Low quality of maternal and child nutritional care at the primary care in Mexico: an urgent call to action for policymakers and stakeholders.

BACKGROUND: Maternal and child malnutrition represents a public health problem in Mexico Primary care (PC) is responsible for introducing women and children under five to the health system, detecting diseases on time, and providing medical services, including pharmacological treatment if necessary. Providing these services with quality is essential to improve maternal and child health. This study evaluated the quality of nutritional care during preconception, pregnancy, postpartum, infancy, and preschool age at the PC health units across six Mexican states between 2020 and 2021. METHODS: We conducted a cross-sectional study with a mixed approach in units of the Secretary of Health to assess the quality of nutritional care during preconception, pregnancy, postpartum, childhood, and preschool age. The level of quality was calculated by the percentage of compliance with 16 indicators that integrated a Quality Index of Maternal and Child Nutritional Care (ICANMI, by its Spanish acronym). Compliance by indicator, by life stage, and overall was categorized using the following cut-off points: poor quality (≤ 70%), insufficient quality (71-89%), and good quality (≥ 90%). The perceptions of the barriers and facilitators that affect maternal and child nutrition were evaluated through semi-structured interviews with health professionals (HP) and users. All qualitative instruments were developed with a gender and intercultural perspective. RESULTS: Considering the whole sample studied, maternal and child nutritional care quality during the five life stages evaluated was bad (compliance: ≤12%), reflected in the ICANMI, which had a compliance of 8.3%. Principal barriers identified to providing high-quality nutritional care were the lack of knowledge and training of health professionals, shortages of equipment, medicine, personnel, and materials, the disappearance of the social cash transfer program Prospera, the absence of local indigenous language translators to support communication between doctor and patient, and the persistence of machismo and other practices of control over women. CONCLUSIONS: These findings underscore the need for initiatives to improve the quality of nutritional care in PC facilities across Chihuahua, State of Mexico, Veracruz, Oaxaca, Chiapas, and Yucatan. It is necessary for government and health authorities, along with various stakeholders, to collaboratively devise, implement, and assess intercultural and gender-oriented policies and programs geared towards ensuring the health infrastructure and enhancing the training of health professionals to diagnose and treat the prevalence and occurrence of diverse forms of malnutrition in both maternal and child populations.

RESUMEN: ANTECEDENTES: La mala nutrición materno-infantil (MMI) representa un problema de salud pública en México. El primer nivel tiene la respondabilidad de introducir a mujeres y niños menores de 5 años al sistema de salud, detectar oportunamente las enfermedades y brindar servicios médicos incluido el farmacológico de ser necesario. Prestar estos servicios con calidad resulta elemental para mejorar la salud de la población materno-infantil. El objetivo de este estudio fue evaluar la calidad de la atención nutricional durante las etapas de preconcepción, embarazo, posparto, infancia y edad preescolar en centros de salud de seis estados de México entre 2020 y 2021. MéTODOS: Se realizó un estudio transversal con metodología mixta en 95 centros de salud la Secretaría de Salud de México para evaluar la calidad de la atención nutricional durante la preconcepción, el embarazo, el posparto, la infancia y la etapa preescolar. El nivel de calidad se calculó mediante el porcentaje de cumplimiento de 16 indicadores que a su vez integraron un Índice de Calidad de la Atención Nutricional Materno Infantil (ICANMI). El cumplimiento por indicador, etapa de vida y global fue categorizado utilizando los siguientes puntos de corte: mala calidad (≤ 70%), calidad insuficiente (71-89%) y buena calidad (≥ 90%). La percepción sobre las barreras y facilitadores que afectan la atención nutricional materno-infantil fueron identificadas a través de entrevistas semiestructuradas y grupos focales realizadas a profesionales de salud, usuarias y usuarios. Todos los instrumentos cualitativos fueron desarrollados con un enfoque de género e interculturalidad. RESULTADOS: La calidad de la atención nutricional materno infantil durante las cinco etapas de la vida evaluadas fue mala (cumplimiento: ≤12%), mientras que el ICANMI tuvo un cumplimiento de 8.3%. Las principales barreras identificadas para brindar una atención nutricional de alta calidad fueron la falta de conocimiento y capacitación de los profesionales de la salud, la escasez de equipos, medicamentos, personal y materiales, la desaparición del programa social de transferencias monetarias Prospera, la ausencia de una lengua indígena local, entre otros. Así como la persistencia de prácticas como el machismo y otras de control sobre las mujeres. CONCLUSIONES: Estos hallazgos subrayan la necesidad inmediata de implementar iniciativas que mejoren el estándar de atención nutricional en los centros de salud en Chihuahua, Estado de México, Veracruz, Oaxaca, Chiapas y Yucatán. Es necesario que el gobierno y las autoridades sanitarias, junto con diversas partes interesadas, diseñen, implementen y evalúen en colaboración políticas y programas orientados a mejorar la calidad de la atención nutricional, con perspectiva de género e interculturalidad. Este esfuerzo tiene como objetivo mitigar la prevalencia y aparición de diversas formas de desnutrición tanto en la población materna como infantil.

A scoping review and critical evaluation of the methodological quality of clinical practice guidelines on nutrition in the preconception.

Introduction: Clinical practice guidelines (CPGs) contain recommendations for specific clinical circumstances, including maternal malnutrition. This study aimed to identify the CPGs that provide recommendations for preventing, diagnosing, and treating women's malnutrition. Additionally, we sought to assess the methodological quality using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Methods: An online search for CPGs was performed, looking for those that contained lifestyle and nutritional recommendations to prevent, diagnose and treat malnutrition in women during the preconception period using PubMed and different websites. The reviewers utilized the AGREE II instrument to appraise the quality of the CPGs. We defined high-quality guidelines with a final score of > 70%. Results: The titles and abstracts from 30 guidelines were screened for inclusion, of which 20 guidelines were fully reviewed for quality assessment. The overall quality assessment of CPGs was 73%, and only 55% reached a high-quality classification. The domains in the guidelines classified as high-quality had the highest scores in "Scope and Purpose" and "Clarity of Presentation" with a median of 98.5 and 93%, respectively. Discussion: Further assessment is needed to improve the quality of the guidelines, which is an opportunity to strengthen them, especially in the domains with the lowest scores.

Growth patterns in childhood and adolescence and adult body composition: a pooled analysis of birth cohort studies from five low and middle-income countries (COHORTS collaboration).

OBJECTIVE: We examined associations among serial measures of linear growth and relative weight with adult body composition. DESIGN: Secondary data analysis of prospective birth cohort studies. SETTINGS: Six birth cohorts from Brazil, Guatemala, India, the Philippines and South Africa. PARTICIPANTS: 4173 individuals followed from birth to ages 22-46 years with complete and valid weight and height at birth, infancy, childhood and adolescence, and body composition in adult life. EXPOSURES: Birth weight and conditional size (standardised residuals of height representing linear growth and of relative weight representing weight increments independent of linear size) in infancy, childhood and adolescence. PRIMARY OUTCOME MEASURES: Body mass index, fat mass index (FMI), fat-free mass index (FFMI), fat mass/fat-free mass ratio (FM/FFM), and waist circumference in young and mid-adulthood. RESULTS: In pooled analyses, a higher birth weight and relative weight gains in infancy, childhood and adolescence were positively associated with all adult outcomes. Relative weight gains in childhood and adolescence were the strongest predictors of adult body composition (ß (95% CI) among men: FMI (childhood: 0.41 (0.26 to 0.55); adolescence: 0.39 (0.27 to 0.50)), FFMI (childhood: 0.50 (0.34 to 0.66); adolescence: 0.43 (0.32 to 0.55)), FM/FFM (childhood: 0.31 (0.16 to 0.47); adolescence: 0.31 (0.19 to 0.43))). Among women, similar patterns were observed, but, effect sizes in adolescence were slightly stronger than in childhood. Conditional height in infancy was positively associated with FMI (men: 0.08 (0.03 to 0.14); women: 0.11 (0.07 to 0.16)). Conditional height in childhood was positively but weakly associated with women's adiposity. Site-specific and sex-stratified analyses showed consistency in the direction of estimates, although there were differences in their magnitude. CONCLUSIONS: Prenatal and postnatal relative weight gains were positive predictors of larger body size and increased adiposity in adulthood. A faster linear growth in infancy was a significant but weak predictor of higher adult adiposity.

City features related to obesity in preschool children: a cross-sectional analysis of 159 cities in six Latin American countries.

Background: Childhood obesity is a rising global health problem. The rapid urbanization experienced in Latin America might impact childhood obesity through different pathways involving urban built and social features of cities. We aimed to evaluate the association between built and social environment features of cities and childhood obesity across countries and cities in Latin America. Methods: Cross-sectional analysis of data from 20,040 children aged 1-5 years living in 159 large cities in six Latin American countries. We used individual-level anthropometric data for excess weight (overweight or obesity) from health surveys that could be linked to city-level data. City and sub-city level exposures included the social environment (living conditions, service provision and educational attainment) and the built environment (fragmentation, isolation, presence of mass transit, population density, intersection density and percent greenness). Multi-level logistic models were used to explore associations between city features and excess weight, adjusting for age, sex, and head of household education. Findings: The overall prevalence of excess weight among preschool children was 8% but varied substantially between and within countries, ranging from 4% to 25%. Our analysis showed that 97% of the variability was between individuals within sub-city units and around 3% of the variance in z-scores of weight for height was explained by the city and sub-city levels. At the city-level, a higher distance between urban patches (isolation, per 1 SD increase) was associated with lower odds of excess weight (OR 0.90, 95% CI 0.82-0.99). Higher sub-city education was also associated with lower odds of excess weight, but better sub-city living conditions were associated with higher odds of excess weight. Interpretation: Built and social environment features are related to excess weight in preschool children. Our evidence from a wide range of large Latin American cities suggests that urban health interventions may be suitable alternatives towards attaining the goal of reducing excess weight early in the life course. Funding: The SALURBAL project (Salud Urbana en América Latina, Urban Health in Latin America) is funded by Wellcome [205177/Z/16/Z].

Development and validation of a new set of indicators to assess the quality of maternal and child nutritional care at the primary care.

Introduction: Maternal and child malnutrition is a worldwide public health problem with short, medium, and long-term adverse consequences for both mother and child. In Mexico, maternal and child malnutrition represents a serious public health problem that must be urgently addressed. In this context, Primary Health Care (PHC) plays an important role in the prevention, detection, monitoring, and treatment of the different forms of maternal and child malnutrition. Assessing the quality of nutritional care offered at this level of care is necessary in order to improve it; however, there are no indicators for the evaluation of this quality. Therefore, this study aimed at developing a set of indicators to assess the quality of maternal and child nutritional care at PHC. Methods: We developed indicators for different stages of life: preconception, pregnancy, infancy, and preschool age. A systematic review of the literature on clinical guidelines for the prevention, diagnosis, and treatment of the different forms of malnutrition was carried out; the recommendations of the guidelines evaluated with good quality were extracted. Results: Based on these recommendations, 22 indicators were constructed. A pilot study was carried out to validate the indicators and 16 indicators were selected to assess the maternal and child nutritional care at PHC.

The urban built environment and adult BMI, obesity, and diabetes in Latin American cities.

Latin America is the world's most urbanized region and its heterogeneous urban development may impact chronic diseases. Here, we evaluated the association of built environment characteristics at the sub-city -intersection density, greenness, and population density- and city-level -fragmentation and isolation- with body mass index (BMI), obesity, and type 2 diabetes (T2D). Data from 93,280 (BMI and obesity) and 122,211 individuals (T2D) was analysed across 10 countries. Living in areas with higher intersection density was positively associated with BMI and obesity, whereas living in more fragmented and greener areas were negatively associated. T2D was positively associated with intersection density, but negatively associated with greenness and population density. The rapid urban expansion experienced by Latin America provides unique insights and vastly expand opportunities for population-wide urban interventions aimed at reducing obesity and T2D burden.

Are Women's Empowerment and Income Inequality Associated with Excess Weight in Latin American Cities?

While income gradients and gender inequalities in excess weight have been noted elsewhere, data from Latin American cities is lacking. We analyzed gender-specific associations between city-level women's empowerment and income inequality with individual-level overweight/obesity, assessing how these associations vary by individual education or living conditions within cities in Latin America. Data came from national surveys and censuses, and was compiled by the SALURBAL project (Urban Health in Latin America). The sample included 79,422 individuals (58.0% women), living in 538 sub-cities, 187 cities, and 8 countries. We used gender-stratified Poisson multilevel models to estimate the Prevalence Rate Ratios (PRR) for overweight/obesity (body mass index ≥ 25 kg/m2) per a unit change in city-level women's empowerment (proxied by a score that measures gender inequalities in employment and education) and income inequality (proxied by income-based Gini coefficient). We also tested whether individual education or sub-city living conditions modified such associations. Higher city labor women's empowerment (in women) and higher city Gini coefficient (in men) were associated with a lower prevalence of overweight/obesity (PRR = 0.97 (95%CI 0.94, 0.99) and PRR = 0.94 (95%CI 0.90, 0.97), respectively). The associations varied by individual education and sub-city living conditions. For labor women's empowerment, we observed weakened associations towards the null effect in women with lower education and in residents of sub-cities with worse living conditions (men and women). For the Gini coefficient, the association was stronger among men with primary education, and a negative association was observed in women with primary education. Our findings highlight the need for promoting equity-based policies and interventions to tackle the high prevalence of excess weight in Latin American cities.

Quality Appraisal of Nutritional Guidelines to Prevent, Diagnose, and Treat Malnutrition in All Its Forms during Pregnancy.

This work aimed to identify clinical practice guidelines (CPGs) that include recommendations for the prevention, diagnosis, and treatment of women's malnutrition during pregnancy and to evaluate the quality of these guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. We conducted a literature review using PubMed and different websites from January 2009 to February 2021. The quality of the CPGs was independently assessed by reviewers using the AGREE II instrument, which defines guidelines scoring >70% in the overall assessment as "high quality". The analysis included 43 guidelines. Among the main findings, we identified that only half of the CPGs (51.1%) obtained a final "high quality" evaluation. AGREE II results varied widely across domains and categories. The two domains that obtained the highest scores were scope and purpose with 88.3% (range 39 to 100%) and clarity of presentation with 87.2% (range 25 to 100%). Among the "high quality" CPGs, the best scores were achieved by the three guidelines published by the National Institute of Health and Care Excellence (NICE) and the World Health Organization (WHO). Due to the importance of maternal nutrition in pregnancy, it is essential to join forces to improve the quality of the guidelines, especially in CPGs that do not meet the reference standards for quality.

Ultraprocessed Products as Food Fortification Alternatives: A Critical Appraisal from Latin America.

Ultraprocessed products (UPPs), associated with obesity and non-communicable diseases (NCDs), are becoming predominant on the global market and a target for market-driven fortification initiatives. The aim of this article is to describe the implications of adding micronutrients to UPPs with excessive amounts of critical nutrients associated with NCDs and provide recommendations for legislation and policies. UPPs with added micronutrients such as breakfast cereals, sugar-sweetened beverages, powder beverages, fruit juices, sauces, and bouillon cubes, among others, are commonly available and heavily promoted in Latin American countries. Misleading advertising of UPPs with added micronutrients and with excessive content of sugar, fat, and salt might increase the consumption of such products, giving them a "health halo effect" that leads consumers to overestimate their nutritional quality and healthfulness. Although international collections of standards such as the Codex Alimentarius provide some guidelines on this matter, countries need to implement national legislations, through a food systems approach, to regulate the marketing and labeling of UPPs. Lastly, there is still the need to foster research to close knowledge gaps and help countries to guide the process of food fortification strategies from a regulatory standpoint.

Age at childbirth and change in BMI across the life-course: evidence from the INCAP Longitudinal Study.

BACKGROUND: Parity has been associated with both short- and long-term weight gain in women. However, it is not clear if timing of parity across the reproductive age has different associations with BMI. METHODS: To prospectively assess the association between age at childbirth and maternal change in BMI, we analyzed data from the ongoing INCAP Longitudinal Study, which started in 1969 in four villages in Guatemala. Cohort women (n=778) provided information on reproductive history and anthropometric measures were measured in 1988-89 (adolescence, 15 to 25y), 2002-04 (early adulthood, 26 to 36y) and 2015-17 (mid adulthood, 37 to 55y). We evaluated the associations of number of live births in the period preceding each study wave (1969-77 to 1988-89, 1988-89 to 2002-04 and 2002-04 to 2015-17) with BMI change in the same period using multivariable linear regression models. RESULTS: Number of live births between 1988 and 89 and 2002-04 was positively associated with increased BMI, while there was not an association between number of live births and BMI in the other intervals. Women who had one, two, or three or more children between 1988 and 89 and 2002-04 had 0.90 (kg/m2, 95% CI: -0.55, 2.35), 2.39 (kg/m2, 95% CI: 1.09, 3.70) and 2.54 (kg/m2, 95% CI: 1.26, 3.82) higher BMI, respectively, than women who did not give birth in the same period. CONCLUSIONS: Our findings suggest that women who had three or more children during early adulthood gained more weight compared to women who had no children in the same period. In contrast, women who had children earlier or later in their reproductive lives did not gain additional weight compared to those who did not have children during that period. Childbirth may have different associations with BMI based on the mother's age.

Protein-Energy Supplementation in Early-Life Decreases the Odds of Mental Distress in Later Adulthood in Guatemala.

BACKGROUND: The prevalence of mental health concerns is growing worldwide, along with lack of access to and receipt of needed treatment. Current gaps in treatment provision have led to exploring alternative methods of prevention, with research linking nutrition and mental health, of particular relevance in low- and middle-income countries, with a high prevalence of undernutrition. OBJECTIVES: To examine whether exposure to a protein-energy nutritional supplement during the first 1000 d of life decreased odds of mental distress in adulthood among men and women in Guatemala compared with receiving a low energy-no protein supplement or supplementation outside the 1000-d window. METHODS: Data from participants (n = 1249) in a longitudinal cohort protein-energy supplementation trial (early-life, supplementation data from 1969 to 1977, ages 0-7 y; life course, outcome data from 2017-2018 follow-up, ages 40-57 y) were analyzed for associations between nutrition in the first 1000 d and mental distress in adulthood (WHO Self-Reporting Questionnaire 20 [SRQ-20]), controlling for early-life variables and current life stress; life course variables (e.g. education) were examined as potential mediators of this relation. Generalized linear mixed models and zero-inflated Poisson generalized linear mixed models were utilized. RESULTS: Both partial and full supplementation with Atole during the first 1000 d were associated with 63% (95% CI: 0.16, 0.87) and 56% (95% CI: 0.19, 1.03) lower odds, respectively, of experiencing mental distress in adulthood. Results did not differ by sex. These inverse relations remained relatively unchanged (partial OR = 0.34 [95% CI: 0.14, 0.83]; full OR = 0.38 [95% CI: 0.16, 0.92]) after controlling for early-life and life course variables, including life stress. CONCLUSIONS: Protein-energy supplementation during the first 1000 d of life in Guatemala, where undernutrition is prevalent, may reduce the prevalence of later mental distress in adulthood. This effect appears to occur directly, rather than indirectly, through pathways of life course variables such as education, wealth, and marital status.

Protein-Energy Supplementation in Early-Life Decreases the Odds of Mental Distress in Later Adulthood in Guatemala.

BACKGROUND: The prevalence of mental health concerns is growing worldwide, along with lack of access to and receipt of needed treatment. Current gaps in treatment provision have led to exploring alternative methods of prevention, with research linking nutrition and mental health, of particular relevance in low- and middle-income countries, with a high prevalence of undernutrition. OBJECTIVES: To examine whether exposure to a protein-energy nutritional supplement during the first 1000 d of life decreased odds of mental distress in adulthood among men and women in Guatemala compared with receiving a low energy-no protein supplement or supplementation outside the 1000-d window. METHODS: Data from participants (n = 1249) in a longitudinal cohort protein-energy supplementation trial (early-life, supplementation data from 1969 to 1977, ages 0-7 y; life course, outcome data from 2017-2018 follow-up, ages 40-57 y) were analyzed for associations between nutrition in the first 1000 d and mental distress in adulthood (WHO Self-Reporting Questionnaire 20 [SRQ-20]), controlling for early-life variables and current life stress; life course variables (e.g. education) were examined as potential mediators of this relation. Generalized linear mixed models and zero-inflated Poisson generalized linear mixed models were utilized. RESULTS: Both partial and full supplementation with Atole during the first 1000 d were associated with 63% (95% CI: 0.16, 0.87) and 56% (95% CI: 0.19, 1.03) lower odds, respectively, of experiencing mental distress in adulthood. Results did not differ by sex. These inverse relations remained relatively unchanged (partial OR = 0.34 [95% CI: 0.14, 0.83]; full OR = 0.38 [95% CI: 0.16, 0.92]) after controlling for early-life and life course variables, including life stress. CONCLUSIONS: Protein-energy supplementation during the first 1000 d of life in Guatemala, where undernutrition is prevalent, may reduce the prevalence of later mental distress in adulthood. This effect appears to occur directly, rather than indirectly, through pathways of life course variables such as education, wealth, and marital status.

Projecting the Impact of Nutrition Policy to Improve Child Stunting: A Case Study in Guatemala Using the Lives Saved Tool.

BACKGROUND: Child stunting is a critical global health issue. Guatemala has one of the world's highest levels of stunting despite the sustained commitment to international nutrition policy best practices endorsed by the Scaling Up Nutrition (SUN) movement. Our objective was to use Guatemala as a case study to project the impact of a recently published national nutrition policy, the Great Crusade, that is consistent with SUN principles. METHODS: We used the Lives Saved Tool (LiST) to project the impact of scaling-up of nutrition interventions proposed in the Great Crusade and recommended by SUN. Our outcomes were changes in stunting prevalence, number of stunting cases averted, and number of cases averted by intervention in children under 5 years of age from 2020 to 2030. We considered 4 scenarios: (1) intervention coverage continues based on historical trends, (2) coverage targets in the Great Crusade are achieved, (3) coverage targets in the Great Crusade are achieved with reduced fertility risk, and (4) coverage reaches an aspirational level. RESULTS: All scenarios led to modest reductions in stunting prevalence. In 2024, stunting prevalence was estimated to change by -0.1% (95% confidence interval [CI]= 0.0%,-0.2%) if historical trends continue, -1.1% (95% CI=-0.8%,-1.5%) in the Great Crusade scenario, and -2.2% (95% CI=-1.6%,-3.0%) in the aspirational scenario. In 2030, we projected a stunting prevalence of -0.4% (95% CI=-0.2%,-0.8%) and -3.7% (95% CI=-2.8%,-5.1%) in the historical trends and aspirational scenario, respectively. Complementary feeding, sanitation, and breastfeeding were the highest-impact interventions across models. CONCLUSIONS: Targeted reductions in child stunting prevalence in Guatemala are unlikely to be achieved solely based on increases in intervention coverage. Our results show the limitations of current paradigms recommended by the international nutrition community. Policies and strategies are needed to address the broader structural drivers of stunting.

Educational inequalities in obesity: a multilevel analysis of survey data from cities in Latin America.

OBJECTIVE: Using newly harmonised individual-level data on health and socio-economic environments in Latin American cities (from the Salud Urbana en América Latina (SALURBAL) study), we assessed the association between obesity and education levels and explored potential effect modification of this association by city-level socio-economic development. DESIGN: This cross-sectional study used survey data collected between 2002 and 2017. Absolute and relative educational inequalities in obesity (BMI ≥ 30 kg/m2, derived from measured weight and height) were calculated first. Then, a two-level mixed-effects logistic regression was run to test for effect modification of the education-obesity association by city-level socio-economic development. All analyses were stratified by sex. SETTING: One hundred seventy-six Latin American cities within eight countries (Brazil, Chile, Colombia, Costa Rica, El Salvador, Guatemala, Mexico and Peru). PARTICIPANTS: 53 186 adults aged >18 years old. RESULTS: Among women, 25 % were living with obesity and obesity was negatively associated with educational level (higher education-lower obesity) and this pattern was consistent across city-level socio-economic development. Among men, 18 % were living with obesity and there was a positive association between education and obesity (higher education-higher obesity) for men living in cities with lower levels of development, whereas for those living in cities with higher levels of development, the pattern was inverted and university education was protective of obesity. CONCLUSIONS: Among women, education was protective of obesity regardless, whereas among men, it was only protective in cities with higher levels of development. These divergent results suggest the need for sex- and city-specific interventions to reduce obesity prevalence and inequalities.

Patterns of Growth in Childhood in Relation to Adult Schooling Attainment and Intelligence Quotient in 6 Birth Cohorts in Low- and Middle-Income Countries: Evidence from the Consortium of Health-Oriented Research in Transitioning Societies (COHORTS).

BACKGROUND: Growth faltering has been associated with poor intellectual performance. The relative strengths of associations between growth in early and in later childhood remain underexplored. OBJECTIVES: We examined the association between growth in childhood and adult human capital in 5 low- and middle-income countries (LMICs). METHODS: We analyzed data from 9503 participants in 6 prospective birth cohorts from 5 LMICs (Brazil, Guatemala, India, the Philippines, and South Africa). We used linear and quasi-Poisson regression models to assess the associations between measures of height and relative weight at 4 age intervals [birth, age ∼2 y, midchildhood (MC), adulthood] and 2 dimensions of adult human capital [schooling attainment and Intelligence Quotient (IQ)]. RESULTS: Meta-analysis of site- and sex-specific estimates showed statistically significant associations between size at birth and height at ∼2 y and the 2 outcomes (P < 0.001). Weight and length at birth and linear growth from birth to ∼2 y of age (1 z-score difference) were positively associated with schooling attainment (ß: 0.13; 95% CI: 0.08, 0.19, ß: 0.17; 95% CI: 0.07, 0.32, and ß: 0.25, 95% CI: 0.10, 0.40, respectively) and adult IQ (ß: 0.74, 95% CI: 0.35, 1.14, ß: 0.73, 95% CI: 0.35, 1.10, and ß: 1.52, 95% CI: 0.96, 2.08, respectively). Linear growth from age 2 y to MC and from MC to adulthood was not associated with higher school attainment or IQ. Change in relative weight in early childhood, MC, and adulthood was not associated with either outcome. CONCLUSIONS: Linear growth in the first 1000 d is a predictor of schooling attainment and IQ in adulthood in LMICs. Linear growth in later periods was not associated with either of these outcomes. Changes in relative weight across the life course were not associated with schooling and IQ in adulthood.

Desarrollo de preferencias alimentarias saludables en etapas tempranas de la vida / Development of healty food preferences early in life

El deterioro de la calidad de la dieta está afectando la salud de los niños menores de dos años. Por tal motivo, es de vital importancia la identificación de factores relacionados con el desarrollo y establecimiento de preferencias alimentarias en etapas tempranas de la vida y brindar recomendaciones que faciliten su adopción. Esta revisión sistemática de la literatura tiene como objetivo resumir la evidencia existente sobre los factores asociados a formar y modelar las preferencias alimentarias en etapas tempranas de la vida. Para esto se realizó una búsqueda en PubMed de estudios que evaluaran la asociación entre la exposición prenatal y posnatal de sabores, introducción temprana de alimentos y habituación al sabor dulce, alimentación complementaria y diversidad dietética. Se incluyeron artículos publicados desde el 2000 hasta el 2019. Resultados de 39 artículos sugieren que la alimentación durante los primeros dos años de vida y el desarrollo de preferencias alimentarias en etapas tempranas de la vida tiene el potencial de modificar los patrones de alimentación y establecerse en etapas posteriores de la vida, por lo que, los primeros mil días de vida constituyen una ventana de oportunidad para formar preferencias alimentarias saludables y mejorar la calidad de dieta de los niños(AU)

Poor diets are damaging children's health. Therefore, it is urgent to identify factors related to the development and establishment of healthy food preferences early in life and to provide recommendations to enable their adoption. This systematic literature review aims to summarize the existing evidence on the factors identified on shaping food preferences early in life. For this, a search was conducted on PubMed about studies evaluating the association between prenatal and postnatal exposure of flavors and the development of food preferences, early food introduction, innate preference to sweet taste, complementary feeding and dietary diversity with the development of food preferences. Articles published from 2000 to 2019 were included. Results from 39 manuscripts suggest that the first 2 years of life are critical for the development of food preferences early in life. These food preferences have the potential to modify children's eating patterns and persist later in life. Therefore, the first 1000 days of life are a key window of opportunity to establish healthy food preferences and shape the quality of children's diet(AU)

Malnutrition in all its forms by wealth, education and ethnicity in Latin America: who are more affected?

OBJECTIVE: To summarise the findings from this supplemental issue on the distribution of malnutrition (stunting/short stature, anaemia and overweight) by wealth, education and ethnicity within and between ten Latin American countries. DESIGN: We retrieved information from each country's article and estimated the average difference in the prevalence of malnutrition between groups. We estimated the associations between countries' malnutrition prevalence and GDP, percentage of women with high education and percentage of non-indigenous ethnicity. SETTING: Nationally representative surveys from ten Latin American countries conducted between 2005 and 2017. PARTICIPANTS: Children (<5 years), adolescent women (11-19 years) and adult women (20-49 years). RESULTS: Socially disadvantaged groups (low wealth, low education and indigenous ethnicity) had on average 15-21 (range across indicators and age groups) percentage points (pp) higher prevalence of stunting/short stature and 3-11 pp higher prevalence of anaemia. For overweight or obesity, adult women with low education had a 17 pp higher prevalence; differences were small among children <5 years, and results varied by country for adolescents by education, and for adults and adolescents by wealth and ethnicity. A moderate and strong correlation (-0·58 and -0·71) was only found between stunting/short stature prevalence and countries' GDP per capita and percentage of non-indigenous households. CONCLUSIONS: Overweight was equally distributed among children; findings were mixed for ethnicity and wealth, whereas education was a protective factor among adult women. There is an urgent need to address the deep inequalities in undernutrition and prevent the emerging inequalities in excess weight from developing further.

Parity, lactation, and long-term weight change in Mexican women.

One post-partum behaviour that may be protective against post-partum weight retention and long-term weight gain among women of reproductive age is lactation because of its potential role in resetting maternal metabolism after pregnancy. However, most of the evidence focuses on weight retention at 6, 12, or 24 months post-partum, and data beyond 2 years after birth are sparse, and findings are inconclusive. Therefore, our aim was to assess the association of parity and mean duration of lactation per child with long-term weight change in Mexican women. We assessed the association of parity and mean duration of lactation per child with long-term weight change in 75,421 women from the Mexican Teachers' Cohort. Several multivariable regression models were fit to assess these associations. We also examined the non-linear association between duration of lactation and weight change using restricted cubic splines. We found that parous women (≥4 children) gained 2.81 kg more (95% CI [2.52, 3.10]) than did nulliparous women. The association between mean duration of lactation per child and weight change appeared to be non-linear. Women who breastfed on average 3-6 months per child had lower gain weight (-1.10, 95% CI [-1.58, -0.47 kg]) than had women who did not breastfeed. This association was linear up to 6 months of lactation per child. Our findings suggest that parity alters weight-gain trajectory in women and that lactation could reduce this alteration. These findings are important in the prevention of excessive weight gain through reproductive years and their future health implications.

Dairy Intake and Risk of Cardiovascular Disease.

PURPOSE OF REVIEW: Due to inconsistent findings on dairy consumption and CVD and all-cause mortality, we performed a narrative literature review to the current literature on dairy and its association with CVD. RECENT FINDINGS: Due to their complex biochemistry, dairy consumption is a rather heterogeneous exposure. Multiple pathways have been proposed from dairy consumption and CVD. Current guidelines advocate for consumption of low-fat dairy products particularly milk, cheese, and yogurt, although the evidence for this is scant. Randomized clinical trials and large prospective studies on lipid-related cardiometabolic disease risk factors are consistent with results from most meta-analyses of prospective cohort studies, which suggest null or inverse relationship between CVD risk and mortality with dairy consumption although there is no clear dose response relationship. Most of current evidence suggests that dairy products are neutral or positive effect on human cardiovascular diseases.