A Decision Framework for Selecting Critically Important Nutrients from Aquatic Foods.

PURPOSE OF REVIEW: Aquatic foods are increasingly being recognized as a diverse, bioavailable source of nutrients, highlighting the importance of fisheries and aquaculture for human nutrition. However, studies focusing on the nutrient supply of aquatic foods often differ in the nutrients they examine, potentially biasing their contribution to nutrition security and leading to ineffective policies or management decisions. RECENT FINDINGS: We create a decision framework to effectively select nutrients in aquatic food research based on three key domains: human physiological importance, nutritional needs of the target population (demand), and nutrient availability in aquatic foods compared to other accessible dietary sources (supply). We highlight 41 nutrients that are physiologically important, exemplify the importance of aquatic foods relative to other food groups in the food system in terms of concentration per 100 g and apparent consumption, and provide future research pathways that we consider of high importance for aquatic food nutrition. Overall, our study provides a framework to select focal nutrients in aquatic food research and ensures a methodical approach to quantifying the importance of aquatic foods for nutrition security and public health.

Study Protocol: Interactive Dynamics of Coral Reef Fisheries and the Nutrition Transition in Kiribati.

The Kiribati 2019 Integrated Household Income and Expenditure Survey (Integrated HIES) embeds novel ecological and human health research into an ongoing social and economic survey infrastructure implemented by the Pacific Community in partnership with national governments. This study seeks to describe the health status of a large, nationally representative sample of a geographically and socially diverse I-Kiribati population through multiple clinical measurements and detailed socio-economic surveys, while also conducting supporting food systems research on ecological, social, and institutional drivers of change. The specific hypotheses within this research relate to access to seafood and the potential nutritional and health benefits of these foods. We conducted this research in 21 of the 23 inhabited islands of Kiribati, excluding the two inhabited islands-Kanton Islands in the Phoenix Islands group with a population of 41 persons (2020 census) and Banaba Island in the Gilbert Islands group with a population of 333 persons (2020 census)-and focusing exclusively on the remaining islands in the Gilbert and Line Islands groups. Within this sample, we focused our intensive human health and ecological research in 10 of the 21 selected islands to examine the relationship between ecological conditions, resource governance, food system dynamics, and dietary patterns. Ultimately, this research has created a baseline for future Integrated HIES assessments to simultaneously monitor change in ecological, social, economic, and human health conditions and how they co-vary over time.

Estimating national and subnational nutrient intake distributions of global diets.

BACKGROUND: Access to high-quality dietary intake data is central to many nutrition, epidemiology, economic, environmental, and policy applications. When data on individual nutrient intakes are available, they have not been consistently disaggregated by sex and age groups, and their parameters and full distributions are often not publicly available. OBJECTIVES: We sought to derive usual intake distributions for as many nutrients and population subgroups as possible, use these distributions to estimate nutrient intake inadequacy, compare these distributions and evaluate the implications of their shapes on the estimation of inadequacy, and make these distributions publicly available. METHODS: We compiled dietary data sets from 31 geographically diverse countries, modeled usual intake distributions for 32 micronutrients and 21 macronutrients, and disaggregated these distributions by sex and age groups. We compared the variability and skewness of the distributions and evaluated their similarity across countries, sex, and age groups. We estimated intake inadequacy for 16 nutrients based on a harmonized set of nutrient requirements and bioavailability estimates. Last, we created an R package-nutriR-to make these distributions freely available for users to apply in their own analyses. RESULTS: Usual intake distributions were rarely symmetric and differed widely in variability and skewness across nutrients and countries. Vitamin intake distributions were more variable and skewed and exhibited less similarity among countries than other nutrients. Inadequate intakes were high and geographically concentrated, as well as generally higher for females than males. We found that the shape of usual intake distributions strongly affects estimates of the prevalence of inadequate intakes. CONCLUSIONS: The shape of nutrient intake distributions differs based on nutrient and subgroup and strongly influences estimates of nutrient intake inadequacy. This research represents an important contribution to the availability and application of dietary intake data for diverse subpopulations around the world.

Caregivers Systematically Overestimate Their Child's Height-for-Age Relative to Other Children in Rural Ethiopia.

BACKGROUND: Stunting affects one-quarter of children <5 y of age, yet little is known about the accuracy of caregivers' perceptions regarding their child's linear growth. Most existing quantitative research on this topic has been conducted in high-income countries and has examined perceptions of children's weight rather than height. OBJECTIVES: In rural Ethiopia where linear growth faltering is highly prevalent, this study aimed to better understand how caregivers perceive their child's growth. The objectives of this analysis were to 1) assess caregivers' perceptions of their child's height; 2) investigate whether there is a discrepancy between a child's actual height and caregivers' perceptions of their child's height; and 3) examine the factors that influence discrepancies in estimating a child's height (secondary outcomes), including the role of the average height in the community (primary outcome). METHODS: We conducted a cross-sectional analysis using data from 808 woman caregivers of children ages 6-35 mo in the Oromia region of Ethiopia. We assessed caregivers' rankings (from 1 to 10) of their child's height relative to other children their age in their village. We then converted these rankings to z scores based on an age- and region-specific distribution in order to calculate their difference with the child's actual height-for-age z score and to determine the degree of overestimation. Lastly, we used multivariate log Poisson regressions to determine factors associated with overestimating a child's height. RESULTS: Forty-three percent of caregivers scored their child's height as the median; 37% overestimated their child's height relative to other children. Regression results showed caregivers who were poorer, and had children who were female, older, and stunted, were more likely to overestimate. CONCLUSIONS: Our findings suggest that caregivers of young children in Oromia systematically overestimated their children's height, which could adversely affect child health if these misperceptions translate to insufficient care-seeking behavior or feeding choices for children.

Anemia Etiology in Ethiopia: Assessment of Nutritional, Infectious Disease, and Other Risk Factors in a Population-Based Cross-Sectional Survey of Women, Men, and Children.

BACKGROUND: While the causes of anemia at an individual level (such as certain nutritional deficiencies, infections, and genetic disorders) are well defined, there is limited understanding of the relative burden of anemia attributable to each cause within populations. OBJECTIVES: We sought to estimate the proportion of anemia cases attributable to nutrition, infectious diseases, and other risk factors among women, men, and children in 6 regions of Ethiopia. METHODS: A population-based cross-sectional study was conducted. Data were obtained from 2520 women of reproductive age (15-49 y), 1044 adult men (15-49 y), and 1528 children (6-59 mo). Participants provided venous blood samples for assessment of their hemoglobin concentration; ferritin, folate, vitamin B12, and C-reactive protein levels; and the presence of malaria infection. Stool samples were collected to ascertain the helminth infection status. Sociodemographic questionnaires and a 24-h diet recall were administered. Population-weighted prevalences of anemia and risk factors were calculated. Multivariable-adjusted associations of risk factors with anemia and partial population attributable risk percentages were estimated using generalized linear models. RESULTS: The anemia prevalences were 17% (95% CI: 13%-21%) among women, 8% (95% CI: 6%-12%) among men, and 22% (95% CI: 19%-26%) among children. Low serum ferritin contributed to 11% (95% CI: -1% to 23%) of anemia cases among women, 9% (95% CI: 0%-17%) among men, and 21% (95% CI: 4%-34%) among children. The proportions of anemia attributable to low serum folate were estimated at 25% (95% CI: 5%-41%) among women and 29% (95% CI: 11%-43%) among men. Dietary iron intake was adequate for nearly all participants, while inadequacy was common for folate and vitamin B12. Inflammation and malaria were responsible for less than 1 in 10 anemia cases. CONCLUSIONS: Folate deficiency, iron deficiency, and inflammation appear to be important contributors to anemia in Ethiopia. Folic acid food fortification, targeted iron interventions, and strategies to reduce infections may be considered as potential public health interventions to reduce anemia in Ethiopia.

The Global Diet Quality Score is Associated with Higher Nutrient Adequacy, Midupper Arm Circumference, Venous Hemoglobin, and Serum Folate Among Urban and Rural Ethiopian Adults.

BACKGROUND: Nutritionally inadequate diets in Ethiopia contribute to a persisting national burden of adult undernutrition, while the prevalence of noncommunicable diseases (NCDs) is rising. OBJECTIVES: To evaluate performance of a novel Global Diet Quality Score (GDQS) in capturing diet quality outcomes among Ethiopian adults. METHODS: We scored the GDQS and a suite of comparison metrics in secondary analyses of FFQ and 24-hour recall (24HR) data from a population-based cross-sectional survey of nonpregnant, nonlactating women of reproductive age and men (15-49 years) in Addis Ababa and 5 predominately rural regions. We evaluated Spearman correlations between metrics and energy-adjusted nutrient adequacy, and associations between metrics and anthropometric/biomarker outcomes in covariate-adjusted regression models. RESULTS: In the FFQ analysis, correlations between the GDQS and an energy-adjusted aggregate measure of dietary protein, fiber, calcium, iron, zinc, vitamin A, folate, and vitamin B12 adequacy were 0.32 in men and 0.26 in women. GDQS scores were inversely associated with folate deficiency in men and women (GDQS Quintile 5 compared with Quintile 1 OR in women, 0.50; 95% CI: 0.31-0.79); inversely associated with underweight (OR, 0.63; 95% CI: 0.44-0.90), low midupper arm circumference (OR, 0.61; 95% CI: 0.45-0.84), and anemia (OR, 0.59; 95% CI: 0.38-0.91) in women; and positively associated with hypertension in men (OR: 1.77, 95% CI: 1.12-2.80). For comparison, the Minimum Dietary Diversity-Women (MDD-W) was associated more positively (P < 0.05) with overall nutrient adequacy in men and women, but also associated with low ferritin in men, overweight/obesity in women, and hypertension in men and women. In the 24HR analysis (restricted to women), the MDD-W was associated more positively (P < 0.05) with nutrient adequacy than the GDQS, but also associated with low ferritin, while the GDQS was associated inversely with anemia. CONCLUSIONS: The GDQS performed capably in capturing nutrient adequacy-related outcomes in Ethiopian adults. Prospective studies are warranted to assess the GDQS' performance in capturing NCD outcomes in sub-Saharan Africa.

Aquatic foods to nourish nations.

Despite contributing to healthy diets for billions of people, aquatic foods are often undervalued as a nutritional solution because their diversity is often reduced to the protein and energy value of a single food type ('seafood' or 'fish')1-4. Here we create a cohesive model that unites terrestrial foods with nearly 3,000 taxa of aquatic foods to understand the future impact of aquatic foods on human nutrition. We project two plausible futures to 2030: a baseline scenario with moderate growth in aquatic animal-source food (AASF) production, and a high-production scenario with a 15-million-tonne increased supply of AASFs over the business-as-usual scenario in 2030, driven largely by investment and innovation in aquaculture production. By comparing changes in AASF consumption between the scenarios, we elucidate geographic and demographic vulnerabilities and estimate health impacts from diet-related causes. Globally, we find that a high-production scenario will decrease AASF prices by 26% and increase their consumption, thereby reducing the consumption of red and processed meats that can lead to diet-related non-communicable diseases5,6 while also preventing approximately 166 million cases of inadequate micronutrient intake. This finding provides a broad evidentiary basis for policy makers and development stakeholders to capitalize on the potential of aquatic foods to reduce food and nutrition insecurity and tackle malnutrition in all its forms.

The role of chicken management practices in children's exposure to environmental contamination: a mixed-methods analysis.

BACKGROUND: Household chicken production presents an opportunity to promote child nutrition, but the benefits might be offset by increased environmental contamination. Using household surveys, direct observations, and in-depth interviews with woman caregivers, we sought to describe the relationship between chicken management practices and household exposure to environmental contamination, and assess barriers to adopting improved husbandry practices. METHODS: First, we analyzed baseline data from 973 households raising chickens in the two interventions arms from the Agriculture-to-Nutrition (ATONU) study in Ethiopia to assess the relationship between animal management practices and environmental exposures. Second, we conducted six-hour direct observations of children's environmental exposures in 18 households. Among these households, we analyzed in-depth interviews with child caregivers. RESULTS: Quantitative analyses showed that households raised approximately 11 chickens, had animal feces visible on the property 67% of the time, and children's hands were visibly dirty 38% of the time. Households with more chickens had lower exposure to animal feces. Having a chicken coop increased the risk of observing animal feces on the property by 30%, but among those with a coop, having an enclosed coop reduced that risk by 83%. Coops that were enclosed, had fencing, and were located further from homes were associated with a reduced risk of observing animal feces and an increased likelihood of children having clean hands. Direct observations showed that chicken coops were often poorly designed or not used. On average, 3 to 5 chickens were inside homes at a time, and livestock and domestic animals were frequently inside of houses and interacting with young children. In-depth interviews revealed that protection of animals, maintenance of household cleanliness and health, type of chicken (local versus improved) and resource constraints influenced management decisions. CONCLUSIONS: Improvements in chicken management practices could mitigate the exposure of household members to environmental contamination. Our findings highlight the need for training and resources to promote safe animal husbandry practices and optimal child health in nutrition-sensitive livestock projects. TRIAL REGISTRATION: Clinical trials number: NCT03152227 ; Retrospectively registered at ClinicalTrials.gov on May 12, 2012.

The Global Cohort of Doctoral Students: Building Shared Global Health Research Capacity in High-Income and Low- and Middle-Income Countries.

Doctoral students in high- and low-income countries pursuing careers in global health face gaps in their training that could be readily filled through structured peer-learning activities with students based at partnering institutions in complimentary settings. We share lessons learned from the Global Cohort of Doctoral Students, a community of doctoral students based at the Harvard T. H. Chan School of Public Health, Haramaya University, University of Gondar, University of Botswana, and University of Rwanda College of Medicine and Health Sciences. Students in the Global Cohort program engage in collaborative research, forums for constructive feedback, and professional development activities. We describe the motivation for the program, core activities, and early successes.

Men's nutrition knowledge is important for women's and children's nutrition in Ethiopia.

In an effort to address undernutrition among women and children in rural areas of low-income countries, nutrition-sensitive agriculture (NSA) and behaviour change communication (BCC) projects heavily focus on women as an entry point to effect nutritional outcomes. There is limited evidence on the role of men's contribution in improving household diets. In this Agriculture to Nutrition trial (Clinicaltrials.gov identifier: NCT03152227), we explored associations between men's and women's nutritional knowledge on households', children's and women's dietary diversity. At the midline evaluation conducted in July 2017, FAO's nutrition knowledge questionnaire was administered to male and female partners in 1396 households. There was a high degree of agreement (88%) on knowledge about exclusive breastfeeding between parents; however, only 56-66% of the households had agreement when comparing knowledge of dietary sources of vitamin A or iron. Factor analysis of knowledge dimensions resulted in identifying two domains, namely, 'dietary' and 'vitamin' knowledge. Dietary knowledge had a larger effect on women's and children's dietary diversities than vitamin knowledge. Men's dietary knowledge had strong positive associations with households' dietary diversity scores (0.24, P value = 0.001), children's dietary diversity (0.19, P value = 0.008) and women's dietary diversity (0.18, P value < 0.001). Distance to markets and men's education levels modified the effects of nutrition knowledge on dietary diversity. While previous NSA and BCC interventions predominantly focused on uptake among women, there is a large gap and strong potential for men's engagement in improving household nutrition. Interventions that expand the role of men in NSA may synergistically improve household nutrition outcomes.

A Chicken Production Intervention and Additional Nutrition Behavior Change Component Increased Child Growth in Ethiopia: A Cluster-Randomized Trial.

BACKGROUND: Chicken production in the context of nutrition-sensitive agriculture may benefit child nutrition in low-income settings. OBJECTIVES: This study evaluated effects of 1) a chicken production intervention [African Chicken Genetic Gains (ACGG)], and 2) the ACGG intervention with nutrition-sensitive behavior change communication (BCC) [ACGG + Agriculture to Nutrition (ATONU)], on child nutrition and health outcomes and hypothesized intermediaries. METHODS: Forty ACGG villages received 25 genetically improved chickens and basic husbandry guidance; of these, 20 ACGG + ATONU villages in addition received a nutrition-sensitive behavior change and homegardening intervention; 20 control clusters received no intervention. We assessed effects of the interventions on height-for-age z scores (HAZ), weight-for-age z scores (WAZ), and weight-for-height z scores (WHZ) at 9 (midline) and 18 mo (endline) through unadjusted and adjusted ordinary least squares (OLS) regressions. We examined the interventions' effects on hypothesized intermediaries including egg production and consumption, dietary diversity, women's empowerment, income, child morbidities, anemia, and chicken management practices through OLS and log binomial models. RESULTS: Data included 829 children aged 0-36 mo at baseline. ACGG + ATONU children had higher midline HAZ [mean difference (MD): 0.28; 95% CI: 0.02, 0.54] than controls. The ACGG group had higher HAZ (MD: 0.28; 95% CI: 0.05, 0.50) and higher WAZ (MD: 0.18; 95% CI: 0.01, 0.36) at endline than controls; after adjusting for potential baseline imbalance, effects were similar but not statistically significant. At endline, differences in ACGG + ATONU children's HAZ and WAZ compared with controls were similar in magnitude to those of ACGG, but not statistically significant. There were no differences in anthropometry between the intervention groups. ACGG + ATONU children had higher dietary diversity and egg consumption than ACGG children at endline. Both interventions showed improvements in chicken management practices. The interventions did not increase anemia, diarrhea, fever, or vomiting, and the ACGG + ATONU group at midline showed reduced risk of fever. CONCLUSIONS: A chicken production intervention with or without nutrition-sensitive BCC may have benefited child nutrition and did not increase morbidity.This trial was registered at clinicaltrials.gov as NCT03152227.

Aflatoxin exposure in utero and birth and growth outcomes in Tanzania.

Some evidence suggests that aflatoxin may contribute to the high prevalence of stunting observed in low-income countries. Whereas several studies have been conducted in West Africa, fewer exist in East Africa and even fewer in nonagricultural contexts. We analyzed serum samples from 400 iron-replete, nonanemic pregnant women from a cohort in Dar es Salaam, Tanzania to determine the extent and magnitude of exposure to aflatoxin and to study the relationship between levels of aflatoxin exposure in utero and infant birth and growth outcomes. Ninety-nine percent of women had detectable concentrations of aflatoxin B1-lysine (AFB1-lysine), with a median level of 1.4-pg/mg albumin, indicating a much lower level compared to studies of rural populations in sub-Saharan Africa. Our results do not show a statistically significant relationship between AFB1-lysine levels and birth weight, small for gestational age, or prematurity. We observe a small statistically significant reduction in gestational age at delivery (0.47 weeks; 95% CI: -0.86, -0.07) as the natural log of AFB1-lysine levels increases by 1 unit of pg/mg of albumin, after controlling for potential confounders. Among a nonrandom set of infants who had measurements for placental weight, haemoglobin at delivery, and follow-up z-score measurements, we find no association between aflatoxin plasma concentrations and these variables. These findings suggest a high prevalence of chronic low-level exposure to aflatoxin, though its effect on birth outcomes in this population remains unclear. Our research adds to a growing body of literature finding mixed associations between aflatoxins on pregnancy outcomes and child growth.

Anemia prevalence and etiology among women, men, and children in Ethiopia: a study protocol for a national population-based survey.

BACKGROUND: Anemia remains a public health challenge in Ethiopia, affecting an estimated 56% of children under age 5 years, 23% of women of reproductive age and 18% of adult men. However, anemia etiology and the relative contribution of underlying risk factors for anemia remains unclear and has hindered implementation of anemia control programs. METHODS/DESIGN: Anemia Etiology in Ethiopia (AnemEE) is a population-based cross-sectional survey of six regions of Ethiopia that includes children, women of reproductive age, and men from regionally representative households. The survey will include detailed assessment of anemia, iron, inflammatory and nutritional biomarkers, diet, comorbidities, and other factors. The objectives of AnemEE are 1) to generate evidence for decision-making on the etiology of anemia in Ethiopia among men, women and children and 2) to simulate the potential effect of iron fortification and other interventions on the prevalence of anemia and risk of iron overload. DISCUSSION: AnemEE will provide the most comprehensive evaluation of anemia etiology in Ethiopia to date due to its detailed assessment of diet, biomarkers, infections and other risk factors in a population-based sample. By generating evidence and simulating potential interventions, AnemEE will inform the development of high-impact anemia control programs and policies. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04002466 . Registered on 28 June 2019. Retrospectively registered.

Market food diversity mitigates the effect of environment on women's dietary diversity in the Agriculture to Nutrition (ATONU) study, Ethiopia.

OBJECTIVE: In Ethiopia, women's dietary diversity is low, primarily due to poor food availability and access, both at home and market level. The present study aimed to describe market access using a new definition called market food diversity (MFD) and estimate the impact of MFD, crop and livestock diversity on dietary diversity among women enrolled in the Agriculture to Nutrition (ATONU) trial. DESIGN: Baseline cross-sectional data collected from November 2016 to January 2017 were used for the analysis. Availability of foods in markets was assessed at the village level and categorized into nine food groups similar to the dietary diversity index for women. Bivariate and multivariate mixed-effects regression analyses were conducted, adjusted for clustering at the village level. SETTING: Chicken-producing farmers in rural Ethiopia.ParticipantsWomen (n 2117) aged 15-49 years. RESULTS: Overall, less than 6 % of women met the minimum dietary diversity (≥5 food groups) and the most commonly consumed food groups were staples and legumes. Median MFD was 4 food groups (interquartile range: 2-8). Multivariate models indicated that women's dietary diversity differed by livestock diversity, food crop diversity and agroecology, with significant interaction effects between agroecology and MFD. CONCLUSIONS: Women's dietary diversity is poor in Ethiopia. Local markets are variable in food availability across seasons and agroecological zones. The MFD indicator captures this variability, and women who have access to higher MFD in the highland agroecological zone have better dietary diversity. Thus, MFD has the potential to mitigate the effects of environment on women's dietary diversity.

Harnessing University Strengths in Multisectoral Collaborations for Planetary Health.

Although significant achievements in human health have been made globally, progress has been made possible, in part, through unconstrained use of natural resources. As the health of our planet worsens, human health is also endangered. Scholars and policymakers from diverse disciplines highlighted complex, multisectoral approaches for addressing poor dietary intake, over- and undernutrition, and chronic diseases in sub-Saharan Africa at the Agriculture, Nutrition, Health, and the Environment in Africa Conference held at Harvard University on 6-7 November 2017. A planetary health approach to addressing these challenges offers a unique opportunity to advance solutions for environmental and social factors that influence agriculture, nutrition, and overall health in the larger context of rapid population growth and transitions in food systems and livelihoods. This paper outlines 3 key avenues for universities to promote science at the intersection of public health and the environment in sub-Saharan Africa.

The Role of Polyphenols in Human Health and Food Systems: A Mini-Review.

This narrative mini- review summarizes current knowledge of the role of polyphenols in health outcomes-and non-communicable diseases specifically-and discusses the implications of this evidence for public health, and for future directions for public health practice, policy, and research. The publications cited originate mainly from animal models and feeding experiments, as well as human cohort and case-control studies. Hypothesized protective effects of polyphenols in acute and chronic diseases, including obesity, neurodegenerative diseases, type 2 diabetes, and cardiovascular diseases, are evaluated. Potential harmful effects of some polyphenols are also considered, counterbalanced with the limited evidence of harm in the research literature. Recent international governmental regulations are discussed, as the safety and health claims of only a few specific polyphenolic compounds have been officially sanctioned. The implications of food processing on the bioavailability of polyphenols are also assessed, in addition to the health claims and marketing of polyphenols as a functional food. Finally, this mini-review asserts the need for increased regulation and guidelines for polyphenol consumption and supplementation in order to ensure consumers remain safe and informed about polyphenols.