Modelling impacts of a salt and sugar tax on hypothetical intra-category food substitutions, BMI and environmental footprints in the UK population.

PURPOSE: Taxes on unhealthy foods can help improve population health in the United Kingdom (UK), but the health effects of food substitutions resulting from these taxes are often unclear. We investigated the potential impacts of a salt and sugar tax on hypothetical intra-category food substitutions, cost, body-mass index (BMI), and environmental footprints. METHODS: Purchase panel data from Kantar (2017) were used to determine the most popular foods high in salt or sugar within eight 'salt-intensive'/'sugar-intensive' food categories. Within food categories, the most popular lower salt (≤ 1.5 g salt/100 g product) and lower sugar (≤ 22.5 g sugar/100 g product) substitutes were also identified. Hypothetical swaps between high salt/sugar foods and lower salt/sugar substitutes were explored, focusing on changes to cost, caloric intake and BMI, and environmental impacts in the UK population. RESULTS: The suggested intra-category substitutions were largely like-for-like and did not accrue an added overall cost to consumers. The substitutions reduced calorie intake by about 200 kcal/day and lowered the prevalence of overweight and obesity in the UK from approximately 60-65% to about 40-45%. The proposed food substitutions led to a total reduction of -2.7Mt of greenhouse gases, ∼ -500.000 ha of land, -0.5km3 of blue water, -12km3 of scarcity weighted water, ∼ -12.000t of phosphorus, and nearly - 14.000t of sulphur dioxide over one year for the UK population due to reductions in calorie intake. CONCLUSION: Food substitutions following a tax on salt and sugar could lead to significant benefits for health and the environment, without necessarily resulting in major changes to people's expenditure on familiar salty and sugary snacks.

The Role of Nutrition in COVID-19 Susceptibility and Severity of Disease: A Systematic Review.

BACKGROUND: Many nutrients have powerful immunomodulatory actions with the potential to alter susceptibility to coronavirus disease 2019 (COVID-19) infection, progression to symptoms, likelihood of severe disease, and survival. OBJECTIVE: The aim was to review the latest evidence on how malnutrition across all its forms (under- and overnutrition and micronutrient status) may influence both susceptibility to, and progression of, COVID-19. METHODS: We synthesized information on 13 nutrition-related components and their potential interactions with COVID-19: overweight, obesity, and diabetes; protein-energy malnutrition; anemia; vitamins A, C, D, and E; PUFAs; iron; selenium; zinc; antioxidants; and nutritional support. For each section we provide: 1) a landscape review of pertinent material; 2) a systematic search of the literature in PubMed and EMBASE databases, including a wide range of preprint servers; and 3) a screen of 6 clinical trial registries. All original research was considered, without restriction to study design, and included if it covered: 1) severe acute respiratory syndrome coronavirus (CoV) 2 (SARS-CoV-2), Middle East respiratory syndrome CoV (MERS-CoV), or SARS-CoV viruses and 2) disease susceptibility or 3) disease progression, and 4) the nutritional component of interest. Searches took place between 16 May and 11 August 2020. RESULTS: Across the 13 searches, 2732 articles from PubMed and EMBASE, 4164 articles from the preprint servers, and 433 trials were returned. In the final narrative synthesis, we include 22 published articles, 38 preprint articles, and 79 trials. CONCLUSIONS: Currently there is limited evidence that high-dose supplements of micronutrients will either prevent severe disease or speed up recovery. However, results of clinical trials are eagerly awaited. Given the known impacts of all forms of malnutrition on the immune system, public health strategies to reduce micronutrient deficiencies and undernutrition remain of critical importance. Furthermore, there is strong evidence that prevention of obesity and type 2 diabetes will reduce the risk of serious COVID-19 outcomes. This review is registered at PROSPERO as CRD42020186194.

Effect of environmental changes on vegetable and legume yields and nutritional quality.

Environmental changes threaten agricultural production, food security, and health. Previous reviews suggest that environmental changes will substantially affect future yields of starchy dietary staples. To date, no comprehensive global analysis of the impacts of environmental change on (nonstaple) vegetables and legumes-important constituents of healthy diets-has been reported. We systematically searched for articles published between 1975 and 2016 on the effects of ambient temperature, tropospheric carbon dioxide (CO2), and ozone (O3) concentrations, water availability, and salinization on yields and nutritional quality of vegetables and legumes. We estimated mean effects of standardized environmental changes using observed exposure-response relationships and conducted meta-analyses where possible. We identified 174 relevant papers reporting 1,540 experiments. The mean (95% CI) reported yield changes for all vegetables and legumes combined were +22.0% (+11.6% to +32.5%) for a 250-ppm increase in CO2 concentration, -8.9% (-15.6% to -2.2%) for a 25% increase in O3 concentration,-34.7% (-44.6% to -24.9%) for a 50% reduction in water availability, and -2.3% (-3.7% to -0.9%) for a 25% increase in salinity. In papers with baseline temperatures >20 °C, a 4 °C increase in temperature reduced mean yields by -31.5% (-41.4% to -21.5%). Impacts of environmental changes on nutritional quality were mixed. In a business-as-usual scenario, predicted changes in environmental exposures would lead to reductions in yields of nonstaple vegetables and legumes. Where adaptation possibilities are limited, this may substantially change their global availability, affordability, and consumption in the mid to long term. Our results stress the importance of prioritizing agricultural developments, to minimize potential reductions in vegetable and legume yields and associated negative health effects.

Improving the use of focus group discussions in low income settings.

BACKGROUND: The quality of data obtained through Focus Group Discussions (FGDs) is highly dependent on appropriate design and facilitation. In low-income settings steep power gradients between researcher and participants, as well as conversational norms, could reduce the ability of participants to voice personal opinions. Activity-oriented exercises have been suggested as a way overcoming these challenges, however little evidence exists - to date - on their use in low-income settings. We selected six exercises for use in Ethiopia and Nigeria and report our experiences. METHODS: The six exercises (picture sorting, associative pictures, picture ranking, decision trees, predictive story-telling and provocative statements) were used in 32 maternal and new-born care themed FGDs conducted in Amhara and Southern Nations Nationalities and People's Regions (Ethiopia) and Gombe State (Nigeria). Six facilitators and two supervisors who used these exercises were interviewed about their experiences. FGD verbatim transcripts and interview notes were analysed to explore methodological effectiveness and respondents' experience. All data were coded in NVIVO using a deductive coding frame. RESULTS: Facilitators and participants described the methods as 'fun' and 'enjoyable'. The exercises yielded more in-depth and complete information than 'normal' FGDs, but facilitator's probing skills and overall FGD group dynamics proved crucial in this success. Explaining and conducting the exercises increased FGD length. Data richness, participant reaction and understanding, and ease of facilitation varied by study site, exercise, and participant group. Overall, the exercises worked better in Nigeria than in Ethiopia. The provocative statement exercise was most difficult for participants to understand, the decision-tree most difficult to facilitate and the picture exercises most enjoyable. The story telling exercise took relatively little time, was well understood, yielded rich data and reduced social desirability bias. DISCUSSION: The majority of the exercises proved successful tools in yielding richer and less biased information from FGDs and were experienced as fun and engaging. Tailoring of the exercises, as well as thorough training and selection of the facilitators, were pivotal in this success. The difference in the two countries shows that adequate piloting and adaptation is crucial, and that some exercises may not be adaptable to all settings.

Analysis of dietary patterns and cross-sectional and longitudinal associations with hypertension, high BMI and type 2 diabetes in Peru.

OBJECTIVE: To determine if specific dietary patterns are associated with risk of hypertension, type 2 diabetes mellitus (T2DM) and high BMI in four sites in Peru. DESIGN: We analysed dietary patterns from a cohort of Peruvian adults in four geographical settings using latent class analysis. Associations with prevalence and incidence of hypertension, T2DM and high BMI were assessed using Poisson regression and generalised linear models, adjusted for potential confounders. SETTING: Four sites in Peru varying in degree of urbanisation. PARTICIPANTS: Adults aged ≥35 years (n 3280). RESULTS: We identified four distinct dietary patterns corresponding to different stages of the Peruvian nutrition transition, reflected by the foods frequently consumed in each pattern. Participants consuming the 'stage 3' diet, characterised by high proportional consumption of processed foods, animal products and low consumption of vegetables, mostly consumed in the semi-urban setting, showed the highest prevalence of all health outcomes (hypertension 32·1 %; T2DM 10·7 %; high BMI 75·1 %). Those with a more traditional 'stage 1' diet characterised by potato and vegetables, mostly consumed in the rural setting, had lower prevalence of hypertension (prevalence ratio; 95 CI: 0·57; 0·43, 0·75), T2DM (0·36; 0·16, 0·86) and high BMI (0·55; 0·48, 0·63) compared with the 'stage 3' diet. Incidence of hypertension was highest among individuals consuming the 'stage 3' diet (63·75 per 1000 person-years; 95 % CI 52·40, 77·55). CONCLUSIONS: The study found more traditional diets were associated with a lower prevalence of three common chronic diseases, while prevalence of these diseases was higher with a diet high in processed foods and low in vegetables.

Dietary recommendations in Spain -affordability and environmental sustainability?

Global food demand is increasing due to population growth and dietary transitions, resulting from rising incomes, are associated with increased prevalence of non-communicable diseases. Improving the sustainability of the food sector is also critical for achieving the Sustainable Development Goals. This study assesses for the first time the greenhouse gases emissions (Carbon Footprint - CF), the water footprint (WF) and the cost of three omnivorous diets recommended in Spain due to their health benefits: the Mediterranean diet (MD), the Southern European Atlantic diet (SEAD) and the Spanish dietary guidelines (NAOS). Analysis was conducted using standard Life Cycle Assessment and WF methods together with current Spanish food price data. The dietary energy recommendation of the SEAD is greater than that of MD and NAOS (11 and 15% respectively), and SEAD also has greater animal source food content than the other two diets. SEAD has a concomitantly higher CF, WF and cost scores in comparison with MD (+30%, +23% and +21% respectively) and NAOS (+15%, +9% and +21% respectively). Adjusting recommendations to meet the suggested Spanish adult dietary energy of 2228 kcal.capita-1.day-1 changed the environmental profiles of the diets and the NAOS has the highest environmental impact. However, the isocaloric diets had approximately the same cost. Analysis of the WF of the diets identified the major contribution of precipitation (the green WF) to the overall WF (88% of the total) and the significant contribution of animal-source foods to dietary WF. Regardless of the dietary scenario, better scores were identified for the Spanish recommendations analysed than those reported for other healthy diets identified in Europe. Differences in the recommended intake levels of certain food groups, cooking techniques and the origin of food products are behind these results. Environmental indicators should be considered alongside nutrition and health metrics when defining national dietary guidelines. Supporting citizens to follow healthy and environmentally-friendly dietary recommendations through, among other things, information campaigns and nutritional education programmes is essential. It is recommended the incorporation not only of health, but also of environmental indicators of these dietary options in the national dietary guidelines, as well as implementation of information campaigns and nutritional education programs among citizens to promote their adhesion since balanced dietary habits rich on plant-based products and low on animal-based ones involve multiple health and environmental benefits.

Effects of family conversation on health care practices in Ethiopia: a propensity score matched analysis.

BACKGROUND: Maternal and newborn mortality rates in Ethiopia are among the highest in sub-Saharan Africa. The majority of deaths take place during childbirth or within the following 48 h. Therefore, ensuring facility deliveries with emergency obstetric and newborn care services available and immediate postnatal follow-up are key strategies to increase survival. In early 2014, the Family Conversation was implemented in 115 rural districts in Ethiopia, covering about 17 million people. It aimed to reduce maternal and newborn mortality by promoting institutional delivery, early postnatal care and immediate newborn care practices. More than 6000 Health Extension Workers were trained to initiate home-based Family Conversations with pregnant women and key household decision-makers. These conversations included discussions on birth preparedness, postpartum and newborn care needs to engage key household stakeholders in supporting women during their pregnancy, labor and postpartum periods. This paper examines the effects of the Family Conversation strategy on maternal and neonatal care practices. METHODS: We used cross-sectional data from a representative sample of 4684 women with children aged 0-11 months from 115 districts collected between December 2014 and January 2015. We compared intrapartum and newborn care practices related to the most recent childbirth, between those who reported having participated in a Family Conversation during pregnancy, and those who had not. Propensity score matched analysis was used to estimate average treatment effects of the Family Conversation strategy on intrapartum and newborn care practices, including institutional delivery, early postnatal and immediate breastfeeding. RESULTS: About 17% of the respondents reported having had a Family Conversation during their last pregnancy. Average treatment effects of 7, 12, 9 and 16 percentage-points respectively were found for institutional deliveries, early postnatal care, clean cord care and thermal care of the newborn (p < 0.05). CONCLUSION: We found evidence that Family Conversation, and specifically the involvement of household members who were major decision-makers, was associated with better intrapartum and newborn care practices. This study adds to the evidence base that involving husbands and mothers-in-law, as well as pregnant women, in behavior change communication interventions could be critical for improving maternal and newborn care and therewith lowering mortality rates.

Early postnatal home visits: a qualitative study of barriers and facilitators to achieving high coverage.

BACKGROUND: Timely interventions in the postnatal period are important for reducing newborn mortality, and early home visits to provide postnatal care are recommended. There has been limited success in achieving timely visits, and a better understanding of the realities of programmes is needed if improvements are to be made. METHODS: We explored barriers and facilitators to timely postnatal visits through 20 qualitative interviews and 16 focus group discussions with families and Health Extension Workers in four Ethiopian sites. RESULTS: All sites reported some inaccessible areas that did not receive visits, but, Health Extension Workers in the sites with more difficult terrain were reported to make more visits that those in the more accessible areas. This suggests that information and work issues can be more important than moderate physical issues. The sites where visits were common had functioning mechanisms for alerting workers to a birth; these were not related to postnatal visits but to families informing Health Extension Workers of labour so they could call an ambulance. In the other sites, families did not know they should alert workers about a delivery, and other alert mechanisms were not functioning well. Competing activities reducing Health Extension Worker availability for visits, but in some areas workers were more organized in their division of their work and this facilitated visits. The main difference between the areas where visits were reported as common or uncommon was the general activity level of the Health Extension Worker. In the sites where workers were active and connected to the community visits occurred more often. CONCLUSIONS: If timely postnatal home visits are to occur, CHWs need realistic catchment areas that reflect their workload. Inaccessible areas may need their own CHW. Good notification systems are essential, families will notify CHWs if they have a clear reasons to do so, and more work is needed on how to ensure notification systems function. Work ethic was a clear influencer on whether home visits occur, studies to date have focused on understanding the motivation of CHWs as a group, more studies on understanding motivation at an individual level are needed.

Risk factors for poor tuberculosis treatment outcomes in Makassar, Indonesia.

Resistant tuberculosis is an important public health problem in South Sulawesi, Indonesia. We conducted a retrospective cohort study of 1,582 smear positive tuberculosis patients registered with the National Tuberculosis Program during 2007 in Makassar, Indonesia, to assess risk factors associated with poor tuberculosis treatment outcomes. Of the 1,582 patients, 265 had a poor treatment outcome. Of the 265 patients with a poor treatment outcome, 216 had defaulted on treatment, 7 failed treatment, 9 died and 33 transferred to another area. After adjusting for sex, age and BCG status, failure acid-fast bacilli (AFB) positive sputum to convert to AFB negative by 2-3 months was the only risk factor significantly associated with a poor treatment outcome (odds ratio 7.57; 95% CI: 1.22-47.1). We hypothesise this could represent resistant tuberculosis. Early identification of resistant tuberculosis is important and should be suspected in patients whose AFB positive sputum samples fail to convert to AFB negative by 2-3 months.

Addressing future food demand in The Gambia: can increased crop productivity and climate change adaptation close the supply-demand gap?

With rising demand for food and the threats posed by climate change, The Gambia faces significant challenges in ensuring sufficient and nutritious food for its population. To address these challenges, there is a need to increase domestic food production while limiting deforestation and land degradation. In this study, we modified the FABLE Calculator, a food and land-use system model, to focus on The Gambia to simulate scenarios for future food demand and increasing domestic food production. We considered the impacts of climate change on crops, the adoption of climate change adaptation techniques, as well as the potential of enhanced fertiliser use and irrigation to boost crop productivity, and assessed whether these measures would be sufficient to meet the projected increase in food demand. Our results indicate that domestic food production on existing cropland will not be sufficient to meet national food demand by 2050, leading to a significant supply-demand gap. However, investments in fertiliser availability and the development of sustainable irrigation infrastructure, coupled with climate change adaptation strategies like the adoption of climate-resilient crop varieties and optimised planting dates, could halve this gap. Addressing the remaining gap will require additional strategies, such as increasing imports, expanding cropland, or prioritising the production of domestic food crops over export crops. Given the critical role imports play in The Gambia's food supply, it is essential to ensure a robust flow of food imports by diversifying partners and addressing regional trade barriers. Our study highlights the urgent need for sustained investment and policy support to enhance domestic food production and food imports to secure sufficient and healthy food supplies amidst growing demand and climate change challenges. Supplementary Information: The online version contains supplementary material available at 10.1007/s12571-024-01444-1.

Mapping the evidence of novel plant-based foods: a systematic review of nutritional, health, and environmental impacts in high-income countries.

CONTEXT: Shifting from current dietary patterns to diets rich in plant-based (PB) foods and lower in animal-based foods (ABFs) is generally regarded as a suitable strategy to improve nutritional health and reduce environmental impacts. Despite the recent growth in supply of and demand for novel plant-based foods (NPBFs), a comprehensive overview is lacking. OBJECTIVES: This review provides a synthesis of available evidence, highlights challenges, and informs public health and environmental strategies for purposeful political decision-making by systematically searching, analyzing, and summarizing the available literature. DATA SOURCES: Five peer-reviewed databases and grey literature sources were rigorously searched for publications. DATA EXTRACTION: Study characteristics meeting the inclusion criteria regarding NPBF nutrient composition and health and environmental outcomes in high-income countries were extracted. DATA ANALYSIS: Fifty-seven peer-reviewed and 36 grey literature sources were identified; these were published in 2016-2022. NPBFs typically have substantially lower environmental impacts than ABFs, but the nutritional contents are complex and vary considerably across brands, product type, and main primary ingredient. In the limited evidence on the health impacts, shifts from ABFs to PB meats were associated with positive health outcomes. However, results were mixed for PB drinks, with links to micronutrient deficiencies. CONCLUSION: If carefully selected, certain NPBFs have the potential to be healthier and nutrient-rich alternatives to ABFs and typically have smaller environmental footprints. More disaggregated categorization of various types of NPBFs would be a helpful step in guiding consumers and key stakeholders to make informed decisions. To enable informed policymaking on the inclusion of NPBFs in dietary transitions as part of a wider net-zero and health strategy, future priorities should include nutritional food standards, labelling, and subdivisions or categorizations of NPBFs, as well as short- and long-term health studies evaluating dietary shifts from ABFs to NPBFs and standardized environmental impact assessments, ideally from independent funders.

Adherence to the Eatwell Guide and population and planetary health: A Rank Prize Forum report.

This report summarises a Forum conducted in June 2023 to explore the current state of the knowledge around the Eatwell Guide, which is the UK government's healthy eating tool, in relation to population and planetary health. The 1.5-day Forum highlighted the limited, albeit promising evidence linking higher adherence to the Eatwell Guide with favourable health outcomes, including reduced overall mortality risk, lower abdominal obesity in post-menopausal women and improved cardiometabolic health markers. Similarly, evidence was presented to suggest that higher adherence to the Eatwell Guide is associated with reduced greenhouse gas emissions. Presentations were given around cultural adaptations of the Eatwell Guide, including African Heritage and South Asian versions, which are designed to increase the acceptability and uptake of the Eatwell Guide in these communities in the United Kingdom. Presentations highlighted ongoing work relevant to the applications of the Eatwell Guide in randomised controlled trials and public health settings, including the development of a screening tool to quantify Eatwell Guide adherence. The Forum ended with a World Café-style event, in which the strengths and limitations of the Eatwell Guide were discussed, and directions for future research were identified. This Forum report serves as a primer on the current state of the knowledge on the Eatwell Guide and population and planetary health and will be of interest to researchers, healthcare professionals and public health officials.

Brucellosis seroprevalence in Bali cattle with reproductive failure in South Sulawesi and Brucella abortus biovar 1 genotypes in the Eastern Indonesian archipelago.

BACKGROUND: Brucellosis is a major cause of infertility and reproductive failure in livestock. While cattle in the Eastern Indonesian archipelago suffers from reproductive problems information on bovine brucellosis in the region is fragmentary. The control of brucellosis requires a major and prolonged effort and confirmation of the infection by isolation with detailed knowledge of the spread of the infection is essential when planning a control program. RESULTS: Serological investigation of Brucella infection in beef cattle tended under extensive farming conditions revealed a high seroprevalence (19.3%; 95% CI, 17-22) in the compliment fixation tests. The results of a rapid and simple field test correlated well with the Rose Bengal test (kappa, 0.917) and indicated an acceptable sensitivity (87.5%) and specificity (98.1%) compared with the complement fixation test. Reproductive failure was reported for 39.0% of the cows with a loss of calves due to abortion or early death amounting to 19.3%. Past reproductive failure did not, however, correlate with seropositivity in the complement fixation test (RP = 1.21; P = 0.847). B. abortus biovar 1 was freshly isolated from the hygromas of two cows and together with thirty banked isolates collected since 1990 from different parts of Sulawesi and Timor eight related genotypes could be distinguished with one genotype being identical to that of an isolate (BfR91) from Switzerland. The Indonesian genotypes formed together with BfR91 and one African and one North American isolate a distinct branch on the B. abortus biovar 1 dendogram. CONCLUSIONS: Bovine brucellosis appears to be widespread in the Eastern Indonesian archipelago and calls for urgent intervention. The fresh isolation of the pathogen together with the observed high seroprevalence demonstrates the presence and frequent exposure of cattle in the area to the pathogen. The application of a rapid and simple field test for brucellosis could be very useful for the quick screening of cattle at the pen side.

Socio-economic and food system drivers of nutrition and health transitions in The Gambia from 1990 to 2017.

In common with many nations undergoing a nutrition transition, micronutrient deficiencies, undernutrition and overnutrition coexist in The Gambia. Addressing these challenges simultaneously would require transformational changes in the country's food system. However, the evidence base that would enable informed decision-making in the Gambian food system has been scant, despite several sources of routinely-collected data being available. This descriptive study brings together data from four open-access global databases on food supply, political, economic, and demographic variables, and nutrition and health between 1990 and 2017 to study potential leverage points for improvement in the food system. It compares trends in food supply and nutritional outcomes in The Gambia against regional and global averages, and identifies potential drivers taken from a food systems framework. The data show that, over the past three decades, total energy supply has increased, and obesity is rising quickly, but iron deficiency persists in a proportion of the population. Overall diet composition is poor, with lower availability of fruit and vegetables and higher supply of sugar and oils compared to regional and global averages. Domestic production is low for most food groups and so a high dependence on imports from other countries bridges the gap in terms of energy supply. Measures of economic development, particularly GDP, were positively related with supply of cereals and animal source foods over time, but no such relationship was observed with fruit and vegetable supply. Food system policy to improve nutrition and health outcomes in The Gambia needs to focus on improving the diversity of food supply - especially fruit and vegetables - and maximizing national domestic production to reduce reliance on food imports. The use of open-source global datasets can be feasible in exploring food system characteristics and trends at the national level and could be applied in other contexts.

Can cereal-legume intercrop systems contribute to household nutrition in semi-arid environments: A systematic review and meta-analysis.

Introduction: Intercropping cereals with legumes can intensify rainfed cereal monocropping for improved household food and nutritional security. However, there is scant literature confirming the associated nutritional benefits. Methodology: A systematic review and meta-analysis of nutritional water productivity (NWP) and nutrient contribution (NC) of selected cereal-legume intercrop systems was conducted through literature searches in Scopus, Web of Science and ScienceDirect databases. After the assessment, only nine articles written in English that were field experiments comprising grain cereal and legume intercrop systems were retained. Using the R statistical software (version 3.6.0), paired t-tests were used to determine if differences existed between the intercrop system and the corresponding cereal monocrop for yield (Y), water productivity (WP), NC, and NWP. Results: The intercropped cereal or legume yield was 10 to 35% lower than that for the corresponding monocrop system. In most instances, intercropping cereals with legumes improved NY, NWP, and NC due to their added nutrients. Substantial improvements were observed for calcium (Ca), where NY, NWP, and NC improved by 658, 82, and 256%, respectively. Discussion: Results showed that cereal-legume intercrop systems could improve nutrient yield in water-limited environments. Promoting cereal- legume intercrops that feature nutrient-dense legume component crops could contribute toward addressing the SDGs of Zero Hunger (SDG 3), Good Health and Well-3 (SDG 2) and Responsible consumption and production (SDG 12).

Comparison of two rapid tests for anti-phenolic glycolipid-I serology in Brazil and Nepal.

The diagnosis of leprosy continues to be based on clinical symptoms and early diagnosis and treatment are critical to preventing disability and transmission. Sensitive and specific laboratory tests are not available for diagnosing leprosy. Despite the limited applicability of anti-phenolic glycolipid-I (PGL-I) serology for diagnosis, it has been suggested as an additional tool to classify leprosy patients (LPs) for treatment purposes. Two formats of rapid tests to detect anti-PGL-I antibodies [ML immunochromatography assay (ICA) and ML Flow] were compared in different groups, multibacillary patients, paucibacillary patients, household contacts and healthy controls in Brazil and Nepal. High ML Flow intra-test concordance was observed and low to moderate agreement between the results of ML ICA and ML Flow tests on the serum of LPs was observed. LPs were "seroclassified" according to the results of these tests and the seroclassification was compared to other currently used classification systems: the World Health Organization operational classification, the bacilloscopic index and the Ridley-Jopling classification. When analysing the usefulness of these tests in the operational classification of PB and MB leprosy for treatment and follow-up purposes, the ML Flow test was the best point-of-care test for subjects in Nepal and despite the need for sample dilution, the ML ICA test yielded better performance among Brazilian subjects. Our results identified possible ways to improve the performance of both tests.

Changes in Climate Vulnerability and Projected Water Stress of The Gambia's Food Supply Between 1988 and 2018: Trading With Trade-Offs.

Background: The coexistence of under- and overnutrition is of increasing public health concern in The Gambia. Fruits, vegetables and pulses are essential to healthy and sustainable diets, preventing micronutrient deficiencies and non-communicable diseases, while cereals significantly contribute to energy intake. However, environmental changes are predicted to intensify, reducing future yields of these crops if agricultural productivity and resilience are not improved. The Gambia is highly climate-vulnerable and import-dependent, but the extent of its reliance on other climate-vulnerable countries for its supply of nutritionally important crops is currently unknown. Methods: We used United Nations Food and Agriculture Organization data, with novel origin-tracing algorithms applied, to analyse The Gambia's supply of cereals, fruits, vegetables and pulses between 1988 and 2018. The climate vulnerability of countries was assessed using Notre Dame Global Adaptation Initiative (ND-GAIN) index scores, and projected water stress (2040) assessed using World Resources Institute (WRI) scores. Multilevel generalized linear mixed-effects models were used to identify changes in the overall climate vulnerability and projected water stress of supply. Results: Between 1988 and 2018, The Gambia's supply of cereals, fruits, vegetables and pulses diversified, with the proportion domestically produced falling (Cereals: 61.4%-27.7%; Fruits: 93.0%-55.7%; Vegetables: 24.6%-16.3%; Pulses: 100.0%-76.0%). The weighted-average ND-GAIN scores improved (indicating less climate vulnerability) for supply of all crops except cereals, but the weighted-average WRI score for supply deteriorated (indicating increased projected water stress) for all crops except vegetables. When just considering imports, weighted-average ND-GAIN scores deteriorated for fruits and cereals while showing no significant change for other food groups, and the WRI score deteriorated for cereals only. Conclusions: Despite some notable improvements in the environmental vulnerability of The Gambia's supply of nutritionally important crops (particularly vegetables), considerable, and in some cases increasing, proportions of their supply are produced in countries that are vulnerable to climate change and future water stress. This may have implications for the availability, affordability, and hence consumption of these crops in The Gambia, ultimately exacerbating existing nutritional challenges. Exploring the options to strengthen supply resilience-such as altering trade patterns, agricultural techniques and diets-should be prioritized.

Dietary and agricultural adaptations to drought among smallholder farmers in South Africa: A qualitative study.

Building resilience to environmental change is an integral part of long-term climate adaptation planning and local policy. There is an increased understanding of the impact of climate change on global crop production however, little focus has been given to local adaptation pathways and rural smallholder community responses, especially regarding food security. It is becoming increasingly evident that local level decision-making plays a vital role in reducing vulnerability to environmental change. This research aimed to qualitatively investigate coping and adaptive strategies adopted by smallholder farming households to respond to the impacts of drought in rural KwaZulu-Natal, South Africa. Focus group discussions (n = 7) consisting of 5-9 participants and individual interviews (n = 9) using pre-tested topic guides, involving a total of 57 adults were conducted in rural areas of drought-affected districts: Msinga, Richmond and Umbumbulu of KwaZulu-Natal, in July 2018. The data were analysed using thematic analysis in NVivo 12. Thematic analysis identified three principal themes: 1. Perceived effects of droughts on the local food system and diets; 2. Current coping strategies; and 3. Enablers for successful adaptation. All sites reported a change in food consumption habits, with the majority perceiving drought to be the main driver behind a shift from vegetable-based to starch-based diets and decreased animal source food consumption. Only short-term coping strategies were implemented across the study sites. However, knowledge of long-term adaptation strategies existed but was unattainable to most respondents. Recommendations of perceived context-specific long-term adaptation strategies that could be used at a local scale were communicated by the respondents. However, they would need external help to actualize them. A need exists to support smallholder communities' short-term response methods to drought to achieve more holistic resilience and successful adaptation. Short-term adaptation strategies, if implemented alone, often have significant trade-offs with longer-term adaptation and building resilience. This study highlights the need for targeted, contextualised policy solutions to improve smallholder productivity during drought through a strategic combination of both short- and longer-term adaptation measures, i.e. short-term adaptation should be guided by a long-term adaptation strategy. Proper planning, including the use of climate scenarios combined with information on nutritional status, is needed to develop context-specific and transformative adaptation strategies. These strategies should aim to strengthen resilience at a local level and should be included as policy recommendations.