Global strategies for the prevention of neural tube defects through the improvement of folate status in women of reproductive age.

INTRODUCTION: Neural tube defects represent a global public health problem, mainly in countries where effective prevention strategies are not yet in place. The global prevalence of neural tube defects is estimated at 18.6/10,000 (uncertainty interval: 15.3-23.0) live births, where ~ 75% of cases result in under-five mortality. Most of the mortality burden is in low- and middle-income countries. The main risk factor for this condition is insufficient folate levels in women of reproductive age. METHODS: This paper reviews the extent of the problem, including the most recent global information on folate status in women of reproductive age and the most recent estimates of the prevalence of neural tube defects. Additionally, we provide an overview of the available interventions worldwide to reduce the risk of neural tube defects by improving folate status in the population, including dietary diversification, supplementation, education, and fortification. RESULTS: Large-scale food fortification with folic acid is the most successful and effective intervention to reduce the prevalence of neural tube defects and associated infant mortality. This strategy requires the coordination of several sectors, including governments, the food industry, health services providers, the education sector, and entities that monitor the quality of the service processes. It also requires technical knowledge and political will. An international collaboration between governmental and non-governmental organizations is essential to succeed in saving thousands of children from a disabling but preventable condition. DISCUSSION: We propose a logical model for building a national-level strategic plan for mandatory LSFF with folic acid and explain the actions needed for promoting sustainable system-level change.

A blueprint for fortification planning and programming: Lessons learned from an analytical review of existing fortification frameworks.

With multiple food fortification frameworks, countries can find it challenging to determine optimal methods for planning and implementing food fortification programmes to combat vitamin and mineral deficiencies, especially without additional technical support. To address this challenge, this study aimed to review existing frameworks to determine consistencies, differences, strengths, and weaknesses across the frameworks, and based on the review findings, formulate an enhanced and streamlined fortification framework. Nineteen frameworks were ultimately examined following a comprehensive literature review and key informant interviews. Generally, the reviewed frameworks amply describe motives and methods for the determination of fortification need and feasibility, industry engagement/quality assurance and quality control, and impact evaluations/surveillance. However, there was limited inclusion or discussion throughout the reviewed frameworks around harmonization of fortification with existing micronutrient interventions; fortification policy and/or strategy; enforcement, incentives, and penalties to ensure producer compliance with industry standards; and periodic fortification programme review and reassessment. The findings were used to develop a comprehensive Fortification Blueprint that aims to provide structured guidance and a library of tools and resources to fortification programme managers and key stakeholders to ensure optimal and sustainable programme design.

Multiple micronutrient supplementation cost-benefit tool for informing maternal nutrition policy and investment decisions.

Antenatal multiple micronutrient supplementation (MMS) is an intervention that can help reach three of the six global nutrition targets, either directly or indirectly: a reduction in low birth weight, stunting, and anaemia in women of reproductive age. To support global guideline development and national decision-making on investments into maternal nutrition, Nutrition International developed a modelling tool called the MMS cost-benefit tool to help users understand whether antenatal MMS is better value for money than iron and folic acid supplementation (IFAS) during pregnancy. The MMS cost-benefit tool can generate estimates on the potential health impact, budget impact, economic value, cost-effectiveness and benefit-cost ratio of investing in MMS compared to IFAS in LMICs. In the 33 countries with data included in the tool, the MMS cost-benefit tool shows that transitioning is expected to generate substantial health benefits in terms of morbidity and mortality averted and can be very cost-effective in multiple scenarios for these countries. The cost per DALY averted averages at US$ 23.61 and benefit-cost ratio ranges from US$ 41-US$ 1304: $1.0, which suggest MMS is good value for money compared with IFAS. With its user-friendly design, open access availability, and online data-driven analytics, the MMS cost-benefit tool can be a powerful resource for governments and nutrition partners seeking timely and evidence-based analyses to inform policy-decision and investments towards the scale-up of MMS for pregnant women globally.

Maternal resources for care are associated with child growth and early childhood development in Bangladesh and Vietnam.

BACKGROUND: Suboptimal child growth and development are significant problems in low- and middle-income countries. Maternal resources for care may help to improve growth and development. This study examined the association of maternal resources for care on child length, motor development and language development of children 12-23.9 months old. METHODS: We used baseline data from the Alive & Thrive household surveys collected in Bangladesh (n = 803) and Vietnam (n = 635). Resources for care were represented by maternal education, knowledge, height, well-nourishment, mental well-being, decision-making, employment, support in chores and perceived support. The regression analyses were adjusted for household wealth and other covariates on households, children and parents and accounted for geographical clustering. RESULTS: Maternal height (Bangladesh ß = 0.150 p < 0.001, Vietnam ß = 0.156 p < 0.001), well-nourishment (Vietnam ß = 0.882 p = 0.007) and mental well-being (Bangladesh ß = 0.0649 p = 0.008, Vietnam ß = 0.0742 p = 0.039) were associated with child length. Well-nourishment (Vietnam ß = 0.670 p = 0.042) and support in chores (Bangladesh ß = 0.0983 p = 0.021) were associated with child motor development. Mental well-being (Vietnam ß = 0.0735 p = 0.013), decision-making autonomy (Bangladesh ß = 0.0886 p = 0.029) and perceived support (Vietnam ß = 0.445 p = 0.003) were associated with child language development. CONCLUSION: Maternal height, well-nourishment, mental well-being, decision-making, support in chores and perceived social support were associated with child outcomes. Interventions that help to improve resources among mothers have potential to foster child growth and development.

Factor Structure and Equivalence of Maternal Resources for Care in Bangladesh, Vietnam, and Ethiopia.

OBJECTIVES: Resources for care among women are crucial for children's growth and development. The objectives of this cross-sectional study were to determine if: (1) the factor structure of measures of maternal resources for care was comparable across countries and consistent with the theoretical constructs and (2) the measures showed equivalence across contexts. METHODS: The study included 4400, 4029 and 2746 women from Bangladesh, Vietnam, and Ethiopia, respectively. The measures of resources for care were maternal education, knowledge, height, body mass index, mental well-being, financial autonomy, decision-making, employment, support in chores, and perceived support. RESULTS: The factor analysis demonstrated that a two-factor solution best explained the structure of resources for care in all three countries. The first factor was associated with financial autonomy and employment in all three countries and with decision-making in two countries. The second factor was associated with education and knowledge in all three countries. The measures of resources for care had measurement equivalence across countries. CONCLUSION FOR PRACTICE: Resources for care were structurally similar and measurement equivalent across countries and can be used for measurement in low- and middle-income countries. Additional work examining the structure and cross-context equivalence of resources for care in other settings is warranted.

Iran in transition.

Being the second-largest country in the Middle East, Iran has a long history of civilisation during which several dynasties have been overthrown and established and health-related structures have been reorganised. Iran has had the replacement of traditional practices with modern medical treatments, emergence of multiple pioneer scientists and physicians with great contributions to the advancement of science, environmental and ecological changes in addition to large-scale natural disasters, epidemics of multiple communicable diseases, and the shift towards non-communicable diseases in recent decades. Given the lessons learnt from political instabilities in the past centuries and the approaches undertaken to overcome health challenges at the time, Iran has emerged as it is today. Iran is now a country with a population exceeding 80 million, mainly inhabiting urban regions, and has an increasing burden of non-communicable diseases, including cardiovascular diseases, hypertension, diabetes, malignancies, mental disorders, substance abuse, and road injuries.

Associations of maternal resources with care behaviours differ by resource and behaviour.

Care is important for children's growth and development, but lack or inadequacy of resources for care can constrain appropriate caregiving. The objectives of this study were to examine whether maternal resources for care are associated with care behaviours specifically infant and young child feeding, hygiene, health-seeking, and family care behaviours. The study also examined if some resources for care are more important than others. This study used baseline Alive & Thrive household surveys from Bangladesh, Vietnam, and Ethiopia. Measures of resources for care were maternal education, knowledge, height, nourishment, mental well-being, decision-making autonomy, employment, support in chores, and perceived instrumental support. Multiple regression analyses were conducted to examine the associations of resources for care with child-feeding practices (exclusive breastfeeding, minimum meal frequency, dietary and diversity), hygiene practices (improved drinking water source, improved sanitation, and cleanliness), health-seeking (full immunization), and family care (psychosocial stimulation and availability of adequate caregiver). The models were adjusted for covariates at child, parents, and household levels and accounted for geographic clustering. All measures of resources for care had positive associations with care behaviours; in a few instances, however, the associations between the resources for care and care behaviours were in the negative direction. Improving education, knowledge, nutritional status, mental well-being, autonomy, and social support among mothers would facilitate provision of optimal care for children.

Review of intervention products for use in the prevention and control of anemia.

Anemia remains a major public health problem, especially in low- and middle-income countries. The World Health Organization recommends several interventions to prevent and manage anemia in vulnerable population groups, including young children, menstruating adolescent girls and women, and pregnant and postpartum women. Daily iron supplementation reduces the risk of anemia in infants, children, and pregnant women, and intermittent iron supplementation reduces anemia risk in menstruating girls and women. Micronutrient powders reduce the risk of anemia in children. Fortifying wheat flour with iron reduces the risk of anemia in the overall population, whereas the effect of fortifying maize flour and rice is still uncertain. Regarding non-nutrition-related interventions, malaria treatment and deworming have been reported to decrease anemia prevalence. Promising interventions to prevent anemia include vitamin A supplementation, multiple micronutrient supplementation for pregnant women, small-quantity lipid-based supplements, and fortification of salt with iodine and iron. Future research could address the efficacy and safety of different iron supplementation formulations, identify the most bioavailable form of iron for fortification, examine adherence to supplementation regimens and fortification standards, and investigate the effectiveness of integrating micronutrient, helminth, and malaria control programs.

Integrating and coordinating programs for the management of anemia across the life course.

Anemia is a major global public health concern with a complex etiology. The main determinants are nutritional factors, infection and inflammation, inherited blood disorders, and women's reproductive biology, but the relative role of each varies between settings. Effective anemia programming, therefore, requires evidence-based, data-driven, contextualized multisectoral strategies, with coordinated implementation. Priority population groups are preschool children, adolescent girls, and pregnant and nonpregnant women of reproductive age. Opportunities for comprehensive anemia programming include: (i) bundling interventions through shared delivery platforms, including antenatal care, community-based platforms, schools, and workplaces; (ii) integrating delivery platforms to extend reach; (iii) integrating anemia and malaria programs in endemic areas; and (iv) integrating anemia programming across the life course. Major barriers to effective anemia programming include weak delivery systems, lack of data or poor use of data, lack of financial and human resources, and poor coordination. Systems strengthening and implementation research approaches are needed to address critical gaps, explore promising platforms, and identify solutions to persistent barriers to high intervention coverage. Immediate priorities are to close the gap between access to service delivery platforms and coverage of anemia interventions, reduce subnational coverage disparities, and improve the collection and use of data to inform anemia strategies and programming.

Effectiveness of nutrition counseling for pregnant women in low- and middle-income countries to improve maternal and infant behavioral, nutritional, and health outcomes: A systematic review.

Background: Nutritional counseling, which includes two-way interactive education, has been hypothesized to improve the health and nutritional status of pregnant women, but little is known about the impact such practice of care might have on maternal and infant health and behavioral outcomes of pregnant women living in low income, low-middle income, and upper-middle-income countries (LMIC)s. Objectives: We conducted a systematic review to appraise the effectiveness and impact on health equity of two-way nutritional counseling practices in LMICs on maternal and infant behavioral, nutritional, and health outcomes. Search Methods: We conducted electronic searches for relevant studies on Medline, Embase, CINAHL, PsychInfo, and the Cochrane CENTRAL for randomized and non-randomized trials on the effectiveness of two-way interactive nutritional counseling among pregnant women from the date of database inception up to June 22, 2021. In addition, we searched references of included studies in systematic reviews, gray literature resources, and unpublished studies or reports that satisfied our eligibility criteria using a focused Google search. Selection Criteria: We included randomized and non-randomized controlled studies (NRS), controlled before and after, and interrupted time series that assessed the effectiveness of two-way interactive nutrition counseling targeting pregnant women in LMICs. Data Collection and Analysis: Data extraction and risk of bias were conducted in duplicate. The risk of bias (ROB) for randomized trials (RCT) was assessed according to the Cochrane Handbook of Systematic Reviews, and ROB for NRS was assessed using the Newcastle-Ottawa scale (NOS). RCT and NRS were meta-analyzed separately. Main Results: Our search identified 6418 records and 52 studies met our inclusion criteria, but only 28 were used in the quantitative analysis. Twenty-eight studies were conducted in Asia, the most in Iran. Eight studies were conducted in Africa. Two-way interactive nutritional counseling during pregnancy may improve dietary caloric intake (mean difference [MD]: 81.65 calories, 95% confidence interval [CI], 15.37-147.93, three RCTs; I 2 = 42%; moderate certainty of evidence using GRADE assessment), may reduce hemorrhage (relative risk [RR]: 0.63; 95% CI, 0.25-1.54, two RCTs; I 2 = 40%; very low certainty of evidence using GRADE assessment), may improve protein (MD: 10.44 g, 95% CI, 1.83-19.05, two RCTs; I 2 = 95%; high certainty of evidence using GRADE assessment), fat intake (MD: 3.42 g, 95% CI, -0.20 to 7.04, two RCTs; I 2 = 0%; high certainty of evidence using GRADE assessment), and may improve gestational weight gain within recommendations (RR: 1.84; 95% CI, 1.10-3.09, three RCTs; I 2 = 69%). Nutrition counseling probably leads to the initiation of breastfeeding immediately after birth (RR: 1.72; 95% CI, 1.42-2.09, one RCT). There was little to no effect on reducing anemia (RR: 0.77; 95% CI, 0.50-1.20, three RCTs; I 2 = 67%; very low certainty of evidence using GRADE assessment) risk of stillbirths (RR: 0.81; 95% CI, 0.52-1.27, three RCTs; I 2 = 0%; moderate certainty of evidence using GRADE assessment) and risk of cesarean section delivery (RR: 0.96; 95% CI, 0.76-1.20, four RCTs; I 2 = 36%; moderate certainty of evidence using GRADE assessment). Authors' Conclusions: Our review highlights improvements in maternal behavioral and health outcomes through interactive nutrition counseling during pregnancy. However, we are uncertain about the effects of nutrition counseling due to the low certainty of evidence and a low number of studies for some key outcomes. Moreover, the effects on health equity remain unknown. More methodologically rigorous trials that focus on a precise selection of outcomes driven by the theory of change of nutrition counseling to improve maternal and infant behavioral and health outcomes and consider equity are required.

Infant and young child feeding in developing countries.

Feeding practices are important determinants of growth and development of children. Using infant and young child feeding indicators and complementary feeding guidelines, 7 practices in 28 countries are described, showing substantial variation across countries. Only 25% of 0- to 5-month-olds were exclusively breastfed, and only half of 6- to 8-month-olds received complementary foods the previous day. Median duration of breastfeeding and increase of fluid intake during diarrhea were low among countries with a high Human Development Index (HDI). Living in high-HDI countries may not translate to positive feeding practices. Across countries, there is a need for promotion, protection, and support of optimal breastfeeding and complementary feeding practices as well as better adherence to recommendations for feeding during illness.

Scaling up prenatal nutrition could reduce the global burden of noncommunicable diseases in the next generation: a modeling analysis.

BACKGROUND: Nutritional conditions during pregnancy may influence the epigenetic development of an individual and consequently their later-life risk of noncommunicable disease (NCD). Improving nutrition for pregnant females may therefore serve the dual purpose of directly improving pregnancy outcomes and preventing NCDs in the next generation. OBJECTIVES: We estimated the impact of prenatal supplementation with iron and folic acid (IFA), multiple micronutrients (MMS), or calcium at 50%, 75%, or 90% coverage on future NCDs by age and sex in 2015. METHODS: We used secondary data sources from 132 countries to quantify the cases of diabetes and hypertension and the deaths from selected NCDs that could be averted or delayed by scaling up prenatal micronutrient supplementation. RESULTS: Globally, >51,000 NCD deaths, 6 million cases of hypertension, and 3 million cases of diabetes could be prevented per offspring birth cohort if mothers were prenatally supplemented with MMS at 90% coverage. For IFA these numbers would be roughly half. Calcium supplementation at 90% could delay 51,000 deaths per birth cohort. Our model suggests that substantial numbers of NCD deaths and cases of hypertension and diabetes could be prevented in future generations by scaling up micronutrient supplementation for mothers during pregnancy. CONCLUSIONS: Highlighting the additional benefits of proven nutrition interventions is critical in ensuring adequate and sustained investments, and programmatic integration. As the double burden of disease continues to grow, population-wide efforts to scale up micronutrient supplementation to pregnant females could help prevent both undernutrition and chronic disease.

Enhancements to nutrition program in Indian integrated child development services increased growth and energy intake of children.

The Indian Integrated Child Development Services (ICDS) provides supplemental food to children aged 6 mo to 6 y. This study assessed the impact of enhancements to the existing Supplemental Nutrition Program of local production of supplemental food, home fortification with a micronutrient powder, and improved program monitoring. A quasi-experimental longitudinal design was used. Data were collected from 15 Anganwadi centers randomly selected from the enhanced program and 15 from the usual program. Multilevel linear regression was used to examine changes over time between the 2 groups accounting for village-level variation in intent-to-treat analysis. Children in the enhanced program initially aged 12-18 mo gained 0.72 (P = 0.02) greater height-for-age Z-score. Significant differences were observed in gain in weight-for-age Z-score among those initially aged 9-11 (2.48; P = 0.01), 12-18 (0.76; P = 0.01), and 19-24 mo old (0.73; P = 0.01), and gain in weight-for-height Z-score among 9-11 (2.66; P = 0.04) and 19-24 mo old (0.99; P = 0.01). For these age groups, the prevalence of stunting, underweight, or wasting averted ranged from 20.3 to 33.4%. Energy intake in the enhanced program was significantly greater for boys initially aged 12-18 mo (575.1 kJ/d; P = 0.03). Results from a qualitative substudy supported the plausibility of observed outcomes. ICDS would be more effective in improving child nutrition if it included these enhancements. The enhancements studied may be useful in improving program delivery and uptake of other similar programs.

Revisiting the concept of growth monitoring and its possible role in community-based nutrition programs.

BACKGROUND: Community-based growth monitoring (GM) and growth monitoring and promotion (GMP) have been implemented worldwide. The literature provides controversial messages regarding their effectiveness. Numerous countries have GM as their main community-based activity and need guidance for future programming. The notion of GM is usually clear, but the follow-up actions include a range of activities and interventions, all under the heading of "promotion." OBJECTIVE: We suggested definitions, objectives, and outcomes of the GM and GMP. By providing some clarity on these conceptual issues we attempted to provide a basis for consensus building and development of recommendations on when this activity should be promoted or discouraged. METHODS: We reviewed basic concepts and global experience of GM and GMP using publications about GM and GMP, UNICEF country reports and other publications, field observations, and reports of recent expert consultations. RESULTS: Realistic added benefits are suggested as compared with general counseling that could also be delivered outside the GM session. We provide a narrow definition of "promotion" in GMP, in which actions are tailored to the results of monitoring, as well as suggest quality implementation criteria. CONCLUSIONS: GM, even if complemented by a promotional package, can have only a limited impact if it is not part of a comprehensive program. GMP cannot be viewed as a competitor to highly effective interventions, but may serve as a possible platform for their delivery. The decision to build community-based programs on a GMP platform should be based on consideration of benefits, feasibility of quality implementation, and capacity of human resources.

Successful delivery of nutrition programs and the sustainable development goals.

Malnutrition affects millions of people globally, especially women, children, and other vulnerable populations. Sustainable Development Goals (SDGs) were set in 2015 to end poverty, protect the planet, and improve the lives and prospects of everyone by 2030. To achieve the SDG goals effective nutrition interventions and programs need to be efficiently delivered to those most in need. Nutrition directly affects 2 SDGs (2 and 3) and indirectly influences five others. In addition, almost all SDGs influence nutrition and thus attaining the SDG goals is also a pre-requisite to achieving the Global Nutrition targets set in 2012. Evidence-based nutrition interventions, for which there is strong evidence of their biological impact, have the potential to directly influence SDGs 2 and 3 if successfully delivered at scale in high-burden countries. Nevertheless, delivery of nutrition programs is a complex process, where policy, government commitment, adequate budget allocation, supplies and delivery systems, training of service providers, informed beneficiaries and program monitoring and evaluation all need to be in place and aligned with each other. Although in the past decade there has been progress in the SDGs that nutrition directly affects, many goals are still off-track, likely due to several pending gaps at policy-level, program-level, and intervention-level. To accelerate the progress toward reaching the SDG goals that are directly influenced by nutrition, countries need to be supported to successfully and sustainably deliver proven interventions and to scale-up and deliver new interventions in new and innovative ways, and the evidence base should be built in promising areas especially integrating (rather than prioritizing over each other) nutrition-specific and sensitive approaches.

PROTOCOL: Effectiveness of nutrition counselling for pregnant women in low- and middle-income countries to improve maternal, infant and child behavioural, nutritional and health outcomes: A systematic review.

The objective of this systematic review is to identify, appraise and synthesise the best available evidence on the effectiveness of nutritional counselling and education interventions on maternal, infant and child health outcomes, and assess the differences in effects across participants' PROGRESS+ characteristics. To achieve these objectives, we will aim to answer the following research questions: What is the effectiveness of nutrition counselling interventions for pregnant women in low- or middle-income countries on maternal, infant and child health outcomes? What are the impacts of nutrition counselling interventions on maternal, infant and child health outcomes across participants' PROGRESS+ characteristics?

Effective nutrition programming for children and the role of UNICEF: consensus points from an expert consultation.

Countries of the world have agreed on eradicating extreme poverty and hunger and reducing the mortality rate of children under five by two-thirds by 2015 as part of the Millennium Development Goals, and without mainstreaming maternal, infant, and young child nutrition in the development agenda, these goals cannot be achieved. Although the recent Lancet Series on Maternal and Child Undernutrition brought attention to the importance of early nutrition interventions to improve child health, nutrition, and future economic productivity, there needs to be a more concerted effort at clarifying the path forward, focusing on moving beyond projects and evidence from randomized, controlled trials towards developing large-scale programs with sound plausibility design to achieve results for children. In an effort to cast a fresh eye on nutrition programming in light of the new evidence, UNICEF Headquarters hosted an Expert Consultation on effective nutrition programming with participants from various academic organizations and United Nations agencies to discuss effective program strategies in nutrition. The consultation resulted in recommendations for UNICEF on eight focus areas for programming and recognition of six overarching themes. It is clear that more action is needed to accelerate progress: more effective global coalitions, better coordination, more coherence, and better targeting of efforts.

Implementation Science in Nutrition: Concepts and Frameworks for an Emerging Field of Science and Practice.

Malnutrition in all its forms has risen on global and national agendas in recent years because of the recognition of its magnitude and its consequences for a wide range of human, social, and economic outcomes. Although the WHO, national governments, and other organizations have endorsed targets and identified appropriate policies, programs, and interventions, a major challenge lies in implementing these with the scale and quality needed to achieve population impact. This paper presents an approach to implementation science in nutrition (ISN) that builds upon concepts developed in other policy domains and addresses critical gaps in linking knowledge to effective action. ISN is defined here as an interdisciplinary body of theory, knowledge, frameworks, tools, and approaches whose purpose is to strengthen implementation quality and impact. It includes a wide range of methods and approaches to identify and address implementation bottlenecks; means to identify, evaluate, and scale up implementation innovations; and strategies to enhance the utilization of existing knowledge, tools, and frameworks based on the evolving science of implementation. The ISN framework recognizes that quality implementation requires alignment across 5 domains: the intervention, policy, or innovation being implemented; the implementing organization(s); the enabling environment of policies and stakeholders; the individuals, households, and communities of interest; and the strategies and decision processes used at various stages of the implementation process. The success of aligning these domains through implementation research requires a culture of inquiry, evaluation, learning, and response among program implementers; an action-oriented mission among the research partners; continuity of funding for implementation research; and resolving inherent tensions between program implementation and research. The Society for Implementation Science in Nutrition is a recently established membership society to advance the science and practice of nutrition implementation at various scales and in varied contexts.

Information Technology and Lifestyle: A Systematic Evaluation of Internet and Mobile Interventions for Improving Diet, Physical Activity, Obesity, Tobacco, and Alcohol Use.

BACKGROUND: Novel interventions are needed to improve lifestyle and prevent noncommunicable diseases, the leading cause of death and disability globally. This study aimed to systematically review, synthesize, and grade scientific evidence on effectiveness of novel information and communication technology to reduce noncommunicable disease risk. METHODS AND RESULTS: We systematically searched PubMed for studies evaluating the effect of Internet, mobile phone, personal sensors, or stand-alone computer software on diet, physical activity, adiposity, tobacco, or alcohol use. We included all interventional and prospective observational studies conducted among generally healthy adults published between January 1990 and November 2013. American Heart Association criteria were used to evaluate and grade the strength of evidence. From 8654 abstracts, 224 relevant reports were identified. Internet and mobile interventions were most common. Internet interventions improved diet (N=20 studies) (Class IIa A), physical activity (N=33), adiposity (N=35), tobacco (N=22), and excess alcohol (N=47) (Class I A each). Mobile interventions improved physical activity (N=6) and adiposity (N=3) (Class I A each). Evidence limitations included relatively brief durations (generally <6 months, nearly always <1 year), heterogeneity in intervention content and intensity, and limited representation from middle/low-income countries. CONCLUSIONS: Internet and mobile interventions improve important lifestyle behaviors up to 1 year. This systematic review supports the need for long-term interventions to evaluate sustainability.