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Bertrand-Protat S, Chen J, Jonquoy A, Frayon S, Thu Win Tin S, Ravuvu A, Caillaud C, Galy O. Prevalence, causes and contexts of childhood overweight and obesity in the Pacific region: a scoping review. Open Res Eur 2023; 3:52. [PMID: 38031554 PMCID: PMC10685071 DOI: 10.12688/openreseurope.15361.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 12/01/2023]
Abstract
Background Non-communicable diseases (NCDs) are a major threat to health and development and account for 75% of deaths in the Pacific Islands Countries and Territories (PICTs). Childhood obesity has been identified as a main risk factor for NCDs later in life. This review compiled overweight and obesity (OWOB) prevalence (anthropometric data) for children aged six to 12 years old living in the Pacific region and identified possible related causes. Methods We conducted a systematic search using PubMed, Google Scholar and ScienceDirect for articles published between January 1980 and August 2022. We also searched for technical reports from Ministries of Health. Guided by the eligibility criteria, two authors independently read the selected articles and reports to extract and summarise relevant information related to overweight and obesity. Results We selected 25 articles, two worldwide analyses of population-based studies and four national reports. Information revealed that childhood OWOB prevalence reached 55% in some PICTs. This review also indicated that age, gender and ethnicity were linked to children's weight status, while dietary practices, sleep time and level of physical activity played a role in OWOB development, as well as the living environment (socio-economic status and food availability), parenting practices and education level. Conclusion This review highlighted that anthropometric data are limited and that comparisons are difficult due to the paucity of surveys and non-standardized methodology. Main causes of overweight and obesity are attributed to individual characteristics of children and behavioural patterns, children's socio-economic environment, parenting practices and educational level. Reinforcement of surveillance with standardised tools and metrics adapted to the Pacific region is crucial and further research is warranted to better understand root causes of childhood OWOB in the Pacific islands. More robust and standardized anthropometric data would enable improvements in national strategies, multisectoral responses and innovative interventions to prevent and control NCDs.
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Affiliation(s)
- Solene Bertrand-Protat
- Interdisciplinary Laboratory of Research in Education, EA 7483, University of New Caledonia, Noumea, New Caledonia
- Pacific Community, 95 Promenade Roger Laroque, Noumea, New Caledonia
| | - Juliana Chen
- Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
- Discipline of Nutrition and Dietetics, Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Aurélie Jonquoy
- Pacific Community, 95 Promenade Roger Laroque, Noumea, New Caledonia
| | - Stéphane Frayon
- Interdisciplinary Laboratory of Research in Education, EA 7483, University of New Caledonia, Noumea, New Caledonia
| | - Si Thu Win Tin
- Pacific Community, 95 Promenade Roger Laroque, Noumea, New Caledonia
| | - Amerita Ravuvu
- Pacific Community, 95 Promenade Roger Laroque, Noumea, New Caledonia
| | - Corinne Caillaud
- Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
- Discipline of Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Olivier Galy
- Interdisciplinary Laboratory of Research in Education, EA 7483, University of New Caledonia, Noumea, New Caledonia
- Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
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Zhou C, Miao H, Zhao Y, Wan X. Food insecurity increases the risk of overweight and chronic diseases in adolescents: a systematic review and meta-analysis. Food Science and Human Wellness 2023. [DOI: 10.1016/j.fshw.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
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Smith T, Chong KH, Cross P, Ipil M, Eliou P, Novotny R, Okely AD. Prevalence and socio-demographic distributions of meeting RMI Guidelines for Healthy Living among elementary school children in Majuro, Republic of Marshall Islands: a cross-sectional population-based survey. Lancet Reg Health West Pac 2023; 37:100783. [PMID: 37693881 PMCID: PMC10485679 DOI: 10.1016/j.lanwpc.2023.100783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 09/12/2023]
Abstract
Background Childhood obesity is high in Republic of Marshall Islands (RMI). We report the prevalence and socio-demographic distribution of selected obesity-related risk factors among children in Majuro, RMI. Methods Sixteen elementary schools were approached and students and parents in Grades 1, 3, and 5 invited to participate in this cross-sectional population-based survey. Accelerometry and a questionnaire were used to collect data on children's physical activity (PA), sleep, screen time and dietary behaviours. Descriptive statistics and mixed-effects logistic regression were used to examine differences in the proportions of children meeting selected RMI Healthy Living Guidelines by sex, school grade and school sector. Findings Thirteen schools and 958 children were recruited, of which 892 (52.2% girls; mean age 9.3 ± 1.8 years) provided useable data. Around 90% met the PA, 29% screen time, 13% sleep, 69% sugar-sweetened beverage and 56% highly processed food guidelines. The proportion meeting individual guidelines was higher among children in Grade 1 compared with Grade 5. Being a girl (0.27; 95% CI 0.16, 0.46) was associated with lower odds of meeting the PA recommendation. Compared with children from Grade 1, those in Grade 5 had lower odds of meeting the PA (0.28; 95% CI 0.15, 0.55), screen time (0.60; 95% CI 0.40, 0.89), sleep duration (0.33; 95% CI 0.18, 0.59), sugar-sweetened beverage (0.35; 95% CI 0.23, 0.53), and consumption of highly processed foods recommendations (0.49; 95% CI 0.33, 0.72). Interpretation While most children in RMI are adequately active, resources are needed to promote healthier levels of screen time, sleep, sugar-sweetened beverage and highly processed food consumption, especially among older children. Funding This study was funded by World Diabetes Foundation; Canvasback Missions, RMI; NHMRC Australia (APP1176858); Pacific Community.
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Affiliation(s)
- Tanner Smith
- Canvasback Missions Inc., P.O. Box 1771, Majuro, 96960, Marshall Islands
| | - Kar Hau Chong
- Early Start, School of Health and Society, Faculty of the Arts, Social Science and Humanities, University of Wollongong, NSW, 2522, Australia
| | - Penny Cross
- Early Start, School of Health and Society, Faculty of the Arts, Social Science and Humanities, University of Wollongong, NSW, 2522, Australia
| | - Maybelline Ipil
- Marshall Islands Epidemiology & Prevention Initiatives (MIEPI), P.O. Box 3666, Majuro, 96960, Marshall Islands
| | - Pranson Eliou
- RMI Public School System, State Department of Education, P.O. Box 3, Majuro, 96960, Marshall Islands
| | - Rachel Novotny
- Department of Human Nutrition, Food and Animal Sciences, College of Tropical Agriculture and Human Resources, University of Hawaii at Manoa, Honolulu, HI, 96822, USA
| | - Anthony D. Okely
- Early Start, School of Health and Society, Faculty of the Arts, Social Science and Humanities, University of Wollongong, NSW, 2522, Australia
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Jakobsen DD, Brader L, Bruun JM. Association between Food, Beverages and Overweight/Obesity in Children and Adolescents-A Systematic Review and Meta-Analysis of Observational Studies. Nutrients 2023; 15. [PMID: 36771470 DOI: 10.3390/nu15030764] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 01/25/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
A healthy diet is essential to prevent childhood obesity, however, adherence to a healthy diet is challenging. The aim of this study was to give a comprehensive overview of the literature investigaating associations between food and beverages and overweight/obesity in children and adolescents in order to identify dietary risk factors. A systematic search was performed in four databases and observational studies were included. Meta-analysis was performed using the random effect model. Sixty records met inclusion criteria and 14 different food or beverage categories were identified. A higher intake of sugar-sweetened beverages increased the odds of overweight/obesity by 1.20 (p < 0.05) (n = 26) and higher intake of fast food increased the odds of overweight/obesity by 1.17 (p < 0.05) (n = 24). Furthermore, higher intake of meat (OR 1.02, p < 0.05 (n:7)) and refined grains (OR 1.28, p < 0.05 (n:3)) was associated with an increased risk of overweight/obesity. In contrast, higher intake of whole grain (OR 0.86, p = 0.04 (n:5)) and more surprisingly sweet bakery (OR 0.59, p < 0.05 (n:3)) was associated with a decreased risk of overweight/obesity. In conclusion, a higher intake of sugar-sweetened beverages and a higher intake of fast food was identified as the primary dietary risk factors for overweight/obesity. Future research is needed to strengthen the generalizability of these results.
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He Y, Luo B, Zhao L, Liao S. Influences of the COVID-19 Pandemic on Obesity and Weight-Related Behaviors among Chinese Children: A Multi-Center Longitudinal Study. Nutrients 2022; 14. [PMID: 36145119 DOI: 10.3390/nu14183744] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/03/2022] [Accepted: 09/06/2022] [Indexed: 12/03/2022] Open
Abstract
COVID-19-related lockdown measures have been affecting children’s weight status and weight-related behaviors, which are often associated with an increase in childhood obesity. However, large-scale longitudinal studies are lacking. Our study aimed to analyze changes in obesity and weight-related behaviors in Chinese children before and during the COVID-19 pandemic and provide references for addressing the high prevalence of childhood obesity. A prospective multi-center longitudinal survey was conducted among Chinese children (n = 5963), collecting data on weight status, COVID-19-related measures, and lifestyle behaviors. Changes were assessed using t-tests and χ2 tests for paired samples, or the Wilcoxon signed-rank test, according to the type and distribution of data. The Generalized Estimating Equations model was used to explore influential factors of obesity. The prevalence of overweight and obesity increased from 9.2% and 8.6% before the pandemic to 10.5% and 10.6% during the pandemic (p < 0.001), respectively. Daily physical activity, sleep duration, and sugar-sweetened beverage consumption decreased while screen time increased. The results of the generalized estimating equations showed that ethnic minority, older age, less daily physical activity, reduced sleep duration, and longer screen time were positively associated with obesity. There is an intensifying trend of obesity in children in the context of the COVID-19 pandemic, to which altered weight-related behaviors might have contributed largely. Maintaining a healthy lifestyle, especially in social crises, should be highlighted to ease the burden of childhood obesity.
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Guerrero RTL, Hattori-Uchima MP, Badowski G, Aflague TF, Wood K, Hammond K, Perez R. Pacific Islands Cohort on Cardiometabolic Health Study: rationale and design. BMC Public Health 2022; 22:1428. [PMID: 35897002 PMCID: PMC9326143 DOI: 10.1186/s12889-022-13783-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 07/11/2022] [Indexed: 11/21/2022] Open
Abstract
Background Pacific Islanders, including those residing in the US Affiliated Pacific Islands (USAPI), experience some of the highest mortality rates resulting from non-communicable diseases (NCDs) worldwide. The Pacific Island Health Officers’ Association declared a Regional State of Health Emergency in 2010 due to the epidemic of NCDs in the USAPI. Obesity, a known risk factor for NCDs, has become an epidemic among both children and adults in Micronesia and other parts of the USAPI. There is some recent information about overweight and obesity (OWOB) among young children in the USAPI, but there is no data looking at the relationship between children and their biological parents. The Pacific Islands Cohort on Cardiometabolic Health (PICCAH) Study aims to collect data on NCD lifestyle factors from two generations of families (n = 600 child-parent dyads or 1,200 participants) living in Guam, Pohnpei, and Palau. Methods The PICCAH Study is an epidemiological study using community-based convenience sampling to recruit participants in USAPI of Guam, Palau, and Pohnpei. The goal is to recruit participant dyads consisting of 1 child plus their biological parent in Guam (500 dyads or 1,000 participants), Pohnpei (50 dyads or 100 participants), and Palau (50 dyads or 100 participants). All participants are having the following information collected: demographic, health, and lifestyle information; anthropometry; diet; physical activity; sleep; acanthosis nigricans; blood pressure; and serum levels of fasting plasma glucose, fasting insulin, glycated hemoglobin, total cholesterol, triglycerides, LDL, and HDL. Discussion The PICCAH Study is designed to establish the baseline of a generational epidemiologic cohort with an emphasis on cardiometabolic risk, and to better understand the extent of DM and CVD conditions and related risk factors of those living in the USAPI jurisdictions of Guam, Pohnpei, and Palau. This study also serves to further build research capacity in the underserved USAPI Region. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-13783-9.
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Affiliation(s)
| | | | - Grazyna Badowski
- University of Guam, UOG Station, 303 University Drive, Mangilao, Guam, 96923
| | - Tanisha F Aflague
- University of Guam, UOG Station, 303 University Drive, Mangilao, Guam, 96923
| | - Kathryn Wood
- University of Guam, UOG Station, 303 University Drive, Mangilao, Guam, 96923
| | - Kristi Hammond
- University of Guam, UOG Station, 303 University Drive, Mangilao, Guam, 96923
| | - Remedios Perez
- University of Guam, UOG Station, 303 University Drive, Mangilao, Guam, 96923
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Liu N, Li H, Guo Z, Chen X, Cheng P, Wang B, Huang G, Shen M, Lin Q, Wu J. Prevalence and factors associated with overweight or obesity among 2- to 6-year-old children in Hunan, China: a cross-sectional study. Public Health Nutr 2022; 25:1-12. [PMID: 35034674 PMCID: PMC9991611 DOI: 10.1017/s136898002200012x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To compare the prevalence of overweight or obesity (ow/ob) with WHO BMI cut-off points, International Obesity Task Force (IOTF) cut-off points and Chinese BMI criteria and examine its potential factors among preschool children in Hunan Province. DESIGN A cross-sectional survey including anthropometric measurements and questionnaires about children's information, caregivers' socio-demographic characteristics and maternal characteristics. χ2 tests and univariate and multivariate binary logistic regression were performed to evaluate the possible factors of ow/ob. SETTING Hunan, China, from September to October 2019. PARTICIPANTS In total, 7664 children 2 to 6 years of age. RESULTS According to Chinese BMI criteria, about 1 in 7-8 children aged 2-6 years had ow/ob in Hunan, China. The overall estimated prevalence of ow/ob among 2- to 6-year-old children was significantly higher when based on the Chinese BMI criteria compared with the WHO BMI cut-off points and IOTF cut-off points. According to Chinese BMI criteria, ow/ob was associated with residing in urban areas, older age, male sex, eating snacking food more frequently, macrosomia delivery, caesarean birth, heavier maternal prepregnancy weight and pre-delivery weight. CONCLUSION The prevalence of ow/ob in preschool children in Hunan Province remains high. More ow/ob children could be screened out according to Chinese BMI cut-offs compared with WHO and IOTF BMI criteria. In the future, targeted intervention studies with matched controls will be needed to assess the long-term effects of intervention measures to provide more information for childhood obesity prevention and treatment.
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Affiliation(s)
- Na Liu
- Department of Endocrinology, Xiang-Ya Hospital, Central South University, Hunan Province410008, People’s Republic of China
| | - Huixia Li
- Department of Child Health Care, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan Province, People’s Republic of China
| | - Zhanjun Guo
- Department of Endocrinology, Xiang-Ya Hospital, Central South University, Hunan Province410008, People’s Republic of China
| | - Xin Chen
- Department of Endocrinology, Xiang-Ya Hospital, Central South University, Hunan Province410008, People’s Republic of China
| | - Peng Cheng
- Department of Endocrinology, Xiang-Ya Hospital, Central South University, Hunan Province410008, People’s Republic of China
| | - Bian Wang
- Department of Endocrinology, Xiang-Ya Hospital, Central South University, Hunan Province410008, People’s Republic of China
| | - Guangwen Huang
- Department of Child Health Care, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan Province, People’s Republic of China
| | - Minxue Shen
- Department of Social Medicine and Health Management, Xiangya School of Public Health, Central South University, Changsha, Hunan Province, People’s Republic of China
| | - Qian Lin
- Xiangya School of Public Health, Central South University, Hunan Province, People’s Republic of China
| | - Jing Wu
- Department of Endocrinology, Xiang-Ya Hospital, Central South University, Hunan Province410008, People’s Republic of China
- Hunan Engineering Research Center for Obesity and its Metabolic Complications, Changsha, Hunan, People’s Republic of China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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Aflague TF, Badowski G, Sanchez H, Sablan D, Schroeder CM, Sanchez E, Leon Guerrero RT. Improving Willingness to Try Fruits and Vegetables and Gross Motor Skills in Preschool Children in Guam. Nutrients 2021; 14:nu14010093. [PMID: 35010968 PMCID: PMC8747019 DOI: 10.3390/nu14010093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 11/16/2022] Open
Abstract
Early childhood interventions have the potential to promote long-term healthy eating and physical activity habits to prevent obesity. However, research studies including indigenous young children are lacking. This study examined the effectiveness of the Food Friends®: Fun with New Foods™ and Get Movin’ with Mighty Moves™ (FFMM) curricula on willingness to try fruits and vegetables (FV) and gross motor (GM) skills among preschoolers in Guam. A pre-post community-based study included preschoolers from Head Start (HS), gifted and talented education (Pre-GATE), and Pre-Kindergarten programs during school years (SY) 2017–2018 and 2018–2019. In SY2017–2018, the intervention group had a significant increase in imported FV when compared with the other three groups. No significant differences between groups were found on the other FV scales. Regarding gross motor skills, no significant differences between groups were found. In SY2018–2019, the intervention group had a significant increase in all FV scales except imported FV when compared with the enhanced intervention group. With gross motor skills, no significant differences were found between groups on its progress. These results warrant FFMM adaptations for the prevention of obesity among Guam preschoolers.
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Affiliation(s)
- Tanisha F. Aflague
- College of Natural and Applied Sciences, University of Guam, Mangilao, GU 96923, USA; (G.B.); (H.S.)
- Correspondence: ; Tel.: +1-671-735-2026
| | - Grazyna Badowski
- College of Natural and Applied Sciences, University of Guam, Mangilao, GU 96923, USA; (G.B.); (H.S.)
| | - Hyett Sanchez
- College of Natural and Applied Sciences, University of Guam, Mangilao, GU 96923, USA; (G.B.); (H.S.)
| | - Dwight Sablan
- Office of Research & Sponsored Programs, University of Guam, Mangilao, GU 96923, USA; (D.S.); (R.T.L.G.)
| | | | - Eloise Sanchez
- Division of Curriculum & Instruction, Guam Department of Education, Barrigada, GU 96913, USA;
| | - Rachael T. Leon Guerrero
- Office of Research & Sponsored Programs, University of Guam, Mangilao, GU 96923, USA; (D.S.); (R.T.L.G.)
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Novotny R, Earle ME, Jung YO, Julian GJ, Hill E, Leon Guerrero RT, Coleman P, Deenik J, Boushey C, Wilkens LR. University of Hawai'i Cancer Center Connection: Pacific Tracker (PacTrac) Version 3.1 Diet and Physical Activity Assessment Tool for the Pacific Region. Hawaii J Health Soc Welf 2021; 80:165-168. [PMID: 34278324 PMCID: PMC8280357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The Pacific Tracker (PacTrac) is a web-based diet and physical activity assessment program created to analyze dietary recall or dietary record data from the Pacific region. Version 3.1 modifications make the tool available for public use (under check it out) to enter, analyze, view and print out data; and for research use, for saving and downloading of multiple entries in a research mode. PacTrac 3.1 (https://nappactrac31.ctahr.hawaii.edu/default.htm) is managed through the Children's Healthy Living Center of Excellence (CHL Center) at the College of Tropical Agriculture and Human Resources at the University of Hawai'i, in collaboration with the University of Hawai'i Cancer Center.
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Affiliation(s)
- Rachel Novotny
- Department Human Nutrition Food and Animal Sciences, College of Tropical Agriculture and Human Resources, University of Hawai'i at Mānoa, Honolulu, HI (RN, EH)
| | - Maj E Earle
- University of Hawai'i Cancer Center, Honolulu, HI (MEE, YOJ, GJJ, CB, LRW)
| | - Yun Oh Jung
- University of Hawai'i Cancer Center, Honolulu, HI (MEE, YOJ, GJJ, CB, LRW)
| | - Greg Joel Julian
- University of Hawai'i Cancer Center, Honolulu, HI (MEE, YOJ, GJJ, CB, LRW)
| | - Erik Hill
- Department Human Nutrition Food and Animal Sciences, College of Tropical Agriculture and Human Resources, University of Hawai'i at Mānoa, Honolulu, HI (RN, EH)
| | | | | | - Jonathan Deenik
- Department of Tropical Plant and Soil Sciences, College of Tropical Agriculture and Human Resources, University of Hawai'i at Mānoa, Honolulu, HI (JD)
| | - Carol Boushey
- University of Hawai'i Cancer Center, Honolulu, HI (MEE, YOJ, GJJ, CB, LRW)
| | - Lynne R Wilkens
- University of Hawai'i Cancer Center, Honolulu, HI (MEE, YOJ, GJJ, CB, LRW)
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Eicher-Miller HA, Fialkowski MK. Nutrition among Vulnerable U.S. Populations. Nutrients 2020; 12:E3150. [PMID: 33076358 DOI: 10.3390/nu12103150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/06/2020] [Accepted: 10/12/2020] [Indexed: 11/17/2022] Open
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Rowan K. Hawai'i Journal Watch: Highlights of recent research from the University of Hawai'i and the Hawai'i State Department of Health. Hawaii J Health Soc Welf 2020; 79:295. [PMID: 33047102 PMCID: PMC7547179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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