The state of food systems worldwide in the countdown to 2030.

This Analysis presents a recently developed food system indicator framework and holistic monitoring architecture to track food system transformation towards global development, health and sustainability goals. Five themes are considered: (1) diets, nutrition and health; (2) environment, natural resources and production; (3) livelihoods, poverty and equity; (4) governance; and (5) resilience. Each theme is divided into three to five indicator domains, and indicators were selected to reflect each domain through a consultative process. In total, 50 indicators were selected, with at least one indicator available for every domain. Harmonized data of these 50 indicators provide a baseline assessment of the world's food systems. We show that every country can claim positive outcomes in some parts of food systems, but none are among the highest ranked across all domains. Furthermore, some indicators are independent of national income, and each highlights a specific aspiration for healthy, sustainable and just food systems. The Food Systems Countdown Initiative will track food systems annually to 2030, amending the framework as new indicators or better data emerge.

What Do United States Adolescents Eat? Food Group Consumption Patterns and Dietary Diversity from a Decade of Nationally Representative Data.

Background: Although the importance of adolescent nutrition has gained attention in the global nutrition community, there is a gap in research focused on adolescent dietary diversity and food group consumption. Objectives: This study aimed to characterize population-level food group consumption patterns and quantify the extent of dietary diversity among United States adolescents using a large nationally representative sample of adolescents aged 10-19 y. Methods: We used 24-h dietary recall data from the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2018 to construct the 10 food groups comprising the minimum dietary diversity for women (MDD-W) indicator and estimated the prevalence of intake of each food group. A composite metric adolescent dietary diversity score (ADDS) was derived for each adolescent where 1 point was awarded per food group. Both population scores and the distribution of individual scores were estimated. Differences in proportions of food groups consumed across sociodemographic categories were tested using the Rao-Scott χ2 test, and pairwise comparisons were expressed as population prevalence differences and prevalence ratios. Results: Food group consumption patterns were very similar across 2 d of dietary recall but varied significantly by sex, race/ethnicity, and income status. The food groups with the highest prevalence of consumption were grains, white, roots, and tubers (∼99%), milk products (∼92%), and meat, poultry, and fish (∼85%), whereas <15% of adolescents consumed key micronutrient-dense foods, such as vitamin A-rich fruits and vegetables and dark green vegetables. The mean ADDS was 4.69, with modest variation across strata. Conclusions: On average, United States youth consumed fewer than 5 food groups on a given day. The lack of dietary variety and relatively low prevalence of consumption of several micronutrient-rich plant-based foods could pose a risk for adolescents' ability to achieve micronutrient adequacy in the United States.

Leveraging the Scaling Up Nutrition Movement to Operationalize Stunting Prevention Activities: Implementation Lessons From Rural Malawi.

BACKGROUND: The rural district of Ntchisi is in the central region of Malawi. Among children aged 6 to 23 months, the stunting prevalence is 40% to 50%. To address this high prevalence, the World Food Programme, with cooperating partners, supported the Government of Malawi to implement an integrated stunting prevention program entitled The Right Foods at the Right Time from 2013 to 2018. OBJECTIVE: To provide implementation lessons learned from systematic documentation of how the Scaling Up Nutrition (SUN) movement, combined with other international and national initiatives and policies, was translated into tailored programming. METHODS: During program conception, early design, and implementation, this descriptive study systematically documented the process of translating SUN principles and government policies into an operational stunting prevention program in rural Malawi. RESULTS: We identified 8 factors that contributed to successful translation of policy into program activities: (1) well-structured National SUN framework, (2) reliable coordination platforms and district ownership, (3) systematic and evidence-informed program design, (4) multiple forms of data used to inform program planning, (5) multisectoral implementation approaches to stunting prevention, (6) innovation in technology to improve overall program efficiency, (7) systematic collaboration among diverse stakeholders, and (8) strong public health nutrition capacity of program team members. CONCLUSIONS: Lessons from this nutrition program in Ntchisi, Malawi, provide one case illustrating how the SUN movement, government policies, and global evidence base can be operationalized into tailored programming for improving nutrition.

Process Evaluation of a Large-Scale Community-Based Nutrition Program in Malawi.

BACKGROUND: Global attention to the study of nutrition program implementation has been inadequate yet is critical for effective delivery and impact at scale. OBJECTIVES: The objective of this mixed-methods process evaluation study was to measure the recruitment, fidelity, and reach of a large-scale, community-based nutrition program in Malawi. METHODS: The nutrition program delivered a small-quantity lipid-based nutrient supplement (SQ-LNS) and social and behavior change communication (SBCC) to improve infant and young child feeding (IYCF) and water, sanitation, and hygiene (WASH) practices in households with children aged 6-23 mo. Program monitoring and evaluation data were used to measure program recruitment, reach, and fidelity. Structured direct observations and knowledge questionnaires with program volunteers measured quality aspects of program fidelity. The number of times activities were done correctly was used to tabulate proportions used to represent program functioning. RESULTS: Half (49.5%) of eligible children redeemed program benefits by 8 mo of age during the first 4 y of program implementation. Implementation of training activities for SBCC cadres exceeded program targets (100.6%), but the completion of certain modules (breastfeeding and complementary feeding) was lower (22.9% and 18.6%, respectively). Knowledge of IYCF, WASH, and SQ-LNS messages by volunteers was >85% for most messages, except ability to list the 6 food groups (35.7%). Structured direct observations of SQ-LNS distributions indicated high fidelity to program design, whereas those of household-level counseling sessions revealed lack of age-appropriate messaging. Program reach showed participation in monthly distribution sessions of 81.0%, group counseling of 93.3%, and individual-level counseling of 36.9%. CONCLUSIONS: This community-based nutrition program was implemented with high fidelity and quality, with specific interventions requiring further attention. The documentation of implementation contributes to our understanding about how program impacts were achieved.

Systematic review of the treatment of moderate acute malnutrition using food products.

There is currently a lack of international guidance on the most appropriate treatment for moderate acute malnutrition (MAM), and discrepancies in national treatment guidelines exist. We aimed to explore whether food interventions are effective for MAM children 6-59 months old and whether they result in better outcomes compared with no treatment or management with nutrition counselling. A systematic literature search was conducted in October 2018, identifying studies that compared treating MAM children with food products versus management with counselling or no intervention. A total of 673 abstracts were screened, 101 full texts were read, and one study was identified that met our inclusion criteria. After broadening the criteria to include micronutrients in the control group and enrolment based on out-dated anthropometric criteria, 11 studies were identified for inclusion. Seven of these found food products to be superior for anthropometric outcomes compared with counselling and/or micronutrient supplementation; two of the studies found no significant benefit of a food product intervention; and two studies were inconclusive. Hence, the majority of studies in this review found that food products resulted in greater anthropometric gains than counselling or micronutrient interventions. This was especially true if the supplementary food provided was of suitable quality and provided for an adequate duration. Improving quality of and adherence to counselling may improve its effectiveness, particularly in food secure contexts. There is currently a paucity of comparable studies on this topic as well as a lack of studies that include important functional outcomes beyond anthropometric proxies.

Four years after implementation of a national micronutrient powder program in Kyrgyzstan, prevalence of iron deficiency and iron deficiency anemia is lower, but prevalence of vitamin A deficiency is higher.

BACKGROUND/OBJECTIVES: In 2009, the Ministry of Health of Kyrgyzstan launched a national Infant and Young Child Nutrition (IYCN) program which included point-of-use fortification of foods with micronutrient powders (MNP) containing iron, vitamin A, and other micronutrients. Caretakers of children aged 6-23 months were given 30 sachets of MNP every 2 months. Micronutrient surveys were conducted in 2009 and 2013. The objective of the study was to compare the prevalence of anemia and deficiencies of iron and vitamin A among children aged 6-29 months prior to the MNP program (2009) with those after full implementation (2013). SUBJECTS/METHODS: Cross-sectional national surveys were conducted in 2009 (n = 666) and 2013 (n = 2150). Capillary blood samples were collected to measure hemoglobin, iron (ferritin and soluble transferrin receptor [sTfR]) and vitamin A (retinol binding protein [RBP]) status, and inflammation status (C-reactive protein [CRP] and α-1-acid glycoprotein [AGP]). Ferritin, sTfR, and RBP were adjusted for inflammation; hemoglobin was adjusted for altitude. RESULTS: The prevalence of anemia was non-significantly lower in 2013 compared to 2009 (32.7% vs. 39.0%, p = 0.076). Prevalence of inflammation-adjusted iron deficiency (54.8% vs. 74.2%, p<0.001) and iron deficiency anemia (IDA, 25.5% vs. 35.1%, p = 0.003) were lower and the prevalence of inflammation-adjusted vitamin A deficiency was higher (4.3% vs. 2.0%, p = 0.013) in 2013 compared to 2009. CONCLUSIONS: Four years after the initiation of a national Infant and Young Child Nutrition program including the introduction of point-of-use fortification with MNP, the prevalence of iron deficiency and IDA is lower, but the prevalence of vitamin A deficiency is higher.

Monitoring and evaluation design of Malawi's Right Foods at the Right Time nutrition program.

Child stunting is a public health problem in Malawi. In 2014, the Government of Malawi launched the Right Foods at the Right Time (RFRT) program in Ntchisi district delivering nutrition social and behavior change communication, a small-quantity lipid-based nutrient supplement to children 6-23 months, and nutrition sensitive activities. Monitoring and evaluation (M&E) systems are key aspects of successful program implementation. We describe these and the methodology for an impact evaluation that was conducted for this program. Two monitoring systems using traditional and electronic platforms were established to register and track program delivery and processes including number of eligible beneficiaries, worker performance, program participation, and to monitor input, output, and outcome indicators. The impact evaluation used comparative cross-sectional and longitudinal designs to assess impact on anthropometric and infant and young child feeding outcomes. Three cross-sectional surveys (base-, mid-, and end-line) and two longitudinal cohorts of children followed in 6-month intervals from 6 to 24 months of age, were conducted in sampled households in the program and a neighboring comparison district. Additional M&E included qualitative studies, a process evaluation, and a cost-effectiveness study. The current paper describes lessons from this program's M&E, and demonstrates how multiple implementation research activities can inform course-correction and program scale-up.

Physical and sociocultural facilitators and barriers to access and utilization of a nutrition program in rural Malawi: a qualitative study.

Childhood stunting holds consequences for child development. A nutrition program delivering small-quantity lipid based nutrient supplements (SQ-LNS) to children 6-23 months and child feeding messages was implemented in Malawi to reduce stunting. This study sought to understand the facilitators and barriers to program participation using in-depth interviews, pile sorts, direct observations, and focus group discussions with caretakers, village leaders and program volunteers. Perceptions of the LNS were positive, and visible changes in child health contributed to program participation. Conflicting priorities that prevented monthly collection of SQ-LNS and limited knowledge of child feeding messages constituted barriers to program participation.

Experiences and lessons learned for delivery of micronutrient powders interventions.

An effective delivery strategy coupled with relevant social and behaviour change communication (SBCC) have been identified as central to the implementation of micronutrient powders (MNP) interventions, but there has been limited documentation of what works. Under the auspices of "The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance," three working groups were formed to summarize experiences and lessons across countries regarding MNP interventions for young children. This paper focuses on programmatic experiences related to MNP delivery (models, platforms, and channels), SBCC, and training. Methods included a review of published and grey literature, interviews with key informants, and deliberations throughout the consultation process. We found that most countries distributed MNP free of charge via the health sector, although distribution through other platforms and using subsidized fee for product or mixed payment models have also been used. Community-based distribution channels have generally shown higher coverage and when part of an infant and young child feeding approach, may provide additional benefit given their complementarity. SBCC for MNP has worked best when focused on meeting the MNP behavioural objectives (appropriate use, intake adherence, and related infant and young child feeding behaviours). Programmers have learned that reincorporating SBCC and training throughout the intervention life cycle has allowed for much needed adaptations. Diverse experiences delivering MNP exist, and although no one-size-fits-all approach emerged, well-established delivery platforms, community involvement, and SBCC-centred designs tended to have more success. Much still needs to be learned on MNP delivery, and we propose a set of implementation research questions that require further investigation.

Patterns and determinants of small-quantity LNS utilization in rural Malawi and Mozambique: considerations for interventions with specialized nutritious foods.

Small-quantity, lipid-based nutrient supplements (SQ-LNS) show promise to improve the quality of maternal and child diets, particularly during the first 1000 days of life. The potential of SQ-LNS to impact positively upon nutritional status relies on numerous factors, including complementary dietary intake, disease prevalence and dynamics of household utilization, including sharing practices. Therefore, this study sought to elucidate the patterns and determinants of SQ-LNS utilization among children 6-23 months and potential sharing practices of other household members prior to intervention development. In Ntchisi, Malawi and Cabo Delgado, Mozambique, both rural, agricultural settings, we conducted two home-feeding trials of 8 and 6 weeks, respectively, nested within a larger multi-phase, emergent formative research design. Multiple methods, including in-depth interviews (n = 38), direct meal observations (n = 80), full-day child observations (n = 38) and spot checks of SQ-LNS supply (n = 23), were conducted with households (n = 35 in Malawi; n = 24 in Mozambique). Overall, the SQ-LNS was utilized contrary to its recommended use, with 50% of households in Malawi reporting running out of stock too early and 87% of households in Mozambique either overusing or underusing the product. Utilization of SQ-LNS was manifested in four patterns of overuse and two of underuse and was determined by factors at multiple levels of influence. Maternal and child health efforts need to consider the reasons behind choices by households to overuse or underuse SQ-LNS and design intervention strategies to increase the likelihood of its appropriate utilization.

Informing a Behavior Change Communication Strategy: Formative Research Findings From the Scaling Up Nutrition Movement in Mozambique.

BACKGROUND: Nutrition interventions targeting the first 1000 days show promise to improve nutritional status, but they require effective implementation. Formative research is thus invaluable for developing such interventions, but there have been few detailed studies that describe this phase of work within the Scaling Up Nutrition (SUN) movement. OBJECTIVE: To inform a stunting prevention intervention in Cabo Delgado, Mozambique, by describing the sociocultural landscape and elucidating characteristics related to young child food, illness, and health. METHODS: This formative research utilized a rapid assessment procedures (RAP) approach with 3 iterative phases that explored local perceptions and behaviors around food and illness among the Macua, Mwani, and Maconde ethnic groups. Ethnographic methods, including in-depth interviews, direct observations, free lists, and pile sorts, were used to collect data from community leaders, caregivers, and children 6 to 23 months. Data were analyzed drawing from grounded theory and cultural domain analysis. RESULTS: Geographic differences drive sociocultural characteristics amid 3 ethnic groups that allow for segmentation of the population into 2 distinct audiences for behavior change communications. These 2 communities have similar classification systems for children's foods but different adult dietary patterns. Small-quantity lipid-based nutrient supplement did not fall into the existing food classification systems of either community, and participants preferred its promotion through community leader channels. Community members in both groups have little recognition of and perceived severity toward nutrition-related illnesses. CONCLUSION: Within Cabo Delgado, the cultural heterogeneity yields substantial differences related to food, illness, and health that are necessary to consider for developing an effective nutrition intervention.

Identifying the Sociocultural Barriers and Facilitating Factors to Nutrition-related Behavior Change: Formative Research for a Stunting Prevention Program in Ntchisi, Malawi.

BACKGROUND: As the Scaling Up Nutrition (SUN) movement gains momentum globally, more attention and resources are being given to integrated nutrition interventions. In 2013, the Government of Malawi, with support from the World Food Programme and partners, initiated such an intervention in Ntchisi District. Aimed to reduce the prevalence of stunting, the intervention has several components, including the provision of a small-quantity, lipid-based nutrient supplement (SQ-LNS) for children aged 6 to 23 months. OBJECTIVE: This paper describes formative research findings derived from a Rapid Assessment Procedures (RAP) approach to inform the integrated nutrition intervention. METHODS: With a three-phase, emergent research design, this study utilized ethnographic methods including in-depth interviews, direct meal observations, and full-day child observations. Free lists and pile sorts were conducted to define food and illness domains through cultural domain analysis. Participants included community leaders, caregivers, health surveillance assistants, and children aged 6 to 23 months. RESULTS: Community members felt that nutrition-related illnesses were less salient and threatening than other illnesses, and food quality was less important than food quantity. Household food allocation occurred in predictable patterns and varied by type of household member and season. Considered an energy-giving food, the SQ-LNS was accepted, but health education and communications tailored to local understanding of nutrition and health are necessary to ensure its appropriate utilization. CONCLUSIONS: Tailoring a communications strategy to Ntchisi, Malawi could only be done through formative research to understand the sociocultural factors influencing nutrition-related behaviors. A RAP approach allowed for a comprehensive understanding of this local environment.

An evaluation of a global vitamin and mineral nutrition surveillance system / Evaluación de un sistema global de vigilancia nutricional sobre vitaminas y minerales

Evaluation at all levels is a fundamental function at World Health Organization (WHO). Evaluation of public health surveillance systems is essential to ensure that problems of public health importance are monitored efficiently and effectively. The WHO's Vitamin and Mineral Nutrition Information System (VMNIS) was evaluated from the perspective of public health surveillance and informatics. Steps included: engaging the stakeholders of the evaluation; describing the surveillance system; focusing the evaluation design; gathering credible evidence regarding system performance; justifying and stating conclusions and recommendations, and sharing lessons learned from the evaluation. Following this assessment, WHO has begun major efforts to upgrade and expand the VMNIS and now the database is more flexible and efficient. The database evaluation summarized in this paper provides a good example of how public health evaluation frameworks can lead to improved surveillance and enhanced information systems, thus making progress toward the ultimate goal of improving public health.

La evaluación en todos los niveles es una función fundamental en la Organización Mundial de la Salud (OMS). La evaluación de los sistemas de vigilancia epidemiológica es esencial para asegurar que los problemas de importancia para la salud pública sean monitorizados de manera eficiente y efectiva. El Sistema de Información Nutricional sobre Vitaminas y Minerales (VMNIS, por sus siglas en inglés) se evaluó desde la perspectiva de sistema de vigilancia e informática en salud pública. Los pasos incluyeron: el involucramiento de las partes interesadas en la evaluación, la descripción del sistema de vigilancia, el enfoque del diseño para la evaluación, la recopilación de pruebas fiables sobre el rendimiento del sistema, la justificación y desarrollo de conclusiones y recomendaciones, y la diseminación de las lecciones aprendidas de la evaluación. Después de este proceso, la OMS inició importantes esfuerzos para mejorar y ampliar el Sistema de Información Nutricional sobre Vitaminas y Minerales para lograr una base de datos más flexible y eficiente. Este artículo resume la evaluación de esta base de datos para documentar un buen ejemplo de cómo los marcos de evaluación en salud pública pueden llevar a mejorar la información en los sistemas de vigilancia contribuyendo de esta manera al objetivo final de mejorar la salud pública.

Effect of lower sodium intake on health: systematic review and meta-analyses.

OBJECTIVE: To assess the effect of decreased sodium intake on blood pressure, related cardiovascular diseases, and potential adverse effects such as changes in blood lipids, catecholamine levels, and renal function. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Cochrane Central Register of Controlled Trials, Medline, Embase, WHO International Clinical Trials Registry Platform, the Latin American and Caribbean health science literature database, and the reference lists of previous reviews. STUDY SELECTION: Randomised controlled trials and prospective cohort studies in non-acutely ill adults and children assessing the relations between sodium intake and blood pressure, renal function, blood lipids, and catecholamine levels, and in non-acutely ill adults all cause mortality, cardiovascular disease, stroke, and coronary heart disease. STUDY APPRAISAL AND SYNTHESIS: Potential studies were screened independently and in duplicate and study characteristics and outcomes extracted. When possible we conducted a meta-analysis to estimate the effect of lower sodium intake using the inverse variance method and a random effects model. We present results as mean differences or risk ratios, with 95% confidence intervals. RESULTS: We included 14 cohort studies and five randomised controlled trials reporting all cause mortality, cardiovascular disease, stroke, or coronary heart disease; and 37 randomised controlled trials measuring blood pressure, renal function, blood lipids, and catecholamine levels in adults. Nine controlled trials and one cohort study in children reporting on blood pressure were also included. In adults a reduction in sodium intake significantly reduced resting systolic blood pressure by 3.39 mm Hg (95% confidence interval 2.46 to 4.31) and resting diastolic blood pressure by 1.54 mm Hg (0.98 to 2.11). When sodium intake was <2 g/day versus ≥ 2 g/day, systolic blood pressure was reduced by 3.47 mm Hg (0.76 to 6.18) and diastolic blood pressure by 1.81 mm Hg (0.54 to 3.08). Decreased sodium intake had no significant adverse effect on blood lipids, catecholamine levels, or renal function in adults (P>0.05). There were insufficient randomised controlled trials to assess the effects of reduced sodium intake on mortality and morbidity. The associations in cohort studies between sodium intake and all cause mortality, incident fatal and non-fatal cardiovascular disease, and coronary heart disease were non-significant (P>0.05). Increased sodium intake was associated with an increased risk of stroke (risk ratio 1.24, 95% confidence interval 1.08 to 1.43), stroke mortality (1.63, 1.27 to 2.10), and coronary heart disease mortality (1.32, 1.13 to 1.53). In children, a reduction in sodium intake significantly reduced systolic blood pressure by 0.84 mm Hg (0.25 to 1.43) and diastolic blood pressure by 0.87 mm Hg (0.14 to 1.60). CONCLUSIONS: High quality evidence in non-acutely ill adults shows that reduced sodium intake reduces blood pressure and has no adverse effect on blood lipids, catecholamine levels, or renal function, and moderate quality evidence in children shows that a reduction in sodium intake reduces blood pressure. Lower sodium intake is also associated with a reduced risk of stroke and fatal coronary heart disease in adults. The totality of evidence suggests that most people will likely benefit from reducing sodium intake.

Effect of increased potassium intake on cardiovascular risk factors and disease: systematic review and meta-analyses.

OBJECTIVE: To conduct a systematic review of the literature and meta-analyses to fill the gaps in knowledge on potassium intake and health. DATA SOURCES: Cochrane Central Register of Controlled Trials, Medline, Embase, WHO International Clinical Trials Registry Platform, Latin American and Caribbean Health Science Literature Database, and the reference lists of previous reviews. STUDY SELECTION: Randomised controlled trials and cohort studies reporting the effects of potassium intake on blood pressure, renal function, blood lipids, catecholamine concentrations, all cause mortality, cardiovascular disease, stroke, and coronary heart disease were included. DATA EXTRACTION AND SYNTHESIS: Potential studies were independently screened in duplicate, and their characteristics and outcomes were extracted. When possible, meta-analysis was done to estimate the effects (mean difference or risk ratio with 95% confidence interval) of higher potassium intake by using the inverse variance method and a random effect model. RESULTS: 22 randomised controlled trials (including 1606 participants) reporting blood pressure, blood lipids, catecholamine concentrations, and renal function and 11 cohort studies (127,038 participants) reporting all cause mortality, cardiovascular disease, stroke, or coronary heart disease in adults were included in the meta-analyses. Increased potassium intake reduced systolic blood pressure by 3.49 (95% confidence interval 1.82 to 5.15) mm Hg and diastolic blood pressure by 1.96 (0.86 to 3.06) mm Hg in adults, an effect seen in people with hypertension but not in those without hypertension. Systolic blood pressure was reduced by 7.16 (1.91 to 12.41) mm Hg when the higher potassium intake was 90-120 mmol/day, without any dose response. Increased potassium intake had no significant adverse effect on renal function, blood lipids, or catecholamine concentrations in adults. An inverse statistically significant association was seen between potassium intake and risk of incident stroke (risk ratio 0.76, 0.66 to 0.89). Associations between potassium intake and incident cardiovascular disease (risk ratio 0.88, 0.70 to 1.11) or coronary heart disease (0.96, 0.78 to 1.19) were not statistically significant. In children, three controlled trials and one cohort study suggested that increased potassium intake reduced systolic blood pressure by a non-significant 0.28 (-0.49 to 1.05) mm Hg. CONCLUSIONS: High quality evidence shows that increased potassium intake reduces blood pressure in people with hypertension and has no adverse effect on blood lipid concentrations, catecholamine concentrations, or renal function in adults. Higher potassium intake was associated with a 24% lower risk of stroke (moderate quality evidence). These results suggest that increased potassium intake is potentially beneficial to most people without impaired renal handling of potassium for the prevention and control of elevated blood pressure and stroke.

An evaluation of a global vitamin and mineral nutrition surveillance system.

Evaluation of public health surveillance systems is essential to ensure that problems of public health importance are monitored efficiently and effectively. The WHO's Vitamin and Mineral Nutrition Information System (VMNIS) was evaluated from the perspective of public health surveillance and informatics. Steps included: engaging the stakeholders of the evaluation; describing the surveillance system; focusing the evaluation design; gathering credible evidence regarding system performance; justifying and stating conclusions and recommendations, and sharing lessons learned from the evaluation. Following this assessment, WHO has begun major efforts to upgrade and expand the VMNIS and now the database is more flexible and efficient. The database evaluation summarized in this paper provides a good example of how public health evaluation frameworks can lead to improved surveillance and enhanced information systems, thus making progress toward the ultimate goal of improving public health.

Impact of a school-based intervention program on obesity risk factors in Mexican children.

OBJECTIVE: To evaluate the impact of an 18-month school obesity prevention intervention on the health behaviors of 4th and 5th grade students based on ecological principles and formative research conducted in Mexico. MATERIALS AND METHODS: A Randomized Control Trial (RCT), design was used to assign 27 schools to one of three conditions: basic or plus interventions and control. School environment measures, children's eating and physical activity behaviors, and body mass index were assessed four times over a 2-year period in a sample of 830 students. RESULTS: In the intervention schools, the availability of healthy foods increased with a concomitant decrease in unhealthy food availability. Food intake showed the same trend. In the intervention schools, children did not engage in more moderate to vigorous physical activity (MVPA) in physical education (PE) class or recess but increased steps taken. Obesity prevalence did not change. CONCLUSION: The intervention improved the school food environment and child healthy behaviors.

Impact of a school-based intervention program on obesity risk factors in Mexican children / Impacto de un programa de intervención en escuelas para la prevención de factores de riesgo de la obesidad en niños mexicanos

Objective. To evaluate the impact of an 18-month school obesity prevention intervention on the health behaviors of 4th and 5th grade students based on ecological principles and formative research conducted in Mexico. Materials and methods. A Randomized Control Trial (RCT), design was used to assign 27 schools to one of three conditions: basic or plus interventions and control. School environment measures, children's eating and physical activity behaviors, and body mass index were assessed four times over a 2-year period in a sample of 830 students. Results. In the intervention schools, the availability of healthy foods increased with a concomitant decrease in unhealthy food availability. Food intake showed the same trend. In the intervention schools, children did not engage in more moderate to vigorous physical activity (MVPA) in physical education (PE) class or recess but increased steps taken. Obesity prevalence did not change. Conclusion. The intervention improved the school food environment and child healthy behaviors.

Objetivo. Evaluar el impacto de una intervención de 18 meses para la prevención de obesidad en escolares de 4o y 5o grados basada en el modelo ecológico en conductas saludables en México. Material y métodos. Diseño experimental para asignar 27 escuelas a uno de los tres tratamientos: intervenciones básicas, intervenciones plus y control. Se midió el impacto en el ambiente escolar, la alimentación y la actividad física e índice de masa corporal en niños. La evaluación se llevó a cabo en dos años en 830 estudiantes. Resultados. En las escuelas de intervención, la disponibilidad de alimentos sanos aumentó y la disponibilidad de alimentos poco saludables disminuyó. La ingesta de alimentos en niños no mostraron las mismas tendencias. En las escuelas de intervención, los niños no participaron más en actividad física moderada y vigorosa. La prevalencia de obesidad no se modificó. Conclusión. La intervención mejoró el entorno alimentario escolar y las conductas saludables de alimentación y actividad física.

Performance of iron spot test with Arabic bread made from fortified white wheat flour.

BACKGROUND: The iron spot test (IST) is a simple qualitative technique for determining the presence of added iron in fortified flour. IST performance in bread has never been investigated. If found to perform well, the IST has the potential to provide a field-friendly method for testing bread and thus support the monitoring and evaluation of flour fortification programs. OBJECTIVE: To assess the performance of the IST in Arabic bread made from white wheat flour. METHODS: Bread samples were collected from 1,737 households during a national micronutrient survey in Jordan. A subsample of Arabic bread (n = 44) was systematically selected for testing by both the IST and spectrophotometry (criterion reference). Performance measures (sensitivity, specificity, and positive and negative predictive values) were calculated using five cutoffs to define the presence of added iron, including > or = 15.0 ppm (approximate level of natural iron in Arabic bread) and four additional cutoffs based on test performance. RESULTS: The iron contents of samples testing negative by IST ranged from 10.4 to 18.4 ppm, with one outlier at 41.0 ppm, which was excluded from subsequent analyses. The iron contents of samples testing positive by IST ranged from 16.1 to 38.4 ppm. With the exception of negative predictive values for the two lowest cutoffs (> or = 15.0 and > or = 16.1 ppm), all performance measures exceeded 83.3%. CONCLUSIONS: These results show promise for the IST as an inexpensive, field-friendly method for testing bread that could have a useful role in the monitoring and evaluation process for flour fortification programs.