Facilitators and Barriers to Traditional Food Consumption in the Cree Community of Mistissini, Northern Quebec.

To identify barriers to traditional food consumption and factors that facilitate it among the Cree community of Mistissini, a series of four focus groups was conducted with a total of twenty-three people. Two ecological models were created, one for facilitating factors and a second for obstacles, illustrating the role of numerous interconnected influences of traditional food consumption. Environmental impact project, laws and regulation, local businesses, traditional knowledge, youth influence, employment status, and nonconvenience of traditional food were named among numerous factors influencing traditional food consumption. The findings of this study can be used by political and public health organizations to promote traditional food where more emphasis should be invested in community and environmental strategies.

Consumption patterns of sweetened food and drink products in a Catholic Middle Eastern Canadian community.

OBJECTIVE: The present study describes the consumption patterns of sweetened food and drink products in a Catholic Middle Eastern Canadian community and examines its associations with physical activity, sedentary behaviours and BMI. DESIGN: A two-stage cross-sectional design was used. In Stage 1 (n 42), 24 h recalls enabled the identification of sweetened products. In Stage 2 (n 192), an FFQ was administered to measure the daily consumption of these products and to collect sociodemographic and behavioural data. Sweetened products were defined as processed culinary ingredients and ultra-processed products for which total sugar content exceeded 20% of total energy. SETTING: Three Catholic Middle Eastern churches located in Montreal, Canada. SUBJECTS: Normoglycaemic men and women (18-60 years old). RESULTS: Twenty-six sweetened products represented an average consumption of 75·4 g total sugars/d or 15·1% of daily energy intake (n 190, 56% women). Soft drinks, juices, sweetened coffee, chocolate, cookies, cakes and muffins were the main sources of consumption and mostly consumed between meals. Age (exp (ß) = 0·99; P < 0·01), physical activity (exp (ß) = 1·08; P < 0·01) and recreational computer use (exp (ß) = 1·17; P < 0·01) were independently associated with sweetened product consumption. The association between sweetened product consumption and physical activity was U-shaped. BMI was not significantly associated with sweetened product consumption but all participants regardless of BMI were above the WHO recommendation for free sugars. CONCLUSIONS: Being physically active and spending less time using a computer may favour a reduced consumption of sweetened products. Very active individuals may, however, overconsume such products.

Household food insecurity and Canadian Aboriginal women's self-efficacy in food preparation.

PURPOSE: Determinants of self-efficacy related to food preparation using store-bought food were examined in women belonging to the Atikamekw Nation. Also examined was whether self-efficacy was associated with household food insecurity. METHODS: A cross-sectional survey was conducted with 107 women responsible for household food supplies. Two self-efficacy scores were calculated, one for healthy food preparation and one for food preparation in general. Household food insecurity was measured with an adapted version of the United States Food Security Core Module. The other variables were household composition, income sources, food supplies, tobacco use, participants' health status, and lifestyle and sociodemographic characteristics. Multiple linear regression was used to analyze associations between self-efficacy and household food insecurity in 99 participants. RESULTS: Severe household food insecurity was associated with significantly lower healthy food preparation scores in Atikamekw women. Other associated variables were food supplies, marital status, alcohol consumption, weight status, and understanding of the native language. CONCLUSIONS: Application of the concept of self-efficacy contributes to a better understanding of the factors influencing food preparation in Atikamekw women. In this study, self-efficacy in healthy food preparation was linked to food insecurity and obesity, particularly in the most serious cases. Efforts to improve diet will require not only behavioural interventions, but public policies.

Poor nutritional status of schoolchildren in urban and peri-urban areas of Ouagadougou (Burkina Faso).

BACKGROUND: Malnutrition is still highly prevalent in developing countries. Schoolchildren may also be at high nutritional risk, not only under-five children. However, their nutritional status is poorly documented, particularly in urban areas. The paucity of information hinders the development of relevant nutrition programs for schoolchildren. The aim of this study carried out in Ouagadougou was to assess the nutritional status of schoolchildren attending public and private schools. METHODS: The study was carried out to provide baseline data for the implementation and evaluation of the Nutrition Friendly School Initiative of WHO. Six intervention schools and six matched control schools were selected and a sample of 649 schoolchildren (48% boys) aged 7-14 years old from 8 public and 4 private schools were studied. Anthropometric and haemoglobin measurements, along with thyroid palpation, were performed. Serum retinol was measured in a random sub-sample of children (N = 173). WHO criteria were used to assess nutritional status. Chi square and independent t-test were used for proportions and mean comparisons between groups. RESULTS: Mean age of the children (48% boys) was 11.5 ± 1.2 years. Micronutrient malnutrition was highly prevalent, with 38.7% low serum retinol and 40.4% anaemia. The prevalence of stunting was 8.8% and that of thinness, 13.7%. The prevalence of anaemia (p = 0.001) and vitamin A deficiency (p < 0.001) was significantly higher in public than private schools. Goitre was not detected. Overweight/obesity was low (2.3%) and affected significantly more children in private schools (p = 0.009) and younger children (7-9 y) (p < 0.05). Thinness and stunting were significantly higher in peri-urban compared to urban schools (p < 0.05 and p = 0.004 respectively). Almost 15% of the children presented at least two nutritional deficiencies. CONCLUSION: This study shows that malnutrition and micronutrient deficiencies are also widely prevalent in schoolchildren in cities, and it underlines the need for nutrition interventions to target them.

Are snacking patterns associated with risk of overweight among Kahnawake schoolchildren?

OBJECTIVE: To understand more specifically how the quality, quantity and frequency of snack food consumption differs in different BMI categories. DESIGN: Four hundred and forty-nine school-aged children (grade 4-6) from a Kanien'kehaka (Mohawk) community provided a 24 h recall and their height and weight in 1994, 1998 and 2002, in three independent cross-sectional samples. Food consumed between two consecutive meals was defined as a snacking occasion. ANOVA and chi2 tests were used to compare food choices between BMI categories according to food quality criteria and food groups in 2006. Logistic regression models were performed to compare results between normal-weight children and those at risk of overweight and between normal-weight and overweight children. RESULTS: Energy intake from snacks tended to be higher for children at risk of overweight, compared with the other two BMI categories. Food groups with a higher energy density were also consumed more frequently by these children, with larger average portions of cereal bars (P < 0.05). Except for dessert consumption, which was less frequent among overweight children, no other variable distinguished risk of overweight in the two logistic regression models tested. CONCLUSIONS: Differences detected in snack food intake between normal-weight children and children at risk of overweight could explain in part the relationship between food choices and risk of overweight. Studies of dietary differences in conjunction with body weight would benefit from considering children at risk of overweight and normal-weight children, rather than children with excess weight only.

Psychosocial correlates of body mass index in four groups of Quebec adults.

The objective of the present analysis was to study the associations between body weight psychosocial correlates and body mass index (BMI) among four groups of adults in the Quebec population. Data were taken from the Social Lifestyles and Health 1998 Survey performed by the Institut de la Statistique du Québec (ISQ). The suggested guidelines of the ISQ were used to estimate the population's proportions and for statistical analysis. The groups studied were 25- to 44- and the 45- to 64-year-old men and women. In all groups, currently trying to lose weight increased the odds of reporting an excess weight. Better perceived eating habits was associated with lower BMI in most groups except in the 25- to 44-year-old women, where the trend was not significant. Higher number of physical activities related to transport and cigarette smoking were associated with lower BMI in both men groups. In both women groups, more frequent consumption of alcoholic beverages decreased significantly the odds of reporting excess body weight. A university degree was associated with a lower BMI only in the 25- to 44-year-old men. Regular practise of leisure time physical activity was associated with a lower BMI only in 45- to 64-year-old women. Opposite associations were observed between perceived health and BMI. In the 45- to 64-year-old men, better perceived health increased the odds of reporting an excess weight. Conversely, the odds of reporting excess weight decreased with better health in 25- to 44-year-old women. Many correlates differ between age group and sex. The identification of these factors illustrates the need to adapt obesity-related programmes toward specific sub-groups within the general population.

Multilevel modelling of sociodemographic predictors of various levels of anaemia among women in Mali.

OBJECTIVE: Anaemia currently affects 40-80% of women in Africa. While risk factors for anaemia have been intensively studied, research has rarely compared risk factors between mild anaemia and moderate/severe anaemia. Also, the contribution of neighbourhood to the prevalence of anaemia has been rarely studied. The aim of the present study was to identify and compare individual and contextual factors associated with various levels of anaemia among women. DESIGN: A multilevel analysis of data from the 2001 Mali Demographic and Health Survey (n 3763) was carried out. Outcomes variables were mild anaemia, moderate-to-severe anaemia and any anaemia. Multilevel regression analyses were performed for each outcome. SETTING: Mali, West Africa. SUBJECTS: Women (n 3763) aged 15 to 49 years, including 512 pregnant women. RESULTS: Among the eleven potential risk factors included in the models, two factors were associated with mild anaemia (BMI and education), three with any anaemia (pregnancy, BMI and education) and six with moderate-to-severe anaemia (pregnancy, BMI, education, wealth, childhood residency and region of residence). Clustering of anaemia within communities was 20% for moderate-to-severe anaemia and 13% for mild anaemia. Despite significant differences in the prevalence of anaemia across regions in Mali, no difference between regions in the risk of mild anaemia was found and only the region of Gao showed a significantly higher risk of moderate-to-severe anaemia. CONCLUSIONS: The findings indicate that sociodemographic risk factors as well as clustering of anaemia varies with the severity of anaemia. Specific studies are needed to identify risk factors of mild anaemia as well as its consequences, as mild anaemia accounts for 20-40% of total prevalence of anaemia in Africa.

Impact of a positive deviance approach to improve the effectiveness of an iron-supplementation program to control nutritional anemia among rural Senegalese pregnant women.

BACKGROUND: Iron supplementation through prenatal care remains the most widespread strategy to control anemia during pregnancy, but its effectiveness is only partial, showing the need to address other approaches. OBJECTIVE: This study was conducted to measure the impact of a positive deviance approach to improve an iron-supplementation program among pregnant women in a rural Senegalese area. METHODS: A positive deviance approach (PD Micah) was compared with an ongoing integrated nutrition and health program intervention (Micah) in a rural Senegalese area. A pre-post evaluation was conducted using independent cross-sectional samples with a total of 371 pregnant women. A sociodemographic questionnaire was administered, and biologic and anthropometric measurements were performed. RESULTS: After 9 months of activities, the mean hemoglobin level rose from 93.9 to 100.7 g/L in the PD Micah group. Distribution of iron supplements through community volunteers and implementation of healthy pregnancy promotion sessions on a monthly basis improved the accessibility to 23.3% in the PD Micah group. No significant change was observed in the Micah group. Logistic regression analysis showed a significantly reduced risk of anemia in the PD Micah area (adjusted odds ratio, 0.25; 95% confidence interval, 0.12 to 0.53). CONCLUSIONS: This intervention shows that a community-based strategy, such as the positive deviance approach, can contribute to improving the effectiveness of iron supplementation during pregnancy.

Consumption of key food items is associated with excess weight among elementary-school-aged children in a Canadian first nations community.

The present analyses aim to identify differences in selected dimensions of diet quality and quantity across body mass index (BMI) categories for Mohawk children in grades 4 through 6 so as to enhance ongoing community intervention strategies within the Kahnawake School Diabetes Prevention Project (KSDPP). Using 24-hour recalls (n=444), no observable differences in energy intake, percent fat, energy density, or diet diversity across BMI categories were observed. Using a new method, we compared the frequency of use and the amounts consumed for only the most-frequently consumed food items across BMI categories. Compared to normal-weight children, and after adjusting for age, children "at risk of overweight" consume potato chips more frequently (P=0.017) and crackers less frequently (P=0.153), while overweight children consumed larger portions of french fries (P=0.027). We conclude that, in this group of children, consuming slightly more french fries or potato chips than what is already consumed by normal-weight children appears to compromise diet quality as far as overweight is concerned.

The Impact of Waiting List BMI Changes on the Short-term Outcomes of Lung Transplantation.

BACKGROUND: Obesity and underweight are associated with a higher postlung transplantation (LTx) mortality. This study aims to assess the impact of the changes in body mass index (BMI) during the waiting period for LTx on early postoperative outcomes. METHODS: Medical records of 502 consecutive cases of LTx performed at our institution between 1999 and 2015 were reviewed. Patients were stratified per change in BMI category between pre-LTx assessment (candidate BMI) and transplant BMI as follows: A-candidate BMI, less than 18.5 or 18.5 to 29.9 and transplant BMI, less than 18.5; B-candidate BMI, less than 18.5 and transplant BMI, 18.5 to 29.9; C-candidate BMI, 18.5 to 29.9 and transplant BMI, 18.5 to 29.9; D-candidate BMI, 30 or greater and transplant BMI, 18.5 to 29.9; and E-candidate BMI, 30 or greater or 18.5 to 29.9 and transplant BMI, 30 or greater. Our primary outcome was in-hospital mortality and secondary outcomes were length of mechanical ventilation, intensive care unit length of stay (LOS), hospital LOS and postoperative complications. RESULTS: BMI variation during the waiting time was common, as 1/3 of patients experienced a change in BMI category. Length of mechanical ventilation (21 days vs 9 days; P = 0.018), intensive care unit LOS (26 days vs 15 days; P = 0.035), and rates of surgical complications (76% vs 44%; P = 0.018) were significantly worse in patients of group E versus group D. Obese candidates who failed to decrease BMI less than 30 by transplant exhibited an increased risk of postoperative mortality (odds ratio, 2.62; 95% confidence interval, 1.01-6.48) compared with patients in group C. Pre-LTx BMI evolution had no impact on postoperative morbidity and mortality in underweight patients. CONCLUSIONS: Our results suggest that obese candidates with an unfavorable pretransplant BMI evolution are at greater risk of worse post-LTx outcomes.

Risk factors for moderate to severe anemia among children in Benin and Mali: insights from a multilevel analysis.

BACKGROUND: Anemia currently affects 2 billion people throughout the world. Although the immediate causes of anemia among children are known (including malnutrition and infections), the importance of contextual determinants and their relationships with individual effects have rarely been explored. OBJECTIVE: To identify anemia risk factors at the individual, household, and community levels among Beninese and Malian children, using simple and multilevel regression methods. METHODS: An analysis was undertaken of nationally representative data collected in 2001 in Benin (n = 2,284) and Mali (n = 2,826) by the Demographic and Health Surveys. Sixteen potential risk factors for anemia were considered at the individual, household, and community levels. Comparative analyses were carried out using simple and multilevel logistic regression models. RESULTS: Simple and multilevel logistic regression analyses yielded broadly similar results. Risk factors for moderate to severe anemia included incomplete immunization, stunted growth, recent infection, absence of bednet, low household living standard, rural residency (Mali), low maternal education, and low community development index (Benin). In addition, multilevel analysis indicated a clustering level of anemia in communities (intraclass correlation) of 14% and 19% in Benin and Mali, respectively. CONCLUSIONS: Risk factors for child anemia appeared at all three levels (individual, household and community). Community-level clustering seemed to be low. Therefore, interventions to address anemia need not be village- or region-specific. Identifying a successful and replicable program is now a priority in child survival endeavors. It is likely that such a program would include a focus on improving immunization coverage, increased bednet usage, and reduced protein-energy malnutrition.

Traditional food attributes must be included in studies of food security in the Canadian Arctic.

OBJECTIVES: The objective was to explore some typically understudied characteristics of food security in Arctic Canada: observed changes to traditional food systems, perceived advantages and health benefits of traditional food and traditional food preferences. STUDY DESIGN: Data analysis used a cross-sectional survey of Yukon First Nations, Dene/Métis and Inuit women in 44 Arctic communities. METHODS: Open-ended responses to 4 questions were used to qualitatively investigate roles traditional foods play in Arctic food security. Chi-square tests were applied to responses to ascertain differences by age and region. A fifth question explored agreement with cultural responses to harvesting and using traditional food. RESULTS: Traditional food was regarded as natural and fresh, tasty, healthy and nutritious, inexpensive, and socially and culturally beneficial. Between 10% and 38% of participants noticed recent changes in the quality or health of traditional food species, with physical changes and decreasing availability being reported most often. Caribou, moose and seal were among the foods considered particularly healthy and held special values in these populations. The opinion that all traditional food was healthy was also popular. More than 85%, of participants agreed with most cultural attributes of traditional food. CONCLUSIONS: This study confirms that traditional food remains important to Arctic indigenous women and that food security in the Arctic is contingent upon access to these foods.

Traditional and market food access in Arctic Canada is affected by economic factors.

OBJECTIVES: This study aimed to evaluate the access that Indigenous women have to traditional and market foods in 44 communities across Arctic Canada. STUDY DESIGN: This secondary data analysis used a cross-sectional survey of 1771 Yukon First Nations, Dene/Métis and Inuit women stratified by age. METHODS: Socio-cultural questionnaires were used to investigate food access and chi-square testing was used to ascertain the distribution of subject responses by age and region. RESULTS: There was considerable regional variation in the ability to afford adequate food, with between 40% and 70% saying they could afford enough food. Similarly, regional variation was reflected in the percentage of the population who could afford, or had access to, hunting or fishing equipment. Up to 50% of the responses indicated inadequate access to fishing and hunting equipment, and up to 46% of participants said they could not afford to go hunting or fishing. CONCLUSIONS: Affordability of market food and accessibility to hunting and fishing in Arctic Canada were major barriers to Indigenous women's food security.

Estimation of traditional food intake in indigenous communities in Denendeh and the Yukon.

OBJECTIVES: Chronic non-communicable diseases related to excessive or unbalanced dietary intakes are on the rise among some Indigenous populations in Canada. Nutritional problems of Indigenous peoples arise in the transition from a traditional diet to a market diet characterized by highly processed foods with reduced nutrient density. This study aimed at assessing traditional food intake of Indigenous people in 18 communities. STUDY DESIGN: This study was cross-sectional with a sample size of 1,356. METHODS: This study used food frequency and 24-hour recall questionnaires to quantify traditional food intake in 18 communities in the McKenzie basin of the Northwest Territories (Denendeh and the Yukon). RESULTS: Typical daily intakes of groups of traditional food items were generated and intake of an extensive list of traditional food detailed for adult men and women. Per capita intake of traditional food items was also calculated. CONCLUSION: Reliance on traditional food intake is still high in Denendeh, as well as in the Yukon. The detailed description of the traditional food system presented here allows an accurate identification of the contribution of traditional food items to nutrient and contaminant intake by Indigenous people for future studies.

Comparison of the dietary intakes of two different groups of children (grades 4 to 6) before and after the Kahnawake Schools Diabetes Prevention Project.

The diet of Mohawk children (grades 4 through 6) was assessed using 24-hour recalls after 4 years' participation in the Kahnawake Schools Diabetes Prevention Project. Analysis compared mean intakes of energy, fat, and sucrose, and proportions of children consuming each food. No significant difference was found in the mean intake of energy, fat, and sucrose. There was a significant decrease in the frequency of consumption of high-fat foods (P<.05) and fruits (P<.001), and a significant increase in the energy contribution of white sugar (P<.05). Results illustrate the complexity of food choices and suggest that specific nutrition education targets need to reflect newly available food-items.

Age differences in vitamin A intake among Canadian Inuit.

BACKGROUND: Inuit traditional food provides ample amounts of preformed vitamin A. However, the dietary transition away from traditional food raises concerns regarding dietary adequacy. Vitamin A is an essential nutrient with inadequate and excessive exposures having adverse effects. OBJECTIVE: To evaluate total dietary vitamin A intake for Canadian Inuit from market food and traditional food sources and to evaluate retinol concentrations in liver and blubber. METHODS: Dietary surveys were conducted in 18 communities representing 5 Inuit regions, and traditional food items were evaluated for nutrient content. RESULTS: Among those 15-40 years of age, 68% of men and 60% of women had a dietary vitamin A intake below the estimated average requirement (EAR) for retinol activity equivalents (RAE)/day. Among those over 40 years of age, only 11 % of men and 15% of women had a dietary vitamin A intake below the EAR. Young Inuit men had a relative risk of 6.2 (95% CI= 4.5-8.4), and young Inuit women had a relative risk of 4.0 (95% CI= 3.1-5.0) for dietary inadequacy compared to the older Inuit men and women, respectively. The median retinol content of liver of ringed seal, caribou, and fish were comparable to levels observed in market food liver. Liver was less frequently consumed by those 15-40 years of age than among older Inuit. DISCUSSION: Sub-optimal vitamin A intake is the predominant nutritional concern rather than excessive exposures. Public health education campaigns are needed to improve vitamin A intake among the younger generations of Inuit men and women.

Ecuadorian Andean women's nutrition varies with age and socioeconomic status.

An agricultural project in Highland Ecuador provided a model context to better understand the nutrition of rural women. The adequacy of women's nutrition and the strength of associations with age and socioeconomic status were studied in 104 rural households over four rounds (two seasons) during the 1995-1996 agricultural year using a cross-sectional with repeated-measures design. Women were at high risk for micronutrient deficiencies (calcium, iron, riboflavin, and vitamin B12) due to low intakes of animal products. Two distinct constructs representing socioeconomic status were identified: modern lifestyle and farming wealth. In multivariate models, farming wealth was associated with quality of women's diet (animal protein adjusted for energy, p = 0.01). Diet quality, in turn, was positively associated with anthropometric status (p = 0.02). Women over the age of 50 weighed approximately 3.7 kg less than younger women and consumed less energy (300 kcal) and micronutrients (p < 0.05). Age was positively associated with respiratory morbidity (p = 0.01). These findings, while directly relevant to a specific context, suggest the need for cross-cultural studies to identify the extent of, and factors contributing to, the risk of nutritional inadequacy in postreproductive women in developing countries.

Food Use and Nutrient Adequacy in Baffin Inuit Children and Adolescents.

In evaluating adequacy of nutrient intake and relative contribution of locally harvested food (i.e., "traditional" food) and imported market food for 164 Baffin Inuit children and adolescents, 604 24-hour recalls were obtained over a one-year period (1987 to 1988). Market food contributed an average of 84% of dietary energy and traditional food, 16%. Total and saturated fat intakes corresponded closely to current recommendations, while sucrose intakes were higher than recommended. Most age and gender categories had a low prevalence of inadequate intakes of iron, zinc, and protein; over 50% of dietary iron and zinc was provided by traditional food. Calcium and vitamin A were obtained largely through market food, and there was a high risk of inadequacy for both nutrients in all age groups. The diets of 16-18-year-old girls were the most often inadequate, due to high consumption of low nutrient-dense food and low consumption of traditional food. Food items rich in vitamin A and calcium should be promoted, and 16-18-year-old girls specifically targeted for education on food choices and health.

Contribution of Selected Traditional and Market Foods to the Diet of Nunavik Inuit Women.

Food composition data were determined for food consumed by 226 Inuit women in Nunavik, estimating the relative contribution of traditional and market food for energy, protein, lipid, carbohydrate, vitamin A, vitamin D, iron, calcium, magnesium, phosphorus, selenium, zinc, and eicosapentaenoic and docosahexaenoic acids. Traditional Inuit food was an important source of protein, vitamin D, iron, selenium, and phosphorus, as well as the main source of eicosapentaenoic and docosahexaenoic acids. The mean contribution of traditional and market food to energy and nutrients was analyzed according to age groups (18-39 and 40-74). Analysis of Inuit women's nutrient intake showed that the contribution of traditional food was greater in the older group than in the younger group, for whom the contribution of market food was greater. Market food contributed the most to Inuit women's energy intake, while 40% of the intake of several nutrients, including protein, vitamin D, iron, phosphorus, and zinc, was derived from traditional food. Inuit women had low vitamin A and calcium intakes. Traditional food had low calcium and vitamin A concentrations, and the Inuit infrequently consumed market food such as milk, dairy products, and yellow and green vegetables. Thus, even though the present study showed that traditional food was the major source of many nutrients in the Inuit diet, market food was also important for the nutritional status of this population, particularly young women. In promoting safe nutritional habits among the Inuit, dietitians must help them maintain traditional food use, which has provided some health advantages (e.g., a lower incidence of cardiovascular disease); encourage consumption of nutritious market foods; and consider the societal values reflected in the traditional diet.

Can an integrated approach reduce child vulnerability to anaemia? Evidence from three African countries.

Addressing the complex, multi-factorial causes of childhood anaemia is best done through integrated packages of interventions. We hypothesized that due to reduced child vulnerability, a "buffering" of risk associated with known causes of anaemia would be observed among children living in areas benefiting from a community-based health and nutrition program intervention. Cross-sectional data on the nutrition and health status of children 24-59 mo (N=2405) were obtained in 2000 and 2004 from program evaluation surveys in Ghana, Malawi and Tanzania. Linear regression models estimated the association between haemoglobin and immediate, underlying and basic causes of child anaemia and variation in this association between years. Lower haemoglobin levels were observed in children assessed in 2000 compared to 2004 (difference -3.30 g/L), children from Tanzania (-9.15 g/L) and Malawi (-2.96 g/L) compared to Ghana, and the youngest (24-35 mo) compared to oldest age group (48-59 mo; -5.43 g/L). Children who were stunted, malaria positive and recently ill also had lower haemoglobin, independent of age, sex and other underlying and basic causes of anaemia. Despite ongoing morbidity, risk of lower haemoglobin decreased for children with malaria and recent illness, suggesting decreased vulnerability to their anaemia-producing effects. Stunting remained an independent and unbuffered risk factor. Reducing chronic undernutrition is required in order to further reduce child vulnerability and ensure maximum impact of anaemia control programs. Buffering the impact of child morbidity on haemoglobin levels, including malaria, may be achieved in certain settings.