Background Adolescents are vulnerable to rapidly evolving food environments. Urbanization is widely thought to contribute to less healthy food environments, and school food environments are often considered less healthy than those at home. These associations, however, have not been quantified. Objectives Assess differences in adolescent food environments in Northern Vietnam by setting (home compared with school) and area (rural, peri-urban or urban). Methods We collected cross-sectional data on adolescents (n = 3005) and surveyed all outlets (n = 6194) that sold food or beverages around adolescents’ homes and schools (n = 13) in 3 sites that differed in urbanicity. We calculated distances from home and school to the nearest outlet selling select food groups and measured outlet density and diversity of foods offered (within a 100-m radius). We analyzed differences by urbanicity and by home/school environment using regression models, accounting for clustering at the commune level. Results Both unhealthy food groups (UFG) (e.g., sugar-sweetened beverages, sweets) and healthy food groups (HFG) (e.g., fruits, nuts/seeds) were closer to adolescents’ homes in the urban (∼21‒50 m) than the peri-urban (∼75‒200 m) and rural (∼155‒270 m) area. Fruits and vegetables were consistently further away than UFG across all areas in home environments, although still close by (∼ 50‒270 m). Urban adolescents were exposed to the greatest density and diversity of both HFG and UFG close to home and school. There were no differences in healthiness of home and school food environments. Conclusions Unhealthy foods were more accessible (in distance) and available (in density) than fruits and vegetables across all settings, but differences were small, and food was always close by. Diversity of HFG and UFG was the greatest in urban areas. Healthy foods should be promoted and made the preferred choice through nudging interventions at point-of-purchase, combined with restrictions on the marketing and availability of unhealthy foods.

Background As adolescents gain autonomy, they interact more independently with their food environments, increasing their vulnerability to rapidly changing and often unhealthy food environments. In Accra, Ghana, unhealthy foods and beverages are widely available and heavily marketed. Objectives This study aimed to assess the healthiness and nutrient adequacy of adolescents’ diets in Accra and to examine whether diet healthiness is associated with independent adolescent food selection and their engagement with home, school, and outlet food environments. Methods We conducted a cross-sectional study using quantitative 24-h dietary recalls among 911 adolescents aged 12 to 18 y living in 5 low- and 5 middle-class neighborhoods in Accra. For each food and beverage consumed, we documented who selected it and where it was obtained and consumed. We calculated the global diet quality score (GDQS) and the prevalence of adequate intake for fruits and vegetables, protein, fiber, total sugar, total fat, saturated fat, and 11 micronutrients. Mixed-effects models assessed associations between independent adolescent food selection and food acquisition location (home, school, or other food outlets), and diet healthiness and macronutrient and micronutrient intake. Results A large proportion of adolescents consumed excessive amounts of total sugar (49%) and total fat (44%) and inadequate amounts of fruits and vegetables (98%), fiber (45%), and 8 of the 11 micronutrients assessed (39%‒100%). Greater adolescent-selected food intake (mean, 62% of energy intake) was associated with lower GDQS and intakes of fruit and vegetables, protein, fiber, and 6 micronutrients and with higher sugar intake (P < 0.05). Greater reliance on foods from the external food environment (school: 14%; other outlets: 46%) showed similar associations with poorer dietary indicators. Conclusions Strengthening the design, implementation, and enforcement of coordinated food policy bundles is needed to shift adolescents’ preferences toward healthy foods and reduce the availability, accessibility, and appeal of unhealthy options in their food environments.

BACKGROUND:Enhanced homestead food production programs (EHFP) including nutrition behavior change communication and women's empowerment activities have limited impacts on child nutrition. This may be due to short program duration or the absence of interventions to improve water, sanitation, and hygiene (WASH), as well as access to nutritious foods. OBJECTIVES:We assessed impacts on child anemia, micronutrient status, and anthropometry of prior village exposure to an EHFP, and of adding WASH alone or WASH with daily small quantity-lipid based nutrient supplements (SQ-LNS). METHODS:This 2-y longitudinal cluster-randomized controlled trial (2014-2016) included 60 villages in Burkina Faso randomized to 4 groups (15 per group): 1) EHFP-2014; 2) EHFP-2014+WASH; 3) EHFP-2010+WASH; and 4) EHFP-2010+WASH+SQ-LNS. Groups 3 and 4 had previously received EHFP (2010-2012). We assessed impacts on child anemia and micronutrient status (n = 1704; 3-12.9 mo at baseline) and anthropometry (n = 2308; 0-12.9 mo at baseline) using difference-in-difference (DID) specifications. We controlled for covariates, adjusted for clustering, and assessed interactive effects by child age at baseline. The trial was registered with clinicaltrials.gov (NCT02236468). RESULTS:We found no impact of prior exposure to EHFP (groups 2 compared with 3) on the outcomes examined. Adding WASH (groups 1 compared with 2) reduced anemia [hemoglobin (Hb) <11 g/dL] (DID = 9.43 pp, P < 0.01) and led to a decline in weight-for-age Z-score (DID -0.11 ± 0.04, P = 0.01). Adding SQ-LNS (groups 3 compared with 4) increased Hb (DID = 0.26 ± 0.13 g/dL, P < 0.05), plasma ferritin (DID = 7.61 ± 2.69 μg/L, P < 0.01), and retinol binding protein (DID = 0.07 ± 0.02 μmol/L, P < 0.01) concentrations. Effects were larger in children <6 mo at baseline, where providing SQ-LNS (>6 mo) positively impacted Hb, plasma ferritin, height-for-age Z-score, weight-for-age Z-score, and underweight. CONCLUSIONS:Using EHFP to deliver WASH and SQ-LNS reduced child anemia and improved micronutrient status. Anthropometric improvements were found in children who joined the program before 6 mo of age and were exposed for the whole complementary feeding period.

Background As adolescents grow older, they increasingly engage with the food environment. Objectives Our study aimed to 1) assess the contribution of prepared out of home (POH) foods to the healthiness of adolescent diets and 2) identify sociodemographic factors associated with POH food intake in a rural, a peri-urban, and an urban area of Vietnam. Methods We conducted a cross-sectional survey among 11- to 19-y-old adolescents (n = 2861) and collected sociodemographic and dietary intake data (24-h recall). The healthiness and micronutrient adequacy of diets were assessed using the Global Diet Quality Score and the micronutrient adequacy ratio, respectively. We used regression analyses with robust standard errors (to account for school-level clustering) to assess the consequences and identify the drivers of POH food intake. Results Of the adolescents, >80% consumed POH foods on the previous day, contributing 22% to 26% of their daily energy intake. Healthy food groups were underrepresented in POH foods, which were higher in fat, saturated fat, and sodium but also had higher micronutrient density than foods prepared at home. POH food intake was associated with higher energy intake and micronutrient adequacy but lower diet healthiness. Socioeconomic status, female sex, pocket money, and smartphone ownership were associated with POH food consumption, with site-specific differences. Conclusions Food environments should be made healthier through front-of-package warning labels, reformulation (e.g., reducing milk fat and sugar), and restrictions on the marketing and availability of unhealthy foods combined with the promotion of healthy foods, snacks, and meals.

BACKGROUND:Urbanization catalyzes significant shifts in diets worldwide, yet its impact on adolescent diets and nutrition is poorly understood. OBJECTIVES:We examined the association between urbanicity and diets and nutritional status among Vietnamese adolescents and their mothers. METHODS:We assessed diets using a multipass 24-h recall (15% repeated) and collected anthropometric data from 2861 adolescents and their mothers (n = 2664) in rural, peri-urban and urban areas. We calculated the Global Diet Quality Score (GDQS: total 0-49; healthy: 0-32; unhealthy: 0-17) and risk categories. We estimated usual intakes (National Cancer Institute's method) and the mean probability of adequacy (MPA) for 11 micronutrients. We compared outcomes across areas using regression models adjusted for school-level clustering. RESULTS:GDQS healthy was higher in the urban area (adolescents 7.5, mothers 9.5) than in the rural area (6.6 and 7.7). GDQS unhealthy was comparable across areas (∼11 in adolescents and mothers). Adolescent and maternal diets in the rural area were most likely to fall in the GDQS high-risk category for nutrient inadequacy and non-communicable diseases(23% and 11%). MPA was low across all areas for both adolescents and mothers (≤40%). The prevalence of overweight/obesity was highest in urban areas among adolescents (29%) and similar across areas among mothers (15%-19%). CONCLUSIONS:Urbanicity was positively associated with healthier diets due to greater healthy food consumption, but also with higher risks of adolescent overweight/obesity. Differences by study area, however, were small and diet healthiness was low across all settings. Innovative school and food environment interventions and policies are needed to promote greater consumption of healthy foods and limit unhealthy food intake among Vietnamese adolescents and their mothers, and to prevent and control rising overweight/obesity.

Growth monitoring and promotion (GMP) visits provide a frequent contact point with caregivers, which can be an opportunity for the promotion of early child development (ECD). Using a combination of quantitative analyses of longitudinal and cross-sectional data and a review of the literature, we investigated whether the GMP platform could improve ECD by identifying children at risk of poor development and delivering responsive parenting education to caregivers of young children. Cross-sectional and lagged regression analyses and area under the receiver operating characteristic curves indicated that growth indices were not accurate predictors of concurrent and later child development. Rather, validated tools, such as the Ages and Stages Questionnaire or the Survey of Well-being of Young Children, could be utilized during GMP visits to screen individual children for suboptimal development. Through a review of published literature on ECD interventions, we identified 10 light-touch ECD interventions that could feasibly be implemented during GMP visits, but only half have been evaluated for their effectiveness. Our findings demonstrate that, although growth indices cannot accurately identify children at risk of suboptimal development, the GMP platform could offer an opportunity to screen children for suboptimal development and to deliver ECD interventions. Further evidence on the implementation and effectiveness of light-touch parenting programs, however, is required.

The global increase in early childhood overweight and obesity has prompted interest in early prediction of overweight and obesity to allow timely intervention and prevent lifelong consequences. A systematic review was conducted to assess the accuracy and feasibility of predicting overweight and obesity in individual children aged 3-7 y using data available in healthcare and community settings on children aged under 24 mo. This review was registered in PROSPERO (CRD42024509603) and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. From 7943 unique articles identified through PubMed, CINAHL, Scopus, and Google Scholar, 14 studies met the inclusion criteria, 13 from high-income countries and 1 from a middle-income country. These studies evaluated the accuracy of predicting childhood overweight or obesity in individual children using anthropometrics-alone or multiple-predictor models. Anthropometrics-alone models yielded areas under the curve (AUCs) ≥ 0.56 with expert guidance and ≥0.77 with machine learning. Multiple-predictor models yielded AUC ≥ 0.68 with expert guidance and ≥0.76 with machine learning. The inclusion of child, parental, and community predictors improved predictive accuracy but led to greater variation in performance across models. Models were more accurate when children were older at the initial assessment, multiple assessments were made, and the time between assessment and outcome prediction was shorter. Prediction models with an AUC ≥ 0.70 used machine learning to optimize variable selection, limiting their practicality for broad-scale implementation in healthcare or community settings. There is insufficient evidence on the accuracy of overweight and obesity prediction models for children in low- and middle-income countries. Existing prediction models are not well-suited for broad-scale screening of individual children for risk of early childhood overweight or obesity.

Growth monitoring and promotion (GMP), the process of periodic anthropometric measurements to assess the adequacy of individual child growth, is implemented across low-income and middle-income countries. The epidemiologic foundations of GMP (i.e., that GMP can accurately diagnose or screen for inadequate growth) have never been critically reviewed. We first assessed growth patterns of individual healthy children. Using longitudinal data from low-income, middle-income, and high-income countries, we evaluated whether commonly used GMP criteria can be used for diagnosis and screening; i.e., whether they accurately identify current, or predict subsequent, inadequate growth in individual children. The growth of individual healthy children does not track along a specific growth curve, which challenges the notion that growth measurements alone can be used to distinguish between healthy and inadequate growth. We demonstrated that GMP criteria do not provide meaningful diagnostic information and that GMP is not a meaningful screening activity: commonly used GMP criteria are inaccurate predictors of (inadequate) growth later in childhood, and collecting individual children's weight and height does not help to identify who needs support or who will benefit. Our results do not undermine the importance of dedicated programs to diagnose wasting in individual children nor do they challenge the need for well-child care to support parents and to ensure children's optimal nutrition, health, and development. Our findings, however, highlight the need to carefully reconsider the current design of GMP in low-income and middle- income countries.

BACKGROUND:Relapse among children treated for wasting is a major concern. OBJECTIVES:We estimated the frequency and determinants of relapse to wasting in 2 populations exposed to PROMIS, an integrated wasting prevention and screening program. METHODS:Using longitudinal data from PROMIS trials in Burkina Faso and Mali, we calculated the incidence rate and period prevalence of relapse to wasting within 6 mo in children who had ≥1 wasting episode ending when they were ≥6 mo old for which they were treated and recovered (NBurkina Faso = 247; NMali = 220). We used backward elimination to select a multivariable model of sociodemographic, nutrition-related, and health-related determinants of relapse. We also evaluated whether prevention interventions [behavior change communication (BCC) and/or small-quantity lipid-based nutrient supplements (SQ-LNS)] were associated with relapse, adjusting for confounders and trial arm. RESULTS:Relapse incidence was 2.6 per child-year in Burkina Faso (n = 291 episodes) and 1.6 per child-year in Mali (n = 300 episodes). In both countries, being fed the recommended food frequency or iron-rich foods after recovering from wasting was associated with lower risk of relapse. In Mali, longer wasting episodes, lack of minimally diverse diet consumption, and several caregiver/household characteristics were associated with higher risk of relapse. In both countries, receipt of BCC after recovery from wasting was associated with lower risk of relapse [incidence rate ratio (IRR)Burkina Faso: 0.51; 95% CI: 0.30, 0.86; IRRMali: 0.26; 95% CI: 0.11, 0.65), as was receipt of SQ-LNS (IRRBurkina Faso: 0.33; 95% CI: 0.16, 0.70; IRRMali: 0.43; 95% CI: 0.19, 0.94), after adjustments. CONCLUSIONS:Children being discharged from wasting treatment are a well-defined vulnerable population who stand to benefit from targeted postdischarge preventive interventions. BCC that includes advice on optimal infant and young child feeding practices and SQ-LNS may help prevent wasting relapse in at-risk children.

BACKGROUND:Obesity is an increasing problem among women of reproductive age (WRA) in Tanzania. OBJECTIVE:We described WRA's nutritional status by sociodemographic factors and assessed associations with diet quality. METHODS:We analyzed baseline data from a cluster-randomized controlled trial in Arusha and Kilimanjaro regions (n = 2415). Diet was assessed using a quantitative 24-h recall. We calculated the Global Diet Quality Score (GDQS; 0-49), with higher scores indicating healthier diet. General obesity was defined as body mass index (BMI) ≥30 kg/m2; morbid obesity as BMI ≥35 kg/m2; and central obesity as: waist circumference (WC) ≥80 cm, WC ≥88 cm, waist-to-hip ratio (WHR) ≥0.85, waist-to-height ratio ≥0.50, and WHR ≥0.85 or BMI ≥30 kg/m2. We tested associations between diet quality and nutritional status using generalized linear models controlling for age and sociodemographic factors and tested interactions to assess differential associations by age groups. RESULTS:The prevalence of general obesity was 25.1%, morbid obesity 8.4%, and central obesity 48.2%-71.6% depending on the definition. Mean GDQS was 20.9 ± 3.9. General and central obesity were more prevalent among women who were older, less educated, had light physical labor occupations, were in the highest wealth quintile, and lived in more urbanized villages, and in more food-secure households. Higher GDQS was associated with lower risk of morbid obesity: risk ratio 0.97 (95% confidence interval: 0.94, 1.00). Higher GDQS was also associated with 0.25-0.27 kg/m2 lower BMI, 0.54-0.66 cm lower WC, and 0.53-0.58 cm lower hip circumference in women aged 30-49 y. CONCLUSIONS:Better diet quality emerged as a protective factor for morbid obesity and for other obesity measures among women aged 30-49 y. Our study suggests that interventions to improve diet quality in Tanzania should target women in their 30s and 40s and those with lower physical activity and higher education, food security, and wealth to maximize effectiveness.

SUMMARY This chapter reviews current knowledge and experience with using food-based approaches in reducing vitamin A and iron deficiencies. It reviews recently published literature, highlights some lessons learned, and identifies knowledge gaps and research priorities. The main strategies reviewed are food-based interventions that aim at: (1) increasing the production, availability, and access to vitamin A and iron-rich foods through the promotion of home production and (2) plant breeding strategies that have the potential to increase the content of vitamin A and iron in diet as well as their bioavailability. The review highlights the fact that significant progress has been achieved in the past few decades in the design and implementation of food-based approaches. Evaluations however remain weak, and without rigorous, carefully conducted evaluations the real potential of food-based approaches in addressing micronutrient malnutrition cannot be fully understood. Plant breeding strategies, although they are at a much earlier stage of development, hold great promise because of their enormous potential to improve the dietary quality of populations relying mainly on cereal staples. Studies on human bioavailability are the next crucial step to help understand the potential contribution of plant breeding towards alleviating micronutrient malnutrition. Our review suggests that food-based interventions could be an essential part of the long-term global strategy for the fight against micronutrient malnutrition, but their real potential is still to be explored.

Background: Little is known about costs and cost effectiveness of interventions that integrate wasting prevention into screening for child wasting. Objectives: This study's ' s objective was to estimate the cost and cost-effectiveness of an intervention that integrated behavior change communication (BCC) and small-quantity lipid-based nutrient supplements (SQ-LNS) into platforms for wasting screening in Burkina Faso (a facility-based platform, where BCC was enhanced compared with standard care) and Mali (a community-based platform, with standard BCC). Methods: Activity-based costing was used to estimate the cost per child-contact for the intervention and the comparison group, which did not receive the intervention. Costs were ascertained from accounting records, interviews, surveys, and observations. The number of child- contacts was calculated using population size estimates and average attendance rates for each service. Costs per disability-adjusted life year (DALY) averted were estimated using a Markov model populated with data from the parent trials on impact of wasting incidence and treatment coverage. Results: In the intervention group in Burkina Faso, the cost per child-contact of facility-based screening was $0.85 of enhanced BCC was $4.28, and of SQ-LNS was $8.86. In Mali, the cost per child-contact of community-based screening was $0.57, standard BCC was $0.72, and SQ-LNS was $4.14. Although no SQ-LNS costs were incurred in the comparison groups (hence lower total costs), costs per child-contact for screening and BCC were higher because coverage of these services was lower. The intervention package cost $1073 per DALY averted in Burkina Faso and $747 in Mali. Conclusions: Integration of wasting prevention into screening for child wasting led to higher total costs but lower unit costs than standard screening due to increased coverage. Greater cost-effectiveness could be achieved if BCC were strengthened and led to improved caregiver health and nutrition practices and if screening triggered appropriate use of services and higher treatment coverage.

Suboptimal diets are the most important preventable risk factor for the global burden of non-communicable diseases. The EAT-Lancet reference diet was therefore developed as a benchmark for gauging divergence from healthy eating standards. However, no previous research has comprehensively explored how and why this divergence exists in poorer countries undergoing nutrition transitions. This study therefore analyzes dietary patterns and drivers of the demand for nutritious foods using nationally representative household surveys from Ethiopia, Kenya, Tanzania, and Uganda. We show how barriers to dietary convergence stem from combinations of poverty, high relative food prices and weak preferences for some specific healthy foods. The article concludes by discussing interventions for strengthening consumer demand for healthy diets in Africa.

AbstractNutrition‐sensitive agriculture programmes have the potential to improve child nutrition outcomes, but livestock intensification may pose risks related to water, sanitation and hygiene (WASH) conditions. We assessed the impact of SELEVER, a nutrition‐ and gender‐sensitive poultry intervention, with and without added WASH focus, on hygiene practices, morbidity and anthropometric indices of nutrition in children aged 2−4 years in Burkina Faso. A 3‐year cluster randomised controlled trial was implemented in 120 villages in 60 communes (districts) supported by the SELEVER project. Communes were randomly assigned using restricted randomisation to one of three groups: (1) SELEVER intervention (n = 446 households); (2) SELEVER plus WASH intervention (n = 432 households); and (3) control without intervention (n = 899 households). The study population included women aged 15−49 years with an index child aged 2−4 years. We assessed the effects 1.5‐years (WASH substudy) and 3‐years (endline) post‐intervention on child morbidity and child anthropometry secondary trial outcomes using mixed effects regression models. Participation in intervention activities was low in the SELEVER groups, ranging from 25% at 1.5 years and 10% at endline. At endline, households in the SELEVER groups had higher caregiver knowledge of WASH‐livestock risks (∆ = 0.10, 95% confidence interval [CI] [0.04−0.16]) and were more likely to keep children separated from poultry (∆ = 0.09, 95% CI [0.03−0.15]) than in the control group. No differences were found for other hygiene practices, child morbidity symptoms or anthropometry indicators. Integrating livestock WASH interventions alongside poultry and nutrition interventions can increase knowledge of livestock‐related risks and improve livestock‐hygiene‐related practices, yet may not be sufficient to improve the morbidity and nutritional status of young children.

Why small-quantity lipid-based nutrient supplements should be integrated into comprehensive strategies to prevent child undernutrition in nutritionally vulnerable populations: response to Gupta et al.’s commentary Kathryn G. Dewey1, Christine P. Stewart, Christine McDonald, K. Ryan Wessells, Charles D. Arnold, Elizabeth L. Prado, Souheila Abbeddou, Seth Adu-Afarwuah, Benjamin F. Arnold, Per Ashorn, Ulla Ashorn, Sania Ashraf, Elodie Becquey, Robert E. Black, Kenneth H. Brown, Parul Christian, John M. Colford Jr., Lia C.H. Fernald, Emanuela Galasso, Lotta Hallamaa, Sonja Y. Hess, Jean H. Humphrey, Lieven Huybregts, Lora L. Iannotti, Kaniz Jannat, Elizabeth Y. Jimenez, Anna Lartey, Agnes Le Port, Jef L. Leroy, Stephen P. Luby, Kenneth Maleta, Andrew Matchado, Susana L. Matias, Mduduzi NN Mbuya, Malay K. Mridha, Rina R. Paul, Harriet Okronipa, Jean-Bosco Ouédraogo, Amy J. Pickering, Andrew J. Prendergast, Marie Ruel, Saijuddin Shaikh, Ann M. Weber, Patricia Wolff 1 Institute for Global Nutrition, University of California, Davis, 2 Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, University of California, San Francisco, 3 Department of Public Health and Primary Care, Ghent University, 4 Department of Nutrition and Food Science, University of Ghana, 5 Francis I. Proctor Foundation, University of California, San Francisco, 6 Department of Paediatrics, Tampere University Hospital, 7 Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, 8 Center for Social Norms and Behavioral Dynamics, University of Pennsylvania, 9 Nutrition, Diets, and Health Unit, International Food Policy Research Institute, 10 Johns Hopkins Bloomberg School of Public Health, 11 Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 12 School of Public Health, University of California, Berkeley, 13 Development Research Group, World Bank, 14 Zvitambo Institute for Maternal and Child Health Research, 15 Brown School, Washington University in St. Louis, 16 School of Health Sciences, Western Sydney University, 17 Departments of Pediatrics and Internal Medicine and College of Population Health, The University of New Mexico, 18 Montpellier Interdisciplinary Center on Sustainable Agri-food systems (MoISA), French National Research Institute for Sustainable Development (IRD), 19 Division of Infectious Diseases and Geographic Medicine, Stanford University, 20 Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, 21 Department of Public Health, Kamuzu University of Health Sciences, 22 Department of Nutritional Sciences and Toxicology, University of California, Berkeley, 23 Global Alliance for Improved Nutrition, 24 Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, 25 State University of Bangladesh, 26 Department of Nutritional Sciences, Oklahoma State University, 27 Institut de Recherche en Sciences de la Santé (IRSS), 28 Department of Civil and Environmental Engineering, University of California, Berkeley, 29 Blizard Institute, Queen Mary University of London, 30 The JiVitA Project of Johns Hopkins University, 31 School of Public Health, Division of Epidemiology, University of Nevada, Reno, 32 Meds & Foods for Kids