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Eeftinck Schattenkerk LD, Vogel I, de Jong JR, Tanis PJ, Gorter R, Tabbers M, van Heurn LWE, Musters G, Derikx JPM. Impact of Presence, Level, and Closure of a Stoma on Growth in Young Children: A Retrospective Cohort Study. Eur J Pediatr Surg 2024; 34:282-289. [PMID: 37003263 PMCID: PMC11076102 DOI: 10.1055/a-2067-4847] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/28/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION A stoma will cause nutrients loss which could result in impaired growth. Impaired growth can negatively impact long-term development. This study aims to evaluate: (1) the effect of stomas on growth comparing small bowel stoma versus colostomy and (2) if early closure (within 6 weeks), proximal small bowel stoma (within 50 cm of Treitz), major small bowel resection (≥ 30 cm), or adequate sodium supplementation (urinary level ≤ 30 mmol/L) influences growth. METHODS Young children (≤ 3 years) treated with stomas between 1998 and 2018 were retrospectively identified. Growth was measured with weight-for-age Z-scores. Malnourishment was defined using the World Health Organization's definition. Comparison between changes in Z-scores at creation, closure, and a year following closure was done by Friedman's test with post hoc Wilcoxon's signed rank test or Wilcoxon's rank-sum test when necessary. RESULTS In the presence of a stoma in 172 children, 61% showed growth decline. Severe malnourishment was seen at the time of stoma closure in 51% of the patients treated by small bowel stoma and 16% of those treated by colostomy. Within a year following stoma closure, 67% showed a positive growth trend. Having a proximal small bowel stoma and undergoing major small bowel resection led to significantly lower Z-scores at closure. Adequate sodium supplementation and early closure did not lead to significant changes in Z-scores. CONCLUSION Stomas have a negative impact on growth in the majority of children. This impact might be decreased by preventing small bowel stomas when possible, specifically proximal stomas, and limiting small bowel resection. Since stoma closure is essential in reversing the negative effect on growth, we opt that early closure might result in an early shift to catch-up growth.
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Affiliation(s)
| | - Irene Vogel
- Department of Surgery, Amsterdam UMC Locatie AMC, Amsterdam, the Netherlands
| | - Justin R. de Jong
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Pieter J. Tanis
- Department of Surgery, Erasmus MC, Rotterdam, Zuid-Holland, the Netherlands
| | - Ramon Gorter
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
| | - Merit Tabbers
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - L. W. Ernest van Heurn
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Gijsbert Musters
- Department of Pediatric Surgery, Amsterdam UMC Locatie AMC, Amsterdam, the Netherlands
| | - Joep P. M. Derikx
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Wand H, Naidoo S, Govender V, Reddy T, Moodley J. Preventing Stunting in South African Children Under 5: Evaluating the Combined Impacts of Maternal Characteristics and Low Socioeconomic Conditions. J Prev (2022) 2024; 45:339-355. [PMID: 38416314 PMCID: PMC11033229 DOI: 10.1007/s10935-024-00766-2] [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] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/05/2024] [Indexed: 02/29/2024]
Abstract
More than 140 million children under five suffered from stunting in 2020. This highlights the ongoing challenge of addressing childhood malnutrition globally. We utilized data from a nationally representative sample of children under five years of age (n = 14,151) who participated in five cycles of the South African National Income Dynamics Study (SA-NIDS) (2008-2017). We estimated the proportion of stunted children attributed to the mothers' anthropometric characteristics and socioeconomic conditions. We also quantified the population-level burden of low-socioeconomic conditions on hunger/food insecurity among pregnant women (n = 22,814) who participated in the nine rounds of the South African General Household Surveys (GHS) (2008-2021). Results from weighted-multivariate logistic regression were incorporated into the population-level impacts of correlates of stunting and low-socioeconomic conditions. The prevalence of stunting declined from 25% in 2008 to 23% in 2017. Mothers' anthropometric measures (underweight/height < 160 cm), marital status, low education, absence of medical insurance and low-socioeconomic conditions were all identified as the most influential risk factors for stunting. Their population-level impacts on stunting increased substantially from 34% (in 2008) to 65% (in 2017). Comprehensive strategies emphasizing enhanced food security, extended breastfeeding, appropriate nutrition, and access to adequate healthcare and education are urgently needed to reduce the burden of food insecurity low-socioeconomic, malnutrition, and its long-term consequences.
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Affiliation(s)
- Handan Wand
- Biostatistics and Databases Program, Kirby Institute, University of New South Wales (UNSW Sydney), Kirby Institute Level 6, Wallace Wurth Building, Kensington, NSW, 2052, Australia.
| | | | | | - Tarylee Reddy
- Biostatistics Unit, South African Medical Research Council, Durban, Kwazulu-Natal, South Africa
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Fazid S, Haq ZU, Gillani BH, Khan AJ, Khan MN, Khan A, Garzon C, Habib I, Tanimoune M, Ihtesham Y, Heald AH. Effectiveness of locally produced ready-to-use supplementary foods on the prevention of stunting in children aged 6-23 months: a community-based trial from Pakistan. Br J Nutr 2024; 131:1189-1195. [PMID: 38012887 PMCID: PMC10918516 DOI: 10.1017/s0007114523002702] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/31/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023]
Abstract
Undernutrition is a major public health problem in developing countries. Around 40·2 % of children are stunted in Pakistan. This longitudinal study aimed to assess the effectiveness of locally produced ready-to-use supplementary foods in the prevention of stunting by detecting change in of children in intervention v. control arm against the 2006 WHO growth reference. A community-based non-randomised cluster-controlled trial was conducted from January 2018 to December 2020 in the district of Kurram, Khyber Pakhtunkhwa, Pakistan. A total of 80 clusters (each cluster comprising ≈ 250-300 households) were defined in the catchment population of twelve health facilities. Children aged 6-18 months were recruited n 1680. The intervention included a daily ration of 50 g - locally produced ready-to-use-supplementary food (Wawa-Mum). The main outcome of this study was a change in length for age z-score (LAZ) v. WHO growth standards. Comparison between the interventions was by t test and ANOVA. Cox proportional hazard models were used to assess the association between stunting occurrence and the utilisation of locally produced supplement. Out of the total 1680, fifty-one out of the total 1680, 51·1 out of the total 1680 and 51·1 % (n 859) were male. Mean age 13·9 months (sd + 859) were male. Mean age 13·9 months (sd + -4·4). At baseline, 36·9 % (n 618) were stunted. In the intervention group, mean LAZ score significantly increased from -1·13(2·2 sd) at baseline to -0·93(1·8 sd) at 6-month follow-up (P value 0·01) compared with the control group. The incidence rate of stunting in the intervention arm was 1·3 v. 3·4 per person year in the control arm. The control group had a significantly increased likelihood of stunting (Hazard Ratio (HR) 1·7, 95 % CI 1·46, 2·05, P value < 0·001) v. the intervention group. Locally produced ready-to-use supplementary food is an effective intervention for reducing stunting in children below 2 years of age. This can be provided as part of a malnutrition prevention package to overcome the alarming rates of stunting in Pakistan.
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Affiliation(s)
- Sheraz Fazid
- Institute of Public Health & Social Sciences, Khyber Medical University, Peshawar, Pakistan
| | - Zia Ul Haq
- Institute of Public Health & Social Sciences, Khyber Medical University, Peshawar, Pakistan
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | | | - Abdul Jalil Khan
- Institute of Public Health & Social Sciences, Khyber Medical University, Peshawar, Pakistan
| | - Muhammad Naseem Khan
- Department of Popualtion Medicine, College of Medicine, Qatar University, Doha, Qatar
| | - Aslam Khan
- Institute of Basic Medical Sciences, Khyber Medical University, Peshawar, Pakistan
| | | | | | | | | | - Adrian H. Heald
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
- The School of Medicine, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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Chapman AJ, Ebido CC, Tening RN, Huang Y, Sougou NM, Kolopaking R, Diallo AH, Anggorowati R, Dial FB, Massonnié J, Firoozmand M, Niang CEHA, Harder MK. Creating culturally-informed protocols for a stunting intervention using a situated values-based approach (WeValue InSitu): a double case study in Indonesia and Senegal. BMC Public Health 2024; 24:987. [PMID: 38589810 PMCID: PMC11003100 DOI: 10.1186/s12889-024-18485-y] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 03/29/2024] [Indexed: 04/10/2024] Open
Abstract
International development work involves external partners bringing expertise, resources, and management for local interventions in LMICs, but there is often a gap in understandings of relevant local shared values. There is a widespread need to better design interventions which accommodate relevant elements of local culture, as emphasised by recent discussions in global health research regarding neo-colonialism. One recent innovation is the concept of producing 'cultural protocols' to precede and guide community engagement or intervention design, but without suggestions for generating them. This study explores and demonstrates the potential of an approach taken from another field, named WeValue InSitu, to generate local culturally-informed protocols. WeValue InSitu engages stakeholder groups in meaning-making processes which 'crystallize' their envelope of local shared values, making them communicable to outsiders.Our research context is understanding and reducing child stunting, including developing interventions, carried out at the Senegal and Indonesia sites of the UKRI GCRF Action Against Stunting Hub. Each national research team involves eight health disciplines from micro-nutrition to epigenetics, and extensive collection of samples and questionnaires. Local culturally-informed protocols would be generally valuable to pre-inform engagement and intervention designs. Here we explore generating them by immediately following the group WeValue InSitu crystallization process with specialised focus group discussions exploring: what local life practices potentially have significant influence on the environments affecting child stunting, and which cultural elements do they highlight as relevant. The discussions will be framed by the shared values, and reveal linkages to them. In this study, stakeholder groups like fathers, mothers, teachers, market traders, administrators, farmers and health workers were recruited, totalling 83 participants across 20 groups. Themes found relevant for a culturally-informed protocol for locally-acceptable food interventions included: specific gender roles; social hierarchies; health service access challenges; traditional beliefs around malnutrition; and attitudes to accepting outside help. The concept of a grounded culturally-informed protocol, and the use of WeValue InSitu to generate it, has thus been demonstrated here. Future work to scope out the advantages and limitations compared to deductive culture studies, and to using other formative research methods would now be useful.
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Affiliation(s)
- Annabel J Chapman
- Values & Sustainability Research Group, School of Architecture, Technology and Engineering, University of Brighton, Brighton, UK
| | - Chike C Ebido
- Department of Environmental Science and Engineering, Fudan University, Shanghai, People's Republic of China
- Department of Zoology and Environmental Biology, University of Nigeria, Nsukka, Nigeria
| | - Rahel Neh Tening
- Department of Environmental Science and Engineering, Fudan University, Shanghai, People's Republic of China
| | - Yanyan Huang
- Department of Environmental Science and Engineering, Fudan University, Shanghai, People's Republic of China
| | - Ndèye Marème Sougou
- Preventive Medicine and Public Health, Université Cheikh Anta Diop (UCAD), Dakar, Senegal
| | - Risatianti Kolopaking
- Faculty of Psychology, Universitas Islam Negeri Syarif Hidayatullah, Jakarta, Indonesia
- Southeast Asian Ministers of Education Organization Regional Centre for Food and Nutrition (SEAMEO RECFON) Universitas Indonesia, Jakarta, Indonesia
| | - Amadou H Diallo
- International Research Laboratory (IRL 3189) Environnement santé et sociétés/CNRS/UCAD, Dakar, Senegal
| | - Rita Anggorowati
- Southeast Asian Ministers of Education Organization Regional Centre for Food and Nutrition (SEAMEO RECFON) Universitas Indonesia, Jakarta, Indonesia
- Department of Medical Records and Health Information, Faculty of Health and Technology, Universitas Bandung, Bandung, Indonesia
| | - Fatou B Dial
- Laboratory of Cultural Anthropology, IFAN, Université Cheikh Anta Diop (UCAD), Dakar, Senegal
| | - Jessica Massonnié
- School of Education, Languages and Linguistics, Faculty of Humanities and Social Sciences, University of Portsmouth, Portsmouth, UK
- Department of Learning and Leadership, IOE, UCL's Faculty of Education and Society, University College London, London, UK
| | - Mahsa Firoozmand
- Values & Sustainability Research Group, School of Architecture, Technology and Engineering, University of Brighton, Brighton, UK
| | | | - Marie K Harder
- Values & Sustainability Research Group, School of Architecture, Technology and Engineering, University of Brighton, Brighton, UK.
- Department of Environmental Science and Engineering, Fudan University, Shanghai, People's Republic of China.
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Lowe C, Sarma H, Gray D, Kelly M. Perspective: Connecting the dots between domestic livestock ownership and child linear growth in low- and middle-income countries. Matern Child Nutr 2024; 20:e13618. [PMID: 38192051 PMCID: PMC10981488 DOI: 10.1111/mcn.13618] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/04/2023] [Accepted: 12/09/2023] [Indexed: 01/10/2024]
Abstract
Child stunting due to linear growth faltering remains a pervasive issue in low- and middle-income countries. Two schools of thought have existed pertaining to the role of domestic livestock ownership (DLO) in child linear growth. On one hand, it is argued that DLO leads to greater income and financial security, resulting in better child-raising conditions, including greater animal-source food (ASF) consumption, having protective effects towards child stunting. On the other hand, researchers argue that DLO contributes to faecal contamination and transmission of zoonotic enteric infections from animals to children, thus having destructive effects on child growth. Reviews of this association have revealed ambiguous findings. In this perspective, we argue that measuring the association between exposures to domesticated animals and child stunting is difficult and the ambiguous associations revealed are a result of confounding and differences in the management of DLO. We also argue that the increasingly prominent area of research of environmental enteric dysfunction, a sub-clinical condition of the small intestine thought to be due to frequent faecal pathogen exposure and associated with stunting, will be a useful tool to measure the potential destructive effects of DLO on child growth. We present our argument and identify challenges and considerations and directions for future research.
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Affiliation(s)
- Callum Lowe
- Department of Applied Epidemiology, National Centre for Epidemiology and Population Health, College of Health and MedicineAustralian National UniversityActonAustralian Capital TerritoryAustralia
| | - Haribondhu Sarma
- Department of Applied Epidemiology, National Centre for Epidemiology and Population Health, College of Health and MedicineAustralian National UniversityActonAustralian Capital TerritoryAustralia
| | - Darren Gray
- Population Health ProgramQIMR Berghofer Medical Research InstituteBrisbaneQueenslandAustralia
| | - Matthew Kelly
- Department of Applied Epidemiology, National Centre for Epidemiology and Population Health, College of Health and MedicineAustralian National UniversityActonAustralian Capital TerritoryAustralia
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Jobarteh ML, Conway-Moore K, Yadav D, Tata DT, Fahmida U, Faye B, Kulkarni B, Saxena D, Heffernan C. Unpacking the intractability of childhood stunting: an introduction to the UKRI GCRF Action Against Stunting Hub. BMJ Paediatr Open 2024; 8:e002333. [PMID: 38519064 PMCID: PMC10961497 DOI: 10.1136/bmjpo-2023-002333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/28/2023] [Indexed: 03/24/2024] Open
Affiliation(s)
- Modou Lamin Jobarteh
- Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Kaitlin Conway-Moore
- Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Dinesh Yadav
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Darius Testa Tata
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Umi Fahmida
- Southeast Asian Ministry of Education Organisation Regional Centre for Food and Nutrition (SEAMEO RECFON), Central Jakarta, DKI Jakarta, Indonesia
| | - Babacar Faye
- Faculté de médecine, Université Cheikh Anta Diop (UCAD), Dakar, Senegal
| | | | - Deepak Saxena
- Indian Institute of Public Health Gandhinagar, Gandhinagar, India
| | - Claire Heffernan
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
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Ancira-Moreno M, Hernández-Cordero S. Letter to the editor: will it be possible to achieve the global nutrition targets in Mexico by 2030? Int J Equity Health 2024; 23:60. [PMID: 38500124 PMCID: PMC10946168 DOI: 10.1186/s12939-024-02111-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/16/2024] [Indexed: 03/20/2024] Open
Abstract
In May 2012, the 65th World Health Assembly (WHA) approved six global nutrition targets by 2025 aimed to reduce stunting in children under five by 40%, maintain childhood wasting below 5%, halt obesity, cut anemia in women by 50%, lower low birth weight prevalence by 30%, and increase exclusive breastfeeding (EBF) within the first 6 months to 50%. These targets were extended to 2030, with all of them remaining as originally planned, but the EBF one (increased to 70%), wasting and overweight (both objectives set to eliminate them to negligible concern). Mexico is projected to achieve only one of the six nutrition targets (wasting) by 2025, falling far short of the stunting, low birth weight, anemia, and exclusive breastfeeding for the updated goals by 2030. This letter to the editor describes the most recent prevalence of malnutrition among mothers and children in Mexico. It discusses the challenges pregnant women and children under five years of age face exercising their right to good food, nutrition, and development. The authors reflect on the urgent need to make structural changes to achieve the global nutrition targets by 2030, highlighting the paramount importance of addressing the profound structural obstacles in Mexico and how Mexico's government must prioritize poverty reduction, reduce the marked inequalities, enhance the quality of nutritional care and healthcare infrastructure, and implement climate-resilient agricultural practices to address this pressing issue.
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Affiliation(s)
- Mónica Ancira-Moreno
- Departamento de Salud, Universidad Iberoamericana, Ciudad de México, México
- Observatorio Materno Infantil (OMI), Universidad Iberoamericana, Ciudad de México, México
| | - Sonia Hernández-Cordero
- Observatorio Materno Infantil (OMI), Universidad Iberoamericana, Ciudad de México, México.
- Instituto de Investigaciones para el Desarrollo con Equidad, Universidad Iberoamericana, Ciudad de México, México.
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Komakech JJ, Emerson SR, Cole KL, Walters CN, Rakotomanana H, Kabahenda MK, Hildebrand DA, Stoecker BJ. Care groups in an integrated nutrition education intervention improved infant growth among South Sudanese refugees in Uganda's West Nile post-emergency settlements: A cluster randomized trial. PLoS One 2024; 19:e0300334. [PMID: 38489346 PMCID: PMC10942045 DOI: 10.1371/journal.pone.0300334] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 02/21/2024] [Indexed: 03/17/2024] Open
Abstract
OBJECTIVE This study examined the effects of a peer-led integrated nutrition education intervention with maternal social support using Care Groups on infant growth among South Sudanese refugees in Uganda. METHODS A community-based cluster-randomized trial (RCT) was conducted among 390 pregnant women (third trimester). Two intervention study arms were Mothers-only(n = 131) and Parents-combined (n = 142) with a Control (n = 117). WHO infant growth standards defined length-for-age z-scores (LAZ) for stunting, weight-for-age z-scores (WAZ) for underweight and weight-for-length z-scores (WLZ) for wasting. The Medical Outcomes Study (MOS) social support index was a proxy measure for social support. A split-plot ANOVA tested the interaction effects of social support, intervention, and time on infant growth after adjusting for covariates. Further, pairwise comparisons explained mean differences in infant growth among the study arms. RESULTS The mean infant birth weight was 3.1 ± 0.5 kg. Over the study period, infant stunting was most prevalent in the Control (≥ 14%) compared to Mothers-only (< 9.5%) and Parents-combined (< 7.4%) arms. There were significant interaction effects of the Care Group intervention and social support by time on infant mean LAZ (F (6, 560) = 28.91, p < 0.001), WAZ (F (5.8, 539.4) = 12.70, p = < 0.001) and WLZ (F (5.3, 492.5) = 3.38, p = 0.004). Simple main effects by the end of the study showed that the intervention improved infant mean LAZ (Mothers-only vs. Control (mean difference, MD) = 2.05, p < 0.001; Parents-combined vs. Control, MD = 2.00, p < 0.001) and WAZ (Mothers-only vs. Control, MD = 1.27, p < 0.001; Parents-combined vs. Control, MD = 1.28, p < 0.001). CONCLUSION Maternal social support with an integrated nutrition education intervention significantly improved infant stunting and underweight. Nutrition-sensitive approaches focused on reducing child undernutrition among post-emergency refugees may benefit from using Care Groups in programs. TRIAL REGISTRATION Clinicaltrials.gov, NCT05584969.
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Affiliation(s)
- Joel J. Komakech
- Department of Food Science, Nutrition, and Health Promotion, Mississippi State University, Starkville, Mississippi, United States of America
| | - Sam R. Emerson
- Department of Nutritional Sciences, Oklahoma State University, Stillwater, OK, United States of America
| | - Ki L. Cole
- Research, Evaluation, Measurement, and Statistics Department, Oklahoma State University, Stillwater, OK, United States of America
| | - Christine N. Walters
- Department of Nutritional Sciences, Oklahoma State University, Stillwater, OK, United States of America
| | - Hasina Rakotomanana
- Department of Nutritional Sciences, Oklahoma State University, Stillwater, OK, United States of America
| | | | - Deana A. Hildebrand
- Department of Nutritional Sciences, Oklahoma State University, Stillwater, OK, United States of America
| | - Barbara J. Stoecker
- Department of Nutritional Sciences, Oklahoma State University, Stillwater, OK, United States of America
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Ramsteijn AS, Ndiaye M, Kalashikam RR, Htet MK, Yadav Dm D, Augustine LF, Zahra NL, Djigal A, Yanti D, Angelin TC, Nurfadilah M, Gorre M, Subrahamanyam D, Vadakattu SS, Munikumar M, Horgan GW, Fahmida U, Faye B, Kulkarni B, Haggarty P. Epigenetic studies in children at risk of stunting and their parents in India, Indonesia and Senegal: a UKRI GCRF Action Against Stunting Hub protocol paper. BMJ Paediatr Open 2024; 8:e001770. [PMID: 38417921 PMCID: PMC10900567 DOI: 10.1136/bmjpo-2022-001770] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 02/21/2023] [Indexed: 03/01/2024] Open
Abstract
INTRODUCTION In 2020, an estimated 150 million children under the age of 5 years were stunted. Stunting results from early-life adversity and it is associated with significant physical and cognitive deficit, lifelong socioeconomic disadvantage and reduced life expectancy. There is a need to understand the causes of stunting and its effects in order to develop strategies to avoid it and to mitigate the consequences once stunting has occurred. Epigenetics is an important mechanism through which early-life factors are thought to influence biological function, with long-term consequences. We describe a series of epigenetic studies designed to understand how early-life adversity results in stunting and to inform the development of practical tools such as predictive markers and therapeutic targets. This work is part of the UKRI GCRF Action Against Stunting Hub. METHODS AND ANALYSIS The project-in India, Indonesia and Senegal-comprises an observational study of mothers, fathers, and offspring (n=500) spanning the first 1000 days of life, and an intervention study in each country. Epigenetic status (DNA methylation) is determined in saliva from babies collected within 1 month of birth and again at 18 months of age, and from mothers and fathers around the time of birth. Epigenome-wide analysis is carried out using the Illumina EPIC array, augmented by high-definition sequencing approaches. Statistical analysis is carried out at the level of candidate genes/regions, higher dimensional epigenetic states and epigenome-wide association. Data analysis focuses on the determinants of stunting, the effectiveness of interventions, population comparisons and the link between epigenetics and other thematic areas, which include anthropometry, microbiome, gut health, parasitology, cognition, nutrition, food hygiene and water sanitation, food systems and the home environment. ETHICS AND DISSEMINATION This study has been approved by the relevant Ethics Committees in Indonesia, India and Senegal, and the UK. Research data will be published and posted in public repositories.
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Affiliation(s)
| | - Magatte Ndiaye
- Service de Parasitologie-Mycologie, Faculté de Médecine, Université Cheikh Anta Diop (UCAD), Dakar, Senegal
| | | | - Min Kyaw Htet
- South East Asian Ministers of Education Organization Regional Centre for Food and Nutrition (SEAMEO RECFON), East Jakarta, Indonesia
| | | | | | - Nur L Zahra
- South East Asian Ministers of Education Organization Regional Centre for Food and Nutrition (SEAMEO RECFON), East Jakarta, Indonesia
| | - Aicha Djigal
- Service de Parasitologie-Mycologie, Faculté de Médecine, Université Cheikh Anta Diop (UCAD), Dakar, Senegal
| | - Dwi Yanti
- South East Asian Ministers of Education Organization Regional Centre for Food and Nutrition (SEAMEO RECFON), East Jakarta, Indonesia
| | - Tiffany C Angelin
- South East Asian Ministers of Education Organization Regional Centre for Food and Nutrition (SEAMEO RECFON), East Jakarta, Indonesia
| | - Mifa Nurfadilah
- South East Asian Ministers of Education Organization Regional Centre for Food and Nutrition (SEAMEO RECFON), East Jakarta, Indonesia
| | - Manjula Gorre
- ICMR-National Institute of Nutrition, Hyderabad, India
| | | | | | | | | | - Umi Fahmida
- South East Asian Ministers of Education Organization Regional Centre for Food and Nutrition (SEAMEO RECFON), East Jakarta, Indonesia
| | - Babacar Faye
- Service de Parasitologie-Mycologie, Faculté de Médecine, Université Cheikh Anta Diop (UCAD), Dakar, Senegal
| | | | - Paul Haggarty
- Rowett Institute, University of Aberdeen, Aberdeen, UK
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Cooper GS, Davies-Kershaw H, Dominguez-Salas P, Fahmida U, Faye B, Ferguson E, Grace D, Häsler BN, Kadiyala S, Konapur A, Kulkarni B, Chengat Prakashbabu B, Pramesthi IL, Rowland D, Selvaraj K, Sudibya ARP, Tine RC, Yadav DMD, Zahra NL, Shankar B, Heffernan C. Investigating market-based opportunities for the provision of nutritious and safe diets to prevent childhood stunting: a UKRI-GCRF action against stunting hub protocol paper. BMJ Paediatr Open 2024; 8:e001671. [PMID: 38417923 PMCID: PMC10900371 DOI: 10.1136/bmjpo-2022-001671] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/13/2022] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND Inadequate access to affordable, safe, desirable and convenient nutrient-dense food is one of the underlying causes of child stunting. While targeted nutrition-sensitive interventions (eg, backyard 'nutri-gardens') may increase dietary diversity within farming households, such interventions have limited scalability across the wider food system where markets remain underdeveloped. This research aims to develop and assess market-based interventions for key nutrient-dense foods to help improve the diets of women and children in the first 1000 days of life. METHODS Data collection uses four parallel approaches in each of the three study countries (India, Indonesia and Senegal). (1) A novel food environment tool will be developed to characterise the accessibility and affordability of nutrient-dense foods in the study countries. The tool will be validated through pretesting using cognitive interviewing and piloting in purposively sampled households, 10 (cognitive interviewing) and 30 (piloting) households in each country; (2) stakeholder interviews (eg, with producers, intermediaries and retailers) will be conducted to map out nutrition-sensitive entry points of key value chains (eg, animal-sourced foods), before hotspots of potential food safety hazards will be identified from food samples collected along the chains; (3) the Optifood and Agrifood tools will be used to identify foods that can address food system nutrient gaps and engage key stakeholders to prioritise market interventions to improve nutrition outcomes. Optifood and Agrifood parameters will be informed by publicly available data, plus interviews and focus groups with value chain stakeholders; (4) informed by the previous three approaches and a campaign of participatory 'group model building', a novel system dynamics model will evaluate the impact of alternative market-based solutions on the availability and affordability of nutrient-dense foods over time. ETHICS AND DISSEMINATION The study has received ethical approval in the United Kingdom, Senegal, Indonesia and India. Dissemination comprises peer-reviewed journals, international disciplinary conferences and multistakeholder dissemination workshops.
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Affiliation(s)
- Gregory S Cooper
- Institute of Sustainable Food, Department of Geography, The University of Sheffield, Sheffield, South Yorkshire, UK
| | - Hilary Davies-Kershaw
- Department of Population Health, London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Public Health, London, UK
| | - Paula Dominguez-Salas
- Animal and Human Health Program, International Livestock Research Institute, Nairobi, Nairobi, Kenya
- Food and Markets Department, Natural Resources Institute, University of Greenwich, London, UK
| | - Umi Fahmida
- Southeast Asian Ministers of Education Organization Regional Centre for Food and Nutrition, Jakarta, DKI Jakarta, Indonesia
- Department of Nutrition, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Babacar Faye
- Department of Parasitology-Mycology, Cheikh Anta Diop University of Dakar, Dakar, Senegal
| | - Elaine Ferguson
- Department of Population Health, London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Public Health, London, UK
| | - Delia Grace
- Animal and Human Health Program, International Livestock Research Institute, Nairobi, Nairobi, Kenya
- Food and Markets Department, Natural Resources Institute, University of Greenwich, London, UK
| | - Barbara N Häsler
- Department of Pathobiology and Population Sciences, The Royal Veterinary College, Hatfield, Hertfordshire, UK
| | - Suneetha Kadiyala
- Department of Population Health, London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Public Health, London, UK
| | - Archana Konapur
- Department of Population Health, London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, UK
| | - Bharati Kulkarni
- Department of Population Health, London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, UK
| | | | - Indriya L Pramesthi
- Southeast Asian Ministers of Education Organization Regional Centre for Food and Nutrition, Jakarta, DKI Jakarta, Indonesia
| | - Dominic Rowland
- Center for International Forestry Research, Bogor Barat, Indonesia
- Centre for Environment, Development and Policy (CeDEP), SOAS, London, UK
| | | | - Arienta R P Sudibya
- Southeast Asian Ministers of Education Organization Regional Centre for Food and Nutrition, Jakarta, DKI Jakarta, Indonesia
| | - Roger C Tine
- Department of Parasitology-Mycology, Cheikh Anta Diop University of Dakar, Dakar, Senegal
| | - D M Dinesh Yadav
- Department of Population Health, London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Public Health, London, UK
| | - Nur L Zahra
- Southeast Asian Ministers of Education Organization Regional Centre for Food and Nutrition, Jakarta, DKI Jakarta, Indonesia
| | - Bhavani Shankar
- Institute of Sustainable Food, Department of Geography, The University of Sheffield, Sheffield, South Yorkshire, UK
| | - Claire Heffernan
- Department of Pathobiology and Population Sciences, The Royal Veterinary College, Hatfield, Hertfordshire, UK
- London International Development Centre, London, UK
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Odii BC, Harder MK, Huang Y, Chapman A, Sougou NM, Kolopaking R, Gavaravarapu S, Diallo AH, Anggorowati R, Fernandez Rao S, Heffernan C. Sociocultural environmental factors and childhood stunting: qualitative studies - a protocol for the Shared Values theme of the UKRI GCRF Action Against Stunting Hub. BMJ Paediatr Open 2024; 8:e001906. [PMID: 38417927 PMCID: PMC10900418 DOI: 10.1136/bmjpo-2023-001906] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 05/03/2023] [Indexed: 03/01/2024] Open
Abstract
INTRODUCTION Stunting is a significant and growing global problem that is resisting scientific attempts to understand it in terms of direct nutrition-related determinants. In recent years, research included more complex, indirect and multifactorial determinants and expanded to include multisectoral and lifestyle-related approaches. The United Kingdom Research Initiative Global Challenges Research Fund's (UKRI GCRF) Action Against Stunting Hub starts on the premise that dominant factors of stunting may vary between contexts and life phases of the child. Thus, the construction of a typology of clustered factors will be more useful to design effective programmes to alleviate it.The Shared Values theme seeks to build a bottom-up holistic picture of interlinked cultural contextual factors that might contribute to child stunting locally, by first eliciting shared values of the groups closest to the problem and then enquiring about details of their relevant daily activities and practices, to reveal links between the two. We define shared values as what groups consider 'valuable, worthwhile and meaningful' to them. METHODS AND ANALYSIS We will recruit 12-25 local stakeholder groups in each site (in India, Indonesia and Senegal) involved in children's food and early learning environments, such as mothers, fathers, grandmothers, teachers, market vendors and health workers. The WeValue InSitu process will be used to assist them to collectively elicit, negotiate and self-articulate their own shared values through exploration of shared tacit knowledge. Focus group discussions held immediately subsequently will ask about daily activities relevant to the children's environment. These contain many examples of cultural contextual factors potentially influencing stunting locally, and intrinsically linked to shared values articulated in the previous session.
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Affiliation(s)
- Benita Chinenye Odii
- Department of Environmental Science and Engineering, Fudan University, Shanghai, PR China
- Department of Linguistics, Igbo and Other Nigerian Languages, University of Nigeria, Nsukka, Enugu, Nigeria
| | - Marie K Harder
- Department of Environmental Science and Engineering, Fudan University, Shanghai, PR China
- Values and Sustainability Research Group, School of Architecture, Technology and Engineering, University of Brighton, Brighton, UK
| | - Yanyan Huang
- Department of Environmental Science and Engineering, Fudan University, Shanghai, PR China
| | - Annabel Chapman
- Values and Sustainability Research Group, School of Architecture, Technology and Engineering, University of Brighton, Brighton, UK
| | - Ndèye Marième Sougou
- Preventive Medicine and Public Health, Université Cheikh Anta Diop (UCAD), Dakar, Senegal
| | - Risatianti Kolopaking
- Southeast Asian Ministers of Education Organization Regional Center for Food and Nutrition (SEAMEO RECFON)-Pusat Kajian Gizi Regional, Universitas Indonesia, Jakarta, Indonesia
- Faculty of Psychology, UIN Syarif Hidayatullah, Jakarta, Indonesia
| | - SubbaRao Gavaravarapu
- Nutrition Information, Communication & Health Education (NICHE) Division, ICMR-National Institute of Nutrition (NIN), Department of Health Research, Ministry of Health & Family Welfare, Govt. of India, Hyderabad, India
| | - Amadou H Diallo
- International Research Laboratory (IRL 3189) Environnement, santé et sociétés, CNRS, UCAD, Dakar, Senegal
| | - Rita Anggorowati
- Southeast Asian Ministers of Education Organization Regional Center for Food and Nutrition (SEAMEO RECFON)-Pusat Kajian Gizi Regional, Universitas Indonesia, Jakarta, Indonesia
- Indonesia Creative Education Institute (ICEI), Bandung, Indonesia
| | - Sylvia Fernandez Rao
- Indian Council of Medical Research, Behavioral Science Unit, Extension and Training Division, Department of Health Research, National Institute of Nutrition, Hyderabad, India
| | - Claire Heffernan
- London International Development Centre, London School of Hygiene & Tropical Medicine, London, UK
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12
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Dominguez-Salas P, Waddington HS, Grace D, Bosire C, Moodley A, Kulkarni B, Dasi T, Banjara SK, Kumar RN, Fahmida U, Htet MK, Sudibya ARP, Faye B, Tine RC, Heffernan C, Saxena D, Dreibelbis R, Häsler B. Understanding the role of household hygiene practices and foodborne disease risks in child stunting: a UKRI GCRF Action Against Stunting Hub protocol paper. BMJ Paediatr Open 2024; 8:e001695. [PMID: 38417924 PMCID: PMC10900323 DOI: 10.1136/bmjpo-2022-001695] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 03/20/2023] [Indexed: 03/01/2024] Open
Abstract
INTRODUCTION Environmental hygiene and food safety are important determinants of child stunting. This research aims to explore the relationship between child stunting and household hygiene practices and behaviours, including the availability of water, sanitation and hygiene (WASH) facilities; the use of safe food and good quality drinking water (especially when used for complementary feeding); hygienic practices in food transport, storage and preparation and the control of cross-contamination from animals, their produce and waste. METHODS AND ANALYSIS This study is part of a wider observational study which aims to investigate the interdisciplinary factors contributing to child stunting using a 'whole child' paradigm. The observational study recruits women during pregnancy in Hyderabad, India, Lombok, Indonesia and Kaffrine, Senegal, and dyads (ie, 500 mother-infant pairs per country) are followed longitudinally up to 24 months after birth. Within the interdisciplinary niche, the study here has developed tools to investigate the potential exposure pathways to environmental pathogen contamination of foods and water. Holistic WASH and food safety data collection tools have been developed to explore exposure pathways at the household level, including: (1) survey questionnaires; (2) spot-checks; (3) biological sampling of drinking water, food and domestic surfaces and (4) direct observation. An integrated analytical approach will be used to triangulate the evidence in order to examine the relationships between child stunting, WASH and food safety behaviours. ETHICS AND DISSEMINATION Ethical approval of the study was granted by the ethics committee of the LSHTM, RVC, ILRI, ICMR, IIPHG, SEAMEO-RECFON, University of Cheikh Anta Diop. Findings of the study will be disseminated through publication in peer-reviewed journals, relevant international conferences, public engagement events, and policy-maker and stakeholder events.
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Affiliation(s)
- Paula Dominguez-Salas
- National Resources Institute, University of Greenwich, London, UK
- Policies, Institutions and Livelihoods Programme, International Livestock Research Institute (ILRI), Nairobi, Kenya, Nairobi, Kenya
| | - Hugh Sharma Waddington
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Delia Grace
- National Resources Institute, University of Greenwich, London, UK
- Animal and Human Health Programme, International Livestock Research Institute (ILRI), Nairobi, Kenya
| | - Caroline Bosire
- Animal and Human Health Programme, International Livestock Research Institute (ILRI), Nairobi, Kenya
| | - Arshnee Moodley
- CGIAR Antimicrobial Resistance Hub, International Livestock Research Institute (ILRI), Nairobi, Kenya
| | - Bharati Kulkarni
- National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, Telangana, India
| | - Teena Dasi
- National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, Telangana, India
| | | | | | - Umi Fahmida
- Southeast Asian Ministry of Education Organisation Regional Centre for Food and Nutrition (SEAMEO RECFON), East Jakarta, Indonesia
| | - Min Kyaw Htet
- Southeast Asian Ministry of Education Organisation Regional Centre for Food and Nutrition (SEAMEO RECFON), East Jakarta, Indonesia
| | - Arienta R P Sudibya
- Southeast Asian Ministry of Education Organisation Regional Centre for Food and Nutrition (SEAMEO RECFON), East Jakarta, Indonesia
| | - Babacar Faye
- Department of Parasitology, Université Cheikh Anta Diop (UCAD), Dakar, Senegal
| | - Roger C Tine
- Department of Parasitology-Mycology, University of Cheikh Anta DIOP, Dakar, Senegal
| | - Claire Heffernan
- Department of Pathobiology and Population Sciences, University of London, London, UK
- London International Development Centre, London, UK
| | - Deepak Saxena
- Public Health Foundation, Indian Institute of Public Health Gandhinagar (IIPHG), New Delhi, Delhi, India
| | - Robert Dreibelbis
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - B Häsler
- Department of Pathobiology and Population Sciences, Royal Veterinary College (RVC), Hatfield, UK
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13
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Davies-Kershaw H, Fahmida U, Htet MK, Kulkarni B, Faye B, Yanti D, Shinta D, Zahra NL, Angelin TC, Madhari R, Pullakhandam R, Palika R, Dasi T, Fernandez Rao S, Banjara SK, Selvaraj K, Palepu DP, Yadev D, Diouf S, Lopez-Sall P, Diallo B, Mouissi P, Fall S, Diallo I, Djigal A, Immerzeel TDV, Tairou F, Diop A, Pradeilles R, Strout S, Momo Kadia B, Tata DT, Jobarteh ML, Allen S, Walker A, Webster JP, Haggarty P, Heffernan C, Ferguson E. Anthropometric, biochemical, dietary, morbidity and well-being assessments in women and children in Indonesia, India and Senegal: a UKRI GCRF Action Against Stunting Hub protocol paper. BMJ Paediatr Open 2024; 8:e001683. [PMID: 38417920 PMCID: PMC10910654 DOI: 10.1136/bmjpo-2022-001683] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 03/28/2023] [Indexed: 03/01/2024] Open
Abstract
INTRODUCTION Child stunting has a complex aetiology, especially in the first 1000 days of life. Nutrition interventions alone have not produced expected impacts in reducing/preventing child stunting, indicating the importance of understanding the complex interplay between environmental, physiological and psychological factors influencing child nutritional status. This study will investigate maternal and child nutrition, health and well-being status and associated factors through the assessment of: (1) anthropometry, (2) biomarkers of nutrition and health status, (3) dietary intakes, (4) fetal growth and development, (5) infant morbidity, (6) infant and young child feeding (IYCF) and (7) perinatal maternal stress, depression and social support. METHODS This study will be conducted in a prospective pregnancy cohort in India, Indonesia and Senegal. Pregnant women will be recruited in the second (Indonesia, Senegal) and third (India) trimester of pregnancy, and the mother and infant dyads followed until the infant is 24 months of age. During pregnancy, anthropometric measures will be taken, venous blood samples will be collected for biochemical assessment of nutrition and health status, dietary intakes will be assessed using a 4-pass-24-hour dietary recall method (MP24HR), fetal ultrasound for assessment of fetal growth. After birth, anthropometry measurements will be taken, venous blood samples will be collected, MP24HR will be conducted, infant morbidity and IYCF practices will be assessed and a sample of breastmilk will be collected for nutrient composition analyses. Perinatal maternal stress, depression, social support and hair cortisol levels (stress) will be measured. The results from this study will be integrated in an interdisciplinary analysis to examine factors influencing infant growth and inform global efforts in reducing child stunting. ETHICS AND DISSEMINATION Ethical approval was granted by the Ethics Committee of the London School of Hygiene and Tropical Medicine (17915/RR/17513); National Institute of Nutrition (ICMR)-Ministry of Health and Family Welfare, Government of India (CR/04/I/2021); Health Research Ethics Committee, University of Indonesia and Cipto Mangunkusumo Hospital (KET-887/UN2.F1/ETIK/PPM.00.02/2019); and the Comité National d'Ethique pour la Recherche en Santé, Senegal (Protocole SEN19/78); the Royal Veterinary College (URN SR2020-0197) and the International Livestock Research Institute Institutional Research Ethics Committee (ILRI-IREC2020-33). Results will be published in peer-reviewed journals and disseminated to policy-makers and participating communities.
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Affiliation(s)
- Hilary Davies-Kershaw
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Umi Fahmida
- Regional Centre for Food and Nutrition, SEAMEO, University of Indonesia, Jakarta, Indonesia
| | - Min Kyaw Htet
- Regional Centre for Food and Nutrition, SEAMEO, University of Indonesia, Jakarta, Indonesia
| | - Bharati Kulkarni
- Deparments of Maternal and Child Health and Dietetics Division, National Institute of Nutrition, Hyderabad, India
| | - Babacar Faye
- Service de Parasitologie-Mycologie- Pédiatrie, Faculté de médecine, UCAD, Dakar, Senegal
| | - Dwi Yanti
- Regional Centre for Food and Nutrition, SEAMEO, University of Indonesia, Jakarta, Indonesia
| | - Dewi Shinta
- Regional Centre for Food and Nutrition, SEAMEO, University of Indonesia, Jakarta, Indonesia
| | - Nur L Zahra
- Regional Centre for Food and Nutrition, SEAMEO, University of Indonesia, Jakarta, Indonesia
| | - Tiffany C Angelin
- Regional Centre for Food and Nutrition, SEAMEO, University of Indonesia, Jakarta, Indonesia
| | - Radhika Madhari
- Deparments of Maternal and Child Health and Dietetics Division, National Institute of Nutrition, Hyderabad, India
| | - Raghu Pullakhandam
- Deparments of Maternal and Child Health and Dietetics Division, National Institute of Nutrition, Hyderabad, India
| | - Ravindranadh Palika
- Deparments of Maternal and Child Health and Dietetics Division, National Institute of Nutrition, Hyderabad, India
| | - Teena Dasi
- Deparments of Maternal and Child Health and Dietetics Division, National Institute of Nutrition, Hyderabad, India
| | - Sylvia Fernandez Rao
- Deparments of Maternal and Child Health and Dietetics Division, National Institute of Nutrition, Hyderabad, India
| | - Santosh Kumar Banjara
- Deparments of Maternal and Child Health and Dietetics Division, National Institute of Nutrition, Hyderabad, India
| | - Kiruthika Selvaraj
- Deparments of Maternal and Child Health and Dietetics Division, National Institute of Nutrition, Hyderabad, India
| | - Dharani Pratyusha Palepu
- Deparments of Maternal and Child Health and Dietetics Division, National Institute of Nutrition, Hyderabad, India
| | - Dinesh Yadev
- Department of Public Health, London International Development Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Saliou Diouf
- Service de Parasitologie-Mycologie- Pédiatrie, Faculté de médecine, UCAD, Dakar, Senegal
| | - Philomene Lopez-Sall
- Service de Parasitologie-Mycologie- Pédiatrie, Faculté de médecine, UCAD, Dakar, Senegal
| | - Babacar Diallo
- Service de Parasitologie-Mycologie- Pédiatrie, Faculté de médecine, UCAD, Dakar, Senegal
| | - Princillia Mouissi
- Service de Parasitologie-Mycologie- Pédiatrie, Faculté de médecine, UCAD, Dakar, Senegal
| | - Sally Fall
- Service de Parasitologie-Mycologie- Pédiatrie, Faculté de médecine, UCAD, Dakar, Senegal
| | - Ibrahima Diallo
- Service de Parasitologie-Mycologie- Pédiatrie, Faculté de médecine, UCAD, Dakar, Senegal
| | - Aicha Djigal
- Service de Parasitologie-Mycologie- Pédiatrie, Faculté de médecine, UCAD, Dakar, Senegal
| | | | - Fassia Tairou
- Service de Parasitologie-Mycologie- Pédiatrie, Faculté de médecine, UCAD, Dakar, Senegal
| | - Assana Diop
- Service de Parasitologie-Mycologie- Pédiatrie, Faculté de médecine, UCAD, Dakar, Senegal
| | - Rebecca Pradeilles
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
- UMR, MOISA, Montpellier, France
| | - Sara Strout
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Benjamin Momo Kadia
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Darius Tetsa Tata
- Department of Public Health, London International Development Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Modou Lamin Jobarteh
- Department of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Stephen Allen
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Alan Walker
- The Rowett Institute, University of Aberdeen, Aberdeen, UK
| | - Joanne P Webster
- Department of Pathobiology and Population Sciences, University of London, London, UK
| | - Paul Haggarty
- The Rowett Institute, University of Aberdeen, Aberdeen, UK
| | - Claire Heffernan
- Department of Public Health, London International Development Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Elaine Ferguson
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
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Checkley W, Thompson LM, Sinharoy SS, Hossen S, Moulton LH, Chang HH, Waller L, Steenland K, Rosa G, Mukeshimana A, Ndagijimana F, McCracken JP, Díaz-Artiga A, Balakrishnan K, Garg SS, Thangavel G, Aravindalochanan V, Hartinger SM, Chiang M, Kirby MA, Papageorghiou AT, Ramakrishnan U, Williams KN, Nicolaou L, Johnson M, Pillarisetti A, Rosenthal J, Underhill LJ, Wang J, Jabbarzadeh S, Chen Y, Dávila-Román VG, Naeher LP, McCollum ED, Peel JL, Clasen TF. Effects of Cooking with Liquefied Petroleum Gas or Biomass on Stunting in Infants. N Engl J Med 2024; 390:44-54. [PMID: 38169489 DOI: 10.1056/nejmoa2302687] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Household air pollution is associated with stunted growth in infants. Whether the replacement of biomass fuel (e.g., wood, dung, or agricultural crop waste) with liquefied petroleum gas (LPG) for cooking can reduce the risk of stunting is unknown. METHODS We conducted a randomized trial involving 3200 pregnant women 18 to 34 years of age in four low- and middle-income countries. Women at 9 to less than 20 weeks' gestation were randomly assigned to use a free LPG cookstove with continuous free fuel delivery for 18 months (intervention group) or to continue using a biomass cookstove (control group). The length of each infant was measured at 12 months of age, and personal exposures to fine particulate matter (particles with an aerodynamic diameter of ≤2.5 μm) were monitored starting at pregnancy and continuing until the infants were 1 year of age. The primary outcome for which data are presented in the current report - stunting (defined as a length-for-age z score that was more than two standard deviations below the median of a growth standard) at 12 months of age - was one of four primary outcomes of the trial. Intention-to-treat analyses were performed to estimate the relative risk of stunting. RESULTS Adherence to the intervention was high, and the intervention resulted in lower prenatal and postnatal 24-hour personal exposures to fine particulate matter than the control (mean prenatal exposure, 35.0 μg per cubic meter vs. 103.3 μg per cubic meter; mean postnatal exposure, 37.9 μg per cubic meter vs. 109.2 μg per cubic meter). Among 3061 live births, 1171 (76.2%) of the 1536 infants born to women in the intervention group and 1186 (77.8%) of the 1525 infants born to women in the control group had a valid length measurement at 12 months of age. Stunting occurred in 321 of the 1171 infants included in the analysis (27.4%) of the infants born to women in the intervention group and in 299 of the 1186 infants included in the analysis (25.2%) of those born to women in the control group (relative risk, 1.10; 98.75% confidence interval, 0.94 to 1.29; P = 0.12). CONCLUSIONS An intervention strategy starting in pregnancy and aimed at mitigating household air pollution by replacing biomass fuel with LPG for cooking did not reduce the risk of stunting in infants. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; HAPIN ClinicalTrials.gov number, NCT02944682.).
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Affiliation(s)
- William Checkley
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lisa M Thompson
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Sheela S Sinharoy
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Shakir Hossen
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lawrence H Moulton
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Howard H Chang
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lance Waller
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kyle Steenland
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Ghislaine Rosa
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Alexie Mukeshimana
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Florien Ndagijimana
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - John P McCracken
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Anaité Díaz-Artiga
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kalpana Balakrishnan
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Sarada S Garg
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Gurusamy Thangavel
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Vigneswari Aravindalochanan
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Stella M Hartinger
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Marilú Chiang
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Miles A Kirby
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Aris T Papageorghiou
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Usha Ramakrishnan
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Kendra N Williams
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Laura Nicolaou
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Michael Johnson
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Ajay Pillarisetti
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Joshua Rosenthal
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Lindsay J Underhill
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Jiantong Wang
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Shirin Jabbarzadeh
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Yunyun Chen
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Victor G Dávila-Román
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Luke P Naeher
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Eric D McCollum
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Jennifer L Peel
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
| | - Thomas F Clasen
- From the Division of Pulmonary and Critical Care (W.C., S.H., K.N.W., L.N.), the Johns Hopkins Center for Global Non-Communicable Disease Research and Training (W.C., S.H., K.N.W., L.N., E.D.M.), the Eudowood Division of Pediatric Respiratory Sciences, School of Medicine (E.D.M.), and the Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health (W.C., L.H.M., E.D.M.), Johns Hopkins University, Baltimore, and Fogarty International Center, National Institutes of Health, Bethesda (J.R.) - both in Maryland; Nell Hodgson Woodruff School of Nursing (L.M.T.) and the Hubert Department of Global Health (S.S.S., U.R.), the Gangarosa Department of Environmental Health (K.S., T.F.C.), and the Department of Biostatistics and Bioinformatics (H.H.C., L.W., J.W., S.J., Y.C.), Rollins School of Public Health, Emory University, Atlanta, and the Departments of Epidemiology and Biostatistics (J.P.M.) and Environmental Health Science (L.P.N.), College of Public Health, University of Georgia, Athens - both in Georgia; the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London (G.R.), and Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford (A.T.P.) - both in the United Kingdom; Eagle Research Center, Kigali, Rwanda (A.M., F.N.); the Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala (J.P.M., A.D.-A.); the Indian Council of Medical Research Center for Advanced Research on Air Quality, Climate, and Health, Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India (K.B., S.S.G., G.T., V.A.); the Latin American Center of Excellence in Climate Change and Health, Universidad Peruana Cayetano Heredia (S.M.H.), and the Biomedical Research Unit, Asociación Benéfica Prisma (M.C.) - both in Lima, Peru; the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston (M.A.K.); Berkeley Air Monitoring Group (M.J.) and the Division of Environmental Health Sciences, University of California at Berkeley (A.P.) - both in Berkeley; the Cardiovascular Imaging and Clinical Research Core Laboratory, Department of Medicine, Washington University in St. Louis, St. Louis (L.J.U., V.G.D.-R.); and the Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins (J.L.P.)
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Beatty A, Borkum E, Leith W, Null C, Suriastini W. A cluster randomized controlled trial of a community-based initiative to reduce stunting in rural Indonesia. Matern Child Nutr 2024; 20:e13593. [PMID: 38041533 PMCID: PMC10750001 DOI: 10.1111/mcn.13593] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 09/29/2023] [Accepted: 11/03/2023] [Indexed: 12/03/2023]
Abstract
We evaluate the impacts of a $120 million project in Indonesia conducted between 2014 and 2018 that sought to reduce stunting through a combination of (1) community-driven development grants targeted at health and education outcomes, (2) training for health providers on infant and young child feeding and growth monitoring and (3) training for sanitarians on a local variation of community-led total sanitation. This cluster randomized controlled trial involved 95 treatment and 95 control subdistricts across South Sumatra, West Kalimantan, and Central Kalimantan provinces. Overall, we find no significant impacts on stunting, the study's primary outcome measure (0.5 pp; 95% confidence interval [CI]: -3.0 to 4.1 percentage points [pp]), or other longer-term undernutrition outcomes about 1 year after the end of the project. The project had a modest impact on some secondary, more proximal outcomes related to maternal and child nutrition, including the percentage of mothers consuming the recommended number of iron-folic acid pills during pregnancy (8.7 pp; 95% CI: 4.1-13.3 pp), 0-5-month-olds being exclusively breastfed (8.7 pp; 95% CI: 1.8-15.6 pp) and 6-23-month-olds receiving the number of recommended meals per day (8.5 pp; 95% CI: 3.8-13.2 pp). However, there were no significant impacts on other proximal outcomes like the number of pre-natal and post-natal checkups, child dietary diversity, child vitamin A receipt or the incidence of child diarrhoea. Our findings highlight that successfully implementing an integrated package of interventions to reduce child stunting may be challenging in practice. Project design needs to consider implementation reality along with best practice-for example, by piloting the synchronous implementation of multifaceted interventions or phasing them in more gradually over a longer timeframe.
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Robinson JA, Dinh PTT. High doses of a national preschool program are associated with the long-term mitigation of adverse outcomes in cognitive development and life satisfaction among children who experience early stunting: a multi-site longitudinal study in Vietnam. Front Public Health 2023; 11:1087349. [PMID: 38186692 PMCID: PMC10770864 DOI: 10.3389/fpubh.2023.1087349] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/24/2023] [Indexed: 01/09/2024] Open
Abstract
Background Stunting (low height-for-age) is a marker of cumulative developmental disadvantage that can also contribute to impaired cognitive development and poor psychological wellbeing. Several interventions designed to preserve stunted children's developmental potential through increasing their cognitive stimulation have proven to be effective. However, their resource-intensive nature limits their sustainability and scalability in the low-and middle-income countries in which 98% of stunted children live. The current study had three aims: to identify the domains of developmental disadvantage associated with stunting at 5 years of age in the Vietnamese context; to examine the relationship between Vietnamese children's stunting status at 5 years of age, the dose of the national preschool program they received, and their cognitive skills and psychological well-being at 4 ages; and to determine whether some doses of the national preschool program were associated with the mitigation of adverse cognitive and wellbeing outcomes among stunted children. Method The Young Lives Study in Vietnam (n = 2,000; 31 sites) provided archival data that allowed calculation of the approximate dose (in hours) of the preschool program received by children, and longitudinal data on children's growth (1, 5, 8, 12, and 15 years), receptive vocabulary (5, 8, 12 and 15 years), reading skills, mathematics skills and life satisfaction (each at 8, 12, and 15 years). Results Stunting at 5 years of age was associated with diverse aspects of financial and social disadvantage, greater exposure to health risks, lower preventive health care, and constraints on maternal care. Scores for all cognitive variables at all ages were positively associated with preschool dose and negatively associated with stunted growth at 5 years of age. That is, effects associated with stunting and preschool dose at 5 years of age continued to be found during the subsequent 10 years. High doses of preschool education (3,000 h or more) were associated with the mitigation of adverse outcomes for most cognitive variables at most ages. Conclusion The current findings raise the possibility that generic preschool programs delivered at high dose may provide a scalable and sustainable intervention to support the life opportunities of children who experience early stunting.
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Affiliation(s)
- J. A. Robinson
- College of Education, Psychology and Social Work, Flinders University, Adelaide, SA, Australia
| | - Phuong Thi Thu Dinh
- Kinder in Wien, Vienna, Austria
- College of Education, Hue University, Hue, Vietnam
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17
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Martin-Cañavate R, Custodio E, Trigo E, Romay-Barja M, Herrador Z, Aguado I, Ramirez F, Faria LM, Silva-Gerardo A, Lima JC, Iráizoz E, Marques T, Vargas A, Gomez A, Puett C, Molina I. Preventing chronic malnutrition in children under 2 years in rural Angola (MuCCUA trial): protocol for the economic evaluation of a three-arm community cluster randomised controlled trial. BMJ Open 2023; 13:e073349. [PMID: 38110392 DOI: 10.1136/bmjopen-2023-073349] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
INTRODUCTION Chronic malnutrition is a serious problem in southern Angola with a prevalence of 49.9% and 37.2% in the provinces of Huila and Cunene, respectively. The MuCCUA (Mother and Child Chronic Undernutrition in Angola) trial is a community-based randomised controlled trial (c-RCT) which aims to evaluate the effectiveness of a nutrition supplementation plus standard of care intervention and a cash transfer plus standard of care intervention in preventing stunting, and to compare them with a standard of care alone intervention in southern Angola. This protocol describes the planned economic evaluation associated with the c-RCT. METHODS AND ANALYSIS We will conduct a cost-efficiency and cost-effectiveness analysis nested within the MuCCUA trial with a societal perspective, measuring programme, provider, participant and household costs. We will collect programme costs prospectively using a combined calculation method including quantitative and qualitative data. Financial costs will be estimated by applying activity-based costing methods to accounting records using time allocation sheets. We will estimate costs not included in accounting records by the ingredients approach, and indirect costs incurred by beneficiaries through interviews, household surveys and focus group discussions. Cost-efficiency will be estimated as cost per output achieved by combining activity-specific cost data with routine data on programme outputs. Cost-effectiveness will be assessed as cost per stunting case prevented. We will calculate incremental cost-effectiveness ratios comparing the additional cost per improved outcome of the different intervention arms and the standard of care. We will perform sensitivity analyses to assess robustness of results. ETHICS AND DISSEMINATION This economic evaluation will provide useful information to the Angolan Government and other policymakers on the most cost-effective intervention to prevent stunting in this and other comparable contexts. The protocol was approved by the República de Angola Ministério da Saúde Comité de Ética (27C.E/MINSA.INIS/2022). The findings of this study will be disseminated within academia and the wider policy sphere. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT05571280).
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Affiliation(s)
- Rocio Martin-Cañavate
- Centro Nacional de Medicina Tropical, Instituto de Salud Carlos III, Madrid, Spain
- Escuela Internacional de Doctorado, Universidad Nacional de Educación a Distancia, Madrid, España
| | - Estefania Custodio
- Centro Nacional de Medicina Tropical, Instituto de Salud Carlos III, Madrid, Spain
- CIBER Enfermedades Infecciosas, ISCIII, Madrid, Spain
| | - Elena Trigo
- Infectious Diseases Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - María Romay-Barja
- Centro Nacional de Medicina Tropical, Instituto de Salud Carlos III, Madrid, Spain
- CIBER Enfermedades Infecciosas, ISCIII, Madrid, Spain
| | - Zaida Herrador
- Centro Nacional de Epidemiologia, Instituto de Salud Carlos III, Madrid, Spain
- CIBER Epidemiología y Salud Publica (CIBERESP), Madrid, Spain
| | - Isabel Aguado
- Infectious Diseases Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ferran Ramirez
- Infectious Diseases Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Ana Silva-Gerardo
- Faculdade de Medicina da Universidade Mandume Ya Ndemufayo, Lubango, Huíla, Angola
| | - Jose Carlos Lima
- Faculdade de Medicina da Universidade Mandume Ya Ndemufayo, Lubango, Huíla, Angola
| | | | - Tayná Marques
- Infectious Diseases Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | | | - Chloe Puett
- Stony Brook University Program in Public Health, Stony Brook, New York, USA
| | - Israel Molina
- Infectious Diseases Department, Vall d'Hebron University Hospital, Barcelona, Spain
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18
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Herrera DJ, Herrera ML, Amora D, Bas S, Miranda CA, Van Hal G. Mixed-method study on the association between inclusion to conditional cash transfer program and the multiple faces of malnutrition in children and adolescents aged 3 to 19 years: a school-based evidence from Caraga Region, the Philippines. BMC Pediatr 2023; 23:630. [PMID: 38093230 PMCID: PMC10717276 DOI: 10.1186/s12887-023-04438-8] [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] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 11/21/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND This study aimed to investigate the association between inclusion to Pantawid Pamilyang Pilipino Program (4Ps), a CCT program in the Philippines, and malnutrition in children and adolescents and examine the perceptions and experiences of parents and other stakeholders on how 4Ps influenced child nutrition. METHODS A concurrent mixed-method study was conducted in the Caraga Region, Philippines. Quantitative data from 5541 children and adolescents aged 3 to 19 were analyzed using multilevel mixed-effect logistic models. To allow in-depth understanding of the programmatic components that support the findings from the quantitative study, eight focused group discussions (FGDs) were concurrently conducted, cumulating 33 participants, including 4Ps parents, school coordinators/teachers, and school nurses. A constructivist grounded theory approach was used for analysis, and joint displays were employed to integrate quantitative and qualitative results. RESULTS Quantitative findings revealed high rates of malnutrition, with significant rates of stunting (12.0%), wasting/thinness (9.4%), and overweight/obesity (16.4%) among children and adolescents. 4Ps beneficiaries had higher odds of stunting and overweight/obesity compared to non-4Ps beneficiaries (AOR = 1.43, 95%CI: 1.08-1.91; AOR = 1.21, 95%CI: 1.01-1.45, respectively). However, no significant association was observed between inclusion to 4Ps and concurrent stunting and wasting/thinness or overweight/obesity (AOR = 1.05, 95%CI: 0.72-1.55). Geographic variations were observed, with 4Ps children in Agusan del Sur having lower odds of stunting than those in Agusan del Norte (AOR = 0.41, 95%CI: 0.23-0.71). Age and gender also showed significant associations with malnutrition. The qualitative analysis provided insights into the challenges contributing to malnutrition, including child labor, sickness, long distances to school, limited access to healthy food, and larger families. Unintended consequences such as cash card mismanagement, inappropriate cash grant allocation, and falsification of school attendance were identified. However, teachers and parents demonstrated resilience by implementing adaptive approaches to enhance child nutrition. CONCLUSIONS While 4Ps beneficiaries exhibit higher odds of stunting and overweight/obesity, the program's association with malnutrition was significantly influenced by geographic variations. It is crucial for social protection programs to prioritize comprehensive support strategies that effectively counter unintended consequences and challenges faced by beneficiaries and other stakeholders and address malnutrition in children and adolescents.
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Affiliation(s)
- Deborah Jael Herrera
- Family Medicine and Population Health Department, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
| | - Miraluna L Herrera
- Action for Greater Advancement of Knowledge (AGAK) Center, Caraga State University, Agusan del Norte, Butuan City, Philippines
| | - Donnacham Amora
- Department of Medical Technology, Agusan del Norte, Butuan Doctors College, Butuan City, Philippines
| | - Sherlyn Bas
- Action for Greater Advancement of Knowledge (AGAK) Center, Caraga State University, Agusan del Norte, Butuan City, Philippines
| | - Caryl Aya Miranda
- Action for Greater Advancement of Knowledge (AGAK) Center, Caraga State University, Agusan del Norte, Butuan City, Philippines
| | - Guido Van Hal
- Family Medicine and Population Health Department, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Hobbs N, Hug J, de Pee S. High Non-affordability of Diets and Malnutrition in Africa's Drylands: Systems Analysis to Guide Action. Food Nutr Bull 2023; 44:S45-S57. [PMID: 37850927 DOI: 10.1177/03795721231178065] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
BACKGROUND Africa's drylands have unique food environments and persistently high rates of wasting and stunting. This article documents findings and experiences from Fill the Nutrient Gap (FNG) processes conducted in 7 Sub-Saharan African countries that include drylands. OBJECTIVE This study advocates for a comprehensive consideration of the specific food environments of drylands using a novel analytical framework and shares findings and best practices for improving food and nutrition security in these contexts. METHODS Three analyses are combined. Analysis 1 re-analyzes cost and non-affordability of nutrient-adequate diets indicators from FNGs by reclassifying areas as drylands and non-drylands. Analysis 2 uses malnutrition estimates in drylands and non-drylands and examines associations with non-affordability of nutrient-adequate diets. Analysis 3 synthesizes evidence from FNG processes to document how those indicators were used to engage stakeholders and inform nutrition policy and practice in drylands. RESULTS The nutrient-adequate diet of a 5-person household was 2.60 USD (41%) more expensive in drylands. A nutrient-adequate diet was not affordable to 71% of households in drylands, compared to 55% in non-drylands. Wasting and stunting prevalence and non-affordability of nutrient-adequate diets were simultaneously high in drylands. CONCLUSION The article presents new evidence that contributes to elucidate specific characteristics of the food environment of Africa's drylands and suggests a framework to improve on those factors systematically. The FNG is innovative in combining an analytical framework with multistakeholder review and dialogue, as well as modeling of possible strategies, to build consensus on possible transformation pathways to improve diets in drylands.
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Affiliation(s)
- Nora Hobbs
- United Nation's World Food Programme, Rome, Italy
| | - Julia Hug
- United Nation's World Food Programme, Rome, Italy
| | - Saskia de Pee
- United Nation's World Food Programme, Rome, Italy
- Tufts University, Boston, MA, USA
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20
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Dewey KG, Arnold CD, Wessells KR, Stewart CP. Lipid-based nutrient supplements for prevention of child undernutrition: when less may be more. Am J Clin Nutr 2023; 118:1133-1144. [PMID: 37742931 DOI: 10.1016/j.ajcnut.2023.09.007] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/25/2023] [Accepted: 09/12/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Both small-quantity and medium-quantity lipid-based nutrient supplements (LNS) have been used for the prevention of child undernutrition. A meta-analysis of 14 trials of small-quantity lipid-based nutrient supplements (SQ-LNS) - no LNS showed effects on length-for-age z-score {LAZ, +0.14 [95% confidence interval (CI): 0.11, 0.16]} and weight-for-length z-score [WLZ, +0.08 (0.06, 0.10)] z-scores, as well as prevalence ratios (95% CI) for stunting [LAZ < -2, 0.88 (0.85, 0.91)] and wasting [WLZ < -2, 0.86 (0.80, 0.93)]. However, little is known about the effects of medium-quantity lipid-based nutrient supplements (MQ-LNS) on growth. OBJECTIVES We aimed to examine the effects of preventive MQ-LNS (∼250-499 kcal/d) provided at ∼6-23 mo of age on growth outcomes - no LNS or provision of SQ-LNS. METHODS We conducted a systematic review of studies of MQ-LNS for prevention, and categorized them as providing <6 mo - ≥6 mo of supplementation; for the latter category, we conducted a meta-analysis, with the main outcomes being change in WLZ and LAZ, and prevalence of wasting and stunting. RESULTS Three studies provided MQ-LNS for 3-5 mo (seasonal) for children 6-36 mo of age, and did not show consistent effects on growth outcomes. Eight studies provided MQ-LNS for 6-18 mo, generally starting at 6 mo of age; in the meta-analysis (max total n = 13,954), MQ-LNS increased WLZ [+0.09 (95% CI: 0.05, 0.13)] and reduced wasting [0.89 (0.81, 0.97)], but had no effect on LAZ [+0.04 (-0.02, 0.11)] or stunting [0.97 (0.92, 1.02)] - no LNS. Two studies directly compared SQ-LNS and MQ-LNS and showed no significant differences in growth outcomes. CONCLUSIONS The current evidence suggests that MQ-LNS offer no added benefits over SQ-LNS, although further studies directly comparing MQ-LNS with SQ-LNS would be useful. One possible explanation is incomplete consumption of the MQ-LNS ration and thus lower than desirable intake of certain nutrients. TRIAL REGISTRATION NUMBER Registry and registry number for systematic reviews or meta-analyses: Registered with PROSPERO as CRD42022382448 on December 18, 2022: =https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022382448.
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Affiliation(s)
- Kathryn G Dewey
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, United States.
| | - Charles D Arnold
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, United States
| | - K Ryan Wessells
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, United States
| | - Christine P Stewart
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, United States
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21
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Xiong T, Wu Y, Hu J, Xu S, Li Y, Kong B, Zhang Z, Chen L, Tang Y, Yao P, Xiong J, Li Y. Associations between High Protein Intake, Linear Growth, and Stunting in Children and Adolescents: A Cross-Sectional Study. Nutrients 2023; 15:4821. [PMID: 38004215 PMCID: PMC10675685 DOI: 10.3390/nu15224821] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/12/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND AND AIMS Childhood and adolescence are critical periods for linear growth and preventing stunting. Current evidence indicates that dietary protein intake in children and adolescents is often two to three times higher than the recommendations in many regions worldwide. However, few studies have focused on the association between high protein intake and linear growth and stunting in this population. We aim to investigate this association in children and adolescents aged 6 to 18 years in a population with relatively high protein consumption. METHODS We conducted a large cross-sectional study involving 3299 participants from Shenzhen, a modern metropolis of China. Protein intake, including total protein, animal protein, and plant protein, was evaluated by a food-frequency questionnaire and expressed as grams per kilogram of body weight per day (g·kg-1·d-1) and as a percentage of total energy intake (%E). The primary outcomes were body height and height-for-age Z score (HAZ). Generalized linear models and logistic regression analyses were employed to examine the associations between protein intake and outcomes. We also conducted stratified analyses across different genders and pubertal stages in the aforementioned associations. RESULTS The mean protein intake was 1.81 g·kg-1·d-1 (17% E). After adjusting for serum calcium, zinc, vitamin D3, vitamin A levels, birth outcomes, lifestyle, and parental characteristics, each standard deviation increase of 1 in protein intake (0.64 kg-1·d-1) is found to be associated with a -5.78 cm change in body height (95% CI: -6.12, -5.45) and a -0.79 change in HAZ (95% CI: -0.84, -0.74). Consistent results were observed when protein intake was expressed as %E or specifically as animal or plant protein. Moreover, the relationship between protein intake and linear growth remained consistent across genders in different pubertal stages, similar to that of the overall participants. CONCLUSIONS Our findings highlight the potential hazards of high protein intake on linear growth in children and adolescents. Caution should be exercised when promoting increased protein consumption in children and adolescents who already have a high intake of protein.
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Affiliation(s)
- Ting Xiong
- Department of Nutrition and Food Hygiene, School of Public Health, Guangzhou Medical University, Guangzhou 511436, China; (T.X.); (Y.W.); (J.H.); (S.X.)
| | - Yuanjue Wu
- Department of Nutrition and Food Hygiene, School of Public Health, Guangzhou Medical University, Guangzhou 511436, China; (T.X.); (Y.W.); (J.H.); (S.X.)
| | - Jiazhen Hu
- Department of Nutrition and Food Hygiene, School of Public Health, Guangzhou Medical University, Guangzhou 511436, China; (T.X.); (Y.W.); (J.H.); (S.X.)
| | - Shiqi Xu
- Department of Nutrition and Food Hygiene, School of Public Health, Guangzhou Medical University, Guangzhou 511436, China; (T.X.); (Y.W.); (J.H.); (S.X.)
| | - Yan Li
- Shenzhen Center for Chronic Disease Control, Shenzhen 518020, China;
| | - Binxuan Kong
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety and the Ministry of Education (MOE) Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (B.K.); (Z.Z.); (L.C.); (Y.T.); (P.Y.)
| | - Zhuangyu Zhang
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety and the Ministry of Education (MOE) Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (B.K.); (Z.Z.); (L.C.); (Y.T.); (P.Y.)
| | - Liangkai Chen
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety and the Ministry of Education (MOE) Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (B.K.); (Z.Z.); (L.C.); (Y.T.); (P.Y.)
| | - Yuhan Tang
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety and the Ministry of Education (MOE) Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (B.K.); (Z.Z.); (L.C.); (Y.T.); (P.Y.)
| | - Ping Yao
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety and the Ministry of Education (MOE) Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (B.K.); (Z.Z.); (L.C.); (Y.T.); (P.Y.)
| | - Jingfan Xiong
- Shenzhen Center for Chronic Disease Control, Shenzhen 518020, China;
| | - Yanyan Li
- Shenzhen Center for Chronic Disease Control, Shenzhen 518020, China;
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22
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Picauly I, Adi AAAM, Meiyetriani E, Mading M, Weraman P, Nashriyah SF, Hidayat AT, Boeky DLA, Lobo V, Saleh A, Peni JA. Path analysis model for preventing stunting in dryland area island East Nusa Tenggara Province, Indonesia. PLoS One 2023; 18:e0293797. [PMID: 37917759 PMCID: PMC10621912 DOI: 10.1371/journal.pone.0293797] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 10/19/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND The problem of stunting is still a fundamental problem in Indonesia's human development. East Nusa Tenggara Province is an archipelago dryland area where in 2007-2021 it has contributed to the highest number of stunting children prevalence in Indonesia. This study aims to determine the relationship of variables in individual, household and district level with the prevalence of stunting. METHODS This type of research is observational study with a cross sectional design. This study used individual secondary data from the Indonesian Nutritional Status Survey in 2021 consisting of 7,835 toddlers and National Social Economics Survey 2021. RESULTS This research found that both specific & sensitive intervention programs had an influence in accelerating the decline in stunting prevalence (higher score on Z Score). Results also revealed the positive influence of the food access variable on nutritional intake. The results of the path analysis test showed that sensitive intervention program variables have a positive effect on food access variable and environmental variable (environmental sanitation) such as the habit of open defecation and healthcare. There was significant relationship on disease history, environment and intake to Height for Age (HAZ) score. CONCLUSIONS In conclusion, direct and indirect factors have important roles to prevent stunting. Sensitive and specific intervention program, food access, macro determinants and environment are the indirect indicators which contribute significantly to the stunting. The risk of children under five years old experiencing malnourished nutritional status increases with a history of infectious disease (diarrhea, ARI, worms). The risk of children under five years experiencing malnourished nutritional status decreases with adequate nutritional intake. It is hoped that there will be a special model of stunting control interventions at the individual level and at the family, household and district level that are integrated and of high quality through multisectoral cooperation in the dryland areas of the islands of East Nusa Tenggara Province.
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Affiliation(s)
- Intje Picauly
- Faculty of Public Health, Department of Public Health, University of Nusa Cendana, Kupang City, East Nusa Tenggara, Indonesia
| | | | - Eflita Meiyetriani
- SEAMEO RECFON, Pusat Kajian Gizi Regional, Universitas Indonesia, Jakarta, Indonesia
| | - Majematang Mading
- Lokalitbangkes Waikabubak, Ministry of Health, West Sumba, East Nusa Tenggara, Indonesia
| | - Pius Weraman
- Faculty of Public Health, Department of Public Health, University of Nusa Cendana, Kupang City, East Nusa Tenggara, Indonesia
| | - Siti Fadhilatun Nashriyah
- Department of Biostatistics, Faculty of Public Health, Universitas Indonesia, Depok, Jakarta, Indonesia
| | - Ahmad Thohir Hidayat
- SEAMEO RECFON, Pusat Kajian Gizi Regional, Universitas Indonesia, Jakarta, Indonesia
| | - Daniela L. Adeline Boeky
- Faculty of Public Health, Department of Public Health, University of Nusa Cendana, Kupang City, East Nusa Tenggara, Indonesia
| | - Varry Lobo
- Lokalitbangkes Waikabubak, Ministry of Health, West Sumba, East Nusa Tenggara, Indonesia
| | | | - Jane A. Peni
- Health Polytechnique Kupang, Ministry of Health, Kupang City, East Nusa Tenggara, Indonesia
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23
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Som SV, Wieringa FT, Campos Ponce M, Polman K, Dakurah P, Duncan D, Blomberg J, Rasphone S, Hoeven MVD. Association of both Water, Sanitation and Hygiene (WASH) and Infant and Young Child Feeding (IYCF) practices with childhood malnutrition in Lao PDR: a cross-sectional study of the 2017 Lao Social Indicator Survey II. BMJ Open 2023; 13:e073974. [PMID: 37832981 PMCID: PMC10582958 DOI: 10.1136/bmjopen-2023-073974] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 09/11/2023] [Indexed: 10/15/2023] Open
Abstract
OBJECTIVE We assessed whether Water, Sanitation and Hygiene (WASH) and Infant and Young Child Feeding (IYCF), either alone or combined, were associated with malnutrition among Lao People's Democratic Republic (Lao PDR) children aged 6 to <24 months. DESIGN This is a secondary analysis of the 2017 Lao Social Indicator Survey II (LSIS II), which used multistage probability proportional to size sampling. Logistic regression analyses were conducted with OR and its corresponding 95% CI. SETTING The LSIS II was conducted a nationwide household-based survey covering all 18 provinces in Lao PDR. PARTICIPANTS We had a total of 3375 children (weighted sample 3345) and 357 households with data on drinking water. OUTCOME MEASURES The outcomes of this study were stunting and wasting. RESULTS The prevalence of stunting and wasting was 28.9% and 10.1%, respectively. Even though households with access to a basic or improved water source were high (82.5%), over 83% of drinking water was contaminated with Escherichia coli. Access to improved sanitation, basic hygiene and adequate IYCF gave a significant lower risk of becoming stunted. The combined effect of these practices on stunting was (adjusted OR (AOR)=0.54; 95% CI=0.41 to 0.73) greater than each practice alone (improved sanitation: AOR=0.75; 95% CI=0.61 to 0.93; basic hygiene: AOR=0.69; 95% CI=0.57 to 0.83; adequate IYCF: AOR=0.79; 95% CI=0.64 to 0.98). Access to improved sanitation and adequate IYCF was associated with a significant lower risk for being wasted, and again the combined effect of these practices was (AOR=0.64; 95% CI=0.44 to 0.92) greater than each practice alone (improved sanitation: AOR=0.68; 95% CI=0.49 to 0.93 and adequate IYCF: AOR=0.66; 95% CI=0.47 to 0.92). CONCLUSION Given the strong associations with both stunting and wasting, and the added benefits when combining WASH and IYCF, there is a need of multisectoral interventions to reduce early childhood malnutrition in Lao PDR.
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Affiliation(s)
- Somphos Vicheth Som
- Section of Infectious Diseases, Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Frank T Wieringa
- UMR QualiSud, French National Research Institute for Sustainable Development, Montpellier, France
| | - Maiza Campos Ponce
- Section of Infectious Diseases, Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Katja Polman
- Section of Infectious Diseases, Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Prosper Dakurah
- United Nations Children's Emergency Fund Lao PDR, Vientiane, Lao People's Democratic Republic
| | - David Duncan
- United Nations Children's Emergency Fund Lao PDR, Vientiane, Lao People's Democratic Republic
| | - Janneke Blomberg
- United Nations Children's Emergency Fund Lao PDR, Vientiane, Lao People's Democratic Republic
| | - Sitthorot Rasphone
- The Ministry of Planning and Investment's National Economic Research Institute, Vientiane, Lao People's Democratic Republic
| | - Marinka van der Hoeven
- Section of Infectious Diseases, Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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24
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Muhamad Z, Mahmudiono T, Abihail CT, Sahila N, Wangi MP, Suyanto B, Binti Abdullah NA. Preliminary Study: The Effectiveness of Nutrition Education Intervention Targeting Short-Statured Pregnant Women to Prevent Gestational Stunting. Nutrients 2023; 15:4305. [PMID: 37836589 PMCID: PMC10574551 DOI: 10.3390/nu15194305] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/02/2023] [Accepted: 10/05/2023] [Indexed: 10/15/2023] Open
Abstract
A short mother with a height < 150 cm is likely to give birth to a short baby with a body length < 48 cm so that later this short baby will become stunted. The success rate of stunting malnutrition prevention and control with specific methods is 30% and the success rate with sensitive methods is 70%. The size at risk for short pregnant women is equal to 30.5%. A major effort to improve the health status of short pregnant women and prevent stunting is to empower short pregnant women with the help of health professionals. This study aimed to analyze the effectiveness of providing nutrition education to pregnant women who have short stature to prevent gestational stunting. This study used a quantitative approach with a quasi-experimental design in the intervention group and the control group. Research results showed that there are differences in the knowledge, attitudes, and actions of pregnant women about prenatal care services before and after the intervention, as well as knowledge of pregnant women about nutrition before and after intervention. The support of the cadres had a great influence on the intervention group compared with the control group, which received only one module. Pregnant women's knowledge of nutritional diets and pregnant women's knowledge of antenatal care (ANC) services directly influence the delivery timing. Interventions to improve the health status of short pregnant women and prevent stunting neonates can be improved by improving the knowledge, attitudes, and behavior of short pregnant women about antenatal care, and knowledge of pregnant women about nutritional intake. The Short Pregnancy Medical Framework Support Model was developed for use in providing support to short pregnant women to prevent infant stunting.
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Affiliation(s)
- Zuriati Muhamad
- Public Health Doctoral Program, Faculty of Public Health, Universitas Airlangga, Surabaya 60115, Indonesia;
- Midwifery Department, Faculty of Health Science, Universitas Muhammadiyah Gorontalo, Gorontalo 96181, Indonesia
| | - Trias Mahmudiono
- Center for Health and Nutrition Education, Counseling, and Empowerment (CHeNECE), Department of Nutrition, Faculty of Public Health, Universitas Airlangga, Surabaya 60115, Indonesia
| | - Chrysoprase Thasya Abihail
- Department of Nutrition, Faculty of Public Health, Universitas Airlangga, Surabaya 60115, Indonesia; (C.T.A.); (M.P.W.)
| | - Nur Sahila
- Department of Health Policy and Administration, Faculty of Public Health, Universitas Airlangga, Surabaya 60115, Indonesia;
| | - Martina Puspa Wangi
- Department of Nutrition, Faculty of Public Health, Universitas Airlangga, Surabaya 60115, Indonesia; (C.T.A.); (M.P.W.)
| | - Bagong Suyanto
- Department of Sociology, Faculty of Social and Political Sciences, Universitas Airlangga, Surabaya 60115, Indonesia;
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25
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Adams KP, Vosti SA, Arnold CD, Engle-Stone R, Prado EL, Stewart CP, Wessells KR, Dewey KG. The cost-effectiveness of small-quantity lipid-based nutrient supplements for prevention of child death and malnutrition and promotion of healthy development: modelling results for Uganda. Public Health Nutr 2023; 26:2083-2095. [PMID: 37606091 PMCID: PMC10564609 DOI: 10.1017/s1368980023001805] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/08/2023] [Accepted: 08/11/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVE Recent meta-analyses demonstrate that small-quantity lipid-based nutrient supplements (SQ-LNS) for young children significantly reduce child mortality, stunting, wasting, anaemia and adverse developmental outcomes. Cost considerations should inform policy decisions. We developed a modelling framework to estimate the cost and cost-effectiveness of SQ-LNS and applied the framework in the context of rural Uganda. DESIGN We adapted costs from a costing study of micronutrient powder (MNP) in Uganda, and based effectiveness estimates on recent meta-analyses and Uganda-specific estimates of baseline mortality and the prevalence of stunting, wasting, anaemia and developmental disability. SETTING Rural Uganda. PARTICIPANTS Not applicable. RESULTS Providing SQ-LNS daily to all children in rural Uganda (> 1 million) for 12 months (from 6 to 18 months of age) via the existing Village Health Team system would cost ∼$52 per child (2020 US dollars) or ∼$58·7 million annually. SQ-LNS could avert an average of > 242 000 disability-adjusted life years (DALYs) annually as a result of preventing 3689 deaths, > 160 000 cases of moderate or severe anaemia and ∼6000 cases of developmental disability. The estimated cost per DALY averted is $242. CONCLUSIONS In this context, SQ-LNS may be more cost-effective than other options such as MNP or the provision of complementary food, although the total cost for a programme including all age-eligible children would be high. Strategies to reduce costs, such as targeting to the most vulnerable populations and the elimination of taxes on SQ-LNS, may enhance financial feasibility.
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Affiliation(s)
- Katherine P Adams
- Institute for Global Nutrition, University of California, Davis, CA95616, USA
| | - Stephen A Vosti
- Department of Agricultural and Resource Economics, University of California, Davis, CA, USA
| | - Charles D Arnold
- Institute for Global Nutrition, University of California, Davis, CA95616, USA
| | - Reina Engle-Stone
- Institute for Global Nutrition, University of California, Davis, CA95616, USA
| | - Elizabeth L Prado
- Institute for Global Nutrition, University of California, Davis, CA95616, USA
| | - Christine P Stewart
- Institute for Global Nutrition, University of California, Davis, CA95616, USA
| | - K Ryan Wessells
- Institute for Global Nutrition, University of California, Davis, CA95616, USA
| | - Kathryn G Dewey
- Institute for Global Nutrition, University of California, Davis, CA95616, USA
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26
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Karlsson O, Kim R, Moloney GM, Hasman A, Subramanian SV. Patterns in child stunting by age: A cross-sectional study of 94 low- and middle-income countries. Matern Child Nutr 2023; 19:e13537. [PMID: 37276243 PMCID: PMC10483943 DOI: 10.1111/mcn.13537] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 04/26/2023] [Accepted: 05/06/2023] [Indexed: 06/07/2023]
Abstract
Child stunting prevalence is primarily used as an indicator of impeded physical growth due to undernutrition and infections, which also increases the risk of mortality, morbidity and cognitive problems, particularly when occurring during the 1000 days from conception to age 2 years. This paper estimated the relationship between stunting prevalence and age for children 0-59 months old in 94 low- and middle-income countries. The overall stunting prevalence was 32%. We found higher stunting prevalence among older children until around 28 months of age-presumably from longer exposure times and accumulation of adverse exposures to undernutrition and infections. In most countries, the stunting prevalence was lower for older children after around 28 months-presumably mostly due to further adverse exposures being less detrimental for older children, and catch-up growth. The age for which stunting prevalence was the highest was fairly consistent across countries. Stunting prevalence and gradient of the rise in stunting prevalence by age varied across world regions, countries, living standards and sex. Poorer countries and households had a higher prevalence at all ages and a sharper positive age gradient before age 2. Boys had higher stunting prevalence but had peak stunting prevalence at lower ages than girls. Stunting prevalence was similar for boys and girls after around age 45 months. These results suggest that programmes to prevent undernutrition and infections should focus on younger children to optimise impact in reducing stunting prevalence. Importantly, however, since some catch-up growth may be achieved after age 2, screening around this time can be beneficial.
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Affiliation(s)
- Omar Karlsson
- Takemi Program in International Health, Harvard T.H. Chan School of Public HealthHarvard UniversityBostonMassachusettsUSA
- Department of Economic History, School of Economics and ManagementLund UniversityLundSweden
| | - Rockli Kim
- Division of Health Policy & Management, College of Health ScienceKorea UniversitySeoulKorea
- Harvard Center for Population and Development StudiesCambridgeMassachusettsUSA
| | - Grainne M. Moloney
- Nutrition Section, United Nations Children's Fund (UNICEF), Kenya Country OfficeUN Complex GigiriNairobiKenya
| | | | - S. V. Subramanian
- Harvard Center for Population and Development StudiesCambridgeMassachusettsUSA
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public HealthHarvard UniversityBostonMassachusettsUSA
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27
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Haque MA, Zaman Wahid B, Farzana FD, Tanvir Ahmed SM, Ali M, Naz F, Rahman SS, Siddiqua TJ, Faruque ASG, Choudhury N, Ahmed T. Influence of the Suchana intervention on exclusive breastfeeding and stunting among children aged under 6 months in the Sylhet region of Bangladesh. Matern Child Nutr 2023; 19:e13535. [PMID: 37244871 PMCID: PMC10483947 DOI: 10.1111/mcn.13535] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/25/2023] [Accepted: 05/06/2023] [Indexed: 05/29/2023]
Abstract
Exclusive breastfeeding (EBF) provides significant health benefits to children. However, mothers may find it difficult to continue EBF for 6 months. The present analysis aimed to examine the influence of the Suchana intervention-a large-scale programme implemented with the aim of improving the health and nutritional status of mothers and children from poor households in the Sylhet region of Bangladesh-on EBF and stunting among children under 6 months. Baseline and endline data were obtained from the Suchana evaluation. EBF was defined as an infant (<6 months) only receiving breast milk in the previous 24 h. Childhood stunting was defined as a length-for-age z-score of less than -2 among children of the same age. Multiple logistic regression analysis was used to assess the associations of the Suchana intervention with EBF and stunting. EBF prevalence improved from 64% at baseline to 85% at the endline in the intervention area, with the intervention group having 2.25 times higher odds of EBF compared to the control group. Stunting prevalence reduced from 28% at baseline to 24% at the endline in the intervention group, but after controlling for covariates, the association between stunting and the intervention was not significant. However, the interaction analysis showed significantly lower stunting prevalence among EBF children in both intervention and control areas. The Suchana intervention had a positive impact on the EBF practice of rural children in a vulnerable region of Bangladesh, and EBF was identified as a significant factor associated with stunting. The findings suggest that the continuation of the EBF intervention has the potential to have an impact on reducing stunting in the region, highlighting the importance of promoting EBF to improve child health and development.
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Affiliation(s)
| | | | | | | | - Mohammad Ali
- Nutrition and Clinical Services DivisionDhakaBangladesh
| | - Farina Naz
- Nutrition and Clinical Services DivisionDhakaBangladesh
| | - Sheikh S. Rahman
- Child Poverty Sector, Save the Children BangladeshDhakaBangladesh
| | | | | | | | - Tahmeed Ahmed
- Nutrition and Clinical Services DivisionDhakaBangladesh
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28
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Benjamin-Chung J, Mertens A, Colford JM, Hubbard AE, van der Laan MJ, Coyle J, Sofrygin O, Cai W, Nguyen A, Pokpongkiat NN, Djajadi S, Seth A, Jilek W, Jung E, Chung EO, Rosete S, Hejazi N, Malenica I, Li H, Hafen R, Subramoney V, Häggström J, Norman T, Brown KH, Christian P, Arnold BF. Early-childhood linear growth faltering in low- and middle-income countries. Nature 2023; 621:550-557. [PMID: 37704719 PMCID: PMC10511325 DOI: 10.1038/s41586-023-06418-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/10/2023] [Indexed: 09/15/2023]
Abstract
Globally, 149 million children under 5 years of age are estimated to be stunted (length more than 2 standard deviations below international growth standards)1,2. Stunting, a form of linear growth faltering, increases the risk of illness, impaired cognitive development and mortality. Global stunting estimates rely on cross-sectional surveys, which cannot provide direct information about the timing of onset or persistence of growth faltering-a key consideration for defining critical windows to deliver preventive interventions. Here we completed a pooled analysis of longitudinal studies in low- and middle-income countries (n = 32 cohorts, 52,640 children, ages 0-24 months), allowing us to identify the typical age of onset of linear growth faltering and to investigate recurrent faltering in early life. The highest incidence of stunting onset occurred from birth to the age of 3 months, with substantially higher stunting at birth in South Asia. From 0 to 15 months, stunting reversal was rare; children who reversed their stunting status frequently relapsed, and relapse rates were substantially higher among children born stunted. Early onset and low reversal rates suggest that improving children's linear growth will require life course interventions for women of childbearing age and a greater emphasis on interventions for children under 6 months of age.
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Affiliation(s)
- Jade Benjamin-Chung
- Department of Epidemiology & Population Health, Stanford University, Stanford, CA, USA.
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA.
- Chan Zuckerberg Biohub, San Francisco, CA, USA.
| | - Andrew Mertens
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - John M Colford
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Alan E Hubbard
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Mark J van der Laan
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Jeremy Coyle
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Oleg Sofrygin
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wilson Cai
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anna Nguyen
- Department of Epidemiology & Population Health, Stanford University, Stanford, CA, USA
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nolan N Pokpongkiat
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Stephanie Djajadi
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anmol Seth
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wendy Jilek
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther Jung
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther O Chung
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Sonali Rosete
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nima Hejazi
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ivana Malenica
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Haodong Li
- Division of Epidemiology & Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ryan Hafen
- Hafen Consulting, LLC, West Richland, WA, USA
| | | | | | - Thea Norman
- Quantitative Sciences, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Parul Christian
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA.
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA.
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29
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Erfina E, Hariati S, Tawali S. Development and evaluation of nursing intervention in preventing stunting in children of adolescent mothers: A mixed-methods research protocol. Nutr Health 2023; 29:369-375. [PMID: 37331967 DOI: 10.1177/02601060231181712] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Background: Adolescent pregnancies are a global problem occurring in many countries. Adolescent pregnancy is a risk factor for stunting in children. Aim: This study was designed to develop and evaluation of nursing interventions to prevent stunting in children of adolescent mothers. Methods: A mixed-methods explanatory sequential design with two phases approach will be applied. Phase I is a qualitative phenomenology descriptive study that will be used. Participants will be adolescent pregnant women from several community health centers (Puskesmas) and healthcare staff in a community public center (Puskesmas) will be selected by purposive sampling. The study will be conducted at community health centers (Puskesmas) in Makassar, South Sulawesi, Indonesia. Data will be gathered through in-depth interviews and focus group discussions and analyzed using thematic analysis. Subsequently, an experimental pre-post-test design with a control group will be used to measure the effectiveness of the nursing intervention on preventing stunting among adolescent mothers in the quantitative phase by behavior toward stunting prevention for adolescent pregnancy and the nutritional status of children. Conclusion: This study will provide insight from both adolescent mothers' and healthcare staff's perspectives on stunting prevention including nutrition of adolescent pregnancy and breastfeeding. We will evaluate the effectiveness and acceptability of nursing intervention in preventing stunting. This will contribute to the international literature on the use of healthcare staff at community health services (puskesmas) to achieve linear growth due to prolonged food insecurity and illnesses in childhood.
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Affiliation(s)
- Erfina Erfina
- Maternity Nursing Department, Faculty of Nursing, Hasanuddin University, Tamalanrea, Makassar, Indonesia
| | - Suni Hariati
- Pediatric Nursing Department, Faculty of Nursing, Hasanuddin University, Tamalanrea, Makassar, Indonesia
| | - Suryani Tawali
- Community Medicine Department, Faculty of Medicine, Hasanuddin University, Tamalanrea, Makassar, Indonesia
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30
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Mertens A, Benjamin-Chung J, Colford JM, Coyle J, van der Laan MJ, Hubbard AE, Rosete S, Malenica I, Hejazi N, Sofrygin O, Cai W, Li H, Nguyen A, Pokpongkiat NN, Djajadi S, Seth A, Jung E, Chung EO, Jilek W, Subramoney V, Hafen R, Häggström J, Norman T, Brown KH, Christian P, Arnold BF. Causes and consequences of child growth faltering in low-resource settings. Nature 2023; 621:568-576. [PMID: 37704722 PMCID: PMC10511328 DOI: 10.1038/s41586-023-06501-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/31/2023] [Indexed: 09/15/2023]
Abstract
Growth faltering in children (low length for age or low weight for length) during the first 1,000 days of life (from conception to 2 years of age) influences short-term and long-term health and survival1,2. Interventions such as nutritional supplementation during pregnancy and the postnatal period could help prevent growth faltering, but programmatic action has been insufficient to eliminate the high burden of stunting and wasting in low- and middle-income countries. Identification of age windows and population subgroups on which to focus will benefit future preventive efforts. Here we use a population intervention effects analysis of 33 longitudinal cohorts (83,671 children, 662,763 measurements) and 30 separate exposures to show that improving maternal anthropometry and child condition at birth accounted for population increases in length-for-age z-scores of up to 0.40 and weight-for-length z-scores of up to 0.15 by 24 months of age. Boys had consistently higher risk of all forms of growth faltering than girls. Early postnatal growth faltering predisposed children to subsequent and persistent growth faltering. Children with multiple growth deficits exhibited higher mortality rates from birth to 2 years of age than children without growth deficits (hazard ratios 1.9 to 8.7). The importance of prenatal causes and severe consequences for children who experienced early growth faltering support a focus on pre-conception and pregnancy as a key opportunity for new preventive interventions.
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Affiliation(s)
- Andrew Mertens
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA.
| | - Jade Benjamin-Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - John M Colford
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Jeremy Coyle
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Mark J van der Laan
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Alan E Hubbard
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Sonali Rosete
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ivana Malenica
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nima Hejazi
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Oleg Sofrygin
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wilson Cai
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Haodong Li
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anna Nguyen
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nolan N Pokpongkiat
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Stephanie Djajadi
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anmol Seth
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther Jung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther O Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wendy Jilek
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | | | - Ryan Hafen
- Hafen Consulting, West Richland, WA, USA
| | | | - Thea Norman
- Quantitative Sciences, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Parul Christian
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA.
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA.
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31
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Mertens A, Benjamin-Chung J, Colford JM, Hubbard AE, van der Laan MJ, Coyle J, Sofrygin O, Cai W, Jilek W, Rosete S, Nguyen A, Pokpongkiat NN, Djajadi S, Seth A, Jung E, Chung EO, Malenica I, Hejazi N, Li H, Hafen R, Subramoney V, Häggström J, Norman T, Christian P, Brown KH, Arnold BF. Child wasting and concurrent stunting in low- and middle-income countries. Nature 2023; 621:558-567. [PMID: 37704720 PMCID: PMC10511327 DOI: 10.1038/s41586-023-06480-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/25/2023] [Indexed: 09/15/2023]
Abstract
Sustainable Development Goal 2.2-to end malnutrition by 2030-includes the elimination of child wasting, defined as a weight-for-length z-score that is more than two standard deviations below the median of the World Health Organization standards for child growth1. Prevailing methods to measure wasting rely on cross-sectional surveys that cannot measure onset, recovery and persistence-key features that inform preventive interventions and estimates of disease burden. Here we analyse 21 longitudinal cohorts and show that wasting is a highly dynamic process of onset and recovery, with incidence peaking between birth and 3 months. Many more children experience an episode of wasting at some point during their first 24 months than prevalent cases at a single point in time suggest. For example, at the age of 24 months, 5.6% of children were wasted, but by the same age (24 months), 29.2% of children had experienced at least one wasting episode and 10.0% had experienced two or more episodes. Children who were wasted before the age of 6 months had a faster recovery and shorter episodes than did children who were wasted at older ages; however, early wasting increased the risk of later growth faltering, including concurrent wasting and stunting (low length-for-age z-score), and thus increased the risk of mortality. In diverse populations with high seasonal rainfall, the population average weight-for-length z-score varied substantially (more than 0.5 z in some cohorts), with the lowest mean z-scores occurring during the rainiest months; this indicates that seasonally targeted interventions could be considered. Our results show the importance of establishing interventions to prevent wasting from birth to the age of 6 months, probably through improved maternal nutrition, to complement current programmes that focus on children aged 6-59 months.
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Affiliation(s)
- Andrew Mertens
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA.
| | - Jade Benjamin-Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - John M Colford
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Alan E Hubbard
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Mark J van der Laan
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Jeremy Coyle
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Oleg Sofrygin
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wilson Cai
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wendy Jilek
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Sonali Rosete
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anna Nguyen
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nolan N Pokpongkiat
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Stephanie Djajadi
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anmol Seth
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther Jung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther O Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ivana Malenica
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nima Hejazi
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Haodong Li
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ryan Hafen
- Hafen Consulting, West Richland, WA, USA
| | | | | | - Thea Norman
- Quantitative Sciences, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Parul Christian
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA.
- Department of Ophthalmology, University of California, San Francisco, CA, USA.
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Hendrickson SM, Thomas A, Raué HP, Prongay K, Haertel AJ, Rhoades NS, Slifka JF, Gao L, Quintel BK, Amanna IJ, Messaoudi I, Slifka MK. Campylobacter vaccination reduces diarrheal disease and infant growth stunting among rhesus macaques. Nat Commun 2023; 14:3806. [PMID: 37365162 PMCID: PMC10293212 DOI: 10.1038/s41467-023-39433-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 06/12/2023] [Indexed: 06/28/2023] Open
Abstract
Campylobacter-associated enteric disease is estimated to be responsible for more than 160 million cases of gastroenteritis each year and is linked to growth stunting of infants living under conditions of poor sanitation and hygiene. Here, we examine naturally occurring Campylobacter-associated diarrhea among rhesus macaques as a model to determine if vaccination could reduce severe diarrheal disease and infant growth stunting. Compared to unvaccinated controls, there are no Campylobacter diarrhea-associated deaths observed among vaccinated infant macaques and all-cause diarrhea-associated infant mortality is decreased by 76% (P = 0.03). By 9 months of age, there is a 1.3 cm increase in dorsal length that equaled a significant 1.28 LAZ (Length-for-Age Z score) improvement in linear growth among vaccinated infants compared to their unvaccinated counterparts (P = 0.001). In this work, we show that Campylobacter vaccination not only reduces diarrheal disease but also potentially serves as an effective intervention that improves infant growth trajectories.
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Affiliation(s)
- Sara M Hendrickson
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR, 97006, USA
| | - Archana Thomas
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR, 97006, USA
| | - Hans-Peter Raué
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR, 97006, USA
| | - Kamm Prongay
- Division of Animal Resources and Research Support, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR, 97006, USA
| | - Andrew J Haertel
- Division of Animal Resources and Research Support, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR, 97006, USA
| | - Nicholas S Rhoades
- Department of Microbiology, Immunology and Molecular Genetics, University of Kentucky, College of Medicine, Lexington, KY, 40506, USA
| | - Jacob F Slifka
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR, 97006, USA
| | - Lina Gao
- Biostatistics and Bioinformatics Core, Oregon National Primate Research Center, Biostatistics Shared Resource, Knight Cancer Institute, Portland, OR, 97239, USA
| | | | - Ian J Amanna
- Najít Technologies, Inc., Beaverton, OR, 97006, USA
| | - Ilhem Messaoudi
- Department of Microbiology, Immunology and Molecular Genetics, University of Kentucky, College of Medicine, Lexington, KY, 40506, USA
| | - Mark K Slifka
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR, 97006, USA.
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Skinner A, Tester-Jones MC, Carrieri D. Undernutrition among children living in refugee camps: a systematic review of prevalence. BMJ Open 2023; 13:e070246. [PMID: 37321810 PMCID: PMC10277121 DOI: 10.1136/bmjopen-2022-070246] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 05/23/2023] [Indexed: 06/17/2023] Open
Abstract
OBJECTIVES This review aimed to provide an overview of the prevalence of undernutrition in children under 5 years old in refugee camps according to the different indicators. In addition, we aimed to evaluate the quality and quantity of relevant epidemiological data available. DESIGN We used a systematic review of prevalence study design to achieve the above aims. We sought eligible observational studies through database searching of OVID Medline, CAB Global Health, Scopus and PubMed; citation chasing; and grey literature searching. SETTING The setting of interest was refugee camps across the globe. PARTICIPANTS Participants in the studies included in the review were children under 5 years old. PRIMARY AND SECONDARY OUTCOME MEASURES Outcome measures of interest were the prevalence of wasting, global acute malnutrition, stunting and underweight. RESULTS The review included 33 cross-sectional studies in 86 sites and a total of 36 750 participants. Overall, the quality of the studies was moderate to high, but some reports lacked clarity around data collection or outcome definitions. The results showed a wide variation in prevalence estimates across the different indicators and between different refugee camps. The median prevalence estimates of global acute malnutrition based on weight-for-height z-score, stunting and underweight were 7.1%, 23.8% and 16.7%, respectively. Using weight-for-height z-score identified a higher prevalence of acute malnutrition than using mid-upper arm circumference in the majority of studies. CONCLUSIONS Acute malnutrition remains a public health problem in many refugee camps, but chronic malnutrition has a high prevalence in more locations. Research and policy must, therefore, focus not only on nutrition but also on the wider determinants of both acute and chronic undernutrition. The difference in prevalence of global acute malnutrition depending on the measure used has implications for screening and diagnosis.
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Affiliation(s)
- Annabel Skinner
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | | | - Daniele Carrieri
- University of Exeter Medical School, University of Exeter, Exeter, UK
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Alam J, Nuzhat S, Billal SM, Ahmed T, Khan AI, Hossain MI. Nutritional Profiles and Zinc Supplementation among Children with Diarrhea in Bangladesh. Am J Trop Med Hyg 2023; 108:837-843. [PMID: 36848897 PMCID: PMC10077008 DOI: 10.4269/ajtmh.22-0532] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 01/02/2023] [Indexed: 03/01/2023] Open
Abstract
Zinc supplementation is an added intervention with oral rehydration solution (ORS) for treating childhood diarrhea as per World Health Organization recommendations. Our study aimed to determine the prevalence of zinc administration in addition to ORS for childhood diarrhea before hospitalization and the nutritional profile of those children admitted to the outpatient department of the largest diarrheal facility in Bangladesh. This study used a screening dataset of a clinical trial (www.clinicaltrials.gov; NCT04039828) on zinc supplementation at a Dhaka hospital (International Centre for Diarrhoeal Disease Research, Bangladesh) between September 2019 and March 2020. A total of 1,399 children aged 3-59 months were included in our study. Children were divided into two groups (one group received zinc and another did not) and were analyzed accordingly; 39.24% (n = 549) children received zinc along with ORS for the current diarrheal episode prior to hospitalization. Percentages of underweight (weight-for-age z-score < -2 SD), stunting (length/height-for-age z-score < -2 SD), wasting (weight-for-length/height z-score < -2 SD), and overweight (weight-for-age z-score > +2 SD) among these children were 13.87% (n = 194), 14.22% (n = 199), 12.08% (n = 169), and 3.43% (n = 48), respectively. In logistic regression after adjusting age, sex, and nutritional status (underweight, stunting, wasting, and overweight), association of dehydration (adjusted odds ratio [aOR]: 0.06; 95% CI: 0.03-0.11; P < 0.01), bloody diarrhea (aOR: 0.18; 95% CI: 0.11-0.92; P < 0.01), and fever (aOR: 0.27; 95% CI: 0.18-0.41; P < 0.01) were less with children who received zinc at home. Bangladesh is one of the leading zinc coverage areas globally but lags behind the target for zinc coverage in diarrheal illness among under-five children. Policymakers should scale up and formulate guidelines with sustainable strategies to encourage zinc supplementation in diarrheal episodes in Bangladesh and elsewhere.
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Affiliation(s)
- Jinat Alam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Sharika Nuzhat
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Shebab Md Billal
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
- Office of the Executive Director, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Public Health Nutrition, James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Azharul Islam Khan
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md. Iqbal Hossain
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
- Department of Public Health Nutrition, James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
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Gabain IL, Ramsteijn AS, Webster JP. Parasites and childhood stunting - a mechanistic interplay with nutrition, anaemia, gut health, microbiota, and epigenetics. Trends Parasitol 2023; 39:167-180. [PMID: 36707340 DOI: 10.1016/j.pt.2022.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/13/2022] [Accepted: 12/16/2022] [Indexed: 01/26/2023]
Abstract
Globally, stunting affects approximately 149.2 million children under 5 years of age. The underlying aetiology and pathophysiological mechanisms leading to stunting remain elusive, and therefore few effective treatment and prevention strategies exist. Crucial evidence directly linking parasites to stunting is often lacking - in part due to the complex nature of stunting, as well as a lack of critical multidisciplinary research amongst key age groups. Here, based on available studies, we present potential mechanistic pathways by which parasitic infection of mother and/or infant may lead to childhood stunting. We highlight the need for future multidisciplinary longitudinal studies and clinical trials aimed at elucidating the most influential factors, and synergies therein, that can lead to stunting, and ultimately towards finding solutions to successfully mitigate against it.
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Affiliation(s)
- Isobel L Gabain
- Department of Pathobiology and Population Sciences, Royal Veterinary College, University of London, Herts, AL9 7TA, UK; London Centre for Neglected Tropical Diseases Research, Imperial College London Faculty of Medicine, St Mary's Hospital Campus, London, W2 1NY, UK.
| | | | - Joanne P Webster
- Department of Pathobiology and Population Sciences, Royal Veterinary College, University of London, Herts, AL9 7TA, UK; London Centre for Neglected Tropical Diseases Research, Imperial College London Faculty of Medicine, St Mary's Hospital Campus, London, W2 1NY, UK
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Dearden K, Mulokozi G, Linehan M, Cherian D, Torres S, West J, Crookston B, Hall C. The Impact of a Large-Scale Social and Behavior Change Communication Intervention in the Lake Zone Region of Tanzania on Knowledge, Attitudes, and Practices Related to Stunting Prevention. Int J Environ Res Public Health 2023; 20:1214. [PMID: 36673972 PMCID: PMC9859305 DOI: 10.3390/ijerph20021214] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/22/2022] [Accepted: 12/26/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Large-scale social and behavioral change communication (SBCC) approaches can be beneficial to achieve improvements in knowledge, attitudes, and practices (KAP). Addressing Stunting in Tanzania Early (ASTUTE) included a significant SBCC component and targeted precursors to stunting including KAP related to maternal and child health, antenatal care, WASH, childhood development, and male involvement. METHODS Baseline, midline, and endline surveys were conducted for a total of 14,996 female caregivers and 6726 male heads of household in the Lake Zone region of Tanzania. Regression analyses were used to estimate differences in KAP from baseline to midline and endline. RESULTS Women's knowledge of handwashing and infant/child feeding practices, and attitudes related to male involvement, consistently improved from baseline to midline and baseline to endline. Women's practices related to antenatal care, breastfeeding, and early child development improved from baseline to midline and baseline to endline. Improvements in KAP among male heads of household were varied across indicators with consistent improvement in practices related to child feeding practices from baseline to midline and baseline to endline. CONCLUSION Many changes in KAP were observed from baseline to midline and baseline to endline and corresponded with SBCC programming in the region. These results provide support for the value of large SBCC interventions. Public health efforts in settings such as Tanzania may benefit from adopting these approaches.
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Affiliation(s)
- Kirk Dearden
- Corus International/IMA World Health, 1730 M St NW #1100, Washington, DC 20036, USA
| | - Generose Mulokozi
- Corus International/IMA World Health, Nyalali Curve, Plot 1657, Dar es Salaam P.O. Box 9260, Tanzania
| | - Mary Linehan
- Corus International/IMA World Health, 1730 M St NW #1100, Washington, DC 20036, USA
| | - Dennis Cherian
- Corus International/IMA World Health, 1730 M St NW #1100, Washington, DC 20036, USA
| | - Scott Torres
- RTI International, 701 13th St NW #750, Washington, DC 20005, USA
| | - Joshua West
- Department of Public Health, Brigham Young University, LSB, Provo, UT 84602, USA
| | - Benjamin Crookston
- Department of Public Health, Brigham Young University, LSB, Provo, UT 84602, USA
| | - Cougar Hall
- Department of Public Health, Brigham Young University, LSB, Provo, UT 84602, USA
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Yani DI, Rahayuwati L, Sari CWM, Komariah M, Fauziah SR. Family Household Characteristics and Stunting: An Update Scoping Review. Nutrients 2023; 15:nu15010233. [PMID: 36615889 PMCID: PMC9824547 DOI: 10.3390/nu15010233] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 12/30/2022] [Accepted: 12/30/2022] [Indexed: 01/03/2023] Open
Abstract
Stunting remains a public health concern in developing countries. Factors related to stunting have been categorized using various frameworks. Family plays an important role in providing nutrients for children; however, no review specifies this aspect for identifying family characteristics related to stunting. This study aimed to identify family household characteristics related to stunting among children aged less than 5 years. A scoping review was undertaken with sources from PubMed, CINAHL, and Scopus, using the keywords "family characteristics" AND "growth". Inclusion criteria were (1) correlational study; (2) published between 2018 and 31 July 2022; (3) families with children under the age of 5 years; and (4) independent variable any measure of stunting factors from family and household factors. Of 376 articles, only 20 met the inclusion criteria of the study. The family household characteristics included individual factors (sex age, history of diarrhea, and birthplace), family factors (family headship, primary caregiver/mother, social-cultural orientation, and family system factors), and environmental factors. Various child variables, family factors, and environmental factors (the type of home, floor type, water access, source of drinking water, and household electricity) were identified as being associated with stunting. Therefore, these factors should be evaluated to prevent and control stunting, and they should be incorporated into health programs targeting stunting.
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Affiliation(s)
- Desy Indra Yani
- Department of Community Health Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung 45363, Indonesia
- Correspondence: ; Tel.: +62-227796647
| | - Laili Rahayuwati
- Department of Community Health Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung 45363, Indonesia
| | - Citra Windani Mambang Sari
- Department of Community Health Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung 45363, Indonesia
| | - Maria Komariah
- Department of Fundamental Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung 45363, Indonesia
| | - Sherllina Rizqi Fauziah
- Study Program of Bachelor of Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung 45363, Indonesia
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Abdulla F, Rahman A, Hossain MM. Prevalence and risk predictors of childhood stunting in Bangladesh. PLoS One 2023; 18:e0279901. [PMID: 36701381 PMCID: PMC9879476 DOI: 10.1371/journal.pone.0279901] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 12/16/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The child nutritional status of a country is a potential indicator of socioeconomic development. Child malnutrition is still the leading cause of severe health and welfare problems across Bangladesh. The most prevalent form of child malnutrition, stunting, is a serious public health issue in many low and middle-income countries. This study aimed to investigate the heterogeneous effect of some child, maternal, household, and health-related predictors, along with the quantiles of the conditional distribution of Z-score for height-for-age (HAZ) of under five children in Bangladesh. METHODS AND MATERIALS In this study, a sample of 8,321 children under five years of age was studied from BDHS-2017-18. The chi-square test was mainly used to identify the significant predictors of the HAZ score and sequential quantile regression was used to estimate the heterogeneous effect of the significant predictors at different quantiles of the conditional HAZ distribution. RESULTS The findings revealed that female children were significantly shorter than their male counterparts except at the 75th quantile. It was also discovered that children aged 7-47 months were disadvantaged, but children aged 48-59 months were advantaged in terms of height over children aged 6 months or younger. Moreover, children with a higher birth order had significantly lower HAZ scores than 1st birth order children. In addition, home delivery, the duration of breastfeeding, and the BCG vaccine and vitamin A received status were found to have varied significant negative associations with the HAZ score. As well, seven or fewer antenatal care visits was negatively associated with the HAZ score, but more than seven antenatal care visits was positively associated with the HAZ score. Additionally, children who lived in urban areas and whose mothers were over 18 years and either normal weight or overweight had a significant height advantage. Furthermore, parental secondary or higher education had a significant positive but varied effect across the conditional HAZ distribution, except for the mother's education, at the 50th quantile. Children from wealthier families were also around 0.30 standard deviations (SD) taller than those from the poorest families. Religion also had a significant relationship with the conditional HAZ distribution in favor of non-Muslim children. CONCLUSIONS To enhance children's nutritional levels, intervention measures should be designed considering the estimated heterogeneous effect of the risk factors. This would accelerate the progress towards achieving the targets of Sustainable Development Goals (SDGs) related to child and maternal health in Bangladesh by 2030.
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Affiliation(s)
- Faruq Abdulla
- Department of Applied Health and Nutrition, RTM Al-Kabir Technical University, Sylhet, Bangladesh
| | - Azizur Rahman
- School of Computing, Mathematics and Engineering, Charles Sturt University, Wagga Wagga, NSW, Australia
| | - Md. Moyazzem Hossain
- Department of Statistics, Jahangirnagar University, Savar, Dhaka, Bangladesh
- School of Mathematics, Statistics and Physics, Newcastle University, Newcastle upon Tyne, United Kingdom
- * E-mail:
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Smith LE, Chagwena DT, Bourke C, Robertson R, Fernando S, Tavengwa NV, Cairns J, Ndhlela T, Matumbu E, Brown T, Datta K, Mutasa B, Tengende A, Chidhanguro D, Langhaug L, Makanza M, Chasekwa B, Mutasa K, Swann J, Kelly P, Ntozini R, Prendergast A. Child Health, Agriculture and Integrated Nutrition (CHAIN): protocol for a randomised controlled trial of improved infant and young child feeding in rural Zimbabwe. BMJ Open 2022; 12:e056435. [PMID: 36585147 PMCID: PMC9809274 DOI: 10.1136/bmjopen-2021-056435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Over one-quarter of children in sub-Saharan Africa are stunted; however, commercial supplements only partially meet child nutrient requirements, cannot be sustainably produced, and do not resolve physiological barriers to adequate nutrition (eg, inflammation, microbiome dysbiosis and metabolic dysfunction). Redesigning current infant and young child feeding (IYCF) interventions using locally available foods to improve intake, uptake and utilisation of nutrients could ameliorate underlying pathogenic pathways and improve infant growth during the critical period of complementary feeding, to reduce the global burden of stunting. METHODS AND ANALYSIS Child Health Agriculture Integrated Nutrition is an open-label, individual household randomised trial comparing the effects of IYCF versus 'IYCF-plus' on nutrient intake during infancy. The IYCF intervention comprises behaviour change modules to promote infant nutrition delivered by community health workers, plus small-quantity lipid-based nutrient supplements from 6 to 12 months of age which previously reduced stunting at 18 months of age by ~20% in rural Zimbabwe. The 'IYCF-plus' intervention provides these components plus powdered NUA-45 biofortified sugar beans, whole egg powder, moringa leaf powder and provitamin A maize. The trial will enrol 192 infants between 5 and 6 months of age in Shurugwi district, Zimbabwe. Research nurses will collect data plus blood, urine and stool samples at baseline (5-6 months of age) and endline (9-11 months of age). The primary outcome is energy intake, measured by multipass 24-hour dietary recall at 9-11 months of age. Secondary outcomes include nutrient intake, anthropometry and haemoglobin concentration. Nested laboratory substudies will evaluate the gut microbiome, environmental enteric dysfunction, metabolic phenotypes and innate immune function. Qualitative substudies will explore the acceptability and feasibility of the IYCF-plus intervention among participants and community stakeholders, and the effects of migration on food production and consumption. ETHICS AND DISSEMINATION This trial is registered at ClinicalTrials.gov (NCT04874688) and was approved by the Medical Research Council of Zimbabwe (MRCZ/A/2679) with the final version 1.4 approved on 20 August 2021, following additional amendments. Dissemination of trial results will be conducted through the Community Engagement Advisory Board in the study district and through national-level platforms. TRIAL REGISTRATION NUMBER NCT04874688.
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Affiliation(s)
- Laura E Smith
- Public and Ecosystem Health, Cornell University, Ithaca, New York, USA
| | - Dexter T Chagwena
- Nutrition, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Nutrition, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Claire Bourke
- Blizard Institute, Queen Mary University, London, UK
| | | | - Shamiso Fernando
- Nutrition, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Naume V Tavengwa
- Nutrition, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | | | | | - Exhibit Matumbu
- Nutrition, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | | | | | - Batsirai Mutasa
- Nutrition, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Alice Tengende
- Nutrition, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Dzivaidzo Chidhanguro
- Nutrition, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Lisa Langhaug
- Nutrition, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Maggie Makanza
- Nutrition, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Bernard Chasekwa
- Nutrition, Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Kuda Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Jonathan Swann
- University of Southampton Faculty of Medicine, Southampton, UK
| | - Paul Kelly
- Barts and The London School of Medicine, London, UK
| | - Robert Ntozini
- Biostatistics & IT, Zvitambo Institute, Harare, Zimbabwe
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Siswati T, Iskandar S, Pramestuti N, Raharjo J, Rubaya AK, Wiratama BS. Drivers of Stunting Reduction in Yogyakarta, Indonesia: A Case Study. Int J Environ Res Public Health 2022; 19:16497. [PMID: 36554378 PMCID: PMC9779185 DOI: 10.3390/ijerph192416497] [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] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/02/2022] [Accepted: 12/06/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Chronic malnutrition in children is a severe global health concern. In Yogyakarta, the number of children who are too short for their age has dropped dramatically over the past few decades. OBJECTIVE To perform an analysis of trends, policies, and programs; and an assessment of government, community, household, and individual drivers of the stunting reduction in Yogyakarta, Indonesia. METHOD Using a mixed-methods approach, there were three types of research: (1) analysis of quantitative data, (2) evaluation of stunting policy, and (3) focus group discussions and in-depth interviews to collect qualitative data. RESULTS The prevalence of stunting has decreased from year to year. Mean height-for-age z-scores (HAZ) improved by 0.22 SDs from 2013 to 2021. Male and female toddlers aged <20 months have relatively the same body length as the WHO median, but it is lower for children >20 months old. The COVID-19 pandemic has contributed to an increase in stunting-concurrent wasting. Nutrition-specific and -sensitive interventions have been carried out with coverage that continues to increase from year to year, although in 2020, or at the beginning of the COVID-19 pandemic, the coverage of specific interventions decreased. The government has committed to tackling stunting by implementing the five pillars of stunting prevention and the eight convergent stunting actions. As the drivers of stunting reduction, national and community stakeholders and mothers, at the village level, cited a combination of poverty reduction, years of formal education, prevention of early marriage, access to food, enhanced knowledge and perception, and increased access to sanitation and hygiene. CONCLUSIONS Nutrition-specific and -sensitive sector improvements have been crucial for decreasing stunting in Yogyakarta, particularly in the areas of poverty reduction, food access, preventing child marriage, sanitation, education, and increasing knowledge and perception.
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Affiliation(s)
- Tri Siswati
- Department of Nutrition, Poltekkes Kemenkes Yogyakarta, Tata Bumi No. 3, Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
- Center of Excellence for Applied Technology Innovation in the Field of Public Health, Poltekkes Kemenkes Yogyakarta, Tata Bumi No. 3 Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
| | - Slamet Iskandar
- Department of Nutrition, Poltekkes Kemenkes Yogyakarta, Tata Bumi No. 3, Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
- Center of Excellence for Applied Technology Innovation in the Field of Public Health, Poltekkes Kemenkes Yogyakarta, Tata Bumi No. 3 Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
| | - Nova Pramestuti
- Balai Litbang Kesehatan Banjarnegara, Selamanik No. 16 A, Banjarnegara 53415, Indonesia
| | - Jarohman Raharjo
- Balai Litbang Kesehatan Banjarnegara, Selamanik No. 16 A, Banjarnegara 53415, Indonesia
| | - Agus Kharmayana Rubaya
- Balai Litbang Kesehatan Banjarnegara, Selamanik No. 16 A, Banjarnegara 53415, Indonesia
- Department of Environmental Health, Poltekkes Kemenkes Yogyakarta, Tata Bumi No. 3, Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
| | - Bayu Satria Wiratama
- Department of Epidemiology, Biostatistics and Population Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei 110, Taiwan
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Herawati DMD, Sunjaya DK. Implementation Outcomes of National Convergence Action Policy to Accelerate Stunting Prevention and Reduction at the Local Level in Indonesia: A Qualitative Study. Int J Environ Res Public Health 2022; 19:13591. [PMID: 36294173 PMCID: PMC9602846 DOI: 10.3390/ijerph192013591] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/11/2022] [Accepted: 10/15/2022] [Indexed: 06/16/2023]
Abstract
The study aims to explore the implementation outcome variables of Indonesia's national policy convergence action in the stunting reduction intervention at district, sub-district, and village levels. The study design was qualitative with an implementation research approach at District Cirebon, Indonesia. Data were collected through in-depth interviews, focus group discussions, study documents, and 6 months of participant observation. We recruited 172 respondents. The assessment instrument used was formed on was implementation outcomes variables. Data were analyzed through coding, categorizing and thematic content analysis based on a predetermined theme. Comparative cross district activity-site analysis was applied between sub-districts and villages. The implementation outcome variables for the convergence action policy were performed well at the district level, in line with the central government's adequate regulation, control, and budget. Meanwhile, the sub-district and village levels only performed aspects of acceptability, appropriateness, and coverage for specific interventions. The acceptability level in the village was only partially running. The barriers at the sub-district and village levels were issues of commitment, staff capacity, and poor coordination. Superficial understanding and capacity weaknesses drove the convergence of the stunting reduction responsibility back into the burden of the health sector at the forefront. Local politics also colored the implementation in the village.
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Ali MK, Flacking R, Sulaiman M, Osman F. Effects of Nutrition Counselling and Unconditional Cash Transfer on Child Growth and Family Food Security in Internally Displaced Person Camps in Somalia-A Quasi-Experimental Study. Int J Environ Res Public Health 2022; 19:13441. [PMID: 36294019 PMCID: PMC9603782 DOI: 10.3390/ijerph192013441] [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] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/06/2022] [Accepted: 10/14/2022] [Indexed: 06/16/2023]
Abstract
The effects of nutrition counselling (NC) and unconditional cash transfer (UCT) in improving growth in children under five and household food security are poorly understood in humanitarian settings. Therefore, this study aimed to evaluate the effects of NC and NC combined with unconditional cash transfer (NC + UCT) on children's growth and food security in Somalia. The study was performed with a quasi-experimental design in two districts in the Banadir region of Somalia. Caregivers (n = 255) with mildly to moderately malnourished children aged 6 to 59 months old (n = 184) were randomized to the NC, NC + UCT and control groups. The interventions consisted of weekly NC for three months alone or in combination with UCT. The outcome variables were wasting, underweight, stunting, and food security. Difference-indifferences analysis was used to estimate the effect of the interventions. Our study did not find any significant impacts of NC or NC + UCT on child wasting, underweight, stunting, food security or household expenses. In conclusion, NC, alone or in combination with UCT, did not impact children's growth or household food security. Thus, a culturally tailored NC programme over a longer period, supplemented with cash transfer, could be beneficial to consider when designing interventions to reduce malnutrition and food insecurity.
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Affiliation(s)
- Mohamed Kalid Ali
- School of Health and Welfare, Dalarna University, 79182 Falun, Sweden
- Food and Agriculture Organisation of the United Nations (FAO), Somalia Country Office, Nairobi P.O. Box 30470-00100, Kenya
| | - Renée Flacking
- School of Health and Welfare, Dalarna University, 79182 Falun, Sweden
| | - Munshi Sulaiman
- BRAC International, Clock Tower, Kampala P.O. Box 31817, Uganda
| | - Fatumo Osman
- School of Health and Welfare, Dalarna University, 79182 Falun, Sweden
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Modjadji P, Masilela LN, Cele L, Mathibe M, Mphekgwana PM. Evidence of Concurrent Stunting and Obesity among Children under 2 Years from Socio-Economically Disadvantaged Backgrounds in the Era of the Integrated Nutrition Programme in South Africa. Int J Environ Res Public Health 2022; 19:12501. [PMID: 36231797 PMCID: PMC9564645 DOI: 10.3390/ijerph191912501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/08/2022] [Accepted: 09/26/2022] [Indexed: 06/16/2023]
Abstract
In view of persistent stunting and increasing rates of obesity coexisting among children in the era of the Integrated Nutrition Programme, a cross-sectional study was conducted to determined concurrent stunting and obesity (CSO) and related factors using a random sample of child-mother pairs (n = 400) in Mbombela, South Africa. Sociodemographic data was collected using a validated questionnaire, and stunting (≥2SD) and obesity (>3SD) were assessed through respective length-for-age (LAZ) and body mass index (BAZ) z-scores. Using SPSS 26.0, the mean age of children was 8 (4; 11) months, and poor sociodemographic status was observed, in terms of maternal singlehood (73%), no education or attaining primary education only (21%), being unemployed (79%), living in households with a monthly income below R10,000 (≈$617), and poor sanitation (84%). The z-test for a single proportion showed a significant difference between the prevalence of CSO (41%) and non-CSO (69%). Testing for the two hypotheses using the Chi-square test showed no significant difference of CSO between boys (40%) and girls (41%), while CSO was significantly different and high among children aged 6-11 months (55%), compared to those aged 0-5 months (35%) and ≥12 months (30%). Further analysis using hierarchical logistic regression showed significant associations of CSO with employment (AOR = 0.34; 95%CI: 0.14-0.78), maternal education status (AOR = 0.39; 95%CI: 0.14-1.09) and water access (AOR = 2.47; 95%CI: 1.32; 4.63). Evidence-based and multilevel intervention programs aiming to prevent CSO and addressing stunting, while improving weight status in children with social disadvantages, are necessary.
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Affiliation(s)
- Perpetua Modjadji
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, 1 Molotlegi Street, Ga-Rankuwa 0208, South Africa
- Non-Communicable Disease Research Unit, South African Medical Research Council, Cape Town 7505, South Africa
| | - Lucy Nomsa Masilela
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, 1 Molotlegi Street, Ga-Rankuwa 0208, South Africa
| | - Lindiwe Cele
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, 1 Molotlegi Street, Ga-Rankuwa 0208, South Africa
| | - Mmampedi Mathibe
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, 1 Molotlegi Street, Ga-Rankuwa 0208, South Africa
| | - Peter Modupi Mphekgwana
- Research Administration and Development, University of Limpopo, Polokwane 0700, South Africa
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Siswati T, Iskandar S, Pramestuti N, Raharjo J, Rubaya AK, Wiratama BS. Impact of an Integrative Nutrition Package through Home Visit on Maternal and Children Outcome: Finding from Locus Stunting in Yogyakarta, Indonesia. Nutrients 2022; 14:nu14163448. [PMID: 36014954 PMCID: PMC9416237 DOI: 10.3390/nu14163448] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/09/2022] [Accepted: 08/17/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Stunting has been a public health problem in several developing countries including Indonesia. One of the strategies to reduce stunting was family assistance. This study was aimed to estimate the effect of family assistance by using an integrative nutrition package through home visits on the growth and development of stunted children. Method: This was an experimental study using pre-test post-test with control group design, conducted in Yogyakarta, Indonesia, on March to May 2022. The intervention group was provided an integrative nutrition package (INP) including maternal education, behavioral change through home visit, as well as monitoring children’s outcome, while the control group was asked to read and follow child care procedure in the maternal and child health (MCH) book as a standard procedure. Both groups were visited by trained health volunteers and had a complementary feeding (CF) package weekly for four weeks. The outcomes of this study were the maternal outcome (knowledge and behavior on children’s growth monitoring (CGM), children’s development monitoring (CDM), and infant/young children feeding (IYCF) as well as children’s outcomes, including body weight (BW), body height (BH), and child score development (CSD). This study used generalized estimating equation (GEE) to estimate the differences in differences (DID) of the impact of intervention compared with control group and compared among three different times (baseline, fourth, and eighth week). Results: There were 60 stunted children under five years in this study, i.e., 30 in intervention group and 30 in control group. From the GEE analysis, it was found that the regression adjusted DID showed statistically significant increase of all outcomes including children’s development score (CDS). The adjusted DID effect (95% CI) on 8th week for children’s weight, height, and development score were 0.31 (0.25–0.37), 0.41 (0.13–0.68), and −0.40 (−0.59–(−0.21)), respectively, among the intervention group. Conclusions: INP through home visit successfully increased maternal and children’s outcomes compared witsh standard procedure. The effect of intervention was found to be consistently significant in the fourth and eighth weeks after intervention. We recommend the local government to apply INP through home visit especially in high-prevalence stunting areas.
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Affiliation(s)
- Tri Siswati
- Department of Nutrition, Politeknik Kesehatan Kemenkes Yogyakarta, Tata Bumi No. 3, Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
- Pusat Unggulan Iptek Inovasi Teknologi Terapan Kesehatan Masyarakat, Politeknik Kesehatan Kemenkes Yogyakarta, Tata Bumi No. 3, Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
- Correspondence:
| | - Slamet Iskandar
- Department of Nutrition, Politeknik Kesehatan Kemenkes Yogyakarta, Tata Bumi No. 3, Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
- Pusat Unggulan Iptek Inovasi Teknologi Terapan Kesehatan Masyarakat, Politeknik Kesehatan Kemenkes Yogyakarta, Tata Bumi No. 3, Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
| | - Nova Pramestuti
- Balai Litbang Kesehatan Banjarnegara, Selamanik No. 16 A, Banjarnegara 53415, Indonesia
| | - Jarohman Raharjo
- Balai Litbang Kesehatan Banjarnegara, Selamanik No. 16 A, Banjarnegara 53415, Indonesia
| | - Agus Kharmayana Rubaya
- Pusat Unggulan Iptek Inovasi Teknologi Terapan Kesehatan Masyarakat, Politeknik Kesehatan Kemenkes Yogyakarta, Tata Bumi No. 3, Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
- Department of Environmental Health, Politeknik Kesehatan Kemenkes Yogyakarta, Tata Bumi No. 3, Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
| | - Bayu Satria Wiratama
- Department of Epidemiology, Biostatistics and Population Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei 11031, Taiwan
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Siswati T, Iskandar S, Pramestuti N, Raharjo J, Rialihanto MP, Rubaya AK, Wiratama BS. Effect of a Short Course on Improving the Cadres' Knowledge in the Context of Reducing Stunting through Home Visits in Yogyakarta, Indonesia. Int J Environ Res Public Health 2022; 19:9843. [PMID: 36011477 PMCID: PMC9408553 DOI: 10.3390/ijerph19169843] [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] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 08/05/2022] [Accepted: 08/06/2022] [Indexed: 06/15/2023]
Abstract
Background: Stunting is primarily a public health concern in Low- and Middle-Income Countries (LMIC). The involvement of Integrated Health Service Post (Indonesian: Posyandu) cadres is among the strategies to combat stunting in Indonesia. Objective: This study aimed to determine the effect of a short course on cadres' knowledge. Method: A single group pre-test post-test design was conducted in Yogyakarta, Indonesia, from March to May 2022. Thirty cadres were selected based on the following criteria: willingness to participate, the number of stunted children in their Posyandu, able to read and write, and full attendance at the short course. The knowledge scores were measured by a questionnaire using true and false answers after a short course (post-test 1) and 4 weeks later (post-test 2). We apply STATA 16 to calculate the Mean Difference (MD) using a t-test and a Generalized Estimated Equation (GEE). Furthermore, the adequacy of the short course was evaluated with in-depth interviews. Result: GEE analysis showed that after controlling for age, education, occupation, and years of experience, the short course improved cadres' knowledge significantly on post-tests 1 and 2, i.e., knowledge regarding Children Growth Monitoring (CGM) (Beta = 6.07, 95%CI: 5.10-7.03 and Beta = 8.57, 95%CI: 7.60-9.53, respectively), Children Development Monitoring (CDM) (Beta = 6.70, 95%CI: 5.75-7.65 and Beta = 9.27, 95%CI: 8.31-10.22, respectively), and Infant Young Children Feeding (IYCF) (Beta = 5.83, 95%CI: 4.44-7.23 and Beta = 11.7, 95%CI: 10.31-13.09, respectively). Furthermore, the short course increased their self-efficacy, confidence, and ability to assist stunted children through home visits. Conclusion: The short courses consistently and significantly boosted cadres' knowledge of CGM, CDM, and IYCF, and appropriately facilitated cadres in visits to the homes of stunted children's home.
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Affiliation(s)
- Tri Siswati
- Department of Nutrition, Politeknik Kesehatan Kemenkes Yogyakarta, Tata Bumi No. 3, Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
- Pusat Unggulan Iptek Inovasi Teknologi Terapan Kesehatan Masyarakat, Politeknik Kesehatan Kemenkes Yogyakarta, Tata Bumi No. 3 Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
| | - Slamet Iskandar
- Department of Nutrition, Politeknik Kesehatan Kemenkes Yogyakarta, Tata Bumi No. 3, Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
- Pusat Unggulan Iptek Inovasi Teknologi Terapan Kesehatan Masyarakat, Politeknik Kesehatan Kemenkes Yogyakarta, Tata Bumi No. 3 Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
| | - Nova Pramestuti
- Balai Litbang Kesehatan Banjarnegara, Selamanik No. 16 A, Banjarnegara 53415, Indonesia
| | - Jarohman Raharjo
- Balai Litbang Kesehatan Banjarnegara, Selamanik No. 16 A, Banjarnegara 53415, Indonesia
| | - Muhammad Primiaji Rialihanto
- Department of Nutrition, Politeknik Kesehatan Kemenkes Yogyakarta, Tata Bumi No. 3, Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
- Pusat Unggulan Iptek Inovasi Teknologi Terapan Kesehatan Masyarakat, Politeknik Kesehatan Kemenkes Yogyakarta, Tata Bumi No. 3 Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
| | - Agus Kharmayana Rubaya
- Pusat Unggulan Iptek Inovasi Teknologi Terapan Kesehatan Masyarakat, Politeknik Kesehatan Kemenkes Yogyakarta, Tata Bumi No. 3 Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
- Department of Environmental Health, Politeknik Kesehatan Kemenkes Yogyakarta, Tata Bumi No. 3, Banyuraden, Gamping, Sleman, Yogyakarta 55293, Indonesia
| | - Bayu Satria Wiratama
- Department of Epidemiology, Biostatistics and Population Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei 11031, Taiwan
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Krebs NF, Hambidge KM, Westcott JL, Garcés AL, Figueroa L, Tshefu AK, Lokangaka AL, Goudar SS, Dhaded SM, Saleem S, Ali SA, Bauserman MS, Derman RJ, Goldenberg RL, Das A, Chowdhury D. Birth length is the strongest predictor of linear growth status and stunting in the first 2 years of life after a preconception maternal nutrition intervention: the children of the Women First trial. Am J Clin Nutr 2022; 116:86-96. [PMID: 35681255 PMCID: PMC9257468 DOI: 10.1093/ajcn/nqac051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/16/2022] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The multicountry Women First trial demonstrated that nutritional supplementation initiated prior to conception (arm 1) or early pregnancy (arm 2) and continued until delivery resulted in significantly greater length at birth and 6 mo compared with infants in the control arm (arm 3). OBJECTIVES We evaluated intervention effects on infants' longitudinal growth trajectory from birth through 24 mo and identified predictors of length status and stunting at 24 mo. METHODS Infants' anthropometry was obtained at 6, 12, 18, and 24 mo after the Women First trial (registered at clinicaltrials.gov as NCT01883193), which was conducted in low-resource settings: Democratic Republic of Congo, Guatemala, India, and Pakistan. Longitudinal models evaluated intervention effects on infants' growth trajectory from birth to 24 mo, with additional modeling used to identify adjusted predictors for growth trajectories and outcomes at 24 mo. RESULTS Data for 2337 (95% of original live births) infants were evaluated. At 24 mo, stunting rates were 62.8%, 64.8%, and 66.3% for arms 1, 2, and 3, respectively (NS). For the length-for-age z-score (LAZ) trajectory, treatment arm was a significant predictor, with adjusted mean differences of 0.19 SD (95% CI: 0.08, 0.30; P < 0.001) and 0.17 SD (95% CI: 0.07, 0.27; P < 0.001) for arms 1 and 2, respectively. The strongest predictors of LAZ at 24 mo were birth LAZ <-2 and <-1 to ≥-2, with adjusted mean differences of -0.76 SD (95% CI: -0.93, -0.58; P < 0.001) and -0.47 SD (95% CI: -0.56, -0.38; P < 0.001), respectively. For infants with ultrasound-determined gestational age (n = 1329), the strongest predictors of stunting were birth LAZ <-2 and <-1 to ≥- 2: adjusted relative risk of 1.62 (95% CI: 1.39, 1.88; P < 0.001) and 1.46 (95% CI: 1.31, 1.62; P < 0.001), respectively. CONCLUSIONS Substantial improvements in postnatal growth are likely to depend on improved intrauterine growth, especially during early pregnancy.
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Affiliation(s)
- Nancy F Krebs
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Denver, CO, USA
| | - K Michael Hambidge
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Denver, CO, USA
| | - Jamie L Westcott
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Denver, CO, USA
| | - Ana L Garcés
- Unidad de Salud Materno Infantil, Instituto de Nutrición de Centroamérica y Panamá (INCAP), Calzada Roosevelt, Guatemala City, Guatemala
| | - Lester Figueroa
- Unidad de Salud Materno Infantil, Instituto de Nutrición de Centroamérica y Panamá (INCAP), Calzada Roosevelt, Guatemala City, Guatemala
| | - Antoinette K Tshefu
- Kinshasa School of Public Health, Hôpital Général de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Adrien L Lokangaka
- Kinshasa School of Public Health, Hôpital Général de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, India
| | - Sangappa M Dhaded
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, India
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Sumera Aziz Ali
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Melissa S Bauserman
- Department of Pediatrics Neonatal-Perinatal Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Richard J Derman
- Department of OBGYN, Thomas Jefferson University, Philadelphia, PA, USA
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Kishore S, Thomas T, Sachdev H, Kurpad AV, Webb P. Modeling the potential impacts of improved monthly income on child stunting in India: a subnational geospatial perspective. BMJ Open 2022; 12:e055098. [PMID: 35383064 PMCID: PMC8984000 DOI: 10.1136/bmjopen-2021-055098] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Approximately one-third of the world's stunted (low height-for-age) preschool-aged children live in India. The success of interventions designed to tackle stunting appears to vary by location and depth of poverty. We developed small-area estimation models to assess the potential impact of increments in household income on stunting across the country. DESIGN Two nationally representative cross-sectional datasets were used: India's National Family Health Survey 4 (2015-2016) and the 68th round of the National Sample Survey on consumer expenditure. The two datasets were combined with statistical matching. Gaussian process regressions were used to perform geospatial modelling of 'stunting' controlling for household wealth and other covariates. SETTING AND PARTICIPANTS The number of children in this sample totalled 259 627. Children with implausible height-for-age z-scores (HAZs) >5 or <-5, or missing data on drinking water, sanitation facility, mother's education, or geolocation and children not residing in mainland India were excluded, resulting in 207 695 observations for analysis. RESULTS A monthly transfer of ~$7 (500 Indian rupees) per capita to every household (not targeted or conditional) was estimated to reduce stunting nationally by 3.8 percentage points on average (95% credible interval: 0.14%-10%), but with substantial variation by state. Estimated reduction in stunting varied by wealth of households, with the poorest quintile being likely to benefit the most. CONCLUSION Improving household income, which can be supported through cash transfers, has the potential to significantly reduce stunting in parts of India where the burdens of both stunting and poverty are high. Modelling shows that for other regions, income transfers may raise incomes and contribute to improved nutrition, but there would be a need for complementary activities for alleviating stunting. While having value for the country as a whole, impact of income gained could be variable, and underlying drivers of stunting need to be tackled through supplementary interventions.
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Affiliation(s)
- Satvik Kishore
- Nutrition, St John's Research Institute, Bengaluru, Karnataka, India
| | - Tinku Thomas
- Division of Biostatistics, St John's Research Institute, Bangalore, Karnataka, India
- Biostatistics, St John's Medical College, Bangalore, Karnataka, India
| | - Harshpal Sachdev
- Department of Paediatrics, Sitaram Bhartia Institute of Science and Research, New Delhi, Delhi, India
| | - Anura V Kurpad
- Division of Nutrition, St John's Medical College, Bangalore, Karnataka, India
| | - Patrick Webb
- Friedman School of Nutrition, Tufts University, Medford, Massachusetts, USA
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Wood CL, van ‘t Hof R, Dillon S, Straub V, Wong SC, Ahmed SF, Farquharson C. Combined growth hormone and insulin-like growth factor-1 rescues growth retardation in glucocorticoid-treated mdxmice but does not prevent osteopenia. J Endocrinol 2022; 253:63-74. [PMID: 35191394 PMCID: PMC9010817 DOI: 10.1530/joe-21-0388] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/21/2022] [Indexed: 11/18/2022]
Abstract
Short stature and osteoporosis are common in Duchenne muscular dystrophy (DMD) and its pathophysiology may include an abnormality of the growth hormone/insulin-like growth factor-1 (GH/IGF-1) axis, which is further exacerbated by long-term glucocorticoid (GC) treatment. Hence, an agent that has anabolic properties and may improve linear growth would be beneficial in this setting and therefore requires further exploration. A 5-week-old x-linked muscular dystrophy (mdx) mice were used as a model of DMD. They were treated with prednisolone ± GH + IGF-1 for 4 weeks and then compared to control mdx mice to allow the study of both growth and skeletal structure. GC reduced cortical bone area, bone fraction, tissue area and volume and cortical bone volume, as assessed by micro computed tomography (CT) In addition, GC caused somatic and skeletal growth retardation but improved grip strength. The addition of GH + IGF-1 therapy rescued the somatic growth retardation and induced additional improvements in grip strength (16.9% increase, P < 0.05 compared to control). There was no improvement in bone microarchitecture (assessed by micro-CT and static histomorphometry) or biomechanical properties (assessed by three-point bending). Serum bone turnover markers (Serum procollagen 1 intact N-terminal propeptide (P1NP), alpha C-terminal telopeptide (αCTX)) also remained unaffected. Further work is needed to maximise these gains before proceeding to clinical trials in boys with DMD.
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Affiliation(s)
- Claire L Wood
- Division of Functional Genetics and Development, Roslin Institute, University of Edinburgh, Edinburgh, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Correspondence should be addressed to C Wood or C Farquharson: or
| | - Rob van ‘t Hof
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Scott Dillon
- Division of Functional Genetics and Development, Roslin Institute, University of Edinburgh, Edinburgh, UK
| | - Volker Straub
- John Walton Muscular Dystrophy Research Centre, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sze C Wong
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Glasgow, UK
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Glasgow, UK
| | - Colin Farquharson
- Division of Functional Genetics and Development, Roslin Institute, University of Edinburgh, Edinburgh, UK
- Correspondence should be addressed to C Wood or C Farquharson: or
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Indra J, Khoirunurrofik K. Understanding the role of village fund and administrative capacity in stunting reduction: Empirical evidence from Indonesia. PLoS One 2022; 17:e0262743. [PMID: 35089957 PMCID: PMC8797224 DOI: 10.1371/journal.pone.0262743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 01/04/2022] [Indexed: 11/20/2022] Open
Abstract
The Indonesian government launched various programs to handle stunting cases, including village funds. This paper examined the effects of village fund programs and village apparatuses’ capacities to combat stunting based on aggregate data at the district level in Indonesia. Using descriptive data analysis and fixed effect panel regression, we observed that village fund programs could significantly reduce Indonesia’s stunting prevalence, especially outside Java. It also revealed that the increasing education of regional leaders does not necessarily positively impact leaders’ skills in handling stunting. At the same time, the number of village officials has a statistically significant influence on reducing stunting prevalence. It advised that the village budget fund can support national priorities in tackling the prevalence of stunting. Furthermore, it is essential to build the capacity of the village head for increasing awareness of health activities, especially early prevention of stunting, in addition to an adequate number of officials.
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Affiliation(s)
- Jul Indra
- Graduate Programme in Economics, Faculty of Economics and Business, University of Indonesia, Depok, Indonesia
| | - Khoirunurrofik Khoirunurrofik
- Graduate Programme in Economics, Faculty of Economics and Business, University of Indonesia, Depok, Indonesia
- Research Cluster on Energy Modeling and Regional Economic Analysis (RCEMREA), Faculty of Economics and Business, Universitas Indonesia, Depok, Indonesia
- * E-mail:
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Thurstans S, Sessions N, Dolan C, Sadler K, Cichon B, Isanaka S, Roberfroid D, Stobaugh H, Webb P, Khara T. The relationship between wasting and stunting in young children: A systematic review. Matern Child Nutr 2022; 18:e13246. [PMID: 34486229 PMCID: PMC8710094 DOI: 10.1111/mcn.13246] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/26/2021] [Accepted: 06/22/2021] [Indexed: 11/27/2022]
Abstract
In 2014, the Emergency Nutrition Network published a report on the relationship between wasting and stunting. We aim to review evidence generated since that review to better understand the implications for improving child nutrition, health and survival. We conducted a systematic review following PRISMA guidelines, registered with PROSPERO. We identified search terms that describe wasting and stunting and the relationship between the two. We included studies related to children under five from low- and middle-income countries that assessed both ponderal growth/wasting and linear growth/stunting and the association between the two. We included 45 studies. The review found the peak incidence of both wasting and stunting is between birth and 3 months. There is a strong association between the two conditions whereby episodes of wasting contribute to stunting and, to a lesser extent, stunting leads to wasting. Children with multiple anthropometric deficits, including concurrent stunting and wasting, have the highest risk of near-term mortality when compared with children with any one deficit alone. Furthermore, evidence suggests that the use of mid-upper-arm circumference combined with weight-for-age Z score might effectively identify children at most risk of near-term mortality. Wasting and stunting, driven by common factors, frequently occur in the same child, either simultaneously or at different moments through their life course. Evidence of a process of accumulation of nutritional deficits and increased risk of mortality over a child's life demonstrates the pressing need for integrated policy, financing and programmatic approaches to the prevention and treatment of child malnutrition.
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Affiliation(s)
- Susan Thurstans
- Department of Population HealthLondon School of Hygiene and Tropical MedicineLondonUnited KingdomUK
- Emergency Nutrition NetworkOxfordUK
| | | | | | | | | | - Sheila Isanaka
- Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
- Department of ResearchEpicentreParisFrance
| | - Dominique Roberfroid
- Faculty of MedicineUniversity of NamurNamurBelgium
- Department of Food Technology, Safety and HealthGhent UniversityGhentBelgium
| | - Heather Stobaugh
- Action Against Hunger USANew YorkNew YorkUSA
- Friedman School of Nutrition Science and PolicyTufts UniversityBostonMassachusettsUSA
| | - Patrick Webb
- Friedman School of Nutrition Science and PolicyTufts UniversityBostonMassachusettsUSA
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