Evidence on Milk Consumption and Production Linkages from Rural Bihar, India

Background

Milk is an important source of protein for many Indian households. However, milk intake is very low. Hence, it is necessary to examine production-consumption linkages of milk within the paradigm of accessibility, availability, and affordability.

Objectives

This study examined linkages between milk consumption and production, accounting for sales and factors associated with production investments in rural Bihar, a major milk-producing state of India with very poor nutritional status.

Methods

A panel of households from the Gaya and Nalanda districts of Bihar were surveyed: the first round in July and August 2019 (n = 2026 households) and the second round from December 2019 to January 2020 (n = 2001 households). Data were collected on household consumption, production, and sale of milk, as well as other foods. The study examines the consumption-production linkage of milk and the association of dietary diversity with consumption from own production, with households as the unit of analysis. Ordinary least square regression analysis of average monthly household milk consumption was used to identify factors associated with milk consumption, particularly milk production.

Results

The median (Quartile 1, Quartile 3) per capita milk consumption per day was 83.3 (41.6, 166.6) mL in the milk-consuming households. Average monthly household milk consumption in liters was higher in milk-producing households [β: 7.1; 95% confidence interval (CI): 6.1, 8.1] than households relying on market purchases. Household milk consumption was higher in the third tertile of milk production than the first tertile of production (β: 14.3 L/wk; 95% CI: 12.1, 17.2) and lower in the highest tertile of household sale quantity (β: -8.8 L/wk in tertile 3, 95% CI: -12.7, -5) than the first tertile of household sale quantity of milk.

Conclusions

The study provides evidence that consumption of milk in rural households is associated with own production such that households with higher production consume more. However, sale preferences restrict the quantity of milk consumed in milk-producing households.

Deteriorating complementary feeding practices and dietary quality in Jordan: Trends and challenges

Quality complementary feeding (CF) of infants and young children is key to their growth and development. But in Jordan, providing appropriate CF remains a challenge. This study assesses trends in infant and young child feeding (IYCF) practices, and consumption by infants and young children aged 6-23 months of breast milk substitutes (BMSs), sugar-sweetened beverages (SSBs), and micronutrient-rich foods in Jordan from 1990 to 2017. We combined dietary data on infants and young children from six Demographic and Health Surveys (DHS) (n = 14,880 children) to compute IYCF indicators. The latter included minimum dietary diversity (MDD), minimum meal frequency (MMF), and minimum acceptable diet (MAD), as well as intake of micronutrient-rich foods and food groups, specific SSBs, and infant formula. We conducted trend analyses using logistic regression models adjusted for child's age in month, child age squared, governorates, urban/rural residence, mother's educational attainment, and household wealth quintiles. We found that the proportion of consumption of micronutrient-rich food groups declined significantly between 1990 and 2017, with fewer infants and young children consuming eggs (OR = 0.39, p ≤ 0.001, 2002 reference), meat, poultry, and fish (OR = 0.25, p ≤ 0.001, 2002 reference), dairy (OR = 0.59, p ≤ 0.001, 2002 reference) and Vitamin A-rich fruits and vegetables (OR = 0.66, p ≤ 0.001, 2002 reference). Conversely, there was increased use of BMSs and sugar-sweetened juices that paralleled a decline in the share of infants and young children meeting appropriate CF practices and consuming micronutrient-rich foods and food groups. By 2017, children aged 6-23 months were significantly less likely to meet MDD, MMF, and subsequently MAD; the odds of consuming BMSs were almost three times the reference (OR = 3.8, p ≤ 0.001, 1990 reference), as were the odds of consuming sugar sweetened juices  (OR = 3.63, p ≤ 0.001, 1990 reference). Food insecurity and undernutrition are low in Jordan; however, overweight and obesity rates are increasing concurrently as are micronutrient deficiencies. This highlights the need for policymakers to address factors at individual and household levels (behaviours and practices) as well as environmental issues (increasing access to unhealthy and ultraprocessed foods).

Neuroprotection of low dose carbon monoxide in Parkinson's disease models commensurate with the reduced risk of Parkinson's among smokers

Paradoxically, cigarette smoking is associated with a reduced risk of Parkinson's disease (PD). This led us to hypothesize that carbon monoxide (CO) levels, which are constitutively but modestly elevated in smokers, might contribute to neuroprotection. Using rodent models of PD based on α-synuclein (αSyn) accumulation and oxidative stress, we show that low-dose CO mitigates neurodegeneration and reduces αSyn pathology. Oral CO administration activated signaling cascades mediated by heme oxygenase-1 (HO-1), which have been implicated in limiting oxidative stress, and in promoting αSyn degradation, thereby conferring neuroprotection. Consistent with a neuroprotective effect of smoking, HO-1 levels in cerebrospinal fluid were higher in human smokers compared to nonsmokers. Moreover, in PD brain samples, HO-1 levels were higher in neurons without αSyn pathology. Thus, CO in rodent PD models reduces pathology and increases oxidative stress responses, phenocopying possible protective effects of smoking evident in PD patients. These data highlight the potential for low-dose CO modulated pathways to slow symptom onset and limit pathology in PD patients.

Women's input and decision-making in agriculture are associated with diet quality in rural Tanzania

Background

Women's empowerment is one critical pathway through which agriculture can impact women's nutrition; however, empirical evidence is still limited. We evaluated the associations of women's participation, input, and decision-making in key agricultural and household activities with women's diet quality.

Methods

We analyzed data from a cross-sectional study of 870 women engaged in homestead agriculture. We used food frequency questionnaires to assess women's diets and computed women's diet quality using the Prime Diet Quality Score (PDQS) (range 0-42), which captures healthy and unhealthy foods. We evaluated women's decision-making in 8 activities, food crop farming, cash crop farming, livestock raising, non-farm economic activities, wage/salary employment, fishing, major household expenditures, and minor household expenditures. Generalized estimating equations (GEE) linear models were used to evaluate associations between (a) women's participation, (b) decision-making, (c) adequate input, (d) adequate extent of independence in decision-making in agriculture, and (e) adequate input in use of agricultural income with their PDQS. Adequate input was defined as input into some, most or all decisions compared to input into few decisions or none. Adequate extent of independence was defined as input to a medium or high extent compared to input to a small extent or none.

Findings

Median PDQS was 19 (IQR: 16-21). Women's adequate input in decision-making on wage and salary employment (estimate: 4.19, 95% CI: 2.80, 5.57) and minor expenditures were associated with higher PDQS vs. inadequate input. Women with independence in decision-making on livestock production (estimate: 0.97, 95% CI: 0.05, 1.90) and minor household expenditures, and women with adequate decision-making in the use of income from wages/salaries (estimate: 3.16, 95% CI: 2.44, 3.87) had higher PDQS. Participation in agricultural activities was positively associated with PDQS.

Conclusions

Women's participation and input in decision-making in wage and salary employment, livestock production, and minor household expenditures were strongly associated with the consumption of better-quality diets. Women participating in multiple farm activities were also likely to have better diet quality. This study adds to the growing evidence on the pathways through which women's empowerment may influence women's nutrition in rural Tanzania.

The state of food systems worldwide in the countdown to 2030

This Analysis presents a recently developed food system indicator framework and holistic monitoring architecture to track food system transformation towards global development, health and sustainability goals. Five themes are considered: (1) diets, nutrition and health; (2) environment, natural resources and production; (3) livelihoods, poverty and equity; (4) governance; and (5) resilience. Each theme is divided into three to five indicator domains, and indicators were selected to reflect each domain through a consultative process. In total, 50 indicators were selected, with at least one indicator available for every domain. Harmonized data of these 50 indicators provide a baseline assessment of the world's food systems. We show that every country can claim positive outcomes in some parts of food systems, but none are among the highest ranked across all domains. Furthermore, some indicators are independent of national income, and each highlights a specific aspiration for healthy, sustainable and just food systems. The Food Systems Countdown Initiative will track food systems annually to 2030, amending the framework as new indicators or better data emerge.

A longitudinal survey on changes in employment and food consumption during the COVID-19 pandemic in rural Bihar, India

BACKGROUND

There is a need for empirical evidence on changes in employment and food consumption during pandemic situations in households belonging to the informal economy.

OBJECTIVE

To examine changes in food insecurity, household diet diversity, and employment in agriculture during the pre-COVID-19 (2019-early 2020) and COVID-19 pandemic (September 2021) periods.

METHODS

A total of 1632 households from a face-to-face pre-COVID-19 survey and 621 of those followed up by a telephonic survey during COVID-19 in Bihar, India, were included in the analyses. Household food insecurity, household diet diversity score (HDDS), and employment change (agriculture or nonagriculture) were assessed during both periods. Food insecurity and diet diversity in the 2 periods were examined by logistic regression. A change in the odds of being food insecure or having low HDDS was examined as an interaction between time and employment status.

RESULTS

Prevalence of food insecurity increased from 21% to 55%, and low diet diversity increased from 47% to 69% in households assessed in both surveys. Employment status was not associated with food insecurity or low HDDS during the baseline survey. However, during the pandemic, ∼30% of households changed their employment from agriculture to nonagriculture and were more likely to be food insecure (adjusted odds ratio [aOR]: 2.77; 95% confidence interval [CI] 1. 78-4.32) and have low HDDS (aOR: 1.66; 95%CI: 1.05-2.61), than those who remained in agriculture. Similarly, those who retained nonagricultural employment during the pandemic were more likely to be food insecure (aOR: 2.23; 95%CI: 1.45-3.43) and have low HDDS (aOR: 1.73; 95%CI: 1.11-2.70), compared to those who remained in agriculture. In propensity score-adjusted interaction analysis of time and employment, food insecurity and low HDDS remained significantly associated with nonagricultural employment during the pandemic.

CONCLUSIONS

Enhanced support to rural households in agricultural occupations could buffer them from unexpected crises, which may also protect their nutritional intake.

Contextual Factors Influencing Production, Distribution, and Consumption of Nutrient-Rich Foods in Bihar, India: A Qualitative Study of Constraints and Facilitators

BACKGROUND

Production-to-consumption linkages are important to improve consumption of nutrient-rich foods to tackle malnutrition. However, understanding specific contextual factors influencing production, distribution, and consumption in rural communities is necessary.

OBJECTIVE

To explore household-, farm-, and market-level factors affecting consumption of nutrient-rich foods among producer and nonproducer households in Bihar, India.

METHODS

We conducted focus group discussions (FGDs) and key informant interviews (KIIs) in producer and nonproducer households of Gaya and Nalanda districts in Bihar to examine factors affecting production and consumption of red lentils, green leafy vegetables (GLVs), milk, eggs, and chicken. Through the KIIs, we identified distribution chains and elicited market-level challenges faced by producers, sellers, and consumers. Data were translated, transcribed, and analyzed thematically using NVivo version 9.

RESULTS

Findings from 27 FGDs indicate that consumers and producers were aware of the importance of nutrient-rich foods to health and the necessity of prioritizing their consumption in children. Food preferences, social factors, seasons, religions, and livestock epidemics influenced consumption. Among producers, consumption was mainly dependent on own production. Nonproducers perceived that production could help overcome the barrier of affordability and improve consumption. Data from 69 KIIs indicated that markets were unfavorable in terms of profitability for producers, spoilage and losses for market players, issues of accessibility, and availability for consumers.

CONCLUSIONS

A local context-specific multipronged approach such as understanding sociocultural factors, own production, and local markets influencing consumption needs to be examined further to improve consumption of nutrient-rich foods among agricultural communities in India.

Uncertainty in phosphorus fluxes and budgets across the U.S. long-term agroecosystem research network

Phosphorus (P) budgets can be useful tools for understanding nutrient cycling and quantifying the effectiveness of nutrient management planning and policies; however, uncertainties in agricultural nutrient budgets are not often quantitatively assessed. The objective of this study was to evaluate uncertainty in P fluxes (fertilizer/manure application, atmospheric deposition, irrigation, crop removal, surface runoff, leachate) and the propagation of these uncertainties to annual P budgets. Data from 56 cropping systems in the P-FLUX database, which spans diverse rotations and landscapes across the U.S. and Canada, were evaluated. Results showed that across cropping systems, average annual P budget was 22.4 kg P ha^-1 (range = -32.7 to 340.6 kg P ha^-1 ), with an average uncertainty of 13.1 kg P ha^-1 (range = 1.0 to 87.1 kg P ha^-1 ). Fertilizer/manure application and crop removal were the largest P fluxes across cropping systems and, as a result, accounted for the largest fraction of uncertainty in annual budgets (61 and 37%, respectively). Remaining fluxes individually accounted for <2% of the budget uncertainty. Uncertainties were large enough that determining whether P was increasing, decreasing, or not changing was inconclusive in 39% of the budgets evaluated. Findings indicate that more careful and/or direct measurements of inputs, outputs, and stocks are needed. Recommendations for minimizing uncertainty in P budgets based on the results of the study were developed. Quantifying, communicating, and constraining uncertainty in budgets among production systems and multiple geographies is critical for engaging stakeholders, developing local and national strategies for P reduction, and informing policy. This article is protected by copyright. All rights reserved.

Measurement of diets that are healthy, environmentally sustainable, affordable, and equitable: A scoping review of metrics, findings, and research gaps

Introduction

Research on the impacts of dietary patterns on human and planetary health is a rapidly growing field. A wide range of metrics, datasets, and analytical techniques has been used to explore the role of dietary choices/constraints in driving greenhouse gas (GHG) emissions, environmental degradation, health and disease outcomes, and the affordability of food baskets. Many argue that each domain is important, but few have tackled all simultaneously in analyzing diet-outcome relationships.

Methods

This paper reviews studies published between January 2015 and December 2021 (inclusive) that examined dietary patterns in relation to at least two of the following four thematic pillars: (i) planetary health, including, climate change, environmental quality, and natural resource impacts, (ii) human health and disease, (iii) economic outcomes, including diet cost/affordability, and (iv) social outcomes, e.g., wages, working conditions, and culturally relevant diets. We systematically screened 2,425 publications by title and abstract and included data from 42 eligible publications in this review.

Results

Most dietary patterns used were statistically estimated or simulated rather than observed. A rising number of studies consider the cost/affordability of dietary scenarios in relation to optimized environmental and health outcomes. However, only six publications incorporate social sustainability outcomes, which represents an under-explored dimension of food system concerns.

Discussion

This review suggests a need for (i) transparency and clarity in datasets used and analytical methods; (ii) explicit integration of indicators and metrics linking social and economic issues to the commonly assessed diet-climate-planetary ecology relationships; (iii) inclusion of data and researchers from low- and middle-income countries; (iv) inclusion of processed food products to reflect the reality of consumer choices globally; and (v) attention to the implications of findings for policymakers. Better understanding is urgently needed on dietary impacts on all relevant human and planetary domains simultaneously.

Children's and adolescents' rising animal-source food intakes in 1990-2018 were impacted by age, region, parental education and urbanicity

Animal-source foods (ASF) provide nutrition for children and adolescents' physical and cognitive development. Here, we use data from the Global Dietary Database and Bayesian hierarchical models to quantify global, regional and national ASF intakes between 1990 and 2018 by age group across 185 countries, representing 93% of the world's child population. Mean ASF intake was 1.9 servings per day, representing 16% of children consuming at least three daily servings. Intake was similar between boys and girls, but higher among urban children with educated parents. Consumption varied by age from 0.6 at <1 year to 2.5 servings per day at 15-19 years. Between 1990 and 2018, mean ASF intake increased by 0.5 servings per week, with increases in all regions except sub-Saharan Africa. In 2018, total ASF consumption was highest in Russia, Brazil, Mexico and Turkey, and lowest in Uganda, India, Kenya and Bangladesh. These findings can inform policy to address malnutrition through targeted ASF consumption programmes.

Relationship between Animal Sourced Food Consumption and Early Childhood Development Outcomes

Early-childhood development (ECD) is an important determinant of a child’s cognitive ability, learning, productivity, and lifetime earnings. Animal-sourced food (ASF), which is a rich source of high-quality protein and micronutrients, has been linked with ECD outcomes. This study investigates the relationship between the number, frequency, and cumulative consumption of ASF at 6, 9, 12, and 18 months of age and ECD outcomes at 24 months of age, controlling for physical growth. The study uses data collected from 701 mother−child pairs from an observational birth cohort study carried out in Banke, Nepal. ECD outcomes were assessed through a standardized ages and stages questionnaire (ASQ-3) tool. Separate multivariable ordinary least squares regression models were used to test for associations. Significant positive association was seen between total ASQ-3 score at 24 months of age and any ASF consumption at 18 months (β = 8.98, p-value < 0.01), controlling for growth outcomes. The study findings highlight the positive contribution and the accumulating benefit of consistent ASF consumption on ECD outcomes. This study recommends support and promotion of ASF intake among young children in Nepal through policy and programming actions relevant to female education; nutrition knowledge; quality ASF production; improved market access; cold storage; and poverty reduction.

Assessing an aflatoxin exposure biomarker: Exploring the interchangeability and correlation between venous and capillary blood samples

Exposure to dietary aflatoxins has been recognized as a potential threat to child nutrition and growth, in addition to being a known carcinogen. The ability to accurately assess concentration of aflatoxin in the blood of at-risk individuals is therefore very important to inform public health policies and on-the-ground programs around the world. Venous blood is frequently used to quantify biomarkers of exposure such as AFB1-lysine adducts. However, venous blood collection methods are invasive, requiring highly trained staff, which makes this method challenging to implement, especially in resource-limited settings. In contrast, capillary blood collection by fingerprick is less invasive and has the potential for application in point-of-need monitoring. The aim of this exploratory study was to investigate the correlation and interchangeability of capillary and venous human blood samples in the quantification of AFB1-lysine adduct concentration. A total of 72 venous and capillary blood samples were collected from 36 women of reproductive age (16-49 years) in northern Uganda. All sample specimens were analyzed using high-performance liquid chromatography with fluorescence detection. Regression analysis and Bland-Altman analysis were performed to compare AFB1-lysine concentrations between venous and capillary sample pairs. Bland-Altman analysis of albumin-normalized AFB1-lysine data-bias was -0.023 pg/mg-albumin and the 95% limits of agreement were 0.51 to -0.56 pg/mg-albumin for log-transformed data. There was a positive correlation between albumin-normalized venous and capillary AFB1-lysine concentrations with r of 0.71 (p < .0001). A lack of any accepted clinical cutoff for aflatoxin exposure makes definition of an 'acceptable' limit for statistical analysis and comparison of methods challenging. Our data suggests a positive correlation between albumin-normalized AFB1-lysine concentrations in venous and capillary sample pairs, but relatively weak agreement and interchangeability based on Bland-Altman analysis.

How do children with severe underweight and wasting respond to treatment? A pooled secondary data analysis to inform future intervention studies

Children with weight-for-age z-score (WAZ) <-3 have a high risk of death, yet this indicator is not widely used in nutrition treatment programming. This pooled secondary data analysis of children aged 6-59 months aimed to examine the prevalence, treatment outcomes, and growth trajectories of children with WAZ <-3 versus children with WAZ ≥-3 receiving outpatient treatment for wasting and/or nutritional oedema, to inform future protocols. Binary treatment outcomes between WAZ <-3 and WAZ ≥-3 admissions were compared using logistic regression. Recovery was defined as attaining mid-upper-arm circumference ≥12.5 cm and weight-for-height z-score ≥-2, without oedema, within a period of 17 weeks of admission. Data from 24,829 children from 9 countries drawn from 13 datasets were included. 55% of wasted children had WAZ <-3. Children admitted with WAZ <-3 compared to those with WAZ ≥-3 had lower recovery rates (28.3% vs. 48.7%), higher risk of death (1.8% vs. 0.7%), and higher risk of transfer to inpatient care (6.2% vs. 3.8%). Growth trajectories showed that children with WAZ <-3 had markedly lower anthropometry at the start and end of care, however, their patterns of anthropometric gains were very similar to those with WAZ ≥-3. If moderately wasted children with WAZ <-3 were treated in therapeutic programmes alongside severely wasted children, we estimate caseloads would increase by 32%. Our findings suggest that wasted children with WAZ <-3 are an especially vulnerable group and those with moderate wasting and WAZ <-3 likely require a higher intensity of nutritional support than is currently recommended. Longer or improved treatment may be necessary, and the timeline and definition of recovery likely need review.

Global dietary quality in 185 countries from 1990 to 2018 show wide differences by nation, age, education, and urbanicity

Evidence on what people eat globally is limited in scope and rigour, especially as it relates to children and adolescents. This impairs target setting and investment in evidence-based actions to support healthy sustainable diets. Here we quantified global, regional and national dietary patterns among children and adults, by age group, sex, education and urbanicity, across 185 countries between 1990 and 2018, on the basis of data from the Global Dietary Database project. Our primary measure was the Alternative Healthy Eating Index, a validated score of diet quality; Dietary Approaches to Stop Hypertension and Mediterranean Diet Score patterns were secondarily assessed. Dietary quality is generally modest worldwide. In 2018, the mean global Alternative Healthy Eating Index score was 40.3, ranging from 0 (least healthy) to 100 (most healthy), with regional means ranging from 30.3 in Latin America and the Caribbean to 45.7 in South Asia. Scores among children versus adults were generally similar across regions, except in Central/Eastern Europe and Central Asia, high-income countries, and the Middle East and Northern Africa, where children had lower diet quality. Globally, diet quality scores were higher among women versus men, and more versus less educated individuals. Diet quality increased modestly between 1990 and 2018 globally and in all world regions except in South Asia and Sub-Saharan Africa, where it did not improve.

Child stunting starts in utero: Growth trajectories and determinants in Ugandan infants

Childhood stunting remains a public health burden worldwide. Although many studies have examined early life and in‐utero risk factors; most have been observational and have used analytic techniques that make inferences limited to population means, thereby obscuring important within‐group variations. This study addressed that important gap. Using data from a birth cohort of Ugandan infants (n = 4528), we applied group‐based trajectory modelling to assess diverse patterns of growth among children from birth to 1‐year old. A multinomial regression model was conducted to understand the relationship between risk factors and observed patterns across groups. We found that the onset of stunting occurred before birth and followed four distinct growth patterns: chronically stunted (Group 1), recovery (Group 2), borderline stunted (Group 3) and normal (Group 4). The average length‐for‐age z‐score (LAZ) at birth was −2.6, −3.9, −0.6 and 0.5 for Groups 1–4, respectively. Although both Groups 1 and 2 were stunted at birth, stunting persisted in Group 1 while children in Group 2 recovered by the fourth month. Group 3 exhibited mild stunting while Group 4 was normal. Wasting and underweight were observed in all groups, with the highest prevalence of underweight in Group 1. Wasting gradually increased among children born already stunted (Groups 1 and 2). This showed the importance of distinguishing children by their growth patterns rather than aggregating them and only comparing population averages against global growth standards. The design of nutrition interventions should consider the differential factors and potential for growth gains relative to different risks within each group.

In a sample of Ugandan infants, the onset of stunting occurred in utero and set in motion a range of possible growth trajectories for the child after birth.

Child growth can be characterised by diverse patterns that suggest temporal variations in children's growth. This provides an opportunity for policymakers to provide specialised and targeted nutrition interventions.

Addressing low birth weight, preterm births and small‐for‐gestational‐age is critical to effectively reduce rates of stunting in rural Uganda.

Role of cash transfers in mitigating food insecurity in India during the COVID-19 pandemic: a longitudinal study in the Bihar state

OBJECTIVE

There are scant empirical data on the impacts of the COVID-19 pandemic on food security across the globe. India is no exception, with insights into the impacts of lockdown on food insecurity now emerging. We contribute to the empirical evidence on the prevalence of food insecurity in Bihar state before and after lockdown, and whether the government's policy of cash transfer moderated negative effects of food insecurity or not.

DESIGN

This was a longitudinal study.

SETTINGS

The study was conducted in Gaya and Nalanda district of Bihar state in India from December 2019 to September 2020.

PARTICIPANTS

A total of 1797 households were surveyed in survey 1, and about 52% (n=939) were followed up in survey 2. Valid data for 859 households were considered for the analysis.

MAIN OUTCOME MEASURES

Using the Food Insecurity Experience Scale, we found that household conditions were compared before and after lockdown. The effect of cash transfers was examined in a quasi-experimental method using a longitudinal study design. Logistic regression and propensity score adjusted analyses were used to identify factors associated with food insecurity.

RESULTS

Household food insecurity worsened considerably during lockdown, rising from 20% (95% CI 17.4 to 22.8) to 47% (95% CI 43.8 to 50.4) at the sample mean. Households experiencing negative income shocks were more likely to have been food insecure before the lockdown (adjusted OR 6.4, 95% CI 4.9 to 8.3). However, households that received cash transfers had lower odds of being food insecure once the lockdown was lifted (adjusted OR 0.75, 95% CI 0.56 to 0.99).

CONCLUSION

These findings provide evidence on how the swift economic response to the pandemic crises using targeted income transfers was relatively successful in mitigating potentially deep impacts of food insecurity.

How Can Nutrition Research Better Reflect the Relationship Between Wasting and Stunting in Children? Learnings from the Wasting and Stunting Project

Childhood wasting and stunting affect large numbers of children globally. Both are important risk factors for illness and death yet, despite the fact that these conditions can share common risk factors and are often seen in the same child, they are commonly portrayed as relatively distinct manifestations of undernutrition. In 2014, the Wasting and Stunting project was launched by the Emergency Nutrition Network. Its aim was to better understand the complex relationship and associations between wasting and stunting and examine whether current separations that were apparent in approaches to policy, financing, and programs were justified or useful. Based on the project's work, this article aims to bring a wasting and stunting lens to how research is designed and financed in order for the nutrition community to better understand, prevent, and treat child undernutrition. Discussion of lessons learnt focuses on the synergy and temporal relationships between children's weight loss and linear growth faltering, the proximal and distal factors that drive diverse forms of undernutrition, and identifying and targeting people most at risk. Supporting progress in all these areas requires research collaborations across interest groups that highlight the value of research that moves beyond a focus on single forms of undernutrition, and ensures that there is equal attention given to wasting as to other forms of malnutrition, wherever it is present.

P-FLUX: A phosphorus budget dataset spanning diverse agricultural production systems in the United States and Canada

Quantifying spatial and temporal fluxes of phosphorus (P) within and among agricultural production systems is critical for sustaining agricultural production while minimizing environmental impacts. To better understand P fluxes in agricultural landscapes, P-FLUX, a detailed and harmonized dataset of P inputs, outputs, and budgets, as well as estimated uncertainties for each P flux and budget, was developed. Data were collected from 24 research sites and 61 production systems through the Long-term Agroecosystem Research (LTAR) network and partner organizations spanning 22 U.S. states and 2 Canadian provinces. The objectives of this paper are to (a) present and provide a description of the P-FLUX dataset, (b) provide summary analyses of the agricultural production systems included in the dataset and the variability in P inputs and outputs across systems, and (c) provide details for accessing the dataset, dataset limitations, and an example of future use. P-FLUX includes information on select site characteristics (area, soil series), crop rotation, P inputs (P application rate, source, timing, placement, P in irrigation water, atmospheric deposition), P outputs (crop removal, hydrologic losses), P budgets (agronomic budget, overall budget), uncertainties associated with each flux and budget, and data sources. Phosphorus fluxes and budgets vary across agricultural production systems and are useful resources to improve P use efficiency and develop management strategies to mitigate environmental impacts of agricultural systems. P-FLUX is available for download through the USDA Ag Data Commons (https://doi.org/10.15482/USDA.ADC/1523365).

Dietary determinants of aflatoxin B1-lysine adduct among infants in Nepal

BACKGROUND

Aflatoxins are mycotoxins produced by naturally occurring fungi on food, and aflatoxin B₁ (AFB₁) is carcinogenic, immunotoxic and hepatotoxic. This study assesses the relationship between AFB₁ in Nepali infants at 12 months of age and their diet at 9 and 12 months of age.

METHODS

The study used data collected from 1329 infants enrolled in the AflaCohort Study. Aflatoxin exposure was assessed at 12 months using serum AFB₁-lysine pg/mg albumin biomarker measured using high performance liquid chromatography-fluorescent detection. Dietary data were collected using food frequency questionnaire. We conducted ordinary least squares and quantile regression analyses with backward elimination to assess lagged (9-month diet and 12-month AFB₁) and contemporaneous (12-month diet and 12-month AFB₁) associations.

RESULTS

Eighty-one percent of children at 12 months had detectable levels of serum AFB₁-lysine (geometric mean: 0.79 pg/mg albumin, 95% CI: 0.74-0.83). The levels ranged from 0.4 to 85 pg/mg albumin. Dietary diversity at 9 and 12 months were not associated with serum AFB₁-lysine levels. Consumption of fish and groundnuts at both 9 and 12 months and infant formula and cauliflower at 9 months were associated with higher serum AFB₁-lysine while consumption of bananas and mangoes at 12 months were negatively associated with serum AFB₁-lysine (p < 0.05).

CONCLUSIONS

High prevalence of detectable AFB₁-lysine among infants, and possible links to their dietary patterns argues for more urgent research into which foods in children's diets are most contaminated, and into optimal entry points in the food chain that would allow for effective actions to minimize exposure.

Modeling the potential impacts of improved monthly income on child stunting in India: a subnational geospatial perspective

OBJECTIVES

Approximately one-third of the world's stunted (low height-for-age) preschool-aged children live in India. The success of interventions designed to tackle stunting appears to vary by location and depth of poverty. We developed small-area estimation models to assess the potential impact of increments in household income on stunting across the country.

DESIGN

Two nationally representative cross-sectional datasets were used: India's National Family Health Survey 4 (2015-2016) and the 68th round of the National Sample Survey on consumer expenditure. The two datasets were combined with statistical matching. Gaussian process regressions were used to perform geospatial modelling of 'stunting' controlling for household wealth and other covariates.

SETTING AND PARTICIPANTS

The number of children in this sample totalled 259 627. Children with implausible height-for-age z-scores (HAZs) >5 or <-5, or missing data on drinking water, sanitation facility, mother's education, or geolocation and children not residing in mainland India were excluded, resulting in 207 695 observations for analysis.

RESULTS

A monthly transfer of ~$7 (500 Indian rupees) per capita to every household (not targeted or conditional) was estimated to reduce stunting nationally by 3.8 percentage points on average (95% credible interval: 0.14%-10%), but with substantial variation by state. Estimated reduction in stunting varied by wealth of households, with the poorest quintile being likely to benefit the most.

CONCLUSION

Improving household income, which can be supported through cash transfers, has the potential to significantly reduce stunting in parts of India where the burdens of both stunting and poverty are high. Modelling shows that for other regions, income transfers may raise incomes and contribute to improved nutrition, but there would be a need for complementary activities for alleviating stunting. While having value for the country as a whole, impact of income gained could be variable, and underlying drivers of stunting need to be tackled through supplementary interventions.

Exposure to multiple mycotoxins, environmental enteric dysfunction and child growth: Results from the AflaCohort Study in Banke, Nepal

Evidence of the impact of exposure to multiple mycotoxins and environment enteric dysfunction (EED) on child growth is limited. Using data from a birth cohort study, the objectives of this study were to (a) quantify exposure to multiple mycotoxins (serum aflatoxin [AFB₁] and ochratoxin A [OTA], urinary fumonisin [UFB₁] and deoxynivalenol [DON]), as well EED (lactulose:mannitol [L:M] ratio); (b) examine the potential combined effects of multiple mycotoxin exposure and EED on growth. Multivariate regressions were used to identify associations between growth measurements (length, weight, anthropometric z‐scores, stunting and underweight) at 24–26 months of age and exposure to mycotoxins and EED at 18–22 months (n = 699). Prevalence of AFB₁, DON, OTA and UFB₁ exposure ranged from 85% to 100%; average L:M ratio was 0.29 ± 0.53. In individual mycotoxin models, AFB₁ exposure was negatively associated with weight, WAZ, increased odds of stunting (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 1.08, 1.52; p = 0.004) and underweight (OR: 1.18, 95% CI: 1.00, 1.38; p = 0.046). Irrespective of other mycotoxin exposure and presence of EED, AFB₁ was negatively associated with length, weight, head circumference, LAZ and WAZ, and with increased odds of stunting and underweight, UFB₁ was associated with increased odds of underweight, and DON was negatively associated with head circumference. EED was associated with the impaired length and weight. These findings suggest that certain mycotoxins and EED may have independent impacts on different facets of growth and that aflatoxin dominates such impacts. Thus, programs reducing exposure to mycotoxin and EED through multi‐sectoral nutrition‐sensitive interventions have the potential to improve child growth.

Mycotoxin exposure was highly prevalent in children aged 18–22 months. Various mycotoxins and EED contribute independently to different manifestations of poor child growth

AFB1 was negatively associated with length, weight, head circumference, LAZ, as well as WAZ, and associated with increased odds of stunting and underweight. UFB1 was also associated with increased odds of underweight. DON was negatively associated with head circumference.

The One Nutrition in Complex Environments (ONCE) study protocol: a cluster-randomized multi-level multi-sectoral intervention to improve nutrition in Uganda

Objective

To implement and measure the effects of a multi-level multi-sectoral social behavior change (SBC) intervention in Agago District of Northern Uganda and to determine the potential for scale-up.

Intervention

Compare the Nutrition Impact and Positive Practice (NIPP) approach to a NIPP+ approach. The NIPP approach involves nutrition education and SBC, whereas the NIPP+ adds agricultural inputs, training, and tools to support improved farm and water quality practices. The intervention effect will be measured through lower levels of aflatoxin in grain, lower water contamination, and improved knowledge on nutrition and health.

Design

This is a three-arm cluster-randomized controlled superiority trial (cRCT). The study arms include the following: group 1: NIPP; group 2: NIPP+, and group 3: control. Groups 1 and 2 will receive a 12-week intervention (NIPP or NIPP+) with active monitoring and longitudinal follow-up at 2, 6, and 12 months post-intervention. Additionally, an in-depth process and performance evaluation of each intervention arm will be undertaken using quantitative and qualitative methods. A total of 60 clusters from 5 subcounties of the Agago district will be randomly selected, and 15 households per cluster will be recruited using specific inclusion/exclusion criteria for a total of 900 households (300/arm). Respondents for the qualitative portion will be purposely selected.

Analysis

We will collect data from all participants at 3 time points: baseline, endline, and 12 months post-intervention. The analysis will utilize intent-to-treat (ITT) using the initial randomization of the treatment arms to determine the overall impact of having the NIPP vs. NIPP+ vs. control. Mixed effects models will be used to determine the role of time-variant and invariant individual household, and community characteristics, as well as measures of exposure and integration on key outcome indicators. A difference-in-difference analysis (baseline/endline, baseline/12 months post-intervention, endline/12 months post-intervention) will also be used to triangulate findings.

Trial registration

NCT04209569. One Nutrition in Complex Environments (ONCE) Registered 24 December 2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06170-7.

Effects of Iron and Vitamin A Levels on Pregnant Women and Birth Outcomes: Complex Relationships Untangled Using a Birth Cohort Study in Uganda

Introduction

Women and infants are among the most vulnerable groups for micronutrient deficiencies. Pregnancy micronutrient status can affect birth outcomes and subsequent infants’ growth.

Methods

We determined the relationship between maternal iron and vitamin A status at delivery using several biomarkers (ferritin, soluble transferrin receptor [sTFR], body iron stores [BIS], hemoglobin and retinol binding protein [RBP]) and birth outcomes (body weight, Z-scores, head circumference, small-for-gestational-age and preterm birth) in rural Uganda. We investigated women who had serum results at the point of delivery and paired them to their infants at birth (n = 1244). We employed multivariable linear and logistic regression, adjusting for clustering at the subcounty level to determine the relationship between maternal micronutrients and birth outcomes.

Results

After adjusting for relevant factors, we found that maternal iron status (ferritin and BIS) and anemia (hemoglobin) were not significantly associated with the assessed birth outcomes. However, there was a significant association between serum sTFR and preterm births (AOR: 0.67; 95% CI 0.48–0.94). For Vitamin A, we observed a significant positive association between RBP and length-for-age (LAZ) at birth (β = 0.12, p < 0.030).

Discussion

These findings indicate that the relationship between maternal iron status and birth outcomes needs to be further investigated, because depending on the biomarker used the associations were either in favor of an adverse birth outcome or not significant. Additionally, they confirm that higher maternal RBP levels could be beneficial for birth outcomes.

Clinicaltrials.gov as NCT04233944.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10995-022-03387-5.

Global, regional, and national consumption of animal-source foods between 1990 and 2018: findings from the Global Dietary Database

Background

Methods

Findings

Interpretation

Funding

Assessing infant cognition in field settings using eye-tracking: a pilot cohort trial in Sierra Leone

OBJECTIVES

To investigate the feasibility of eye-tracking-based testing of the speed of visual orienting in malnourished young children at rural clinics in Sierra Leone.

DESIGN

Prospective dual cohort study nested in a cluster-randomised trial.

SETTING

8 sites participating in a cluster-randomised trial of supplementary feeding for moderate acute malnutrition (MAM).

PARTICIPANTS

For the MAM cohort, all infants aged 7-11 months at the eight sites were enrolled, 138 altogether. For controls, a convenience sample of all non-malnourished infants aged 7-11 months at the same sites were eligible, 60 altogether. A sample of 30 adults at the sites also underwent eye-tracking tests as a further control.

INTERVENTIONS

Infants with MAM were provided with supplementary feeding.

OUTCOME MEASURES

The primary outcomes were feasibility and reliability of eye-tracking-based testing of saccadic reaction time (SRT). Feasibility was assessed by the percent of successful tests in the infants. Reliability was measured with intraclass correlation coefficients (ICCs). Secondary outcomes were mean SRT based on nutritional state as well as and changes in mean SRT after supplementary feeding of MAM children.

RESULTS

Infants exhibited consistent orienting to targets on a computer screen (>95% of valid trials). Mean SRTs had moderate stability within visits (ICCs 0.60-0.69) and across the 4-week test-retest interval (0.53) in infants; the adult control group had greater SRT stability (within visit ICC=0.92). MAM infants had a trend toward higher adjusted SRT at baseline (difference=12.4 ms, 95% CI -2 to 26.9, p=0.09) and improvement in SRT 4 weeks thereafter (difference=-14 ms, 95% CI -26.2 to -1.7, p=0.025) compared with age-matched controls.

CONCLUSIONS

The results demonstrate the feasibility of eye-tracking-based testing in a resource-poor field setting and suggest eye-tracking measures have utility in the detection of group level effects of supplementary feeding.

Evaluation of the Quality of Evidence of the Association of Foods and Nutrients With Cardiovascular Disease and Diabetes: A Systematic Review

IMPORTANCE

Poor diet is a leading global factor associated with cardiometabolic disease (CMD). Understanding the quality of evidence of the associations between specific dietary factors and CMD, including effect size (relative risk [RR]) and uncertainty, is essential to guide policy and consumer actions to achieve healthy diet and public health goals.

OBJECTIVE

To assess the quality of evidence of the associations between specific dietary factors and CMD as well as the quantitative evidence for RRs and the uncertainty of these risk estimates.

EVIDENCE REVIEW

PubMed and the reference lists of eligible articles were searched between May 1, 2015, and February 26, 2021, for systematic reviews with meta-analyses of randomized clinical trials and prospective cohort studies that analyzed the consumption of 1 or more of the dietary factors of interest; reported dose-response meta-analyses; included healthy adults; and assessed 1 or more of the outcomes of interest. Study characteristics and RR estimates were extracted in duplicate. For identified associations, quality of evidence was assessed using the Bradford-Hill criteria for causation.

FINDINGS

A total of 2058 potentially relevant reports were identified, from which 285 full-text articles were assessed for eligibility. The final selection of articles included 28 meta-analyses representing 62 associations between diet and CMD. Among these associations, 10 foods, 3 beverages, and 12 nutrients had at least probable evidence of associations with coronary heart disease, stroke, and/or diabetes. Most RRs ranged from 0.87 to 0.96 per daily serving change for protective associations and from 1.06 to 1.15 per daily serving change for harmful associations. Most identified associations were protective (n = 38) and a smaller number were harmful (n = 24), with a higher risk associated with higher intake.

CONCLUSIONS AND RELEVANCE

This systematic review summarized the current quality of evidence of the associations of specific dietary factors with coronary heart disease, stroke, and diabetes. These findings may inform dietary guidance, the assessment of disease burden in specific populations, policy setting, and future research.

Consumption of animal source foods, especially fish, is associated with better nutritional status among women of reproductive age in rural Bangladesh

In rural Bangladesh, intake of nutrient-rich foods, such as animal source foods (ASFs), is generally suboptimal. Diets low in nutrients and lacking in diversity put women of reproductive age (WRA) at risk of malnutrition as well as adverse birth outcomes. The objective of this study was to assess the relationship between maternal dietary diversity, consumption of specific food groups and markers of nutritional status, including underweight [body mass index (BMI) < 18.5 kg/m² ], overweight (BMI ≥ 23 kg/m² ) and anaemia (haemoglobin < 120 g/dl) among WRA in Bangladesh. This analysis used data from the third round of a longitudinal observational study, collected from February through May of 2017. Dietary data were collected with a questionnaire, and Women's Dietary Diversity Score (WDDS) was calculated. Associations between WDDS, food group consumption and markers of nutritional status were assessed with separate adjusted logistic regression models. Among WRA, the prevalence of underweight, overweight and anaemia was 13.38%, 40.94% and 39.99%, respectively. Women who consumed dark green leafy vegetables (DGLV) or eggs were less likely to be anaemic or underweight, respectively, and women who consumed ASFs, particularly fish, were less likely to be underweight compared with women who did not consume these foods. WDDS did not show any consistent relationship with WRA outcomes. Interventions that focus on promoting optimal nutritional status among WRA in Bangladesh should emphasise increasing consumption of specific nutrient-rich foods, including ASFs, DGLV and eggs, rather than solely focusing on improving diet diversity in general.

The relationship between wasting and stunting in young children: A systematic review

In 2014, the Emergency Nutrition Network published a report on the relationship between wasting and stunting. We aim to review evidence generated since that review to better understand the implications for improving child nutrition, health and survival. We conducted a systematic review following PRISMA guidelines, registered with PROSPERO. We identified search terms that describe wasting and stunting and the relationship between the two. We included studies related to children under five from low- and middle-income countries that assessed both ponderal growth/wasting and linear growth/stunting and the association between the two. We included 45 studies. The review found the peak incidence of both wasting and stunting is between birth and 3 months. There is a strong association between the two conditions whereby episodes of wasting contribute to stunting and, to a lesser extent, stunting leads to wasting. Children with multiple anthropometric deficits, including concurrent stunting and wasting, have the highest risk of near-term mortality when compared with children with any one deficit alone. Furthermore, evidence suggests that the use of mid-upper-arm circumference combined with weight-for-age Z score might effectively identify children at most risk of near-term mortality. Wasting and stunting, driven by common factors, frequently occur in the same child, either simultaneously or at different moments through their life course. Evidence of a process of accumulation of nutritional deficits and increased risk of mortality over a child's life demonstrates the pressing need for integrated policy, financing and programmatic approaches to the prevention and treatment of child malnutrition.

COVID-19: using chest CT of major trauma patients to monitor and evaluate the second wave in London and the development of routine monitoring in practice

AIM

To follow-up previous work evaluating incidental findings of COVID-19 signs on computed tomography (CT) images of major trauma patients to include the second wave prior to any major effects from vaccines.

MATERIALS AND METHODS

The study population included all patients admitted following major trauma between 1 January 2020 and 28 February 2021 with CT including the lungs (n=1776). Major trauma patients admitted pre-COVID-19 from alternate months from January 2019 to November 2019 comprised a control group (n=837). The assessing radiologists were blinded to the time period and used double reading in consensus to determine if the patient had signs of COVID-19. Lung appearances were classified as no evidence of COVID-19, minor signs, or major signs.

RESULTS

The method successfully tracked the second wave of the COVID-19 pandemic in London. The estimated population affected by the disease based on those with major signs was similar to estimates of the proportion of the population in London with antibodies (around 30% by end February 2021) and the total of major and minor signs produced a much higher figure of 68%, which may include all those with both antibody and just T-cell responses.

CONCLUSIONS

Incidental findings on CT from major trauma patients may provide a novel and sensitive way of tracking the virus. It is recommended that all major trauma units include a simple question on signs of COVID-19 to provide an early warning system for further waves.

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.

The global and regional costs of healthy and sustainable dietary patterns: a modelling study

BACKGROUND

Adoption of healthy and sustainable diets could be essential for safe-guarding the Earth's natural resources and reducing diet-related mortality, but their adoption could be hampered if such diets proved to be more expensive and unaffordable for some populations. Therefore, we aimed to estimate the costs of healthy and sustainable diets around the world.

METHODS

In this modelling study, we used regionally comparable food prices from the International Comparison Program for 150 countries. We paired those prices with estimates of food demand for different dietary patterns that, in modelling studies, have been associated with reductions in premature mortality and environmental resource demand, including nutritionally balanced flexitarian, pescatarian, vegetarian, and vegan diets. We used estimates of food waste and projections of food demand and prices to specify food system and socioeconomic change scenarios up to 2050. In the full cost accounting, we estimated diet-related health-care costs by pairing a comparative risk assessment of dietary risks with cost-of-illness estimates, and we estimated climate change costs by pairing the diet scenarios with greenhouse gas emission footprints and estimates of the social cost of carbon.

FINDINGS

Compared with the cost of current diets, the healthy and sustainable dietary patterns were, depending on the pattern, up to 22-34% lower in cost in upper-middle-income to high-income countries on average (when considering statistical means), but at least 18-29% more expensive in lower-middle-income to low-income countries. Reductions in food waste, a favourable socioeconomic development scenario, and a fuller cost accounting that included the diet-related costs of climate change and health care in the cost of diets increased the affordability of the dietary patterns in our future projections. When these measures were combined, the healthy and sustainable dietary patterns were up to 25-29% lower in cost in low-income to lower-middle-income countries, and up to 37% lower in cost on average, for the year 2050. Variants of vegetarian and vegan dietary patterns were generally most affordable, and pescatarian diets were least affordable.

INTERPRETATION

In high-income and upper-middle-income countries, dietary change interventions that incentivise adoption of healthy and sustainable diets can help consumers in those countries reduce costs while, at the same time, contribute to fulfilling national climate change commitments and reduce public health spending. In low-income and lower-middle-income countries, healthy and sustainable diets are substantially less costly than western diets and can also be cost-competitive in the medium-to-long term, subject to beneficial socioeconomic development and reductions in food waste. A fuller accounting of the costs of diets would make healthy and sustainable diets the least costly option in most countries in the future.

FUNDING

Global Panel on Agriculture and Food Systems for Nutrition and Wellcome Trust.

Effective nutrition governance is correlated with better nutrition outcomes in Nepal

BACKGROUND

The public health burden of undernutrition remains heavy and widespread, especially in low-income countries like Nepal. While predictors of undernutrition are well documented, few studies have examined the effects of political will and quality of policy or program implementation on child growth.

METHODS

Data were collected from two nationwide studies in Nepal to determine the relationship between a metric of nutrition 'governance' (the Nutrition Governance Index), derived from interviews with 520 government and non-government officials responsible for policy implementation and anthropometry measured for 6815 children in 5556 households. We employed Generalized Estimating Equation (GEE) and multilevel regression models.

RESULTS

A higher NGI (more effective nutrition governance) is positively associated with height-for-age as well as weight-for-height in children over 2 years of age compared to younger children (HAZ; β = 0.02, p < 0.004, WHZ; β = 0.01, p < 0.37). Results from the hierarchical model show that a one-point increase in the NGI is significantly associated with a 12% increase in HAZ and a 4% increase in WHZ in older children (> 24 months old). Mothers' education, child's age, BMI and no fever in the past 30 days were also protective of stunting and wasting. Seven percent and 17% of the overall variance in HAZ and WHZ, respectively, are accounted for by variations across the 21 district locations in which sampled households were located. Mean HAZ differs considerably across districts (intercept = 0.116, p < 0.001).

CONCLUSIONS

These results highlight the importance of effective management of policy-based programming and resource use to bring about nutrition gains on the ground. The NGI explained a non-negligible amount of variation in HAZ and WHZ, which underscores the fundamental role that good governance plays in promoting child nutrition and growth, and the value of seeking to measure it to assist governments in moving policies from paper to practice.

P14.24 Estimating survival outcomes in elderly (70+ years) patients with primary glioblastoma

BACKGROUND

Elderly patients with glioblastoma are perceived to face a poor prognosis, with perceptions around older age and a relative lack of randomized data raising a concern about their undertreatment. The EANO guidelines recommend &gt;70-year-old patients with good performance status to undergo maximal safe resection followed by hypofractionated (40 Gy in 15 fractions, i.e. RT40/15) radiotherapy with or without concurrent and adjuvant Temozolomide (TMZ), depending on MGMT promoter methylation. This study evaluated the relative survival impact of biological, histological, surgical and oncological factors and aimed to devise a scoring system to estimate the survival of elderly glioblastoma patients, with an aim to more accurately guide treatment in this cohort.

METHODS

The records of 169 elderly (≥70 years) patients with a new diagnosis of IDH-wild type glioblastoma were retrospectively examined for gender, age, WHO performance status (PS), comorbidities, MGMT methylation, surgical intervention and chemoradiation regime. The adjusted survival impact of these factors was determined using Cox proportional hazards model and used to devise a two-stage scoring system to estimate survival of patients at the stage of surgical (Elderly Glioblastoma Surgical Score, EGSS) and oncological management (Elderly Glioblastoma Oncological Score, EGOS).

RESULTS

The overall median survival (MS) of the cohort was 28.8 weeks. Subtotal resection (MS=27.7 weeks, 95%CI 24.1–31.6 weeks, HR=0.58) and gross-total resection (MS=77.8 weeks, 95%CI 67.0–88.6 weeks, HR=0.36) were associated with significant overall survival benefit compared to biopsy alone (MS=18.2 weeks, 95%CI 15.7–20.7 weeks, HR=5.23), p&lt;0.05. Hypofractionated radiation with Temozolomide (RT40/15+TMZ, MS=60.9 weeks, 95%CI 49.9–71.8 weeks, HR=0.13) was non-inferior to the Stupp protocol (RT60/30+TMZ, MS=50.6 weeks, 95%CI 32.4–66.7 weeks, HR=0.11), p=0.72. Negative prognosticators included age above 75 years, biopsy alone and no chemoradiotherapy. Subgroup analysis revealed that MGMT unmethylated 70–75 year old patients who received the Stupp protocol had significantly improved overall survival (MS=57.6 weeks, 95%CI 27.7–88.1 weeks) compared to standard of care RT40/15 alone (MS=29.7 weeks, 95%CI 7.1–51.6 weeks), p=0.002. EGSS and EGOS scores estimated survival with 65% and 73% accuracy, respectively.

CONCLUSION

When appropriate and safe, a subgroup of elderly glioblastoma patients may benefit from more aggressive surgical and oncological management. The proposed EGSS and EGOS scores takes into account important prognostic factors to help guide which patients should receive such treatment.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Host Fecal mRNAs Predicted Environmental Enteric Dysfunction among Children with Moderate Acute Malnutrition in Sierra Leone

Examining the role of environmental enteric dysfunction (EED) in child growth requires noninvasive, field-appropriate biomarkers. Alternatives to the traditionally used lactulose:mannitol (L:M) test have been explored, but few studies have compared the L:M test to host fecal mRNA transcripts. The objectives of this study were to examine whether 1) host fecal mRNA transcripts could predict presence and severity of EED, measured using the L:M test, and 2) EED modifies the effect of specialized nutritious foods (SNFs) on recovery from moderate acute malnutrition (MAM). This substudy was nested within a cluster randomized trial comparing four SNFs in the treatment of MAM among children 6 to 59 months in Sierra Leone. EED was assessed at enrollment using the L:M test and 15 host fecal mRNA transcripts on 522 children. Recovery from MAM was defined as achieving mid-upper arm circumference ≥ 12.5 cm within 12 weeks of supplementation. Random forest classification models were used to examine prediction of presence and severity of EED by host fecal mRNA transcripts. Logistic regression was used to test for effect modification by L:M test variables including % lactulose excreted (%L). Eight host fecal mRNA transcripts (AQP9, REG3A, IFI30, DECR1, BIRC3, SELL, PIK3AP1, DEFA6) identified EED (%L ≥ 0.2) and severe EED (%L ≥ 0.45) with high sensitivity and specificity. The L:M test variables did not modify the effect of SNFs on recovery from MAM. In this study, we found host fecal mRNA transcripts that could be biomarkers of EED but did not find EED to modify the effect of SNFs on MAM treatment.

Global Dietary Database 2017: data availability and gaps on 54 major foods, beverages and nutrients among 5.6 million children and adults from 1220 surveys worldwide

Background

We aimed to systematically identify, standardise and disseminate individual-level dietary intake surveys from up to 207 countries for 54 foods, beverages and nutrients, including subnational intakes by age, sex, education and urban/rural residence, from 1980 to 2015.

Methods

Between 2008–2011 and 2014–2020, the Global Dietary Database (GDD) project systematically searched for surveys assessing individual-level intake worldwide. We prioritised nationally or subnationally representative surveys using 24-hour recalls, Food-Frequency Questionnaires or short standardised questionnaires. Data were retrieved from websites or corresponding members as individual-level food group microdata or aggregate stratum-level data. Standardisation included quality assessment; data cleaning; categorising of foods and nutrients and their units; aggregation by demographic strata and energy adjustment.

Results

We standardised and incorporated 1220 surveys into the final GDD 2017 database, together represented 188 countries and 99.0% of the world’s population in 2015. 72.1% were nationally, 17.0% subnationally, and 10.9% community-level representative. 41.2% used Food-Frequency Questionnaires; 23.4%, 24-hour recalls; 15.8%, Demographic Health Survey questionnaires; 13.1%, biomarkers and 6.4%, household surveys. 73.9% of surveys included data on children; 52.2%, by urban and rural residence; and 30.2%, by education. Most surveys were in high-income countries, followed by sub-Saharan Africa and Asia. Most commonly ascertained foods were fruits (N=803 surveys), non-starchy vegetables (N=787) and sugar-sweetened beverages (N=440); and nutrients, sodium (N=343), energy (N=256), calcium (N=224) and fibre (N=200). Least available data were on iodine, vitamin A, plant protein, selenium, added sugar and animal protein.

Conclusions

This systematic search, retrieval and standardised effort provides the most comprehensive empirical evidence on dietary intakes across and within countries worldwide.

WHZ and MUAC Overlap but Identify Different Children As Acutely Malnourished, and Diagnosis Is Sensitive to Child Sex. Insights From Burkina Faso and Sierra Leone

Objectives

To examine differences in outcomes when using MUAC and/or WHZ to identify wasted children by sex in Burkina Faso and Sierra Leone.

Methods

Spearman's correlation was calculated to examine the relationship between MUAC and WHZ. Kappa Statistics were calculated to examine the agreement between MUAC and WHZ in identifying wasted children. Sensitivity and specificity of WHZ using MUAC as benchmark for identifying wasting was calculated.

Results

There were 6112 children total in Burkina Faso (51% male); 2650 children total in Sierra Leone (43% male). In Burkina Faso, the correlation between MUAC and WHZ for both sexes was significant (lowest r = 0.79, p &lt; 0.001; highest r = 0.86, p &lt; 0.001). Agreement between the two measures in identifying wasted children was fair for female (k = 0.29, p &lt; 0.001), but poor for male children (k = 0.16, p &lt; 0.001). Sensitivity analysis revealed that WHZ identified the same MAM and SAM children more often for males (MAM: 40%–68%; SAM: 25%–100%) than females (MAM: 25%–61%; SAM: 13%–80%). Specificity analysis revealed that WHZ identified non-malnourished children similarly for both sexes (male: 86%–96%; female: 94%–98%). In Sierra Leone, the correlation between MUAC and WHZ was high in relation to both sexes (r = 0.78, p &lt; 0.001). Agreement between the two measures in identifying wasted children was fair for both sexes (k = 0.24, p &lt; 0.001). Sensitivity analysis showed that WHZ identified the same MAM and SAM children more often for males (MAM: 33–66.7%; SAM: 20–100%) than females (MAM: 15–33%; SAM: 9–50%). Specificity analysis showed that WHZ identified non-malnourished children for both sexes similarly (MAM: 75%–100%; SAM: 94%–100%).

Conclusions

Poor overlap was found between MUAC and WHZ in diagnosing wasted children, and high sensitivity of these measures to sex of child. Both measures should be used together to inclusively identify all wasted children for treatment.

Funding Sources

United States Agency for International Development's Bureau for Humanitarian Assistance (USAID/BHA) and legacy Office of Food for Peace (FFP).

In-Home Observations Are a Useful Tool to Assess the Household Enabling Environment for Child Nutrition in Burkina Faso and Sierra Leone

Objectives

Two field studies assessed the effectiveness and cost-effectiveness of specialized nutritious foods (SNF) to prevent and treat malnutrition among children 6–24 months old in Burkina Faso and 6–59 months old in Sierra Leone. In-home observations (IHO) were conducted to understand household use of SNFs. The IHO data are unique, as local enumerators directly observed caregiver behaviors that would otherwise be provided by self-report. In this study, we examined household factors that may influence child nutrition, including child feeding, care, and hygiene practices among caregivers, and sanitary conditions of the home environment.

Methods

Local enumerators conducted 3–5-day IHO among a subset of 321 and 176 beneficiary households in Sierra Leone and Burkina Faso, respectively. Using time-stamped checklists and detailed observation notes, they recorded household activities, focused on feeding and care of beneficiary children. Detailed enumerator notes were analyzed using qualitative content analysis.

Results

Similar trends emerged in both countries. Poor hand-washing and food hygiene practices were common among caregivers; children consumed poor quality, starchy diets; children were most often cared for by their mothers and other adult, female relatives. Child feeding during illness was poor, and child mouthing of unsanitary household objects was common. In Burkina Faso, domestic animals were frequently present in the courtyard and near children during meals.

Conclusions

Future nutrition interventions may consider approaches that address multiple household factors that contribute to an enabling environment for child nutrition. Further, considering the feasibility of field application, the IHO method may be used in future nutrition programs to provide information beyond what could be obtained accurately from caregiver self report, and thus help inform nutrition behavior change strategies.

Funding Sources

Support for this research was provided by the USAID Bureau for Humanitarian Assistance.

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

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

•

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

•

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

•

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

•

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

•

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

Effectiveness and cost-effectiveness of 4 supplementary foods for treating moderate acute malnutrition: results from a cluster-randomized intervention trial in Sierra Leone

BACKGROUND

Moderate acute malnutrition (MAM) affects 33 million children annually. Investments in formulations of corn-soy blended flours and lipid-based nutrient supplements have effectively improved MAM recovery rates. Information costs and cost-effectiveness differences are still needed.

OBJECTIVES

We assessed recovery and sustained recovery rates of MAM children receiving a supplementary food: ready-to-use supplementary food (RUSF), corn soy whey blend with fortified vegetable oil (CSWB w/oil), or Super Cereal Plus with amylase (SC + A) compared to Corn Soy Blend Plus with fortified vegetable oil (CSB+ w/oil). We also estimated differences in costs and cost effectiveness of each supplement.

METHODS

In Sierra Leone, we randomly assigned 29 health centers to provide a supplement containing 550 kcal/d for ∼12 wk to 2691 children with MAM aged 6-59 mo. We calculated cost per enrollee, cost per child who recovered, and cost per child who sustained recovery each from 2 perspectives: program perspective and caregiver perspective, combined.

RESULTS

Of 2653 MAM children (98.6%) with complete data, 1676 children (63%) recovered. There were no significant differences in the odds of recovery compared to CSB+ w/oil [0.83 (95% CI: 0.64-1.08) for CSWB w/oil, 1.01 (95% CI: 0.78-1.3) for SC + A, 1.05 (95% CI: 0.82-1.34) for RUSF]. The odds of sustaining recovery were significantly lower for RUSF (0.7; 95% CI 0.49-0.99) but not CSWB w/oil or SC + A [1.08 (95% CI: 0.73-1.6) and 0.96 (95% CI: 0.67-1.4), respectively] when compared to CSB+ w/oil. Costs per enrollee [US dollars (USD)/child] ranged from $105/child in RUSF to $112/child in SC + A and costs per recovered child (USD/child) ranged from $163/child in RUSF to $179/child in CSWB w/oil, with overlapping uncertainty ranges. Costs were highest per sustained recovery (USD/child), ranging from $214/child with the CSB+ w/oil to $226/child with the SC + A, with overlapping uncertainty ranges.

CONCLUSIONS

The 4 supplements performed similarly across recovery (but not sustained recovery) and costed measures. Analyses of posttreatment outcomes are necessary to estimate the full cost of MAM treatment. This trial was registered at clinicaltrials.gov as NCT03146897.

Body Composition Changes in Children during Treatment for Moderate Acute Malnutrition: Findings from a 4-Arm Cluster-Randomized Trial in Sierra Leone

BACKGROUND

Measures that better describe "healthy" and sustainable recovery during nutritional treatment of children with moderate acute malnutrition (MAM) are needed.

OBJECTIVES

We compared changes to body composition among children receiving 1 of 4 specialized nutritious food (SNFs) during treatment of MAM and by recovery and relapse outcomes.

METHODS

The study was nested within a prospective, cluster-randomized, community-based, cost-effectiveness trial assessing 4 SNFs to treat children aged 6-59 mo with MAM [midupper arm circumference (MUAC) ≥11.5 cm and <12.5 cm without bipedal edema] in Sierra Leone. Biweekly SNF rations (1 of 3 fortified-blended foods or a lipid-based nutrient supplement) were given until children recovered (MUAC ≥12.5 cm), or up to 7 rations (∼12 wk). Deuterium dilution was used to estimate fat-free mass (FFM) and fat mass (FM) at enrollment and after 4 wk of treatment to ensure similar treatment exposure among the participants. Another MUAC measurement was performed among recovered children 4 wk after program exit to determine whether recovery was sustained. ANOVA, paired t tests, and linear regression models were used to determine significant differences in changes from baseline to 4 wk.

RESULTS

Among 312 analyzed participants, mean baseline weight comprised ∼80% FFM; mean weight gained after 4 wk comprised ∼82% FFM. Changes in FM and FFM among 4 SNFs were similar. Children who recovered gained more weight (241%), FFM (179%), and weight-for-height z score (0.44 compared with 0) compared with those who did not recover; sustainers gained 150% more weight. FM gains were positive among recovered children and sustainers, as well as negative among those who did not recover or sustain recovery, but not significantly different.

CONCLUSIONS

Four SNFs had similar effects on body composition in children after 4 wk of treatment for MAM, showing a healthy pattern of weight gain, the majority being FFM. Differential responses to treatment underscore a need for further research to provide targets for healthy, sustainable recovery. This trial was registered at clinicaltrials.gov as NCT03146897.

Sustained intake of animal-sourced foods is associated with less stunting in young children

The value of animal-sourced foods (ASFs) in providing key nutrients, particularly for child growth and where diets are of low quality, is understood mainly from cross-sectional assessment of current consumption. Longitudinal panel data from Nepal, Bangladesh and Uganda were used here to assess associations among previous (lagged) and contemporaneous ASF intake with linear growth of children aged 6-24 months. Lagged ASF consumption was significantly correlated with a 10% decline in stunting in Nepali children who consumed any ASF in the previous year, while current intake was associated with a 9% decline in stunting in Uganda. Previous consumption of two or more ASFs showed a stronger association, ranging from a 10% decline in stunting in Bangladesh to a 16% decline in Nepal. This novel lagged analysis emphasizes the need for regular and appropriate levels of ASF intake by young children to support healthy growth in resource-constrained settings.