Cultural adaptations and methodological innovations to group model building for the systems actions to reduce malnutrition in all its forms in Southeast Asian countries and China (SYSTAM CHINA-SEACS International Consortium) project.

BACKGROUND: Group Model Building (GMB) is a participatory system dynamics method increasingly used to address complex public health issues like obesity. GMB represents a set of well-defined steps to engage key stakeholders to identify shared drivers and solutions of a given problem. However, GMB has not yet been applied specifically to develop multi-duty interventions that address multiple inter-related issues such as malnutrition in all its forms (MIAIF). Moreover, a recent systematic review of empirical applications of a systems approach to developing obesity interventions found no published work from non-western, low- and middle-income countries (LMICs). In this paper we describe adaptations and innovations to a common GMB process to co-develop systemic MIAIF interventions with Chinese decision-makers. METHODS: We developed, piloted and implemented multiple cultural adaptations and two methodological innovations to the commonly used GMB process in Fang Cheng Gang city, China. We included formal, ceremonial and policy maker engagement events before and between GMB workshops, and incorporated culturally tailored arrangements during participant recruitment (officials of the same seniority level joined the same workshop) and workshop activities (e.g., use of individual scoring activities and hand boards). We made changes to the commonly used GMB activities which enabled mapping of shared drivers of multiple health issues (in our case MIAIF) in a single causal loop diagram. We developed and used a 'hybrid' GMB format combining online and in person facilitation to reduce travel and associated climate impact. RESULTS: Our innovative GMB process led to high engagement and support from decision-makers representing diverse governmental departments across the whole food systems. We co-identified and prioritised systemic drivers and intervention themes of MIAIF. The city government established an official Local Action Group for long-term, inter-departmental implementation, monitoring and evaluation of the co-developed interventions. The 'hybrid' GMB format enabled great interactions while reducing international travel and mitigating limitations of fully online GMB process. CONCLUSIONS: Cultural and methodological adaptations to the common GMB process for an Asian LMIC setting were successful. The 'hybrid' GMB format is feasible, cost-effective, and more environmentally friendly. These cultural adaptations could be considered for other Asian settings and beyond to address inter-related, complex issues such as MIAIF.

Unhealthy weight among young children in the Middle East and North African region.

OBJECTIVE: To understand early-life growth in the Middle East and North Africa (MENA) region, and how it has changed over time, we estimated the prevalence of wasting and overweight at ages under 5 years. DESIGN: Cross-sectional data from twenty-nine Demographic and Health Surveys with direct anthropometric data and parent-reported demographic information were examined. The study utilised the WHO Child Growth Standards to classify overweight (weight-for-height z-score ≥ 2 sd above the median), wasting (weight-for-height z-score ≤ 2 sd below the median) and unhealthy weight defined as either wasting or overweight. SETTING: Nationally representative for nine of the MENA countries (Armenia, Azerbaijan, Egypt, Jordan, Mauritania, Morocco, Tunisia, Turkey and Yemen). PARTICIPANTS: Children under age 5 from nine MENA countries between 1987 and 2016 (n 155 961). RESULTS: Across the region, at the most recent time point, between 7·3 and 23·6 % of children experienced unhealthy weight (Jordan - 7·3 %, Egypt -23·6 %); 1·7 and 16·6 % had wasting (Turkey, Yemen) and 2·0 and 15·0 % had overweight (Yemen, Egypt). Overweight was more common than wasting in all countries except Yemen and Mauritania. Between 1987 and 2016, the prevalence of unhealthy weight in the region increased (10·0-18·4 %) due to increases in both wasting and overweight. Boys had a higher prevalence of unhealthy weight than girls. CONCLUSION: Undernutrition continues to be a problem in some countries in the MENA region, and overnutrition is emerging as a health concern in many countries in the region. Countries in the region must advance programmes that reduce undernutrition while not overlooking or inadvertently promoting overnutrition.

Validation of the efficacy of the NUTRISCORE for the nutritional screening of cancer patients in China.

BACKGROUND: Malnutrition is common in cancer patients. The NUTRISCORE is a newly developed cancer-specific nutritional screening tool and was validated by comparison with the Patient-Generated Subjective Global Assessment (PG-SGA) and Malnutrition Screening Tool (MST) in Spain. We aimed to evaluate the performance of the NUTRISCORE, MST, and PG-SGA in estimating the risk of malnutrition in Chinese cancer patients. METHODS: Data from an open parallel and multicenter cross-sectional study in 29 clinical teaching hospitals in 14 Chinese cities were used. Cancer patients were assessed for malnutrition using the PG-SGA, NUTRISCORE, and MST. The sensitivity, specificity, and areas under the receiver operating characteristic curve were estimated for the NUTRISCORE and MST using the PG-SGA as a reference. RESULTS: A total of 1000 cancer patients were included. The mean age was 55.9 (19 to 92 years), and 47.5% were male. Of these patients, 450 (45.0%) had PG-SGA B and C, 29 (2.9%) had a NUTRISCORE ≥5, and 367 (36.7%) had an MST ≥ 2. Using the PG-SGA as a reference, the sensitivity, specificity, and area under the curve values of the NUTRISCORE were found to be 6.2, 99.8%, and 0.53, respectively. The sensitivity, specificity, and area under the curve values of the MST were 50.9, 74.9%, and 0.63, respectively. The kappa index between the NUTRISCORE and PG-SGA was 0.066, and that between the MST and PG-SGA was 0.262 (P < 0.05). CONCLUSIONS: The NUTRISCORE had an extremely low sensitivity in cancer patients in China compared with the MST when the PG-SGA was used as a reference.

Effect of nutritional education on anthropometric deficits among pre-school aged children in south West Ethiopia: quasi-experimental study.

BACKGROUND: Under-nutrition is a global problem and one of the most serious public health issues. Globally, 156 million under-five children were stunted, and 50 million were wasted in 2016. Malnutrition among preschool-age children is caused by low socioeconomic status, food insecurity, poor feeding practices, and infectious diseases. This intervention aimed to evaluate the effect of nutrition education delivered through trained health professionals in improving the nutritional status of preschool -aged children. METHODS: A quasi-experimental design among 588 preschool -aged children was used. A multistage sampling technique followed by a systematic random sampling technique was used to identify caregivers with preschool-aged children. Structured questionnaires were used to collect data. The baseline difference in demographic and socioeconomic characteristics between the two groups was examined using a chi-square test and an independent sample t-test was used to determine the mean difference in under-nutrition between the intervention and control groups. Generalized estimating equations (GEE) were used to determine the change in the difference in outcome between the intervention and control groups as well as the association of predictors with under-nutrition in children. The Adjusted odds ratio (AOR) with the corresponding 95% confidence intervals was reported to show the strength of the association. Variables with a p-value of less than 0.05 were considered statistically significant in multivariable analysis. RESULTS: In this study, the nutritional status of preschool age children was significantly associated with nutrition education intervention [AOR = 0.566, 95% CI: (0.347, 0.923)], place of delivery [AOR = 0.724, 95% CI: (0.551, 0.951)], ARI in the last 2 weeks [AOR = 1.823, 95% CI: (1.226, 2.710)], source of drinking water [AOR = 0.624, 95% CI: (0.484, 0.805)] and household food security [AOR = 1.311, 95% CI: (1.030, 1.669)] . CONCLUSIONS: Findings of this study showed that nutrition education can effectively reduce the magnitude of under-nutrition among preschool children. Under-nutrition was e significantly associated with nutritional education, place of delivery, ARI in the last 2 weeks, source of drinking water, and food security. Therefore, both government and non-government should consider the impacts of nutrition education to alleviate under-nutrition and improve the health status of preschool-age children.

Dietary Diversity and Undernutrition in Children Aged 6-23 Months in Sub-Saharan Africa.

Dietary diversity plays a major role in the health status of children. However, evidence on its crucial role on children's health status remains inconclusive in sub-Saharan Africa (SSA). In this study, we examined the association between dietary diversity and undernutrition among children aged 6-23 months in SSA. We pooled data from the most recent Demographic and Health Surveys of 32 countries in SSA from 2010 to 2020. A sample of 48,968 mother-child pairs of children within the ages of 6-23 months and mothers aged 15-49 years were included in this study. Multilevel logistic regression analysis was carried out to examine the association between dietary diversity and stunting, wasting, and underweight. The results were presented as crude odds ratios (cOR) and adjusted odds ratios (aOR) with their 95% confidence intervals. Statistical significance was set at p < 0.05. The overall prevalence of minimum dietary diversity was 25.1%, with South Africa recording the highest prevalence (43.9%) and Burkina Faso recording the lowest prevalence (5.6%). The highest prevalence of stunting was recorded by Burundi (51.8%) while the lowest prevalence was found in Ghana (13.6%), with an overall regional prevalence of 28.6%. For wasting, prevalence from all countries was found to be 9.4%. South Africa recorded the lowest prevalence of wasting (2.1%) while Niger recorded the highest prevalence (27.3%). Lastly, the prevalence of underweight ranged from 5.3% in South Africa to 41.8% in Niger, with an all-country prevalence of 16.4%. Children who had adequate minimum dietary diversity had 12% less likelihood of being stunted (aOR = 0.88, 95% CI = 0.83, 0.94), compared to those who had inadequate minimum dietary diversity. Having an adequate minimum dietary diversity significantly lowered the risk of underweight among children by 17% (aOR = 0.83, 95% CI = 0.77, 0.91). Having an adequate minimum dietary diversity was associated with 13% reduced odds of wasting among children (aOR = 0.87, 95% CI = 0.78, 0.97), compared to those who had inadequate minimum dietary diversity. This study highlights the significant association between minimum dietary diversity and stunting, wasting, and underweight among 6-23 month-old children in SSA. There is an urgent need for additional nutrition-specific interventions and strengthening of existing interventions aimed at improving infant and young child feeding practices, including complementary feeding practices among children aged 6-23 months in the 32 countries in SSA. Such interventions should focus more on countries where the prevalence of adequate minimum dietary diversity was low and undernutrition was high.

Prevalence and Determinants of the Co-Occurrence of Overweight or Obesity and Micronutrient Deficiencies among Adults in the Philippines: Results from a National Representative Survey.

The double burden of malnutrition (DBM) affects many low- and middle-income countries. However, few studies have examined DBM at the individual level, or undernutrition and overnutrition co-occurring within the same person. This study aims to investigate the prevalence and determinants of DBM among adults in the Philippines. Data from the 2013 National Nutrition Survey were used. The sample size in the analysis was 17,010 adults aged ≥20 years old, after excluding pregnant and lactating women. DBM was defined as the co-occurrence of overweight/obesity and anemia (definition #1), overweight/obesity and anemia or vitamin A deficiency (definition #2), and overweight/obesity and anemia or vitamin A deficiency or iodine insufficiency (definition #3). Anthropometric measurements and biochemical markers were used for DBM assessment. Data were analyzed using descriptive statistics, the chi-square test, and logistic regression by R software. Results showed that definition #3 is the predominant type of DBM (7.0%) in the general population, whereas the prevalence of DBM has increased to 23.7% in overweight/obese persons. Sex, age, educational attainment, marital status, household size, wealth quintile, and smoking status were the determinants of DBM. This study revealed that Filipino adults experience malnutrition critically and must be addressed through food and nutrition interventions.

Ethnic Differences in Loneliness, Depression, and Malnutrition Among Older Adults During COVID-19 Quarantine.

BACKGROUND: Depression in older adults may result from a variety of reasons such as loneliness feelings and malnutrition. OBJECTIVE: To examine the direct and indirect effect of loneliness feelings on depressive symptoms, mediated by malnutrition, among older adults from different cultures during the Coronavirus disease 2019 (Covid-19) pandemic quarantine. METHOD: A convenience sample of 101 Arabs and 100 Jewish older adults aged 65 and over was interviewed. Using bootstrapping, we tested the strength and significance of the conditional indirect effect of malnutrition (mediator) on the relationship between loneliness feelings and depressive symptoms. RESULTS: The relationship between loneliness feelings and depressive symptoms was mediated by malnutrition and Arab older adults reported a higher level than Jewish older adults of loneliness, depression, and malnutrition during the Covid-19 pandemic quarantine. CONCLUSIONS AND IMPLICATIONS: To reduce loneliness feelings, depressive symptoms, and malnutrition in times of crisis like the Covid-19 pandemic, it is essential to develop new communication methods for and with older adults in general, with particular attention paid to ethnic differences, that will be effective in reducing loneliness and in promoting nutrition intervention. Possible solutions include new social network technologies for reducing loneliness, with continued reliance on phone communication for combined intervention that includes psychological support accompanied by instructions for a healthy lifestyle and malnutrition prevention.

Malnutrition in all its forms by wealth, education and ethnicity in Latin America: who are more affected?

OBJECTIVE: To summarise the findings from this supplemental issue on the distribution of malnutrition (stunting/short stature, anaemia and overweight) by wealth, education and ethnicity within and between ten Latin American countries. DESIGN: We retrieved information from each country's article and estimated the average difference in the prevalence of malnutrition between groups. We estimated the associations between countries' malnutrition prevalence and GDP, percentage of women with high education and percentage of non-indigenous ethnicity. SETTING: Nationally representative surveys from ten Latin American countries conducted between 2005 and 2017. PARTICIPANTS: Children (<5 years), adolescent women (11-19 years) and adult women (20-49 years). RESULTS: Socially disadvantaged groups (low wealth, low education and indigenous ethnicity) had on average 15-21 (range across indicators and age groups) percentage points (pp) higher prevalence of stunting/short stature and 3-11 pp higher prevalence of anaemia. For overweight or obesity, adult women with low education had a 17 pp higher prevalence; differences were small among children <5 years, and results varied by country for adolescents by education, and for adults and adolescents by wealth and ethnicity. A moderate and strong correlation (-0·58 and -0·71) was only found between stunting/short stature prevalence and countries' GDP per capita and percentage of non-indigenous households. CONCLUSIONS: Overweight was equally distributed among children; findings were mixed for ethnicity and wealth, whereas education was a protective factor among adult women. There is an urgent need to address the deep inequalities in undernutrition and prevent the emerging inequalities in excess weight from developing further.

Malnutrition prevalence among children and women of reproductive age in Mexico by wealth, education level, urban/rural area and indigenous ethnicity.

OBJECTIVE: To compare the prevalence of malnutrition (undernutrition and excess weight) by wealth, education level, ethnicity and urban/rural areas in Mexican children and women of reproductive age. DESIGN: We compared the prevalence of overweight, obesity, wasting/underweight, stunting/short stature and anaemia by socioeconomic and ethnic indicators. For each indicator, we estimated prevalence ratios (PR) adjusted by all other socioeconomic and ethnic indicators. We analysed if results differed by urban/rural areas. SETTING: Mexican National Health and Nutrition Survey 2012. PARTICIPANTS: Children <5 years, non-pregnant women 11-19 years and non-pregnant women 20-49 years (n 33 244). RESULTS: In most age groups, belonging to non-indigenous households, with high wealth, high education and in urban areas were inversely associated with stunting or short stature (PR ranging from 0·40 to 0·83), and wealth and education were inversely associated with anaemia (PR ranging from 0·53 to 0·78). The prevalence of overweight was similar across subgroups among children <5 years; however, among women 11-19 years, wealth, non-indigenous household and urban areas were positively associated (PR ranging from 1·16 to 1·33); and among women 20-49 years, education was inversely associated (PR 0·83). CONCLUSIONS: Socially disadvantaged populations have a higher prevalence of undernutrition, whereas the prevalence of excess weight is either equal (children <5 years), slightly lower (women 11-19 years) or even higher (women 20-49 years) with lower education. These results highlight the need for specific actions to address social inequalities in malnutrition in the Mexican population.

Association of all forms of malnutrition and socioeconomic status, educational level and ethnicity in Colombian children and non-pregnant women.

OBJECTIVE: To examine the association of all forms of malnutrition and socioeconomic status (SES), educational level and ethnicity in children <5 years, non-pregnant adolescent women (11-19 years) and non-pregnant adult women (20-49 years) in Colombia. DESIGN: Cross-sectional analysis of data from the 2010 Colombian National Nutrition Survey. The prevalence of malnutrition was compared across categories of SES, educational level and ethnicity. SETTING: Colombia. PARTICIPANTS: The sample for the current analysis comprised children <5 years, non-pregnant adolescent women (11-19 years) and non-pregnant adult women (20-49 years). RESULTS: In children <5 years, a low SES and maternal educational level were significantly associated with a lower prevalence of overweight/obesity compared with high levels of SES and maternal education, that is, the prevalence of overweight/obesity was 1·4 and 1·6 times lower in categories of low SES and educational levels, respectively. In contrast, the prevalence of wasting, stunting and anaemia was higher in the lowest SES and maternal educational categories (the prevalence was between 1·1 and 1·8 times higher for these indicators). In women, the lowest SES (11 and 19 years) and educational levels (20 and 49 years) exhibited a higher prevalence in all forms of malnutrition compared with their counterparts in the highest categories (i.e. overweight/obesity, stunting and anaemia). Additionally, indigenous or Afro-Colombian children and women had the highest prevalence of malnutrition in comparison with other ethnicities. CONCLUSIONS: These results suggest that public policies should address all forms of malnutrition that occur in the most vulnerable populations in Colombia using multiple strategies.

Nutrition status in adult Chilean population: economic, ethnic and sex inequalities in a post-transitional country.

OBJECTIVE: To assess the relationship between malnutrition, socioeconomic status (SES) and ethnicity in Chilean adult population. DESIGN: Nationally representative survey (ENS) conducted in 2016-2017. Sociodemographic information, weight, height and hemoglobin (Hb) were measured (2003 ENS). Excess weight was defined as BMI ≥25 kg/m2. Undernutrition included underweight (BMI <18·5 kg/m2), short stature (height <1·49 m in women and <1·62 m in men) or anaemia (Hb <12 g/l). Education and household income level were used as indicators of SES; ethnicity was self-reported. We applied linear combinations of estimators to compare the prevalence of excess weight and undernutrition by SES and ethnicity. SETTING: Chile. PARTICIPANTS: In total, 5082 adults ≥20 years (64 % women) and 1739 women ≥20 years for anaemia analyses. RESULTS: Overall, >75 % of women and men had excess weight. Low SES women either by income or education had higher excess weight ((82·0 (77·1, 86·1) v. 65·0 (54·8, 74·1)) by income; (85·3 (80·6, 89·0) v. 68·2 (61·6, 74·1) %) by education) and short stature (20-49 years; 31(17·9, 48·2) v. 5·2 (2·2,11·4) by education); obesity was also more frequent among indigenous women (20-49 years; 55·8 (44·4, 66·6) v. 37·2 (32·7, 42·0) %) than non-indigenous women. In men, excess weight did not significantly differ by SES or ethnicity, but short stature concentrated in low SES (20-49 years; 47·6 (24·6, 71·6) v. 4·5 (2·1, 9·5) by education) and indigenous men (21·5 (11·9, 5·5, 11·9) v. 8·2 (5·5, 11·9)) (P < 0·05 for all). CONCLUSIONS: In Chile, malnutrition is disproportionately concentrated among women of low SES and indigenous origin; these inequalities should be considered when implementing prevention policies.

Malnutrition in all its forms and socioeconomic status in Bolivia.

OBJECTIVE: To estimate the prevalence of malnutrition (undernutrition and excess BMI) among children under the age of 5 years and women of reproductive age in Bolivia considering three socioeconomic indicators: wealth, education and ethnicity. DESIGN: We used the 2008 nationally representative Bolivian Demographic and Health Survey (DHS). Malnutrition's prevalence was estimated by wealth, ethnicity and educational level. Wealth index was measured based on the DHS methodology and nutritional status by using WHO standards and indicators. Education level (EL) was categorized by years of formal education. SETTING: Bolivia. PARTICIPANTS: In total, 5·903 children <5 years, 3·345 adolescent women (15-19 years) and 12·297 women (20-49 years) with available information on anthropometric measurements·. RESULTS: A disproportionate prevalence of malnutrition was observed among different wealth groups: lower wealth tertiles show the higher prevalence of stunting (>30 %) and anaemia (>40 %) in all ages· The prevalence of overweight and obesity tends to rise with age from childhood (10·02-11·60) to adolescence (27·9-31·03), reaching highest levels in women of reproductive age (56·02-57·76). According to wealth tertiles, higher prevalence of overweight and obesity was found in children of high tertile (12·23), adolescent women of low (32·56) and adult women of medium tertile (63·08). CONCLUSIONS: The present study shows that currently Bolivia is in a transitional stage, faces not only the problem of undernutrition but also those of overnutrition, showing strong inequalities according to socioeconomic and education status. This study calls for state-specific policies keeping in view of the nature of inequality in malnutrition in the country and its differential characteristics across wealth status.

Socio-economic and ethnic disparities of malnutrition in all its forms in Guatemala.

OBJECTIVE: To analyse disparities of malnutrition in all its forms by socio-economic indicators in children aged <5 years, adolescent girls and women of reproductive age (WRA). DESIGN: We defined wasting/underweight, stunting/short stature, overweight and obesity following the WHO criteria for children aged <5 years, adolescents and WRA. We evaluated the prevalence of malnutrition by wealth status, education level and ethnicity (indigenous/non-indigenous). SETTING: Guatemalan 2014-2015 National Maternal and Child Health Survey. PARTICIPANTS: Children aged <5 years (n 11 962), adolescent girls aged 15-19 years (n 1086) and WRA aged 20-49 years (n 11 354). RESULTS: Stunting/short stature prevalence among children, adolescents and WRA was 2·8, 2·1 and 2·0 times higher in the poorest compared with the richest; 2·9, 2·9 and 2·1 times higher in the lower educational level than in the highest; and 1·7, 1·7 and 1·6 times higher in the indigenous than in the non-indigenous population. In contrast, overweight/obesity prevalence among children, adolescents and WRA was 1·6, 2·1 and 1·8 times higher in the richest compared with the poorest; 1·6, 1·3 and 1·3 times higher in the higher educational level than in the lowest; and 1·3, 1·7 and 1·3 times higher in the non-indigenous than in the indigenous population. CONCLUSIONS: Stunting/short stature is more prevalent among low-income, low-education and indigenous populations in all age groups. In contrast, overweight/obesity is more prevalent in high-income, high-education and non-indigenous populations in all age groups. These outcomes demonstrate socio-economic and ethnic disparities for malnutrition in all its forms.

Malnutrition in all its forms and social inequalities in Brazil.

OBJECTIVE: To describe malnutrition (undernutrition and excess weight) by income, education and race/ethnicity in the Brazilian population. DESIGN: Cross-sectional study. SETTING: Brazil. PARTICIPANTS: Children aged <5 years (n 14 580), adolescents aged 11-19 years (n 31 892) and adults aged 20-49 years (n 84 660). RESULTS: Among children, prevalence of excess weight, wasting and stunting was 16·9, 2·8 and 6·0 %, respectively. Differences related to income, education and race/ethnicity were verified, except for prevalence of wasting by education level. Girls and boys presented 18·4 and 20·5 % of excess weight, 2·8 and 3·7 % of underweight and 5·5 and 7·3 % of stunting, respectively. Prevalence of excess weight was lower among poorer, lower-educated (only for boys) and white adolescents, while stunting was lower among higher-income, higher-educated and white adolescents. Over three-quarters of women and almost half of men presented excess weight. Among adults, 3·9 % of women and 1·7 % of men were underweight, and 5·7 % of women and 0·2 % of men presented short stature. Prevalence of excess weight for women was higher among lower education and black, while for men it was higher among higher income and education and white. Short stature was more prevalent among black and mixed-race, low-educated and low-income women. Underweight prevalence was higher among low-educated, black and mixed-race women. CONCLUSIONS: In Brazil, the prevalence of excess weight was at least threefold higher than that of undernutrition for children and adolescents and at least sevenfold higher for adults. Social inequalities were observed in the distribution of malnutrition across the lifespan and by gender.

Prevalence of obesity and diabetes in the socioeconomic transition of rural Mayas of Yucatan from 1962 to 2000.

Background: The Mayas of the State of Yucatan in Mexico are the only aboriginal group with obesity and diabetes data before 1997. Objective: To analyze socioeconomic trends associated with the increase in obesity and diabetes seen in rural Yucatan from 1962 to 2000. Methods: Body weight, height and venous Fasting Blood Glucose (FBG) were measured in 263 rural Maya adults participating in a 2000 nutrition survey. Results: Diabetes (FBG > 125 mg/dL) and obesity (BMI ≥ 30 kg/m2) were 10.6% and 35.7%, respectively. These results contrast with those of a 1962 survey where diabetic prevalence was 2.3% and 0% in women and men respectively, with widespread adult pellagra and malnutrition. An important socioeconomic transition that took place in Yucatan during this lapse appeared to be associated to the obesity and diabetes increase. Conclusions: Rural Yucatan evolved from malnutrition conditions to high prevalence of obesity and diabetes in less than 40 years. This change was associated with the transition from an agroindustry-based economy, characterized by high-energy expenditure and low protein intake, to lower energy requirements of a Government-subsidized economy with larger food supply.

Malnutrition inequalities in Ecuador: differences by wealth, education level and ethnicity.

OBJECTIVE: To describe and quantify the magnitude and distribution of stunting, wasting, anaemia, overweight and obesity by wealth, level of education and ethnicity in Ecuador. DESIGN: We used nationally representative data from the 2012 Ecuadorian National Health and Nutrition Survey. We used the Multidimensional Poverty Index (MPI) as a proxy of wealth. The MPI identifies deprivations across three dimensions (health, education and standard of living). We defined education by years of schooling and ethnicity as a social construct, based on shared social, cultural and historical experiences, using Ecuadorian census categories. SETTING: Urban and rural Ecuador, including the Amazon rainforest and the Galapagos Islands. PARTICIPANTS: Children aged <5 years (n 8580), adolescent women aged 11-19 years (n 4043) and adult women aged 20-49 years (n 15 203). RESULTS: Among children <5 years, stunting and anaemia disproportionately affected low-wealth, low-education and indigenous groups. Among adolescent and adult women, higher rates of stunting, overweight and obesity were observed in the low-education and low-wealth groups. Stunting and short stature rates were higher in indigenous women, whereas overweight and obesity rates were higher in Afro-Ecuadorian women. CONCLUSIONS: Malnutrition differs significantly across sociodemographic groups, disproportionately affecting those in the low wealth tertile and ethnic minorities. Rates of stunting remain high compared with other countries in the region with similar economic development. The effective implementation of double-duty actions with the potential to impact both sides of the double burden is urgently required.

Malnutrition in all its forms and socio-economic disparities in children under 5 years of age and women of reproductive age in Peru.

OBJECTIVE: To compare the distribution of malnutrition by socio-economic indicators (SEI) in Peruvian children under 5 years and women of reproductive age (WRA). DESIGN: We analysed data from the National Demographic and Family Health Survey. WHO criteria were used to define malnutrition indicators (overweight/obesity combined (OW); wasting/underweight; stunting/short stature; anaemia). Linear combination test was used to compare the prevalence of malnutrition by SEI (wealth index as a proxy of socio-economic status (SES); education; ethnicity). Prevalence ratio (PR) was used to describe disparities and associations between malnutrition and SEI. SETTING: Peru (2015). PARTICIPANTS: Children (n 22 833) under 5 years and WRA (n 33 503; 5008 adolescents and 28 495 adults). RESULTS: The most prevalent form of malnutrition was anaemia (32·0 %) in children and OW in adolescent and adult WRA (31·3 and 65·1 %, respectively). Adjusted models showed that stunting and anaemia were significantly lower among children with high SES (PR = 0·25, 0·67), high-educated mothers (PR = 0·26, 0·76) and higher in indigenous children (PR = 1·3, 1·2); conversely, OW was higher among those with high SES and high-educated mothers (PR = 1·8, 1·6) compared with their lowest counterparts. In WRA, stunting/short stature was lower among those with high SES, high education and higher in indigenous adult women. OW in adolescents and adults was higher in high SES (PR = 1·4, 1·1), lower in indigenous adult women (PR = 0·84) and lower in high-educated adult women (PR = 0·86). CONCLUSIONS: In the studied population, the distribution of malnutrition was associated with SEI disparities. Effective policies that integrate actions to overcome the double burden of malnutrition and reduce disparities are needed.

Caution is Needed in Interpreting Hemoglobin A1c Levels in the Muslim Bedouin Population of Southern Israel.

BACKGROUND: The Bedouins living in southern Israel are a Muslim-Arab population that is transitioning from a nomadic lifestyle to life in permanent settlements. The population has unique characteristics that could affect hemoglobin A1c (HbA1c) measurements. The objective of this study was to describe the socio-demographic and unique morbidity characteristics of this community and their effect on HbA1c measurements. Consanguinity, especially among cousins in the Bedouin population, results in a high prevalence of autosomal recessive genetic diseases such as thalassemia (underestimate of HbA1c), hemoglobinopathies (underestimate and overestimate), Gilbert's disease, and glucose-6-phosphate dehydrogenase deficiency, an X-linked disorder, which can cause hyperbilirubinemia with an overestimate of HbA1c. Furthermore, nutritional deficiencies, autosomal recessive diseases, high birth rates, parasitic infections, and poverty can all cause high rates of anemia (iron and vitamin B12 deficiencies) that can raise HbA1c levels. Congenital dyserythropoietic anemia is found among Bedouin tribes in the Negev region and can lead to an underestimation of HbA1c levels. Pregnancy can also affect HbA1c levels. Medical teams working in the Bedouin community and in other Muslim populations with similar morbidity characteristics throughout the world should identify patients with medical conditions that can affect HbA1c measurements and be aware of possible measurement alternatives such as fructosamine and glycated albumin.

Racial Disparities in Nutritional Risk among Community-Dwelling Older Adults in Adult Day Health Care.

Information regarding nutritional risk among users of American adult day health centers (ADHCs), 60% of whom are racial minorities, is scant. This study examined nutritional risk and associated factors in a diverse sample ADHC users aged 50+ using secondary cross-sectional analysis of data collected between 2013 and 2017. Risk was assessed using the DETERMINE checklist, and results were stratified by race. The majority of the sample (N = 188) was at moderate (45.2%) or high (38.5%) nutritional risk, with statistically significant racial differences. Blacks were at greater risk than any other group: 65% had high nutritional risk; 76.5% ate <5 servings of fruits, vegetables, or milk daily; 21% ate <2 meals daily, 48.5% reported involuntary weight loss/gain, and 41.2% had tooth loss/mouth pain. Older adults in ADHCs are at elevated risk of malnutrition, disproportionately so amongst blacks. Both routine nutrition screening and population-specific approaches are needed to attenuate risk.