Public Health Nutrition

BackgroundIn 2016, Chile implemented a multi-phase set of policies that mandated warning labels, restricted food marketing to children, and banned school sales of unhealthy foods and beverages. Chiles law, particularly the warning label component, set the precedent for a rapid global proliferation of similar policies. While our initial evaluation showed policy-linked decreases in purchases of products carrying the warning label, a longer-term evaluation is needed, particularly as later phases of Chiles law included stricter nutrient thresholds and introduced a daytime ban on advertising of labeled foods for all audiences. The objective is to evaluate changes in purchases of energy, sugar, sodium, and saturated fat purchased after Phase 2 implementation of the Chilean policies. Methods and FindingsThis before- and after-study used longitudinal data on monthly food and beverage purchases from 2,844 Chilean households (138,391 household-months) from July 1, 2013 until June 30, 2019. Nutrition facts panel data from food and beverage packages were linked at the product level and reviewed by nutritionists. Products were considered to carry the warning label if they contained added sugar, sodium, or saturated fat, and exceeded the final phase nutrient or calorie thresholds (thus would carry the warning label). Using correlated random-effects models and an interrupted time series design, we estimated the nutrient content of food and beverage purchases associated with Phase 1 and Phase 2 compared to a counterfactual scenario based on pre-policy trends. Compared to the counterfactual, we observed significant decreases in purchases of foods and beverages carrying the warning label during Phase 2, including a relative 36.8% reduction in sugar (-30.3 calories, 95% CI -34.5, -26.3), a 23.0% relative reduction in energy (-51.6 calories, 95% CI -60.7, -42.6), a 21.9% relative reduction in sodium (-85.8 mg, 95% CI -105.0, -66.7) and a 15.7% relative reduction in saturated fat (-6.4 calories, 95% CI -8.4, -4.3). Decreases were partially offset by increases in non-labeled purchases, but the net effect shows a significant decrease in total nutrients of concern purchased during Phase 2. Reductions in sugar and energy were driven by beverage purchases, whereas reductions in sodium and saturated fat were driven by foods. The pattern of declines in purchases was similar for households of lower vs. higher socioeconomic status. A key limitation of this study is that the data include only a portion of what Chilean households purchase that, while including important categories impacted by the law, do not cover an entire diet. ConclusionsThe Chilean policies on food labeling, marketing, and school food sales led to declines in nutrients of concern during a more complete phase of implementation, particularly from foods and drinks carrying the warning label.

The COVID-19 pandemic has had profound impacts on the global food system, supply chain, and employment, which, in turn, has created numerous challenges to food access and food security. Early exploratory studies suggest significant increases in food insecurity in the United States. Comprehensive longitudinal research across multiple locations is needed to understand the range of impacts and responses at the household level and to improve preparedness for future events. This protocol paper outlines the formation of the National Food Access and COVID research Team (NFACT), a collaborative, interdisciplinary, multi-state research effort that will utilize common measurement tools, codebooks, code, data aggregation tools, and outreach materials to collectively examine and communicate the effect of COVID-19 on household food access and security. NFACT is led by an executive committee of researchers from four institutions, with additional NFACT collaborating institutions across more than a dozen states. A survey was developed by the NFACT executive team in March 2020, with additional refinements in May 2020, using both existing validated questions and new original questions, which were piloted and validated in Vermont. The project provides suggestive guidance for recruitment, and is designed to allow each study site to adopt recruitment strategies that meet their budget and needs. Primary outcomes of interest include food security status, employment status, food access challenges and concerns, dietary intake, and use of food assistance programs. Additional outcomes assess emotional eating, stigma, COVID-19 perceptions and experiences, and pro-environmental purchasing behaviors. This protocol and the establishment of NFACT provide important advancements in COVID-19 and food security research by generating harmonized data and assessing comparable outcomes across geographies and time. The collaborative, open-source approach makes research tools available to teams who might not have the resources to design their own tools, and can enable streamlined data collection, large-scale comparative analyses, and cost savings through reduced administrative tasks. The project has contributed to building new networks between and within states. Enabling facilitation and implementation of instruments in study sites has provided flexibility and meaningful opportunity for local stakeholder engagement and relevant outreach for informed public health decision-making.

ObjectiveHousehold Consumption and Expenditure Surveys (HCES) are increasingly used to assess diets in low- and middle-income countries, but their validity compared to individual-level dietary data remains uncertain. We assessed the strengths and limitations of HCES data for informing strategies to improve diets and nutrition in Tanzania. DesignExploratory analysis of food group consumption from HCES (individualized using the adult female equivalent approach) and 24-hour dietary recall (24hR). We examined concordance and trends by socioeconomic characteristics between methods for 10 food groups and fortifiable food vehicles. SettingRural Arusha and Kilimanjaro regions, and national data from the Tanzania National Panel Survey Wave 5. ParticipantsThe analysis included 2,599 adult women who completed a 24hR and lived in 2,604 households contributing to HCES data in Arusha and Kilimanjaro. Nationally, 4,469 households were included, with a regional subsample of 370 households from Arusha and Kilimanjaro. ResultsDietary patterns were similar using HCES and 24hR data, including low consumption of nutrient-dense foods, while HCES were effective at capturing usual intake of food items eaten episodically. However, compared to 24hR data, energy intakes were substantially lower using HCES data, particularly in large households (42% difference), while there was poor concordance between methods for fruit and meat consumption and for wealth-related trends in cereal and vegetable intake. ConclusionHCES data can provide valuable insights for nutrition policy and planning, however, careful communication and interpretation of evidence is required, given limitations such as assumptions on within-household allocation of foods. Methods development could reduce measurement error.

BackgroundNutritional warnings are used as a public health strategy to prevent increases in obesity prevalence. Peru approved in 2013 and implemented in 2019 a Law requiring nutritional warnings on the marketing and packaging of processed foods high in sugar, sodium, saturated fat, and containing transfat. The complexity behind the implementation of this set of policies over six years provide unique learnings, essential to inform the obesity prevention context, especially when facing strong opposition from powerful stakeholders such as the food industry. AimsDescribe milestones and key stakeholders roles and stances during the nutritional warnings policy design in Peru; and identify and analyze the main drivers of policy change that explain its approval. MethodologyIn 2021, interviews were conducted with 25 key informants, advocates and opponents of the policy, closely involved in its design. Interviews were analyzed using the Kaleidoscope Model as a theoretical framework. Relevant policy documents and news were also analyzed. ResultsMilestones for this policy were the approval of the Law, Regulation, and Manual. Policy supporters were mainly from the Congress, civil society organizations, and Health Ministers; whereas opponents came from other parties in the Congress, ministries linked to the economic sector, the food industry, and media. Across the years, warnings evolved from a single text, to traffic lights, to the approved black octagons. Main challenges included the strong opposition of powerful stakeholders; the lack of agreement for defining the appropriate evidence for nutritional warning parameters and design; and the political instability of the country. Based on the Kaleidoscope Model, the policy successfully targeted a relevant problem (unhealthy eating decisions) and had powerful advocates who effectively used focusing events to reposition the warnings in the policy agenda across the years. Negotiations weakened the policy but led to its approval. Importantly, government veto players were mostly in favor of the policy, which enabled its final approval despite the strong opposition. ConclusionsDespite the strong opposition faced and technical and political difficulties to define the best parameters and warnings design, Perus nutritional warnings policy was approved. Lessons learned are essential to inform similar and related prevention policies in Peru and elsewhere.

BackgroundThe COVID-19 pandemic has intensified economic hardships, with potential negative impacts on food insecurity and infant feeding beliefs and practices. The relationship between food insecurity and infant feeding beliefs and practices during the pandemic is not yet fully understood. Neither is how these relationships changed over the course of the waves of the pandemic. We examined these relationships in a cohort of infants born during the various waves of the COVID-19 pandemic in New York City (NYC). MethodsWe conducted a cross-sectional analysis of infants enrolled from birth into the COVID-19 Mother-Baby Outcomes (COMBO) study and born March 2020 to May 2024. We measured food insecurity in the prior 30 days with a 2-item survey adapted from Hunger Vital Sign, infant feeding confidence at hospital discharge, and current infant feeding practices. ResultsIn our sample, 40% of women had been exposed to prenatal SARS-CoV-2 infection and approximately 24% of mothers were food insecure. There was a significant association between food insecurity and prenatal SARS-CoV-2 infection, Spanish as ones preferred language, and self-identifying as Latina. In unadjusted models of the entire sample, food insecurity was associated with formula feeding, with 44% of food insecure mothers opting to formula feed vs. 28% of food secure mothers (p<0.001), but this relationship was no longer significant after adjusting for covariates (p=0.059). In comparing the first and second waves of the pandemic (March 2020-December 2021 vs. January 2022-May 2024), there was no significant difference in rate of food insecurity. When comparing different waves of the pandemic, food insecurity was associated with increased likelihood of formula feeding, even after adjusting for confounders. DiscussionFood insecurity was initially associated with feeding methods, but this relationship lost significance after adjusting for confounders. However, when analyzed separately, food insecurity was significantly linked to lower odds of exclusive breastfeeding during different waves of the pandemic, suggesting the influence of external factors like policy changes and social support variations. Other factors, such as maternal BMI, ethnicity, and delivery mode, were also significantly associated with breastfeeding practices, highlighting the need for targeted interventions to support breastfeeding, especially among food-insecure mothers.

BackgroundThe introduction of mandatory calorie labelling among large food businesses (chains) in England in 2022 has been found to have little impact on consumer behaviour, but overall calories on restaurant menus have decreased slightly. This study examined menu changes post policy implementation, and the population groups likely to have been affected most. MethodsMenu data from 169 chains in Great Britain were extracted from two online food delivery platforms in June 2022 and June 2023. We selected 10 categories (specific foods or chains) jointly with public and policy advisors. Menu changes over time were assessed with multilevel models accounting for whether an item was continuously on the menu and for the type of chain. Where changes were found, we assessed differences in purchasing frequency by consumer characteristics using 2022 OOH purchase data (Worldpanel by Numerator, GB OOH Panel). ResultsChanges were observed in two (out of 10) categories examined and were driven by changing items on the menu rather than reformulating continuous dishes. Chains that used a healthy tag on the delivery website increased the share of mains under 600 kcal by 3.7 percentage points (95% CI 0.2 to 7.2), while average calories did not change (-17.6 kcal/item, 95% CI -38.7 to 3.4). Men, people aged 35-44 years and with high SES were found to purchase more frequently from these chains. Across all chains, the share of lower-calorie coffees decreased by 10 pp (95% CI -18.0 to - 0.02), with purchasing more frequent among men and increasing with age. ConclusionsAlthough data were available for one year only post-policy implementation, menu changes among the investigated foods and chains were limited. While menu change may equitably improve population dietary health, dietary inequalities may exacerbate if only healthy chains already offering lower-calorie food change their menus.

Assessing behaviors related to food choice at individual- and household-levels is essential for improving household diets, but assessment tools are limited. We conducted a systematic review to identify gaps in existing assessment tools for food acquisition, preparation, and household consumption practices in South Asia, wherein diets are rapidly changing, and triple burden of malnutrition is emerging. Systematic search of three academic databases (PubMed, Scopus, and Web of Science Core Collection) using pre-defined keywords were undertaken to identify studies assessing food acquisition, food preparation, and household consumption practices in South Asia, published in English between 2000 and December 2023. Following PRISMA guidelines, two reviewers independently screened titles, abstracts, and full texts based on the inclusion criteria, and extracted data on study characteristics and the assessment tools used to examine the food choice behaviors. Of 11,288 unique articles identified, 46 were included for synthesis. Food acquisition behaviors were assessed by 25 studies, food preparation by eight studies and household consumption practices by 26 studies. Most studies used quantitative methods (n=30), some used qualitative (n=13), and few used mixed methods (n=3), and varied by type of behavior assessed. Likert scales were the most widely used tools of quantitative assessments, while semi-structured interviews were the most common for qualitative assessments. Across the 46 studies, 59 different tools were used to assess food-related behaviors and only 14 studies claimed using validated tools and many studies did not include the full tool in the text or supplement (n=22). Our review highlights the need for expanding food choice behavior assessments to include the less-studied populations such as exploring young children and adolescents food choice behaviors and developing a contextually adaptable repository of validated tools to advance our understanding of food choice behaviors in various settings. Registry: Open Science Framework Registries Registration DOI: https://doi.org/10.17605/OSF.IO/5GPEF

BackgroundThe Israeli operation in the Gaza Strip has damaged much of the territorys food system, exposing vulnerable population groups to poor nutrition. We retrospectively estimated food availability per capita and the contribution of different food sources and categories during the first ten months of the war. MethodsWe described the composition and caloric value of food trucked into Gaza based on United Nations data over the period 7 October 2023 to 31 August 2024 and compared these with the Israeli governments. We supplemented trucking data with information on baseline stocks, agricultural output, air or seaborne deliveries, population denominators and pre-war caloric intake estimates into a probabilistic simulation to estimate caloric availability in both northern and south-central governorates. ResultsBetween October 2023 and April 2024, food trucks entering Gaza remained below pre-war levels. Israeli data offered higher estimates of food weight trucked in but appeared to feature extreme approximation. Following Israels takeover of crossings in May 2024, United Nations data likely featured underreporting, though even Israeli data indicated declining deliveries. The share of food categories changed little during the period analysed, but trucked-in foods caloric value was lowest just as food was scarcest (February-March 2024). Trucks accounted for three-fourths of food in south-central Gaza, but <20% in the north; air and sea deliveries made up a small percentage. During at least 12 weeks in northern and 4 weeks in south-central Gaza, per-capita caloric availability was below the recommended intake. ConclusionsIsrael, as occupying power, did not ensure sufficient food availability throughout the analysis period, and its data appear unreliable. Existing stocks probably mitigated caloric deficits resulting from insufficient deliveries, but air and sea routes added little. Strengthened coordination of food deliveries may be warranted to optimise caloric quantity and dietary diversity despite aid restrictions.

ObjectiveTo assess the energy contribution of ultra-processed foods (UPF) and its association to sociodemographic and anthropometric factors in 6-35 months old children in the databases of national surveys carried out in 2008-2010, 2015-2016 and 2019. MethodsAll surveys were stratified multi-stage random samples. Sub-samples had 24-hr food recall on a random day for each child, using a modified multiple step method with visual aids and scales. UPF were defined based on the Nova 4 classification system. Factors were evaluated with two generalized linear models (binomial for the percentage of UPF consumers and normal for the mean UPF energy contribution among UPF consumers only). Estimations and models were adjusted by the sampling design. Results2887 children were included. UPF contributed 29% [CI95 27 to 31] of the total energy intake. UPF contributed 31% [30 to 33%] of energy intake among UPF consumers, decreasing with age, increasing with height-for-age and showing seasonal variation. UPF were consumed by 86% [84 to 89%] of children, increasing with age and height-for-age, slightly increasing over the years and decreasing with poverty. UPF energy contribution comes mainly from milk and derivatives 19% [17 to 20] and cereals 5% [4 to 6]. ConclusionsThe mean UPF energy contribution and the percentage of UPF consumers vary with age, height, poverty and survey year in 6-35 months old children in Peru.

IntroductionThe treatment of severe childhood malnutrition focuses on short-term outcomes, like mortality prevention and anthropometric recovery. However, emerging evidence suggests a possible association between post-malnutrition growth and later non-communicable disease (NCD) risk. Our aim was to inform future child malnutrition treatment programmes by describing perceptions of optimal rates of post-malnutrition weight gain/growth; assessing how short- and long-term outcomes are currently understood and prioritised; understanding perceptions of the role of malnutrition treatment services in preventing longer-term NCDs. MethodsA mixed methods study, involving a global cross-sectional online survey (December 2023-March 2024) and key informant interviews (March-July 2024). Participants were professionals with experience in severe malnutrition and/or child health, identified through convenience and snowballing sampling. Quantitative data were analysed by descriptive statistics, while qualitative data were explored by thematic analysis. ResultsSixty-eight survey respondents were included, from a range of backgrounds. Ten were also interviewed. Almost half of survey participants perceived 5-10 g/kg/d as optimal weight gain in both inpatient and outpatient treatment. In terms of programme aims, 71% ranked preventing mortality as the most important. Two-thirds (66%) rated reducing the risk of adulthood NCDs as a very important long-term aim, while 3% said this was of low/no importance. Slower post-malnutrition weight gain was seen as beneficial by 69% of respondents, while 13% had opposing views and 18% were unsure. Key concerns were avoiding overfeeding/physiological disturbances and radical changes among those who supported slower weight gain, and worries about not meeting energy requirements among those who did not. ConclusionsThere is strong consensus that preventing mortality remains the key aim of malnutrition treatment programmes but also increasing recognition of a potential to impact long-term NCD risk. Towards this, perceptions of optimal post-malnutrition weight gain targets vary, and better evidence is urgently needed to inform future policy/practice. What is already known on this topicTreatment of severe childhood malnutrition focuses on short-term outcomes, such as mortality prevention and anthropometric recovery. Longer-term outcomes are rarely considered, yet recent evidence suggests a possible association between rapid post-malnutrition growth and later non-communicable disease (NCD) risk. What this study addsPolicy makers, programme managers, researchers, and other professionals leading current nutrition treatment programmes prioritise short-term outcomes of malnutrition treatment but most also believe that treatment can impact long-term outcomes, including NCDs. However, perceptions of the importance of any impact vary, as do ideas about how this can be achieved and concerns regarding risk-benefit balance (e.g., slower growth might reduce future NCD risk but compromise short-term outcomes like mortality). How this study might affect research, practice or policyVaried opinions on post-malnutrition weight gain and growth reflect large current evidence gaps and the urgent need for future research to determine optimal weight gain targets and growth patterns. Our data also highlights the need for greater consideration of long-term outcomes when planning malnutrition-related programmes and policy.

ObjectiveTo investigate mothers experiences during the 2022 infant formula shortage in the United States and its perceived impacts on infants diet and health. MethodsMothers of infants under 8 months old were recruited from Washington D.C. using social media and neighborhood listservs and invited to participate in a virtual study meeting between June 22 and July 14, 2022. Mothers completed a brief survey with questions about their demographic characteristics, infants anthropometric characteristics, and infant feeding practices, and participated in an in-depth, qualitative interview about their experiences during the infant formula shortage. Survey data were analyzed using means and frequencies, as appropriate. Qualitative interviews were recorded, transcribed verbatim, coded, and thematically analyzed. ResultsThe sample (n=28) was predominantly White and highly educated. Five overarching themes were identified, including the shortage had: 1) adverse impacts on mothers mental and emotional health; 2) significant financial and intangible costs; and 3) led to changes in infant feeding practices; and, 4) social and family networks were helpful in navigating the shortage; and 5) mothers felt fortunate to have resources to breastfeed and/or obtain formula. Most mothers reported the shortage had not yet detrimentally impacted their infants health. ConclusionsEven among highly educated women with access to financial, social, structural resources, the infant formula shortage adversely impacted mothers mental and emotional health, and has been costly, in terms of financial and intangible costs. Findings demonstrate the urgent need to develop strategies to support mothers in feeding their infants, especially mothers who may lack the resources to locate and obtain formula.

ObjectiveThis study examined the effect of home and wild food procurement (HWFP) activities (i.e., gardening, hunting, fishing, foraging, preserving food, raising livestock, and raising poultry for eggs) on food security status, fruit and vegetable intake, and meat consumption. DesignWe used data collected in 2021 and 2022 through two statewide representative surveys (n = 2,001). Dietary intake was assessed using the Dietary Screener Questionnaire. We analyzed the data using linear regression, logistic regression, and ordinal logistic regression models. SettingMaine and Vermont, United States Participants2,001 adults (18 years and older) ResultsSixty-one percent of respondents engaged in HWFP activities; the majority of those gardened. Households engaging in most individual HWFP activities had greater odds of being food insecure. HWFP engagement was positively associated with fruit and vegetable consumption. Specifically, gardening was associated with an additional one cup-equivalent in fruit and vegetable consumption per week compared to respondents that did not garden. Furthermore, when exploring these relationships disaggregated by food security status, we find that this effect is stronger for food insecure households than food secure households. Respondents from households that hunted were more likely to eat wild game meat and also consumed red and white meat more frequently compared to households that did not hunt. ConclusionOverall, our results indicate potential public health and food security benefits from engaging in HWFP activities. Future research should continue to examine a full suite of HWFP activities and their relationship to diet, health, and food security.

BackgroundFood insecurity poses a threat to adolescent nutrition and health, especially in low- and middle-income countries (LMICs), with potential lifelong consequences. This study assessed the prevalence and drivers of adolescent food insecurity in Ghanas Volta and Oti regions. ObjectivesTo assess the prevalence and predictors of food insecurity among adolescents in the Volta and Oti regions of Ghana. MethodsO_ST_ABSDesignC_ST_ABSA community-based cross-sectional study SettingThe study was conducted in the Volta and Oti regions of Ghana. ParticipantsThe sample included 667 adolescents aged 10-19 years. Outcome MeasureWe measured food insecurity using the Household Food Insecurity Access Scale (HFIAS). Data were collected using a two-stage sampling approach. Adolescents food insecurity status was categorised into food secure, mildly, moderately, or severely food insecure. Multivariable logistic regression analysis was employed to identify the risk factors associated with food insecurity. ResultsApproximately 47.5% of the surveyed adolescents reported experiencing periods of inadequate food intake during the 12 months preceding the survey. Among adolescents experiencing food scarcity, the periods from January to March (32.2%) and April to June (28.8%) were identified as the peak times of limited food availability. In total, 61% of adolescents in the Volta and Oti regions experienced food insecurity, with 23.5% classified as severely food insecure, 47.7% worried about not having enough food, and 54% could not access preferred foods due to limited resources. Approximately 50.1% consumed a monotonous diet and 44.1% consumed foods they perceived as socially unacceptable. Urban residence (aOR = 0.67; CI=0.46-0.97), higher maternal education (aOR=0.41; CI=0.22-0.78), and higher wealth (aOR=0.02; CI=0.0-0.09) were associated with reduced odds of food insecurity. ConclusionThere was a high prevalence of adolescent food insecurity in the Volta and Oti regions of Ghana. This has profound implications for adolescent nutrition, health, and overall well-being. Peak periods of food scarcity align with the broader seasonal food scarcity patterns and lean seasons in Ghana. The high rates of food insecurity directly impede the goal of achieving SDG 2 and 3. Key predictors include urban-rural differences, maternal education, and wealth. Urgent action is needed to address these factors and ensure consistent access to nutritious food. Strengths and limitations of this studyO_LIWe used the widely accepted Household Food Insecurity Access Scale (HFIAS), a standardized and comprehensive tool for assessment of food insecurity. C_LIO_LIWe employed multistage systematic sampling, enhancing representativeness and generalizability within the Volta and Oti regions. C_LIO_LIA cross-sectional design limits the ability to establish causal relationships. C_LIO_LIPotential self-reporting bias may affect data accuracy due to socially desirable or inaccurate responses. C_LIO_LIFindings may not be generalisable beyond the studied regions because of socioeconomic and cultural differences. C_LI

BackgroundExposure to marketing for foods high in sugar, salt, and fat is considered a key risk factor for childhood obesity. To support efforts to limit such marketing, the World Health Organization Regional Office for Europe has developed a nutrient profile model (WHO NPM). Germanys Federal Ministry of Food and Agriculture plans to use this model in proposed new legislation on food marketing directed towards children, but the model has not yet been tested on products on the German market. Against this backdrop, the present paper aims to assess the feasibility and implications of implementing the WHO NPM in Germany. MethodsWe applied the WHO NPM to a random sample of 660 food and beverage products across 22 product categories on the German market drawn from Open Food Facts, a publicly available product database. We calculated the share of products permitted for marketing to children based on the WHO NPMs nutrient and ingredient criteria, both under current market conditions and for several hypothetical reformulation scenarios. We also assessed effects of adaptations to and practical challenges in applying the WHO NPM. ResultsThe median share of products permitted for marketing to children across the models 22 product categories was 20% (interquartile range (IQR) 3-59%) and increased to 38% (IQR 11-73%) with model adaptations for fruit juice and milk proposed by Germanys Federal Ministry of Food and Agriculture. With targeted reformulation (assuming a 30% reduction in fat, sugar, sodium and/or energy) the share of products permitted for marketing to children increased substantially (defined as a relative increase by at least 50%) in several product categories (including bread, processed meat, yogurt and cream, ready-made and convenience foods, and savoury plant-based foods), but changed less in the remaining categories. Practical challenges in applying the model included the ascertainment of the trans-fatty acid content of products, and the classification of products not required to carry nutrient declarations, such as fresh meats, fish, and similar products. DiscussionThe application of the WHO NPM to a random sample of food and beverage products on the German market was found to be feasible. Its use in the proposed new legislation on food marketing in Germany seems likely to serve its intended public health objective of limiting marketing in a targeted manner specifically for less healthy products. It seems plausible that it may incentivise reformulation in some product categories. Practical challenges in applying the model could be addressed with appropriate adaptations and procedural provisions.

ObjectiveThis study aimed to monitor the initial 12 months of the implementation of the updated nutrition labeling regulations in Brazil approved in 2020, focusing on the presence and readability of the front-of-package nutrition labeling (FOPNL) on food packages and the presence of added sugars information in the nutrition facts panel. MethodsWe used data on nutrition information and FOPNL of 6,829 products launched at Brazilian food retail between November 2022 and October 2023, available at the Mintel - Global New Products Database. We applied eligibility criteria stipulated by regulations to identify products eligible for FOPNL. We classified the foods according to the NOVA classification, identified the products with added sugars information in the nutrition facts panel and those with FOPNL for added sugar, saturated fat or sodium. Moreover, we analyzed the temporal trends in FOPNL presence. Last, a subsample of 202 product labels was analyzed to identify non-compliance with FOPNL readability standards. ResultsIn the first year of implementation 63.9% of the products analyzed were eligible for at least one critical nutrients FOPNL; however, only 12.9% already featured FOPNL by the end of the 12-month implementation period. Among ultra-processed products, 65.1% were supposed to have FOPNL, but only 14.4% did. Less than 30% of sweet cookies, ice cream, tabletop sweeteners, and candies with added sugar in the list of ingredients declared this information in the nutritional facts panel. Analysis of label images revealed non-compliance with FOPNL readability regarding its location on the packaging, FOPNL in removable parts of the packaging or hidden positions, and inadequate color pattern and format. ConclusionThe implementation of the nutrition labeling regulations in Brazil within the first 12 months reached less than 15% of eligible foods and beverages, indicating non-compliance by the food industry. Such inadequacies undermine the expected impact of promoting healthier choices at the point of food purchase.

Introduction: Minimum dietary diversity (MDD) is a key indicator of complementary feeding among children aged 6-23 months. This study examines the prevalence, trends, and determinants of MDD in Bangladesh over the period 2014 - 2022. Design: Secondary analysis of the Bangladesh Demographic and Health Survey (BDHS) data between 2014 and 2022. The primary outcome was MDD defined as consumption of at least 5 of 8 food groups (MDD-8). We included 6,080 children aged 6-23 months to assess trends over time. The pooled datasets were used to identify factors associated with MDD-8. Multiple logistic regression was performed to assess the association between different factors and MDD-8, accounting for the complex survey design. Setting: Bangladesh Results: The proportion of children achieving MDD-8 increased from 26.4% in 2014 to 38.7% in 2017, but plateaued at 37.1% in 2022, with an average annual increase of 4.3% between 2014 and 2022. MDD-8 improved with child age. Higher odds of achieving MDD-8 were observed among children surveyed in later years, from wealthier households, with mothers who had >=4 ANC visits, received PNC, had higher education, were employed, and had media exposure. Older age and higher birth order were also associated with achieving adequate MDD. Children in Chattogram and Sylhet were less likely to meet MDD-8 compared to Dhaka. Conclusions: While dietary diversity improved between 2014 and 2017, progress stalled thereafter. Targeted, multisectoral strategies focusing on womens empowerment, health service utilisation, media engagement, and disadvantaged regions are needed to improve child dietary diversity in Bangladesh.

BackgroundLow income and food insecure households are at risk of poor dietary quality and food insecurity. Especially in childhood, consuming a nutritionally adequate diet is an essential driver of health, growth, and development. Prior research has shown many household-level factors can present challenges to support the nutritional needs of the members of low income and food insecure households. ObjectiveThe aim of the scoping review is to identify the contributing factors to dietary quality and food security in U.S. households of school-aged children and synthesize the evidence. MethodsThe scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols Extension for Scoping Reviews (PRISMA-ScR) using search terms addressing food insecurity, low-income and dietary behaviors in the database PubMed (NCBI). Screening by 3 independent reviewers at the title, abstract, and full study phases identified forty-three studies included in the review. ResultsThe studies addressed six themes: parental behaviors, child/adolescent behaviors, food procurement behaviors, food preparation behaviors, and psychosocial factors. Most studies were cross-sectional (n = 40, 93%) and focused on parental behaviors (n = 24, 56%), followed by food procurement behaviors, and food preparation behaviors. ConclusionThe findings can be used to inform the development of future nutritional education interventions aimed at improving the dietary quality and food security in households with children. The themes identified were interrelated and suggest that providing parents with education on the following topics: 1) the importance of modeling positive eating behaviors in the home, 2) approaches to support and encourage positive feeding practices with their children, and 3) practical strategies to overcome barriers to purchasing and preparing foods of high nutrient quality. For example, delivering educational sessions on meal selection and preparation and improving nutritional knowledge hold promise to improve dietary quality among food insecure and low-income households.

ABSTRACTChildhood undernutrition, manifested as stunting, wasting, and underweight, remains a major public health challenge, particularly in low- and middle-income countries. In Zambia, the burden of undernutrition remains persistently high despite ongoing interventions. This study analyzed trends and determinants of nutritional status among children under five years using data from the Zambia Demographic and Health Survey (ZDHS) conducted in 2001, 2007, 2013-14, and 2018. The analysis assessed the prevalence of stunting, underweight, and wasting in children aged 0-59 months, using mean Z-scores and standard deviations. Logistic regression models were applied to identify key socio-demographic and health-related risk factors, with analyses performed in Python, accounting for survey design and weights. Findings revealed a notable decline in malnutrition: stunting dropped from 45.6% in 2001 to 34.7% in 2018; underweight from 27.3% to 11.6%; while wasting remained stable at approximately 4%. Severe stunting and underweight also decreased significantly, whereas severe wasting fluctuated. Prevalence rates were higher when excluding children under six months (left-truncated data), suggesting possible protection from early infancy due to exclusive breastfeeding. Key predictors of malnutrition included low birth weight, poverty, regional disparities, and diarrheal episodes. Despite progress, stunting remains a pressing concern. The higher rates observed in older infants point to the need for strengthened interventions targeting the postnatal period. Enhancing maternal and child health services, improving nutrition programs, and addressing poverty are critical to sustaining reductions in childhood malnutrition.

BackgroundFederal and state school nutrition policies over the past 20 years have improved nutritional quality of school meals, childrens diet quality, and childhood obesity prevalence in the United States. However, increasing use of mobile food delivery apps during school hours may introduce new dietary risks among adolescents. This study aimed to assess the usage patterns and perceptions of mobile food delivery during school hours among adolescents. MethodsWe administered a national online survey in July-August 2025 using the AmeriSpeak Teen Omnibus platform administered by NORC at the University of Chicago. The respondents were 1,027 adolescents aged 13-17 years. We estimated and statistically compared survey-weighted distributions of self-reported types and frequencies of mobile food app usage characteristics during and after school by age, sex, race/ethnicity, household income levels, and regional strata using Chi-squared tests. We also conducted thematic analyses of responses to an open-ended question asking whether participants supported or opposed usage of mobile food delivery services during school hours. ResultsNearly 1 in 4 adolescents used mobile food delivery services during school hours and nearly half used them after school. Large proportions of adolescents (58.8% and 34.1%) used these services to order fast foods and sugar-sweetened beverages, respectively, while grain bowls, fruit, non-deep fried vegetables, and unsweetened beverages were less popular. About 34% of adolescents in the western U.S. attended schools that allowed mobile food delivery during school hours, a substantially higher proportion than other national regions; however, adolescents in the west more frequently avoided using these services due to the perceived high costs. Nearly half of the respondents support the idea of mobile food delivery during school hours, although distraction from their learning environment was a major concern regardless of their support or opposition. ConclusionsMobile food delivery during school hours is a relatively new method of food acquisition for adolescent students. School nutrition policy should consider students access to and usage patterns of both physical and digital food environments to help ensure development of lifelong healthy eating habits among adolescents.

We examined diet among children 6-23 and 24-59 months participating in a 2-year longitudinal study with six waves of data collection in Samburu and Turkana counties, Kenya. Information on child feeding practices was collected using methods recommended by the World Health Organization and UNICEF. Grains, roots, and tubers were nearly universally consumed. Dairy was the dominant animal source food (ASF), though declined sharply from Wave 1-5 among children 6-23 months and remained low across waves among children 24-59 months. The proportion of children who consumed fruits and vegetables, legumes and nuts, and eggs was low across waves. About half of children 6-23 months consumed sweet drinks at Wave 1 and consumption increased thereafter in both counties. Among children 24-59 months, nearly 90% of children in Samburu and about 65% in Turkana consumed a sweet drink across waves. Across all survey waves, only 11% and 5% of observations included foods from four or more food groups (representing minimum dietary diversity) in Samburu and Turkana, respectively. The mean number of food groups consumed ranged between 1.5 and 2.5, even among food secure households, though children in food secure households consumed about 0.5 more food groups. Children were more likely to consume dairy or any other ASF compared with their mothers, suggesting that mothers prioritize the nutritional needs of children over their own. The high prevalence of sweet drink consumption is mainly from sweetened tea, which is most likely given as a substitute for milk when milk is unavailable in pastoral and agropastoral households.