Public Health Nutrition

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.

BackgroundPaediatric liquid medicines (PLMs) routinely contain sucrose to improve palatability, yet their cariogenic potential is well established. Healthcare professionals awareness and prescribing practices regarding sugar-free PLMs have received limited study in India, particularly in Uttarakhand. MethodsA descriptive cross-sectional study was conducted among 500 healthcare professionals aged [&ge;]25 years, using a pilot-tested structured questionnaire (Cronbachs = 0.85), administered online and in person across Uttarakhand districts (January-March 2024). After excluding 69 incomplete responses, 431 participants were analysed (response rate: 86.2%), comprising general medicine practitioners (49%, n = 211), paediatricians (27%, n = 116), and dental practitioners (24%, n = 104). Descriptive statistics and chi-square tests were applied (p < 0.05). ResultsPrescription decisions were primarily driven by childs age and weight (58%), cost (40%), and pharmaceutical brand (37%). While 88% recognised PLM sweetness and 67% were aware of pH-dental harm links, only 20% associated PLMs with dental caries. Overall awareness of hidden sugars was 73%. Eighty-three percent knew of sugar-free alternatives (50% local availability), yet 80% found them less palatable and 85% costlier. Only 48% routinely provided oral health advice. A statistically significant association was found between specialty and sugar-free PLM awareness (p = 0.03), with dental practitioners recording the highest awareness (90%). ConclusionsHealthcare professionals demonstrated variable levels of knowledge, attitudes, and practices regarding PLMs, with critical gaps in caries recognition (20%) and oral health counselling (48%). Despite high sugar-free PLM awareness, uptake is constrained by perceived cost and palatability barriers. Targeted continuing medical education and policy measures, including sucrose-free labelling promotion, are needed to improve paediatric oral health outcomes in Uttarakhand. KEY MESSAGESO_LIOnly 20% of healthcare professionals in Uttarakhand associated pediatric liquid medicines (PLMs) with dental caries, representing a critical knowledge gap despite 88% recognising their sweetness. C_LIO_LIOverall awareness of hidden sugars in PLMs was 73%, yet only 48% routinely provided post-prescription oral health counsellingsubstantially below international benchmarks. C_LIO_LIEighty-three percent were aware of sugar-free PLM alternatives, but adoption was constrained by perceived inferior palatability (80%) and higher cost ([~]10% premium, cited by 85%). C_LIO_LIDental practitioners demonstrated significantly higher sugar-free PLM awareness than general practitioners and pediatricians (p = 0.03), supporting the case for interprofessional oral health education in medical training. C_LIO_LITargeted continuing medical education (CME) and policy measuresincluding sucrose-free labelling mandates and institutional formulary inclusionare needed to convert awareness into prescribing practice change. C_LI

Introduction Acute malnutrition in children aged 6-23 months remains critical in Tigray, Ethiopia, where global acute malnutrition (GAM) rates have reached emergency levels. Small-quantity lipid-based nutrient supplements (SQ-LNS) show promise for prevention, but evidence from post-conflict settings is limited. Objective This study evaluated SQ-LNS effectiveness in preventing acute malnutrition and rightward shifting in the distribution of weight-for-height among young children in post-conflict Tigray, Ethiopia. Methods A non-randomized cluster trial enrolled 8,442 children aged 6-23 months across four districts. The intervention group (n=6,838) received daily 20g SQ-LNS sachets for six months plus behavior change communication; the control group (n=1,604) received standard nutrition programming. Primary outcomes were acute malnutrition prevalence (WHZ < -2 or MUAC < 12.5cm) and distribution of weight-for-height z-scores. Data were collected biweekly and analyzed using longitudinal comparisons and difference-in-differences (DiD) estimation. Results Acute malnutrition declined from 22.1% to 4.2% in the intervention group (17.9 percentage point reduction) versus 19.6% to 11.4% in controls (8.2-point reduction). Mean WHZ scores increased from -0.35 to +0.33 in the intervention group (gain of +0.68 z-scores), while controls improved from -0.79 to -0.63 (gain of +0.16). The net intervention effect (DiD) showed a 4.9 percentage point reduction in WHZ-defined GAM and a 9.7-point reduction in MUAC-defined GAM. Mean WHZ and MUAC increased significantly more in the intervention group (DiD: +0.52 z-scores and +3.88 mm, respectively). Critically, the entire WHZ distribution shifted rightward, indicating population-level nutritional improvement, not merely reduced caseloads. Conclusions Six months of daily SQ-LNS effectively prevented acute malnutrition and shifted the entire weight-for-height distribution rightward among young children in post-conflict Tigray. Benefits extended beyond treatment, lifting whole-population nutritional status and building resilience. Findings support SQ-LNS inclusion in post-conflict nutrition packages and highlight the importance of assessing distributional outcomes, not just prevalence, when evaluating nutritional interventions. Trial registration number This trial was registered as NCT06103084.

Background: Accurate dietary assessment is essential for precision nutrition and effective nutrition surveillance. However, portion size estimation remains a persistent challenge, particularly in culturally diverse regions such as Central Asia. Traditional self-reporting tools often yield inconsistent results due to communal eating practices and unfamiliarity with standard measures. Objective: To address these limitations, this study aimed to compare three methods: unassisted human judgment, visual food atlas assistance, and an artificial intelligence (AI) model, using Central Asian food items. Methods: In this cross-sectional study, 128 participants from Astana, Kazakhstan, visually estimated portion sizes of 51 foods and 8 beverages from standardized photographs. Participants were randomized into two groups: one using unassisted visual estimation and the other aided by a regionally tailored digital food atlas. Additionally, an AI model trained on Central Asian food images was evaluated. Actual food weights served as the reference standard. Accuracy was assessed using Mean Absolute Error (MAE) and Mean Absolute Percentage Error (MAPE) across food types and portion sizes. Results: The atlas-assisted group demonstrated the highest accuracy, with the lowest MAE (80.81g) and MAPE (44.76%) across all portions. The AI model showed promising results for average portions (MAE: 79.07g, MAPE: 67.91%) but underperformed on small portions, particularly for meat-based items. Unassisted estimates were the least accurate (MAE: 133.86g, MAPE: 79.40%). Across food categories, visual aids consistently improved accuracy, while AI demonstrated variability by texture and portion size. Conclusions: Culturally adapted visual atlases significantly enhance portion size estimation accuracy in non-Western, communal-eating contexts. While AI models hold promise for dietary assessments, particularly with standard portions and beverages, further refinement is needed for complex food items and small portion types. These findings support the integration of visual and AI-based tools into region-specific dietary monitoring strategies.

Introduction High consumption of ultra-processed foods (UPF) is associated with adverse health outcomes and weight gain. Despite increasing calls for behavioural strategies to reduce UPF intake, no theory-informed intervention targeting UPF reduction has been evaluated in UK adults in alignment with national dietary guidance. We assessed the feasibility, acceptability, and preliminary behavioural and clinical outcomes of a multi-component intervention designed to reduce UPF consumption (and increase physical activity (PA)/minimally processed food (MPF) intake). Methods In this exploratory single-arm pre-post study, adults (N=45) living with overweight or obesity and habitual UPF intake [&ge;]50% of total energy were offered a 6-month behavioural intervention following a controlled feeding phase (UPDATE trial, stage 1). The intervention was developed using the Behaviour Change Wheel and Capability, Opportunity, Motivation-Behaviour (COM-B) model and included one-to-one sessions with a behavioural scientist, tailored print and digital materials, peer-support meetings, and a moderated group chat. Feasibility outcomes included uptake, retention, and intervention fidelity. Secondary outcomes included COM-B constructs, dietary intake, PA, clinical and self-reported outcomes, and qualitative feedback. Results Uptake was 91% (41/45). Retention at 6 months was 68% (28/41), with 83% (34/41) providing follow-up data (intention-to-treat). Median attendance at one-to-one sessions was 86% (interquartile range (IQR): 57-100) with 56% (23/41) attending all sessions (per-protocol). Fidelity to core behaviour change techniques was high. At 6 months, COM-B scores improved for healthy eating (+7%, standard deviation (SD): 8; p<0.001) and physical activity (+5%, SD: 9; p=0.013). UPF intake decreased by 25% of total energy (95% confidence interval (95%CI): -32, -17), with a corresponding increase in minimally processed foods (+23%; 95%CI: 17, 29). Vigorous physical activity increased (+60 min/week, IQR: 0-180), weekday sitting time decreased (-61 min/day, SD: 110), and weight reduced by 3.8 kg (IQR: -8.5-1.0; p=0.001). Findings were similar in per-protocol analyses. Qualitative data indicated perceived improvements in wellbeing and habit formation. Conclusion This theory-informed intervention demonstrated good feasibility and acceptability and was associated with improvements in targeted behavioural mechanisms and health-related outcomes. A randomised controlled pilot trial is warranted to evaluate effectiveness and refine implementation.

Child undernutrition remains a major public health challenge in Kenya. Suboptimal feeding practices contribute significantly to persistent underweight and stunting. This study evaluated the effect of a community-based Positive Deviance Hearth (PDH) intervention on feeding practices among children aged 6-59 months in Sub County within a County of study. The study adopted a two-group pretest-posttest randomized experimental study design conducted for six months period, among 84 caregiver-child pairs in intervention and control groups. A multi-stage sampling was employed to identify study settings and participants. Structured and pretested questionnaires, 24-hour food recall questionnaires and meal diversity questionnaires were used for data collection at pre-intervention and post-intervention periods. Data was analyzed using R software v.4.5.2. The differences between intervention and control groups at baseline and endline were assessed using difference-in-difference analysis, relevantly summarized using adjusted DID estimates, 95% confidence intervals and p-values, with p<0.05 considered significant. The PDH intervention significantly improved feeding practices among children 6-59 months. Meal frequency increased for 9-23 months (DiD = +1.4; 95% CI: 1.2-1.7; p = 0.034) and 24 months and above (DiD = +1.2; 95% CI: 1.1-1.5; p = 0.017), and dietary diversity rose (DiD = +1.3; 95% CI: 1.1-1.9; p < 0.001). Nutrient-dense food consumption improved, including legumes (DiD = +32.6%; p < 0.001) and animal-source foods (DiD = +35.4%; p < 0.001). Energy and protein intake increased across all age groups (p < 0.05), and micronutrients iron, vitamin A, vitamin C also rose significantly (p < 0.05). The PDH intervention substantially improved caregiver feeding practices, increased dietary diversity, and enhanced macro- and micronutrient intake, demonstrating its effectiveness as a scalable, community-driven strategy for sustainably improving child nutrition in high-burden settings.

Although the co-occurrence of diarrhea and malnutrition is well documented, research has largely focused on the acute management of diarrheal illness. Despite its importance, longitudinal evidence characterizing post-diarrheal recovery trajectories is sparse. We sought to characterize post-diarrheal nutritional recovery trajectories among children aged 6-35 months who were malnourished at enrollment using data from the Enterics for Global Health (EFGH) Shigella Surveillance study (2022-2024). EFGH enrolled children aged 6-35 months presenting with medically-attended diarrhea and followed them at 4 weeks and 3 months post-enrollment. This analysis included children with baseline wasting, stunting, or underweight (z-score < -2) and complete anthropometric follow-up. Latent class mixed-effects models were used to identify distinct post-diarrheal growth trajectories based on changes in anthropometric z-scores over time. Multinomial modified Poisson regression models examined associations between baseline factors and trajectory membership. Among 9,480 enrolled children, 16.5% (n=1,561) were wasted, 22.7% (n=2,155) stunted, and 21.0% (n=1,994) underweight at baseline. Wasting showed greater recovery potential (80.8%) compared with stunting (38.5%) and underweight (40.3%). Recovery was shaped by factors across multiple levels. Clinical severity markers ( prolonged diarrhea, dehydration, and hypoxemia) increased the risk of nutritional failure. Age also influenced outcomes: infants were more likely to worsen, whereas older toddlers more often experienced stagnation. Interventions including exclusive breastfeeding, oral rehydration therapy, appropriate antibiotics, and zinc supplementation, improved outcomes, while unimproved sanitation undermined recovery. These findings highlight the need for integrated strategies combining infection control, nutritional rehabilitation, and water, sanitation, and hygiene interventions tailored to the childrens developmental stage. Key MessagesO_LIPost-diarrheal nutritional recovery is highly heterogeneous, with wasting showing the greatest potential for improvement, while stunting and underweight often result in persistent growth stagnation. C_LIO_LIBaseline anthropometric deficits alone are insufficient to predict recovery, highlighting the need for dynamic monitoring and individualized management. C_LIO_LIInfants are particularly vulnerable to acute nutritional deterioration, while older toddlers frequently experience growth stagnation. C_LIO_LIModifiable protective factors including exclusive breastfeeding, ORS, zinc, and appropriate antibiotics, improved outcomes, whereas poor sanitation undermined recovery. C_LIO_LIIntegrated strategies, tailored to a childs developmental stage, combining clinical care, nutrition, and environmental interventions are critical to support sustained child growth and development. C_LI

Abstract Background Between 2021 and 2022, primary care obesity management was entering the early diffusion phase of newer anti obesity pharmacotherapy, as GLP1 based treatments began reshaping expectations. However, it was unclear whether primary care clinicians and practice environments were prepared to deliver comprehensive obesity care. (1,2) Methods In 2021 to 2022, we surveyed 276 clinicians from three cohorts: an opt-in national physician panel (Cohort A), clinicians from an integrated health system (Cohort B), and clinicians from a rural accountable care organization (Cohort C). The survey, informed by formative patient and physician focus groups conducted in 2021, assessed current and desired competence, attitudes, confidence, perceived forces for change, and barriers to obesity care. Analyses were descriptive (means and standard deviations). Results Across cohorts, desired competence exceeded current competence. The largest gaps involved recommending behavioral interventions, developing comprehensive care plans, and providing ongoing obesity management support. Attitudes toward obesity care were generally favorable, while confidence that current practices reflected best practice was only moderate. Professional and personal forces for change were moderate, patient driven motivators were moderate to high, whereas social (peer/organizational) reinforcement was weak. Reported barriers extended beyond knowledge deficits to include patient engagement, competing demands, cost, and practical constraints. Conclusions At the threshold of the GLP1 era, primary care clinicians were motivated to improve obesity care but lacked consistent support to deliver comprehensive management. The relative absence of peer and organizational reinforcement suggests that readiness for change reflected not only individual knowledge and attitudes, but also the degree of peer and organizational reinforcement that supports comprehensive obesity care in routine practice.

BackgroundAdequate maternal nutritional knowledge is essential for healthy pregnancy outcomes, yet many pregnant women lack good nutritional knowledge. This study assessed nutritional knowledge and associated factors among pregnant women in the Krowor Municipality of Ghana. MethodsA facility-based cross-sectional study was conducted among pregnant women attending antenatal clinics in two public health facilities. Structured questionnaires were used to collect data on sociodemographic characteristics and nutritional knowledge. Data were analysed using descriptive statistics and chi-square tests at a 5% significance level. ResultsMost respondents demonstrated moderate nutritional knowledge (mean score =11.24 {+/-} 2.48), with 45% classified as having moderate knowledge. Income level (p = 0.00), education (p = 0.007), gestational age (p = 0.042), employment status (p = 0.007), and religion (p = 0.005) were significantly associated with nutritional knowledge. ConclusionThe study highlights notable gaps in nutritional knowledge among pregnant women in Krowor Municipality. Socioeconomic and obstetric factors strongly influenced nutritional knowledge. Strengthening antenatal nutrition counselling and improving socioeconomic support may help improve the nutritional knowledge of pregnant women.

Background: Child acute malnutrition remains persistently above emergency thresholds in Chad's Sahelian drylands, with a predictable, but rarely recognized, dry season peak linked to declining pasture and livestock productivity, reduced milk availability and heightened exposure to zoonotic infections. Humanitarian responses remain largely reactive and treatment-focused, with limited evidence on preventive strategies that address drivers embedded in local livelihood systems. We evaluated the effectiveness and return on investment (ROI) of an integrated livestock management intervention designed to prevent the dry-season peak of child acute malnutrition in pastoral and agro-pastoral communities in Chad. Methods: We conducted a cluster-randomised controlled trial in Kanem and Barh-El-Gazel provinces, Chad. Seventy-six villages were randomised (1:1) to intervention or control. Eligible households had at least one child aged 6-59 months and access to milking livestock during the dry season. The intervention (December 2024-June 2025) combined livestock feed supplementation to sustain milk production near households during the dry season, household-level zoonotic risk mitigation, and nutrition counselling. Primary outcomes were the prevalence of global acute malnutrition (GAM) and severe acute malnutrition (SAM) at the dry-season peak (May 2025), assessed in a prespecified random subsample of 52 clusters. All 76 clusters were assessed post-peak (July 2025). Analyses followed an intention-to-treat approach using mixed-effects models. A societal ROI analysis was conducted over six months with projections to 24 months. Findings: At the dry-season peak, 821 children 6-59 months from 521 households were assessed across 52 villages. GAM prevalence was 22.2% in intervention villages versus 47.4% in controls (adjusted OR 0.29 [95% CI 0.18-0.49]; p<0.001), and SAM prevalence was 4.4% versus 19.4% (adjusted OR 0.17 [0.08-0.37]; p<0.001). Intervention households had higher daily milk availability (+588 mL per household; p<0.001), and children consumed more milk (+102 mL per day; p=0.008). Odds of self-reported diarrhoeal disease and acute respiratory infection were substantially lower among children in intervention villages (aOR 0.21 [0.10-0.44] and 0.22 [0.11-0.46], respectively). Post-peak, women's dietary diversity increased (aOR 3.68 [1.90-7.13]), alongside reduced workload, lower household food insecurity and distress livestock sales, improved livestock condition, and a benefit-cost ratio of 5.40 at six months, rising to 16.40 at 24 months. Interpretation: Protecting livestock productivity and sustaining children's access to milk while reducing zoonotic exposure during the pastoral lean season effectively prevents seasonal peaks of child acute malnutrition. This integrated anticipatory action and One Health livelihood-based approach offers a scalable, dignifying, high-return lifesaving preventive model for pastoral and agro-pastoral humanitarian settings.

Introduction: Adults in Nigeria face a growing nutrition challenge: while some struggle with undernutrition, others are increasingly affected by overweight and obesity. This double burden of malnutrition reflects socioeconomic divides, where income, education, and household conditions shape food choices and health. This study examined how socioeconomic factors influence dietary diversity, nutritional knowledge, and nutritional status among adults in urban and rural communities of Ekiti State. Methods and Analysis: A descriptive cross-sectional survey was conducted among 350 adults selected via multistage sampling. Data were collected using structured questionnaires and anthropometric measurements. Dietary diversity was assessed using food group frequency, and nutritional status was determined by BMI. Associations were analyzed using chi-square tests (p < 0.05). Results: Significant urban-rural divides were identified: urban respondents were more educated (48.8% tertiary), while rural households were more dependent on farming (35.0%) and low-income (62.0% <70,000). Dietary patterns differed significantly: urban diets favored legumes (58.4%) and cereals (56.0%), while rural diets predominated in sugar/honey (90.0%) and roots/tubers (71.0%). Nutritional knowledge was higher in urban areas. Nutritional status revealed a dual burden: 20.4% of urban and 22.0% of rural respondents were underweight, while combined overweight/obesity affected 18.4% of urban and 25.0% of rural participants. Conclusion: Socioeconomic factors strongly dictate dietary choices and health in Ekiti State. Urban areas show greater diversity but rising obesity risks, while rural areas face persistent undernutrition. These findings highlight the need for tailored, state-specific interventions addressing both food insecurity and emerging diet-related chronic disease risks. Keywords: Socioeconomic factors, Dietary diversity, Nutritional knowledge, Double burden of malnutrition, Ekiti State, Nigeria.

OBJECTIVE: To evaluate the return on investment (ROI) of a community based Diabetes Self Management Program (DSMP) enhanced with health related social needs (HRSN) screening and referrals, implemented by the New York City (NYC) Department of Health and Mental Hygiene with three community based organizations in highly impacted, under resourced neighborhoods. RESEARCH DESIGN AND METHODS: A retrospective cost benefit analysis from a public sector payer perspective was conducted among 171 adults with type 2 diabetes who completed a six week, peer led DSMP delivered by community health workers (CHWs) in English, Spanish, and Korean during 2018 2019. A time driven, activity based costing model captured direct implementation costs, CHW workforce turnover, and administrative overhead. Monetized benefits included avoided diabetes related complications, reductions in self reported emergency department (ED) visits and hospitalizations, and quality adjusted life year (QALY) gains from improved medication adherence. Univariate sensitivity analyses tested robustness under conservative assumptions. RESULTS: Total program costs were $179,224; monetized benefits totaled $1,824,213, yielding a net benefit of $1,644,989 and an ROI of 918%, approximately $10 returned per $1 invested. Excluding QALY gains, ROI remained 551%. Self reported ED visits declined from 149 to 82 and hospitalizations from 93 to 24 in the six months following intervention. Over 80% of participants reported housing instability; 72% were Medicaid covered and 16% uninsured. Sensitivity analyses confirmed a positive ROI under all conservative scenarios. CONCLUSIONS: A CHW led, community based DSMP integrated with HRSN screening and referrals delivered substantial economic and public health value among adults facing housing instability and structural barriers to care. Findings support inclusion of DSMP as a covered benefit in Medicaid managed care, value based payment arrangements, and housing access initiatives to advance equitable diabetes outcomes.

Background Affecting 40% of infants and young children worldwide, anaemia in sub-Saharan Africa hampers cognitive and physical development, often in ways that cannot be reversed. Iron-based micronutrient powders (MNPs) are recommended to combat anaemia, but concerns remain about their safety and effectiveness in malaria-endemic areas. We evaluated the impact of iron-based MNPs on growth measurements and malaria-related anaemia among preschool children in Ghana. Methods We conducted a secondary analysis of a cluster-randomized, double-blind, placebo-controlled trial in the Bono Region, Ghana. Children aged 6-35 months (n=1,958) received daily MNP containing 12{middle dot}5mg elemental iron or placebo for five months. Anthropometric indices, haemoglobin, and malaria parasitaemia were assessed at baseline and endline. Adjusted analysis of covariance (ANCOVA) models estimated effects on height-for-age (HAZ), weight-for-age (WAZ), and weight-for-height (WHZ) z scores. Binomial regression with identity link estimated risk differences for malaria-induced anaemia. Cluster-robust standard errors were applied at the compound level, and intracluster correlation coefficients (ICCs) were estimated. Results 1,815 (92{middle dot}7%) children completed the endline survey, but 1,806 were included in the final analysis. Baseline characteristics were balanced between groups. Iron-containing MNP had no significant effect on endline HAZ ({beta}=0{middle dot}026, p=0{middle dot}609), WAZ ({beta}=-0{middle dot}015, p=0{middle dot}719), or WHZ ({beta}=-0{middle dot}035, p=0{middle dot}463). However, the intervention reduced the risk of malaria-induced anaemia (risk difference 0{middle dot}050, 95% CI 0{middle dot}004-0{middle dot}096; p=0{middle dot}032). Female sex was associated with higher HAZ ({beta}=0{middle dot}149, p=0{middle dot}005). Conclusion Iron-containing MNP did not improve short-term growth but was associated with a modest reduction in malaria-induced anaemia. These findings support the safe use of iron fortification in malaria-endemic settings while underscoring the need for integrated strategies to address persistent growth faltering and gender specificity.

Background: College-attending young adults frequently experience declines in diet quality, physical activity, and psychological well-being during the transition to independent living, contributing to weight gain during the first year of college. Although multicomponent lifestyle interventions have been developed to address these behaviors, the responsiveness to such programs could differ across demographic factors associated with health behaviors, such as sex, race, and ethnicity. Hence, this secondary analysis of large-scale college health trials evaluated whether the effectiveness of such interventions differed by these demographic factors. Methods: Data were combined from two multi-site randomized controlled trials: Young Adults Eating and Active for Health (YEAH) trial and the Get FRUVED trial. Both interventions used theory-based approaches to promote healthy weight management through improvements in diet quality, physical activity, and stress management. Baseline-adjusted linear regression models evaluated the effects of group (intervention, control) and its interactions with sex, race (White, Black, Other), or Hispanic ethnicity. Models were adjusted for baseline outcome values, baseline BMI, study (YEAH vs. FRUVED), and state of data collection. Results: Intervention participants reported higher fruit and vegetable intake, lower processed meat intake, and longer sleep duration compared with controls. However, there was significant heterogeneity in these dietary outcomes by ethnicity, race, and sex. Non-Hispanic participants in the intervention group had higher fruit and vegetable intake compared to controls (p < 0.05). And, within the intervention group, Hispanic females had lower bacon/sausage intake than Hispanic males and non-Hispanic females (p < 0.05). With respect to race, Black participants reported higher total processed meat intake than White and Other race participants (p <0.05). These demographic factors did not moderate the intervention's impact on physical activity, sleep duration, and perceived stress. Overall, the intervention appeared to be the least effective for Hispanic males who exhibited higher body weight and waist circumference compared with Hispanic females and non-Hispanic males (p < 0.05). Conclusions: Multicomponent lifestyle interventions can improve selected dietary outcomes among college students, but effectiveness may differ across demographic subgroups. Culturally and sex-tailored strategies that consider the intersecting influences of sex, race, and ethnicity may enhance intervention effectiveness during the transition to college.

Objective: To investigate in the National School Feeding Program (PNAE) the local level drivers and barriers to the implementation of four guidelines: the banning of sugary drinks; restrictions on the procurement of processed and ultra-processed foods; the mandatory increase in weekly servings of fruits and vegetables offered to students; and mandatory direct procurement from family farmers. Design: Qualitative study that used semi-structured interviews. Street level bureaucracy theory informed the theoretical framework and thematic analysis. Setting: Brazilian municipalities, across the country five geographic regions (North, Northeast, Southeast, South, and Midwest). Participants: Stakeholders (e.g. nutritionists, school cooks, and food procurement managers) involved in the local implementation of the PNAE program across the country. Results: Ninety stakeholders were interviewed. Stakeholders reported having autonomy to perform their activities, collaboration and support from other members within the local government and food providers, adequate infrastructure such as a well-equipped kitchens, the availability of trained personnel, and political commitment as drivers for optimum program implementation. Reported barriers included lack of support and resistance to change among cooks, teachers and parents; insufficient physical and human resources; and limited political commitment. When barriers outweighed drivers, interviewees reported adapting their practices, often in restrictive ways that could compromise the implementation of the program. Conclusions: Drivers and barriers to local PNAE implementation were generally similar across studied municipalities, although their magnitude varied. In contexts of greater economic vulnerability and fiscal constraint, additional support and targeted actions from the federal government may be required to strengthen local implementation

BackgroundThe rapid growth of the worlds urban population has contributed to the expansion of informal urban settlements in many cities across the world. In these settings, lack of safe sanitation combined with high population density and poverty contributes to heightened health risks for often vulnerable populations. The aim of this study was to evaluate the effect of a shared, onsite sanitation intervention on the nutritional status of children in Maputo, Mozambique. MethodsThe Maputo Sanitation (MapSan) trial was a controlled before-and-after study to evaluate the effect of a shared, onsite sanitation intervention on child health in Maputo, Mozambique. Here, we report the effects on childhood stunting, wasting and underweight, and height-for-age, weight-for-height and weight-for-age z-scores. Children were enrolled aged 1-48 months at baseline and outcomes were measured before and 12 and 24 months after the intervention, with concurrent measurement among children in a comparable control arm. The primary analysis was intention-to-treat. The trial was registered at ClinicalTrials.gov, number NCT02362932. ResultsWe enrolled 757 and 852 children in the intervention and control groups respectively. There was no evidence for an effect of the intervention on any outcome at 12 or 24 months of follow-up except for wasting where there was very weak evidence for an effect (adjusted prevalence ratio: 0.497; 95% CI: 0.22-1.11; p=0.09). In two exploratory analyses - one including only those children born into compounds post-intervention and a second excluding children in control compounds which had independently improved their sanitation facilities during follow-up - we found that stunting increased in the intervention group whilst wasting decreased. ConclusionsThis study contributes to the growing evidence on the role of sanitation in shaping child health outcomes in informal urban settlements. We found no evidence for an effect on stunting and weak evidence for an effect on wasting. More research is needed to understand how sanitation can reduce childhood undernutrition in complex urban environments.

Background Maternal iron requirements increase substantially during pregnancy, and ferritin concentrations typically decline as gestation progresses. However, the physiologic significance of this decline remains uncertain, and whether reductions in maternal iron stores relate to birth outcomes is unclear. Objectives To examine associations between maternal ferritin trajectories during pregnancy and postpartum and infant anthropometric outcomes. Methods We conducted a secondary longitudinal analysis of 1,496 mother - infant pairs from the Alberta Pregnancy Outcomes and Nutrition cohort. Serum ferritin was measured longitudinally in the second and third trimesters and at three months postpartum, with limited first-trimester data available. Values below 15 g/L indicated iron deficiency. Multivariable linear regression assessed associations between inflammation-adjusted third-trimester serum ferritin and infant birthweight and length. Change in serum ferritin between the second and third trimesters ({delta} ferritin) was examined as a marker of late-gestation iron mobilization. Postpartum serum ferritin was modelled using restricted cubic splines to account for nonlinear associations with birth weight and length. Results Ferritin concentrations declined progressively across pregnancy, with 61% of women classified as iron deficient in the third trimester. Lower inflammation-adjusted third-trimester ferritin was associated with higher birthweight, corresponding to approximately 84g higher birthweight per 2.7 - fold decrease in ferritin (p < 0.001). Women experiencing the largest decline in ferritin between the second and third trimester delivered infants approximately 155 g heavier than those with minimal change (p = 0.001). Higher birthweight was associated with greater odds of postpartum iron deficiency (OR per 1 kg = 1.83; 95% CI: 1.12 - 2.99). Conclusions In this healthy cohort, maternal iron depletion in late pregnancy was associated with higher birthweight, consistent with preferential fetal iron transfer. Women delivering larger infants exhibited higher odds of iron deficiency, suggesting sustained maternal iron depletion following greater fetal iron accretion.

Background Childhood sensory and intellectual disabilities represent significant yet under-recognized barriers to learning and human capital development. This study analyzes prevalence and severity of these conditions among 149.3 million children aged 5-19 years across 25 countries in Latin America and the Caribbean (LAC) using Global Burden of Disease 2023 data. Methods We extracted GBD 2023 estimates for vision loss, hearing loss, and intellectual disability across 25 LAC countries, stratified by age, sex, and severity. Regional estimates were calculated using population-weighted averages. Severity distributions were compared with OECD countries to contextualize regional patterns. Results: These conditions are estimated to affected 9,282,921 children (6.22%; 95% UI: 5.89-6.54%). Hearing loss was predominant, affecting an estimated 5.42 million (3.63%, 3.41-3.86), with 87.6% mild-to-moderate. Intellectual disability estimated to affected 2.56 million (1.71%, 1.58-1.85), with 61.7% borderline-to-mild. Vision loss estimated to affected 1.30 million (0.87%, 0.79-0.96), with 89% that can be effectively addressed with spectacles. Prevalence increased with age across all conditions. Male predominance was consistent for intellectual disability (2.00% vs 1.42%). Annual economic cost totaled US$19.3-29.0 billion, while comprehensive interventions would require US$9.45-14.23 billion with benefit-cost ratios of 2:1 to 15:1. Conclusions The distribution of children across milder levels of difficulty underscores the opportunity for education and public health systems to provide timely and accessible support. With approximately 88% of sensory impairments addressable through established technologies, investments in inclusive services can yield strong social and economic returns.

Estimates of the marginal cost per disability-adjusted life year (DALY) averted from government health expenditure (GHE) provide an empirical basis for allocating scarce health resources to maximise population health. Existing cross-country estimates have informed priority setting in several countries and international policy discussions but are based on data that are now more than a decade old. Since then, patterns of health expenditure, disease burden, and global health financing have changed substantially. This paper provides updated estimates of the marginal cost per DALY averted for 92 low- and middle-income countries (LMIC) by applying previously estimated elasticities of the effect of GHE on health outcomes from Ochalek et al. (2018) to recent data on mortality, morbidity, population structure, and GHE. Two policy options for improving health in LMIC are assessed: (1) the implications of countries allocating 15% of general government expenditure to health consistent with the Abuja Declaration; and (2) reallocating development assistance for health (DAH) to maximise health across countries. Scenario analyses use the estimated elasticities to reflect diminishing marginal returns to health expenditure when calculating the health gains associated with additional resources. Updated estimates of the marginal costs per DALY averted range from approximately $78 to $15,789 across countries. In most countries (72%), estimates are higher than in the previous analysis, largely reflecting increases in GHE. Increasing domestic expenditure to achieve the Abuja Declaration objective would avert 234 million DALYs but require $563 billion across countries. Reallocating $39.1 billion in existing DAH could avert 133.6 million DALYs. Updated estimates provide an empirical basis for informing both domestic priority setting and the allocation of international health financing. Aligning donor funding with country-specific opportunity costs could substantially increase the global health gains achieved with limited resources.

IntroductionIncreasing global prevalence of overweight and obesity underscores the need for context-specific evidence to guide preventive policy implementation. Previous modelling showed that promoting healthy indigenous foods, implementing a 20% tax on sugar-sweetened beverages (SSBs), and introducing mandatory kilojoule menu labelling in formal-sector restaurants in Kenya were health-promoting, cost-saving, and cost-effective. Cost-effectiveness evidence is strengthened when considered alongside broader policy implementation considerations. We engaged stakeholders to assess additional implementation considerations relevant to decision-makers and to evaluate the stakeholder engagement process used in the modelling study. MethodsUsing the Assessing Cost-Effectiveness approach, we conducted a stakeholder-engaged study with national-level Kenya stakeholders recruited through purposive and snowball sampling. Through deliberative dialogue at a hybrid workshop, stakeholders assessed implementation considerations such as equity, feasibility and sustainability using a colour-coded scoring tool. We evaluated the engagement process using an anonymous survey covering seven stakeholder-engaged research domains. We analysed responses thematically. ResultsAcross the three interventions, most implementation considerations for feasibility, reach and impact, affordability, acceptability, and sustainability were assessed as medium or high. Industry acceptability of kilojoule labelling and SSB tax and affordability of kilojoule labelling to industry were rated low. Equity scores varied. Stakeholders proposed complementary measures that could raise low ratings to favorable scores. Clarity on stakeholder roles was identified as a key strength of the engagement process, while competing time commitments limited participation. ConclusionStakeholder insights contextualise prior cost-effectiveness evidence within policy-relevant implementation considerations and inform current fiscal and regulatory debates. Evaluation of the stakeholder engagement process underscores its contribution to strengthening public health research.