The global problems of child malnutrition and mortality in different world regions

Identifying determinants of malnutrition in under-five children in Bangladesh: insights from the BDHS-2022 cross-sectional study

Malnutrition remains one of the most pressing global health challenges, particularly in developing countries like Bangladesh, where it continues to significantly impact child health and contribute to chronic illness and high child mortality. Despite the potential of machine learning to improve malnutrition predictions, research in this area remains limited in the country. This study utilizes Bangladesh Demographic and Health Survey (BDHS) 2022 data to identify and quantify key determinants of under-five malnutrition (underweight, wasting, stunting) and evaluates various machine learning models for predicting malnutrition. By addressing a critical gap, this research provides deeper insights into the root causes of malnutrition in Bangladesh. Descriptive statistics were conducted to summarize the key characteristics of the dataset. Boruta algorithm was employed to identify important features related to malnutrition which were then used to evaluate several machine learning models, including K-Nearest Neighbors (KNN), Neural Networks (NN), Classification and Regression Trees (CART), XGBoost (XGBM), Support Vector Machines (SVM), and Random Forest (RF), in addition to the traditional logistic regression (LR) model. The best-performing model was selected to identify the most important factors contributing to malnutrition. The significance of these variables was further assessed using Feature Importance plot (Based on Gini Importance) and Shapley Additive Explanation (SHAP) values. Model performance was evaluated through various metrics, including accuracy, 95% Confidence Interval (CI), Cohen's kappa, sensitivity, specificity, F1 score and precision. The study examined a cohort of 7,910 children, reporting prevalence rates of 19% for stunting, 8% for wasting, and 17% for underweight. The Boruta algorithm identified 18 confirmed features for stunting, 22 for wasting, and 19 for underweight. For stunting, the Random Forest (RF) model outperformed other methods with an accuracy of 64.19%, 95% CI of (0.623, 0.666), Cohen's kappa of 0.158, sensitivity of 56.25%, specificity of 66.00%, F1 score of 0.750 and precision of 0.60. In wasting prediction, RF achieved the highest accuracy at 76.68%, 95% CI of (0.743, 0.787), Cohen's kappa of 0.049, sensitivity of 27.22%, specificity of 80.98%, F1 score of 0.865 and precision of 0.810. Similarly, for underweight, RF demonstrated superior performance with an accuracy of 68.18%, 95% CI of (0.662, 0.703), Cohen's kappa of 0.130, sensitivity of 43.02%, specificity of 73.48%, F1 score of 0.792 and precision of 0.735. Across all malnutrition types, the RF model consistently outperformed traditional logistic regression (LR) and other ML techniques in terms of accuracy, sensitivity, specificity, and other performance metrics. For stunting, key predictors identified in both the Shapley and Gini importance plots included mother's education, father's occupation, place of delivery, wealth index, birth order, and toilet facility; for wasting, significant predictors were antenatal care, unmet family planning, mother's BMI, birth interval, father's occupation, and television ownership; and for underweight, important factors included father's occupation, mother's education, child's age, birth order, wealth index, and place of delivery. This study highlights the effectiveness of Random Forest (RF) in predicting malnutrition outcomes-stunting, wasting, and underweight-using key features identified by the Boruta algorithm. While RF demonstrates moderate performance in predicting stunting and underweight, it shows strong predictive ability for wasting. This underscores RF's potential in guiding targeted interventions for wasting, though further improvements are needed for stunting and underweight predictions. Moreover, the study identifies key contributors for each malnutrition outcome. By pinpointing these determinants, the study provides actionable insights for designing targeted interventions to combat malnutrition more effectively. These findings align with the global development agenda, particularly Sustainable Development Goal (SDG) 2: Zero Hunger and SDG 3: Good Health and Well-being, reinforcing efforts to reduce malnutrition and improve child health outcomes in Bangladesh.

Socio-demographic and environmental determinants of under-five child mortality in Ethiopia: using Ethiopian demographic and Health 2019 survey

BACKGROUND

The under-five mortality rate is a reliable indicator of a country's general level of development and the wellbeing of its children. Life expectancy is a good indicator of a population's standard of living.

OBJECTIVES

To identify Socio-demographic and Environmental determinants of under-five child mortality in Ethiopia.

METHODS

A national representative cross sectional study and a quantitative study were conducted among 5753 households selected based on 2019 Mini-Ethiopian Demographic and Health Survey (EDHS-2019) data. The analysis was done using STATA version 14 statistical software. Bivariate and multivariate analyses were used. To assess the determinants of under-five child mortality in multivariate analysis, p values less than 0.05 were considered statistically significant, and odds ratios with 95% CI (confidence interval) were used.

RESULTS

A total of 5,753 children were included in the study. Sex of the head of the household being female (AOR = 2:350, 95% CI: 1.310, 4.215), the U5CM for being their mother were currently married (AOR = 2:094, 95% CI: 1.076, 4.072), The odds of U5CM was less by 80% (AOR = 1.797, 95% CI: 1.159-2.782) with the number of under-five children at the household born 2-4th order as compared to those children born on the first order. For the mothers visit anti natal care four and above visit (AOR = 1:803, 95% CI: 1.032, 3.149), for the way of delivery (AOR = 0:478, 95% CI: 0.233, 0.982).

CONCLUSION

Multivariate logistic analysis reflected that way of delivery, mothers had being currently marred, sex of the head of the household and number of antenatal care visit were found to be significant predictors of under-five child mortality. So, government policy, nongovernmental organizations, and all concerned bodies should be focused on the major determinants of under-five child mortality and put in a lot more effort to reduce under-five child mortality.

A hybrid ensemble approach to accelerate the classification accuracy for predicting malnutrition among under-five children in sub-Saharan African countries

BACKGROUND

The proper intake of nutrients is essential to the growth and maturation of youngsters. In sub-Saharan Africa, 1 in 7 children dies before age 5 y, and more than a third of these deaths are attributed to malnutrition. The main purpose of this study was to develop a majority voting-based hybrid ensemble (MVBHE) learning model to accelerate the prediction accuracy of malnutrition data of under-five children in sub-Saharan Africa.

METHODS

This study used available under-five nutritional secondary data from the Demographic and Health Surveys performed in sub-Saharan African countries. The research used bagging, boosting, and voting algorithms, such as random forest, decision tree, eXtreme Gradient Boosting, and k-nearest neighbors machine learning methods, to generate the MVBHE model.

RESULTS

We evaluated the model performances in contrast to each other using different measures, including accuracy, precision, recall, and the F1 score. The results of the experiment showed that the MVBHE model (96%) was better at predicting malnutrition than the random forest (81%), decision tree (60%), eXtreme Gradient Boosting (79%), and k-nearest neighbors (74%).

CONCLUSIONS

The random forest algorithm demonstrated the highest prediction accuracy (81%) compared with the decision tree, eXtreme Gradient Boosting, and k-nearest neighbors algorithms. The accuracy was then enhanced to 96% using the MVBHE model. The MVBHE model is recommended by the present study as the best way to predict malnutrition in under-five children.

The Effects of Breastfeeding for Four Months on Thinness, Overweight, and Obesity in Children Aged 3 to 6 Years: A Retrospective Cohort Study from National Physical Fitness Surveillance of Jiangsu Province, China

Objective: To explore the effects of breastfeeding during the first four months of life on thinness, overweight, and obesity and to analyze the influential factors in children aged three to six years in eastern China. Methods: This study was designed as a retrospective cohort study, and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines were followed. A total of 8053 subjects were included in this secondary analysis of data from the 2015 “Physical Fitness Surveillance data of Jiangsu, China”. The subjects were classified into three groups on the basis of feeding patterns: breastfeeding, mixed feeding, and formula feeding. The International Obesity Task Force (IOTF) definitions of BMI were used to define thinness, overweight, and obesity. Multivariate logistic regression models and subgroup analysis were used to assess the association between feeding patterns and childhood thinness, overweight, obesity, and overweight/obesity, adjusted for potential confounders (sex, age grade, area, region/economy, gestational age, birthweight, childbearing age, mother’s education, and caretaker). Results: The prevalence of breastfeeding was 63.8%, and the prevalence of thinness, overweight, obesity, and overweight/obesity reached 2.7%, 11.2%, 4.7%, and 15.9%, respectively. Breastfeeding participants had a lower risk of overweight and overweight/obesity with adjusted ORs of 0.652 (95% CI: 0.533, 0.797; p < 0.001) and 0.721 (95% CI: 0.602, 0.862; p < 0.001), respectively; however, there was no difference in thinness and obesity (both p > 0.05) compared with formula feeding. There was no statistical difference between mixed and formula feeding, in terms of thinness, overweight, obesity, or overweight/obesity (all p > 0.05). Subgroup analysis showed that breastfeeding for three years, preterm, and a childbearing age of 25−29 years had higher adjusted ORs for thinness, and in 5−6 years, urban areas, southern/developed economy regions, post-mature, childbearing age ≥ 25 years, and other caretakers had higher and invalid breastfeeding-adjusted ORs (all p > 0.05 except overweight in the urban grade) for both overweight and overweight/obesity. Conclusions: Breastfeeding during the first four months was not associated with the thinness of children aged 3−6 years in eastern China, and the protective effect of breastfeeding against overweight or overweight/obesity could be confirmed. However, the effects of breastfeeding on thinness, overweight, and obesity may change or become invalid in some subgroups, suggesting that there may be potential interactions between feeding patterns and influential factors.

A machine learning classifier approach for identifying the determinants of under-five child undernutrition in Ethiopian administrative zones

BACKGROUND

Undernutrition is the main cause of child death in developing countries. This paper aimed to explore the efficacy of machine learning (ML) approaches in predicting under-five undernutrition in Ethiopian administrative zones and to identify the most important predictors.

METHOD

The study employed ML techniques using retrospective cross-sectional survey data from Ethiopia, a national-representative data collected in the year (2000, 2005, 2011, and 2016). We explored six commonly used ML algorithms; Logistic regression, Least Absolute Shrinkage and Selection Operator (L-1 regularization logistic regression), L-2 regularization (Ridge), Elastic net, neural network, and random forest (RF). Sensitivity, specificity, accuracy, and area under the curve were used to evaluate the performance of those models.

RESULTS

Based on different performance evaluations, the RF algorithm was selected as the best ML model. In the order of importance; urban-rural settlement, literacy rate of parents, and place of residence were the major determinants of disparities of nutritional status for under-five children among Ethiopian administrative zones.

CONCLUSION

Our results showed that the considered machine learning classification algorithms can effectively predict the under-five undernutrition status in Ethiopian administrative zones. Persistent under-five undernutrition status was found in the northern part of Ethiopia. The identification of such high-risk zones could provide useful information to decision-makers trying to reduce child undernutrition.

Prevalence of undernutrition and potential risk factors among children below five years of age in Somali region, Ethiopia: evidence from 2016 Ethiopian demographic and health survey

BACKGROUND

Childhood under-nutrition is far-reaching in low and middle-income nations. Undernutrition is one of the major open wellbeing concerns among newborn children and youthful children in Ethiopia. The present study aimed to explore the potential risk factors of undernutrition among children under 5 years of age in Somali Region, Ethiopia.

METHODS

The data for this study was extricated from the Ethiopian Demographic and Health Survey (EDHS) 2016. The data collected from 1339 children born 5 years before was considered within the analysis. A multivariable binary logistic regression analysis was utilized at a 5% level of significance to decide the individual and community-level variables related to childhood malnutrition.

RESULTS

The prevalence of stunting, underweight and wasting were 27.4, 28.7 and 22.7%, respectively. About 16.1% of children were both stunted and underweight; the extent of both being underweight and wasted was 11.7%, the prevalence of both stunted and wasted children was 5.5%, and all three malnutrition conditions were 4.7% children. Among the variables considered in this study, age of the child in months, type of birth, anemia level, size of child at birth, sex of the child, mothers' BMI and sources of drinking water were significantly related to stunting, underweight and wasting in Somali Region.

CONCLUSIONS

The prevalence of stunting, underweight and wasting was relatively high. Undernutrition is one of the major open wellbeing concerns among children in Somali region. The impact of these variables ought to be considered to develop strategies for decreasing the lack of healthy sustenance due to undernutrition in the study areas. Hence, intercession should be centered on making strides for the under-nutrition determinant variables of the children to be solid, to improve the child's wholesome status, and decrease child mortality quickly.

Assessment of Nutritional Status and Body Composition in Tibetan Adolescent girls of Kangra district, Himachal Pradesh

Malnutrition among adolescents is an important public health issue in India. The aim of the present study was to assess nutritional status and body composition characteristics of adolescent girls and their interrelationships with physical activity and socioeconomic status (SES). Nutritional status and body composition characteristics were assessed in terms of body mass index (BMI), upper arm muscle area by height (UAMAH) and percent body fat (PBF) among 276 Tibetan adolescent girls from Kangra district, Himachal Pradesh. Overall, 12.7% of the girls were in the wasting category (using Z-score based classification for UAMAH) and 9.8% were thin. About 16.3% girls were obese. Significant variabilities of PBF have been observed with respect to age and levels of physical activity and wasting. Adolescent girls were observed to have higher lean body mass than body fat.

Contraceptive use among women with a history of induced abortion: findings from a national sample of sexually active, non-pregnant women in Ghana

OBJECTIVE

The aim of the study was to examine the relationship between a history of induced abortion and current use of contraception among reproductive-aged women in Ghana.

METHODS

The analysed data were a weighted sample of 6544 sexually active, non-pregnant women aged 15-49 years, obtained from the 2014 Ghana Demographic and Health Survey. Survey logistic regression analysis was used to estimate the odds of currently using any contraception and of using a modern method of contraception, given a history of induced abortion in the period 2009-2014.

RESULTS

A history of induced abortion between 2009 and 2014 was reported by 17.4% of women (95% CI 16.0%, 18.9%); 28.7% (95% CI 26.9%, 30.6%) were currently using a method of contraception and 23.0% (95% CI 21.4%, 24.7%) were currently using a modern method of contraception. The majority (80.1%) of current contraceptive users were using a modern method. The adjusted analysis revealed no statistically significant association between a history of induced abortion and current contraceptive behaviour. Other factors were associated with modern contraceptive use.

CONCLUSION

Overall, the use of contraception among sexually active women in Ghana was found to be low. Our findings showed that women's experience of induced abortion was unlikely to influence their current use of modern contraception.

Prevalence and associated factors of undernutrition among under-five children from model and non-model households in east Gojjam zone, Northwest Ethiopia: a comparative cross-sectional study

Background

Developing countries, undernutrition remains significant public health attention, as it was a combined consequence of poor dietary consumption and recurrent infectious illness especially in countries same Ethiopia. Undernutrition is associated with morbidity and mortality among children. This study, therefore, was conducted to assess the prevalence and associated factors of undernutrition among under-five children from the model and non-model households at Eastern Gojjam administrative Zone, northwest Ethiopia.

Methods

A community-based comparative cross-sectional study was conducted from 1st July 2015 to 30th August 2015 in East Gojjam Zone among 507 households (170 from model-household and 337 from non-model household) selected using a multistage sampling technique. Data were collected using questionnaire and nutritional anthropometric measurement. The Emergency Nutrition Assessment for Standardized Monitoring and Assessment of Relief and Transition was used to convert raw anthropometric data into Z-scores. The collected data were entered into EpiData, and analysis was conducted using Statistical Package for Social Sciences (SPSS) version 22. The Emergency Nutrition Assessment for Standardized Monitoring and Assessment of Relief and Transition was used to convert raw anthropometric data into Z scores. Descriptive statistics were used to report the prevalence of outcome variable, undernutrition (intermesh of underweight, stunting, and wasting). In addition, results were presented using narration, tables, and figures including frequency and percentage. Adjusted Odds Ratio (AOR) with its 95% Confidence Interval (CI) was computed. Univariate and multivariate logistic regression analyses were done. A p-value less than 0.05 of was considered to declare a result as statistically significant.

Results

This study found that the prevalence of undernutrition explained by stunting (height-for-age Z-score (HAZ) < − 2), underweight (weight-for-age Z-score (WAZ) < − 2) and wasting (weight-for-height Z-score (WHZ) < − 2) were 44.7% [95%CI 41.11, 48.29%]c, 15.3% [95%CI: 12.17, 18.43%] and 10% [95% CI 8.0, 12.0%], and 52.5% [95% CI: 48.62, 56.98%], 24.3% [95% CI: 20.22, 28.38%] and 11.3% [95% CI: 8.45, 14.15%] in under-five children among model household and non-model respectively. Protected water (AOR = 0.08, 95% CI: 0.03, 0.18) and less than three times daily intake of food (AOR = 4.06, 95% CI: 1.53, 10.82) were predictors for undernutrition among under-five model household. Protected source of drinking water (AOR = 0.07, 95% CI: 0.03, 0.13), households that ever-had education on complementary feeding (AOR = 0.19, 95% CI: 0.09, 0.25) and starting complementary feeding on 6 month after birth (AOR = 0.19, 95% CI: 0.09, 0.25) were significant predictors for under-five undernutrition among non-model households.

Conclusion

The prevalence of undernutrition explained by stunting, underweight and wasting among under-five children in both model and non-model households were high. The prevalence of all the three parameters (stunting, underweight and wasting) was higher among the non-model households compared to the models, even if the differences were not statistically significant. Use of an unprotected source of drinking water and less than three times daily intake of food were found to be associated with undernutrition among under-five children in the model households. On the other hand, having educational exposure on complementary feeding, using drinking water from protected sources and initiation of complementary feedings at age of 6 months were found to be associated with undernutrition among children in the non-model households. Therefore, the concerned bodies must access safe and adequate water supply, works on information dissemination using mass media on timely initiation of complementary feeding, save water and on meal frequency should be strengthened.

Electronic supplementary material

The online version of this article (10.1186/s40795-019-0290-y) contains supplementary material, which is available to authorized users.

Intimate Partner Violence, Depression, and Child Growth and Development

BACKGROUND

Evidence on the relationship between maternal depression and exposure to intimate partner violence (IPV) with child physical growth and development is equivocal. Our aim in the current study is to examine these relationships among women and their children in Tanzania.

METHODS

The Bayley Scales of Infant Development and anthropometric measures were used to assess children 18 to 36 months of age (n = 1031). Maternal exposure to IPV and depression were assessed using the Tanzania Demographic and Health Survey questionnaire and the Patient Health Questionnaire-9, respectively. We used linear regression models to calculate standardized mean differences (SMDs) for developmental outcomes and generalized linear models to estimate the associations with nutritional status.

RESULTS

Mild depressive symptoms in mothers (Patient Health Questionnaire-9 ≥5) and exposure to physical and sexual IPV were associated with lower SMDs for motor skills (-0.14 [P = .023] and -0.23 [P < .01], respectively), expressive communication (-0.13 [P = .187] and -0.23 [P < .01], respectively), receptive communication (-0.19 [P < .009] and -0.16 [P = .03], respectively), and cognitive development (-0.08 [P = .245] and -0.12 [P = .07], respectively). Exposure to physical and sexual IPV was associated with higher risk for stunting (relative risk = 1.6; P < .001).

CONCLUSIONS

This study reveals that maternal depressive symptoms and IPV are associated with adverse child nutritional and developmental outcomes. Further research is needed to develop programs to address IPV and depression among women and enhance the growth and development of their children.

Exploring the association between body mass index and dental caries in 3–7-year-old children, living in Łódź, Poland

Dental caries and childhood obesity are major problems affecting the health of children and preventing these conditions in children have been recognized as public health priorities (Hong et al. 2008; Odgien et al. 2010). The aim of the present study was to analyze the association between age-specific body mass index (BMI-for age) and dental caries in 3- to 7-year-olds. A cross-sectional study was conducted on 729 children from randomly chosen kindergartens and elementary schools in the urban area of Lodz, Poland. Anthropometric measurements were taken and the BMI-for-age was calculated for each child. Dental examinations were performed according to the WHO criteria. The sum of decayed, missing, filled primary/ permanent teeth and surfaces - dmft/DMFT and dmft/DMFTS, and caries prevalence were computed. The percentage distribution of the BMI categories in the study group was: 72.7% normal weight, 8.92% underweight, 12.89% overweight and 5.49% obese. Caries prevalence in the primary dentition was significantly lower in underweight children than in those who were of normal weight (p=0.004) or were overweight (p=0.039). However, controlling for age and gender, no significant association was noted between BMI and caries prevalence in either dentition group. The Kruskal-Wallis test failed to reveal any significant differences in mean dmft across the four BMI groups in the whole population, nor within particular age groups, nor in DMFT in 5- to 7-year-olds. There was no association between BMI and dental caries either in the primary dentition or permanent teeth in the early period after eruption.

Understanding low uptake of contraceptives in resource-limited settings: a mixed-methods study in rural Burundi

Background

Family planning can reduce deaths, improve health, and facilitate economic development in resource-limited settings. Yet, modern contraceptive methods are often underused. This mixed-methods study, conducted in rural Burundi, sought to explain low uptake of contraceptives by identifying utilization barriers. Results may inform development of family planning interventions in Burundi and elsewhere.

Methods

We investigated uptake of contraceptives among women of reproductive age in two rural districts of Burundi, using an explanatory sequential, mixed-methods research design. We first assessed availability and utilization rates of modern contraceptives through a facility-based survey in 39 health clinics. Barriers to uptake of contraceptives were then explored through qualitative interviews (N = 10) and focus groups (N = 7).

Results

Contraceptives were generally available in the 39 clinics studied, yet uptake of family planning averaged only 2.96%. Greater uptake was positively associated with the number of health professionals engaged and trained in family planning service provision, and with the number of different types of contraceptives available. Four uptake barriers were identified: (1) lack of providers to administer contraception, (2) lack of fit between available and preferred contraceptive methods, (3) a climate of fear surrounding contraceptive use, and (4) provider refusal to offer family planning services.

Conclusions

Where resources are scarce, availability of modern contraceptives alone will likely not ensure uptake. Interventions addressing multiple uptake barriers simultaneously have the greatest chance of success. In rural Burundi, examples are community distribution of contraceptive methods, public information campaigns, improved training for health professionals and community health workers, and strengthening of the health infrastructure.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2144-0) contains supplementary material, which is available to authorized users.

Developmental trajectories of body mass index and emotional-behavioral functioning of underweight children: A longitudinal study

Although several studies have addressed developmental trajectories from childhood to adolescence of internalizing/externalizing problems, limited attention has been given to underweight children. Two groups were recruited for this study from a community sample: underweight (Ug, N = 80, 50% female) and normal weight (NWg, N = 80, 50% female) to examine the developmental trajectories of body mass index and emotional-behavioral functioning of underweight children from the age two years, and their risk of eating disorder at early adolescence. The study was organized over four waves, each of three years. Pediatricians measured BMI, parents completed the Child Behavior Checklist (CBCL) and the Eating Disorders Inventory-Referral Form (EDI-3-RF). Our results showed that children in the two groups recorded different BMI trajectories over time. In NWg, male and female subjects started from a higher BMI at T1 than their peers. In Ug, internalizing and externalizing problems in males and females remained higher than their peers at all points of assessment. Males and females in Ug scored higher than those in NWg on EDI-3-RF total score. Our results indicate a need for effective physical and psychological assessment of underweight children in community samples to prevent psychological difficulties and eating disorders in adolescence.

Child nutritional status: a representative survey in a metropolitan school

OBJECTIVE

To assess the prevalence of obesity, overweight, and thinness among children in an Italian school.

METHODS

Five hundred ninety-five children (289 males and 306 females) were enrolled, aged between 6 and 19 years old, in Italian school in Rome. Body mass index (BMI) was calculated according to International Obesity Task Force (IOFT) cut-off points. By age criterion all participants have been classified in age classes.

RESULTS

A normal BMI was recorded in 73.6% of all cases. Obesity, overweight, and thinness prevalence was 5.9%, 9.6%, and 10.9%, respectively, without statistical differences in both genders, except the prevalence of overweight that resulted statistically significant (13.1% males versus 6.2% females, P < 0.05). Differences in the age groups have been found. About 23.4% of children between 7 to 11 years were defined obese and about 42.3% between 6 to 8 years thin grade 2, respectively.

CONCLUSION

The study reports the low prevalence of overweight and obesity, in contrast to the unexpected thinness prevalence. The identification of specific age groups with abnormal nutritional status could be the first step to address future epidemiological investigations in order to plan strategic approach in selected age periods.

The paradox of nutrition-related diseases in the Arab countries: the need for action

The aim of this review was to highlight the current situation of nutrition-related diseases in the Arab countries, and factors associated with prevalence of these diseases. PubMed and Google Scholar were searched for data relating to such nutrition-related diseases published between January 1990 and May 2011. The picture of nutritional status in the Arab countries has changed drastically over the past 30 years as a result of changes in the social and economic situation. Two contrasting nutrition-related diseases exist, those associated with inadequate intake of nutrients and unhealthy dietary habits such as growth retardation among young children and micronutrient deficiencies; and those associated with changes in lifestyle such as cardiovascular disease, cancer, osteoporosis, diabetes and obesity (diet-related non-communicable diseases). Factors contributing to nutritional problems vary from country to country, depending on socio-economic status. In general, unsound dietary habits, poor sanitation, poverty, ignorance and lack of access to safe water and health services are mainly responsible for under-nutrition. Changes in lifestyle and dietary habits as well as inactivity are associated with the occurrence of diet-related non-communicable diseases. Programs to prevent and control nutrition-related diseases are insufficient and ineffective, due mainly to a focus on curative care at the expense of preventive health care services, lack of epidemiological studies, lack of nutritional surveillance, inadequate nutrition information and lack of assessment of the cost-effectiveness of nutrition intervention programs.

Changes in nutritional status of children and adolescents in Shandong, China from 1995 to 2005

BACKGROUND

Nutritional status of children and adolescents has long been known to be a determinant of health and disease; both obesity and underweight are associated with health consequences. However, no studies have been reported on changes in nutritional status of children and adolescents in Shandong, China.

AIM

The present study assessed the changes in nutritional status of children and adolescents in Shandong Province from 1995 to 2005.

SUBJECTS AND METHODS

Data used derived from two national surveys on students' constitution and health carried out by the government in 1995 and 2005 in Shandong Province, China. Increments of stature, body weight, body mass index (BMI) and haemoglobin (Hb) for children and adolescents aged 7, 9, 12, 14 and 17 years were reported. Prevalence of underweight, overweight and obesity were obtained according to the screening criteria of underweight, overweight and obesity for Chinese students using BMI and prevalence of anaemia was obtained according to the WHO criteria.

RESULTS

Means of stature, body weight, BMI and Hb for both boys and girls surveyed in 2005 were significantly higher than 1995 values. The range of increments of stature and body weight for adolescents aged 7, 9, 12, 14 and 17 years were 1.95-3.66 cm and 2.21-6.25 kg for boys and 1.40-2.91 cm and 1.48-3.10 kg for girls. In the past 10 years, rates of overweight and obesity increased, while underweight was not as evident: for overweight from 7.95% (boys) and 5.21% (girls) in 1995 to 13.62% (boys) and 8.25% (girls) in 2005; and for obesity from 3.48% (boys) and 2.07% (girls) in 1995 to 11.17% (boys) and 5.64% (girls) in 2005. The rate of anaemia decreased, from 19.99% (boys) and 23.43% (girls) in 1995 to 10.28% (boys) and 13.07% (girls) in 2005.

CONCLUSION

The nutritional status of children and adolescents has shown some improvement, although prevalence of overweight and obesity increased significantly during the 10-year period. Concerted efforts should be made to appropriately control the prevalence of overweight and obesity.

Changes in central fatness and abdominal obesity in children and adolescents from Cracow, Poland 1983-2000

BACKGROUND

In the light of the world increase of overall and abdominal obesity, little is known about the trends in abdominal obesity and its prevalence in Poland, a country which at the end of 20th underwent a socio-economic transformation that conduced to obesogenic environments.

AIM

The study traced the trends and prevalence of abdominal obesity in two successive cohorts of children and adolescents from Cracow, Poland between 1983 and 2000.

SUBJECTS AND METHODS

The data examined in this study were from two series of cross-sectional studies; the first in 1983 included 3252 boys and 3288 girls, and the second in 2000 included 2409 boys and 2093 girls aged 4-20. Waist circumference (WC) and waist-to-height ratio (WHtR) were applied to assess the type of fat distribution.

RESULTS

Means of WC and WHtR were higher in juvenile but lower in childhood and late adolescence periods in boys and girls from the 2000 cohort as compared to the 1983 one. The prevalence of abdominal obesity in Cracow children examined in 1983 was 3.9% for boys and 2.4% for girls, and in 2000 was 6.4% and 3.1%, respectively (in boys: chi(2) = 16.03, p = 0.0001; in girls: chi(2) = 1.90, p = 0.1684).

CONCLUSIONS

The 1983-2000 trend towards increasing prevalence of abdominal obesity in children and adolescents from Cracow is not as intensive as in other European countries, e.g. Britain, but it requires further monitoring.

Neo-liberal economic practices and population health: a cross-national analysis, 1980–2004

Although there has been substantial debate and research concerning the economic impact of neo-liberal practices, there is a paucity of research about the potential relation between neo-liberal economic practices and population health. We assessed the extent to which neo-liberal policies and practices are associated with population health at the national level. We collected data on 119 countries between 1980 and 2004. We measured neo-liberalism using the Fraser Institute’s Economic Freedom of the World (EFW) Index, which gives an overall score as well as a score for each of five different aspects of neo-liberal economic practices: (1) size of government, (2) legal structure and security of property rights, (3) access to sound money, (4) freedom to exchange with foreigners and (5) regulation of credit, labor and business. Our measure of population health was under-five mortality. We controlled for potential mediators (income distribution, social capital and openness of political institutions) and confounders (female literacy, total population, rural population, fertility, gross domestic product per capita and time period). In longitudinal multivariable analyses, we found that the EFW index did not have an effect on child mortality but that two of its components: improved security of property rights and access to sound money were associated with lower under-five mortality (p = 0.017 and p = 0.024, respectively). When stratifying the countries by level of income, less regulation of credit, labor and business was associated with lower under-five mortality in high-income countries (p = 0.001). None of the EFW components were significantly associated with under-five mortality in low-income countries. This analysis suggests that the concept of ‘neo-liberalism’ is not a monolithic entity in its relation to health and that some ‘neo-liberal’ policies are consistent with improved population health. Further work is needed to corroborate or refute these findings.

Effects of socio-economic and behavioural factors on childhood malnutrition in Yemen

This study examined the effects of socio-economic and behavioural factors on childhood malnutrition in Yemen. The three anthropometric indicators such as height-for-age, weight-for-height and weight-for-age are used to examine the nutritional status of children aged less 5 years in Yemen. The independent variables include background characteristics, behavioural risk factors and illness characteristics. Data for the study come the most recent Yemen Demographic and Health Survey, a nationally representative sample, conducted in Yemen in 1997. Logistic regression analysis is used to estimate the odds of being malnourished. The three anthropometric indicators show high to very high levels of child malnutrition in Yemen. The prevalence of stunting and underweight is so widespread that almost every other child under the age of 5 is either stunted or underweight. Social, economic and behavioural factors show very significant association with childhood malnutrition. The study results indicate the importance of social and behavioural factors in describing childhood malnutrition in Yemen. The study results will help develop nutritional and health promotion policies in order to improve childhood malnutrition in this country.

Mortality in HIV-infected Ugandan adults receiving antiretroviral treatment and survival of their HIV-uninfected children: a prospective cohort study

BACKGROUND

Antiretroviral therapy (ART) is increasingly available in Africa, but physicians and clinical services are few. We therefore assessed the effect of a home-based ART programme in Uganda on mortality, hospital admissions, and orphanhood in people with HIV-1 and their household members.

METHODS

In 2001, we enrolled and followed up 466 HIV-infected adults and 1481 HIV-uninfected household members in a prospective cohort study. After 5 months, we provided daily co-trimoxazole (160 mg trimethoprim and 800 mg sulfamethoxazole) prophylaxis to HIV-infected participants. Between May, 2003, and December, 2005, we followed up 138 infected adults who were eligible and 907 new HIV-infected participants and their HIV-negative household members in a study of ART (mainly stavudine, lamivudine, and nevirapine). Households were visited every week by lay providers, and no clinic visits were scheduled after enrolment. We compared rates of death, hospitalisation, and orphanhood during different study periods and calculated the number needed to treat to prevent an outcome.

FINDINGS

233 (17%) of 1373 participants with HIV and 40 (1%) of 4601 HIV-uninfected household members died. During the first 16 weeks of ART and co-trimoxazole, mortality in HIV-infected participants was 55% lower than that during co-trimoxazole alone (14 vs 16 deaths per 100 person-years; adjusted hazard ratio 0.45, 95% CI 0.27-0.74, p=0.0018), and after 16 weeks, was reduced by 92% (3 vs 16 deaths per 100 person-years; 0.08, 0.06-0.13, p<0.0001). Compared with no intervention, ART and co-trimoxazole were associated with a 95% reduction in mortality in HIV-infected participants (5 vs 27 deaths per 100 person-years; 0.05, 0.03-0.08, p<0.0001), 81% reduction in mortality in their uninfected children younger than 10 years (0.2 vs 1.2 deaths per 100 person-years; 0.19, 0.06-0.59, p=0.004), and a 93% estimated reduction in orphanhood (0.9 vs 12.8 per 100 person-years of adults treated; 0.07, 0.04-0.13, p<0.0001).

INTERPRETATION

Expansion of access to ART and co-trimoxazole prophylaxis could substantially reduce mortality and orphanhood among adults with HIV and their families living in resource-poor settings.

A new Inequity-in-Health Index based on Millennium Development Goals: methodology and validation

OBJECTIVES

Developing a new Inequity-in-Health Index (IHI) assuming inequity as "inequality of health outcomes," based on Millennium Development Goals (MDG).

STUDY DESIGN AND SETTING

Ecological study. Countries from around the world were included from United Nations, the World Bank, and a nonprofit organization's databases. The reliability and validity of this bidimensional IHI was tested. Main factor analysis (promax rotation) and main component analysis were used.

RESULTS

Six variables were used for constructing the IHI was constructed with six variables: underweight children, child mortality, death from malaria in children aged 0-4, death from malaria at all ages, births attended by skilled health personnel, and immunization against measles. The IHI had high internal consistency (Cronbach's alpha=0.8504), was reliable (Spearman>0.9, P=0.0000), and had 0.3033pi around the world (range: 0pi-0.5984pi). IHI had high correlation with the human development and poverty indexes, health gap indicator, life expectancy at birth, probability of dying before 40 years of age, and Gini coefficients (Spearman>0.7, P=0.0000). IHI discriminated countries by income, region, indebtedness, and corruption level (Kruskal Wallis, P<0.01). IHI had sensitivity to change (P=0.0000).

CONCLUSION

IHI is a bidimensional, valid and reliable index to monitor MDG. A new reliable methodology for developing bidimensional indicators is shown, which could be used for constructing other ones with their corresponding scores and graphs.

Body mass index cut offs to define thinness in children and adolescents: international survey

OBJECTIVE

To determine cut offs to define thinness in children and adolescents, based on body mass index at age 18 years.

DESIGN

International survey of six large nationally representative cross sectional studies on growth.

SETTING

Brazil, Great Britain, Hong Kong, the Netherlands, Singapore, and the United States.

SUBJECTS

97 876 males and 94 851 females from birth to 25 years.

MAIN OUTCOME MEASURE

Body mass index (BMI, weight/height(2)).

RESULTS

The World Health Organization defines grade 2 thinness in adults as BMI <17. This same cut off, applied to the six datasets at age 18 years, gave mean BMI close to a z score of -2 and 80% of the median. Thus it matches existing criteria for wasting in children based on weight for height. For each dataset, centile curves were drawn to pass through the cut off of BMI 17 at 18 years. The resulting curves were averaged to provide age and sex specific cut-off points from 2-18 years. Similar cut offs were derived based on BMI 16 and 18.5 at 18 years, together providing definitions of thinness grades 1, 2, and 3 in children and adolescents consistent with the WHO adult definitions.

CONCLUSIONS

The proposed cut-off points should help to provide internationally comparable prevalence rates of thinness in children and adolescents.

The basic principles of migration health: population mobility and gaps in disease prevalence

Currently, migrants and other mobile individuals, such as migrant workers and asylum seekers, are an expanding global population of growing social, demographic and political importance. Disparities often exist between a migrant population's place of origin and its destination, particularly with relation to health determinants. The effects of those disparities can be observed at both individual and population levels. Migration across health and disease disparities influences the epidemiology of certain diseases globally and in nations receiving migrants. While specific disease-based outcomes may vary between migrant group and location, general epidemiological principles may be applied to any situation where numbers of individuals move between differences in disease prevalence. Traditionally, migration health activities have been designed for national application and lack an integrated international perspective. Present and future health challenges related to migration may be more effectively addressed through collaborative global undertakings. This paper reviews the epidemiological relationships resulting from health disparities bridged by migration and describes the growing role of migration and population mobility in global disease epidemiology. The implications for national and international health policy and program planning are presented.

Cotrimoxazole prophylaxis by HIV-infected persons in Uganda reduces morbidity and mortality among HIV-uninfected family members

BACKGROUND

The effect of cotrimoxazole prophylaxis taken by persons with HIV on community health and antimicrobial resistance is unknown.

OBJECTIVE

To assess the effect of cotrimoxazole prophylaxis taken by persons with HIV on morbidity, mortality, and antimicrobial resistance of diarrheal pathogens infecting their HIV-negative family members.

DESIGN

Prospective cohort in rural Uganda.

METHODS

A total of 879 persons with HIV and 2771 HIV-negative family members received weekly home-visits. After 5 months, persons with HIV received daily cotrimoxazole prophylaxis and households were followed for an average of 17 additional months.

FINDINGS

During the study, 224 participants with HIV (25%) and 29 household members (1%) died. Mortality among HIV-negative family members < 10 years old was 63% less during the cotrimoxazole period than before [hazard ratio, 0.37; 95% confidence interval (CI), 0.14-0.95; P = 0.04]. Malaria among family members was less common during cotrimoxazole treatment [incidence rate ratio (IRR), 0.62; CI, 0.53-0.74; P < 0.0001], as were diarrhea (IRR, 0.59; CI, 0.45-0.76; P = 0.0001), and hospitalizations (IRR, 0.57; CI, 0.36-0.92; P = 0.02). Death of a parent with HIV was associated with a threefold increase in mortality among HIV-negative children < 10 years old (hazard ratio, 2.9; CI, 1.1-8.1; P = 0.04). Of 134 bacterial isolates from family members before cotrimoxazole treatment, 89 (66%) were resistant to cotrimoxazole; of 75 recovered during cotrimoxazole treatment, 54 (72%) were resistant (P = 0.41).

INTERPRETATION

Cotrimoxazole prophylaxis taken by persons with HIV was associated with decreased morbidity and mortality among family members. Antimicrobial resistance among diarrheal pathogens infecting family members did not increase. Concerns regarding the spread of bacterial resistance should not impede implementation of cotrimoxazole programs.