Evidence of potential impacts of a nutrition-sensitive agroecology program in Andhra Pradesh, India, on dietary diversity, nutritional status, and child development

INTRODUCTION

While a number of studies have examined the nutritional impacts of agroecological interventions, few have examined impacts on child development, maternal and child anemia, and men's dietary diversity. Moreover, there have been few such evaluations at scale. We evaluated the impact of a large-scale, multi-component food-based nutrition intervention involving homestead food production, nutrition counselling, cooking demonstrations, and crop planning exercises.

METHODS

A cross-sectional assessment was conducted in 2021-2022 of 50 intervention villages where the nutrition-sensitive agroecology program had been implemented since 2018 and 79 control villages where only the agroecology program had been implemented. Data on self-reported dietary intake, caregiver-reported early child development, anthropometric measurements, and hemoglobin concentrations were collected using standardized procedures by trained Nutrition Farming Fellows, who were also responsible for implementing the program.

RESULTS

A sample of 3,511 households (1,121 intervention and 2,390 control) participated in the survey. Dietary diversity scores (DDS) among women and men were mean (SD) 6.53 (±1.62) and 6.16 (±1.65), respectively, in intervention villages and 5.81 (±1.58) and 5.39 (±1.61), respectively, in control villages (p<0.01). DDS among children 6-24 months of age in intervention and control villages was 2.99 (±1.52) and 2.73 (±1.62), respectively (p<0.01). Children <2 years of age were less likely to be anemic in intervention versus control villages (59% versus 69%, p<0.01). Children 18-35 months age in intervention villages had higher child development scores than children in control villages (all p<0.05).

CONCLUSION

Nutrition-sensitive agroecological programs may be effective in improving diets, nutrition, and child development in rural India.

Effects of red meat taxes and warning labels on food groups selected in a randomized controlled trial

BACKGROUND

High consumption of red and processed meat contributes to both health and environmental harms. Warning labels and taxes for red meat reduce selection of red meat overall, but little is known about how these potential policies affect purchases of subcategories of red meat (e.g., processed versus unprocessed) or of non-red-meat foods (e.g., cheese, pulses) relevant to health and environmental outcomes. This study examined consumer responses to warning labels and taxes for red meat in a randomized controlled trial.

METHODS

In October 2021, we recruited 3,518 US adults to complete a shopping task in a naturalistic online grocery store. Participants were randomly assigned to one of four arms: control (no warning labels or tax), warning labels only (health and environmental warning labels appeared next to products containing red meat), tax only (prices of products containing red meat were increased 30%) or combined warning labels + tax. Participants selected items to hypothetically purchase, which we categorized into food groups based on the presence of animal- and plant-source ingredients (e.g., beef, eggs, pulses), meat processing level (e.g., processed pork versus unprocessed pork), and meat species (e.g., beef versus pork). We assessed the effects of the warning labels and tax on selections from each food group.

RESULTS

Compared to control, all three interventions led participants to select fewer items with processed meat (driven by reductions in processed pork) and (for the tax and warning labels + tax interventions only) fewer items with unprocessed meat (driven by reductions in unprocessed beef). All three interventions also led participants to select more items containing cheese, while only the combined warning labels + tax intervention led participants to select more items containing processed poultry. Except for an increase in selection of pulses in the tax arm, the interventions did not affect selections of fish or seafood (processed or unprocessed), eggs, or plant-based items (pulses, nuts & seeds, tofu, meat mimics, grains & potatoes, vegetables).

CONCLUSIONS

Policies to reduce red meat consumption are also likely to affect consumption of other types of foods that are relevant to both health and environmental outcomes.

TRIAL REGISTRATION

NCT04716010 on www.

CLINICALTRIALS

gov .

Dietary quality and dietary greenhouse gas emissions in the USA: a comparison of the planetary health diet index, healthy eating index-2015, and dietary approaches to stop hypertension

BACKGROUND

The Planetary Health Diet Index (PHDI) measures adherence to the dietary pattern presented by the EAT-Lancet Commission, which aligns health and sustainability targets. There is a need to understand how PHDI scores correlate with dietary greenhouse gas emissions (GHGE) and how this differs from the carbon footprints of scores on established dietary recommendations. The objectives of this study were to compare how the PHDI, Healthy Eating Index-2015 (HEI-2015) and Dietary Approaches to Stop Hypertension (DASH) relate to (a) dietary GHGE and (b) to examine the influence of PHDI food components on dietary GHGE.

METHODS

We used life cycle assessment data from the Database of Food Recall Impacts on the Environment for Nutrition and Dietary Studies to calculate the mean dietary GHGE of 8,128 adult participants in the 2015-2016 and 2017-2018 cycles of the National Health and Nutrition Examination Survey (NHANES). Poisson regression was used to estimate the association of (a) quintiles of diet score and (b) standardized dietary index Z-scores with dietary GHGE for PHDI, HEI-2015, and DASH scores. In secondary analyses, we used Poisson regression to assess the influence of individual PHDI component scores on dietary GHGE.

RESULTS

We found that higher dietary quality on all three indices was correlated with lower dietary GHGE. The magnitude of the dietary quality-dietary GHGE relationship was larger for PHDI [-0.4, 95% CI (-0.5, -0.3) kg CO2 equivalents per one standard deviation change] and for DASH [-0.5, (-0.4, -0.6) kg CO2-equivalents] than for HEI-2015 [-0.2, (-0.2, -0.3) kg CO2-equivalents]. When examining PHDI component scores, we found that diet-related GHGE were driven largely by red and processed meat intake.

CONCLUSIONS

Improved dietary quality has the potential to lower the emissions impacts of US diets. Future efforts to promote healthy, sustainable diets could apply the recommendations of the established DASH guidelines as well as the new guidance provided by the PHDI to increase their environmental benefits.

Adherence to the Planetary Health Diet Index and correlation with nutrients of public health concern: an analysis of NHANES 2003-2018

BACKGROUND

The Planetary Health Diet Index (PHDI) is a novel measure adapted to quantify alignment with the dietary evidence presented by the EAT-Lancet Commission on Food, Planet, Health.

OBJECTIVES

To examine how population-level health and sustainability of diet as measured by the PHDI changed from 2003 to 2018, and to assess how PHDI correlated with inadequacy for nutrients of public health concern (iron, calcium, potassium, and fiber) in the United States.

METHODS

We estimated survey-weighted trends in PHDI scores and median intake of PHDI components in a nationally representative sample of 33,859 adults aged 20+ y from 8 cycles (2003-2018) of the National Health and Nutrition Examination Survey with 2 d of dietary recall data. We used the National Cancer Institute method to examine how PHDI correlated with inadequate intake of iron, calcium, potassium, and fiber.

RESULTS

Out of a theoretical range of 0-140, the median PHDI value increased by 4.2 points over the study period, from 62.7 (95% confidence interval [CI]: 62.0, 63.4) points in 2003-2004 to 66.9 (66.2, 67.7) points in 2017-2018 (P-trend < 0.001), although most of this change occurred before 2011-2012 and plateaued thereafter. For adequacy components that are encouraged for consumption, nonstarchy vegetable intake significantly decreased over time, whereas whole grains, nuts and seeds, and unsaturated oils increased. For moderation components with recommended limits for consumption, poultry and egg intake increased, but red and processed meat, added sugars, saturated fats, and starchy vegetables decreased over time. Higher PHDI values were associated with a lower probability of iron, fiber, and potassium inadequacy.

CONCLUSIONS

Although there have been positive changes over the past 20 y, there is substantial room for improving the health and sustainability of the United States diet. Shifting diets toward EAT-Lancet recommendations would improve nutrient adequacy for iron, fiber, and potassium. Policy action is needed to support healthier, more sustainable diets in the United States and globally.

The diabetes care continuum in Venezuela: Cross-sectional and longitudinal analyses to evaluate engagement and retention in care

The impact of the humanitarian crisis in Venezuela on care for noncommunicable diseases (NCDs) such as diabetes is unknown. This study aims to document health system performance for diabetes management in Venezuela during the humanitarian crisis. This longitudinal study on NCDs is nationally representative at baseline (2014-2017) and has follow-up (2018-2020) data on 35% of participants. Separate analyses of the baseline population with diabetes (n = 585) and the longitudinal population with diabetes (n = 210) were conducted. Baseline analyses constructed a weighted care continuum: all diabetes; diagnosed; treated; achieved glycaemic control; achieved blood pressure, cholesterol, and glycaemic control; and achieved aforementioned control plus non-smoking. Weighted multinomial regression models controlling for region were used to estimate the association between socio-demographic characteristics and care continuum stage. Longitudinal analyses constructed an unweighted care continuum: all diabetes; diagnosed; treated; and achieved glycaemic control. Unweighted multinomial regression models controlling for region were used to estimate the association between socio-demographic characteristics and changes in care continuum stage. Among 585 participants with diabetes at baseline, 71% were diagnosed, 51% were on treatment, and 32% had achieved glycaemic control. Among 210 participants with diabetes in the longitudinal population, 50 (24%) participants' diabetes management worsened, while 40 (19%) participants improved. Specifically, the proportion of those treated decreased (60% in 2014-2017 to 51% in 2018-2020), while the proportion of participants achieving glycaemic control did not change. Although treatment rates have declined substantially among people with diabetes in Venezuela, management changed less than expected during the crisis.

Dietary quality and cardiometabolic indicators in the USA: A comparison of the Planetary Health Diet Index, Healthy Eating Index-2015, and Dietary Approaches to Stop Hypertension

BACKGROUND

The Planetary Health Diet Index (PHDI) measures adherence to the sustainable dietary guidance proposed by the EAT-Lancet Commission on Food, Planet, Health. To justify incorporating sustainable dietary guidance such as the PHDI in the US, the index needs to be compared to health-focused dietary recommendations already in use. The objectives of this study were to compare the how the Planetary Health Diet Index (PHDI), the Healthy Eating Index-2015 (HEI-2015) and Dietary Approaches to Stop Hypertension (DASH) relate to cardiometabolic risk factors.

METHODS AND FINDINGS

Participants from the National Health and Nutrition Examination Survey (2015-2018) were assigned a score for each dietary index. We examined disparities in dietary quality for each index. We used linear and logistic regression to assess the association of standardized dietary index values with waist circumference, blood pressure, HDL-C, fasting plasma glucose (FPG) and triglycerides (TG). We also dichotomized the cardiometabolic indicators using the cutoffs for the Metabolic Syndrome and used logistic regression to assess the relationship of the standardized dietary index values with binary cardiometabolic risk factors. We observed diet quality disparities for populations that were Black, Hispanic, low-income, and low-education. Higher diet quality was associated with improved continuous and binary cardiometabolic risk factors, although higher PHDI was not associated with high FPG and was the only index associated with lower TG. These patterns remained consistent in sensitivity analyses.

CONCLUSIONS

Sustainability-focused dietary recommendations such as the PHDI have similar cross-sectional associations with cardiometabolic risk as HEI-2015 or DASH. Health-focused dietary guidelines such as the forthcoming 2025-2030 Dietary Guidelines for Americans can consider the environmental impact of diet and still promote cardiometabolic health.

Impact of taxes and warning labels on red meat purchases among US consumers: A randomized controlled trial

BACKGROUND

Policies to reduce red meat intake are important for mitigating climate change and improving public health. We tested the impact of taxes and warning labels on red meat purchases in the United States. The main study question was, will taxes and warning labels reduce red meat purchases?

METHODS AND FINDINGS

We recruited 3,518 US adults to participate in a shopping task in a naturalistic online grocery store from October 18, 2021 to October 28, 2021. Participants were randomized to one of 4 conditions: control (no tax or warning labels, n = 887), warning labels (health and environmental warning labels appeared next to products containing red meat, n = 891), tax (products containing red meat were subject to a 30% price increase, n = 874), or combined warning labels + tax (n = 866). We used fractional probit and Poisson regression models to assess the co-primary outcomes, percent, and count of red meat purchases, and linear regression to assess the secondary outcomes of nutrients purchased. Most participants identified as women, consumed red meat 2 or more times per week, and reported doing all of their household's grocery shopping. The warning, tax, and combined conditions led to lower percent of red meat-containing items purchased, with 39% (95% confidence interval (CI) [38%, 40%]) of control participants' purchases containing red meat, compared to 36% (95% CI [35%, 37%], p = 0.001) of warning participants, 34% (95% CI [33%, 35%], p < 0.001) of tax participants, and 31% (95% CI [30%, 32%], p < 0.001) of combined participants. A similar pattern was observed for count of red meat items. Compared to the control, the combined condition reduced calories purchased (-312.0 kcals, 95% CI [-590.3 kcals, -33.6 kcals], p = 0.027), while the tax (-10.4 g, 95% CI [-18.2 g, -2.5 g], p = 0.01) and combined (-12.8 g, 95% CI [-20.7 g, -4.9 g], p = 0.001) conditions reduced saturated fat purchases; no condition affected sodium purchases. Warning labels decreased the perceived healthfulness and environmental sustainability of red meat, while taxes increased perceived cost. The main limitations were that the study differed in sociodemographic characteristics from the US population, and only about 30% to 40% of the US population shops for groceries online.

CONCLUSIONS

Warning labels and taxes reduced red meat purchases in a naturalistic online grocery store. Trial Registration: http://www.clinicaltrials.gov/ NCT04716010.

Women's empowerment, production choices, and crop diversity in Burkina Faso, India, Malawi, and Tanzania: a secondary analysis of cross-sectional data

BACKGROUND

Bolstering farm-level crop diversity is one strategy to strengthen food system resilience and achieve global food security. Women who live in rural areas play an essential role in food production; therefore, we aimed to assess the associations between women's empowerment and crop diversity.

METHODS

In this secondary analysis of cross-sectional data, we used data from four cluster-randomised controlled trials done in Burkina Faso, India, Malawi, and Tanzania. We assessed women's empowerment using indicators from the Women's Empowerment in Agriculture Index. Farm-level crop diversity measures were the number of food crops grown, number of food groups grown, and if nutrient-dense crops were grown. We used a two-stage modelling approach. First, we analysed covariate-adjusted country-specific associations between women's empowerment and crop diversity indicators using multivariable generalised linear models. Second, we pooled country-specific associations using random-effects models.

FINDINGS

The final analytic sample included 1735 women from Burkina Faso, 4450 women from India, 547 women from Malawi, and 574 women from Tanzania. Across all countries, compared with households in which women provided input into fewer productive decisions, households of women with greater input into productive decisions produced more food crops (mean difference 0·36 [95% CI 0·16-0·55]), a higher number of food groups (mean difference 0·16 [0·06-0·25]), and more nutrient-dense crops (percentage point difference 3 [95% CI 3-4]). Across all countries, each additional community group a woman actively participated in was associated with cultivating a higher number of food crops (mean difference 0·20 [0·04-0·35]) and a higher number of food groups (mean difference 0·11 [0·03-0·18]), but not more nutrient-dense crops. In pooled associations from Burkina Faso and India, asset ownership was associated with cultivating a higher number of food crops (mean difference 0·08 [0·04-0·12]) and a higher number of food groups (mean difference 0·05 [0·04-0·07]), but not more nutrient-dense crops.

INTERPRETATION

Greater women's empowerment was associated with higher farm-level crop diversity among low-income agricultural households, suggesting that it could help enhance efforts to strengthen food system resilience.

FUNDING

Bill & Melinda Gates Foundation.

Pregnancy pesticide exposure and child development in low- and middle-income countries: A prospective analysis of a birth cohort in rural Bangladesh and meta-analysis

BACKGROUND

Despite considerable evidence on a negative association between pregnancy pesticide exposure and child development in high-income countries, evidence from low- and middle-income countries (LMICs) is limited. Therefore, we assessed associations between pregnancy pesticide exposure and child development in rural Bangladesh and summarised existing literature in a systematic review and meta-analysis.

METHODS

We used data from 284 mother-child pairs participating in a birth cohort established in 2008. Eight urinary pesticide biomarkers were quantified in early pregnancy (mean gestational age 11.6±2.9 weeks) as an index of pesticide exposure. The Bayley Scales of Infant and Toddler Development, Third Edition were administered at 20-40 months of age. Associations between creatinine-adjusted urinary pesticide biomarker concentrations and child development scores were estimated using multivariable generalised linear models. We searched ten databases up to November 2021 to identify prospective studies on pregnancy pesticide exposure and child development conducted in LMICs. We used a random-effects model to pool similar studies, including our original analysis. The systematic review was pre-registered with PROSPERO: CRD42021292919.

RESULTS

In the Bangladesh cohort, pregnancy 2-isopropyl-4-methyl-6-hydroxypyrimidine (IMPY) concentrations were inversely associated with motor development (-0.66 points [95% CI -1.23, -0.09]). Pregnancy 3,5,6-trichloro-2-pyridinol (TCPY) concentrations were inversely associated with cognitive development, but the association was small: -0.02 points (-0.04, 0.01). We observed no associations between 4-nitrophenol and 3-phenoxybenzoic acid (3-PBA) concentrations and child development. The systematic review included 13 studies from four LMICs. After pooling our results with one other study, we found consistent evidence that pregnancy 3-PBA concentrations were not associated with cognitive, language, or motor development.

CONCLUSION

Evidence suggests that pregnancy exposure to some organophosphate pesticides is negatively associated with child development. Interventions to reduce in-utero pesticide exposure in LMICs may help protect child development.

Maternal and paternal employment in agriculture and early childhood development: A cross-sectional analysis of Demographic and Health Survey data

Considerable literature from low- and lower-middle-income countries (LLMICs) links maternal employment to child nutritional status. However, less is known about the role of parental employment and occupation type in shaping child development outcomes. Additionally, little empirical work has examined the mechanisms through which parental occupation influences child outcomes. Our objective was to investigate the associations between maternal and paternal employment (comparing agricultural and non-agricultural employment) and child development and to examine childcare practices and women's empowerment as potential mechanisms. We pooled nine Demographic and Health Surveys (Benin, Burundi, Cambodia, Congo, Haiti, Rwanda, Senegal, Togo, and Uganda) with data on 8,516 children aged 36-59 months. We used generalised linear models to estimate associations between parental employment and child development, child stimulation (number of activities provided by the mother, father, and other household members), child supervision (not left alone or with older child for >1 hour), early childhood care and education programme (ECCE) attendance, and women's empowerment. In our sample, all fathers and 85% of mothers were employed. In 40% of families, both parents were employed in agriculture. After adjusting for child, parental and household confounders, we found that parental agricultural employment, relative to non-agricultural employment, was associated with poorer child development (relative risk (RR) 0.86 (95% CI 0.80, 0.92), more child stimulation provided by other household members (mean difference (MD) 0.26 (95% CI 0.09, 0.42)), less adequate child supervision (RR, 0.83 (95% 0.78, 0.80)), less ECCE attendance (RR 0.46 (95% CI 0.39, 0.54)), and lower women's empowerment (MD -1.01 (95% CI -1.18, -0.84)). Parental agricultural employment may be an important risk factor for early childhood development. More research using more comprehensive exposure and outcome measures is needed to unpack these complex relationships and to inform interventions and policies to support working parents in the agricultural sector with young children.

Pesticide exposure and child growth in low- and middle-income countries: A systematic review

BACKGROUND

In low- and middle-income countries (LMICs), pesticides are widely used in agricultural and residential settings. Little is known about how pesticides affect child growth.

OBJECTIVES

To systematically review and synthesise the evidence on the associations between pesticide exposure and adverse birth outcomes and/or impaired postnatal growth in children up to 5 years of age in LMICs.

METHODS

We searched 10 databases from inception through November 2021. We included cohort and cross-sectional studies investigating associations between self-reported or measured prenatal or postnatal pesticide exposure and child growth (postnatal child linear/ponderal growth, and/or birth outcomes). Two researchers screened studies, extracted data, and assessed certainty using GRADE. The protocol was preregistered with PROSPERO (CRD42021292919).

RESULTS

Of 939 records retrieved, 31 studies met inclusion criteria (11 cohort, 20 cross-sectional). All studies assessed prenatal exposure. Twenty-four studies reported on birth weight. Four found positive associations with organochlorines (0.01-0.25 standardised mean difference (SMD)) and two found negative associations (-0.009 SMD to -55 g). Negative associations with organophosphates (-170 g, n = 1) and pyrethroids (-97 to -233 g, n = 2) were also documented. Two (out of 15) studies reporting on birth length found positive associations with organochlorines (0.21-0.25 SMD) and one found negative associations (-0.25 to -0.32 SMD). Organophosphate exposure was negatively associated with birth length (-0.37 cm, n = 1). Organophosphate exposure was also associated with higher risk/prevalence of low birth weight (2 out of nine studies) and preterm birth (2 out of six studies). Certainty of the evidence was "very low" for all outcomes.

CONCLUSION

The limited literature from LMICs shows inconclusive associations between prenatal pesticide exposure, child growth, and birth outcomes. Studies with accurate quantitative data on exposure to commonly used pesticides in LMICs using consistent methodologies in comparable populations are needed to better understand how pesticides influence child growth.

The socioeconomic gradient of alcohol use: an analysis of nationally representative survey data from 55 low-income and middle-income countries

BACKGROUND

Alcohol is a leading risk factor for over 200 conditions and an important contributor to socioeconomic health inequalities. However, little is known about the associations between individuals' socioeconomic circumstances and alcohol consumption, especially heavy episodic drinking (HED; ≥5 drinks on one occasion) in low-income or middle-income countries. We investigated the association between individual and household level socioeconomic status, and alcohol drinking habits in these settings.

METHODS

In this pooled analysis of individual-level data, we used available nationally representative surveys-mainly WHO Stepwise Approach to Surveillance surveys-conducted in 55 low-income and middle-income countries between 2005 and 2017 reporting on alcohol use. Surveys from participants aged 15 years or older were included. Logistic regression models controlling for age, country, and survey year stratified by sex and country income groups were used to investigate associations between two indicators of socioeconomic status (individual educational attainment and household wealth) and alcohol use (current drinking and HED amongst current drinkers).

FINDINGS

Surveys from 336 287 participants were included in the analysis. Among males, the highest prevalence of both current drinking and HED was found in lower-middle-income countries (L-MICs; current drinking 49·9% [95% CI 48·7-51·2] and HED 63·3% [61·0-65·7]). Among females, the prevalence of current drinking was highest in upper-middle-income countries (U-MIC; 29·5% [26·1-33·2]), and the prevalence of HED was highest in low-income countries (LICs; 36·8% [33·6-40·2]). Clear gradients in the prevalence of current drinking were observed across all country income groups, with a higher prevalence among participants with high socioeconomic status. However, in U-MICs, current drinkers with low socioeconomic status were more likely to engage in HED than participants with high socioeconomic status; the opposite was observed in LICs, and no association between socioeconomic status and HED was found in L-MICs.

INTERPRETATION

The findings call for urgent alcohol control policies and interventions in LICs and L-MICs to reduce harmful HED. Moreover, alcohol control policies need to be targeted at socially disadvantaged groups in U-MICs.

FUNDING

Deutsche Forschungsgemeinschaft and the National Center for Advancing Translational Sciences of the US National Institutes of Health.

Developing health and environmental warning messages about red meat: An online experiment

INTRODUCTION

The United States has among the highest per capita red meat consumption in the world. Reducing red meat consumption is crucial for minimizing the environmental impact of diets and improving health outcomes. Warning messages are effective for reducing purchases of products like sugary beverages but have not been developed for red meat. This study developed health and environmental warning messages about red meat and explored participants' reactions to these messages.

METHODS

A national convenience sample of US red meat consumers (n = 1,199; mean age 45 years) completed an online survey in 2020 for this exploratory study. Participants were randomized to view a series of either health or environmental warning messages (between-subjects factor) about the risks associated with eating red meat. Messages were presented in random order (within-subjects factor; 8 health messages or 10 environmental messages). Participants rated each warning message on a validated 3-item scale measuring perceived message effectiveness (PME), ranging from 1 (low) to 5 (high). Participants then rated their intentions to reduce their red meat consumption in the next 7 days.

RESULTS

Health warning messages elicited higher PME ratings than environmental messages (mean 2.66 vs. 2.26, p<0.001). Health warning messages also led to stronger intentions to reduce red meat consumption compared to environmental messages (mean 2.45 vs. 2.19, p<0.001). Within category (health and environmental), most pairwise comparisons of harms were not statistically significant.

CONCLUSIONS

Health warning messages were perceived to be more effective than environmental warning messages. Future studies should measure the impact of these messages on behavioral outcomes.

Impact of large-scale, government legislated and funded organic farming training on pesticide use in Andhra Pradesh, India: a cross-sectional study

BACKGROUND

The use of pesticides in agriculture has been associated with the destruction of biodiversity and damage to human health. A marked reduction in pesticide use is urgently required globally, but whether this can be achieved rapidly and at scale is unclear. We aimed to assess whether government-legislated and funded organic farming training in Andhra Pradesh, India, reduced pesticide use by farmers and sales of pesticides by pesticide retailers.

METHODS

We did a cross-sectional survey between Aug 11 and Nov 26, 2020, among farmers and pesticide retailers in Kurnool District of Andhra Pradesh (India). We assessed the impact of the Andhra Pradesh Community Managed Natural Farming (APCNF) programme, which aims to transition 100% of the agricultural land of Andhra Pradesh (population approximately 49 million, 6 million of whom are farmers) to organic farming practices by 2030. We did cross-sectional phone interview surveys of farmers and face-to-face surveys of pesticide retailers. We used multivariable Poisson regression models to estimate relative risks (RRs) and logistic regression models to estimate odds ratios (ORs).

FINDINGS

962 farmers were invited to participate, of whom 894 (93%) consented (709 conventional farmers and 149 APCNF farmers). 47 pesticide retailers were invited to participate, of whom 38 (81%) consented. APCNF farmers had practised APCNF for a median of 2 years (IQR 1-3). APCNF farmers were less likely to use pesticides than conventional farmers (adjusted RR 0·65 [95% CI 0·57-0·75]), although pesticide use remained high among both APCNF and conventional farmers (73 [49%] of 148 APCNF farmers vs 695 [99%] of 700 conventional farmers; p<0·0001). APCNF farmers had lower pesticide expenditures than conventional farmers (median US$0 [IQR 0-170] for APCNF farmers vs $175 [91-281] for conventional farmers; p=0·0001). Increased frequency of meeting with agricultural extension workers was associated with reduced pesticide use among ACPNF farmers. Seven (18%) of 38 retailers reported a decrease in sales of pesticides in the past 4 years; no difference in the odds of reporting a decrease in pesticide sales in the past 4 years was identified between APCNF retailers and conventional retailers (OR 0·95 [95% CI 0·58-1·57]).

INTERPRETATION

Despite a major government drive for organic agriculture, about half of APCNF farmers continued to use pesticides and no impact on pesticide sales at local retailers was observed. A combination of policy instruments (eg, bans on highly hazardous pesticides), not solely training for farmers, might be needed to eliminate pesticide use in agriculture.

FUNDING

Scottish Funding Council and UK Research and Innovation.

Research Capacity for Prevention and Control of Non-communicable Diseases and their Risk Factors in Nepal: Findings of a Needs Assessment Study

Background Despite a high burden, there are limited trainings in non-communicable disease research in Nepal. Objective We conducted a needs assessment to assess existing research training capacity in academic health institutions of Nepal for the prevention and control of noncommunicable diseases, identify gaps in research, and explore the feasibility of developing research training program in Nepal targeting non-communicable diseases. Method We did mixed-method research and reviewed academic institution curricula and scientific articles authored by Nepali researchers. We conducted 14 Focus Group Discussions with bachelor and masters level students of public health and community medicine; 25 In-depth Interviews with department heads and faculties, and government stakeholders. We surveyed medical and public health students on their research knowledge and skills development. Result Research methodology component was addressed differently across academic programs. One-third (33.7%) of students expressed lack of skills for analysis and interpretation of data. They felt that there is a wide scope and career-interest in non-communicable diseases research in Nepal. However, specific objectives in the curriculum and practical aspects regarding non-communicable diseases were lacking. Most of the non-communicable diseases research in Nepal are prevalence studies. Lack of funding, conflicting priorities with curative services, and inadequate training for advanced research tools were reported as major barriers. Conclusion Nepal must strengthen the whole spectrum of research capacity: epidemiological skills, research management, and fund development. Generation of a critical mass of non-communicable disease researchers must go together with improved funding from the government, non-governmental, and external funding organizations.

Awareness of and reactions to health and environmental harms of red meat among parents in the United States

OBJECTIVE

Evidence of the health and environmental harms of red meat is growing, yet little is known about which harms may be most impactful to include in meat reduction messages. This study examined which harms consumers are most aware of and which most discourage them from wanting to eat red meat.

DESIGN

Within-subjects randomised experiment. Participants responded to questions about their awareness of, and perceived discouragement in response to, eight health and eight environmental harms of red meat presented in random order. Discouragement was assessed on a 1-to-5 Likert-type scale.

SETTING

Online survey.

PARTICIPANTS

544 US parents.

RESULTS

A minority of participants reported awareness that red meat contributes to health harms (ranging from 8 % awareness for prostate cancer to 28 % for heart disease) or environmental harms (ranging from 13 % for water shortages and deforestation to 22 % for climate change). Among specific harms, heart disease elicited the most discouragement (mean = 2·82 out of 5), followed by early death (mean = 2·79) and plants and animals going extinct (mean = 2·75), though most harms elicited similar discouragement (range of means, 2·60-2·82). In multivariable analyses, participants who were younger, identified as Black, identified as politically liberal, had higher general perceptions that red meat is bad for health and had higher usual red meat consumption reported being more discouraged from wanting to eat red meat in response to health and environmental harms (all P < 0·05).

CONCLUSIONS

Messages about a variety of health and environmental harms of red meat could inform consumers and motivate reductions in red meat consumption.

How Americans eat red and processed meat: an analysis of the contribution of thirteen different food groups

OBJECTIVE

Dietary patterns characterised by high intake of red and processed meat are associated with detrimental health and environmental outcomes. To better understand how Americans consume red and processed meat, this study examined the food groups that are the greatest contributors to red and processed meat intake in US diets.

DESIGN

Cross-sectional analysis of total red and processed meat, unprocessed red meat and processed meat using data from the National Health and Nutrition Examination Survey (2015-2016 and 2017-2018). Items containing red or processed meat were classified into thirteen mutually exclusive food groups. For highly consumed food groups (≥10 % of meat intake), contribution to meat intake was further assessed by source, sex, income and education.

SETTING

Nationally representative sample of the US population.

PARTICIPANTS

Teens (aged 12-19 years) and adults (aged ≥20 years) who reported meat consumption (n 8178).

RESULTS

Meat mixed dishes (18·6 % (95 % CI 16·2, 20·9)), burgers (17·3 % (95 % CI 15·3, 19·3)) and beef excluding ground (17·0 % (95 % CI 13·8, 20·1)) were the top contributors to unprocessed red meat intake. For processed meat, four food groups made up about four-fifths of total intake: cold cuts and cured meats (37·7 % (95 % CI 34·6, 40·8)), sausages and frankfurters (20·3 % (95 % CI 18·6, 22·0)), bacon (14·0 % (95 % CI 12·3, 15·6)) and pizza (10·1 % (95 % CI 8·7, 11·5)). Fast-food restaurants were the top source for burgers and pizza, whereas stores were the top source for all other highly consumed food groups. Few differences were seen in patterns of intake by sociodemographic characteristics.

CONCLUSIONS

No single food group accounts for a majority of meat intake in the USA. Many behaviour change opportunities for healthier, more sustainable substitutions exist.

A Community-Based Noncommunicable Disease Prevention Intervention in Punjab, India: Baseline Characteristics of 11,322 Adults

Background

Noncommunicable diseases (NCD) are the leading cause of death in India, with cardiovascular diseases (CVD) in particular accounting for nearly 1 in 3 deaths. The prevention of key CVD risk factors - namely, diabetes and hypertension - is a public health priority.

Objectives

The objective is to describe the results of large-scale, community-based NCD screening using the Government of India's Community Based Assessment Checklist (CBAC) scoring system.

Materials and Methods

Trained enumerators visited each household in 10 villages in Punjab, India, between September 2019 and March 2020. Standardized methods were used to measure blood pressure, blood glucose, waist circumference, family medical history, and lifestyle behaviors.

Results

A total of 11,322 adults (52.1% women; mean age 48.3 years) completed the assessment and 14.4% were classified as high-risk (CBAC >4). Those classified as high-risk were significantly more likely to have hypertension (46.0% vs. 20.6% among low-risk, P < 0.0001) and diabetes (12.0% vs. 7.7%, P < 0.0001). Only 26.8% of those with hypertension were diagnosed and only 14.9% treated. Proportions among those with diabetes were similarly low: 29.2% diagnosed and 16.0% treated.

Conclusions

To the best of our knowledge, this is the first study to estimate the prevalence of high-risk CBAC scores in a population-based sample. Given that the Government of India aims to undertake population-based screening of all adults >30 years for NCDs, the results of this study are directly translatable.

Patterns of multimorbidity in India: A nationally representative cross-sectional study of individuals aged 15 to 49 years

There is a dearth of evidence on the epidemiology of multimorbidity in low- and middle-income countries. This study aimed to determine the prevalence of multimorbidity in India and its variation among states and population groups. We analyzed data from a nationally representative household survey conducted in 2015-2016 among individuals aged 15 to 49 years. Multimorbidity was defined as having two or more conditions out of five common chronic morbidities in India: anemia, asthma, diabetes, hypertension, and obesity. We disaggregated multimorbidity prevalence by condition, state, rural versus urban areas, district-level wealth, and individual-level sociodemographic characteristics. 712,822 individuals were included in the analysis. The prevalence of multimorbidity was 7·2% (95% CI, 7·1% - 7·4%), and was higher in urban (9·7% [95% CI, 9·4% - 10·1%]) than in rural (5·8% [95% CI, 5·7% - 6·0%]) areas. The three most prevalent morbidity combinations were hypertension with obesity (2·9% [95% CI, 2·8% - 3·1%]), hypertension with anemia (2·2% [95% CI, 2·1%- 2·3%]), and obesity with anemia (1·2% [95% CI, 1·1%- 1·2%]). The age-standardized multimorbidity prevalence varied from 3·4% (95% CI: 3·0% - 3·8%) in Chhattisgarh to 16·9% (95% CI: 13·2% - 21·5%) in Puducherry. Being a woman, being married, not currently smoking, greater household wealth, and living in urban areas were all associated with a higher risk of multimorbidity. Multimorbidity is common among young and middle-aged adults in India. This study can inform screening guidelines for chronic conditions and the targeting of relevant policies and interventions to those most in need.

A Direct Assessment of the External Domain of Food Environments in the National Capital Region of India

Data on food environments in India and other low- and middle-income countries are scarce. The objective of this study was to assess the four dimensions of the external domain of food environments (availability, price, vendor and product properties, and marketing) in food establishments in the National Capital Region of India. The assessment focused on fruits, vegetables, and ultra-processed foods. The 60 food establishments surveyed were categorized as stores, restaurants, or mobile food vendors. Only 13.3% of food establishments sold fruits and vegetables. Stores were more likely to sell vegetables than mobile food vendors (14.8 vs. 6.2%, respectively) and sold a greater variety of both fruits and vegetables as compared to mobile food vendors [mean (SD) of 8.6 (3.2) fruits and 18.6 (9.2) vegetables available at stores vs. 5.5 (5.7) fruits and 25 vegetables available at the one mobile food vendor who sold vegetables]. However, these healthy food items were more expensive at stores. The availability (100% of stores, 12.5% of mobile food vendors, and 12.5% of restaurants) and variety (156 types) of ultra-processed foods across food establishments were higher than fruits and vegetables. A greater percentage of food establishments displayed advertisements for ultra-processed foods as compared to unprocessed or minimally processed foods such as fruits and vegetables. The National Capital Region of India has an unhealthy food environment. Regulations that limit the availability of ultra-processed foods and improve the availability and affordability of fruits and vegetables are needed to reverse the rising tide of chronic non-communicable diseases in this setting.

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.

Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys

BACKGROUND

As the prevalence of hypercholesterolemia is increasing in low- and middle-income countries (LMICs), detailed evidence is urgently needed to guide the response of health systems to this epidemic. This study sought to quantify unmet need for hypercholesterolemia care among adults in 35 LMICs.

METHODS AND FINDINGS

We pooled individual-level data from 129,040 respondents aged 15 years and older from 35 nationally representative surveys conducted between 2009 and 2018. Hypercholesterolemia care was quantified using cascade of care analyses in the pooled sample and by region, country income group, and country. Hypercholesterolemia was defined as (i) total cholesterol (TC) ≥240 mg/dL or self-reported lipid-lowering medication use and, alternatively, as (ii) low-density lipoprotein cholesterol (LDL-C) ≥160 mg/dL or self-reported lipid-lowering medication use. Stages of the care cascade for hypercholesterolemia were defined as follows: screened (prior to the survey), aware of diagnosis, treated (lifestyle advice and/or medication), and controlled (TC <200 mg/dL or LDL-C <130 mg/dL). We further estimated how age, sex, education, body mass index (BMI), current smoking, having diabetes, and having hypertension are associated with cascade progression using modified Poisson regression models with survey fixed effects. High TC prevalence was 7.1% (95% CI: 6.8% to 7.4%), and high LDL-C prevalence was 7.5% (95% CI: 7.1% to 7.9%). The cascade analysis showed that 43% (95% CI: 40% to 45%) of study participants with high TC and 47% (95% CI: 44% to 50%) with high LDL-C ever had their cholesterol measured prior to the survey. About 31% (95% CI: 29% to 33%) and 36% (95% CI: 33% to 38%) were aware of their diagnosis; 29% (95% CI: 28% to 31%) and 33% (95% CI: 31% to 36%) were treated; 7% (95% CI: 6% to 9%) and 19% (95% CI: 18% to 21%) were controlled. We found substantial heterogeneity in cascade performance across countries and higher performances in upper-middle-income countries and the Eastern Mediterranean, Europe, and Americas. Lipid screening was significantly associated with older age, female sex, higher education, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Awareness of diagnosis was significantly associated with older age, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Lastly, treatment of hypercholesterolemia was significantly associated with comorbid hypertension and diabetes, and control of lipid measures with comorbid diabetes. The main limitations of this study are a potential recall bias in self-reported information on received health services as well as diminished comparability due to varying survey years and varying lipid guideline application across country and clinical settings.

CONCLUSIONS

Cascade performance was poor across all stages, indicating large unmet need for hypercholesterolemia care in this sample of LMICs-calling for greater policy and research attention toward this cardiovascular disease (CVD) risk factor and highlighting opportunities for improved prevention of CVD.

Testing front-of-package warnings to discourage red meat consumption: a randomized experiment with US meat consumers

BACKGROUND

Reducing red meat is a strategy to improve public health and mitigate climate change in the United States and other high-income countries. Policies requiring warnings on the front of red meat packages are a promising intervention to shift consumers towards healthier and more sustainable food choices. We aimed to explore participants' reactions to health and environmental warning messages about red meat.

METHODS

Between June and July 2020, we recruited a national convenience sample of US red meat consumers (n = 1,235; mean age 44 years) for an online survey. Participants were randomly assigned to one of four label conditions: no-label control, health warning, environment warning, and combined health and environment warning (both warnings shown side-by-side). Participants viewed three types of burritos (red meat [steak], chicken, and vegetarian) and selected their preferred item (primary outcome), the item they perceived to be most damaging to health, and the item they perceived to be most damaging to the environment (secondary outcomes). Participants then viewed their assigned warning on a series of other red meat products (no-label control participants were randomly re-assigned to one of the warning conditions) and rated the warnings on perceived message effectiveness, believability, negative emotions, perceived risk, attention, and learning something new. Finally, participants reported their intentions to reduce red meat consumption.

RESULTS

There were no significant differences in selection of the steak burrito between label conditions or in selection of the item most damaging to the environment. Those exposed to the health warning were more likely to select the steak burrito as most damaging to health compared to those exposed to other label conditions (health 73 %, combined 64 %, environment 60 %, no-label control 63 %, p < 0.05). The combined and health warnings elicited higher perceived message effectiveness ratings than the environment warning (combined mean 2.91, health 2.84, environment 2.61, p < 0.05).

CONCLUSIONS

Warnings did not have a significant effect on item preference in the choice experiment. However, combined and health warnings performed better than the environment warning across a variety of warning label reaction measures. More research will be needed to understand whether warnings elicit behavioral change in real-world environments.

TRIAL REGISTRATION

Analyses and hypotheses were preregistered on https://aspredicted.org/ph7mb.pdf on 23 June 2020.

Targeting Hypertension Screening in Low- and Middle-Income Countries: A Cross-Sectional Analysis of 1.2 Million Adults in 56 Countries

Background

As screening programs in low‐ and middle‐income countries (LMICs) often do not have the resources to screen the entire population, there is frequently a need to target such efforts to easily identifiable priority groups. This study aimed to determine (1) how hypertension prevalence in LMICs varies by age, sex, body mass index, and smoking status, and (2) the ability of different combinations of these variables to accurately predict hypertension.

Methods and Results

We analyzed individual‐level, nationally representative data from 1 170 629 participants in 56 LMICs, of whom 220 636 (18.8%) had hypertension. Hypertension was defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or reporting to be taking blood pressure–lowering medication. The shape of the positive association of hypertension with age and body mass index varied across world regions. We used logistic regression and random forest models to compute the area under the receiver operating characteristic curve in each country for different combinations of age, body mass index, sex, and smoking status. The area under the receiver operating characteristic curve for the model with all 4 predictors ranged from 0.64 to 0.85 between countries, with a country‐level mean of 0.76 across LMICs globally. The mean absolute increase in the area under the receiver operating characteristic curve from the model including only age to the model including all 4 predictors was 0.05.

Conclusions

Adding body mass index, sex, and smoking status to age led to only a minor increase in the ability to distinguish between adults with and without hypertension compared with using age alone. Hypertension screening programs in LMICs could use age as the primary variable to target their efforts.

Impact of Crop Diversity on Dietary Diversity Among Farmers in India During the COVID-19 Pandemic

Crop diversity is thought to have small, positive impacts on dietary diversity among farming households, particularly when market access is restricted. Policy responses to the COVID-19 pandemic severely restricted market access. To date, no study has explored the relationship between crop and dietary diversity in this context. To address this gap, we used longitudinal data collected from 833 farmers across 12 states in India at three time points between May and August 2020. Dietary diversity was measured using a modified version of the FAO Minimum Dietary Diversity score for women, which has been used in representative samples of the Indian population in both men and women. Eight food groups were included: (1) starchy staples (rice, wheat, and potatoes), (2) pulses, (3) nuts, (4) vegetables, (5) fruits, (6) dairy, (7) eggs, and (8) fleshy foods (meat, poultry, and fish). Multivariate polynomial logistic regression was used to estimate the association between crop and dietary diversity. Models were adjusted for educational attainment, caste, farm size, having a kitchen garden, and livestock ownership. Participants were, on average, 42.2 years old and 94.2% were male. Dietary diversity decreased over the study period, especially between baseline and follow-up 1, when lockdown measures were the most restrictive (34.2% of participants experienced a decline compared to 16.1% from follow-up 1 to follow-up 2). Compared to farmers who cultivated 1 crop (monocroppers), farmers who cultivated 2 crops or 3 or more crops were significantly less likely to experience a decline in dietary diversity from baseline to follow-up 1: adjusted relative risk (RR) (95% confidence interval [CI]), 0.52 (0.35, 0.78) and 0.48 (0.31, 0.75), respectively. There was no significant association between crop diversity and change in dietary diversity from follow-up 1 to follow-up 2, when phased re-opening had begun. These findings suggest that farmers with greater crop diversity in India were more resilient to market disruptions from the COVID-19 pandemic. Thus, while the links between crop and dietary diversity may be small under normal circumstances, diversifying production systems may play an increasingly important role, as there is greater uncertainty due to global events such as pandemics and climate change.

Impact of the COVID-19 pandemic on agricultural production, livelihoods, and food security in India: baseline results of a phone survey

The aim of this study was to evaluate the impact of the COVID-19 lockdown on agricultural production, livelihoods, food security, and dietary diversity in India. Phone interview surveys were conducted by trained enumerators across 12 states and 200 districts in India from 3 to 15 May 2020. A total of 1437 farmers completed the survey (94% male; 28% 30-39 years old; 38% with secondary schooling). About one in ten farmers (11%) did not harvest in the past month with primary reasons cited being unfavorable weather (37%) and lockdown-related reasons (24%). A total of 63% of farmers harvested in the past month (primarily wheat and vegetables), but only 44% had sold their crop; 12% were still trying to sell their crop, and 39% had stored their crop, with more than half (55%) reporting lockdown-related issues as the reason for storing. Seventy-nine percent of households with wage-workers witnessed a decline in wages in the past month and 49% of households with incomes from livestock witnessed a decline. Landless farmers were about 10 times more likely to skip a meal as compared to large farmers (18% versus 2%), but a majority reported receiving extra food rations from the government. Nearly all farmers reported consuming staple grains daily in the past week (97%), 63% consumed dairy daily, 40% vegetables daily, 26% pulses daily, and 7% fruit daily. These values are much lower than reported previously for farmers in India around this time of year before COVID-19: 94-95% dairy daily, 57-58% pulses daily, 64-65% vegetables daily, and 42-43% fruit daily. In conclusion, we found that the COVID-19 lockdown in India has primarily impacted farmers' ability to sell their crops and livestock products and decreased daily wages and dietary diversity.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12571-021-01164-w.

Investigating sex differences in the accuracy of dietary assessment methods to measure energy intake in adults: a systematic review and meta-analysis

BACKGROUND

To inform the interpretation of dietary data in the context of sex differences in diet-disease relations, it is important to understand whether there are any sex differences in accuracy of dietary reporting.

OBJECTIVE

To quantify sex differences in self-reported total energy intake (TEI) compared with a reference measure of total energy expenditure (TEE).

METHODS

Six electronic databases were systematically searched for published original research articles between 1980 and April 2020. Studies were included if they were conducted in adult populations with measures for both females and males of self-reported TEI and TEE from doubly labeled water (DLW). Studies were screened and quality assessed independently by 2 authors. Random-effects meta-analyses were conducted to pool the mean differences between TEI and TEE for, and between, females and males, by method of dietary assessment.

RESULTS

From 1313 identified studies, 31 met the inclusion criteria. The studies collectively included information on 4518 individuals (54% females). Dietary assessment methods included 24-h recalls (n = 12, 2 with supplemental photos of food items consumed), estimated food records (EFRs; n = 11), FFQs (n = 10), weighed food records (WFRs, n = 5), and diet histories (n = 2). Meta-analyses identified underestimation of TEI by females and males, ranging from -1318 kJ/d (95% CI: -1967, -669) for FFQ to -2650 kJ/d (95% CI: -3492, -1807) for 24-h recalls for females, and from -1764 kJ/d (95% CI: -2285, -1242) for FFQ to -3438 kJ/d (95% CI: -5382, -1494) for WFR for males. There was no difference in the level of underestimation by sex, except when using EFR, for which males underestimated energy intake more than females (by 590 kJ/d, 95% CI: 35, 1,146).

CONCLUSION

Substantial underestimation of TEI across a range of dietary assessment methods was identified, similar by sex. These underestimations should be considered when assessing TEI and interpreting diet-disease relations.

Availability and Nutrient Composition of Vegetarian Items at US Fast-Food Restaurants

BACKGROUND

Consumer demand for vegetarian options is growing. Fast-food restaurants have responded by adding high-profile vegetarian offerings, but little is known about the overall availability or nutrient profile of vegetarian options at these establishments, or how these items compare with nonvegetarian items.

OBJECTIVE

The purpose of this study was to quantify trends in the availability and nutrient profile of vegetarian items in US fast-food restaurants from 2012 to 2018.

DESIGN

This study was a longitudinal analysis of secondary data. We used nutrient data from the MenuStat database for menu offerings at 36 large US fast-food chain restaurants (2012 to 2018). Vegetarian items were identified through automated key word searches and item description hand-coding.

OUTCOME MEASURES

Annual counts and proportions of vegetarian and nonvegetarian items by category, and annual trends and differences in predicted mean calories; saturated, unsaturated, and trans fats; sugar; nonsugar carbohydrates; protein; sodium between and within vegetarian and nonvegetarian items.

STATISTICAL ANALYSIS PERFORMED

We report counts and proportions of vegetarian items by menu category, then use Tobit regression models to examine annual trends and differences in predicted mean nutrients between and within vegetarian and nonvegetarian items. Sensitivity analyses were calorie-adjusted.

RESULTS

The annual proportion of vegetarian items remained consistent (approximately 20%), and counts increased (2012, n = 601; 2018, n = 713). Vegetarian items had significantly fewer calories (2018: -95 kcal) and, even after adjustment for calories, lower saturated fat (-1.6 g), unsaturated fat (-1.8 g), protein (-3.8 g), and sodium (-62 mg) annually (P < .05) compared with nonvegetarian items. Vegetarian items were significantly higher in sugar (2018: +2.0 g; P < .01) and nonsugar carbohydrates (2018: +9.7 g; P < .01), after calorie adjustment, compared with nonvegetarian items.

CONCLUSIONS

Vegetarian items were generally lower in several overconsumed nutrients of public health concern (eg, sodium and saturated fat) than nonvegetarian items, but nutrient changes suggest surveillance remains important as vegetarian options increase in popularity.

Prevalence and Correlates of Cardio-Metabolic Risk Factors Among Regular Street Food Consumers in Dar es Salaam, Tanzania

BACKGROUND

Regular street food consumers (RSFCs) in Africa are at an increased risk of unhealthy eating practices, which have been associated with intermediate risk factors of cardio-metabolic diseases. However, knowledge of the magnitude and correlates of these risk factors is limited in Tanzania. This study aimed to fill this gap using data collected from RSFCs in Dar es Salaam, the largest city in Tanzania.

METHODOLOGY

A cross-sectional study was carried out among 560 RSFCs in three districts of Dar es Salaam between July and September 2018. Information on socio-economic factors and demographics, behavioral risks, anthropometric and biochemical indicators was collected. Adjusted odds ratios (OR) and prevalence ratio (PR) with corresponding 95% confidence intervals (CI) were estimated using multivariable binary logistic and modified Poisson regression models, respectively.

RESULTS

On average, participants consumed 11 street food meals/week. The prevalence (95% CI) of cardio-metabolic risk factors was 63.9% (60.6-69.9%) for overweight/obesity, 42.5% (38.3-46.9%) for raised blood pressure, 13.5% (10.9-16.8%) for raised triglycerides and 6.6% (4.9-9.3%) for raised glucose levels. The correlates of overweight/obesity were female vs male sex (APR=1.3; 95% CI 1.2-1.5), age of 41-64 vs 25-40 years (APR=1.4; 95% CI 1.2-1.6), high vs low income (APR=1.2; 95% CI 1.04-1.3), being married/cohabiting vs other (APR=1.2; 95% CI 1.01-1.4) and family history of diabetes vs no family history (APR=1.2; 95% CI 1.01-1.3). Age 41-64 vs 25-40 years, was the only significant factor associated with raised blood pressure APR (95% CI) 2.2 (1.7-2.9) and raised glucose AOR (95% CI) 3.9 (1.5-10.5).

CONCLUSION

Our study revealed that RSFCs are at risk of cardio-metabolic health problems, especially women, middle-aged people and those with higher incomes. Transdisciplinary studies to understand the drivers of street food consumption are needed in order to inform interventions to mitigate the risk of developing cardio-metabolic diseases. These interventions should target both street food vendors and their consumers.

Per- and polyfluoroalkyl substance plasma concentrations and metabolomic markers of type 2 diabetes in the Diabetes Prevention Program trial

BACKGROUND

Per- and polyfluoroalkyl substances (PFAS) are widely used chemicals, some of which have been linked to type 2 diabetes. We tested whether PFAS concentrations were cross-sectionally associated with metabolites previously shown to predict incident type 2 diabetes using the Diabetes Prevention Program (DPP), a trial of individuals at high risk of type 2 diabetes.

METHODS

We evaluated 691 participants enrolled in the DPP with baseline measures of 10 PFAS (including total perfluorooctanesulfonic acid (PFOS), total perfluorooctanoic acid (PFOA), and Sb-PFOA [branched isomers of PFOA]) and 77 metabolites. We used log2-transformed PFAS concentrations as exposures and standardized metabolite concentrations as outcomes in linear regression models adjusted for age, sex, race/ethnicity, use of anti-hyperlipidemic or triglyceride-lowering medication, income, years of education, marital status, smoking, and family history of diabetes, with Benjamini-Hochberg linear step-up false discovery rate correction.

RESULTS

Sb-PFOA was associated with the largest number of tested metabolites (29 of 77). Each doubling in Sb-PFOA was associated with higher leucine (β = 0.07 [95%CI: 0.02, 0.11] SD) and lower glycine (-0.08 [95%CI: 0.03, -0.13] SD). Each doubling of either total PFOA or n-PFOA was associated with -0.13 [95%CI: 0.04, -0.22] SD lower glycine. PFOA and Sb-PFOA were positively associated with multiple triacylglycerols and diacylglycerols, and total PFOS, total PFOA, and Sb-PFOA were positively associated with phosphatidylethanolamines.

CONCLUSIONS

PFAS concentrations are associated with metabolites linked to type 2 diabetes (particularly amino acid, glycerolipid and glycerophospholipid pathways). Further prospective research is needed to test whether these metabolites mediate associations of PFAS and type 2 diabetes.

Patterns of Red and Processed Meat Consumption across North America: A Nationally Representative Cross-Sectional Comparison of Dietary Recalls from Canada, Mexico, and the United States

Close economic ties encourage production and trade of meat between Canada, Mexico, and the US. Understanding the patterns of red and processed meat consumption in North America may inform policies designed to reduce meat consumption and bolster environmental and public health efforts across the continent. We used nationally-representative cross-sectional survey data to analyze consumption of unprocessed red meat; processed meat; and total red and processed meat. Generalized linear models were used to separately estimate probability of consumption and adjusted mean intake. Prevalence of total meat consumers was higher in the US (73.6, 95% CI: 72.3-74.8%) than in Canada (65.6, 63.9-67.2%) or Mexico (62.7, 58.1-67.2%). Men were more likely to consume unprocessed red, processed, and total meat, and had larger estimated intakes. In Mexico, high wealth individuals were more likely to consume all three categories of meat. In the US and Canada, those with high education were less likely to consume total and processed meat. Estimated mean intake of unprocessed red, processed, and total meat did not differ across sociodemographic strata. Overall consumption of red and processed meat remains high in North America. Policies to reduce meat consumption are appropriate for all three countries.

Food purchasing decisions of Malawian mothers with young children in households experiencing the nutrition transition

As overweight/obesity prevalence increases in sub-Saharan Africa, information is needed about factors influencing food purchases in households with overweight members. This study assessed food purchasing decisions of Malawian mothers with young children (N = 54 dry season, N = 55 rainy season) among whom the mother, child, or both were overweight. Research assistants completed structured observations of mothers shopping for food during the dry season and of the types and quantities of foods in mothers' homes during the rainy season. After each observation, research assistants conducted an in-depth interview about factors that influenced food purchases, including asking mothers to sort 12 factors into piles that always, sometimes, or never influence their food purchases. Observations showed mothers most often shopped at outdoor markets to buy foods needed to prepare relish, such as tomatoes (71%), green leafy vegetables (58%), cooking oil (58%), and fish (40%). At home, maize flour (80%) and salt (66%) were the most common foods. Pile sorts and in-depth interviews revealed cost, taste preferences, freshness, and healthiness were the strongest factors influencing food purchases. Mothers described buying a smaller quantity or making substitutions (e.g., fish instead of meat) if a food is too expensive. Many mothers reported buying foods their family likes and prioritizing children's preferences. Freshness of foods, especially fruits and vegetables, and whether foods were perceived to be healthy also influenced food purchases, but mothers' knowledge of which foods were healthy was mixed. Mothers used some of their minimal funds to buy unhealthy foods (e.g., packaged or fried snacks) for their children, despite their overall emphasis on food cost and healthiness. These findings can be used by programs to reinforce healthy and decrease unhealthy food purchases by mothers with young children in Malawi.

Association between duration of residence and prevalence of type 2 diabetes among male South Asian expatriate workers in the United Arab Emirates: a cross-sectional study

Expatriates account for about 80% of the total population in the United Arab Emirates (UAE). This study aimed to evaluate the hypothesis that prevalence of type 2 diabetes in male South Asian expatriates increases with increased length of residence in the UAE.

DESIGN, SETTINGS AND PARTICIPANTS

This cross-sectional study recruited a representative sample (n=1375) of male South Asian expatriates aged ≥18 years in Al Ain, UAE. Sociodemographic, anthropometric and lifestyle data were obtained using a pilot-tested adapted version of the WHO STEPS instrument.

MAIN OUTCOME MEASURES

Duration of residence was used as a marker for acculturation. Type 2 diabetes was defined as a self-reported physician diagnosis of diabetes or a glycosylated haemoglobin blood level ≥6.5%.

RESULTS

Mean (±SD) age of participants was 34.0±9.9 years. Overall, the prevalence of type 2 diabetes was 8.3% (95% CI 6.8% to 9.8%). Diabetes prevalence was positively associated with longer duration of residence in the UAE, 2.7%, <5 years; 8.2%, 5-10 years; and 18.8%, >10 years. After adjusting for age, nationality, and income and age, expatriates were more likely to develop diabetes if residing in the UAE for 5-10 years (OR=2.18; 95% CI 1.02 to 4.67) or >10 years (OR=3.23; 95% CI 1.52 to 6.85) compared with those residing for <5 years.

CONCLUSIONS

After controlling for potential confounding factors, longer duration of residence was significantly associated with a higher prevalence of type 2 diabetes in male South Asian expatriate workers in the UAE.

Drivers of food consumption among overweight mother-child dyads in Malawi

To address the increase in overweight and obesity among mothers and children in sub-Saharan Africa, an understanding of the factors that drive their food consumption is needed. We hypothesized food consumption in Malawi is driven by a combination of factors, including season, food accessibility (area of residence, convenience of purchasing food, female autonomy), food affordability (household resources, food expenditures, household food insecurity), food desirability (taste preferences, body size preferences), demographics, and morbidity. Participants in Lilongwe and Kasungu Districts were enrolled across three types of mother-child dyads: either the mother (n = 120), child (n = 80), or both (n = 74) were overweight. Seven-day dietary intake was assessed using a quantitative food frequency questionnaire during the dry and rainy seasons. Drivers associated with intake of calories, macronutrients, and 11 food groups at p<0.1 in univariate models were entered into separate multivariate linear regression models for each dietary intake outcome. Mother-child dyads with an overweight child had a higher percent of calories from carbohydrates and lower percent of calories from fat compared to dyads with a normal weight child (both p<0.01). These mothers also had the highest intake of grains (p<0.01) and their children had the lowest intake of oil/fat (p = 0.01). Household food insecurity, maternal taste preferences, and maternal body size preferences were the most consistent predictors of food group consumption. Household food insecurity was associated with lower intake of grains, fruits, meat and eggs, oil/fat, and snacks. Maternal taste preferences predicted increased consumption of grains, legumes/nuts, vegetables, fish, and oil/fat. Maternal body size preferences for herself and her child were associated with consumption of grains, legumes/nuts, dairy, and sweets. Predictors of food consumption varied by season, across food groups, and for mothers and children. In conclusion, indicators of food affordability and desirability were the most common predictors of food consumption among overweight mother-child dyads in Malawi.

Diet quality, weight loss, and diabetes incidence in the Diabetes Prevention Program (DPP)

BACKGROUND

We evaluated whether diet quality is a predictor of weight loss and reduced diabetes risk, independent of caloric intake in the Diabetes Prevention Program (DPP) cohort, a randomized clinical trial of adults at risk for diabetes.

METHODS

This secondary analysis included 2914 participants with available data (964 intensive lifestyle (ILS), 977 metformin, 973 placebo). Dietary intake was assessed using a 117-item food frequency questionnaire. Diet quality was quantified using the Alternative Healthy Eating Index 2010 (AHEI). AHEI ranges from 0 to 110, with higher scores corresponding to higher quality diets. ILS participants had greater improvement (p < 0.001) in AHEI over 1-year (4.2 ± 9.0) compared to metformin (1.2 ± 8.5) and placebo (1.4 ± 8.4). We examined the association between AHEI change and weight change from baseline to 1-year using linear regression, and that between 1-year AHEI change and incident diabetes, using hazard models over an average 3 years follow-up. Models were evaluated within treatment group and adjusted for relevant characteristics including caloric intake, physical activity, BMI and AHEI. Models testing incident diabetes were further adjusted for baseline fasting and 2 h glucose.

RESULTS

An increase in AHEI score was associated with weight loss in ILS [β per 10-point increase (SE) -1.2 kg (0.3, p < 0.001)], metformin [- 0. 90 kg (0.2, p < 0.001)] and placebo [- 0.55 kg (0.2, p = 0.01)]. However, AHEI change was not associated with incident diabetes in any group before or after adjustment for weight change.

CONCLUSIONS

Controlling for weight, diet quality was not associated with diabetes incidence but helps achieve weight loss, an important factor in diabetes prevention.

Association between country preparedness indicators and quality clinical care for cardiovascular disease risk factors in 44 lower- and middle-income countries: A multicountry analysis of survey data

BACKGROUND

Cardiovascular diseases are leading causes of death, globally, and health systems that deliver quality clinical care are needed to manage an increasing number of people with risk factors for these diseases. Indicators of preparedness of countries to manage cardiovascular disease risk factors (CVDRFs) are regularly collected by ministries of health and global health agencies. We aimed to assess whether these indicators are associated with patient receipt of quality clinical care.

METHODS AND FINDINGS

We did a secondary analysis of cross-sectional, nationally representative, individual-patient data from 187,552 people with hypertension (mean age 48.1 years, 53.5% female) living in 43 low- and middle-income countries (LMICs) and 40,795 people with diabetes (mean age 52.2 years, 57.7% female) living in 28 LMICs on progress through cascades of care (condition diagnosed, treated, or controlled) for diabetes or hypertension, to indicate outcomes of provision of quality clinical care. Data were extracted from national-level World Health Organization (WHO) Stepwise Approach to Surveillance (STEPS), or other similar household surveys, conducted between July 2005 and November 2016. We used mixed-effects logistic regression to estimate associations between each quality clinical care outcome and indicators of country development (gross domestic product [GDP] per capita or Human Development Index [HDI]); national capacity for the prevention and control of noncommunicable diseases ('NCD readiness indicators' from surveys done by WHO); health system finance (domestic government expenditure on health [as percentage of GDP], private, and out-of-pocket expenditure on health [both as percentage of current]); and health service readiness (number of physicians, nurses, or hospital beds per 1,000 people) and performance (neonatal mortality rate). All models were adjusted for individual-level predictors including age, sex, and education. In an exploratory analysis, we tested whether national-level data on facility preparedness for diabetes were positively associated with outcomes. Associations were inconsistent between indicators and quality clinical care outcomes. For hypertension, GDP and HDI were both positively associated with each outcome. Of the 33 relationships tested between NCD readiness indicators and outcomes, only two showed a significant positive association: presence of guidelines with being diagnosed (odds ratio [OR], 1.86 [95% CI 1.08-3.21], p = 0.03) and availability of funding with being controlled (OR, 2.26 [95% CI 1.09-4.69], p = 0.03). Hospital beds (OR, 1.14 [95% CI 1.02-1.27], p = 0.02), nurses/midwives (OR, 1.24 [95% CI 1.06-1.44], p = 0.006), and physicians (OR, 1.21 [95% CI 1.11-1.32], p < 0.001) per 1,000 people were positively associated with being diagnosed and, similarly, with being treated; and the number of physicians was additionally associated with being controlled (OR, 1.12 [95% CI 1.01-1.23], p = 0.03). For diabetes, no positive associations were seen between NCD readiness indicators and outcomes. There was no association between country development, health service finance, or health service performance and readiness indicators and any outcome, apart from GDP (OR, 1.70 [95% CI 1.12-2.59], p = 0.01), HDI (OR, 1.21 [95% CI 1.01-1.44], p = 0.04), and number of physicians per 1,000 people (OR, 1.28 [95% CI 1.09-1.51], p = 0.003), which were associated with being diagnosed. Six countries had data on cascades of care and nationwide-level data on facility preparedness. Of the 27 associations tested between facility preparedness indicators and outcomes, the only association that was significant was having metformin available, which was positively associated with treatment (OR, 1.35 [95% CI 1.01-1.81], p = 0.04). The main limitation was use of blood pressure measurement on a single occasion to diagnose hypertension and a single blood glucose measurement to diagnose diabetes.

CONCLUSION

In this study, we observed that indicators of country preparedness to deal with CVDRFs are poor proxies for quality clinical care received by patients for hypertension and diabetes. The major implication is that assessments of countries' preparedness to manage CVDRFs should not rely on proxies; rather, it should involve direct assessment of quality clinical care.

Dietary intake and cardiometabolic risk factors among Venezuelan adults: a nationally representative analysis

BACKGROUND

Increasing trends in global obesity have been attributed to a nutrition transition where healthy foods are replaced by ultra-processed foods. It remains unknown if this nutrition transition has occurred in Venezuela, a country undergoing a socio-political crisis with widespread food shortages.

METHODS

We described dietary intake of Venezuelans from a nationally representative study conducted between 2014 and 2017. We conducted a cross-sectional analysis of dietary, sociodemographic, and clinical data from Venezuelans ≥20 years of age (n = 3420). Dietary intake was assessed using a semi-quantitative food frequency questionnaire. Standardized clinical and anthropometric measurements estimated obesity, type 2 diabetes, and hypertension. A Dietary Diversity Score (DDS) was calculated using an amended Minimum Dietary Diversity for Women score where the range was 0 to 8 food groups, with 8 being the most diverse. Analyses accounted for complex survey design by estimating weighted frequencies of dietary intake and DDS across sociodemographic and cardiometabolic risk-based subgroups.

RESULTS

The prevalence of obesity was 24.6% (95% CI: 21.6-27.7), type 2 diabetes was 13.3% (11.2-15.7), and hypertension was 30.8% (27.7-34.0). Western foods were consumed infrequently. Most frequently consumed foods included coffee, arepas (a salted corn flour cake), and cheese. Mean DDS was 2.3 food groups (Range: 0-8, Standard Error: 0.07) and this score did not vary among subgroups. Men, younger individuals, and those with higher socioeconomic status were more likely to consume red meat and soft drinks once or more weekly. Women and those with higher socioeconomic status were more likely to consume vegetables and cheese once or more daily. Participants with obesity, type 2 diabetes, and hypertension had lower daily intake of red meat and arepas compared to participants without these risk factors.

CONCLUSIONS

Despite high prevalence of cardiometabolic risk factors, adults in Venezuela have not gone through a nutrition transition similar to that observed elsewhere in Latin America. Dietary diversity is low and widely consumed food groups that are considered unhealthy are part of the traditional diet. Future studies are needed in Venezuela using more comprehensive measurements of dietary intake to understand the effect of the socio-political crisis on dietary patterns and cardiometabolic risk factors.

Pilot Educational Intervention to Promote Safe Pesticide Use Practices Among Farmworkers in Nepal

OBJECTIVES

The misuse of pesticides among farmworkers in Nepal is commonplace. To address this, we implemented a pilot educational intervention (three modules delivered over 3 days and lasting approximately 3 h each) in Kavre District of Nepal. Modules included: (i) health and environmental effects of pesticides, (ii) use of personal protective equipment, and (iii) label literacy and behavioral factors that influence pesticide exposure. In addition, 10 posters with key messages from each of the modules were hung throughout communities.

METHODS

Surveys were administered to cross-sectional convenience samples of farmworkers at baseline (n = 106) and 1 year later (n = 98). Practices relating to pesticides at baseline and endline were compared using multivariable logistic regression to adjust for differences in demographic and socioeconomic characteristics between the samples.

RESULTS

Compared with the baseline sample, farmworkers in the endline sample were significantly more likely to report: getting information regarding the amount of pesticides to use from experts or pesticide labels (versus personal judgment); wearing gloves while mixing pesticides; wearing boots while working in the field; using personal hygiene practices after handling pesticides such as bathing or washing hands and feet; changing clothes after handling pesticides; checking the wind direction before spraying; and delaying entry for a longer period of time after spraying.

CONCLUSIONS

These results suggest that a simple educational intervention can improve pesticide handling practices among farmworkers in Nepal. Future research should explore the impact of such interventions on pesticide exposure levels and health outcomes, and the potential to scale up these programs nationally.

Body size preferences and food choice among mothers and children in Malawi

Overweight in mothers and children in sub-Saharan Africa is rapidly increasing and may be related to body size perceptions and preferences. We enrolled 268 mother-child (6-59 months) pairs in central Malawi; 71% of mothers and 56% of children were overweight/obese, and the remainder were normal weight. Interviewers used seven body silhouette drawings and a questionnaire with open- and closed-ended questions to measure mothers' perceptions of current, preferred and healthy maternal and child body sizes and their relation to food choices. Overweight/obese and normal weight mothers' correct identification of their current weight status (72% vs. 64%), preference for overweight/obese body size (68% both) and selection of an overweight/obese silhouette as healthy (94% vs. 96%) did not differ by weight status. Fewer overweight/obese than normal weight mothers' preferred body silhouette was larger than their current silhouette (74% vs. 29%, p < .001). More mothers of overweight than normal weight children correctly identified the child's current weight status (55% vs. 42%, p < .05) and preferred an overweight/obese body size for the child (70% vs. 58%, p < .01), and both groups selected overweight/obese silhouettes as healthy for children. More than half of mothers in both groups wanted their child to be larger than the current size. Mothers said that increasing consumption of fruits, vegetables, meat, milk, grains, fizzy drinks and fatty foods could facilitate weight gain, but many cannot afford to purchase some of these foods. Their desired strategies for increasing weight indicate that body size preferences may drive food choice but could be limited by affordability.

Analysis of Attained Height and Diabetes Among 554,122 Adults Across 25 Low- and Middle-Income Countries

OBJECTIVE

The prevalence of type 2 diabetes is rising rapidly in low-income and middle-income countries (LMICs), but the factors driving this rapid increase are not well understood. Adult height, in particular shorter height, has been suggested to contribute to the pathophysiology and epidemiology of diabetes and may inform how adverse environmental conditions in early life affect diabetes risk. We therefore systematically analyzed the association of adult height and diabetes across LMICs, where such conditions are prominent.

RESEARCH DESIGN AND METHODS

We pooled individual-level data from nationally representative surveys in LMICs that included anthropometric measurements and diabetes biomarkers. We calculated odds ratios (ORs) for the relationship between attained adult height and diabetes using multilevel mixed-effects logistic regression models. We estimated ORs for the pooled sample, major world regions, and individual countries, in addition to stratifying all analyses by sex. We examined heterogeneity by individual-level characteristics.

RESULTS

Our sample included 554,122 individuals across 25 population-based surveys. Average height was 161.7 cm (95% CI 161.2-162.3), and the crude prevalence of diabetes was 7.5% (95% CI 6.9-8.2). We found no relationship between adult height and diabetes across LMICs globally or in most world regions. When stratifying our sample by country and sex, we found an inverse association between adult height and diabetes in 5% of analyses (2 out of 50). Results were robust to alternative model specifications.

CONCLUSIONS

Adult height is not associated with diabetes across LMICs. Environmental factors in early life reflected in attained adult height likely differ from those predisposing individuals for diabetes.

Per- and Polyfluoroalkyl Substance Exposure, Gestational Weight Gain, and Postpartum Weight Changes in Project Viva

OBJECTIVE

The purpose of this study was to test the extent to which pregnancy per- and polyfluoroalkyl substance (PFAS) concentrations were associated with gestational weight gain and postpartum weight changes.

METHODS

This study was composed of 1,614 women recruited between 1999 and 2002 via the Project Viva cohort with pregnancy plasma concentrations of six PFAS, including perfluorooctanesulfonic acid, perfluorooctanoic acid (PFOA), and 2-(N-ethyl-perfluorooctane sulfonamido) acetic acid. Gestational weight gain was defined as the difference between last pregnancy weight and prepregnancy weight, 1-year postpartum weight retention as the difference between 1-year postpartum weight and prepregnancy weight, and 3-year postpartum weight change as the difference between 3-year postpartum weight and prepregnancy weight.

RESULTS

During pregnancy, women gained 0.37 kg (95% CI: 0.11-0.62) more weight per doubling of 2-(N-ethyl-perfluorooctane sulfonamido) acetic acid. At 1 year post partum, women retained 0.55 kg (95% CI: 0.07-1.04) more weight per doubling of PFOA. At 3 years post partum, women gained 0.91 kg (95% CI: 0.25-1.56) more weight per doubling in PFOA. Findings were similar after adjustment for all PFAS. Other PFAS were not associated with weight changes. Postpartum associations were stronger among women with higher prepregnancy BMI. Models were adjusted for demographics.

CONCLUSIONS

Pregnancy PFAS were associated with greater gestational weight gain, weight retention, and weight gain years after pregnancy.

Pregnancy Per- and Polyfluoroalkyl Substance Concentrations and Postpartum Health in Project Viva: A Prospective Cohort

CONTEXT

Per- and polyfluoroalkyl substances (PFAS) are environmental chemicals linked to weight gain and type 2 diabetes.

OBJECTIVE

We examined the extent to which PFAS plasma concentrations during pregnancy were associated with postpartum anthropometry and biomarkers.

DESIGN, PATIENTS, AND MEASURES

We studied women recruited between 1999 and 2002 in the Project Viva prospective cohort with pregnancy plasma concentrations of PFAS, including perfluorooctanesulfonic acid (PFOS), perfluorooctanoic acid (PFOA), and 2-(N-ethyl-perfluorooctane sulfonamide) acetic acid (EtFOSAA). Three-year postpartum anthropometry measurements were available from 786 to 801 women, blood pressure from 761 women, and blood biomarkers from 450 to 454 women. We used multivariable regression to evaluate the association of log2-transformed PFAS with postpartum anthropometry, blood pressure, and blood biomarkers (leptin, adiponectin, sex hormone binding globulin [SHBG], hemoglobin A1c, interleukin-6 [IL-6], C-reactive protein), adjusting for age, prepregnancy body mass index, marital status, race/ethnicity, education, income, smoking, parity, and breastfeeding history.

RESULTS

Pregnancy concentrations of certain PFAS were associated with greater adiposity (eg, 0.4 cm [95% confidence interval [95%CI]: -0.1, 0.9] greater waist circumference per doubling in EtFOSAA; 0.2 cm [95%CI: -0.1, 0.5] greater mid-upper arm circumference per doubling in PFOA; 1.2 mm [95%CI: 0.1, 2.2] thicker sum of subscapular and triceps skinfolds per doubling in PFOS) and higher systolic blood pressure (eg, 1.2 mm Hg [95%CI: 0.3, 2.2] per doubling in PFOS) at 3 years postpartum. Higher EtFOSAA concentrations were also associated with 10.8% higher IL-6 (95%CI: 3.3, 18.9) and 6.1% lower SHBG (95%CI: 0.7, 11.2) per doubling.

CONCLUSIONS

Pregnancy concentrations of EtFOSAA, PFOS, and PFOA were associated with adverse postpartum cardiometabolic markers.

Metabolic syndrome among children aged 6 to 11 years, Al Ain, United Arab Emirates: Role of obesity

OBJECTIVES

To evaluate the association of metabolic syndrome with the varying degrees of obesity among children aged 6 to 11 years in Al Ain, United Arab Emirates (UAE).

METHODS

As an ancillary to the primary study examining prevalence of MetS in a random sample of 1186 adolescents from 114 schools in Al Ain, parents and siblings aged 6 to 11 years were invited to participate in this study. After informed consent from parents and assent from children, trained nurses administered questionnaires to assess socio-demographic and lifestyle variables and conducted anthropometric measurements. Fasting blood samples were drawn to measure plasma lipids and glucose. We used Centers for Diseases Control and Prevention (CDC)-defined categories of body mass index (BMI = kg/m² ) for normal weight (<85th percentile), overweight (≥85th to 94th percentile), and obese (≥95th percentiles). MetS was defined according to National Cholesterol Education Program's (NCEP)/Adult Treatment Panel III (ATP III) criteria.

RESULTS

Of the total 234 siblings aged 6 to 11 years, 8.9% (95% Confidence Interval [CI]: 5.6-13.4) had MetS. The prevalence of MetS increased with the severity of obesity, 4.5% in normal, 16.7% in overweight, and 30.0% in obese subjects. The age, sex, and ethnicity adjusted odds (1.55, 95% CI: 1.23-1.96) of MetS increased significantly with per unit increase in BMI.

CONCLUSIONS

The prevalence of MetS in study subjects increased with an increase in BMI. School-based interventions targeting metabolic risks in this population are urgently needed.

The Association of Cooking Fuel Use, Dietary Intake, and Blood Pressure among Rural Women in China

Household air pollution (HAP) from solid cooking fuels continues to affect 600 million people in China and has been associated with high blood pressure. The role of diet in HAP-associated high blood pressure has yet to be evaluated in China. The aim of this study was to estimate the impact of cooking fuel on change in blood pressure and evaluate whether intake of antioxidant- and omega-3 fatty acid-rich foods (fruits, vegetables, and seafood) attenuates any adverse effects of solid fuel use on blood pressure. We analyzed longitudinal data collected between 1991 and 2011 from nonpregnant women aged 18 to 80 years living in rural areas of China. We used linear mixed effects models to estimate the association between cooking fuel (coal or wood versus clean [electric or liquid petroleum gas]) and blood pressure. Possible mediation of the fuel effect by diet was assessed by the difference method. A total of 6671 women were included in this study. Women less than 40 years of age cooking with cleaner fuels over time had lower rates of change in systolic blood pressure compared to women cooking with coal (p = 0.004), and this effect was not mediated by dietary intake. Associations between fuel use and change in diastolic blood pressure were not significant. These findings lend further support for there being a direct effect of reducing HAP on improvements in blood pressure, independent of concurrent dietary intake.

Informing Health and Environmental Policies to Reduce Red and Processed Meat Intake in North America: Sociodemographic Predictors of Consumption in the US, Canada, and Mexico

Objectives

Close economic ties have encouraged production and trade of meat between the US, Canada, and Mexico. Understanding the sociodemographic correlates of red and processed meat intake in North America may inform policies designed to reduce greenhouse gas emissions and non-communicable diseases.

Methods

Data were from one day of 24-hour dietary recall in the US National Health and Nutrition Examination Survey (2013–2016), Mexico National Health and Nutrition Survey (2016), and Canadian Community Health Survey (2015). Adult participants were classified as consumers or non-consumers of the following three categories: red meat (mammalian muscle and organ meat); processed meat (all meats processed for preservation and flavor); and any meat (red and/or processed meat). Negative binomial regression accounting for complex survey design was used to model sociodemographic correlates (sex, ten-year age categories, wealth, and education) of being a consumer of red, processed, and any meat.

Results

The overall prevalence of any meat consumption in a given day was higher in the US (74%) than in Canada (66%) or Mexico (63%). Age was not associated with meat intake. In the US and Canada, females were less likely to consume all three categories of meat (all P &lt; 0.001). In Mexico, females were less likely to be in the any meat consumer category (P &lt; 0.001). Compared to high school or lower, those with college education or higher were less likely to consume processed (all P &lt; 0.05) and any meat (all P &lt; 0.05). In the US only, college education or higher was associated with a lower likelihood of eating red meat (P &lt; 0.001). There was no association between education and meat intake in Mexico. Compared to the lowest wealth tertile, in Canada and Mexico, individuals in the highest wealth tertile were more likely to consume processed (all P &lt; 0.01) or any (all P &lt; 0.01) meat. In Mexico only, those with greater wealth were more likely to eat red meat (P &lt; 0.05). There was no association between wealth and meat intake in the US.

Conclusions

Overall consumption of red and processed meat remains high in North America. Although the sociodemographic predictors vary across country, population-based approaches to reduce meat intake are appropriate for all three settings.

Funding Sources

Carolina Population Center; Wellcome Trust.