Inventory on the dietary assessment tools available and needed in africa: a prerequisite for setting up a common methodological research infrastructure for nutritional surveillance, research, and prevention of diet-related non-communicable diseases.

OBJECTIVE: To carry out an inventory on the availability, challenges, and needs of dietary assessment (DA) methods in Africa as a pre-requisite to provide evidence, and set directions (strategies) for implementing common dietary methods and support web-research infrastructure across countries. METHODS: The inventory was performed within the framework of the "Africa's Study on Physical Activity and Dietary Assessment Methods" (AS-PADAM) project. It involves international institutional and African networks. An inventory questionnaire was developed and disseminated through the networks. Eighteen countries responded to the dietary inventory questionnaire. RESULTS: Various DA tools were reported in Africa; 24-Hour Dietary Recall and Food Frequency Questionnaire were the most commonly used tools. Few tools were validated and tested for reliability. Face-to-face interview was the common method of administration. No computerized software or other new (web) technologies were reported. No tools were standardized across countries. CONCLUSIONS: The lack of comparable DA methods across represented countries is a major obstacle to implement comprehensive and joint nutrition-related programmes for surveillance, programme evaluation, research, and prevention. There is a need to develop new or adapt existing DA methods across countries by employing related research infrastructure that has been validated and standardized in other settings, with the view to standardizing methods for wider use.

[Educational practices and diabetes study of health professionals in Burkina Faso and Mali]. / Pratiques éducatives et diabète : étude auprès des professionnels de santé au Burkina Faso et au Mali.

OBJECTIVE: To examine educational practices in type 2 diabetes among health professionals. METHODS: A cross-sectional study took place from June to September 2012 in Bamako and Ouagadougou. The study population consisted of all health professionals responsible for diabetes care in secondary and tertiary public health facilities. RESULTS: A total of 78 participants were interviewed. Doctors and nurses accounted for 77% and 23% respectively. The median number of patients seen in consultation was 10 per week (range 1-100). The median age of experience in diabetes care for health professionals was 5 years (range: 1-25 years). Sixteen participants reported giving advice for cooking. Of the 62 that did not, the reasons given were mainly: non-competence to give such advice (60/62); lack of time (35/62) and useless counseling (5/62). For out-of-home meals, recommendations included: taking a meal to work (60/77); avoiding meals outside the home (30/77); avoid alcohol and oils at parties (10/77). CONCLUSION: The recommendations made to patients come down to information and advice. As a result, the data collected lacks an educational strategy that aims to render the patient more independent by facilitating his adherence to counseling and improving his quality of life.

Evaluation of the international standardized 24-h dietary recall methodology (GloboDiet) for potential application in research and surveillance within African settings.

BACKGROUND: Collection of reliable and comparable individual food consumption data is of primary importance to better understand, control and monitor malnutrition and its related comorbidities in low- and middle-income countries (LMICs), including in Africa. The lack of standardised dietary tools and their related research support infrastructure remains a major obstacle to implement concerted and region-specific research and action plans worldwide. Citing the magnitude and importance of this challenge, the International Agency for Research on Cancer (IARC/WHO) launched the "Global Nutrition Surveillance initiative" to pilot test the use of a standardized 24-h dietary recall research tool (GloboDiet), validated in Europe, in other regions. In this regard, the development of the GloboDiet-Africa can be optimised by better understanding of the local specific methodological needs, barriers and opportunities. The study aimed to evaluate the standardized 24-h dietary recall research tool (GloboDiet) as a possible common methodology for research and surveillance across Africa. METHODS: A consultative panel of African and international experts in dietary assessment participated in six e-workshop sessions. They completed an in-depth e-questionnaire to evaluate the GloboDiet dietary methodology before and after participating in the e-workshop. RESULTS: The 29 experts expressed their satisfaction on the potential of the software to address local specific needs when evaluating the main structure of the software, the stepwise approach for data collection and standardisation concept. Nevertheless, additional information to better describe local foods and recipes, as well as particular culinary patterns (e.g. mortar pounding), were proposed. Furthermore, food quantification in shared-plates and -bowls eating situations and interviewing of populations with low literacy skills, especially in rural settings, were acknowledged as requiring further specific considerations and appropriate solutions. CONCLUSIONS: An overall positive evaluation of the GloboDiet methodology by both African and international experts, supports the flexibility and potential applicability of this tool in diverse African settings and sets a positive platform for improved dietary monitoring and surveillance. Following this evaluation, prerequisite for future implementation and/or adaptation of GloboDiet in Africa, rigorous and robust capacity building as well as knowledge transfer will be required to roadmap a stepwise approach to implement this methodology across pilot African countries/regions.

Public health nutrition capacity: assuring the quality of workforce preparation for scaling up nutrition programmes.

OBJECTIVE: To describe why and how capacity-building systems for scaling up nutrition programmes should be constructed in low- and middle-income countries (LMIC). DESIGN: Position paper with task force recommendations based on literature review and joint experience of global nutrition programmes, public health nutrition (PHN) workforce size, organization, and pre-service and in-service training. SETTING: The review is global but the recommendations are made for LMIC scaling up multisectoral nutrition programmes. SUBJECTS: The multitude of PHN workers, be they in the health, agriculture, education, social welfare, or water and sanitation sector, as well as the community workers who ensure outreach and coverage of nutrition-specific and -sensitive interventions. RESULTS: Overnutrition and undernutrition problems affect at least half of the global population, especially those in LMIC. Programme guidance exists for undernutrition and overnutrition, and priority for scaling up multisectoral programmes for tackling undernutrition in LMIC is growing. Guidance on how to organize and scale up such programmes is scarce however, and estimates of existing PHN workforce numbers - although poor - suggest they are also inadequate. Pre-service nutrition training for a PHN workforce is mostly clinical and/or food science oriented and in-service nutrition training is largely restricted to infant and young child nutrition. CONCLUSIONS: Unless increased priority and funding is given to building capacity for scaling up nutrition programmes in LMIC, maternal and child undernutrition rates are likely to remain high and nutrition-related non-communicable diseases to escalate. A hybrid distance learning model for PHN workforce managers' in-service training is urgently needed in LMIC.

Contribution to the development of a food guide in Benin: linear programming for the optimization of local diets.

OBJECTIVE: Food guides are important tools for nutrition education. While developing a food guide in Benin, the objective was to determine the daily number of servings per food group and the portion sizes of common foods to be recommended. DESIGN: Linear programming (LP) was used to determine, for each predefined food group, the optimal number and size of servings of commonly consumed foods. Two types of constraints were introduced into the LP models: (i) WHO/FAO Recommended Nutrient Intakes and dietary guidelines for the prevention of chronic diseases; and (ii) dietary patterns based on local food consumption data recently collected in southern Benin in 541 adults. Dietary intakes of the upper tertile of participants for diet quality based on prevention and micronutrient adequacy scores were used in the LP algorithms. SETTING: Southern area of the Republic of Benin. SUBJECTS: Local key-players in nutrition (n 30) from the government, academic institutions, international organizations and civil society were partners in the development of the food guide directed at the population. RESULTS: The number of servings per food group and the portion size for eight age-sex groups were determined. For four limiting micronutrients (Fe, Ca, folate and Zn), local diets could be optimized to meet only 70 % of the Recommended Nutrient Intakes, not 100 %. CONCLUSIONS: It was possible to determine the daily number of servings and the portion sizes of common foods that can be recommended in Benin with the help of LP to optimize local diets, although Recommended Nutrient Intakes were not fully met for a few critical micronutrients.

Perspectives for integration into the local health system of community-based management of acute malnutrition in children under 5 years: a qualitative study in Bangladesh.

BACKGROUND: Acute malnutrition is a major cause of death among under-five children in low- and middle-income countries. United Nations agencies recommend the integration of community-based management of acute malnutrition (CMAM) into the local health systems for sustainability. The objective of the study was to assess the preparedness of the health system to implement CMAM targeting children under-five years in two sub-districts of Bangladesh. METHODS: The assessment was performed through direct observation of 44 health centres, individual interviews of seven policy makers, three donors, four health and nutrition implementing partners, 29 health workers, and review of secondary data. Assessment themes, derived from the WHO six Building Blocks, were nutrition governance, nutrition financing, health service delivery, human resources, equipment and supply, referral, monitoring and supervision mechanism. They were subdivided into 16 criteria. Findings were compared with CMAM operational recommendations according to WHO, Valid International and Food and Nutrition Technical Assistance guidelines. RESULTS: The government of Bangladesh has developed inpatient and outpatient CMAM guidelines, and a policy offering free-of-charge health care for under-five children. Nutrition coordination was not under full government leadership. Most of funds (74%) dedicated to CMAM were provided by donors, for short-term interventions. Of the total 44 health centres assessed, 39 (88.6%) were active, among which 4 (10.2%) delivered inpatient services, 35 (89.8%) outpatient services, and 24 (61.5%) outreach services. These were regarded as opportunities to include CMAM activities. There were 48.9% vacant positions and the health workers were not trained for management of acute malnutrition. Equipment and supplies did not meet the operational recommendations for management of acute malnutrition. CONCLUSION: Implementing CMAM through the health centres of both sub-districts would warrant progressive strengthening of the overall health system in the light of identified barriers. A short term strategy would consist of strengthening government coordination of nutrition interventions, exploring additional funding sources, equipping and supplying functional health centres, training health workers and actively involving community health workers to cope with health facility staff shortage. A mid-term strategy would consist of securing permanent funding for CMAM, rehabilitating non-functional health centres, attracting and retaining health workers in rural areas.

Association of high-sensitivity C-reactive protein with cardiometabolic risk factors and micronutrient deficiencies in adults of Ouagadougou, Burkina Faso.

Increasing evidence suggests that high-sensitivity C-reactive protein (hs-CRP) is associated with cardiometabolic risk factors (CMRF) while being also related to micronutrient deficiencies. As part of a project on the double burden of under- and overnutrition in sub-Saharan Africa, we assessed the relationship between hs-CRP and both CMRF and micronutrient deficiencies in a population-based cross-sectional study carried out in the Northern district of Ouagadougou, the capital city of Burkina Faso. We randomly selected 330 households stratified by income tertile. In each income stratum, 110 individuals aged 25-60 years and having lived in Ouagadougou for at least 6 months were randomly selected, and underwent anthropometric measurements and blood sample collection. The prevalence of high hs-CRP was 39.4 %, with no sex difference. Vitamin A-deficient subjects (12.7 %) exhibited significant risk of elevated hs-CRP (OR 2.5; P= 0.015). Serum ferritin was positively correlated with log hs-CRP (r 0.194; P= 0.002). The risk of elevated hs-CRP was significant in subjects with BMI ≥ 25 kg/m² (OR 6.9; 95 % CI 3.6, 13.3), abdominal obesity (OR 4.6; 95 % CI 2.2, 7.3) and high body fat (OR 10.2; 95 % CI 5.1, 20.3) (P< 0.001, respectively). Independent predictors of hs-CRP in linear regression models were waist circumference (ß = 0.306; P= 0.018) and serum TAG (ß = 0.158; P= 0.027). In this sub-Saharan population, hs-CRP was consistently associated with adiposity. Assuming that plasma hs-CRP reflects future risk of cardiovascular events, intervention which reduces CRP, or chronic and acute nutrition conditions associated with it, could be effective in preventing their occurrence particularly in sub-Saharan Africa.

Urbanisation, nutrition transition and cardiometabolic risk: the Benin study.

A rising prevalence of CVD and diabetes has been observed in sub-Saharan Africa, particularly in cities. The aim of the present study conducted in Benin was to examine the mediating role of nutrition transition in the relationship of urbanisation level and socio-economic status (SES) to cardiometabolic risk markers. A total of 541 subjects in apparent good health were randomly selected from the main city of Cotonou, a small town and its surrounding rural areas. SES was assessed based on a proxy for income and on education. Dietary intake and physical activity were assessed with at least two non-consecutive 24 h recalls. Scores for micronutrient adequacy and preventive diet were used as indicators of diet quality. Cardiometabolic risk markers were BMI, waist circumference (WC), blood pressure, serum cholesterol and insulin resistance according to homeostasis model assessment. A more advanced stage of nutrition transition, which correlated with lower diet quality scores and less physical activity, was observed in the large city compared with less urbanised locations. More obesity and more adverse cholesterol profiles, but also lower blood pressure, were present in the large city. Urbanisation, income, sedentary lifestyle and alcohol consumption, but not diet quality, independently contributed to higher BMI and WC. Higher micronutrient adequacy was independently associated with a better cholesterol profile. The study confirmed the positive rural-urban gradient in nutrition transition and cardiometabolic risk, except for blood pressure. This risk could be mitigated by a more adequate diet, particularly micronutrient intake, and a more active lifestyle.

The double burden of malnutrition and cardiometabolic risk widens the gender and socio-economic health gap: a study among adults in Burkina Faso (West Africa).

OBJECTIVE: To document the double burden of malnutrition and cardiometabolic risk factors (CMRF) in adults and its occurrence according to different sociodemographic parameters. DESIGN: Population-based cross-sectional observational study. We first randomly selected 330 households stratified by tertile of the income levels proxy as low, middle and high income. SETTING: Northern district of Ouagadougou, the capital city of Burkina Faso. SUBJECTS: In each income stratum, 110 individuals aged 25-60 years and who had lived permanently in Ouagadougou for at least 6 months were randomly selected, followed with collection of anthropometric, socio-economic and clinical data, and blood samples. RESULTS: The overall obesity/overweight prevalence was 24.2 % and it was twice as high in women as in men (34.1 % v. 15.5 %, P < 0.001). Hypertension, hyperglycaemia and low HDL cholesterol prevalence was 21.9 %, 22.3 % and 30.0 %, respectively, without gender difference. The prevalence of the metabolic syndrome was 10.3 %. Iron depletion and vitamin A deficiency affected 15.7 % and 25.7 % of participants, respectively, with higher rates in women. Coexistence of at least one nutritional deficiency and one CMRF was observed in 23.5 % of participants, and this 'double burden' was significantly higher in women than in men (30.4 % v. 16.1 %, P = 0.008) and in the low income group. CONCLUSIONS: CMRF are becoming a leading nutritional problem in adults of Ouagadougou, while nutritional deficiencies persist. The double nutritional burden exacerbates health inequities and calls for action addressing both malnutrition and nutrition-related chronic diseases.

Poor nutritional status of schoolchildren in urban and peri-urban areas of Ouagadougou (Burkina Faso).

BACKGROUND: Malnutrition is still highly prevalent in developing countries. Schoolchildren may also be at high nutritional risk, not only under-five children. However, their nutritional status is poorly documented, particularly in urban areas. The paucity of information hinders the development of relevant nutrition programs for schoolchildren. The aim of this study carried out in Ouagadougou was to assess the nutritional status of schoolchildren attending public and private schools. METHODS: The study was carried out to provide baseline data for the implementation and evaluation of the Nutrition Friendly School Initiative of WHO. Six intervention schools and six matched control schools were selected and a sample of 649 schoolchildren (48% boys) aged 7-14 years old from 8 public and 4 private schools were studied. Anthropometric and haemoglobin measurements, along with thyroid palpation, were performed. Serum retinol was measured in a random sub-sample of children (N = 173). WHO criteria were used to assess nutritional status. Chi square and independent t-test were used for proportions and mean comparisons between groups. RESULTS: Mean age of the children (48% boys) was 11.5 ± 1.2 years. Micronutrient malnutrition was highly prevalent, with 38.7% low serum retinol and 40.4% anaemia. The prevalence of stunting was 8.8% and that of thinness, 13.7%. The prevalence of anaemia (p = 0.001) and vitamin A deficiency (p < 0.001) was significantly higher in public than private schools. Goitre was not detected. Overweight/obesity was low (2.3%) and affected significantly more children in private schools (p = 0.009) and younger children (7-9 y) (p < 0.05). Thinness and stunting were significantly higher in peri-urban compared to urban schools (p < 0.05 and p = 0.004 respectively). Almost 15% of the children presented at least two nutritional deficiencies. CONCLUSION: This study shows that malnutrition and micronutrient deficiencies are also widely prevalent in schoolchildren in cities, and it underlines the need for nutrition interventions to target them.

Partnership research on nutrition transition and chronic diseases in West Africa - trends, outcomes and impacts.

BACKGROUND: Nutrition-related chronic diseases (NRCD) are rising quickly in developing countries, and the nutrition transition is a major contributor. Low-income countries have not been spared. Health issues related to nutritional deficiencies also persist, creating a double burden of malnutrition (DBM). There is still a major shortage of data on NRCD and DBM in Sub-Saharan Africa. A research program has been designed and conducted in partnership with West African institutions since 2003 to determine how the nutrition transition relates to NRCD and the DBM in order to support prevention efforts. METHODS: In Benin, cross-sectional studies among apparently healthy adults (n=540) from urban, semi-urban and rural areas have examined cardiometabolic risk (hypertension, obesity, dyslipidemia, insulin resistance) in relation to diet and lifestyle, also factoring in socio-economic status (SES). Those studies were followed by a longitudinal study on how risk evolves, opening the way for mutual aid groups to develop a prevention strategy within an action research framework. In Burkina Faso, a cross-sectional study on the nutritional status and dietary patterns of urban school-age children (n=650) represented the initial stages of an action research project to prevent DBM in schools. A cross-sectional study among adults (n=330) from the capital of Burkina Faso explored the coexistence, within these individuals, of cardiometabolic risk factors and nutritional deficiencies (anemia, vitamin A deficiency, chronic energy deficiency), as they relate to diet, lifestyle and SES. RESULTS: The studies have shown that the prevalence of NRCD is high among the poor, thereby exacerbating social inequalities. The hypothesis of a positive socio-economic (and rural-urban) gradient was confirmed only for obesity, whereas the prevalence of hypertension, insulin resistance and dyslipidemia did not prove to be higher among affluent city dwellers. Women were particularly affected by abdominal obesity, at 48% compared to 6% of men. Protective factors against the risk of NRCD were physical activity and adequate micronutrient intake. The research also showed that nutritional deficiencies were not restricted to schoolchildren in rural areas because in the capital of Ouagadougou, for example, 40% of schoolchildren were anaemic and 40% were vitamin A deficient. Partnership research has expanded to include advocacy and human resources training. CONCLUSION: These initial studies on NRCD in West Africa indicate the relevance and urgency of prevention, even among low-income groups and countries. They show that the fight against NRCD as well as nutritional deficiencies should focus on women. Seeing how researchers from the African partner institutions have connections with decision-making authorities, the research findings could have an impact on prevention policies and programs in communities and schools alike. Greater support must nevertheless be provided to lobbying and advocacy work for an even greater impact. As well, the sustainability of the research program remains a challenge that requires resource mobilization and training for the purpose.

Impact of the Nutrition-Friendly School Initiative: analysis of anthropometric and biochemical data among school-aged children in Ouagadougou.

The Nutrition-Friendly School Initiative was developed in 2006 to counter the double burden of malnutrition and implemented on a pilot basis in primary schools in Ouagadougou (Burkina Faso) in 2009. A baseline study was conducted in intervention and control schools and repeated in 2014 to assess the impact. This paper reports on anthropometric and biochemical data in the final and baseline surveys. Both studies were conducted in the fifth grade classes of the same primary schools in Ouagadougou. Six intervention schools had been selected and matched at baseline with six control schools. The total sample consisted of 699 and 651 pupils in 2009 and 2014, respectively. Anthropometric and hemoglobin measurements were performed on all children, whereas serum retinol was measured in a random subsample to assess Vitamin A Deficiency (VAD). Independent t-tests and chi-squared tests were used for comparison of means and proportions, respectively, and multiple logistic regressions were conducted to examine associations between nutritional parameters and school characteristics. Final rates of anaemia and VAD were 32.6% and 26.1%, respectively, down from 40.4% and 38.7% at baseline. The final prevalence rate of stunting was 8.1%, thinness was 8.7% and overweight/obesity was 4.4%. Thinness declined significantly in 2014 compared to 2009, but there was no change in the rate of stunting even though the rate of overweight/obesity showed an upward trend. When comparing intervention with control schoolchildren, the only significant differences found in the final survey were less thinness and less anaemia in the intervention children. However, the prevalence of anaemia was also significantly lower in the intervention group at baseline. Our results point to a significant improvement in the nutritional status of schoolchildren in Ouagadougou and suggest a positive, although modest, role for the Nutrition-Friendly School Initiative in reducing thinness, but not overweight.

Dietary patterns and quality in West-African immigrants in Madrid.

BACKGROUND: Eating patterns of immigrants deserve to be better documented because they may reflect the extent of acculturation and associated health risks. The study assessed dietary patterns and quality in Bubi immigrants (from Equatorial Guinea) using cluster analysis and comparing different diet quality indexes. METHODS: A random sample of 83 Bubi men and 130 women living in Madrid were studied. A 99-item food frequency questionnaire was administered, body weights and heights were self-reported and socio-demographic and health information was collected during interviews. Usual intakes were collapsed into 19 food groups. Cluster analysis of standardized food intakes per 1000 kcalories was performed. Dietary quality was appraised using the Alternative Mediterranean Diet Score, the Alternative Healthy Eating Index and scores of micronutrient adequacy and prevention based on WHO/FAO recommendations. RESULTS: Two dietary patterns were identified. The 'Healthier' pattern, so confirmed by two dietary quality indexes, featured a higher consumption of fish, fruits, vegetables, legumes, dairy products and bread while the 'Western' pattern included more processed meat, animal fat, and sweetened foods and drinks. One third of the subjects were in the 'Healthier' food cluster, with the same proportion of men and women. Age >or= 30 and residence in Madrid >or= 11 years were independently associated with the healthier diet. Consumption of traditional foods was unrelated to dietary pattern, however. Overall, Bubi diets were somewhat protective because of high intakes of fruits and vegetables and monounsaturated fat (olive oil), but not with respect to sugar, cholesterol, omega-3 fatty acids and fibre. Less than two thirds of subjects had adequate intakes of iron, calcium and folate in both dietary phenotypes. Body mass index, physical exercise, and self-reported health and cardiovascular disease condition showed no significant association with the dietary pattern. CONCLUSION: Cluster analysis combined with dietary quality assessment facilitates the interpretation of dietary patterns, but choosing the appropriate quality indexes is a problem. A small number of such indexes should be standardized and validated for international use. In the group studied, younger subjects and more recent immigrants were more likely to have a 'Western' pattern and should be a priority target for nutrition communication.

Chronic disease and malnutrition biomarkers among unemployed immigrants and Canadian born adults.

BACKGROUND: Immigration status and unemployment may intersect on the health outcomes of men and women. This study aimed to identify intersections between unemployment and immigration in inflammatory, metabolic and nutritional blood markers and assess gender differences. METHODS: We used Canadian Health Measures Survey data on 2493 participants aged 18 to 65. Outcomes were chronic inflammation (high-sensitivity C-reactive protein (hsCRP) and fibrinogen), nutritional (albumin and hemoglobin), and metabolic blood markers (glycosylated hemoglobin, blood glucose, total and high density lipoprotein (HDL) cholesterol). Multivariate linear regressions were used to assess the associations between each biomarker, unemployment and immigrant status, controlling for age, education, province, smoking, physical inactivity and body mass index and testing for multiplicative interactions between unemployment, immigrant status and gender. RESULTS: Unemployment was associated with higher inflammation (hsCRP and fibrinogen) in Canadian born men; Canadian born employed women showed higher hsCRP values compared with corresponding employed men. Unemployed immigrant women presented the highest values of hsCRP while employed immigrant women had the lowest hsCRP. Unemployment was associated with higher glucose; immigrant status was associated with higher glucose and glycosylated hemoglobin. Unemployed immigrants had significantly lower levels of hemoglobin and albumin than employed immigrants, and Canadian-born citizens regardless of their employment status. Some of these associations were attenuated after adjustment by body mass index, physical inactivity and smoking. CONCLUSION: Blood biomarkers unveil intersections among unemployment, immigration and gender. This study provides evidence on biological pathways of unemployment on the likelihood of common chronic diseases, inflammation and potential malnutrition with some increased vulnerabilities in unemployed immigrants, and particularly in unemployed immigrant women.

Poverty: the double burden of malnutrition in mothers and the intergenerational impact.

Women are doubly vulnerable to malnutrition, because of their high nutritional requirements for pregnancy and lactation and also because of gender inequalities in poverty. Undernutrition and overnutrition coexist in developing countries undergoing rapid nutrition transition, and women are susceptible to this double burden of "dysnutrition," often cumulating stunting or micronutrient malnutrition with obesity or other nutrition-related chronic diseases. The purpose of the present paper is to describe the adverse impact of income and gender inequities on women's nutritional health, and the dramatic consequences, not only for women themselves, but for children, families, and societies. Improving women's resources, including health, nutrition, education, and decisional power, is critical for equity and for the health of children and adults of future generations, since poor fetal and infancy nutrition is another risk factor for chronic diseases, in particular abdominal obesity, type 2 diabetes, hypertension, and cardiovascular disease. Addressing malnutrition and nutrition-related chronic diseases simultaneously is a challenge facing developing countries, and examples of promising initiatives are provided. Focusing on women along the lifecycle, according to the continuum of care approach, is essential to achieving the Millennium Development Goals and to breaking the intergenerational cycle of poverty, malnutrition, and ill-health.