Evolution of food and beverage prices after the front-of-package labelling regulations in Chile.

INTRODUCTION: This study assesses the impact on prices of the 2016 Chilean comprehensive food policy package, centred around front-of-package warning labels for food and beverages high in saturated fats, sugars, calories and/or salt, on food and beverage prices, labelled or not. METHODS: Data from Kantar WorldPanel Chile, from January 2014 to December 2017, were used. The methodology implemented was interrupted time series analyses with a control group on Laspeyres Price Indices on labelled food and beverage products. RESULTS: After the regulations were implemented, prices among different categories of products (eg, high-in; reformulated but still high-in; reformulated and not high-in; not high-in) did not change with regulations relative to the control group. Specific price indices (relative to the control group) for households from different socioeconomic strata remained unchanged. CONCLUSIONS: Even where reformulation was extensive, we found no evidence that it was associated with price changes, at least during Chile's first year and a half of regulation implementation.

Socioeconomic Patterns in Budget Share Allocations of Regulated Foods and Beverages in Chile: A Longitudinal Analysis.

Chile has enacted stringent legislation regulating food and beverage labeling and advertising. This study assesses the changes in the average relative allocations of food and beverage budgets for regulated versus not regulated products in households of different socioeconomic and demographic backgrounds. A household fixed effect before-after model is estimated and the marginal effects in the changes of levels and trends in budget shares and purchased volumes after the implementation of the regulations are examined. The results highlight how impactful food policies can shift consumption toward healthier products.

Assessment of a consensus definition of obesity and metabolic health phenotypes in children at different pubertal stages.

Not all individuals with obesity develop metabolic complications, which has brought about the concepts of metabolically healthy and unhealthy obesity (MHO/MUO). However, inconsistent definitions of these conditions have limited their understanding. We assessed whether a recently-proposed consensus definition for MHO/MUO correlates with adiposity and reflects metabolic risk parameters during puberty. Low-middle income children from the Growth and Obesity Cohort Study (Santiago, Chile) were included (n = 949; 1692 visits at Tanner (T)2, T4 and/or one-year post menarche (1YPM)). Anthropometry, body composition and metabolic parameters were compared between MUO and MHO, and also in children without obesity. The risk for presenting MUO phenotype was significantly elevated with higher waist-height ratio (T2), zBMI (T2, T4), trunk fat, and C-reactive protein (T4). Elevated cardiometabolic indices were important predictors of the "unhealthy" phenotype allocation in children with or without obesity. Our observations suggest that the consensus definition in children at T2, T4 and 1YPM reflects metabolic risk and central obesity. Metabolic health phenotype allocation by this equation enables easy detection of risk factors that call for action to prevent long-term metabolic derangements in children with obesity and, importantly, also those without obesity.

Why Don't You [Government] Help Us Make Healthier Foods More Affordable Instead of Bombarding Us with Labels? Maternal Knowledge, Perceptions, and Practices after Full Implementation of the Chilean Food Labelling Law.

Experimental and real-life evaluations show that the use of front-of-package warning labels (FoP) in unhealthy foods is well understood and can modify people's behaviors. However, it is unclear whether these effects remain in the long term because of the risk of message fatigue. The purpose of this study is to explore after four years of implementation of the Chilean Food Labelling law people's dietary behavior and FoP labels attention. Nine focus groups of mothers (7-10 people each) of children (2-14 yo) were conducted in Santiago, Chile, and macrocodes were developed, combining an iterative process of deductive and inductive thematic analyses. We found that mothers experienced labels' fatigue but also had greater knowledge about nutrition and appreciation for more natural foods. This greater knowledge about better nutrition interferes with the perception that healthier and less processed foods are financial and physically inaccessible. The key role of schools as an environment for promoting healthier diets in children was strengthened by the mothers. These results suggest that policies based on providing consumer information need reinforcement campaigns to maintain their effectiveness and that we also need to advance policies to improve access and affordability of healthy foods to ensure better diets.

Global Mental Health and Nutrition: Moving Toward a Convergent Research Agenda.

Both malnutrition and poor mental health are leading sources of global mortality, disease, and disability. The fields of global food security and nutrition (FSN) and mental health have historically been seen as separate fields of research. Each have undergone substantial transformation, especially from clinical, primary care orientations to wider, sociopolitical approaches to achieve Sustainable Development Goals. In recent years, the trajectories of research on mental health and FSN are further evolving into an intersection of evidence. FSN impacts mental health through various pathways such as food insecurity and nutrients important for neurotransmission. Mental health drives FSN outcomes, for example through loss of motivation and caregiving capacities. They are also linked through a complex and interrelated set of determinants. However, the heterogeneity of the evidence base limits inferences about these important dynamics. Furthermore, interdisciplinary projects and programmes are gaining ground in methodology and impact, but further guidance in integration is much needed. An evidence-driven conceptual framework should inform hypothesis testing and programme implementation. The intersection of mental health and FSN can be an opportunity to invest holistically in advancing thinking in both fields.

Exposición a químicos disruptores endócrinos obesogénicos y obesidad en niños y jóvenes de origen latino o hispano en Estados Unidos y Latinoamérica: una perspectiva del curso de la vida.

En el 2019, en seguimiento a un taller dirigido por el Global Health Studies del Fogarty International Center sobre el tema de la prevención de la obesidad infantil y las sinergias de investigación que surgen a través de las colaboraciones transfronterizas, convocamos a un grupo de expertos de Estados Unidos y Latinoamérica para que realizaran una revisión narrativa de la literatura epidemiológica sobre el papel obesogénico de los químicos disruptores endócrinos (EDC, por sus siglas en inglés) en la etiología de la obesidad infantil entre la juventud latina de Estados Unidos y Latinoamérica. Además de resumir y sintetizar los resultados de las investigaciones sobre este tema publicados en la última década, contextualizamos los hallazgos dentro de un marco bioconductual de curso de vida para identificar relaciones exposición-desenlace impulsadas por resultados de investigación, identificar inconsistencias y deficiencias de la literatura actual, y discutir el papel de las regulaciones políticas, todo con el objetivo de identificar posibles vías para la prevención temprana de la obesidad en las poblaciones hispanas/latinas.

Food environment solutions for childhood obesity in Latin America and among Latinos living in the United States.

The food environment is a major contributor to unhealthy diets in children and, therefore, to the increasing rates of obesity. Acclaimed by scholars across the world, Latin American countries have been leaders in implementing policies that target different aspects of the food environment. Evidence on the nature and to what extent children are exposed and respond to unhealthy food environments in the region and among Latinos in the United States is, however, deficient. The objective of this review is to use the integrated International Network for Food and Obesity/noncommunicable diseases (NCDs) Research, Monitoring and Action Support (INFORMAS) framework to create healthy food environment to (i) compare the key elements of childhood obesity-related food environments in Latin America and for Latinos living in the United States; (ii) describe the evidence on solutions to improve childhood obesity-related food environments; and (iii) identify research priorities to inform solutions to fight childhood obesity in these populations. We found that an integrated body of evidence is needed to inform an optimal package of policies to improve food environments to which children in Latin America and Latino children in the United States are exposed and more efficiently translate policy solutions to help curb growing childhood obesity levels across borders.

Towards unified and impactful policies to reduce ultra-processed food consumption and promote healthier eating.

The global surges in obesity and nutrition-related non-communicable diseases (NCDs) have created a need for decisive new food policy initiatives. A major concern has been the impact of ultra-processed foods (UPFs) and ultra-processed drinks on weight gain and on the risk of several NCDs. These foods, generally high in calories, added sugar, sodium, and unhealthy fats, and poor in fibre, protein, and micronutrients, have extensive negative effects on human health and on the environment (due to their associated carbon emission and water use). There is a growing tendency worldwide, and especially in South America, for food companies to add micronutrients to UPFs to make health claims regarding these products, to which food-regulating authorities refer to fake foods. Although more than 45 countries and smaller subregional or urban entities have created taxes on ultra-processed drinks, such as sugar-sweetened beverages, only a few have adopted taxes on snacks and other UPFs, and none have added major subsidies for truly healthy, fresh or minimally processed food for people from lower socioeconomic backgrounds. Another major focus has been on developing effective package labelling. A smaller number of countries have selected the most impactful warning labels and linked them with other measures to create a mutually reinforcing set of policies; a few other countries have developed effective school food policies. We herein present in-depth results from key countries involved in all these actions and in comprehensive marketing controls, and conclude with our recommendations for the future. This field is quite new; progress to date is substantial, but much more is left to learn.

Food industry political practices in Chile: "the economy has always been the main concern".

BACKGROUND: In the business literature, the term "corporate political activity" (CPA) refers to the political strategies undertaken by corporations to protect or expend their markets, by influencing, directly or indirectly, the policy process. There is evidence that food industry actors use such political practices, which poses a significant threat to public health. Our study objective was to identify the political practices of the food industry in Chile. RESULTS: In Chile, food industry actors supported community initiatives, particularly those targeted at children and those focused on environmental sustainability. Food industry actors also funded research through prizes, scholarships, and by supporting scientific events. Food industry actors lobbied against the development and implementation of a front-of-pack nutrition labelling policy, including with support from the Ministries of Economy, Agriculture and Foreign Affairs. Food industry actors, for example, claimed that there would be unintended negative consequences for society and the economy, and that the policy would breach trade agreements. The same arguments were used against a proposed tax increase on sugar-sweetened beverages. Food industry actors stressed their crucial role in the Chilean economy and claimed to be part of the solution in the prevention and control of obesity, with a particular focus on their efforts to reformulate food products, and their support of physical activity initiatives. Interviewees noted that the political influence of the food industry is often facilitated by the neo-liberal and market-driven economy of Chile. Nevertheless, this system was questioned through social protests that started in the country during data collection. CONCLUSIONS: In Chile, food industry actors used numerous action- and argument-based CPA practices which may influence public health policy, research, and practice. Despite strong influence from the food industry, Chile adopted a front-of-pack nutrition labelling policy. While the country has some measures in place to manage the interactions between government officials or public health professionals, and the industry, there is still a need to develop robust mechanisms to address undue influence from corporations.

Nutrition status in adult Chilean population: economic, ethnic and sex inequalities in a post-transitional country.

OBJECTIVE: To assess the relationship between malnutrition, socioeconomic status (SES) and ethnicity in Chilean adult population. DESIGN: Nationally representative survey (ENS) conducted in 2016-2017. Sociodemographic information, weight, height and hemoglobin (Hb) were measured (2003 ENS). Excess weight was defined as BMI ≥25 kg/m2. Undernutrition included underweight (BMI <18·5 kg/m2), short stature (height <1·49 m in women and <1·62 m in men) or anaemia (Hb <12 g/l). Education and household income level were used as indicators of SES; ethnicity was self-reported. We applied linear combinations of estimators to compare the prevalence of excess weight and undernutrition by SES and ethnicity. SETTING: Chile. PARTICIPANTS: In total, 5082 adults ≥20 years (64 % women) and 1739 women ≥20 years for anaemia analyses. RESULTS: Overall, >75 % of women and men had excess weight. Low SES women either by income or education had higher excess weight ((82·0 (77·1, 86·1) v. 65·0 (54·8, 74·1)) by income; (85·3 (80·6, 89·0) v. 68·2 (61·6, 74·1) %) by education) and short stature (20-49 years; 31(17·9, 48·2) v. 5·2 (2·2,11·4) by education); obesity was also more frequent among indigenous women (20-49 years; 55·8 (44·4, 66·6) v. 37·2 (32·7, 42·0) %) than non-indigenous women. In men, excess weight did not significantly differ by SES or ethnicity, but short stature concentrated in low SES (20-49 years; 47·6 (24·6, 71·6) v. 4·5 (2·1, 9·5) by education) and indigenous men (21·5 (11·9, 5·5, 11·9) v. 8·2 (5·5, 11·9)) (P < 0·05 for all). CONCLUSIONS: In Chile, malnutrition is disproportionately concentrated among women of low SES and indigenous origin; these inequalities should be considered when implementing prevention policies.

An evaluation of Chile's Law of Food Labeling and Advertising on sugar-sweetened beverage purchases from 2015 to 2017: A before-and-after study.

BACKGROUND: Chile's Law of Food Labeling and Advertising, implemented in 2016, was the first national regulation to jointly mandate front-of-package warning labels, restrict child-directed marketing, and ban sales in schools of all foods and beverages containing added sugars, sodium, or saturated fats that exceed set nutrient or calorie thresholds. The objective of this study is to evaluate the impact of this package of policies on household beverage purchases. METHOD AND FINDINGS: In this observational study, monthly longitudinal data on packaged beverage purchases were collected from urban-dwelling households (n = 2,383) participating in the Kantar WordPanel Chile Survey from January 1, 2015, to December 31, 2017. Beverage purchases were linked to nutritional information at the product level, reviewed by a team of nutritionists, and categorized as "high-in" or "not high-in" according to whether they contained high levels of nutrients of concern (i.e., sugars, sodium, saturated fat, or energy) according to Chilean nutrient thresholds and were thus subject to the law's warning label, marketing restriction, and school sales ban policies. The majority of high-in beverages were categorized as such because of high sugar content. We used fixed-effects models to compare the observed volume as well as calorie and sugar content of postregulation beverage purchases to a counterfactual based on preregulation trends, overall and by household-head educational attainment. Of households included in the study, 37% of household heads had low education (less than high school), 40% had medium education (graduated high school), and 23% had high education (graduated college), with the sample becoming more educated over the study period. Compared to the counterfactual, the volume of high-in beverage purchases decreased 22.8 mL/capita/day, postregulation (95% confidence interval [CI] -22.9 to -22.7; p < 0.001), or 23.7% (95% CI -23.8% to -23.7%). High-educated and low-educated households showed similar absolute reductions in high-in beverage purchases (approximately 27 mL/capita/day; p < 0.001), but for high-educated households this amounted to a larger relative decline (-28.7%, 95% CI -28.8% to -28.6%) compared to low-educated households (-21.5%, 95% CI -21.6% to -21.4%), likely because of the high-educated households' lower level of high-in beverage purchases in the preregulation period. Calories from high-in beverage purchases decreased 11.9 kcal/capita/day (95% CI -12.0 to -11.9; p < 0.001) or 27.5% (95% CI -27.6% to -27.5%). Calories purchased from beverages classified as "not high-in" increased 5.7 kcal/capita/day (95% CI 5.7-5.7; p < 0.001), or 10.8% (10.8%-10.8%). Calories from total beverage purchases decreased 7.4 kcal/capita/day (95% CI -7.4 to -7.3; p < 0.001), or 7.5% (95% CI -7.6% to -7.5%). A key limitation of this study is the inability to assess causality because of its observational nature. We also cannot determine whether observed changes in purchases are due to reformulation or consumer behavioral change, nor can we parse out the effects of the labeling, marketing, and school sales ban policies. CONCLUSIONS: Purchases of high-in beverages significantly declined following implementation of Chile's Law of Food Labeling and Advertising; these reductions were larger than those observed from single, standalone policies, including sugar-sweetened-beverage taxes previously implemented in Latin America. Future research should evaluate the effects of Chile's policies on purchases of high-in foods, dietary intake, and long-term purchasing changes.

Structural responses to the obesity and non-communicable diseases epidemic: Update on the Chilean law of food labelling and advertising.

Chile approved the law of food labelling and advertising in 2012; this law aims to address the obesity epidemic, particularly in children. The implementation details were published in 2015, and the law was implemented finally in 2016, as described in the current article. Regulated foods were defined based on a specially developed nutrient profiling, which considered natural foods as gold standard. For liquid foods, amounts of energy, sugars, saturated fats, and sodium in 100 mL of cow's milk were used as cut-offs. For solid foods, values within the 90th - 99th percentile range for energy and critical nutrients were selected as cut-off within a list of natural foods. A stop sign stating "High in " was chosen as warning label for packaged regulated foods. Regulated foods were also forbidden to be sold or offered for free at kiosks, cafeterias, and feeding programme at schools and nurseries. Besides, regulated foods cannot be promoted to children under 14 years. A staggered implementation of the regulation was decided, with nutrients cut-offs becoming increasingly stricter over a 3-year period. These regulatory efforts are in the right direction but will have to be sustained and complemented with other actions to achieve their ultimate impact of halting the obesity epidemic.

Sugar-Sweetened Beverage Intake among Chilean Preschoolers and Adolescents in 2016: A Cross-Sectional Analysis.

BACKGROUND: Chile has the highest sugar-sweetened beverage (SSB) sales of any country and a growing burden of childhood obesity. This study examines SSB intake in Chilean children after a 5% SSB tax increase in 2014 but prior to marketing, labeling, and school policies implemented in 2016. METHODS: 24-h recalls were collected in 2016 from two cohorts comprised of preschoolers 3⁻5 years of age (n = 961) and adolescents 12⁻14 years of age (n = 770) from low⁻moderate income neighborhoods. Beverages were categorized as regulated or unregulated according to whether they exceeded nutrient thresholds established by the 2016 policies. RESULTS: Preschoolers consumed mainly beverage calories from regulated dairy beverages and substitutes (109 kcal, SD 30), unregulated dairy beverages (102 kcal, SD 24), and regulated fruit and vegetables drinks (44 kcal, SD 20). For adolescents, the greatest contributions came from regulated sodas (77 kcal, SD 47), regulated dairy beverages and substitutes (41 kcal, SD 16), and unregulated coffee and tea (41 kcal, SD 11). Overall, regulated beverages provided a greater proportion of calories than unregulated for preschoolers (15.0% vs. 11.8%) and for adolescents (9.1% vs. 5.0%). CONCLUSIONS: Before major policy implementation, regulated beverages accounted for a higher percentage of energy intake than unregulated beverages among both age groups. Future research will be needed to evaluate the impact of Chile's new policies on sugary beverage intake in children.

Chile's 2014 sugar-sweetened beverage tax and changes in prices and purchases of sugar-sweetened beverages: An observational study in an urban environment.

BACKGROUND: On October 1, 2014, the Chilean government modified its previous sugar-sweetened beverage (SSB) tax, increasing the tax rate from 13% to 18% on industrialized beverages with high levels of sugar (H-SSBs) (greater than 6.25 grams [g] sugar/100 milliliters [mL]) and decreasing the tax rate from 13% to 10% on industrialized beverages with low or no sugar (L-SSBs) (less than 6.25 g sugar/100 mL). This study examines changes in beverage prices and household beverage purchases following the implementation of the tax reform. METHODS AND FINDINGS: We used longitudinal data collected between January 1, 2013, and December 31, 2015, from 2,000 households. We defined the pretax period as January 1, 2013, to September 30, 2014, and the posttax period as October 1, 2014, to December 31, 2015. We conducted a pre-post analysis for changes in prices and purchases, with the latter examined by volume and calories. We compared posttax changes in prices and purchases to a counterfactual, defined as what would have been expected in the posttax period based on pretax trends. All results are stated as comparisons to this counterfactual. We linked beverages at the bar code level to nutrition facts panel data collected by a team of Chilean nutritionists who categorized them by taxation level and beverage subcategory, which included carbonated and noncarbonated H-SSBs and concentrated, ready-to-drink L-SSBs and untaxed beverages. We reconstituted concentrated beverages and analyzed all beverages using as-consumed volumes and calories. Posttax monthly prices of H-SSBs increased, but these changes were small. Prices of carbonated H-SSBs increased by 2.0% (95% confidence interval [CI] 1.0%-3.0%), while those of noncarbonated H-SSBs increased by 3.9% (95% CI 1.6%-6.2%). Prices of L-SSB concentrates decreased after the tax by 6.7% (95% CI -8.2%--4.6%), and prices of ready-to-drink L-SSBs increased by 1.5% (95% CI 0.3%-2.7%). Households decreased monthly per capita purchases of H-SSBs by 3.4% by volume (95% CI -5.9%--0.9%) and 4.0% by calories (95% CI -6.3%--1.9%), and this change was greater among high socioeconomic status (SES) households. The volume of household purchases of L-SSBs increased 10.7% (95% CI 7.5%-13.9%), while that of untaxed beverage purchases decreased by 3.1% (95% CI -5.1%--1.1%). The main limitation of this study was that there was no control group, so we were unable to assess the causal impact of the tax. CONCLUSIONS: The modifications of Chile's SSB tax were small, and observed changes in prices and purchases of beverages after the tax were also small. Our results are consistent with previous evidence indicating that small increases in SSB taxes are unlikely to promote large enough changes in SSB purchases to reduce obesity and noncommunicable diseases (NCDs).

Prevalence of child-directed and general audience marketing strategies on the front of beverage packaging: the case of Chile.

OBJECTIVE: Front-of-package (FOP) marketing strategies of a wide variety of beverages were catalogued to examine the prevalence of each strategy prior to a sweeping Chilean restriction of child-directed marketing aimed at reducing obesity-related disease among Chile's youth. DESIGN: Photographs of 1005 beverage packages were quantitatively content-analysed to code whether a variety of child-directed, health-oriented and other marketing strategies (e.g. sales promotions) were present on each product's FOP. Strategies were then analysed based on beverages' product category, total sugar, energy and tax status (beverages with added sugars are taxed at different rates). SETTING: Photographs were taken in six urban supermarkets in Santiago, Chile, representing five different supermarket chains. RESULTS: Beverages using child-directed characters or nature/fruit references were higher in total sugar and beverages with child-directed characters or childhood/family references were higher in energy than beverages without these respective strategies. Of the beverages taxed at the highest rate (greatest amount of added sugars), 49 % used nutrition and health appeals and 80 % used nature or fruit appeals. Plain waters and plain milks were less likely than other selected product categories to use health-oriented appeals or multiple FOP strategies in combination. CONCLUSIONS: FOP marketing on beverages varied according to the nutritional quality of the product, with heavier use of health-oriented and child-directed strategies in less healthy products. Marketing activities warrant continued observation to evaluate how industry responds to new marketing restrictions as these restrictions are evaluated in the light of existing taxes and other regulatory efforts to improve diets and reduce obesity-related disease.

Ultra-processed foods and added sugars in the Chilean diet (2010).

OBJECTIVE: To assess the consumption of ultra-processed foods and analyse its association with the content of added sugars in the Chilean diet. DESIGN: Cross-sectional study of national dietary data obtained through 24 h recalls and classified into food groups according to the extent and purpose of food processing (NOVA classification). SETTING: Chile. SUBJECTS: A probabilistic sample of 4920 individuals (aged 2 years or above) studied in 2010 by a national dietary survey (Encuesta Nacional de Consumo Alimentario). RESULTS: Ultra-processed foods represented 28·6 (se 0·5) % of total energy intake and 58·6 (se 0·9) % of added sugars intake. The mean percentage of energy from added sugars increased from 7·7 (se 0·3) to 19·7 (se 0·5) % across quintiles of the dietary share of ultra-processed foods. After adjusting for several potential sociodemographic confounders, a 5 percentage point increase in the dietary share of ultra-processed foods determined a 1 percentage point increase in the dietary content of added sugars. Individuals in the highest quintile were three times more likely (OR=2·9; 95 % CI 2·4, 3·4) to exceed the 10 % upper limit for added sugars recommended by the WHO compared with those in the lowest quintile, after adjusting for sociodemographic variables. This association was strongest among individuals aged 2-19 years (OR=3·9; 95 % CI 2·7, 5·9). CONCLUSIONS: In Chile, ultra-processed foods are important contributors to total energy intake and to the consumption of added sugars. Actions aimed at limiting consumption of ultra-processed foods are being implemented as effective ways to achieve WHO dietary recommendations to limit added sugars and processed foods, especially for children and adolescents.

Assessing the public health impact of developmental origins of health and disease (DOHaD) nutrition interventions.

Investing in the maternal and early-infancy periods (the first 1,000 days, i.e. from -1 to +2 years) is presently acknowledged as a key priority to ensure good nutrition and prevent all forms of malnutrition. The concept is to invest during this period to maximize the human development potential, and the early-life agenda includes prevention of stunting and promotion of optimal brain development as well as ensuring the quality of life of those who survive. Thus, public health assessments of specific interventions need to go beyond the traditional indices of prevention of death and disease. We need to consider including a full range of outcomes such as disability-adjusted life years (DALY) and quality-adjusted life years (QALY) and not only the number of deaths. The long-term outcomes of maternal and infant interventions to prevent obesity and related noncommunicable diseases remain uncertain in terms of their biological impact even under ideal conditions (efficacy); we need interventions with proven effectiveness under real-world conditions (effectiveness). Conversely, interventions to prevent undernutrition have already been proven effective and are considered cost-effective based on rigorous economic analyses. Continuous evaluation of interventions implemented using the developmental origins of health and disease (DOHaD) model needs to be undertaken, as this will allow progressive improvement and thus maximize the potential impact on the health and well-being of populations. We need to consider the population-attributable risk of obesity and chronic disease and conduct an economic evaluation of the lifelong impact of chronic diseases not only in terms of lives lost but also in relation to lost DALY and QALY. This should help to prioritize preventive actions in line with patterns of disease and disability considering the existing resources and demands.

Tobacco use in pregnant women: analysis of data from Demographic and Health Surveys from 54 low-income and middle-income countries.

BACKGROUND: Worldwide, use of tobacco is viewed as an important threat to the health of pregnant women and their children. However, the extent of tobacco use in pregnant women in low-income and middle-income countries (LMICs) remains unclear. We assessed the magnitude of tobacco use in pregnant women in LMICs. METHODS: We used data from Demographic and Health Surveys (DHS) done in 54 LMICs between Jan 1, 2001, and Dec 1, 2012, comprising 58 922 pregnant women (aged 15-49 years), which were grouped by WHO region. Prevalence of current tobacco use (smoked and smokeless) was estimated for every country. Pooled estimates by regions and overall were obtained from random-effects meta-analysis. FINDINGS: Pooled prevalence of any tobacco use in pregnant women in LMICs was 2·6% (95% CI 1·8-3·6); the lowest prevalence was in the African region (2·0%, 1·2-2·9) and the highest was in the Southeast Asian region (5·1%, 1·3-10·9). The pooled prevalence of current tobacco smoking in pregnant women ranged from 0·6% (0·3-0·8) in the African region to 3·5% (1·5-12·1) in the Western Pacific region. The pooled prevalence of current smokeless tobacco use in pregnant women was lowest in the European region (0·1%, 0·0-0·3) and highest in the Southeast Asian region (2·6%, 0·0-7·6). INTERPRETATION: Overall, tobacco use in pregnant women in LMICs was low; however high prevalence estimates were noted in some LMICs. Prevention and management of tobacco use and exposure to second-hand smoke in pregnancy is crucial to protect maternal and child health in LMICs. FUNDING: None.

Addressing the double burden of malnutrition with a common agenda.

Addressing malnutrition in all its forms represents an integrated agenda addressing the root causes of malnutrition at all stages of the life course. The issue is not about choosing between addressing undernutrition in the poor versus overnutrition in the affluent. We must recognize that the interventions required to address stunting are different from those needed to reduce underweight and wasting. In most developing regions, there is a coexistence between underweight and stunting in infants and children, while in the adult population it may be overweight and stunting. Malnutrition in all its forms refers to both underweight and overweight. Underweight is defined by a low weight-for-age, a child is underweight because of wasting (low weight-for-height) or stunting (low length-for-age). Stunting refers to low height-for-age independent of their weight-for-age, some stunted children may have excess weight for their stature length. Overweight is excess weight-for-length/-height or high-BMI-for-age. The prevention of nutrition-related chronic diseases is a life-long process that starts in fetal life and continues throughout infancy and later stages of life. It requires promoting healthy diets and active living at each stage. The agenda requires that we tackle malnutrition in all its forms.