The double burden of malnutrition in SE Asia and the Pacific: priorities, policies and politics

Double-duty actions addressing the double burden of malnutrition among adolescents aged 10-19: protocol for a scoping review

Background

The global adolescent population faces the challenge of the double burden of malnutrition (DBM), characterized by the coexistence of undernutrition and overweight/obesity, including diet-related non-communicable diseases (NCDs). This dual challenge, prevalent across various socio-economic backgrounds, necessitates double-duty actions, i.e., integrated interventions designed to concurrently address both sets of conditions. These actions are critical for fostering the overall health and well-being of adolescents. The objective of this review is to describe the content, setting, and delivery mechanisms of double-duty actions, synthesize their impacts on adolescents' nutritional status, and offer policy and program implications for future interventions.

Methods

As part of this scoping review, we will conduct a comprehensive search across multiple databases, including MEDLINE, Embase, CENTRAL, CINAHL, and Google Scholar, to identify relevant interventions, programs, policies, guidelines, evaluation studies, and strategies targeting DBM among adolescents aged 10-19 years. Inclusion criteria encompass a range of evidence sources with methodologically sound and well-described study designs. All full-text articles and abstracts will be independently screened by two reviewers to ensure a comprehensive inclusion of papers that align with the established criteria. The final protocol is available on Open Science Forum (https://osf.io/kxapb).

Discussion

Addressing DBM through integrated double-duty actions is crucial for achieving global nutrition and public health goals. However, challenges persist in the form of uncoordinated efforts, lack of comprehensive evidence for what interventions work among adolescents, and the need for context-specific strategies to effectively address the heterogeneity of DBM. The results of this scoping review may provide evidence for future policies and interventions, emphasizing integrated, multi-sectoral strategies tailored to the unique needs of the adolescent population.

Benchmarking the nutrient composition and labelling practices of commercially produced ready-to-eat purées and meals for older infants and young children across seven Southeast Asian countries

Commercially produced complementary foods (CPCF), including ready-to-eat CPCF purées and meals, are gaining popularity among caregivers of older infants and young children (IYC) as a convenient alternative to home-prepared foods in low and middle-income countries. However, there is growing concern regarding the suitability of these products for older IYC, as they can contain high levels of sugar and/or sodium. Given the rapidly evolving market in Southeast Asia, it is crucial to monitor the appropriate composition and promotion of CPCF in the region. This study examined the nutrient composition and labelling practices of CPCF purées and meals sold in 2021 in the capital cities of seven Southeast Asian countries: Phnom Penh (Cambodia), Jakarta (Indonesia), Manila (Philippines), Bangkok (Thailand), Vientiane (Lao PDR), Hanoi (Viet Nam), Kuala Lumpur (Malaysia). The study adapted a nutrient profiling model from the WHO Regional Office for Europe to determine the proportion of products suitable for promotion for older IYC. The proportion of CPCF purées and meals that would require a high sugar front-of-pack warning based on the percentage energy from total sugar was also determined. Of the 459 CPCF purées/meals assessed, only 37.7% of the products met all nutrient composition requirements and none met all labelling requirements. In addition, most CPCF purées and meals were identified as having high total sugar content. To ensure that older IYC consume appropriate CPCF products, Southeast Asian countries need to implement and enforce regulations concerning the nutrient composition and labelling practices of CPCF purées and meals.

Prevention of childhood overweight and obesity in Mongolia, the Philippines and Vietnam: identifying priority actions

Low- and middle-income countries are increasingly faced with a triple burden of malnutrition: endemic underweight, micronutrient deficiencies and rising prevalence of overweight. This study aimed to address existing knowledge gaps and to identify priority policy options in Mongolia, the Philippines and Vietnam. A landscape analysis approach was adopted using methods set out in a UNICEF global toolkit. Quantitative and qualitative data were compiled from a range of global and national sources on childhood overweight and obesity, risk factors and policy responses. Key informant interviews and validation workshops were undertaken with key food and nutrition stakeholders from government and non-government organizations to identify priority policy options for the prevention of overweight and obesity among children. Overweight and obesity among children are increasing in all three countries. Associated risk factors are related to maternal nutrition, birthweight, breastfeeding, as well as diets and physical activity shaped by increasingly obesogenic environments. Key informants identified undefined policy approaches, poor community understanding and food and beverage industry influence as barriers to addressing overweight and obesity. Key policy priorities include restricting the marketing of unhealthy food and beverages, unhealthy food and beverage taxation, introduction of front-of-pack nutrition labels and improving school nutrition environments. Mongolia, the Philippines and Vietnam are all facing an increasing burden of childhood overweight and obesity. Despite differing national contexts, similar environmental factors are driving this rise. A suite of evidence-based policies can effectively be introduced to address obesogenic environments.

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.

Double burden of malnutrition among women in reproductive Age (15-49 years) in Sierra Leone: a secondary data analysis of the demographic health survey 2019 (SLDHS-2019)

BACKGROUND

The double burden of malnutrition (DBM) is rising globally, particularly in sub-Saharan Africa. In Sierra Leone, the incidence of overweight, obesity (OWOB), and overnutrition among women has sharply increased. This finding accompanies the high incidence of undernutrition, which has been prevalent for decades. This study aimed to determine the prevalence of different malnutrition categories (underweight, overweight, obesity, and overnutrition) and associated factors among women of reproductive age (15-49 years) in Sierra Leone using secondary data analysis of the Sierra Leone Demographic Health Survey of 2019 (SLDHS-2019).

METHODS

We conducted secondary data analysis of the SLDHS-2019 of 7,514 women aged 15-49 years. We excluded pregnant, post-natal, lactating, and post-menopausal women. Data was collected using validated questionnaires, and respondents were selected through a multistage stratified sampling approach. A multivariable logistic regression analysis was used to determine factors associated with malnutrition among 15-49-year-old women in Sierra Leone.

RESULTS

Among 15-49-year-old women in Sierra Leone, the prevalence of underweight was 6.7% (95%CI: 4.5-8.9%); overweight at 19.7% (95%CI: 17.7-21.7%); obesity was 7.4% (95% CI: 5.2-9.6%); and overnutrition, 27.1% (95%CI: 25.2-29.0%). Women aged 25-34 years were more likely to be underweight (adjusted Odds Ratios, aOR = 1.670, 95%CI: 1.254-2.224; p < 0.001) than those aged 15-24 years; women who were not married were less likely to be underweight (aOR = 0.594, 95%CI: 0.467-0.755; p < 0.001) than married women. Women from the North were less likely to be underweight (aOR = 0.734, 95%CI: 0.559-0.963; p = 0.026) than the East, and those who did not listen to the radio were less likely to be underweight (aOR = 0.673; 95%CI: 0.549-0.826; p < 0.001) than those who did. Overweight was less likely among 25-34 years (aOR = 0.609, 95%CI: 0.514-0.722; p < 0.001) and 35-49 years (aOR = 0.480, 95%CI: 0.403-0.571; p < 0.001) age-groups than 15-24 years; more likely among not married women (aOR = 1.470, 95%CI:1.249-1.730; p < 0.001) than married; less likely among working-class (aOR = 0.840, 95%CI: 0.720-0.980; p = 0.026) than not working-class; most likely in women from the North (aOR = 1.325, 95%CI:1.096-1.602; p = 0.004), and less likely among women from the South (aOR = 0.755, 95%CI: 0.631-0.903; p = 0.002) than the East; less likely among women of middle-wealth-index (aOR = 0.656, 95%CI: 0.535-0.804; p < 0.001), richer-wealth-index (aOR = 0.400, 95%CI: 0.309-0.517; p < 0.001), and richest-wealth-index (aOR = 0.317, 95%CI: 0.234-0.431; p < 0.001) than the poorest-wealth-index; and more likely among women who did not listen to radios (aOR = 1.149; 95%CI:1.002-1.317; p = 0.047) than those who did. The predictors of overweight among women 15-49 years are the same as obesity and overnutrition, except overnutrition and obesity were less likely in female-headed households (aOR = 0.717,95%CI: 0.578-0.889; p < 0.001).

CONCLUSION

The prevalence of all categories of malnutrition among women of reproductive age in Sierra Leone is high, affirming a double burden of malnutrition in this study population. Underweight was more likely among the 25-34-year age group than 15-24-year. The predictors of overweight, obesity, and overnutrition were being unmarried/single, residing in the North, and not listening to the radio. There is an urgent need for policymakers in Sierra Leone to design comprehensive educational programs for women of reproductive age on healthy lifestyles and the dangers of being underweight or over-nourished.

District-level heterogeneity in overweight or obesity among women of reproductive age: A geo-spatial analysis in India

BACKGROUND

Globally by 2030, 38% of the world's population would be overweight, and another 20% would be obese. This has led to rising concerns regarding how swiftly and substantially the world is moving towards this epidemic of "globesity". India too is facing an increased burden of overweight and obese population. The changing dietary patterns are significantly associated with the increasing prevalence of overweight/obesity and related complications, especially among women. Hence, the present study aims to observe the spatial patterns of overweight or obesity among women in reproductive age group in India and factors associated with it.

METHODS

The study analyzed data from a cross-sectional nationwide household survey, i.e. National Family Health Survey (NFHS-4), 2015-16. The primary outcome variable of this study was overweight/obesity among reproductive-age women, which was measured through the body mass index (BMI) of the women. Bivariate and multivariate logistic regression analysis was used to analyze the data. Additionally, for spatial analysis in terms of overweight/obesity among women in India, univariate and bivariate Moran's I index measurements were used along with the usage of spatial regression models.

RESULTS

The value of spatial-autocorrelation for overweight or obese was 0.64, which depicts the moderately high prevalence of the overweight/obesity coverage over districts of India. The overall prevalence overweight/obesity among women in India is around 25% and higher proportion of women from urban areas (37.8%), and non-poor (33.4%) economic group reported to be overweight or obese. From spatial lag model, the lag coefficient was found to be 0.28, implying that a change in the prevalence of overweight/obesity among women in a certain district may statistically lag the prevalence of overweight/obesity by 28% in the neighbouring districts. There were significantly high clustering of overweight/obese women and non-poor wealth quintiles in 132 districts, mainly from states of Punjab, Haryana, Gujarat, Maharashtra, Kerala, Tamil Nadu, Karnataka and Andhra Pradesh. Additionally, there was high-high clustering of overweight/obese women and those who ever had caesarean in 82 districts, mostly from Kerala, Tamil Nadu, Andhra Pradesh and Karnataka.

CONCLUSION

The spatial patterns on the prevalence of overweight and obesity in India show that the women belonging to the southern states' districts are more overweight or obese in comparison to other states. The determinants like older age, higher education, urban residence, higher economic status are the key factors contributing to the prevalence of overweight or obesity among women in the reproductive age group. The study concludes and recommends an urgent need of interventions catering to urban women belonging to higher socio-economic status, to reduce the risks of health consequences due to overweight and obesity.

Accuracy of declared nutrient content on labels of commercial complementary food products in Cambodia, Indonesia and Senegal

Commercially produced complementary foods (CPCF) have the potential to fill nutritional gaps in the diets of older infants and young children. This study evaluated the accuracy of nutrient declarations on labels of 43 commonly available CPCF in three peri-urban/urban locations: Khsach Kandal district, Cambodia (n = 11); Bandung, Indonesia (n = 11) and Guédiawaye and Dakar departments, Senegal (n = 21). Label values (LV) from product nutrient declarations were compared to analytical values (AV) derived from laboratory nutrient analysis for macronutrients (carbohydrate, protein and total fat), nutrients of public health concern (saturated fat, total sugar and sodium), and micronutrients of interest (calcium, iron and zinc). European Union guidance for nutrition label accuracy was used to set tolerance ranges for each nutrient LV relative to AV. LV were missing for one or more nutrients in 88.4% (n = 38) of the CPCF products and no CPCF met EU tolerance thresholds for all nine nutrients assessed. Over half of products with LV for key micronutrients (55.6%, n = 10/18) and macronutrients (54.8%, n = 23/42) met tolerances for LV accuracy. Eighty-five percent (n = 11/13) of products with LV for nutrients of public health concern were determined to be accurate. Nutrient content claims for iron appeared on 19 (44.2%) of the 43 products. Of the products which made an iron content claim, 26.3% had inaccurate LV with the majority of these containing less iron than declared. Regulatory action is needed to ensure that CPCF labelling communicates complete and accurate nutrient content information that enables caregivers to make informed decisions for feeding older infants and young children.

Sex difference and socioeconomic inequality of underweight, overweight and obesity among adult population in Bangladesh

Background: Due to rapid socioeconomic development and epidemiological transition, socioeconomic inequality of underweight, overweight, and obesity are becoming a public health concern in Bangladesh. There is a need for country-specific evidence of nutrition inequalities in Bangladesh. Aim: The aim of the study was to measure socioeconomic inequality and decomposition analysis along with the sex differences in underweight, overweight, and obesity among the adult population. Methods: A secondary data analysis was performed in the Bangladesh Demographic and Health Survey (BDHS) 2017-18, a cross-sectional survey used a multi-stage cluster sampling technique. Sociodemographic variables including age, sex, education, socioeconomic status, marital status, and anthropometric data of height and weight were considered for analysis. Body mass index was used for defining underweight, overweight, and obesity. Concentration index (CI) and decomposition analysis were performed for underweight, overweight, and obesity. Results: The proportion of underweight was 15.0%, overweight (23.0%), and obese (5.0%). Underweight was higher in males, whereas overweight and obesity were higher in females. The CI of underweight was -0.121 (p < 0.001), indicating socioeconomic inequality concentrated on lowering socioeconomic status; living in rural areas contributed 14.2% to this inequality. The CI of overweight and obesity was 0.213 (p < 0.001) and 0.142 (p < 0.001), respectively, indicating that inequalities of overweight and obesity concentrated in higher socioeconomic status; urban residency contributed 14.1% and 18.0% to socioeconomic inequality of overweight and obesity. Conclusion: Underweight remains a significant problem for poor people in rural areas, but overweight and obesity were highly prevalent in the higher socioeconomic status of urban areas. Education level and young age group significantly contribute to the socioeconomic inequality of malnutrition. A more detailed epidemiological study is required to understand the causes of socioeconomic disparities of nutritional status in Bangladesh.

Determinants of maternal, infant, and young child nutrition during the 1,000-day window of opportunity in Solomon Islands: A focused ethnographic study

Introduction

This focused ethnographic study used qualitative, ethnographic, and participatory methods to explore determinants of maternal, infant, and young child nutrition (MIYCN) during the first 1,000 days of life as part of efforts to address the double burden of malnutrition in Solomon Islands.

Methods

An iterative study design was used to first explore and then confirm findings related to food and nutrition security and social and behavioral determinants of MIYCN in urban and rural settings. The first phase included in-depth interviews, household observations, free lists, and seasonal food availability calendar workshops while the second phase included focus group discussions, pile sorts, participatory community workshops, and repeated household observations.

Results and discussion

We found that MIYCN is shaped by a complex interaction of factors at the macro- and micro-levels. At the macro-level, globalization of the food system, a shifting economy, and climate change are driving a shift toward a delocalized food system based on imported processed foods. This shift has contributed to a food environment that leaves Solomon Islanders vulnerable to food and nutrition insecurity, which we found to be the primary determinant of MIYCN in this context. At the micro-level, this food environment leads to household- and individual-level food decisions that often do not support adequate MIYCN. Multi-sectoral interventions that address the macro- and micro-level factors shaping this nutrition situation may help to improve MIYCN in Solomon Islands.

Strategies used by the soft drink industry to grow and sustain sales: a case-study of The Coca-Cola Company in East Asia

BACKGROUND

The market and non-market activities of the food and beverage industry contribute to unhealthy and unsustainable dietary patterns, increasingly in low-income and middle-income countries (LMICs). We aimed to describe how The Coca-Cola Company (TCCC), as the world market leader in the sugar-sweetened beverage sector, operationalises their activities in LMICs in East Asia, among the world's most highly populated yet under-researched countries, to illustrate the ways in which these activities may negatively influence health outcomes.

METHODS

We adopted a theoretically-guided qualitative research design and documentary analysis method. Data sources included: industry documents and web pages, marketing case studies obtained from the World Advertising Research Centre, media reports, global trade summaries and websites of industry associations. To guide data analysis, we synthesised a conceptual framework from existing commercial determinants of health literature, to describe ways in which the market and non-market activities of TCCC influence health.

RESULTS

TCCC leverages subsidiary companies and investments in international networks to expand its supply chains. The company engages in frequent political activities to minimise the implementation of nutrition policies that may impact profits. The company markets products, particularly on digital and mobile devices, often targeting children, adolescents and mothers, and undertakes public relations activities related to human rights, environmental sustainability and community and economic supports, and these public relations activities are often integrated into marketing campaigns. The identified activities of TCCC are frequently in direct contrast to efforts to improve the healthfulness of population diets in East Asia LMICs.

CONCLUSIONS

A public health analysis of the market and non-market activities of corporations active in unhealthy commodity industries needs to be broad in scope to cover the diverse set of strategies used to increase their market power and influence. Governments should consider a suite of policy options to attenuate these commercial determinants of unhealthy diets.

Prevalence and Correlates of Underweight among Women of Reproductive Age in Nepal: A Cross-Sectional Study

This study aimed to examine the prevalence of underweight and determine the sociodemographic and household environmental correlates of underweight among women of reproductive age in Nepal. This study also compared the time trends in the prevalence of underweight with the trends in the prevalence of overweight and obesity. This cross-sectional study was a secondary data analysis of the nationally representative population-based Nepal Demographic and Health Surveys (NDHSs). Firstly, the time trends of the prevalence of underweight (body mass index (BMI) < 18.5 kg/m2) among women aged 15-49 years were examined at five-year intervals, from the 1996, 2001, 2006, 2011, and 2016 NDHSs (n = 33,507). Secondly, the sociodemographic and household environmental correlates of underweight were examined from the latest NDHS 2016 (n = 6165). Univariable and multivariable logistic regression analyses were performed to examine the sociodemographic and household environmental correlates of underweight. From 1996 to 2016, the prevalence of underweight decreased from 25.3% (95% confidence interval (CI) 23.8%, 26.8%) to 16.9% (95%CI 16.0%, 17.8%), while the prevalence of overweight and obesity increased from 1.6% (95%CI 1.2%, 2.1%) to 15.6% (95%CI 14.7%, 16.5%) and 0.2% (95%CI 0.1%, 0.4%) to 4.1% (95%CI 3.6%, 4.6%), respectively. Sociodemographic factors, such as age, educational status, marital status, wealth index, and religion, were independently associated with the risk of underweight. Similarly, household environmental factors, such as province of residence, ecological zone, type of toilet facility, and household possessions, including television and mobile phone, were independently associated with the risk of underweight. Despite the declining trends, the prevalence of underweight among Nepalese women remains a public health challenge. Understanding the key sociodemographic and household environmental correlates of underweight may assist in streamlining the content of health promotion campaigns to address undernutrition and potentially mitigate adverse health outcomes.

Initial investigation of associations between feeding practices, eating behaviours, and weight status in Vietnamese children using modified questionnaires

AIMS

This cross-sectional study aims to extend the preliminary validation of the Feeding Practices and Structure Questionnaire (FPSQ) and Children's Eating Behaviour Questionnaire (CEBQ) in the Vietnamese context by examining associations between maternal feeding practices, child eating behaviours, and child weight status.

METHODS

Modified versions of the FPSQ and CEBQ were used to measure maternal feeding practices and child eating behaviours, respectively, in a sample of Vietnamese mothers of children within the age range of two to five years (n = 100). Children's weight-for-height z-scores (WHZs) were calculated using weight and height measurements obtained by clinicians. Pearson's correlation coefficients were used to examine bivariate associations between maternal feeding practices, child eating behaviours, and child WHZs. Significant variables were then entered into a multivariable regression model.

RESULTS

Child WHZs were associated with maternal persuasive feeding, and child slowness in eating, enjoyment of food/food responsiveness, and emotional undereating, but in multivariable regression analysis, only persuasive feeding (β = -0.44, p = 0.027) and slowness in eating (β = -0.39, p = 0.036) contributed significantly to the model.

CONCLUSIONS

The findings provide some evidence of construct validity for the modified questionnaires. Potential implications of dietary-related behaviours on weight status in preschool-aged children in Viet Nam are evident. However, further validation and analysis in larger datasets must be undertaken in order to examine these associations with increased certainty.

Does maternal overnutrition carry child undernutrition in India?

Background and objectives

Studies in low-and middle-income countries where nutrition transition is underway provides mixed evidence of double burden of maternal overnutrition and child undernutrition among mother-child pairs. Shifting dietary pattern and rapid increase in overweight/obesity among adults with persistent child undernutrition indicate that India is experiencing nutrition transition and double burden of malnutrition. Hence, the study explores the presence of and the factors associated with mother-child dyads of over- and undernutrition in India.

Methods and materials

The study uses National Family Health Survey 2015–16 data. The analytic sample consists of 28,817 weighted mother-child pairs where an overweight/obese mother is paired with an undernourished child. The nutritional status of children is defined according to WHO 2006 child growth standards as underweight (i.e., low weight-for-age), stunting (i.e., low height-for-age) and wasting (i.e., low weight-for-height). Maternal overweight/obesity (i.e., BMI ≥ 25 kg/m²) is defined using adult BMI criterion. Descriptive, bivariate, and adjusted multivariable logistic regression analysis are conducted.

Results

Of the overweight/obese mothers, 21.3%, 26.5%, and 14% have underweight, stunted, and wasted children respectively. In adjusted models, maternal short stature (aOR: 2.94, 95% CI: 2.30–3.75), age of child (aOR: 3.29, 95% CI: 2.76–3.92), and poorest wealth status (aOR: 2.01, 95% CI: 1.59–2.54) are significant predictors of overweight/obese mothers and stunted child pairs. Similarly, poor wealth status (aOR: 1.68, 95% CI:1.32–2.14), maternal stature (aOR: 2.70, 95% CI: 2.08–3.52), and child aged 2–5 years (aOR: 1.77, 95% CI:1.51–2.08) are also significantly associated with higher occurrence of overweight/obese mother and-underweight child pairs.

Conclusion

Findings of the study are consistent with the phase of nutrition transition and double burden of malnutrition. The paper concludes with suggestions to improve the socioeconomic condition, more strategic nutrition specific investments and policy interventions to eliminate all forms of malnutrition for achieving SDGs.

Inequalities in overweight and obesity among reproductive age group women in India: evidence from National Family Health Survey (2015-16)

Background

In developing nations like India, fertility and mortality have decreased, and diseases related to lifestyle have become more common. Females in India are more prone to being overweight and obese than their male counterparts, more specifically in affluent families than the poor ones. Understanding the overweight and obesity trend may help develop feasible public health interventions to reduce the burden of obesity and associated adverse health outcomes.

Methods

The study utilizes the fourth round of the National Family Health Survey (NFHS-4), 2015–16. Descriptive statistics, bivariate and multivariate analysis was used to check the significant relationship between overweight and obesity, and other background characteristics. Income-related inequality in overweight and obesity among women was quantified by the concentration index and the concentration curve. Further, Wagstaff decomposition analysis was done to decompose the concentration index, into the contributions of each factor to the income-related inequalities.

Results

Overweight & obesity among women had a significant positive association with their age and educational level. The odds of overweight and obesity were 57% more likely among women who ever had any caesarean births than those who did not [AOR: 1.57; CI: 1.53–1.62]. The likelihood of overweight and obesity was 4.31 times more likely among women who belonged to richest [AOR: 5.84; CI: 5.61–6.08] wealth quintile, than those who belonged to poor wealth quintile. Women who ever terminated the pregnancy had 20% higher risk of overweight and obesity than those who did not [AOR: 1.20; CI: 1.17–1.22]. The concentration of overweight and obesity among women was mostly in rich households of all the Indian states and union territories. Among the geographical regions of India, the highest inequality was witnessed in Eastern India (0.41), followed by Central India (0.36).

Conclusion

The study results also reveal a huge proportion of women belonging to the BMI categories of non-normal, which is a concern and can increase the risks of developing non-communicable diseases. Hence, the study concludes and recommends an urgent need of interventions catering to urban women belonging to higher socio-economic status which can reduce the risks of health consequences due to overweight and obesity. Development nutrition-specific as well as sensitive interventions can be done for mobilization of local resources that addresses the multiple issues under which a woman is overweight or obese.

Impact of Prolonged COVID-19 Lockdown on Body Mass Index, Eating Habits, and Physical Activity of University Students in Bangladesh: A Web-Based Cross-Sectional Study

Objectives

This current study aims to assess the prevalence and factors associated with body mass index (BMI), dietary patterns, and the extent of physical activities among university students following the prolonged coronavirus disease 2019 (COVID-19) lockdown in Bangladesh.

Methods

A cross-sectional web-based survey was conducted between July 10 to August 10, 2021, through a pre-designed Google Form to collect the data from Bangladeshi university students (age: ≥18 years). Informed consent was electronically obtained from each participant, and a simple snowball technique was employed during the sampling. Frequency and percentage distribution, paired t-test, chi-square [χ2] test, and multinomial and binary logistic regression analyses were consecutively applied to analyze the collected data.

Results

Among the total participants (n = 1,602), 45.1% were female and 55.6% were 22-25 years' age group students. The BMI (mean ± standard deviation, SD) during the COVID-19 lockdown was 23.52 ± 7.68 kg/m2, which was 22.77 ± 4.11 kg/m2 during the pre-lockdown period (mean difference = 0.753; p < 0.001). The multinomial logistic regression analysis found a significant impact of gender [male vs. female: adjusted relative risk ratio (RRR) = 1.448; 95% confidence interval (CI) = 1.022, 2.053; p = 0.037], age (years) (<22 vs. >25: RRR =0.389, 95% CI = 0.213,0.710; p = 0.002, and 22-25 vs. >25: RRR = 0.473, 95% CI = 0.290, 0.772; p = 0.003), monthly family income (BDT) (<25,000 vs. >50,000: RRR = 0.525, 95% CI = 0.334,0.826; p = 0.005), university type (public vs. private: RRR = 0.540, 95% CI = 0.369, 0.791; p = 0.002), eating larger meals/snacks (increased vs. unchanged: RRR = 2.401, 95% CI = 1.597, 3.610; p < 0.001 and decreased vs. unchanged: RRR = 1.893, 95% CI = 1.218, 2.942; p = 0.005), and verbally or physically abuse (yes vs. no: RRR = 1.438, 95% CI = 0.977, 2.116; p = 0.066) on obesity during COVID-19 pandemic. Besides, the female students and those who have constant eating habits, were more likely to be underweight. Additionally, the binary logistic regression analysis found that the students from private universities [others vs. private: adjusted odds ratio (AOR) = 0.461, 95% CI = 0.313, 0.680; p < 0.001], urban areas (urban vs. rural: AOR = 1.451, 95% CI = 1.165, 1.806; p = 0.001), wealthier families (<25,000 BDT vs. >50,000 BDT: AOR = 0.727, 95% CI = 0.540, 0.979; p = 0.036), and who were taking larger meals/snacks (increased vs. unchanged: AOR = 2.806, 95% CI = 2.190, 3.596; p < 0.001) and had conflicts/arguments with others (no vs. yes: AOR = 0.524, 95% CI = 0.418, 0.657; p < 0.001), were significantly more physically inactive. Finally, the level of education and smoking habits significantly influenced the eating habits of university students during the extended strict lockdown in Bangladesh.

Conclusion

The current findings would be helpful tools and evidence for local and international public health experts and policymakers to reverse these worsening effects on students mediated by the prolonged lockdown. Several effective plans, programs, and combined attempts must be earnestly implemented to promote a smooth academic and daily life.

The nutrition transition, food retail transformations, and policy responses to overnutrition in the East Asia region: A descriptive review

BACKGROUND

The East Asia region is facing an increasing burden of overweight, obesity and related noncommunicable diseases, resulting from an ongoing nutrition transition. This study aimed to document the growing burden of overweight and obesity, and the accompanying dietary shifts, in the East Asia region and describe the policy responses to this.

METHODS

We present noncommunicable disease risk factor collaboration data on trends in the burden of malnutrition, and Euromonitor International data on trends in dietary purchases, in the East Asia region. We searched the NOURISHING and GINA databases to identify food and nutrition policies implemented in these countries.

RESULTS

There is an ongoing nutrition transition in the East Asia region, notably in upper-middle and lower-middle income countries. The prevalence of overweight, obesity, and accompanying health conditions, purchases of ultra-processed foods and beverages, and purchasing from supermarkets, fast-food and takeaway outlets, and other convenience retailers, are increasing. The policy response to this nutrition transition is limited, with the majority of policies implemented in higher-income countries.

CONCLUSIONS

East Asian countries are facing a growing burden of malnutrition, due in part to the dietary shifts occurring here. An ecological approach to policy intervention is needed to drive transformative food systems change.

Correlation between Catch-up Growth in Early Childhood with Cognitive Ability among School-Aged Children (10–12 Years): A Longitudinal Study

BACKGROUND: Children’s cognitive abilities are influenced by the nutritional condition of children in early childhood. Catch-up growth in early childhood affects cognitive abilities at school age. AIM: This study aims to analyze the effect of catch-up growth in early childhood on the cognitive abilities of school-aged children in Indonesia. METHODS: This study was a cohort study incorporating 10 years of follow-up using three waves of secondary data (1997, 2000, and 2007) from the Indonesia Family Life Survey. Research studies and data analysis were carried out from April to September 2021. The initial data collection of the study was conducted in 1997 when the children were 0–23 months old, then followed in 2000 (age 3–5 years) and 2007 (age 10–12 years). The study subjects were 537 children aged 0–23 months in 1997. Cognitive ability was measured using the Raven Progressive Matrices method. Statistical analysis for cognitive ability scores with catch-up growth was carried out using one-way analysis of variance and multivariate analysis using the generalized linear model. RESULTS: Significant differences were observed in the cognitive ability scores of normal children and stunted children who did not experience catch-up growth (p<0.001), but the cognitive scores of normal children are not significantly different from the stunting catch-up growth group. Other factors that affect the cognitive ability score were as follows: (1) Child factors consist of child stunting status, head circumference, hemoglobin levels, duration of breastfeeding, and complete basic immunization history; (2) parental factors such as father’s occupation, parental education, and number of parity; (3) household socioeconomic factors (household income and wealth index); and (4) environmental factors (housing area, father’s smoking habit, defecation facilities, and household drinking water sources). CONCLUSION: Cognitive abilities of school-age children were most influenced by catch-up growth, stunting status, duration of breastfeeding, number of parity, father’s education, father’s occupation, and father’s smoking habit. Children who experience catch-up growth have better cognitive abilities than stunted non-catch-up group or who experience stunting during early life.

Predictor of Obese Mothers and Stunted Children in the Same Roof: A Population-Based Study in the Urban Poor Setting Indonesia

Stunting leads to the poor cognitive development, increases the risk of child mortality, and elevates the risk of non-communicable diseases. This study aimed to determine the magnitude of double burden of malnutrition (DBM) in the urban poor setting in Indonesia and investigate its predictors. This was a cross-sectional study involving 436 mothers proportionally chosen from 16 integrated health posts in Surabaya, Indonesia. The households were categorized into the two groups based on the body mass index (BMI) of mother and the height-for-age z-score (HAZ) of child; households without DBM and household with DBM. Energy, carbohydrate, protein, and fat intake were obtained using 24-h food recall and socioeconomic status was measured using a structured questionnaire. Data on socioeconomic status were educational level of mother and occupation, household income, and food expenditure. The prevalence of household with DBM was 27.5%; 12.4% pair stunted children and normal weight mother; 45.6% pair of overweight/obese mother and normal height children. The logistic regression analysis showed significant differences in the education level and occupation of mother, protein intake of the children, and fat intake of the mother between households with and without DBM. This study offers an important insight to improve the knowledge of mother related to the protein intake of children to reduce stunting risk and fat intake of mother to prevent over-nutrition.

Beyond personal factors: Multilevel determinants of childhood stunting in Indonesia

BACKGROUND

Stunting is still a major public health problem in low- and middle-income countries, including Indonesia. Previous studies have reported the complexities associated with understanding the determinants of stunting. This study aimed to examine the household-, subdistrict- and province-level determinants of stunting in Indonesia using a multilevel hierarchical mixed effects model.

METHODS

We analyzed data for 8045 children taken from the 2007 and 2014 waves of the Indonesian Family and Life Surveys (IFLS). We included individual-, family-/household- and community-level variables in the analyses. A multilevel mixed effects model was employed to take into account the hierarchical structure of the data. Moreover, the model captured the effect of unobserved household-, subdistrict- and province-level characteristics on the probability of children being stunted.

RESULTS

Our findings showed that the odds of childhood stunting vary significantly not only by individual child- and household-level characteristics but also by province- and subdistrict-level characteristics. Among the child-level covariates included in our model, dietary habits, neonatal weight, a history of infection, and sex significantly affected the risk of stunting. Household wealth status and parental education are significant household-level covariates associated with a higher risk of stunting. Finally, the risk of stunting is higher for children living in communities without access to water, sanitation and hygiene.

CONCLUSIONS

Stunting is associated with not only child-level characteristics but also family- and community-level characteristics. Hence, interventions to reduce stunting should also take into account family and community characteristics to achieve effective outcomes.

A landscape of micronutrient status in women through the reproductive years: Insights from seven regions in Asia

Optimal micronutrient status is critical to the health of women, particularly during their reproductive years. A woman’s health and nutritional status during the preconception stage thus has significant implications for pregnancy outcomes and her offspring’s health later in life. In this review, we evaluated micronutrient intakes and status (iron, folate, and vitamin B12) of women in their reproductive years and during pregnancy, along with associated health consequences and dietary causes, across seven regions in Asia, namely, Hong Kong, Indonesia, the Philippines, Singapore, Taiwan, Thailand, and Vietnam. A structured literature search, targeting peer-reviewed publication databases, as well as data from international and national sources in the public domain, was conducted. Our review of the nutritional landscape demonstrates that micronutrient deficiency–related conditions, especially anemia and its associated health consequences, are common among Asian women of reproductive age, yet the dietary causes are poorly studied. Inadequate or borderline dietary intake of micronutrients and low consumption of micronutrient supplements were evident, despite existing recommendations, food fortification, and supplementation strategies. Evaluation of current programs through nutrition monitoring and improvement of supplementation strategies, such as supplementing with multiple micronutrients, alongside food-based programs, will help better support the health of women through their reproductive years.

The Triple Burden of Malnutrition Among Adolescents in Indonesia

BACKGROUND

Indonesia is a prime example of the triple burden of malnutrition. Indonesian adolescents are among the hardest hit, with approximately one in four adolescent girls suffering from anemia, while nearly one in seven adolescents is overweight or obese.

OBJECTIVES

The present editorial provides a snapshot of the various research papers included in this Supplement, which calls for increased attention to adolescent nutrition in Indonesia and beyond.

RESULTS

Despite major steps to reduce undernutrition and overweight, including a renewed focus on anemia among adolescent girls, major gaps remain in our understanding of various nutrition issues concerning adolescents. These include various drivers and determinants of the triple burden of malnutrition, evidence-based interventions that are supported by large-scale implementation research and evaluation, and effective delivery platforms to reach the most vulnerable groups of adolescents.

CONCLUSION

The time has come to position adolescent nutrition as central to development, and mainstream it into health sector plans, strategies, and policies. It is our hope that this issue will stimulate the urgently needed interventions, implementation research and required programs that will safeguard the nutritional wellbeing of today's forgotten generation.

Underweight and overweight/obesity among adults in Afghanistan: prevalence and correlates from a national survey in 2018

BACKGROUND

The study aimed to estimate the prevalence and correlates of underweight and overweight/obesity among adults in Afghanistan.

METHODS

National cross-sectional survey data of 3779 persons aged 18-69 years were analysed. Multinomial logistic regression was used to estimate factors associated with underweight and overweight/obesity relative to normal weight.

RESULTS

In all, 7.8% of the study sample was underweight (BMI < 18.5 kg/m²), 49.5% had normal weight (BMI 18.5-24.9 kg/m²), 25.5% overweight (25.0-29.9 kg/m²), and 17.2% obesity. In adjusted multinomial logistic regression, factors negatively associated with underweight were male sex (adjusted relative risk ratio (ARRR): 0.30, 95% confidence interval (CI): 0.15-0.58) and hypertension (ARRR: 0.51, 95% CI: 0.27-0.95) and factors positively associated with underweight were sedentary behaviour (ARRR: 1.85, 95% CI: 1.11-3.10) and current tobacco use (ARRR: 2.58, 95% CI: 1.08-6.16). Factors positively associated with overweight/obesity were aged 30-44 years (ARRR: 2.00, CI: 1.51-2.66) and aged 45-69 years (ARRR: 1.58, CI: 1.09-2.31) (compared to 18-29 years) (ARRR: 1.28, CI: 1.14-2.18), hypertension (ARRR: 2.74, CI: 1.89-3.96), and type 2 diabetes (ARRR: 1.82, CI: 1.13-2.94), and high physical activity (ARRR: 0.70, CI: 0.50-0.98) was negatively associated with overweight/obesity.

CONCLUSION

Almost one in ten adult respondents were underweight and more than two in five were overweight/obese, confirming a dual burden of malnutrition in Afghanistan.

Dietary agrobiodiversity for improved nutrition and health outcomes within a transitioning indigenous Solomon Island food system

Indigenous food systems of Pacific Small Island Developing Countries contain vast biological and cultural diversity. However, a nutrition transition is underway, characterized by shifts away from traditional diets in favour of imported and modern foods, contributing to some of the highest rates of obesity and Diabetes Type 2 Mellitus in the world. Using a mixed method approach, this study aimed to assess dietary agrobiodiversity’s relationship with nutrition indicators related to diet quality and anthropometrics within the context of the rural and Indigenous food system of Baniata village, located in the Western Province of Solomon Islands (Melanesia). A secondary aim was to evaluate the contribution of agrobiodiversity from the local food system to diet quality. A comprehensive nutrition survey was administered to the women primarily responsible for cooking of randomly selected households (n = 30). Additionally, 14 participatory focus group discussions captured the historical narrative of food system transitions, were hosted over a period of seven days, and included men, women and youth. Dietary intakes of the participants were reported below the estimated average requirement (EAR) for several essential nutrients, including protein (53%), calcium (96.6%), vitamin B1 (86.6%), vitamin B2 (80%), vitamin A (80%), zinc (40%) and fibre (77%). Focus group participants built a timeline of key historical and climatic transitions perceived to be drivers of dietary shifts away from traditional foods and towards imported and processed foods. Participants identified 221 species and varieties of agrobiodiverse foods available for cultivation or wild collection. Based on 24 h diet recalls, 87 were found to be utilised. Participants who consumed foods of a wider diversity of species richness had a higher probability of achieving recommended nutrition intakes and a lower body fat percentage (r2 = 0.205; p = 0.012). Our results suggest a nutrition transition is underway, and strategies harnessing traditional knowledge of nutrient-dense, agrobiodiverse foods can help improve food and nutrition security.

What stops us from eating: a qualitative investigation of dietary barriers during pregnancy in Punjab, Pakistan

OBJECTIVE

Adequate dietary intake during pregnancy is vital for the health and nutritional status of both mother and fetus. The nutritional status of reproductive age women in Pakistan is poor, with 14 % being underweight (BMI < 18·5) and 42 % experiencing Fe deficiency anaemia. This may stem from beliefs, practices and other barriers influencing dietary intake. This qualitative study seeks to determine which factors impact dietary intake during pregnancy in rural Punjab.

DESIGN

In-depth interviews and focus group discussions were conducted and then analysed using thematic analysis.

SETTING

Three purposively selected rural districts (Sahiwal, Okara and Pakpatan) with the highest prevalence of maternal and child malnutrition in the province of Punjab, Pakistan.

PARTICIPANTS

Mothers with children under age two (n 29) and healthcare providers with at least 5 years of experience working in the district (n 12).

RESULTS

We identified a combination of physiological, socio-cultural and structural barriers that inhibited healthful dietary intake during pregnancy. The primary physiological barriers to optimal dietary intake and dietary practices included food aversions and food cravings. Food classification, fear of a difficult childbirth, fear of high blood pressure and household food politics were the principal socio-cultural barriers. Additionally, two structural barriers, inadequate antenatal counseling and a lack of affordable food options, were identified.

CONCLUSIONS

Our study demonstrates that complex barriers prevent pregnant women in the Punjab area from consuming adequate dietary intake and that antenatal health education programmes and structural interventions are needed to support healthful dietary practices during this critical period.

Double Burden of Malnutrition in the Asia-Pacific Region-A Systematic Review and Meta-analysis

Background: Double Burden of Malnutrition (DBM)—the coexistence of undernutrition along with overnutrition—is a significant public health issue in the Asia-Pacific region. The scope of the DBM in this region is largely unknown. This review aims to determine the prevalence of under- and overnutrition as major DBM components and to investigate whether there has been a shift from under- to overnutrition in the Asia-Pacific region.

Methods: Online databases including PubMed and Web of Science were searched for original studies on DBM prevalence in the Asia-Pacific region; particularly, those published from January 2008 to December 2018 were screened for eligibility. We collected data on indicators of under- and overnutrition on the population level and adapted the ratio of prevalence of overweight/obesity versus prevalence of underweight as the main outcome indicator. Pooled prevalence estimates of DBM and the ratio of overnutrition versus undernutrition were generated using R (3.4.0).

Results: In total, 33 studies were included in this review. Pooled analysis demonstrated that DBM was generally presented among countries/areas in the Asia-Pacific region except in high-income countries (HICs). Overall, the prevalence of undernutrition was 8.8% (95% CI 7.3–10.6%) while overnutrition among the same population reached 23.0% (95% CI 20.3–26.0%). Countries in the Oceania region or HICs reported low level of undernutrition (less than 3%). All subgroup analysis (geolocation, income level, sex, age) reported pooled prevalence of overweight/obesity as more than 18%. Overall, the whole region and all subgroups were more likely to experience a higher prevalence of overnutrition than undernutrition, except that low- and lower-middle-income countries (L-MICs) had similar prevalence for over- and undernutrition.

Conclusion: DBM in the Asia-Pacific region is alarmingly high and is titled toward overnutrition. As a result, future interventions/policy targeting to maintain a healthy weight for the population should not just focus on prevention and treatment toward one direction.

Physical Activity and the Home Environment of Pre-School-Aged Children in Urban Bangladesh

Physical activity (PA) is a key determinant of health and development, yet few studies have examined PA levels and risk factors for low PA among young children in low- and middle-income countries. This study aimed to describe the PA and sedentary (SED) behavior levels of preschool-aged children in Dhaka, Bangladesh, and to estimate the associations between potential risk factors in the home built environment and moderate to vigorous PA (MVPA). In a sample of preschool-aged children (n = 65) in Dhaka, PA and SED behavior were measured for 7 days using ActiGraph GT3X-BT accelerometers. Characteristics of the home built environment, socioeconomic factors, and anthropometry were also measured. Linear mixed-effects models were used to estimate multivariable-adjusted associations between characteristics of the home environment and MVPA. Preschool-aged children spent a mean (±standard deviation) 421 ± 48 and 82 ± 23 min per day sedentary and in MVPA, respectively. There were no statistically significant associations between factors in the home built environment (indoor area, presence of an open stairwell, and presence of gross motor activity facilitating items) and MVPA. These findings suggest that the studied characteristics of the home built environment may not significantly influence the MVPA observed among preschool-aged children in Dhaka. Future research should focus on other structural and behavioral factors that facilitate PA among young children in dense urban settings.

Socio-economic status and the double burden of malnutrition in Cambodia between 2000 and 2014: overweight mothers and stunted children

OBJECTIVE

The Cambodian population has experienced an increase in the proportion of stunted children who have overweight mothers during a period of rapid social and economic growth. We aimed to identify socio-economic factors associated with this household-level double burden over time.

DESIGN

We used data from four Cambodia Demographic and Health Surveys from 2000 to 2014 to study the impact of socio-economic status (SES) on the link between child stunting and overweight mothers in two periods 2000-2005 v. 2010-2014. We hypothesised that SES would be a primary factor associated with this phenomenon.

PARTICIPANTS

We included 14 988 children under the age of 5 years, among non-pregnant mothers aged 15-49 years of age and conducted analysis on a subsample of 1572 children with overweight mothers.

SETTING

Nationally representative household survey across all regions.

RESULTS

SES factors, specifically household wealth and maternal employment in service or manual occupations (in 2010-2014), are the main drivers of stunting among children of overweight mothers. Children with overweight mothers in the poorest households are more than twice as likely to be stunted than in the richest in both periods (2000-2005: adjusted OR (aOR) = 2·53, 95 % CI: 1·25, 5·13; 2010-2014: aOR = 2·61, 95 % CI: 1·43, 4·77), adjusting for other SES factors, indicating that despite decreasing income inequality, the poorest continue to bear excess risk of a double burden of malnutrition. Maternal short stature also doubled the likelihood of child stunting in both periods, which suggests intergenerational transmission of adversity and physical underdevelopment.

CONCLUSIONS

Socio-economic inequalities should be addressed to reduce disparities in the household-level double burden of malnutrition.

Aquatic Foods and Nutrition in the Pacific

National rates of aquatic food consumption in Pacific Island Countries and Territories are among the highest in the world, yet the region is suffering from extensive levels of diet-related ill health. The aim of this paper is to examine the variation in consumption patterns and in nutrient composition of aquatic foods in the Pacific, to help improve understanding of their contribution to food and nutrition security. For this examination we analysed nutrient composition data and trade data from two novel region-specific databases, as well as consumption data from national and village level surveys for two Melanesian case studies, Vanuatu and Solomon Islands. Results demonstrated that consumption depends on availability and the amount and type of aquatic food consumed, and its contribution to nutrition security varies within different geographic and socio-demographic contexts. More data is needed on locally relevant species and consumption patterns, to better inform dietary guidelines and improve public health both now and into the future. Advice on aquatic food consumption must consider the nutrient composition and quantity of products consumed, as well as accessibility through local food systems, to ensure they contribute to diverse and healthy diets.

Prevalence and associated factors of underweight, overweight and obesity among women of reproductive age group in the Maldives: Evidence from a nationally representative study

Background

Global epidemiological transition across various countries have documented the coexistence of undernutrition and overnutrition. South Asian countries are facing this public health hazard in remarkable manner. To enrich the evidence and relation with women’s health in the Maldives, this study was undertaken to examine the prevalence and associated factors of underweight, overweight and obesity among reproductive age women.

Methods

This study was conducted utilizing data from the Maldives Demographic and Health Survey 2016–17. After presenting descriptive analyses, multivariable logistic regression analysis method was used to examine the prevalence and associations between different nutritional status categories. These were grouped based on the WHO recommended cut-off value and relevant socio-demographic determinants among reproductive age women.

Results

A total weighted sample of 6,634 reproductive age Maldivian women (15–49 years) were included in the analysis. The overall prevalence of overweight and obesity was 63%, while the underweight prevalence was 10%. The younger age group (15–24 years) had a higher prevalence of underweight (26%). On the other hand, an overweight and obesity prevalence of 82.6% was observed among the older age group (35–49 years). Regression analysis showed that residents of the North and Central Provinces, those in the higher quintiles of wealth index, married women and those with parity of more than two children, were all significantly negatively correlated to being underweight. Increased age, being married or separated/divorced/widowed and having more than three children was found to have a significant positive association with overweight and obesity.

Conclusions

Maldives is facing nutritional transition and a major public health hazard demonstrated by the high burden of overweight and obesity and persistence of chronic problem of undernutrition. Surveillance of vulnerable individuals with identified socio-demographic factors and cost-effective interventions are highly recommended to address the persistent underweight status and the emerging problem of overweight/obesity.

Prevalence and regional variations of coexistence of child stunting and maternal overweight or obesity in Myanmar

OBJECTIVE

The current study aimed to investigate double burden of malnutrition within households at the national and subnational levels and to identify its association with sociodemographic factors in Myanmar.

DESIGN

All the variables were extracted from children's file of the Myanmar Demographic and Health Survey 2015-2016. Children under five were identified as stunted based on a height-for-age < -2 sd below the WHO reference median. Maternal overweight/obesity was defined as a BMI ≥ 23 kg/m2. A stunted child with an overweight/obese mother (SCOM) was classified as a double-burden household.

SETTING

A national household survey in Myanmar.

PARTICIPANTS

Children under five and their mothers (n 3954 pairs).

RESULTS

Mean ages of children and mothers were 29 (se 0·14) months and 30·9 (se 0·32) years, respectively. National prevalence of childhood stunting and maternal overweight/obesity was 28·0 % and 39·4 %, respectively, and the prevalence of SCOM was 9·1 %. Significant regional differences were found in SCOM, ranging from 3·6 % in Naypyitaw to 12 % in Kachin and Mon and 14·6 % in Kayah. In the multinomial logistic regression analysis, relative to neither a stunted child nor an overweight/obese mother, child's age, maternal age, maternal experience of a teen birth, short mothers, mothers with primary education and in middle or rich wealth tertiles, and some regions (Kachin, Kayah, Shan, Sagaing, Taninthayi, Ayeyarwaddy, Mon and Yangon) were associated with greater odds of SCOM.

CONCLUSIONS

The current study showed a relatively high national prevalence of SCOM and significant regional variations. Overarching policies and programmes with culturally sensitive strategies need to be formulated and implemented.

Dietary diversity and food intake of urban preschool children in North-Western Sri Lanka

Childhood malnutrition, associated with poor diet, is a clear public health threat in Sri Lanka, with high rates of under‐nutrition and micronutrient deficiencies coupled with the growing risk of overweight/obesity in urban locations. This study explored the dietary diversity and food intake of urban living Sri Lankan preschool children. A cross‐sectional analysis of the baseline data from a cohort study was conducted with parents/caregivers of children aged 2–6 years, from 21 preschool centres in Kurunegala District, Sri Lanka. Demographic and socio‐economic factors, dietary diversity score (DDS) (n = 597) and food intake (n = 458) (using a food frequency questionnaire) were assessed. Children had a mean DDS of 4.56 ± 0·85 out of 9, with most (91.1%) in the medium DDS category (DDS of 3.1–6.0), consuming rice as most common food. Lentils were consumed more than any meat or alternative food groups at all DDS levels. Child DDS differs with parent/caregiver age and ethnicity. Mean daily intakes of fruit (1.02) and vegetables (0.84) servings align with approximately half of national recommendations, with less than 20% of children meeting daily recommendations. More than one‐third consumed sugary snacks and confectionaries daily and 1 in 10 had them twice a day. Around 40% reported watching television while eating the evening meal. Despite the majority having reasonable DDSs (medium category), findings highlighted inadequate intakes of fruits and vegetables, excessive intakes of sugary snacks and unhealthy dietary and social behaviours, suggests the need for population‐based interventions to promote healthier dietary habits.

Nutritional status of Tajik children and women: Transition towards a double burden of malnutrition

The double burden of malnutrition, an emerging concern in developing countries, can exist at various levels: individual, household, and population. Here, we explore the nutritional status of Tajik women (15-49 years) and children (5-59 months) focusing on overweight/obesity along with undernutrition (underweight, stunting, and micronutrient deficiencies). For this, nutritional markers (haemoglobin (Hb), transferrin receptor (TfR), serum ferritin (Sf), retinol binding protein (RBP), vitamin D, serum folate, and urinary iodine), height, and weight were assessed from 2,145 women and 2,149 children. Dietary intake, weaning, and breastfeeding habits were recorded using a 24-hr recall and a questionnaire. Overweight (24.5%) and obesity (13.0%) are increasing among Tajik women compared with previous national surveys (2003 and 2009). Prevalence of iron deficiency and anaemia was 38.0% and 25.8%, respectively; 64.5% of women were iodine deficient, 46.5% vitamin A deficient, and 20.5% had insufficient folate levels. Women in rural areas had significantly lower iron status and body mass index and higher iodine intake compared with urban areas; 20.9% of children were stunted, 2.8% wasted, 6.2% underweight, 52.4% iron deficient, and 25.8% anaemic; all more prominent in rural areas. Dietary diversity was higher among urban women. Intraindividual or household double burden was not seen. In summary, double burden of malnutrition constituted an increase in overweight among women, especially in urban areas, and persisting levels of undernutrition (stunting, iron, and vitamin A deficiency), predominately in rural areas. A holistic, innovative approach is needed to improve infant and young children feeding and advise mothers to maintain an adequate diet.

Supporting Women's Participation in Developing A Seaweed Supply Chain in Kiribati for Health and Nutrition

Seaweeds are a source of food throughout the Pacific region. Kiribati, however, does not have a strong history of using seaweed in their diets, despite having reliable access to indigenous edible seaweeds. A series of peer-led seaweed training workshops held in Kiribati between 2018 and 2019 provided women with knowledge, skills, and motivational support needed to engage in the seaweed supply chain, from harvesting, processing, and marketing to consumption. This study aimed to identify opportunities and enablers to support women’s participation across the seaweed supply chain. Structured interviews with 49 women explored their interest and expected costs and benefits from involvement in the supply chain. There was high interest in most seaweed-related activities and the key motivators were health and nutrition for themselves and their family. Participants were also interested in developing and sharing new skills and saw the potential for income generation. However, there were also clear barriers including a desire for further training in seaweed harvesting, processing, and recipe creation; additional social support; and in public promotion. Given the natural resources and desire of women to engage in developing this new edible seaweed supply chain in Kiribati, there is now a need for capacity development to build social and economic wellbeing and food security across the broader community. Additional peer-to-peer training opportunities may look to other Pacific Islands where seaweed is already an established and traditional food.

Malnutrition in rural Solomon Islands: An analysis of the problem and its drivers

Solomon Islands, like many Pacific Island nations, suffer from the burden of malnutrition. External drivers including population growth, declining agriculture and fisheries productivity and global food trade have contributed to the transition to greater reliance on imported foods. Globally, diets are recognized as both a cause of and solution to the burden of malnutrition. Using a mixed‐method approach this study assessed nutritional status and key determinants of malnutrition among women and young children in rural Solomon Island communities. Quantitative 24‐hour recall surveys identified diets of women and young children in these communities to be very limited in diversity. Typical daily diets comprised of fish, sweet potato (and/or rice) and slippery cabbage (a leafy green) usually boiled in coconut milk or baked. Participatory research using problem tree and biocultural approaches identified basic determinants of poor diets and opportunities to address these challenges. We highlight three domains of opportunity to improve diets across multiple scales; 1) improve nutrition‐sensitive agriculture and fisheries to produce and distribute diverse, productive and nutrient rich foods; 2) nutrition education and empowerment, focusing on the first 1000 days of life, to influence and inform choices regarding food consumption; and 3) reducing the consumption of imported, energy‐rich nutrient poor foods through national and regional policies. These multi‐scale domains highlight that food system approaches that strengthen integrated policy and empower people are essential for healthy and sustainable diets in Solomon Islands and more broadly in the Pacific region.

The double burden of overnutrition and undernutrition in mother-child dyads in Kenya: demographic and health survey data, 2014

The double burden of overnutrition and undernutrition is rapidly becoming a public health concern in low- and middle-income countries. We explored the occurrence of mother-child pairs of over- and undernutrition and the contributing factors using the 2014 Kenya Demographic and Health Survey data. A weighted sample of 7830 mother-child pairs was analysed. The children's nutritional status was determined using the WHO 2006 reference standards while maternal nutritional status was determined with BMI. Descriptive statistics, bivariate and multivariate logistic regression analysis were conducted. The proportion of overweight and obese mothers was 26 % (18·8 % overweight and 7·2 % obese). The prevalence of child stunting, underweight and wasting was 26·3, 12·8 and 5·1 %, respectively. Out of the overweight/obese mothers (weighted n 2034), 20 % had stunted children, 5·4 % underweight children and 3·1 % wasted children. Overweight/obese mother-stunted child pairs and overweight/obese mother-underweight child pairs were less likely to occur in the rural areas (adjusted OR (aOR) = 0·43; P < 0·01) in comparison with those residing in the urban areas (aOR = 0·54; P = 0·01). Children aged more than 6 months were more likely to be in the double burden dyads compared with children below 6 months of age (P < 0·01). The double burden mother-child dyads were more likely to be observed in wealthier households. Mother-child double burden is a notable public health problem in Kenya. Household wealth and urban residence are determinants of the double burden. There is need for target-specific interventions to simultaneously address child undernutrition and maternal overweight/obesity.

Overweight and Obesity Coexist with Thinness among Lao's Urban Area Adolescents

INTRODUCTION

In recent decades, the developing countries of Southeast Asia, including the Lao People's Democratic Republic (Lao PDR), have experienced a rapid growth of their urban population. Partly as a result of that, issues of undernutrition and overnutrition became a significant public health problem.

OBJECTIVE

To examine the prevalence of overweight and obesity and their related factors, among the school-attending adolescents in the Lao capital of Vientiane.

METHODS

A cross-sectional data on 300 adolescents aged 15-19 were collected during the months of March, April, and May 2018 by means of a self-administrated questionnaire. Anthropometric measurements were used to obtain data on height and weight. Pearson's chi-squared test, Fisher exact tests, and univariable and multivariable logistic regressions were applied in the course of the statistical analysis.

RESULTS

The study found a high prevalence of overweight/obesity (23.3%) and thinness (10.3%). Poor eating habits were noted in 67.0% of adolescents, even though 78.0% of them had a good knowledge of nutrition. Factors significantly associated with the overweight/obesity were low physical activities (aOR = 18.3; 95% CI: 5.51-60.66) and adolescents living with their guardians (aOR = 0.25; 95% CI: 0.08-0.79). Results also indicated that, in 47.3% of the cases, teachers, acting as a source of health and nutrition information, can prevent the risk of adolescents' overweight/obesity (aOR = 2.05, 95% CI = 1.11-3.80) but not their thinness (aOR = 0.4, 95% CI = 0.17-0.88).

CONCLUSIONS

Laotian adolescents are facing the spectrum of malnutrition in urban areas. To improve adolescents' nutritional status, there is a need for a collaborative approach of public health agencies that would address the issues of an effective food and nutrition policy. The school curricula should also include programs on nutrition and physical education.

Family and community factors shaping the eating behaviour of preschool-aged children in low and middle-income countries: A systematic review of interventions

Low and middle-income countries are experiencing the dual burden of malnutrition which is, at least in part, attributable to changes in eating behaviours of children under age five. Development of food choices is influenced by multiple factors and understanding the interplay of these factors in early childhood in these countries is necessary to promote healthy food choices. We conducted a systematic review to examine the evidence of family and community factors targeted in interventions to influence the eating behaviour of preschool-aged children in low and middle-income countries. A search for peer-reviewed papers was conducted using CINAHL, MEDLINE, PsycINFO, Scopus and ProQuest Health Management published prior to September 2018, in English language including preschool-aged children (PROSPERO registration CRD42018108474). Fourteen studies published between 1994 and 2017 were eligible for inclusion. Factors that were consistently and positively associated with children's healthy food consumption were household food availability, nutritional knowledge of family or caregivers and family income. Unhealthy food consumption in children was inversely associated with family or caregivers' nutritional knowledge. Children's micronutrient intake was positively associated with household food availability, nutritional knowledge of family or caregivers and food availability within the surrounding environment. Findings highlight the importance of targeting nutritional knowledge of family or caregivers to facilitate healthy eating behaviours in children. In addition, creating a supportive family environment via increasing household food availability and family income should be considered when designing interventions to promote healthy eating behaviours in preschool-aged children living in low and middle-income countries.

Various forms of double burden of malnutrition problems exist in rural Kenya

BACKGROUND

The coexistence of overweight/obesity and undernutrition is often referred to as the double burden of malnutrition (DB). DB was shown to exist in many developing countries, especially in urban areas. Much less is known about DB in rural areas of developing countries. Also, the exact definition of DB varies between studies, making comparison difficult. The objective of this study is to analyse DB problems in rural Kenya, using and comparing different DB definitions and measurement approaches.

METHODS

Food intake and anthropometric data were collected from 874 male and female adults and 184 children (< 5 years) through a cross-section survey in rural areas of Western Kenya. DB at the individual level is defined as a person suffering simultaneously from overweight/obesity and micronutrient deficiency or stunting. DB at the household level is defined as an overweight/obese adult and an undernourished child living in the same household, using underweight, stunting, wasting, and micronutrient deficiency as indicators of child undernutrition.

RESULTS

DB at the individual level is found in 19% of the adults, but only in 1% of the children. DB at the household level is relatively low (1-3%) when using wasting or underweight as indicators of child undernutrition, but much higher (13-17%) when using stunting or micronutrient deficiency as indicators.

CONCLUSION

Various forms of DB problems exist in rural Kenya at household and individual levels. Prevalence rates depend on how exactly DB is defined and measured. The rise of overweight and obesity, even in rural areas, and their coexistence with different forms of undernutrition are challenges for food and nutrition policies.

Food sources, energy and nutrient intakes of adults: 2013 Philippines National Nutrition Survey

BACKGROUND

Comprehensive assessment of dietary intakes of foods and nutrients in Filipino adults are lacking. This study evaluated energy and nutrient intakes and food sources of key nutrients consumed by Filipino adults.

METHODS

The participants were from the 2013 National Nutrition Survey wherein food intake of young adults aged 19-49 years (n = 12,896) and older adults aged 50 years and above (n = 7853) were collected using 24-h recalls. Usual nutrient intakes were estimated using PC-SIDE program. The Philippines Dietary Reference Intakes were used to calculate proportions of inadequate intake using Estimated Average Requirement (EAR) and Acceptable Macronutrient Distribution Ranges (AMDR). Energy adequacy was evaluated using the Institute of Medicine (IOM) equation for Estimated Energy Requirements (EER).

RESULTS

The nutrient intakes with the highest prevalence of inadequacy (> 50%) were: iron (97-99%), vitamin C (96-98%), calcium (95-98%), riboflavin (86-91%), folate (89-90%), thiamine (73-89%), energy (67-70%), total fat (55-67%), and vitamin A (54-56%). Refined rice, pork and breads contributed most to daily intakes of energy, protein, carbohydrates, thiamine, riboflavin, and iron. Low intake of vegetables, fruits and dairy was common in both age groups.

CONCLUSIONS

This study demonstrated that intakes of many nutrients were markedly inadequate among adults in the Philippines, due to the rice-dominant dietary pattern with few nutrient-dense foods. These results can be used to support the development of specific interventions to improve the shortfalls in nutrient intakes.

Socio-Ecological Model of Correlates of Double Burden of Malnutrition in Developing Countries: A Narrative Review

(1) Background: The double burden of malnutrition (DBM) is a complex problem involving the coexistence of under- and over-nutrition within the same individual, household or population. This review aimed to discuss the correlates of the double burden of malnutrition through the socio-ecological model (SEM); (2) Methods: The PubMed database was systematically searched for peer-reviewed articles related to the double burden of malnutrition. Information on correlates of the double burden of malnutrition was extracted for analysis and discussion in alignment with the levels of the socio-ecological model.; (3) Results and Discussion: The correlates of the double burden of malnutrition identified from previous literature were: Race/genetics; maternal short stature; breastfeeding status; low maternal education; family size; household food security; household dietary diversity; and rural and urban settings. In the absence of evidence linking factors in a certain level of the SEM and the double burden of malnutrition, we employed correlates of overweight status and obesity to complete this narrative. Potential intervention strategies were proposed in alignment with the targets and settings identified, based on the socio-ecological approach; (4) Conclusions: The double burden of malnutrition is a public health phenomenon associated with a variety of socio-ecological determinants. An integrated approach is needed to address the root causes of malnutrition in all its forms, and at all life stages.

Patterns and risk factors of double burden of malnutrition among adolescent girls and boys in Indonesia

OBJECTIVES

As an emerging middle-income country, Indonesia is grappling with the double burden of malnutrition across all age groups, including adolescents. Slow gains in reducing undernutrition are compounded by rapidly increasing overnutrition. This study aims to determine the patterns and determinants of this double burden, particularly stunting, thinness and overweight, among adolescent girls and boys aged 12-18 years in Indonesia.

METHODS

A cross-sectional survey was conducted among 2,160 girls and boys in the districts of Klaten and Lombok Barat in 2017. Data were collected on adolescents' nutritional status, sociodemographic characteristics, morbidity, dietary intake and physical activity and other relevant factors. Multivariable logistic regression models using generalized estimation equation were employed to determine risk factors for stunting, thinness and overweight.

RESULTS

About a quarter of adolescent girls (25%) and boys (21%) were stunted. Approximately 5% of girls and 11% of boys were thin, whereas 11% girls and boys each were overweight. Living in a higher wealth household (OR = 0.67; 95% CI: 0.49-0.91), compared to a lower wealth household, and living in a district with higher socioeconomic status (OR = 0.63; 95% CI: 0.51-0.79) were associated with lower odds of being stunted. Adolescent education was also protective against stunting (OR = 0.52; 95% CI: 0.33-0.88). Older adolescents aged 15-18 years were more likely to be stunted (OR = 1.88; 95% CI: 1.42-2.46). Being a girl was associated with reduced odds of being thin (OR = 0.42; 95% CI: 0.30-0.58). Higher household wealth (OR = 1.93; 95% CI: 1.27-2.97) predicted being overweight, while maternal primary or some secondary education, compared to no or incomplete primary education, was protective against adolescent overweight (OR = 0.60; 95% CI: 0.40-0.90).

CONCLUSION

Indonesian adolescent girls and boys face both extreme spectrums of malnutrition. Addressing the dual burden of malnutrition requires a multi-pronged approach, and urgent shift is warranted in nutrition policy and programmes targeting adolescents to effectively address the associated underlying determinants.

Dietary Diversity of an Adult Solomon Islands Population

Ongoing dietary transitions in the Solomon Islands has resulted in an over-reliance on commercially sourced foods, leading to food insecurity, and a subsequent rise in multiple forms of malnutrition. The aim of this study was to investigate the individual dietary diversity and food preferences of the adult population living in Auki, Solomon Islands. A cross-sectional study involving 133 adults was undertaken in the Auki district via an interviewer-administered questionnaire. Individual dietary diversity scores (DDS) were determined based on the results of a 24-h recall method. Overall mean DDS was 7.27 (range 2-12). Females and participants who lived outside the Auki town center had significantly higher dietary diversity scores. Low consumption of a variety of nutritious foods within food groups and high consumption of energy dense processed foods, indicates that diet quality is likely limited in some of this population. Participants desire for a diverse diet including local foods suggests that current dietary diversity status in this population may be influenced by food security rather than food preference.

Innovative matrix for applying a food systems approach for developing interventions to address nutrient deficiencies in indigenous communities in India: a study protocol

BACKGROUND

Indigenous communities retain knowledge of the land and food resources rooted in historical continuity within their region of residence. Food systems research can be leveraged to identify strategies to encourage sustainable use of complex multi-species agroforestry systems by indigenous communities contributing to nutritional needs while simultaneously preserving the ecosystems and their benefits to society. Till date, the analyses of food systems have predominantly focused on high income countries often overlooking the alternatives (dietary and production) that would be most relevant to low and middle income countries (LMIC). Thus, innovative methodological approaches are needed to comprehensively characterize diverse food systems in LMICs with special reference to indigenous communities.

DESIGN

This protocol paper describes a food systems approach that will be employed to understand diverse and dynamic food systems of vulnerable tribal communities of Jharkhand, India and leverage their agroforestry systems to improve dietary diversity, nutrition status and address food security. Four tribal groups namely Santhal, Ho, Munda and Sauria Paharia of Godda, West Singhbhum and Khunti districts of Jharkhand would be studied. This will be an exploratory cross-sectional study design, along with a longitudinal component to capture seasonality in dietary intake and agricultural diversity. A mixed methods approach will be used based on a conceptual framework on drivers of food systems, food supply chain, food environment (both wild & cultivated, and market food environments), as well as consumer behaviour and maternal and child health outcomes in tribal communities. The quantitative surveys will be conducted on socio-economic, demographic profile of households, their availability of, access to and utilization of food environment and nutritional status of reproductive age group women and children under 5 years. Qualitative enquiries will examine barriers and facilitators to increase sustainable production, procurement and consumption of indigenous foods. The final outcome would be development of interventions to promote indigenous food consumption.

DISCUSSION

By utilizing a combination of value chain analysis and 'Optifoods linear programming software' that will use above information on indigenous community, dietary intake, nutritional status and food environment, evidence based interventions promoting indigenous food systems aimed at addressing food and nutritional security of tribal communities will be developed.

Stratification of BMI categories among older adults within and across countries

OBJECTIVE

Within- and across-country nutritional disparities were examined among older adults in six different countries at varying levels of development.

DESIGN

Cross-sectional study.

PARTICIPANTS

Older adults (aged 50 years or over) in China, Ghana, India, Mexico, Russia and South Africa using the Study on global AGEing and adult health (SAGE).

RESULTS

While the distribution of BMI categories varied by country, development-related characteristics were generally related to BMI category in a similar way: urban-living, educated and wealthier individuals were typically more likely to be in a higher BMI category. However, there were some exceptions that corroborate findings in more developed countries. Indeed, a pooled partial proportional odds model which included gross domestic product per capita interactions made the case for intertwining processes of development and the nutrition transition.

CONCLUSIONS

Population segments to be targeted by nutrition policy and programme implementation might need to change over the course of development.

Factors associated with the double burden of malnutrition among adolescents, National Adolescent School-Based Health Survey (PENSE 2009 and 2015)

Objective

To assess the sociodemographic factors associated with the double burden of malnutrition (DBM) among Brazilian adolescents.

Methods

This was a descriptive study based on data from 59,637 and 10,770 students who participated in the National Adolescent School-Based Health Survey (PeNSE), 2009 and 2015 editions, respectively. Weight and height measurements were obtained to evaluate nutritional status. DBM was classified as follows: adolescents with high BMI-for-age and low height-for-age (BMI/A: Z-score > +1 and H/A: Z-score < -2). Sociodemographic data on the participants were also collected. A multinomial logistic regression analysis was used to detect associations of interest.

Results

The prevalence of DBM in the 2009 and 2015 editions of the PeNSE was 0.4% and 0.3%, respectively. In the 2009 edition, the chance of DBM was lower among boys (OR = 0.60; 95% CI = 0.45–0.81) and higher among those over 14 years old (OR = 2.40; 95% CI = 1.80–3.20), living in the country’s north and northeast regions (OR = 2.01; 95% CI = 1.49–2.84), and from families with a low maternal education level (OR = 1.48; 95% CI = 1.07–2.04). In the 2015 edition, no significant associations were found regarding the DBM outcome.

Conclusion

The results indicate the presence of socioeconomic inequalities in the occurrence of DBM in the 2009 edition of the PeNSE. Simultaneous interventions in the area of equity are necessary to prevent the advancement of nutrition-related problems.