Food biodiversity: Quantifying the unquantifiable in human diets.

Dietary diversity is an established public health principle, and its measurement is essential for studies of diet quality and food security. However, conventional between food group scores fail to capture the nutritional variability and ecosystem services delivered by dietary richness and dissimilarity within food groups, or the relative distribution (i.e., evenness or moderation) of e.g., species or varieties across whole diets. Summarizing food biodiversity in an all-encompassing index is problematic. Therefore, various diversity indices have been proposed in ecology, yet these require methodological adaption for integration in dietary assessments. In this narrative review, we summarize the key conceptual issues underlying the measurement of food biodiversity at an edible species level, assess the ecological diversity indices previously applied to food consumption and food supply data, discuss their relative suitability, and potential amendments for use in (quantitative) dietary intake studies. Ecological diversity indices are often used without justification through the lens of nutrition. To illustrate: (i) dietary species richness fails to account for the distribution of foods across the diet or their functional traits; (ii) evenness indices, such as the Gini-Simpson index, require widely accepted relative abundance units (e.g., kcal, g, cups) and evidence-based moderation weighting factors; and (iii) functional dissimilarity indices are constructed based on an arbitrary selection of distance measures, cutoff criteria, and number of phylogenetic, nutritional, and morphological traits. Disregard for these limitations can lead to counterintuitive results and ambiguous or incorrect conclusions about the food biodiversity within diets or food systems. To ensure comparability and robustness of future research, we advocate food biodiversity indices that: (i) satisfy key axioms; (ii) can be extended to account for disparity between edible species; and (iii) are used in combination, rather than in isolation.Supplemental data for this article is available online at https://doi.org/10.1080/10408398.2022.2051163 .

Multiscalar Evaluation of the Water Distribution System and Diarrheal Disease Risk in Addis Ababa, Ethiopia.

Despite growing urbanization, our understanding of the impacts of water and sanitation on human health has largely come from studies in rural sectors. To this end, we collected data at both regional (water quality measures from water treatment systems) and community (cross-sectional surveys) scales to examine determinants of enteric pathogen infection and diarrheal disease among infants in Addis Ababa, Ethiopia. Regionally, the Legedadi water treatment plant had significantly lower heterotrophic plate counts, total coliform counts, and fecal coliform counts compared with the Gefersa water treatment plant. The number of pathogen types in infant stool also differed by plant. Decreases in chlorine levels and increases in the relative abundance of Gammaproteobacteria with distance from treatment plants suggest a compromised water distribution system. In communities, infants in households that obtained water from yard pipes or public taps had significantly lower odds of diarrhea compared to households that had water piped into their dwellings (OR = 0.35, 95% CI 0.16, 0.76, and OR = 0.39, 95% CI 0.15, 1.00, respectively). Similarly, infants in households that boiled or filtered water had significantly lower odds of diarrhea compared to households that did not treat water (OR = 0.40, 95% CI 0.19, 0.86 and OR = 0.23, 95% CI 0.06, 0.84, respectively). Integrating multiscalar data better informs the health impacts of water in urban settings.

Personal, behavioural and socio-environmental correlates of emerging adults' sustainable food consumption in a cross-sectional analysis.

OBJECTIVE: Describe how dietary intake patterns of US young adults align with the EAT-Lancet Planetary Health Diet (PHD) sustainable diet goals and identify personal, behavioural, and socio-environmental correlates of sustainable intake. DESIGN: Data on past-year dietary intake were captured using a FFQ. The PHD was applied to specific food groups, and a total PHD score was calculated. Linear regression models were used to identify associations between personal, behavioural and socio-environmental factors and PHD scores. SETTING: This cross-sectional analysis uses data from the second wave of EAT 2010-2018 (Eating and Activity over Time), a population-based longitudinal study recruited in Minnesota. PARTICIPANTS: Ethnically/racially diverse group of participants (n 1308) with a mean age of 22·1 (sd 2·0) years. RESULTS: The mean PHD score was 4·1 (sd 1·4) on a scale of 0-14, with 14 representing the most sustainable. On average, participants consumed fewer whole grains, fish, legumes, soya, and nuts than ideal for a sustainable diet, and an excess of eggs, added sugar, and meat. The PHD score was higher for participants with higher socio-economic status (SES) and greater educational attainment. Higher home availability of healthy food (ß = 0·24, P < 0·001) and less frequent fast-food consumption (ß = -0·26, P < 0·001) were the strongest correlates of PHD scores. CONCLUSIONS: Results suggest that a high percentage of participants may not be achieving the sustainable diet goals defined by the PHD. Reductions in meat consumption and increases in plant-based foods are necessary to increase the sustainability of US young adults' diets.

The association between food environment, diet quality and malnutrition in low- and middle-income adult populations across the rural-Urban gradient in Vietnam.

BACKGROUND: Economic reforms and trade liberalisation in Vietnam have transformed the food environment, influencing dietary patterns and malnutrition status. The present study focuses on the relationship between food environments (proximity and density of food outlets) and malnutrition (underweight, overweight, obesity) through diet quality in adult populations across urban, periurban and rural areas of Vietnam. METHODS: We evaluated food environment by geospatial mapping of food outlets through a transect walk across the "food ecosystem" from rural to urban areas. Diet quality was assessed using the Diet Quality Index - Vietnamese (DQI-V) comprising Variety, Adequacy, Moderation and Balance components. Malnutrition status was determined using body mass index. We performed a mediation analysis utilising mixed effect models to control for neighbourhood clustering effects. Confounders included age, education, income and nutrition knowledge score. RESULTS: Analysis of data from 595 adult participants (mean ± SD age: 31.2 ± 6.4 years; 50% female) found that longer distance to the nearest food outlet was associated with higher overall DQI-V (ß = 2.0; 95% confidence interval = 0.2-3.8; p = 0.036) and the Moderation component (ß = 2.6; 95% confidence interval = 1.2-4.0; p = 0.001). Outlet density shows a negative association with the odds of underweight among women (odds ratio = 0.62; 95% confidence interval = 0.37-0.96). However, we did not observe statistically significant relationships between diet quality and malnutrition. Education and nutrition knowledge scores were positively associated with diet diversity, while income was negatively associated with diet moderation. CONCLUSIONS: The findings of the present study have important implications for nutrition and dietetics practice in Vietnam and globally. It emphasises the need to consider various dimensions of sustainable diets, including economic, health and socio-cultural/political factors. Longer distances to food outlets are associated with higher diet quality, whereas lower food outlet density increases the odds of underweight among women. This poses challenges in balancing modernisation and its adverse effects on sustainable food systems. Socio-economic status consistently correlated with diet quality and malnutrition, necessitating further research to promote healthy diets across socio-economic strata.

Women's empowerment, children's nutritional status, and the mediating role of household headship structure: Evidence from sub-Saharan Africa.

We aimed to examine the association between women's empowerment and childhood nutritional status while accounting for the mediating role of household headship structure. Cross-country, cross-sectional quantitative data from the most recent Demographic and Health Surveys (2015-2018) were used. Women's empowerment was measured as a composite index of participation in household decision-making, attitude towards domestic violence, and asset ownership. Childhood nutrition status was measure as anaemia (haemoglobin concentration < 110g/L), stunting (height-for-age z-scorescore <-2) and the co-occurrence of anaemia and stunting. Applying the Lewbel two-stage least squares, women's migration status was used as an instrumental variable. We used data on 25,665 woman-child dyads from eight sub-Saharan African countries: Burundi (2016), Ethiopia (2016), Guinea (2018), Malawi (2016), Mali (2018), Zimbabwe (2015), Uganda (2016), and Tanzania (2015). The women were in their reproductive ages (15-49 years) and children were under 5 years old. The findings showed that an increase in women's empowerment index reduces children's likelihood of being anaemic and having a co-occurrence of anaemia and stunting [coeff (SE), -0.114 (0.025) and -0.072 (0.032), respectively]. Specifically, an increase in asset ownership or decision-making dimensions of empowerment significantly reduces the likelihood of anaemia and the co-occurrence of anaemia and stunting among children. Children of empowered women from male-headed households were more likely to be anaemic and be concurrently anaemic and stunted compared to their counterparts whose mothers were from female-headed households. Interventions designed to improve childhood nutrition through women's empowerment approaches need to consider asset ownership and instrumental agency of women while acknowledging the mediating effect of household headship typology.

Food biodiversity and total and cause-specific mortality in 9 European countries: An analysis of a prospective cohort study.

BACKGROUND: Food biodiversity, encompassing the variety of plants, animals, and other organisms consumed as food and drink, has intrinsic potential to underpin diverse, nutritious diets and improve Earth system resilience. Dietary species richness (DSR), which is recommended as a crosscutting measure of food biodiversity, has been positively associated with the micronutrient adequacy of diets in women and young children in low- and middle-income countries (LMICs). However, the relationships between DSR and major health outcomes have yet to be assessed in any population. METHODS AND FINDINGS: We examined the associations between DSR and subsequent total and cause-specific mortality among 451,390 adults enrolled in the European Prospective Investigation into Cancer and Nutrition (EPIC) study (1992 to 2014, median follow-up: 17 years), free of cancer, diabetes, heart attack, or stroke at baseline. Usual dietary intakes were assessed at recruitment with country-specific dietary questionnaires (DQs). DSR of an individual's yearly diet was calculated based on the absolute number of unique biological species in each (composite) food and drink. Associations were assessed by fitting multivariable-adjusted Cox proportional hazards regression models. In the EPIC cohort, 2 crops (common wheat and potato) and 2 animal species (cow and pig) accounted for approximately 45% of self-reported total dietary energy intake [median (P10-P90): 68 (40 to 83) species consumed per year]. Overall, higher DSR was inversely associated with all-cause mortality rate. Hazard ratios (HRs) and 95% confidence intervals (CIs) comparing total mortality in the second, third, fourth, and fifth (highest) quintiles (Qs) of DSR to the first (lowest) Q indicate significant inverse associations, after stratification by sex, age, and study center and adjustment for smoking status, educational level, marital status, physical activity, alcohol intake, and total energy intake, Mediterranean diet score, red and processed meat intake, and fiber intake [HR (95% CI): 0.91 (0.88 to 0.94), 0.80 (0.76 to 0.83), 0.69 (0.66 to 0.72), and 0.63 (0.59 to 0.66), respectively; PWald < 0.001 for trend]. Absolute death rates among participants in the highest and lowest fifth of DSR were 65.4 and 69.3 cases/10,000 person-years, respectively. Significant inverse associations were also observed between DSR and deaths due to cancer, heart disease, digestive disease, and respiratory disease. An important study limitation is that our findings were based on an observational cohort using self-reported dietary data obtained through single baseline food frequency questionnaires (FFQs); thus, exposure misclassification and residual confounding cannot be ruled out. CONCLUSIONS: In this large Pan-European cohort, higher DSR was inversely associated with total and cause-specific mortality, independent of sociodemographic, lifestyle, and other known dietary risk factors. Our findings support the potential of food (species) biodiversity as a guiding principle of sustainable dietary recommendations and food-based dietary guidelines.

Maternal Overweight and Obesity during Pregnancy Are Associated with Neonatal, but Not Maternal, Hepcidin Concentrations.

BACKGROUND: Overweight or obesity among pregnant women may compromise maternal and neonatal iron status by upregulating hepcidin. OBJECTIVES: This study determined the association of 1) maternal and neonatal iron status with maternal and neonatal hepcidin concentrations, and 2) maternal prepregnancy weight status with maternal and neonatal hepcidin concentrations. METHODS: We examined hematologic data from 405 pregnant women and their infants from the placebo treatment group of a pregnancy iron supplementation trial in rural China. We measured hepcidin, serum ferritin (SF), soluble transferrin receptor (sTfR), and high-sensitivity C-reactive protein in maternal blood samples at mid-pregnancy and in cord blood at delivery. We used regression analysis to examine the association of maternal prepregnancy overweight or obese status with maternal hepcidin concentration in mid-pregnancy and cord hepcidin concentrations. We also used path analysis to examine mediation of the association of maternal prepregnancy overweight or obese status with maternal iron status by maternal hepcidin, as well as with neonatal hepcidin by neonatal iron status. RESULTS: Maternal iron status was positively correlated with maternal hepcidin at mid-pregnancy (SF: r = 0.63, P < 0.001; sTfR: r = -0.37, P < 0.001). Neonatal iron status was also positively correlated with cord hepcidin (SF: r = 0.61, P < 0.001; sTfR: r = -0.39, P < 0.001). In multiple linear regression models, maternal prepregnancy overweight or obese status was not associated with maternal hepcidin at mid-pregnancy but was associated with lower cord hepcidin (coefficient = -0.21, P = 0.004). Using path analysis, we observed a significant indirect effect of maternal prepregnancy overweight or obese status on cord hepcidin, mediated by neonatal iron status. CONCLUSIONS: In both pregnant women and neonates, hepcidin was responsive to iron status. Maternal prepregnancy overweight status, with or without including obese women, was associated with lower cord blood hepcidin, likely driven by lower iron status among the neonates of these mothers.

EAT-Lancet diet score requires minimum intake values to predict higher micronutrient adequacy of diets in rural women of reproductive age from five low- and middle-income countries.

The EAT-Lancet Commission promulgated a universal reference diet. Subsequently, researchers constructed an EAT-Lancet diet score (0-14 points), with minimum intake values for various dietary components set at 0 g/d, and reported inverse associations with risks of major health outcomes in a high-income population. We assessed associations between EAT-Lancet diet scores, without or with lower bound values, and the mean probability of micronutrient adequacy (MPA) among nutrition-insecure women of reproductive age (WRA) from low- and middle-income countries (LMIC). We analysed single 24-h diet recall data (n 1950) from studies in rural DRC, Ecuador, Kenya, Sri Lanka and Vietnam. Associations between EAT-Lancet diet scores and MPA were assessed by fitting linear mixed-effects models. Mean EAT-Lancet diet scores were 8·8 (SD 1·3) and 1·9 (SD 1·1) without or with minimum intake values, respectively. Pooled MPA was 0·58 (SD 0·22) and energy intake was 10·5 (SD 4·6) MJ/d. A one-point increase in the EAT-Lancet diet score, without minimum intake values, was associated with a 2·6 (SD 0·7) percentage points decrease in MPA (P < 0·001). In contrast, the EAT-Lancet diet score, with minimum intake values, was associated with a 2·4 (SD 1·3) percentage points increase in MPA (P = 0·07). Further analysis indicated positive associations between EAT-Lancet diet scores and MPA adjusted for energy intake (P < 0·05). Our findings indicate that the EAT-Lancet diet score requires minimum intake values for nutrient-dense dietary components to avoid positively scoring non-consumption of food groups and subsequently predicting lower MPA of diets, when applied to rural WRA in LMIC.

Livestock ownership and anaemia in Sub-Saharan African households.

OBJECTIVE: To determine the association between livestock ownership and Hb concentration of women of child-bearing age (WCBA) and preschool-aged children in Sub-Saharan Africa (SSA). DESIGN: A prospective analysis of publicly available cross-sectional data, using linear and logistic regressions controlling for potential confounders. SETTING: Twenty-eight countries in SSA. PARTICIPANTS: 162 305 WCBA and 118 607 children aged 6-59 months. RESULTS: More than half of WCBA (62·5 %) and children (58 %) belonged to households that owned livestock. The average altitude-adjusted blood Hb concentration for WCBA and children was 12.23 and 10·24 g/dL, respectively. In adjusted models, higher number of livestock owned was associated with lower Hb concentration for children but not for WCBA. The magnitude of the association for children was small, with one additional unit of livestock owned reducing Hb concentration by 0·001 g/dL. Higher numbers of cattle, cows and bulls, sheep, and goats were associated with lower Hb concentration for both groups. The number of certain categories of livestock owned was associated with the consumption of relevant foods by children. There was no association between the consumption of animal-source foods and Hb concentration or between livestock ownership and diarrhoeal diseases or fever among children. CONCLUSIONS: Livestock ownership in SSA had a net negative association with the Hb concentration of children and no association with that of WCBA. The results highlight the need for research aimed at clarifying the mechanisms linking livestock ownership and nutritional status, and identifying entry points for leveraging livestock ownership to improve the health of women and children in SSA.

Crop diversity is associated with higher child diet diversity in Ethiopia, particularly among low-income households, but not in Vietnam.

OBJECTIVES: To examine associations of household crop diversity with school-aged child dietary diversity in Vietnam and Ethiopia and mechanisms underlying these associations. DESIGN: We created a child diet diversity score (DDS) using data on seven food groups consumed in the last 24 h. Generalised estimating equations were used to model associations of household-level crop diversity, measured as a count of crop species richness (CSR) and of plant crop nutritional functional richness (CNFR), with DDS. We examined effect modification by household wealth and subsistence orientation, and mediation by the farm's market orientation. SETTING: Two survey years of longitudinal data from the Young Lives cohort. PARTICIPANTS: Children (aged 5 years in 2006 and 8 years in 2009) from rural farming households in Ethiopia (n 1012) and Vietnam (n 1083). RESULTS: There was a small, positive association between household CNFR and DDS in Ethiopia (CNFR-DDS, ß = 0·13; (95 % CI 0·07, 0·19)), but not in Vietnam. Associations of crop diversity and child diet diversity were strongest among poor households in Ethiopia and among subsistence-oriented households in Vietnam. Agricultural earnings positively mediated the crop diversity-diet diversity association in Ethiopia. DISCUSSION: Children from households that are poorer and those that rely more on their own agricultural production for food may benefit most from increased crop diversity.

Multiple burdens of malnutrition and relative remoteness in rural Ecuadorian communities.

OBJECTIVE: Social and economic changes associated with new roads can bring about rapid nutritional transitions. To study this process, we: (1) describe trends in adult overweight and obesity (OW/OB) among rural Afro-Ecuadorians over time and across a gradient of community remoteness from the nearest commercial centre; (2) examine the relationship between male and female adult OW/OB and factors associated with market integration such as changing livelihoods and (3) examine the co-occurrence of adult OW/OB and under-five stunting and anaemia. DESIGN: Adult anthropometry was collected through serial case-control studies repeated over a decade across twenty-eight communities. At the same time, anthropometry and Hb were measured for all children under 5 years of age in every community. SETTING: Northern coastal Ecuador. PARTICIPANTS: Adults (n 1665) and children under 5 years of age (n 2618). RESULTS: From 2003 and 2013, OW/OB increased from 25·1 % to 44·8 % among men and 59·9 % to 70·2 % among women. The inverse relationship between remoteness and OW/OB in men was attenuated when adjusting for urban employment, suggesting that livelihoods mediated the remoteness-OW/OB relationship. No such relationship was observed among women. Communities with a higher prevalence of male OW/OB also had a greater prevalence of stunting, but not anaemia, in children under 5 years of age. CONCLUSIONS: The association between male OW/OB and child stunting at the community level, but not the household level, suggests that changing food environments, rather than household- or individual-level factors, drove these trends. A closer examination of changing socio-economic structures and food environments in communities undergoing rapid development could help mitigate future public health burdens.

High Prevalence of Low Birth Weight Babies Born to Pregnant Women Referred to a District Hospital in Rural Zambia.

OBJECTIVES: Low birthweight (LBW) is a significant public health problem in sub-Saharan Africa and LBW in rural Zambia is high. Our study explored the prevalence of LBW for newborns whose mothers were referred from a rural health center to a district referral hospital in Lundazi, Zambia. METHODS: A five-month retrospective record review of Ministry of Health data was performed to examine birthweight characteristics of a convenience sample of newborns from ten facilities referring to one district hospital (n = 234). RESULTS: Among all cases, 21% (n = 49) of newborns were LBW. For LBW newborns, 73% (n = 36) were preterm with mothers having a pregnancy duration of less than 37 weeks. Newborns whose mothers experienced twin pregnancies (p = .021) and prolonged labor (p = .033) were more often LBW. However, regression models demonstrated no difference among newborns with and without LBW for prolonged labor (p = .344) and twin pregnancies (p = .324) when controlling for variables that could interact with the maternal-newborn delivery outcomes. CONCLUSIONS: for Practice Healthcare providers and policy makers need to address the short and long-term effects of LBW throughout the lifecycle in rural Zambia. More maternal-newborn health research is needed to understand the underlying socioeconomic, social, and cultural determinants influencing LBW in rural Zambia.

Maternal knowledge of essential newborn care in rural Zambia.

Maternity waiting homes (MWHs) may offer an intervention to improve newborn outcomes in rural Zambia. This study compared maternal knowledge of newborn care for women referred from facilities with and without MWHs. Topics assessed included: (1) umbilical cord care; (2) thermal and skin care; (3) nutrition, and; (4) prevention of diarrhea, and; (5) newborn danger signs prompting care-seeking. A two-group comparison design with a convenience sample was employed using a face-to-face interviews at one district hospital. Descriptive, inferential, and multivariate analyses were employed to compare knowledge. Overall, mothers demonstrated newborn care knowledge in accordance with World Health Organization (WHO) guidelines for newborn health and there were no significant differences in maternal knowledge of newborn care practices among MWH and non-MWH users. Younger mothers more often did not know about umbilical cord care, newborn skin care, and newborn danger signs. MWH users went more often for antenatal care than non-MWH users. In both groups, we found as the number of ANC visits increases, odds of answering "Don't know" decreases. This study is the first to assess maternal newborn care knowledge and MWH use in rural Zambia. Both MWH users and non-users in the rural district were knowledgeable about essential newborn care.

Perceptions and beliefs about anaemia: A qualitative study in three agroecological regions of Ghana.

Little evidence exists concerning perceptions of anaemia in Ghanaian communities, which limits understanding of how to potentially improve health in settings with high anaemia prevalence. We explored lay perceptions of anaemia to understand local knowledge and beliefs and to provide an opportunity to inform interventions. A cross-sectional, qualitative study was conducted in selected communities in three regions of Ghana with high prevalence of anaemia. Forty-eight focus group discussions (FGDs) were conducted with adolescent girls, adult women of reproductive age and adult men (16 FGDs for each demographic group). Participants across the three demographic groups generally described anaemia as inadequate blood in the body and reported that poor diet, heat, alcohol intake, physiological factors and diseases such as malaria were the main causes of anaemia. Consequences of anaemia mentioned in the FGDs included dizziness, weight loss, loss of appetite and weakness. Prevention of anaemia was perceived to result from improved diet, avoidance of exposure to heat and improved sanitation to avoid diseases. The findings suggest that despite areas of convergence between lay and biomedical knowledge on the causes, consequences and prevention of anaemia, the burden of anaemia remains high in the study regions. This highlights a disconnect between local knowledge of anaemia and the health and nutrition behaviours needed to reduce its incidence. Effective interventions can be developed with and for communities that build upon existing knowledge while filling remaining knowledge gaps or misconceptions.

Associations between livestock ownership and lower odds of anaemia among children 6-59 months old are not mediated by animal-source food consumption in Ghana.

Livestock ownership may mitigate anaemia among young children by providing access to animal-source foods (ASFs) yet exacerbate anaemia by exposing children to animal-source pathogens. This study aimed to assess the association between household livestock ownership and child anaemia and examine whether this relationship is mediated by child ASF consumption or by child morbidity and inflammation. We conducted a cross-sectional study of 470 children aged 6-59 months in Greater Accra, Ghana. Child blood samples were analysed for haemoglobin concentration, iron status biomarkers and inflammatory biomarkers. Caregivers were asked about the child's frequency of ASF consumption in the past 3 months. Livestock ownership was categorized into five typologies to distinguish households by the number and combinations of species owned. In adjusted logistic regression, children from households in Type 5, owning cattle, small livestock (goats, sheep or pigs) and poultry, had lower odds of anaemia compared with those in Type 1, owning no livestock (OR [95% CI]: 0.32 [0.14, 0.71]). Although children from households that owned poultry were more likely to consume chicken meat, and children from households with cattle were more likely to drink cow's milk, consumption of these ASFs did not mediate the observed association between livestock ownership and child anaemia. There were no associations between livestock ownership and children's symptoms of illness or inflammation. Further research is needed to understand how ownership of certain livestock species, or a greater diversity of livestock species, may be associated with the risk of child anaemia, including the role of dietary and income-based pathways.

Factors Associated with Anemia Status Among Children Aged 6-59 months in Ghana, 2003-2014.

BACKGROUND: In 2008, 78% of Ghanaian children under 5 years old were anemic versus 48% of children globally. In this study, we identified proximal and distal determinants of severe-moderate anemia and mild anemia related to socioeconomic status, nutrition, and health access. METHODS: Using data from the 2003, 2008, and 2014 Ghana Demographic and Health Surveys (GDHS), the odds of severe-moderate anemia and mild anemia compared to no anemia, in relation to various hypothesized risk factors, were assessed using a multivariable, multinomial logistic regression, which accounted for survey design. RESULTS: From among 7739 households sampled, severe-moderate anemia was found in approximately 52%, 56%, and 40% of children during 2003, 2008, and 2014, respectively. The proportion of children diagnosed as not anemic was 26% in 2003, 22% in 2008, and 33% in 2014. There are large disparities in anemia prevalence among regions and between urban and rural areas. In 2014, children who were younger (aged 6-24 months), had a recent fever, were from poorer families, and whose mothers were less educated had greater odds of being severely-moderately anemic. These results remained significant when controlling for other risk factors. Predictors of anemia in Ghana remained relatively consistent among the three time periods when the GDHS was administered. CONCLUSIONS: The prevalence of anemia in Ghana among children aged 6-59 months has remained unacceptably high. To reduce anemia in these children, the Ghanaian government should concentrate on educating women through both the traditional school system and antenatal care visits.

Child-level double burden of malnutrition in the MENA and LAC regions: Prevalence and social determinants.

Although the prevalence of obesity has rapidly increased in the low- and middle-income countries of the Middle East and North Africa (MENA) and Latin America and the Caribbean (LAC) regions, child undernutrition remains a public-health challenge. We examined region-specific sociodemographic determinants of this double burden of malnutrition, specifically, the co-occurrence of child stunting and overweight, using Demographic and Health Survey and Multiple Indicator Cluster Survey data (2003-2016) from 11 countries in the MENA (n = 118,585) and 13 countries in the LAC (n = 77,824) regions. We used multiple logistic regressions to model region-specific associations of maternal education and household wealth with child nutritional outcomes (6-59 months). The prevalence of stunting, overweight, and their co-occurrence was 24%, 10%, and 4.3% in children in the MENA region, respectively, and 19%, 5%, and 0.5% in children in the LAC region, respectively. In both regions, higher maternal education and household wealth were significantly associated with lower odds of stunting and higher odds of overweight. As compared with the poorest wealth quintiles, decreased odds of co-occurring stunting and overweight were observed among children from the second, third, and fourth wealth quintiles in the LAC region. In the MENA region, this association was only statistically significant for the second wealth quintile. In both regions, double burden was not statistically significantly associated with maternal education. The social patterning of co-occurring stunting and overweight in children varied across the two regions, indicating potential differences in the underlying aetiology of the double burden across regions and stages of the nutrition transition.

Impact of pre-analytical variables on deep learning accuracy in histopathology.

AIMS: Machine learning (ML) binary classification in diagnostic histopathology is an area of intense investigation. Several assumptions, including training image quality/format and the number of training images required, appear to be similar in many studies irrespective of the paucity of supporting evidence. We empirically compared training image file type, training set size, and two common convolutional neural networks (CNNs) using transfer learning (ResNet50 and SqueezeNet). METHODS AND RESULTS: Thirty haematoxylin and eosin (H&E)-stained slides with carcinoma or normal tissue from three tissue types (breast, colon, and prostate) were photographed, generating 3000 partially overlapping images (1000 per tissue type). These lossless Portable Networks Graphics (PNGs) images were converted to lossy Joint Photographic Experts Group (JPG) images. Tissue type-specific binary classification ML models were developed by the use of all PNG or JPG images, and repeated with a subset of 500, 200, 100, 50, 30 and 10 images. Eleven models were generated for each tissue type, at each quantity of training images, for each file type, and for each CNN, resulting in 924 models. Internal accuracies and generalisation accuracies were compared. There was no meaningful significant difference in accuracies between PNG and JPG models. Models trained with more images did not invariably perform better. ResNet50 typically outperformed SqueezeNet. Models were generalisable within a tissue type but not across tissue types. CONCLUSIONS: Lossy JPG images were not inferior to lossless PNG images in our models. Large numbers of unique H&E-stained slides were not required for training optimal ML models. This reinforces the need for an evidence-based approach to best practices for histopathological ML.

Child stunting is associated with child, maternal, and environmental factors in Vietnam.

Child stunting in Vietnam has reduced substantially since the turn of the century but has remained relatively high for several years. We analysed data on children 6-59 months (n = 85,932) from the Vietnam Nutritional Surveillance System, a nationally representative cross-sectional survey. Multivariable Poisson regression models were used to estimate relative risk (RR) of stunting, stratified by child age and ecological region. Covariates at the child, maternal, household, and environmental levels were included based on available data and the World Health Organization conceptual framework on child stunting. Among children 6-23 months, the strongest associations with child stunting were child age in years (RR: 2.49; 95% CI [2.26, 2.73]), maternal height < 145 cm compared with ≥150 cm (RR: 2.04; 95% CI [1.85, 2.26]), living in the Northeast compared with the Southeast (RR: 2.01; 95% CI [1.69, 2.39]), no maternal education compared with a graduate education (RR: 1.77; 95% CI, [1.44, 2.16]), and birthweight < 2,500 g (RR: 1.75; 95% CI [1.55, 1.98]). For children 24-59 months, the strongest associations with child stunting were no maternal education compared with a graduate education (RR: 2.07; 95% CI [1.79, 2.40]), living in the Northeast compared with the Southeast (RR: 1.94; 95% CI [1.74, 2.16]), and maternal height < 145 cm compared with ≥150 cm (RR: 1.81; 95% CI [1.69, 1.94]). Targeted approaches that address the strongest stunting determinants among vulnerable populations are needed and discussed. Multifaceted approaches outside the health sector are also needed to reduce inequalities in socioeconomic status.

Peri-Urban, but Not Urban, Residence in Bolivia Is Associated with Higher Odds of Co-Occurrence of Overweight and Anemia among Young Children, and of Households with an Overweight Woman and Stunted Child.

Background: Urban populations have grown globally alongside emerging simultaneous burdens of undernutrition and obesity. Yet, how heterogeneous urban environments are associated with this nutritional double burden is poorly understood. Objective: We aimed to determine: 1) the prevalence of the nutritional double burden and its components in urban, peri-urban, and rural areas of Bolivia; and 2) the association of residence in these areas with the nutritional double burden and its components. Design: We surveyed 3946 randomly selected households from 2 metropolitan regions of Bolivia. Census data and remotely sensed imagery were used to define urban, peri-urban, and rural districts along a transect in each region. We defined 5 nutritional double burdens: concurrent overweight and anemia among women of reproductive age (15-49 y), and children (6-59 mo), respectively; concurrent overweight and stunting among children; and households with an overweight woman and, respectively, an anemic or stunted child. Capillary hemoglobin concentrations were measured to assess anemia (women: hemoglobin <120 g/L; children: hemoglobin <110 g/L), and overweight and stunting were calculated from height, weight, and age data. Results: In multiple logistic regression models, peri-urban, but not urban residence, was associated with higher odds of concurrent overweight and anemia among children (OR: 1.8; 95% CI; 1.0, 3.2) and of households with an overweight woman and stunted child (1.8; 1.2, 2.7). Examining the components of the double burden, peri-urban women and children, respectively, had higher odds of overweight than rural residents [women (1.5; 1.2, 1.8); children (1.5; 1.0, 2.4)], and children from peri-urban regions had higher odds of stunting (1.5; 1.1, 2.2). Conclusions: Peri-urban, but not urban, residence in Bolivia is associated with a higher risk of the nutritional double burden than rural areas. Understanding how heterogeneous urban environments influence nutrition outcomes could inform integrated policies that simultaneously address both undernutrition and obesity.