between 6 and 27 months of age in Burkina Faso reveals both chronic and episodic growth faltering

BACKGROUND

Linear growth faltering is determined primarily by attained heights in infancy, but available data consist mainly of cross-sectional heights at each age.

OBJECTIVES

This study used longitudinal data to test whether faltering occurs episodically in a few months of very low growth, which could potentially be prevented by timely intervention, or is a chronic condition with slower growth in every month of infancy and early childhood.

METHODS

Using anthropometric data collected monthly between August 2014 and December 2016, we investigated individual growth curves of 5039 children ages 6-27 mo in Burkina Faso (108,580 observations). We evaluated growth-curve smoothness by level of attained length at ∼27 mo by analyzing variation in changes in monthly growth rates and using 2-stage regressions: 1) regressing each child's length on their age and extracting R2 to represent curve smoothness, initial length, and average velocity by age; and 2) regressing extracted parameters on individual-level attained length.

RESULTS

Short children started smaller and remained on their initial trajectories, continuously growing slower than taller children. Growth between 9 and 11 mo was the most influential on attained length; for each 1-cm/mo increase in growth velocity during this period, attained length increased by 6.71 cm (95% CI: 6.59, 6.83 cm). Furthermore, a 0.01 increase in R2 from individual regression of length on age was associated with a 3.10-cm higher attained length (95% CI: 2.80, 3.41 cm), and having 2 consecutive months of slow growth (<15th centile relative to the sample) was associated with 1.7-cm lower attained length (95% CI: -1.80, -1.59 cm), with larger effects in younger children, suggesting that smoother growth patterns were also associated with higher attained length.

CONCLUSIONS

Children who experience extreme growth faltering are likely less resilient to systematic growth-limiting conditions as well as episodic insults to their growth.This trial was registered at clinicaltrials.gov as NCT02071563.

Food Compass is a nutrient profiling system using expanded characteristics for assessing healthfulness of foods

Nutrient profiling systems (NPS) aim to discriminate the healthfulness of foods for front-of-package labelling, warning labels, taxation, company ratings and more. Existing NPS often assess relatively few nutrients and ingredients, use inconsistent criteria across food categories and have not incorporated the newest science. Here, we developed and validated an NPS, the Food Compass, to incorporate a broader range of food characteristics, attributes and uniform scoring principles. We scored 54 attributes across 9 health-relevant domains: nutrient ratios, vitamins, minerals, food ingredients, additives, processing, specific lipids, fibre and protein, and phytochemicals. The domain scores were summed into a final Food Compass Score (FCS) ranging from 1 (least healthy) to 100 (most healthy) for all foods and beverages. Content validity was confirmed by assessing nutrients, food ingredients and other characteristics of public health concern; face validity was confirmed by assessing the FCS for 8,032 foods and beverages reported in NHANES/FNDDS 2015-16; and convergent and discriminant validity was confirmed from comparisons with the NOVA food processing classification, the Health Star Rating and the Nutri-Score. The FCS differentiated food categories and food items well, with mean ± s.d. ranging from 17.1 ± 17.2 for savoury snacks and sweet desserts to 81.6 ± 16.0 for legumes, nuts and seeds. In many food categories, the FCS provided important discrimination of specific foods and beverages as compared with NOVA, the Health Star Rating or the Nutri-Score. On the basis of demonstrated content, convergent and discriminant validity, the Food Compass provides an NPS scoring a broader range of attributes and domains than previous systems with uniform and transparent principles. This publicly available tool will help guide consumer choice, research, food policy, industry reformulations and mission-focused investment decisions.

Assessing Diet Quality Where Families Share Their Meals: Evidence from Malawi

BACKGROUND

Where families eat together from a common dish, the shared meal must be nutrient dense enough in each nutrient to meet the needs of the highest-need member.

OBJECTIVES

This study aimed to develop an aggregate household nutrient requirement benchmark that satisfies all members' needs in a context in which meals are shared and to illustrate how that metric could inform food and nutrition policy making.

METHODS

We merged nationally representative survey data for Malawi in 2010, 2013, and 2016-2017 with individual nutrient requirements and local food composition data to compute the adequacy of each household's aggregate consumption given its demographic composition and primary occupation. To meet each person's nutrient needs at any level of energy balance, the nutrient density of their shared diet needs to be within boundaries of the most restrictive member. We classified the adequacy of each household's diet using these energy-adjusted densities and examined differences by sociodemographic characteristics.

RESULTS

Accounting for meal sharing and nutrient density needs of the highest-need member, virtually all households' food consumption is insufficiently nutrient dense in riboflavin, selenium, lipids, and vitamin B-12, and most consumption is insufficiently nutrient dense in zinc and phosphorus as well. Meeting needs of women, adolescent girls, and young children using shared diets would on average require 145% more iron, 98% more zinc, and approximately 70% more phosphorus and vitamin C than if their needs were met with individualized diets.

CONCLUSIONS

Establishing shared nutrient requirements is feasible using existing survey data and can help set sufficiency criteria in settings in which families share meals. In Malawi, current diets and food composition are inadequate for many nutrients, especially in households with more women and adolescent girls. The results call for concerted investment to increase access to and use of more nutrient-dense foods.

The International Diet-Health Index: a novel tool to evaluate diet quality for cardiometabolic health across countries

Introduction

Diet is a major modifiable risk factor for cardiometabolic disease; however, interpretable measures capturing impacts of overall diet on health that can be easily used by policymakers at the global/national levels are not readily available.

Methods

We developed the International Diet-Health Index (IDHI) to measure health impacts of dietary intake across 186 countries in 2010, using age-specific and sex-specific data on country-level dietary intake, effects of dietary factors on cardiometabolic diseases and country-specific cardiometabolic disease profiles. The index encompasses the impact of 11 foods/nutrients on 12 cardiometabolic diseases, the mediation of health effects of specific dietary intakes through blood pressure and body mass index and background disease prevalence in each country–age–sex group. We decomposed the index into IDHI_beneficial for risk-reducing factors, and IDHI_adverse for risk-increasing factors. The flexible functional form of the IDHI allows inclusion of additional risk factors and diseases as data become available.

Results

By sex, women experienced smaller detrimental cardiometabolic effects of diet than men: (females IDHI_adverse range: −0.480 (5th percentile, 95th percentile: −0.932, –0.300) to −0.314 (−0.543, –0.213); males IDHI_adverse range: (−0.617 (−1.054, –0.384) to −0.346 (−0.624, –0.222)). By age, middle-aged adults had highest IDHI_beneficial (females: 0.392 (0.235, 0.763); males: 0.415 (0.243, 0.949)) and younger adults had most extreme IDHI_adverse (females: −0.480 (−0.932, –0.300); males: −0.617 (−1.054, –0.384)). Regionally, Central Latin America had the lowest IDHI_overall (−0.466 (−0.892, –0.159)), while Southeast Asia had the highest IDHI_overall (0.272 (−0.224, 0.903)). IDHI_overall was highest in low-income countries and lowest in upper middle-income countries (−0.039 (−0.317, 0.227) and −0.146 (−0.605, 0.303), respectively). Among 186 countries, Honduras had lowest IDHI_overall (−0.721 (−0.916, –0.207)), while Malaysia had highest IDHI_overall (0.904 (0.435, 1.190)).

Conclusion

IDHI encompasses dietary intakes, health effects and country disease profiles into a single index, allowing policymakers a useful means of assessing/comparing health impacts of diet quality between populations.

Beyond price and income: Preferences and food values in peri-urban Viet Nam

Sub-optimal diets are one of the most important risk factors contributing to the global burden of disease. Developing a better understanding of the drivers of food choice, including the role of individual preferences, is important to address this issue. The objective of this mixed methods research was to identify the relative importance of preferences for different food quality attributes (e.g. nutrition, food safety, price and convenience) that might influence shopping habits and food choice in the context of a rapidly changing peri-urban food environment in Hanoi Province, Viet Nam. A total of 264 women were randomly selected and interviewed using Best-Worst Scaling to elicit preferences among food quality attributes for different food groups (leafy green vegetables, fruits, instant foods, snack foods). A subset of these respondents (n = 40) participated in focus group discussions in order to explore their preferences and food values in more detail. The food quality attributes considered to be most important varied by food group with nutrition and food safety (both immediate and future health) ranking highest for leafy green vegetables and fruits, convenience for instant foods, and taste for snack foods. Price was considered least important across all food groups. Focus group discussions reinforced these results with additional insights particularly regarding trade-offs between nutrition, food safety, convenience, and price. This research demonstrates the feasibility of identifying important drivers of consumption in a South East Asian context using Best-Worst Scaling. These results could help inform the design of behavior change interventions and guide food system policies that seek to shift consumer choices towards healthier diets.

Modelling the potential cost-effectiveness of food-based programs to reduce malnutrition

Poor quality diets contribute to malnutrition globally, but evidence is weak on the cost-effectiveness of food-based interventions that shift diets. This study assessed 11 candidate interventions developed through Delphi techniques to improve diets in India, Nigeria, and Ethiopia. A Markov simulation model incorporated time, individual-level, nutrition, and policy parameters to estimate health impacts and cost-effectiveness for reducing stunting, anaemia, diarrhea, and mortality in preschool children. At an assumed 80% coverage, interventions considered would potentially save between 0·16 and 3·20 years of life per child. The average cost-effectiveness ratio ranged from US$9 to US$2000 per life year saved. This approach, linking expert knowledge, known costs, and modelling, offers potential for estimating cost-effective investments for better informed policy choice where empirical evidence is limited.

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Few studies estimate the potential cost-effectiveness of programs for improving health through diets.

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Expert knowledge linked to modelling offers a basis for assessing potential alternatives where data are lacking.

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Our analysis assessed 11 candidate interventions for Ethiopia, India, and Nigeria derived from local expert opinion.

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Modelling demonstrates these programs' potential health impacts and cost-effectiveness.

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The modelling of estimated benefits can support best-buy policy and program choices.

Food Systems as Drivers of Optimal Nutrition and Health: Complexities and Opportunities for Research and Implementation

The Sustainable Development Goals (SDGs) are intricately linked to food systems. Addressing challenges in food systems is key to meeting the SDGs in Africa and South Asia, where undernutrition and micronutrient deficiencies persist, alongside increased nutrition transition, overweight and obesity, and related chronic diseases. Suboptimal diets are a key risk factor for mortality and 3 billion people cannot afford a healthy diet; in addition, food systems are not prioritizing environmental sustainability. Optimizing food systems and increasing agricultural productivity beyond calories, to nutrient-rich vegetables and fruits, legumes, and livestock, and sustainable fishing, are required. Strengthening of research around food systems-on pathways, value chains, and development and validation of metrics of diet quality-is required. The development of new technology in crop management and pest control and addressing natural resource degradation is key. Engaging with the public and private sectors, outreach to donors and policymakers, and strengthening cross-disciplinary collaborations are imperative to improving food systems.

Global dietary convergence from 1970 to 2010, despite inequality in agriculture, leaves undernutrition concentrated in a few countries

Humans globally have similar nutritional needs but face large differences in natural resource endowments and local food production. This study quantifies food system inequality across countries based on natural resource inputs, food/nutrient outputs, and nutrition/health outcomes, from 1970 to 2010. Animal source foods and overweight/obesity show rapid convergence while availability of selected micronutrients demonstrate slower convergence. However, all variables are more equally distributed than national income per capita, whose Gini coefficient declined from 0·71 to 0·65. Inequalities in total and animal-source dietary energy declined from 0·16 to 0·10 and 0·55 to 0·36, respectively. There was convergence in overweight/obesity prevalence from 0·39 to 0·27, while undernutrition and stunting became increasingly concentrated in a few high-burden countries. Characterizing cross-country inequalities in agricultural resources, foods, nutrients, and health can help identify critical opportunities for agriculture and food policies, as well as prioritize research objectives and funding allocation for the coming decade.

Cost and affordability of nutritious diets at retail prices: Evidence from 177 countries

Many policies and programs aim to bring nutritious diets within reach of the poor. This paper uses retail prices and nutrient composition for 671 foods and beverages to compute the daily cost of essential nutrients required for an active and healthy life in 177 countries around the world. We compare this minimum cost of nutrient adequacy with the subsistence cost of dietary energy and per-capita spending on all goods and services, to identify stylized facts about how diet cost and affordability relate to economic development and nutrition outcomes. On average, the most affordable nutrient adequate diet exceeds the cost of adequate energy by a factor of 2.66, costing US$1.35 per day to meet median requirements of healthy adult women in 2011. Affordability is lowest in Sub-Saharan Africa. The sensitivity of diet costs to each requirement reveals the high cost of staying within acceptable macronutrient ranges, particularly the upper limit for carbohydrates. Among micronutrients, total diet costs are most sensitive to requirements for calcium as well as vitamins A, C, E, B12, folate and riboflavin. On average, about 5% of dietary energy in the least-cost nutrient adequate diets is derived from animal source foods, with small quantities of meat and fish. Over 70% of all animal products in least-cost diets is eggs and dairy, but only in upper-middle and high-income countries. In lower income countries where egg and dairy prices are significantly higher, they are replaced by larger volumes of vegetal foods. When controlling for national income, diet costs are most significantly correlated with rural travel times and rural electrification. These data suggest opportunities for targeted policies and programs that reduce market prices and the cost of nutritious diets, while improving affordability through nutrition assistance, safety nets and higher earnings among low-income households.

Seasonality of diet costs reveals food system performance in East Africa

Seasonal fluctuations in food prices reflect interactions between climate and society, measuring the degree to which predictable patterns of crop growth and harvest are offset by storage and trade. Previous research on seasonality in food systems has focused on specific commodities. This study accounts for substitution between items to meet nutritional needs, computing seasonal variation in local food environments using monthly retail prices for 191 items across Ethiopia, Malawi, and Tanzania from 2002 through 2016. We computed over 25,000 least-cost diets meeting nutrient requirements at each market every month and then measured the magnitude and timing of seasonality in diet costs. We found significant intensity in Malawi, Tanzania, and Ethiopia (10.0, 6.3, and 4.0%, respectively), driven primarily by synchronized price rises for nutrient-dense foods. Results provide a metric to map nutritional security, pointing to opportunities for more targeted investments to improve the year-round delivery of nutrients.

Can shorter mothers have taller children? Nutritional mobility, health equity and the intergenerational transmission of relative height

This study develops the concept of nutritional mobility, defined here as the probability that a mother ranked low in her cohort's height distribution will have a child who attains a higher rank order. We demonstrate that rank-order regression provides a robust metric of health equity, revealing differences in opportunities for each child to reach their own growth potential. We estimate four indicators of nutritional mobility and test for associations between nutritional mobility and various local economic and environmental factors. Nutritional mobility has improved over time, and the nutrition environment contributes about 2.86 times as much as a mother's height to her child's expected rank in height-for-age. Populations with the least mobility are in Latin America, and the most mobility is in more urbanized areas of Africa and Asia. Rank-order mobility is an important aspect of health equity, offering valuable insight into the role of socioecological factors in nutrition improvement across generations.

Fortified blended flour supplements displace plain cereals in feeding of young children

Lipid-based nutritional supplements (LNS) and fortified blended flours (FBF) are widely used to increase the nutrient density of children's diets and improve their health, but their effectiveness could be modified by displacement of other foods. We reanalysed data from a cost-effectiveness trial comparing impacts on anthropometry of three FBFs (Corn Soy Blend Plus [CSB+], Corn Soy Whey Blend [CSWB], SuperCereal Plus [SC+]) and one LNS (Ready-to-use Supplementary Food [RUSF]) among infants aged 7-23 months in Burkina Faso. Using dietary diversity data from a single 24-h recall period (n = 1,591 children, observed once over 18-month study period), we fit logistic regression models to estimate differences in intake of each food group making up the infant and young child minimum dietary diversity score and linear models to test for differences in dietary diversity score among children in each supplement arm. We tested for differences in breastfeeding time using the subsample for which breastfeeding was observed (n = 176). Children who consumed one of the three FBFs had lower odds of consuming household grains, roots and tubers compared with the LNS consumers (odds ratios [ORs] = 0.35-0.47; 95% confidence intervals [CIs]: 0.20-1.05). Consumption of other foods, dietary diversity and breastfeeding did not differ significantly at the 5% significance level. FBFs displaced the household's own cereals more than LNS, with no difference in the child's consumption of other more nutrient-rich family foods. Given limited stomach capacity and feeding time, providing fortified cereals may help improve children's overall diet quality in settings where children would otherwise be fed nutrient-poor root crops or cereal grains.

Performance bonuses in the public sector: Winner-take-all prizes versus proportional payments to reduce child malnutrition in India

We conduct a randomized trial to compare incentives for improved child outcomes among salaried caregivers in Chandigarh, India. A contest whose prize is divided among workers in proportion to measured gains yielded more improvement than a winner-take-all program. In our population of about 2000 children served by 85 workers, using proportional rewards led to weight-for-age malnutrition rates that were 4.3 percentage points lower at 3 months (when rewards were paid) and 5.9 points lower at 6 months (after the contest had ended), with mean weight-for-age z scores that were 0.071 higher at 3 months, and 0.095 higher at 6 months. Proportional bonuses led to larger and more sustained gains because of better performance by lower-ranked workers, whose efforts were not rewarded by a winner-take-all prize. Results are consistent with previous laboratory trials and athletic events, demonstrating the value of proportional rewards to improve development outcomes.

Affordability of the EAT-Lancet reference diet: a global analysis

BACKGROUND

The EAT-Lancet Commission drew on all available nutritional and environmental evidence to construct the first global benchmark diet capable of sustaining health and protecting the planet, but it did not assess dietary affordability. We used food price and household income data to estimate affordability of EAT-Lancet benchmark diets, as a first step to guiding interventions to improve diets around the world.

METHODS

We obtained retail prices from 2011 for 744 foods in 159 countries, collected under the International Comparison Program. We used these data to identify the most affordable foods to meet EAT-Lancet targets. We compared total diet cost per day to each country's mean per capita household income, calculated the proportion of people for whom the most affordable EAT-Lancet diet exceeds total income, and also measured affordability relative to a least-cost diet that meets essential nutrient requirements.

FINDINGS

The most affordable EAT-Lancet diets cost a global median of US$2·84 per day (IQR 2·41-3·16) in 2011, of which the largest share was the cost of fruits and vegetables (31·2%), followed by legumes and nuts (18·7%), meat, eggs, and fish (15·2%), and dairy (13·2%). This diet costs a small fraction of average incomes in high-income countries but is not affordable for the world's poor. We estimated that the cost of an EAT-Lancet diet exceeded household per capita income for at least 1·58 billion people. The EAT-Lancet diet is also more expensive than the minimum cost of nutrient adequacy, on average, by a mean factor of 1·60 (IQR 1·41-1·78).

INTERPRETATION

Current diets differ greatly from EAT-Lancet targets. Improving diets is affordable in many countries but for many people would require some combination of higher income, nutritional assistance, and lower prices. Data and analysis for the cost of healthier foods are needed to inform both local interventions and systemic changes.

FUNDING

Bill & Melinda Gates Foundation.

First foods: Diet quality among infants aged 6-23 months in 42 countries

Diet quality is closely linked to child growth and development, especially among infants aged 6-23 months who need to complement breastmilk with the gradual introduction of nutrient-rich solid foods. This paper links Demographic and Health Survey data on infant feeding to household and environmental factors for 76,641 children in 42 low- and middle-income countries surveyed in 2006-2013, providing novel stylized facts about diets in early childhood. Multivariate regressions examine the associations of household socioeconomic characteristics and community level indicators of climate and infrastructure with dietary diversity scores (DDS). Results show strong support for an infant-feeding version of Bennett's Law, as wealthier households introduce more diverse foods at earlier ages, with additional positive effects of parental education, local infrastructure and more temperate agro-climatic conditions. Associations with consumption of specific nutrient-dense foods are less consistent. Our findings imply that while income growth is indeed an important driver of diversification, there are strong grounds to also invest heavily in women's education and food environments to improve diet quality, while addressing the impacts of climate change on livelihoods and food systems. These results reveal systematic patterns in how first foods vary across developing countries, pointing to new opportunities for research towards nutrition-smart policies to improve children's diets.

Correcting for artifactual correlation between misreported month of birth and attained height-for-age reduces but does not eliminate measured vulnerability to season of birth in poorer countries

BACKGROUND

Height-for-age z-scores (HAZ) are associated with month of birth (MOB) in many nutrition surveys, but that link could be an artifactual result of measurement error in child birthdates.

OBJECTIVE

We corrected estimates of the associations between HAZ and MOB for a common type of age misreporting, to measure the remaining seasonality in HAZ and identify country characteristics associated with vulnerability to seasonal changes in early life.

DESIGN

We used nationally representative repeated cross-sections from all available Demographic and Health Surveys (DHS), totaling 1,363,806 children from 218 surveys in 72 countries over 1986-2016, to estimate the seasonal patterns in HAZ by MOB within each survey. Then, we corrected these estimates for each survey's random errors in recorded birth month implied by differences in attained height between children reported as born in December of one year versus January of the next. Indicators of seasonal variation between other months were modeled as functions of national-level incomes using linear regression, and visualizations were constructed using nonparametric local polynomial smoothing regressions.

RESULTS

Over all surveys, misreporting MOB accounted for about one-eighth of the gap in attained height between the worst and best months to be born, which averaged 0.41 HAZ in the raw data and 0.34 HAZ after correction for age misreporting. A linear correction reduced apparent seasonality of HAZ by MOB in 49 of 72 countries, and the remaining nonartifactual differences by season of birth were larger in countries with lower average income per capita.

CONCLUSIONS

Measurement error in child MOB helps to explain the association between attained height and seasonal variation in early life environments, but significant seasonality in HAZ by MOB remains in many poor countries. Higher national income is associated with smoother outcomes across birth months, and birth registration efforts would improve nutrition research.

Misreporting Month of Birth: Diagnosis and Implications for Research on Nutrition and Early Childhood in Developing Countries

A large literature has used children’s birthdays to identify exposure to shocks and estimate their impacts on later outcomes. Using height-for-age z scores (HAZ) for more than 990,000 children in 62 countries from 163 Demographic and Health Surveys (DHS), we show how random errors in birth dates create artifacts in HAZ that can be used to diagnose the extent of age misreporting. The most important artifact is an upward gradient in HAZ by recorded month of birth (MOB) from start to end of calendar years, resulting in a large HAZ differential between December- and January-born children of –0.32 HAZ points. We observe a second artifact associated with round ages, with a downward gradient in HAZ by recorded age in months, and then an upward step after reaching ages 2, 3, and 4. These artifacts have previously been interpreted as actual health shocks. We show that they are not related to agroclimatic conditions but are instead linked to the type of calendar used and arise mainly when enumerators do not see the child’s birth registration cards. We explain the size of the December–January gap through simulation in which 11 % of children have their birth date replaced by a random month. We find a minor impact on the average stunting rate but a larger impact in specific error-prone surveys. We further show how misreporting MOB causes attenuation bias when MOB is used for identification of shock exposure as well as systematic bias in the impact on HAZ of events that occur early or late in each calendar year.

Orange Fanta versus orange fruit: A novel measure of nutrition knowledge in Malawi

This paper introduces a novel survey instrument to identify distinct components of nutrition knowledge and test for links between knowledge and dietary choices in Southern Malawi. Our first aim is to distinguish respondents' familiarity with recommended behaviours, such as when to start breastfeeding or introduce solid foods, from respondents' factual knowledge about mechanisms, such as whether biscuits or papaya and orange fruit or orange Fanta contribute more to future health. We find knowledge of nutrition behaviours to be strongly associated with more schooling, older age, and being female, whereas knowledge of mechanisms is associated only with training and employment as a health professional. We then test whether this expanded definition of nutrition knowledge is associated with dietary intake when controlling for other factors and find no significant links in these data. Results point to the need for knowledge surveys and public health behaviour-change campaigns to address the kinds of information that might have the most influence on actual behaviour, potentially including the mechanisms involved in food composition, food safety, and disease transmission.

Designing programs to improve diets for maternal and child health: estimating costs and potential dietary impacts of nutrition-sensitive programs in Ethiopia, Nigeria, and India

Improving maternal and child nutrition in resource-poor settings requires effective use of limited resources, but priority-setting is constrained by limited information about program costs and impacts, especially for interventions designed to improve diet quality. This study utilized a mixed methods approach to identify, describe and estimate the potential costs and impacts on child dietary intake of 12 nutrition-sensitive programs in Ethiopia, Nigeria and India. These potential interventions included conditional livestock and cash transfers, media and education, complementary food processing and sales, household production and food pricing programs. Components and costs of each program were identified through a novel participatory process of expert regional consultation followed by validation and calibration from literature searches and comparison with actual budgets. Impacts on child diets were determined by estimating of the magnitude of economic mechanisms for dietary change, comprehensive reviews of evaluations and effectiveness for similar programs, and demographic data on each country. Across the 12 programs, total cost per child reached (net present value, purchasing power parity adjusted) ranged very widely: from 0.58 to 2650 USD/year among five programs in Ethiopia; 2.62 to 1919 USD/year among four programs in Nigeria; and 27 to 586 USD/year among three programs in India. When impacts were assessed, the largest dietary improvements were for iron and zinc intakes from a complementary food production program in Ethiopia (increases of 17.7 mg iron/child/day and 7.4 mg zinc/child/day), vitamin A intake from a household animal and horticulture production program in Nigeria (335 RAE/child/day), and animal protein intake from a complementary food processing program in Nigeria (20.0 g/child/day). These results add substantial value to the limited literature on the costs and dietary impacts of nutrition-sensitive interventions targeting children in resource-limited settings, informing policy discussions and serving as critical inputs to future cost-effectiveness analyses focusing on disease outcomes.

Measuring the Affordability of Nutritious Diets in Africa: Price Indexes for Diet Diversity and the Cost of Nutrient Adequacy

Policies and programs often aim to improve the affordability of nutritious diets, but existing food price indexes are based on observed quantities that may not meet nutritional goals. To measure changes in the cost of reaching international standards of diet quality, we introduce a new cost of diet diversity index based on the lowest-cost way to include at least five different food groups as defined by the widely used minimum dietary diversity for women (MDD-W) indicator and compare that to a Cost of Nutrient Adequacy indicator for the lowest-cost way to meet estimated average requirements of essential nutrients and dietary energy. We demonstrate application of both indexes using national average monthly prices from two very different sources: an agricultural market information system in Ghana (2009-14) and the data used for national consumer price indexes in Tanzania (2011-15). We find that the cost of diet diversity index for Ghana fluctuated seasonally and since mid-2010 rose about 10% per year faster than national inflation, due to rising relative prices for fruit, which also drove up the cost of nutrient adequacy. In Tanzania there were much smaller changes in total daily costs, but more adjustment in the mix of food groups used for the least-cost diet. These methods can show where and when nutritious diets are increasingly (un)affordable, and which nutritional criteria account for the change. These results are based on monthly national average prices, but the method is generalizable to other contexts for monitoring, evaluation, and assessment of changing food environments. JEL codes: I15, Q11, Q18.

Education and micronutrient deficiencies: an ecological study exploring interactions between women's schooling and children's micronutrient status

Background

Formal education can be a nutrition-sensitive intervention that supports the scale-up and impact of nutrition-specific actions. Maternal education has long been linked to child survival, growth, and development while adult earnings and nutrition are tied to years in school as a child. However, less is known about the relationship between maternal education and the micronutrient status of children, women and the general population.

Methods

Using country-level data and an ecological study design, we explored the global associations between women’s educational attainment and: a) anemia and vitamin A deficiency (VAD) in children aged 6–59 months; b) anemia in non-pregnant women; and c) zinc deficiency, urinary iodine excretion (UIE), and the proportion of infants protected against iodine deficiency in the general population Cross-sectional relationships (2005–2013) were assessed using linear regression models.

Results

Percentage of women without schooling was negatively associated with all outcomes. Number of years of schooling among women was positively associated with all outcomes except for UIE and the proportion of infants protected against iodine deficiency. Income level was a significant effect modifier of the effect of years of women’s schooling on child anemia as well as of the proportion of women without formal education on zinc deficiency in the population. The relationship was strongest in low-income countries for child anemia, and was not significant in upper middle-income countries. For zinc deficiency, the relationship was not significant in low or lower middle income countries, which may suggest that a minimum threshold of resources needs to be reached before education can influence zinc status.

Conclusions

While relationships between maternal schooling and micronutrient outcomes vary around the globe, more schooling is generally linked to lower rates of deficiency. These findings draw policy-relevant connections between formal education and anemia and micronutrient status globally. It is necessary to examine the mechanisms through which this relationship may be working at both household and country level.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5312-1) contains supplementary material, which is available to authorized users.

Agricultural Transformation, Nutrition Transition and Food Policy in Africa: Preston Curves Reveal New Stylised Facts

This paper uses a Preston Curve approach to test for changes over time in agriculture, nutrition and food policy, comparing national averages in Africa and elsewhere at each level of national income per capita from the 1990s to the 2010s. Our statistical tests and data visualisations reveal that, at each level of income, African countries have faster rural population growth, a larger share of workers in agriculture and lower agricultural labour productivity than countries elsewhere, with no significant shift in these patterns from the 1990s to the 2010s. In contrast, there have been structural shifts towards less child stunting everywhere, and towards more adult obesity in high-income countries. The overall pattern of African governments' food policies and government expenditures have not shifted, however, as they continue price interventions and low investment levels characteristic of low-income countries around the world.

Household food production is positively associated with dietary diversity and intake of nutrient-dense foods for older preschool children in poorer families: Results from a nationally-representative survey in Nepal

BACKGROUND

Nutrition-sensitive interventions supporting enhanced household food production have potential to improve child dietary quality. However, heterogeneity in market access may cause systematic differences in program effectiveness depending on household wealth and child age. Identifying these effect modifiers can help development agencies specify and target their interventions.

OBJECTIVE

This study investigates mediating effects of household wealth and child age on links between farm production and child diets, as measured by production and intake of nutrient-dense food groups.

METHODS

Two rounds (2013 and 2014) of nationally representative survey data (n = 5,978 observations) were used to measure production and children's dietary intake, as well as a household wealth index and control variables, including breastfeeding. Novel steps used include measuring production diversity in terms of both species grown and food groups grown, as well as testing for mediating effects of family wealth and age of child.

RESULTS

We find significant associations between child dietary diversity and agricultural diversity in terms of diversity of food groups and of species grown, especially for older children in poorer households, and particularly for fruits and vegetables, dairy and eggs. With each additional food group produced, log-odds of meeting minimum dietary diversity score (≥4) increase by 0.25 (p = 0.01) for children aged 24-59 months. For younger children aged 18-23 months there is a similar effect size but only in the poorest two quintiles of household wealth, and for infants 6-18 months we find no correlation between production and intake in most models.

CONCLUSIONS

Child dietary intake is associated with the composition of farm production, most evident among older preschool children and in poorer households. To improve the nutrition of infants, other interventions are needed; and for relatively wealthier households, own farm production may displace market purchases, which could attenuate the impact of household production on child diets.

Priority interventions to improve maternal and child diets in Sub-Saharan Africa and South Asia

Nutrition‐sensitive interventions to improve overall diet quality are increasingly needed to improve maternal and child health. This study demonstrates feasibility of a structured process to leverage local expertise in formulating programmes tailored for current circumstances in South Asia and Africa. We assembled 41 stakeholders in 2 regional workshops and followed a prespecified protocol to elicit programme designs listing the human and other resources required, the intervention's mechanism for impact on diets, target foods and nutrients, target populations, and contact information for partners needed to implement the desired programme. Via this protocol, participants described 48 distinct interventions, which we then compared against international recommendations and global goals. Local stakeholders' priorities focused on postharvest food systems to improve access to nutrient‐dense products (75% of the 48 programmes) and on production of animal sourced foods (58%), as well as education and social marketing (23%) and direct transfers to meet food needs (12.5%). Each programme included an average of 3.2 distinct elements aligned with those recommended by United Nations system agencies in the Framework for Action produced by the Second International Conference on Nutrition in 2014 and the Compendium of Actions for Nutrition developed for the Renewed Efforts Against Child Hunger initiative in 2016. Our results demonstrate that a participatory process can help local experts identify their own priorities for future investments, as a first step in a novel process of rigorous, transparent, and independent priority setting to improve diets among those at greatest risk of undernutrition.

Nutrient composition of premixed and packaged complementary foods for sale in low- and middle-income countries: Lack of standards threatens infant growth

Premixed flours for infant porridge are increasingly produced and sold in developing countries to complement continued breastfeeding. Such complementary food (CF) products have known efficacy against malnutrition in children from 6 to 24 months of age, but ingredient ratios and production processes may vary. This study provides the first systematic measurement of their actual nutrient composition. We purchased samples of 108 premixed CF products in 22 low- and middle-income countries, and commissioned blind laboratory measurement of each product's macronutrients and micronutrients. We compared measured contents to nutrient claims on their packaging and to CF standards from the Codex Alimentarius, the Super Cereal Plus product used in nutrition assistance programs, and the Lutter and Dewey (2003) recommendations, as well as our own modeled nutrient requirements for a healthy breastfed child. Actual densities are significantly different from nutrient claims for protein (p = .013) and fat (p = .000). Only 15% of samples met two of the three benchmarks for fat, 32% met the most stringent protein standard, while only 22% met them for iron, and 21% for zinc. The median healthy child consuming breast milk plus enough of these solid foods to meet energy needs would experience deficits of zinc at 6 months, iron at 6 and 9 months, and dietary fat from 12 months of age. In summary, premixed CF products can provide adequate nutrient density but usually do not, revealing the need and opportunity for independent monitoring and quality assurance to help grain millers making premixed foods maintain uniform ingredient ratios and production practices.

Impact of caregiver incentives on child health: Evidence from an experiment with Anganwadi workers in India

This paper tests the effectiveness of performance pay and bonuses among government childcare workers in India. In a controlled study of 160 ICDS centers serving over 4000 children, we randomly assign workers to either fixed bonuses or payments based on the nutritional status of children in their care, and also collect data from a control group receiving only standard salaries. In all three study arms mothers receive nutrition information. We find that performance pay reduces underweight prevalence by about 5 percentage points over 3 months, and height improves by about one centimeter. Impacts on weight continue when incentives are renewed and return to parallel trends thereafter. Fixed bonuses are less expensive but lead to smaller and less precisely estimated effects than performance pay, especially for children near malnutrition thresholds. Both treatments improve worker effort and communication with mothers, who in turn feed a more calorific diet to children at home.

Nutrition Smoothing: Can Proximity to Towns and Cities Protect Rural Children against Seasonal Variation in Agroclimatic Conditions at Birth?

A large literature links early-life environmental shocks to later outcomes. This paper uses seasonal variation across the Democratic Republic of the Congo to test for nutrition smoothing, defined here as attaining similar height, weight and mortality outcomes despite different agroclimatic conditions at birth. We find that gaps between siblings and neighbors born at different times of year are larger in more remote rural areas, farther from the equator where there are greater seasonal differences in rainfall and temperature. For those born at adverse times in places with pronounced seasonality, the gains associated with above-median proximity to nearby towns are similar to rising one quintile in the national distribution of household wealth for mortality, and two quintiles for attained height. Smoothing of outcomes could involve a variety of mechanisms to be addressed in future work, including access to food markets, health services, public assistance and temporary migration to achieve more uniform dietary intake, or less exposure and improved recovery from seasonal diseases.

Climatic conditions and child height: Sex-specific vulnerability and the protective effects of sanitation and food markets in Nepal

Environmental conditions in early life are known to have impacts on later health outcomes, but causal mechanisms and potential remedies have been difficult to discern. This paper uses the Nepal Demographic and Health Surveys of 2006 and 2011, combined with earlier NASA satellite observations of variation in the Normalized Difference Vegetation Index (NDVI) at each child's location and time of birth to identify the trimesters of gestation and periods of infancy when climate variation is linked to attained height later in life. We find significant differences by sex: males are most affected by conditions in their second trimester of gestation, and females in the first three months after birth. Each 100-point difference in NDVI at those times is associated with a difference in height-for-age z-score (HAZ) measured at age 12-59 months of 0.088 for boys and 0.054 for girls, an effect size similar to that of moving within the distribution of household wealth by close to one quintile for boys and one decile for girls. The entire seasonal change in NDVI from peak to trough is approximately 200-300 points during the 2000-2011 study period, implying a seasonal effect on HAZ similar to one to three quintiles of household wealth. This effect is observed only in households without toilets; in households with toilets, there is no seasonal fluctuation, implying protection against climatic conditions that facilitate disease transmission. We also use data from the Nepal Living Standards Surveys on district-level agricultural production and marketing, and find a climate effect on child growth only in districts where households' food consumption derives primarily from their own production. Robustness tests find no evidence of selection effects, and placebo regression results reveal no significant artefactual correlations. The timing and sex-specificity of climatic effects are consistent with previous studies, while the protective effects of household sanitation and food markets are novel indications of mechanisms by which households can gain resilience against adverse climatic conditions.

Energy Contents of Frequently Ordered Restaurant Meals and Comparison with Human Energy Requirements and U.S. Department of Agriculture Database Information: A Multisite Randomized Study

BACKGROUND

Excess energy intake from meals consumed away from home is implicated as a major contributor to obesity, and ∼50% of US restaurants are individual or small-chain (non-chain) establishments that do not provide nutrition information.

OBJECTIVE

To measure the energy content of frequently ordered meals in non-chain restaurants in three US locations, and compare with the energy content of meals from large-chain restaurants, energy requirements, and food database information.

DESIGN

A multisite random-sampling protocol was used to measure the energy contents of the most frequently ordered meals from the most popular cuisines in non-chain restaurants, together with equivalent meals from large-chain restaurants.

SETTING

Meals were obtained from restaurants in San Francisco, CA; Boston, MA; and Little Rock, AR, between 2011 and 2014.

MAIN OUTCOME MEASURES

Meal energy content determined by bomb calorimetry.

STATISTICAL ANALYSIS PERFORMED

Regional and cuisine differences were assessed using a mixed model with restaurant nested within region×cuisine as the random factor. Paired t tests were used to evaluate differences between non-chain and chain meals, human energy requirements, and food database values.

RESULTS

Meals from non-chain restaurants contained 1,205±465 kcal/meal, amounts that were not significantly different from equivalent meals from large-chain restaurants (+5.1%; P=0.41). There was a significant effect of cuisine on non-chain meal energy, and three of the four most popular cuisines (American, Italian, and Chinese) had the highest mean energy (1,495 kcal/meal). Ninety-two percent of meals exceeded typical energy requirements for a single eating occasion.

CONCLUSIONS

Non-chain restaurants lacking nutrition information serve amounts of energy that are typically far in excess of human energy requirements for single eating occasions, and are equivalent to amounts served by the large-chain restaurants that have previously been criticized for providing excess energy. Restaurants in general, rather than specific categories of restaurant, expose patrons to excessive portions that induce overeating through established biological mechanisms.

Agriculture, nutrition, and health in global development: typology and metrics for integrated interventions and research

Despite rhetoric arguing that enhanced agriculture leads to improved nutrition and health, there is scant empirical evidence about potential synergies across sectors or about the mix of actions that best supports all three sectors. The geographic scale and socioeconomic nature of these interventions require integration of previously separate research methods. This paper proposes a typology of interventions and a metric of integration among them to help researchers build on each other's results, facilitating integration in methods to inform the design of multisector interventions. The typology recognizes the importance of regional effect modifiers that are not themselves subject to randomized assignment, and trade-offs in how policies and programs are implemented, evaluated, and scaled. Using this typology could facilitate methodological pluralism, helping researchers in one field use knowledge generated elsewhere, each using the most appropriate method for their situation.

Effects and determinants of mild underweight among preschool children across countries and over time

Research on malnutrition typically focuses on extreme cases which pose the greatest individual health risks, but researchers comparing populations might find that variation in mild malnutrition conveys valuable information about public health. This paper constructs and compares new measures of the prevalence, depth and severity of both mild and extreme underweight in children from three months to three years of age, as measured by 130 DHS surveys for 53 countries over a period from 1986 to 2006. We find that variance in mild underweight has a larger and more robust correlation with child mortality than variance in severe underweight, and is itself more closely correlated with local agricultural output, over a wide range of regression specifications. We conclude that the prevalence of mild underweight deserves greater attention as a useful signal of changing public health conditions among preschool children in developing countries.