BACKGROUND:Adjustment of haemoglobin concentrations for elevation is essential for anaemia assessments of both individuals and populations. Whereas the previous WHO anaemia definitions released in 2001 used an elevation adjustment derived from small sample sizes with limited representativeness, the 2024 WHO global anaemia definitions reflect empirical assessments across several geographies and settings derived from population-representative surveys. We aimed to assess the effect of these changes on estimates of global anaemia burden. METHODS:In this population-based modelling study, using an identical set of input data from population-based surveys, we created two datasets in parallel, where each input haemoglobin concentration was adjusted using the WHO 2001 and WHO 2024 elevation adjustment methods. We estimated mild, moderate, and severe anaemia prevalence by age and sex for 204 countries and territories from 1990 to 2023 for each dataset using spatiotemporal Gaussian process regression and ensemble distribution modelling. We then analysed the overall differences in anaemia prevalence and years lived with disability to assess the effect of the WHO 2024 elevation adjustment method on the global landscape of anaemia. Uncertainty was propagated in each step of the modelling process by sampling draws of the posterior distribution of each estimated quantity. FINDINGS:Global anaemia prevalence for all ages and both sexes in 2023 was estimated to be 26·4% (95% uncertainty interval [UI] 22·6-31·9) using the WHO 2024 elevation adjustment method, which was 2·4 percentage points (2·2-2·7) higher than the total anaemia prevalence estimated using the WHO 2001 method (24·0% [20·6-29·3]). This increase equates to 198 million (196-199) newly enumerated cases, increasing the rank of anaemia from the third to the second largest cause of disability globally. The largest absolute increases in anaemia prevalence were in locations between 500 m and 2000 m in elevation, which include countries in eastern sub-Saharan Africa, central Asia, central America, and South America. INTERPRETATION:Understanding the effect of anaemia requires unbiased and comparable estimates of anaemia burden. To our knowledge, we produced the first set of global estimates of anaemia burden by location, year, age, and sex using the WHO 2024 elevation adjustment method and compared them with estimates using the previous method. Policy makers should consider this modification when designing interventions to manage and prevent anaemia, particularly in regions most affected by changes in elevation adjustment. FUNDING:Gates Foundation.

BACKGROUND:In Peru, legally mandated universal micronutrient supplementation policies preclude randomized trials. OBJECTIVE:To evaluate hemoglobin (Hb) outcomes associated with enhanced follow-up of therapeutic iron or preventive multiple micronutrient powder (MNP) supplementation among high-altitude infants within a real-world natural experiment. METHODS:This observational study leveraged a policy-driven natural experiment to analyze two population-based cohorts of 317 infants aged 6-12 months from Puno, Peru (3,832 m), evaluated before and after implementation of strict follow-up. According to national guidelines, infants with anemia received therapeutic iron syrup (ferrous sulfate or iron polymaltose), while non-anemic infants received preventive MNP. Supplements were provided monthly for six months. Hemoglobin was measured at baseline and follow-up and adjusted for altitude using the WHO 2024 criteria. Adequate Hb response was defined as an increase ≥1 g/dL. Multivariable regression models assessed factors associated with hemoglobin response. RESULTS:Overall, 14.8% of infants achieved an Hb increase ≥1 g/dL (18.7% vs. 11.8% in the strict and non-strict follow-up groups, respectively). Among non-anemic infants at baseline, adequate Hb response was more frequent under strict follow-up (8.3% vs. 2.7%). In the prespecified primary adjusted model, strict follow-up was associated with higher odds of achieving an adequate Hb response (aOR 3.53; 95% CI 1.40-8.84), compared with the crude estimate (OR 2.45; 95% CI 1.30-4.63). In sensitivity analyses incorporating additional socioeconomic, nutritional, and program-related covariates, the association was attenuated (aOR 2.18; 95% CI 0.53-8.99). When evaluated as a continuous outcome, strict follow-up was associated with greater hemoglobin increases (adjusted mean difference 0.74 g/dL; 95% CI 0.23-1.25). At six months, altitude-adjusted anemia prevalence was lower in the strict follow-up group than in the non-strict group (25.2% vs. 38.2%, p = 0.019). Baseline anemia and older age were independently associated with larger hemoglobin gains. CONCLUSIONS:Strict follow-up was associated with greater increases in hemoglobin concentration and lower altitude-adjusted anemia prevalence at follow-up. Although anemia prevalence was lower among infants receiving strict follow-up, residual anemia remained common after six months of supplementation. These findings suggest that enhanced programmatic follow-up may improve hematologic outcomes under routine public health conditions, while additional factors contributing to anemia persistence warrant further investigation.

Objective: To synthesize the existing literature on the etiologic mechanisms of anemia, challenges in anemia measurement, and diagnostic criteria among children in Peru Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews was followed. PubMed, Web of Science, Scopus, Embase, and the Latin American and Caribbean Health Sciences Literature databases were searched for relevant studies published from 1990 to 2024. Two reviewers independently screened and extracted data from included publications. Etiologic proportions were pooled from heterogeneous studies. Data were analyzed from February 3 to August 1, 2025. Results: The scoping review included 55 studies comprising data on 4 688 221 children. Twenty studies focused on high-altitude populations and 35 on causal mechanisms of anemia, with some studies addressing both; 45 were cross-sectional (82%). Sample sizes ranged from small community studies (9 children) to large nationally representative studies (2 087 768 children). Eight studies did not report sample size. Five studies used existing databanks for spatial analyses or clustering methods to estimate anemia prevalence. Reported causes of anemia according to the findings of individual regional studies were: parasitic infections (53.0%), iron deficiency (14.0%), vitamin B-12 deficiency (13.0%), inflammation (8.0%), folate deficiency (0.2%), and unknown causes (36.0%), although estimates were not directly comparable across studies. Measurement approaches varied, with HemoCue portable hemoglobinometers used in 56.0% of studies. Use of altitude correction formulas was associated with an average increase of more than 30 percentage points in reported anemia prevalence. Conclusions: This scoping review found that anemia in Peruvian children is multifactorial, with regional studies identifying diverse etiologic mechanisms, most commonly parasitic infections and iron deficiency; nationally representative data are lacking. Variability in diagnostic methods, particularly in altitude adjustment, and limited comparability may complicate prevalence estimates. Standardized and validated approaches to anemia assessment are urgently needed to support context-specific interventions and effectively address the childhood anemia burden in Peru.

Background:The extent to which inflammation from overweight or obesity influences interpretation of commonly used vitamin A status biomarkers is uncertain. Objectives:We examined relationships among weight status, inflammation, and retinol or retinol-binding protein (RBP) among women (15-49 y) and children (6-59 mo) with normal weight to overweight or obesity. Methods:Cross-sectional data were separately analyzed from 24 surveys representing 24 countries (n = 16,771 women in 13 surveys and n = 24,707 children in 22 surveys) from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project, excluding observations with underweight, wasting, pregnancy, or malaria. Relationships were assessed between BMI (women) or BMI-for-age z-score (BAZ, children), inflammatory biomarkers C-reactive protein (CRP) and/or α1-acid glycoprotein (AGP), and retinol or RBP by linear regression. We also examined potential mediation by CRP and/or AGP in relationships between BMI/BAZ and retinol/RBP with structural equation modeling. Regression and mediation models accounted for complex survey designs and were adjusted for potential confounders. Results:Among women, BMI was positively associated with retinol/RBP in 5 of 13 surveys and positively associated with CRP and/or AGP in 10 of 13 surveys; associations between biomarkers of inflammation and retinol/RBP varied in direction and magnitude. Among children, BAZ was positively associated with retinol/RBP in 3 of 22 surveys and positively associated with CRP in 1 survey (none with AGP); inflammation biomarkers were consistently negatively associated with retinol/RBP. In 3 of 13 women's surveys and 1 of 22 children's surveys, inflammation partially mediated the relationship between BMI/BAZ and retinol/RBP; however, the direction of associations varied. Conclusions:In these surveys limited to individuals without undernutrition or malaria, inflammation associated with overweight or obesity does not appear to impact vitamin A assessment when measured with retinol/RBP. However, findings support measurement of biomarkers reflecting inflammation (of any source) to interpret vitamin A status, particularly among children.

The effects of armed conflict on children are devastating, with more than 520 million children and adolescents residing in conflict zones worldwide. Armed conflicts not only cause death and destruction but also lead to widespread displacement, exposing children to physical injuries, sexual violence, family separation, food insecurity, and disruption of essential services like education and health care. All pediatricians and health care providers play crucial roles in addressing the complex challenges faced by children in these settings. Pediatric professionals are called to advocate for policy reforms, ensure culturally appropriate, sensitive, and trauma-informed care and community support, and engage in research to mitigate short- and long-term harm and promote resilience. Strategic interventions include ensuring access to health care and mental health services, safeguarding education, and providing bereavement and psychosocial support during and after resettlement. In doing so, pediatricians can help protect children's rights and foster a future where every child, regardless of conflict, has the opportunity to thrive.

BackgroundIn 2024, the World Health Organization (WHO) introduced new hemoglobin cutoffs for diagnosing anemia. The WHO also incorporated revised altitude adjustments and lowered thresholds to diagnose anemia for children aged 6-23 months. Puno, Peru has historically reported the highest prevalence of anemia in the country, exceeding 70% in infants and young children.ObjectiveTo assess the impact of the new WHO cutoffs on anemia prevalence and evaluate whether they affected the proportion of anemia attributable to iron deficiency (ID), inflammation, and other causes.MethodsA cross-sectional study was conducted among 310 children aged 6-59 months in Puno, Peru. Participants were recruited via convenience sampling during routine medical check-ups. Venous blood samples were analyzed using an automated hemoglobin analyzer and serum biomarker evaluations. Anemia prevalence was determined based on WHO guidelines for children aged 6-59 months (and 6-23 months and 24-59 months as subgroups). The ratio of anemia due to ID (Ferritin <12 ng/mL) or inflammation (IL-6 > 60 pg/mL) was estimated using adjusted Poisson regression models, reporting prevalence ratios (PR).ResultsApplying the new WHO guidelines, anemia prevalence changed from 50% to 42.2% in children aged 6-59 months (62% to 47% in children aged 6-23 months and from 45.9% to 40.6% in children aged 24-59 months). The proportion of anemia due to ID was 27.5%, due to inflammation was 45.9%, and due to other causes was 26.6%. ID was significantly associated with anemia in both unadjusted and adjusted analyses (PR: 1.4, 95% CI: 1.1-1.8; PR: 1.32, 95% CI: 1.0-1.7). The 2024 WHO guidelines did not substantially alter the estimated proportion of anemia associated with ID or inflammation.ConclusionsApplication of the new WHO cutoffs resulted in a lower estimated prevalence of anemia among young children. ID accounted for only a small proportion of cases of anemia, emphasizing the need for further research into other causes of childhood anemia in Peru.

Abstract Background Maternal micronutrient deficiencies (MNDs) and inflammation contribute to adverse birth outcomes While the individual effects of MNDs have been studied, the consequence of co-occurring MNDs remains unclear. Objectives To examine the associations between maternal micronutrient deficiencies and inflammation with adverse birth outcomes (ABOs). Methods Data from 5,408 pregnant women across 11 datasets from 10 countries were analyzed. Descriptive analyses explored the distribution of MNDs (iron, vitamin A, zinc, serum folate, vitamin D, and vitamin B12) and inflammation (c-reactive protein >5 mg/L or α-(1)-acid glycoprotein > 1g/L) by maternal characteristics (age, height, education, socioeconomic status [SES]) using chi-square tests. Associations of 1) single MNDs and inflammation and 2) co-occurring MNDs (2 deficiencies at a time) with low birth weight (LBW, < 2500 g), preterm birth (PTB, < 37 wks), and small-for-gestational age (SGA, < 10th percentile for gestational age), were examined using modified Poisson regression to estimate relative risk (RR), adjusting for age, SES, and dataset. Results Young maternal age and short height were associated with up to 9.7% and 25% higher prevalence of MNDs and inflammation, respectively. Lower education and SES level were associated with higher prevalence of Vitamin B12 deficiency. Women with folate deficiency had an increased risk of LBW (RR [95% CI]: 1.22 [1.06, 1.39]). Co-occurring MNDs for folate and vitamin B12 were also associated with increased LBW risk (1.38 [1,1.9]) as was folate deficiency without iron (1.28 [1.09, 1.51]) or vitamin B12 deficiency (1.67 [1.09, 2.56]) compared with mothers without either deficiency. Iron deficiency without vitamin B12 deficiency was associated with a reduced LBW risk (0.4 [0.2, 0.79]). Conclusion Maternal MNDs, especially folate and vitamin B12, are linked to adverse birth outcomes. Complex nutrient interactions highlight the need to explore these relationships to improve maternal and neonatal health interventions.

BACKGROUND:Inflammation may bias the estimation of burden of certain micronutrient deficiencies; however, few studies have examined the magnitude and direction of this bias in school-age children and adolescents. OBJECTIVES:Associations between biomarkers of inflammation [C-reactive protein (CRP) and α-1-acid-glycoprotein (AGP)] and multiple micronutrient biomarkers [serum folate (SFO), red blood cell folate (RBC folate), serum vitamin B12, serum 25(OH)D, and serum zinc] were examined in children aged 5 to 19 y. METHODS:This analysis included 13 cross-sectional surveys of children (n = 46,363) from 12 countries with ≥1 micronutrient biomarker of interest, CRP or AGP, and n > 100 per survey. Spearman rank correlations between each micronutrient and inflammation biomarker were calculated by survey. To examine the dose-response relationship between inflammation and micronutrient levels, geometric means of each micronutrient biomarker were plotted across deciles of AGP and CRP, stratified by age groups (5-9, 10-14, and 15-19 y), and overall (5-19 y). RESULTS:Prevalence of inflammation (CRP >5 mg/L or AGP >1 g/L) ranged from 2.7% to 29.6% by survey with medians ranging from 0.5 to 0.8 g/L for AGP and 0.2 to 1.9 mg/L for CRP. The prevalence of micronutrient deficiencies ranged from 0.1% to 87.7% for SFO, 0.1% to 24.4% for RBC folate, 0.5% to 54.8% for vitamin B12, 4.6% to 25.6% for serum 25(OH)D, and 0.6% to 57.3% for zinc, with median values from 4.2 to 45.5 nmol/L for SFO, 452.1 to 1000.0 nmol/L for RBC folate, 131 to 442 pmol/L for vitamin B12, 43.2 to 60.0 nmol/L for serum 25(OH)D, and 59.4 to 92.9 μg/dL for zinc. Associations between micronutrient biomarkers and AGP or CRP were weak (most absolute r < 0.2) with no clear pattern across positive, negative, and null associations. Geometric means of micronutrient biomarkers did not show clear patterns of association with CRP or AGP deciles, overall or stratified by sex or age group. CONCLUSIONS:With weak and inconsistent correlations between inflammation and select micronutrient biomarkers, these findings do not support the routine adjustment for inflammation when estimating folate, vitamin B12, vitamin D, or zinc deficiencies in children aged 5 to 19 y.

This study evaluated dose-response relationships between hemoglobin concentration in pregnancy and maternal and neonatal outcomes based on comprehensive systematic reviews using the Burden of Proof meta-analytic framework. Risk estimates accounting for uncertainty and quantitative star ratings were generated to assess evidence strength. Our analysis revealed that even small deviations above or below hemoglobin levels with the lowest predicted risk - particularly on the low end (anemia)-were associated with non-linear increased risks of all-cause maternal and neonatal mortality, postpartum hemorrhage, maternal sepsis, preterm birth, low birthweight and large-for-gestational-age. Across outcomes with at least moderate evidence strength (>2 stars), maternal hemoglobin levels associated with the lowest risk ranged from 109-135 g/L, challenging the appropriateness of fixed anemia thresholds. Even modest population-level shifts in hemoglobin distributions could meaningfully affect the burden of adverse outcomes, supporting more refined, trimester- and outcome-specific thresholds to better identify at-risk individuals and guide clinical interventions.

Anaemia, a condition affecting more than 1 center dot 9 billion people worldwide, disproportionately affects children, adolescent girls, and women. Despite longstanding interventions and guidelines, most countries are not on track to meet global anaemia reduction targets, and cuts in global health funding in 2025 further threaten progress. This Lancet Haematology Commission aims to reinvigorate efforts to prevent and control anaemia by addressing key gaps in data, evidence, implementation, governance, and target-setting approaches.

INTRODUCTION:Peru carries a high burden of childhood anemia, particularly in high-altitude regions where hemoglobin (Hb) adjustment for altitude is recommended. This study aimed to evaluate whether the proportion of anemia attributable to iron deficiency (ID), inflammation, and red blood cell indices varies by altitude in children, using different diagnostic criteria. METHODS:We conducted a cross-sectional study of 280 children aged 6 to 72 months residing in Arequipa, Peru at altitudes ranging from 9 to 4310 m above sea level. Venous blood samples were collected to assess Hb, complete blood count, and serum biomarkers of iron status and inflammation. Spearman's rank correlation was used to examine relationships between altitude and hematologic or biochemical parameters. Logistic regression models evaluated associations between altitude, Hb concentration, and anemia prevalence, defined with and without altitude adjustment. RESULTS:Anemia prevalence increased from 12% to 31% after applying altitude-adjusted Hb thresholds. At mid-altitudes (1000-<3000 m), prevalence rose from 8.3% to 43.8% (P < .001), and at ≥3000 m, from 0% to 16.3% (P < .001). Overweight and obese children had a higher anemia prevalence using unadjusted Hb (28.6% vs 10.5%; P < .05), a difference that disappeared after adjustment. Iron deficiency was present in 5.6% of participants, while inflammation was detected up to 26.5%. Receiver operating characteristic (ROC) analysis indicated that unadjusted Hb thresholds had better diagnostic performance for identifying iron deficiency anemia (IDA) compared to altitude-adjusted definitions. CONCLUSION:These findings suggest that altitude-adjusted Hb cutoffs may overestimate anemia prevalence and lead to misclassification of IDA in high-altitude pediatric populations.

Objectives To evaluate how postmortem anthropometric malnutrition (PAM) measures align with expert panel attribution of malnutrition as a causal or significant condition in under-5 mortality (U5M).Design Cohort study using data from the Child Health and Mortality Prevention Surveillance network, incorporating clinical records, postmortem anthropometrics, minimally invasive tissue sampling, clinical abstraction and verbal autopsy to determine multiple causes of death.Setting/participants 1405 deaths of children aged 1–59 months from six African countries between 2016 and 2023.Primary and secondary outcome measures PAM was determined using z-scores from the WHO Child Growth Standards: underweight (weight-for-age<(−2)), wasting (arm circumference-for-age or weight-for-length<(−2)) and stunting (length-for-age <(−2)). Performance metrics (sensitivity (SE), specificity (SP) and positive predictive values (PPV)) were calculated to determine the alignment between PAM and expert panel attribution of malnutrition as a causal or significant condition to death.Results Nearly 75% of cases demonstrated moderate-to-severe malnutrition by PAM, while expert panels attributed malnutrition in 41% of cases. Performance metrics varied across anthropometric indices: underweight exhibited the highest SE (89.7%), while wasting based on arm circumference had the highest SP (81.9%) and PPV (76.8%). Discrepancies between PAM classification and expert panel attribution differed significantly by site, age, location of death and preventability of death (p<0.05). Adjusted multivariate regression showed that expert panel attribution was more likely with increasing severity of PAM.Conclusions The proportion of U5M attributable to malnutrition ranged between 41% (expert panel attribution) and 74% (PAM). Variability in classification underscores the need for monitoring and quality improvement measures to address discrepancies. Improved alignment between PAM and panel assessments is essential for accurately identifying malnutrition-related deaths and designing effective interventions to reduce U5M.

Inflammation and infections such as malaria affect concentrations of many micronutrient biomarkers and hence estimates of nutritional status. We aimed to assess the relationship between malaria infection and micronutrient biomarker concentrations in pre-school children (PSC), school-age children (SAC) and women of reproductive age (WRA) in Malawi and examine the potential role of malarial immunity on the relationship between malaria and micronutrient biomarkers. Data from the 2015/2016 Malawi micronutrient survey were used. The associations between current or recent malaria infection, detected by rapid diagnostic test and concentration of serum ferritin, soluble transferrin receptor (sTfR), zinc, serum folate, red blood cell folate and vitamin B12 were estimated using multivariable linear regression. Factors related to malarial immunity including age, altitude and presence of hemoglobinopathies were examined as effect modifiers. Serum ferritin, sTfR and zinc were adjusted for inflammation using the BRINDA method. Malaria infection was associated with 68 % (95 % CI 51, 86), 28 % (18, 40) and 34 % (13, 45) greater inflammation-adjusted ferritin in PSC, SAC and WRA, respectively (P < 0·001 for each). In PSC, the positive association was stronger in younger children, high altitude and children who were not carriers of the sickle cell trait. In PSC and SAC, sTfR was elevated (+ 25 % (16, 29) and + 15 % (9, 22) respectively, P < 0·001). Serum folate and erythrocyte folate were elevated in WRA with malaria (+ 18 % (3, 35) and + 11 % (1, 23), P = 0·01 and P = 0·003 respectively). Malaria affects the interpretation of micronutrient biomarker concentrations, and examining factors related to malarial immunity may be informative.

Climate change threatens food security and child nutrition in Africa. This study assessed the impact of community-based, solar-powered drip irrigation gardens (SMGs) on the nutritional status of children in households reliant on local food production. Women’s groups (WGs) from 16 matched villages in Northern Benin were randomly assigned to receive SMGs (WG_SMG) or continue traditional irrigation (WG_C). Additional households without women’s groups (NWG_SMG and NWG_C) were recruited from intervention and comparison villages. Children aged 1–5 years participated in baseline and one-year follow-up surveys. Outcomes included dietary diversity, anthropometry, anemia, and micronutrient status. Dietary diversity was assessed using the WHO minimum dietary diversity indicator, based on consumption from at least five of eight food groups in the previous 24 h. Anemia was defined as hemoglobin < 10.5 g/dL or < 11 g/dL, age dependent. Difference-in-differences analysis estimated treatment effects (TEs). WG_SMG participation increased the percentage of children meeting minimum dietary diversity compared with all groups (TE: 0.64; p < 0.001). Hemoglobin concentrations increased in WG_SMG children versus all groups (TE: 0.53; p < 0.05), with reductions in anemia compared with WG_C (TE: − 0.15; p < 0.05). WG_SMG membership also improved weight-for-age z-scores (TE: 0.35; p < 0.05) and reduced wasting (TE: − 0.04; p < 0.01). Effects remained statistically significant when clustering at child or village levels. Children from women-owned SMGs had improved dietary diversity, hemoglobin status, and growth outcomes while reducing anemia and wasting compared to controls. Expanding this technology may enhance food security and child nutrition in climate-vulnerable regions.

Anemia is an important cause of child morbidity and mortality. Postmortem point-of-care hemoglobin testing is a potential method for assessing anemia at death, but its reliability has not been extensively studied. We aimed to assess the feasibility and validity of postmortem point-of-care hemoglobin assessment using HemoCue in the setting of a child mortality surveillance program in South Africa.In a pilot cohort study, 44 children under five years of age who died in an academic hospital in South Africa were enrolled. Hemoglobin levels were measured from venous blood antemortem using standard hematology analyzers and postmortem using the HemoCue 201 from blood collected within 72 hours of death (either by needle aspiration or from whole blood collected in an EDTA tube). Updated World Health Organization hemoglobin cutoffs to define anemia were used. Wilcoxon signed-rank tests, equivalence tests, and regression models assessed the concordance between antemortem and postmortem hemoglobin concentrations. Postmortem testing showed a significant decrease in hemoglobin concentrations compared to antemortem levels. However, no significant differences were found between hemoglobin measurements from needle aspiration and those from EDTA tubes postmortem. The prevalence of anemia increased from 52% antemortem to 73-77% postmortem, with the most notable rises in moderate and severe anemia. Bland-Altman analysis confirmed a systematic, not random, decrease in postmortem hemoglobin measurements. Upon applying a fixed adjustment of 2.5 g/dL, the sensitivity and specificity of postmortem hemoglobin testing to diagnose anemia were 69.6% and 61.9%, respectively. Postmortem point-of-care hemoglobin testing using HemoCue is feasible and offers a potentially valid reflection of antemortem anemia status in deceased children, despite consistently lower measured values postmortem. These findings support the utility of postmortem hemoglobin assessments in determining the presence and severity of anemia at the time of death.

Background Global health (GH) interest is rising among graduate medical education (GME) trainees, yet GH engagement is marred by the impact of colonization or racism, and there remains a lack of training to confront these challenges. Objective To develop a modular, open-access curriculum that provides training in decolonization for GH GME and evaluate its feasibility and impact on learners' critical reflection on decolonization. Methods From 2019 to 2022, 40 GH educators, including international and indigenous scholars from diverse organizations, created the Global Health Education for Equity, Anti-Racism, and Decolonization (GHEARD) curriculum. Using Kern's 6 steps of curriculum development, critical gaps were identified and shaped into 8 modules, including a facilitator training module. Learning objectives and activities were developed using strategies grounded in transformative learning theory and trauma-informed educational approaches. The curriculum was peer-reviewed and piloted at multiple national conferences and institutions to assess feasibility and effectiveness in fostering critical reflection on decolonization. Results Pilot testing demonstrated GME implementation feasibility. Based on initial educator feedback, facilitator tools and an implementation guide were incorporated to enhance usability. Nearly all (59 of 61) trainees felt GHEARD was effective or very effective in encouraging reflection on decolonization, and 72% (32 of 44) felt GHEARD encouraged reflection on motivations for engaging in GH. GHEARD was launched as a free online resource in June 2023 and garnered 3192 views by December 2024. Conclusions To our knowledge, GHEARD is the first comprehensive decolonization curriculum designed specifically for GME. Program evaluation indicates GHEARD is feasible to implement and effective in promoting critical reflection on decolonization.

BACKGROUND:Diagnosis of iron deficiency commonly relies on measurement of serum ferritin concentrations. WHO guidelines identify serum ferritin thresholds for iron deficiency among healthy individuals of less than 15 μg/L for women and less than 12 μg/L for children under 5 years, based on expert opinion. We report thresholds for iron deficiency for apparently healthy non-pregnant women and young children based on physiological indicators. METHODS:We performed secondary analyses of cross-sectional data from women (aged 15-49 years) and children (aged 6-59 months) from 12 countries in Africa, Asia, Europe, and central America from available surveys (2007-19). Using haemoglobin and soluble transferrin receptor concentrations as individual-level indicators of iron deficiency, we identified country-specific serum ferritin thresholds. We conducted multivariate meta-analysis using individual participant data to assess multinational heterogeneity and intercountry consistency. FINDINGS:Data were collected from July, 2007 to March, 2019. 18 251 individuals (13 864 women and 4387 children) were included in the final analysis. The thresholds of pooled serum ferritin levels corresponding to the starting point of decline in circulating haemoglobin concentrations were 24·8 μg/L (95% CI 24·4-25·2) for women and 22·1 μg/L (20·8-23·4) for children based on the national survey data from 12 countries. The thresholds were consistent among countries (pheterogeneity: women=0·73, children=0·43) but median serum ferritin concentrations and lower 5% reference ranges differed. In all countries, the prevalence of iron deficiency was higher using physiologically based thresholds than that using WHO current guidelines for women (36·0% [95% CI 25·3-46·8] vs 20·1% [11·5-28·7], p<0·0001) and for children (34·2% [24·3-44·1] vs 16·6% [11·2-22·0], p<0·0001). INTERPRETATION:These results provide evidence that the prevalence of iron deficiency as indicated by physiological measures is substantially higher than those based on current WHO guidelines. The consistency of physiologically based serum ferritin thresholds in apparently healthy women and young children offers a potential means to achieve evidence-informed coordination in thresholds for iron deficiency across populations. The use of physiologically based serum ferritin thresholds could help in detecting the clinical and functional outcomes of iron deficiency. FUNDING:None.