The double burden of malnutrition: aetiological pathways and consequences for health.

Malnutrition has historically been researched and addressed within two distinct silos, focusing either on undernutrition, food insecurity, and micronutrient deficiencies, or on overweight, obesity, and dietary excess. However, through rapid global nutrition transition, an increasing proportion of individuals are exposed to different forms of malnutrition during the life course and have the double burden of malnutrition (DBM) directly. Long-lasting effects of malnutrition in early life can be attributed to interconnected biological pathways, involving imbalance of the gut microbiome, inflammation, metabolic dysregulation, and impaired insulin signalling. Life-course exposure to early undernutrition followed by later overweight increases the risk of non-communicable disease, by imposing a high metabolic load on a depleted capacity for homoeostasis, and in women increases the risk of childbirth complications. These life-course trajectories are shaped both by societal driving factors-ie, rapidly changing diets, norms of eating, and physical activity patterns-and by broader ecological factors such as pathogen burden and extrinsic mortality risk. Mitigation of the DBM will require major societal shifts regarding nutrition and public health, to implement comprehensive change that is sustained over decades, and scaled up into the entire global food system.

Correction: Interventions for treating children and adolescents with overweight and obesity: an overview of Cochrane reviews.

This paper was originally published under a standard licence. This has now been amended to a CC BY licence in the PDF and HTML.

Interventions for treating children and adolescents with overweight and obesity: an overview of Cochrane reviews.

Children and adolescents with overweight and obesity are a global health concern. This is an integrative overview of six Cochrane systematic reviews, providing an up-to-date synthesis of the evidence examining interventions for the treatment of children and adolescents with overweight or obesity. The data extraction and quality assessments for each review were conducted by one author and checked by a second. The six high quality reviews provide evidence on the effectiveness of behaviour changing interventions conducted in children <6 years (7 trials), 6-11 years (70 trials), adolescents 12-17 years (44 trials) and interventions that target only parents of children aged 5-11 years (20 trials); in addition to interventions examining surgery (1 trial) and drugs (21 trials). Most of the evidence was derived from high-income countries and published in the last two decades. Collectively, the evidence suggests that multi-component behaviour changing interventions may be beneficial in achieving small reductions in body weight status in children of all ages, with low adverse event occurrence were reported. More research is required to understand which specific intervention components are most effective and in whom, and how best to maintain intervention effects. Evidence from surgical and drug interventions was too limited to make inferences about use and safety, and adverse events were a serious consideration.

Entrepreneurialism and health-promoting retail food environments in Canadian city-regions.

The retail sector is a dynamic and challenging component of contemporary food systems with an important influence on population health and nutrition. Global consensus is clear that policy and environmental changes in retail food environments are essential to promote healthier diets and reduce the burden of obesity and non-communicable diseases. In this article, we explore entrepreneurialism as a form of social change-making within retail food environments, focusing on small food businesses. Small businesses face structural barriers within food systems. However, conceptual work in multiple disciplines and evidence from promising health interventions tested in small stores suggest that these retail places may have a dual role in health promotion: settings to strengthen regional economies and social networks, and consumer environments to support healthier diets. We will discuss empirical examples of health-promoting entrepreneurialism based on two sets of in-depth interviews we conducted with public health intervention actors in Toronto, Canada, and food entrepreneurs and city-region policy actors in St. John's, Canada. We will explore the practices of entrepreneurialism in the retail food environment and examine the implications for population health interventions. We contend that entrepreneurialism is important to understand on its own and also as a dimension of population health intervention context. A growing social scientific literature offers a multifaceted lens through which we might consider entrepreneurialism not only as a set of personal characteristics but also as a practice in networked and intersectoral cooperation for public and population health.

Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years.

BACKGROUND: Child and adolescent overweight and obesity has increased globally, and can be associated with significant short- and long-term health consequences. This is an update of a Cochrane review published first in 2003, and updated previously in 2009. However, the update has now been split into six reviews addressing different childhood obesity treatments at different ages. OBJECTIVES: To assess the effects of diet, physical activity and behavioural interventions (behaviour-changing interventions) for the treatment of overweight or obese children aged 6 to 11 years. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS as well as trial registers ClinicalTrials.gov and ICTRP Search Portal. We checked references of studies and systematic reviews. We did not apply any language restrictions. The date of the last search was July 2016 for all databases. SELECTION CRITERIA: We selected randomised controlled trials (RCTs) of diet, physical activity, and behavioural interventions (behaviour-changing interventions) for treating overweight or obese children aged 6 to 11 years, with a minimum of six months' follow-up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity. DATA COLLECTION AND ANALYSIS: Two review authors independently screened references, extracted data, assessed risk of bias, and evaluated the quality of the evidence using the GRADE instrument. We contacted study authors for additional information. We carried out meta-analyses according to the statistical guidelines in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS: We included 70 RCTs with a total of 8461 participants randomised to either the intervention or control groups. The number of participants per trial ranged from 16 to 686. Fifty-five trials compared a behaviour-changing intervention with no treatment/usual care control and 15 evaluated the effectiveness of adding an additional component to a behaviour-changing intervention. Sixty-four trials were parallel RCTs, and four were cluster RCTs. Sixty-four trials were multicomponent, two were diet only and four were physical activity only interventions. Ten trials had more than two arms. The overall quality of the evidence was low or very low and 62 trials had a high risk of bias for at least one criterion. Total duration of trials ranged from six months to three years. The median age of participants was 10 years old and the median BMI z score was 2.2.Primary analyses demonstrated that behaviour-changing interventions compared to no treatment/usual care control at longest follow-up reduced BMI, BMI z score and weight. Mean difference (MD) in BMI was -0.53 kg/m2 (95% confidence interval (CI) -0.82 to -0.24); P < 0.00001; 24 trials; 2785 participants; low-quality evidence. MD in BMI z score was -0.06 units (95% CI -0.10 to -0.02); P = 0.001; 37 trials; 4019 participants; low-quality evidence and MD in weight was -1.45 kg (95% CI -1.88 to -1.02); P < 0.00001; 17 trials; 1774 participants; low-quality evidence.Thirty-one trials reported on serious adverse events, with 29 trials reporting zero occurrences RR 0.57 (95% CI 0.17 to 1.93); P = 0.37; 4/2105 participants in the behaviour-changing intervention groups compared with 7/1991 participants in the comparator groups). Few trials reported health-related quality of life or behaviour change outcomes, and none of the analyses demonstrated a substantial difference in these outcomes between intervention and control. In two trials reporting on minutes per day of TV viewing, a small reduction of 6.6 minutes per day (95% CI -12.88 to -0.31), P = 0.04; 2 trials; 55 participants) was found in favour of the intervention. No trials reported on all-cause mortality, morbidity or socioeconomic effects, and few trials reported on participant views; none of which could be meta-analysed.As the meta-analyses revealed substantial heterogeneity, we conducted subgroup analyses to examine the impact of type of comparator, type of intervention, risk of attrition bias, setting, duration of post-intervention follow-up period, parental involvement and baseline BMI z score. No subgroup effects were shown for any of the subgroups on any of the outcomes. Some data indicated that a reduction in BMI immediately post-intervention was no longer evident at follow-up at less than six months, which has to be investigated in further trials. AUTHORS' CONCLUSIONS: Multi-component behaviour-changing interventions that incorporate diet, physical activity and behaviour change may be beneficial in achieving small, short-term reductions in BMI, BMI z score and weight in children aged 6 to 11 years. The evidence suggests a very low occurrence of adverse events. The quality of the evidence was low or very low. The heterogeneity observed across all outcomes was not explained by subgrouping. Further research is required of behaviour-changing interventions in lower income countries and in children from different ethnic groups; also on the impact of behaviour-changing interventions on health-related quality of life and comorbidities. The sustainability of reduction in BMI/BMI z score and weight is a key consideration and there is a need for longer-term follow-up and further research on the most appropriate forms of post-intervention maintenance in order to ensure intervention benefits are sustained over the longer term.

Exploring Knowledge, Attitudes, and Practices Related to Breast and Cervical Cancers in Mongolia: A National Population-Based Survey.

BACKGROUND: Mongolia bears the second-highest cancer burden in the world (5,214 disability-adjusted life years per 100,000 people, age standardized). To determine drivers of the growing burden of noncommunicable diseases, including breast and cervical cancers, a national knowledge, attitudes, and practices (KAP) survey was implemented in 2010. METHODS: This paper analyzed the results of the 2010 KAP survey, which sampled 3,450 households nationally. Reflecting Mongolian screening policies, women aged 30 and older were included in analyses of questions regarding breast and cervical cancer (n = 1,193). Univariate and multivariate odds ratios (MORs) were derived through logistic regression to determine associations between demographic covariables (residence, age, education, employment) and survey responses. RESULTS: This study found that 25.7% (95% confidence interval [CI]: 23.3-28.3) and 22.1% (95% CI: 19.8-24.5) of female participants aged 30 years or older self-rated their knowledge of breast and cervical cancers, respectively, as "none." Employment and education were associated with greater awareness of both cancers and participation in screening examinations (p < .05). Clinical breast examinations were more common among rural than urban participants (MOR: 1.492; 95% CI: 1.125-1.979). Of all female participants, 17% (95% CI: 15.3-18.5) knew that cervical cancer is vaccine preventable. CONCLUSION: Our results suggest that cancer control in Mongolia should emphasize health education, particularly among lower-educated, rural, and unemployed women. The health infrastructure should be strengthened to reflect rural to urban migration. Finally, although there is awareness that early detection improves outcomes, a significant proportion of women do not engage in screening. These trends warrant further research on barriers and solutions. IMPLICATIONS FOR PRACTICE: The rising burden of breast and cervical cancers, particularly in low- and middle-income countries, necessitates the development of effective strategies for cancer control. This paper examines barriers to health service use in Mongolia, a country with a high cancer burden. The 2010 national knowledge, attitude and practices survey data indicate that cancer control efforts should focus on improving health education among lower-educated, rural, and unemployed populations, who display the least knowledge of breast and cervical cancers. Moreover, the findings support the need to emphasize individual risk for disease in cancer education and ensure that the health-care infrastructure reflects Mongolia's urbanization.

Open access: academic publishing and its implications for knowledge equity in Kenya.

Traditional, subscription-based scientific publishing has its limitations: often, articles are inaccessible to the majority of researchers in low- and middle-income countries (LMICs), where journal subscriptions or one-time access fees are cost-prohibitive. Open access (OA) publishing, in which journals provide online access to articles free of charge, breaks this barrier and allows unrestricted access to scientific and scholarly information to researchers all over the globe. At the same time, one major limitation to OA is a high publishing cost that is placed on authors. Following recent developments to OA publishing policies in the UK and even LMICs, this article highlights the current status and future challenges of OA in Africa. We place particular emphasis on Kenya, where multidisciplinary efforts to improve access have been established. We note that these efforts in Kenya can be further strengthened and potentially replicated in other African countries, with the goal of elevating the visibility of African research and improving access for African researchers to global research, and, ultimately, bring social and economic benefits to the region. We (1) offer recommendations for overcoming the challenges of implementing OA in Africa and (2) call for urgent action by African governments to follow the suit of high-income countries like the UK and Australia, mandating OA for publicly-funded research in their region and supporting future research into how OA might bring social and economic benefits to Africa.

Tobacco smoking in Mongolia: findings of a national knowledge, attitudes and practices study.

BACKGROUND: In 2009, 48% of males aged 15 or over in Mongolia consumed tobacco, placing Mongolia among the countries with the highest prevalence of male smokers in the world. Importantly, tobacco use is one of the four major risk factors contributing to the global burden of non-communicable diseases (NCDs) - the leading cause of mortality in Mongolia. However, the knowledge, attitudes and practices of the Mongolian population with regards to smoking are largely unmeasured. In this context, a national NCDs knowledge, attitudes and practices survey focusing, among other things, on NCD risk factors was implemented in Mongolia in late 2010 to complement the previous WHO STEPwise approach to Surveillance Survey (STEPS) findings from 2009. This publication explores the smoking-related findings of the Knowledge, Attitudes and Practices Survey (KAPS). METHODS: A nationally representative sample size was calculated using methodologies aligned with the WHO STEPS surveys. As a result, 3450 people from across Mongolia were selected using a multi-stage, random cluster sampling method from permanent residents aged between 15 and 64 years. The KAP survey questionnaire was interviewer-administered on a door-to-door basis. RESULTS: In Mongolia at 2010, 46.3% of males and 6.8% of females were smokers. This practice was especially dominant among males and urban dwellers (MOR 2.2), and more so among the middle-aged (45-54) (MOR 2.1) while still displaying a high prevalence among Mongolian youth (15.5%). The probability of smoking was independent of the level of education. Although the level of awareness of the health hazards related to tobacco smoking was generally very high in the population, this was influenced by the level of education as more people with a primary and secondary level of education believed that smoking at least one pack of cigarette per day was required to harm one's health (MOR 5.8 for primary education and 2.5 for secondary). Finally, this knowledge did not necessarily translate into a behavioural outcome as 15.5% of the population did not object to people smoking in their house, and especially so among males (MOR 4.1). CONCLUSION: The findings of this KAP survey corroborate the 2009 WHO STEPS Survey findings with regards to the prevalence of tobacco smoking in Mongolia. It identifies males, urban dwellers and Mongolian youth as groups that should be targeted by public health measures on tobacco consumption, while keeping in mind that higher levels of awareness of the harms caused by tobacco smoking do not necessarily translate into behavioural changes.

Exploring knowledge, attitudes, and practices related to alcohol in Mongolia: a national population-based survey.

BACKGROUND: The leading cause of mortality in Mongolia is Non-Communicable Disease. Alcohol is recognised by the World Health Organization as one of the four major disease drivers and so, in order to better understand and triangulate recent national burden-of-disease surveys and to inform policy responses to alcohol consumption in Mongolia, a national Knowledge, Attitudes and Practices survey was conducted. Focusing on Non-Communicable Diseases and their risk factors, this publication explores the alcohol-related findings of this national survey. METHODS: A door-to-door, household-based questionnaire was conducted on 3450 people from across Mongolia. Participants were recruited using a multi-stage random cluster sampling technique, and eligibility was granted to permanent residents of households who were aged between 15 and 64 years. A nationally representative sample size was calculated, based on methodologies aligned with the WHO STEPwise approach to Surveillance. RESULTS: Approximately 50% of males and 30% of females were found to be current drinkers of alcohol. Moreover, nine in ten respondents agreed that heavy episodic drinking of alcohol is common among Mongolians, and the harms of daily alcohol consumption were generally perceived to be high. Indeed, 90% of respondents regarded daily alcohol consumption as either 'harmful' or 'very harmful'. Interestingly, morning drinking, suggestive of problematic drinking, was highest in rural men and was associated with lower-levels of education and unemployment. CONCLUSION: This research suggests that Mongolia faces an epidemiological challenge in addressing the burden of alcohol use and related problems. Males, rural populations and those aged 25-34 years exhibited the highest levels of risky drinking practices, while urban populations exhibit higher levels of general alcohol consumption. These findings suggest a focus and context for public health measures addressing alcohol-related harm in Mongolia.

Exploring knowledge, attitudes and practices related to diabetes in Mongolia: a national population-based survey.

BACKGROUND: Non-communicable diseases (NCDs) are now the leading causes of mortality in Mongolia, and diabetes, in particular, is a growing public health threat. Mongolia is a nation undergoing rapid and widespread epidemiological transition and urbanisation: a process that is expected to continue in coming decades and is likely to increase the diabetes burden. To better inform policy and public-health responses to the impact of the growth in NCDs, a national NCD Knowledge, Attitudes and Practices survey was implemented in Mongolia in 2010; a section of which focused on diabetes. METHODS: This survey was a nationally-representative, household-based questionnaire conducted by field-workers. Households were selected using a multi-stage, cluster sampling technique, with one participant (aged 15-64) selected from each of the 3540 households. Questions explored demographic and administrative parameters, as well as knowledge attitudes and practices around NCDs and their risk factors. RESULTS: This research suggests low levels of diabetes-related health knowledge in Mongolia. Up to fifty percent of Mongolian sub-populations, and one in five of the total population, had never heard the term diabetes prior to surveying. This research also highlights a high level of misunderstanding around the symptomatology and natural progression of diabetes; for example, one-third of Mongolians were unaware that the disease could be prevented through lifestyle changes. Further, this study suggests that a low proportion of Mongolians have received counseling or health education about diabetes, with lowest access to such services for the urban poor and least educated sub-populations. CONCLUSIONS: This research suggests a low prevalence of diabetes-related health-knowledge among Mongolians. In this light, health-education should be part of any national strategy on diabetes.

Hypertension and hypertension-related disease in mongolia; findings of a national knowledge, attitudes and practices study.

BACKGROUND: Mongolia has a high and increasing burden of hypertension and related disease, with cardiovascular diseases among the leading causes of death. Yet little is known about the knowledge, attitudes and practices of the Mongolian population with regards to blood pressure. With this in mind, a national Non-Communicable Diseases knowledge, attitudes and practices survey on blood pressure was implemented in late 2010. This paper reports on the findings of this research. METHODS: Using a multi-stage, random cluster sampling method 3450 participant households were selected from across Mongolia. This survey was interviewer-administered and included demographic and socio-economic questions. Sample size was calculated using methods aligned with the World Health Organization STEPS surveys. RESULTS: One fifth of participants reported having never heard the term 'blood pressure'. This absence of health knowledge was significantly higher in men, and particularly younger men. The majority of participants recognised high blood pressure to be a threat to health, with a higher level of risk awareness among urban individuals. Education level and older age were generally associated with a heightened knowledge and risk perception. Roughly seven in ten participants were aware of the relationship between salt and blood pressure. Exploring barriers to screening, participants rated a 'lack of perceived importance' as the main deterring factor among fellow Mongolians and overall, participants perceived medication and exercise as the only interventions to be moderately effective at preventing high blood pressure. CONCLUSION: Rural populations; younger populations; men; and less educated populations, all with lower levels of knowledge and risk perception regarding hypertension, present those most vulnerable to it and the related health outcomes. This research intimates major health knowledge gaps in sub-populations within Mongolia, regarding health-risks related to hypertension.

Non-communicable diseases: harnessing the current opportunities.

Non-communicable diseases (NCDs) are receiving growing attention, which brings a unique opportunity to utilise solutions available to address them. These diseases are largely preventable; proven, cost-effective interventions are available; and when NCDs emerge, means exist to treat them, prevent complications, and to improve quality of life. Yet, there is a lack in progress in responding effectively to NCDs, and the current discussion and research focus predominantly on challenges rather than the opportunities, which this paper outlines.