Public Health Nutrition

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.

BackgroundValidated food portion size photographs can increase accuracy of estimatingportion sizes during dietary surveys. Our objective was to assess the validity of food portion size photographs in estimating portion sizes to be used in 24-hour dietary recall food consumption study. MethodsWe recruited two hundred and six women of reproductive age (13-45 years) residing in Roysambu sub-county in the northern parts of Nairobi City, Kenya. Eleven foods from the Photographic Food Atlas for Kenyan Adolescents (9-14 years) were examined. Participants were served pre-weighed portions. After eating, each participant was asked to estimate the amount of food they consumed, using the Food Atlas. Validity was assessed by calculating percentage of estimates within and outside of {+/-}10% of consumed portion size, the mean percent difference between estimated and consumed portions, Spearmans correlation coefficients, and Pearsons chi-square test. ResultsThe proportion of participants with estimates within {+/-} 10% of the consumed portion size ranged between 15-65%. Mean differences between the consumed and estimated portion sizes varied -45% for stewed beans to +60% for watermelon. Generally, small portions were overestimated while large portions were underestimated. Correlation coefficients ranged from 0.12 to 0.77 and all the coefficients were statistically significant except for watermelon (p=0.22). Accuracy of estimations was not associated with participants age or educational level. ConclusionsThe validity of the tested food proportion size photographs was adequate for quantifications of most food items. However, the studys findings also indicated that further improvement is needed before wider use in Kenya.

Maternal dietary diversity is vital for the health of both mothers and children during lactation, yet it is often compromised in low- and middle-income countries. This cross-sectional study among 251 lactating mothers in Tarakeswor Municipality, Nepal, assessed dietary diversity using a 24-hour dietary recall and the Minimum Dietary Diversity for Women (MDD-W) indicator. Overall, 68.1% of mothers achieved the minimum dietary diversity ([≥]5 of 10 food groups), with a mean score of 5.03 {+/-} 1.25. In multivariable analysis, higher odds of meeting MDD were observed among mothers with secondary or higher education (aOR = 7.5; 95% CI: 3.8-15.0), employment (aOR = 2.9; 95% CI: 1.4-5.8), joint or extended family structure (aOR = 3.7; 95% CI: 1.9-7.0), the highest wealth quintile (aOR = 4.2; 95% CI: 1.9-9.1), food-secure households (aOR = 4.5; 95% CI: 2.3-7.9), adequate nutrition knowledge (aOR = 5.2; 95% CI: 2.7-9.8), [≥]4 antenatal care visits (aOR = 1.9; 95% CI: 1.0-3.4), and higher empowerment (aOR = 3.9; 95% CI: 1.9-7.8). These findings highlight substantial socioeconomic disparities in maternal dietary diversity and underscore the need for integrated, equity-focused nutrition interventions in rapidly urbanizing settings in low- and middle-income countries.

Front-of-pack nutrition labels (FOPLs) have been adopted as a key government strategy to address the significant burden of diet-related noncommunicable diseases. However, research on public knowledge and perceptions of FOPLs and their relationships with sugar-sweetened beverage (SSB) and artificially sweetened beverage (ASB) consumption remains limited. A cross-sectional study with 2870 individuals was conducted to explore their knowledge and perceptions of Nutri-Grade, a national front-of-pack nutrition labeling scheme introduced in Singapore in 2022. Knowledge was not significantly associated with SSB consumption; however, individuals who perceived these labels more positively were significantly less likely to consume SSBs daily (AOR=0.72, p<0.001) and consumed fewer types of SSBs weekly (IRR=0.91, p<0.001). Moderation analyses indicated that greater knowledge of Nutri-Grade FOPLs was associated with a higher likelihood of SSB consumption among younger individuals and those residing in areas with higher house prices. Additionally, individuals with positive perceptions were more likely to consume SSBs daily when living in areas with food court density exceeding 2.99 per km{superscript 2} (AOR = 1.12, p = 0.004). Individuals with positive perceptions of Nutri-Grade FOPL were also less likely to consume ASBs (AOR=0.69, p<0.001), whereas, in contrast to SSBs, greater knowledge of Nutri-Grade FOPLs was associated with increased ASB consumption (AOR=1.42, p<0.001). These findings indicate that informational labeling itself is insufficient to change consumption behavior. Although positive perceptions of Nutri-Grade FOPLs provide a protective effect, this effect diminishes when the food environment is taken into account.

PurposeAdequate hydration is vital for health, yet many people do not meet fluid recommendations. This study aimed to characterise the role of water and sugar-sweetened beverages in hydration across different levels of socioeconomic status (SES) in the UK. MethodsIn a pre-registered cross-sectional study, participants (N = 1,112) recalled beverages consumed on the previous day and reported urine colour as an indicator of their hydration status. We analysed water intake (H1), sugar-sweetened beverage (SSB) intake (H2), and SES (education; H3) as predictors of hydration status using stepwise binomial logistic regression adjusted for health, demographic, and lifestyle covariates. ResultsForty percent of participants were classified as underhydrated. Higher water intake was associated with a greater likelihood of adequate hydration: Drinking one extra glass of water per day (250 ml) increased the odds of being adequately hydrated by about 16%. However, SSB intake was not associated with hydration unless intake from other drink sources was held constant. Having a higher versus lower level of education was not significantly associated with hydration status, although finer-grained and income-based analyses suggested modest socioeconomic differences. ConclusionWater intake--rather than SSB intake--is the primary correlate of adequate hydration in this UK sample. Public health initiatives should emphasise the importance of water for hydration, invest in ways to make water more appealing, and promote the use of urine colour as a marker of hydration status.

BackgroundOverweight and obesity are causing growing public health, economic and clinical burden, particularly within under-resourced communities. There is an urgent need to develop an in-depth understanding of experiences of weight management, and preferences for support within under-resourced communities, with a view to developing more effective weight management interventions. MethodsFocus groups were run in under-resourced communities using storyboarding; a method to facilitate inclusive communication (n=37). Thematic analysis was applied to textual and visual data, and a realist lens applied to provide in-depth insight into weight management experiences and needs. We believe this is the first study to use this combined methodology to explore weight management experiences and needs. ResultsCombining storyboarding with a realist lens, generated four themes. Living circumstances indicated that mental health, individual needs, and cost of weight management services were key contextual factors. Mechanisms of weight management identified emotional eating and portion control to be central to individual weight management. Yo-yo dieting centred on participants experiences of weight regain after attempting weight loss. Weight management intervention needs indicated psychological support was perceived as severely lacking, and the only route to attain sustained weight management. Offering both in-person and online support for weight management was considered important to reach more people. ConclusionMoving weight management support from short- to long-term and incorporating more robust psychological support would better serve the needs of people living in under-resourced communities who are overweight or obese. Ideally interventions should be multicomponent and tailored to individual needs and circumstances.

As plant-based (PB) diets become more common among UK children, understanding their nutritional adequacy and environmental impact is vital. This study assessed nutrient intake and dietary greenhouse gas emissions among children following omnivorous, vegetarian, and vegan diets. A cross-sectional analysis was conducted using three-day weighed food diaries from 39 UK children aged 2-12 years (omnivore n=15; and PB: vegetarian n=11; vegan n=13). Nutrients were analysed with and without supplementation using Nutritics software. GHGEs were calculated at the ingredient level (kgCO2e/day) and grouped by Eatwell Guide food categories. No dietary group met all nutrient reference values. Omnivores exceeded recommended intakes for saturated fat and free sugars while failing to meet the recommended intake for fibre, whereas PB children had intakes of these nutrients in the healthy range. PB diets were adequate in protein and vitamin B12 even in the absence of supplementation. Vegan children also met iron requirements from diet alone, whereas omnivore and vegetarian children did not meet iron targets without supplementation. Vitamin D intake was insufficient across all groups when supplements were excluded, with only vegan children achieving recommended levels through supplementation. Zinc requirements were met only by vegetarian children with the aid of supplements and were not met by vegan or omnivore children with or without supplementation. Iodine intake remained inadequate in vegan children even with supplementation. Mean daily GHGEs differed significantly between diet groups (p < 0.001): omnivores having the highest emissions, while vegans had the lowest emissions: 46% lower than omnivores, and 20% lower than vegetarians. Well-planned PB diets can meet most nutrient needs in UK children when supported by fortified foods and supplements, while substantially reducing dietary GHGEs compared with omnivorous diets. Shifting away from animal protein and dairy provides the greatest opportunity for improving both nutritional quality and environmental sustainability.

BackgroundCentral obesity is a critical public health issue linked to non- communicable diseases and long-term maternal health risks. Women beyond the postpartum period often face barriers to weight management, yet limited evidence exists on their specific challenges and the role of healthcare systems in addressing them. This study aimed to assess central obesity among women beyond postpartum period, focusing on the associated challenges and available health support systems. MethodologyA cross-sectional design was employed whereby 120 women (1 to 5 years postpartum), aged 18 - 49 years, attending selected one private and two government health facilities in Morogoro Urban District participated. Face-to-face interviews using semi-structured questionnaires and anthropometric measurements of waist and hip circumference were conducted. Data were recorded using Kobo digital Toolbox. Key findingsHigh prevalence of central obesity, with 68.3% of participants having a waist circumference above normal ([&ge;]80 cm) was observed. Although no socio-demographic factor assessed showed a statistically significant association with central obesity, trends indicated higher odds among older (OR=1.544; 95% CI, 0.084-28.557), married (OR= 1.730; 95% CI, 0.612-4.892) and higher income women (OR= 4.878; 95% CI, 0.367-64.818). Lifestyle behaviors such as low physical activity, poor dietary habits and lack of portion control were prevalent. 57.5% reported lacking information on weight and waist management. Despite attending health care facilities, 94.2% of the women had never received guidance from health providers regarding weight or central obesity management and 95% reported not receiving any form of support such as nutrition counseling or exercise recommendations. ConclusionThe study concludes that central obesity is highly prevalent among women beyond postpartum period and is influenced by poor lifestyle behaviors and inadequate healthcare system support. It recommends integrating weight management strategies into routine postpartum care and strengthening healthcare systems to offer tailored guidance and support to women after childbirth.

Engaging with stakeholders/contributors is vital to achieve a comprehensive approach to policymaking about the food (kai) system. The food system in Aotearoa New Zealand (Aotearoa NZ) is associated with high environmental impacts and inequitably distributed health consequences by ethnicity and socio-economic status. We engaged with contributors from government agencies, industry, academics, community, rural and urban M[a]ori communities to develop policy actions to support New Zealanders to eat healthy sustainable food. This paper outlines methods used to score contributor identified policies with follow-up focus groups and interviews where the highest scored policies were discussed, to understand contributor perspectives on the scope, implementation, barriers, and possible unintended consequences of these policies. Semi-structured interviews (12) and focus groups (6) were conducted. The top five scored policies among all contributors were: healthy food and drink policies in schools and kura (M[a]ori-language immersion schools); supporting m[a]ra kai (food garden) and community gardens; garden to table programmes in schools and kura; education about sustainable and healthy food; and increasing incomes. The top five policies for M[a]ori were: healthy food and drink policies in schools and kura; garden to table programmes in schools and kura; remove GST from core foods; increase incomes and make local food cheaper by supporting local growers. Considerations for policy implementation involved implementing multiple policies at once, the importance of evaluation, finding existing examples of policies, strong collaboration for long-term outcomes, and centring policies through a M[a]ori framework.

BackgroundPacked lunches are a common feature of early childhood food provision, yet evidence describing their nutritional composition in early years settings remains limited. Understanding the foods provided during this developmental period is important, given the potential influence of early dietary exposures on later health. AimTo characterise the composition, nutritional quality, cost, and dietary patterns of packed lunches brought from home in Early Childhood Education and Care settings, and to examine variation by child age and area-level deprivation. MethodsA cross-sectional analysis was conducted using a remote food photography method to assess packed lunches provided for children aged 1-4 years attending early years settings across Essex, UK. Food items were categorised into predefined groups, and nutrient composition was estimated. Area-level deprivation was determined using the English Index of Multiple Deprivation (2019). Non-parametric tests assessed between-group differences. Principal components analysis (PCA) was used to identify patterns of co-occurring foods. ResultsA total of 389 packed lunches were analysed. Starchy foods (82%), fruit (81%), dairy or alternatives (72%), and savoury snacks (74%) were commonly provided, while vegetables were less frequent and fish was rarely observed (1.5%). Overall, 97.7% of lunches contained at least one ultra-processed food (UPF), with a median of three UPF items per lunch and 74% of total energy derived from UPFs. Median energy provision was 400 kcal (IQR 309-518). Nutrient composition was broadly similar across deprivation groups, although cake and biscuit counts and UPF item counts were modestly higher in more deprived areas. The median estimated lunch cost was {pound}1.79 and did not differ by deprivation. ConclusionsPacked lunches in early years settings frequently contained ultra-processed foods and showed considerable variability in nutritional quality. Socioeconomic differences were limited, suggesting that contemporary packed lunch practices may reflect influences operating across population groups. Further research across diverse regions is warranted to better understand the provision of packed lunches and their implications for early dietary exposure.

ObjectiveTo investigate the burden of environmental enteric dysfunction (EED) and its association with water, sanitation, and hygiene (WASH) and linear growth amongst infants in rural Central Java, Indonesia. Study designA longitudinal study of 119 infants aged between 5-19 months was conducted in five villages of Wonosobo District, Central Java, Indonesia. Anthropometric measurements of infants and their mothers were performed at baseline and 5-month follow-up alongside a quantitative questionnaire on household, socio-economic, WASH and caregiving variables and stool sample collection for the investigation of alpha-1-antitrypsin (AAT), neopterin (NEO), and myeloperoxidase (MPO) levels. Linear mixed-effects regression models estimated the associations between WASH and height-for-age z-score (HAZ) on log-transformed EED biomarkers. ResultsBiomarkers increased from baseline to follow-up despite a declining trend with age and 68.7%, 79.0%, and 71.4% of infants experienced elevated AAT, NEO, and MPO respectively follow-up. Infants had higher AAT if they averaged > 30 minutes playing on soiled surfaces per day ({beta} = 0.11, p<0.05). NEO was elevated in infants with diarrhoea ({beta} = 1.04, p<0.05), municipal water source ( = {beta} 0.71, p<0.05), and in infants who mouthed soiled fomites weekly ({beta} = 0.55, p<0.05). Infants in houses with municipal water source had higher MPO ({beta} = 0.56, p<0.05) and higher MPO if mouthing soil weekly ({beta} = 0.41, p<0.05). Compared to infants at risk of stunting, stunted infants at baseline had lower AAT at follow-up ({beta} = -0.39, p<0.05) while infants with HAZ > -1 had lower AAT at baseline ( = -0.43, p<0.05). HAZ at baseline was positively associated with NEO at follow-up ({beta} = 0.36, p<0.05). MPO was higher in infants with HAZ > -1 at follow-up ({beta} = 0.59, p<0.05) and stunted infants ({beta} = -0.54, p<0.05) compared to infants at risk of stunting. ConclusionElevated EED biomarker levels were frequent and associated weakly with WASH and HAZ with bi-directionality, highlighting the need for quality birth cohort studies to improve understanding of EED and develop interventions.

IntroductionDepression is highly prevalent among young adults worldwide. While research links health behaviours, such as dietary intake, to depression, few studies have examined these associations among young adults in low- and middle-income countries, including South Africa. This study investigated whether dietary intake was associated with an increased risk of depression in a cohort of young South African adults, aged 20-30 years, as part of the Global burden of disease Lifestyle And mental Disorder (GLAD) project. MethodsThis five-year prospective cohort study was conducted in the North West Province of South Africa in accordance with the GLAD project protocol (DERR1-10.2196/65576). Dietary exposures were evaluated using three non-consecutive 24-hour dietary recalls, measuring daily intake of various food groups and nutrients as defined by the Global Burden of Disease study. Depression outcomes were assessed at baseline (N=1039) and follow-up (N=551) using the Patient Health Questionnaire (PHQ-9, cut-off [&ge;]10). Logistic and Poisson regression analyses were performed, with results presented as odds ratios (OR) and relative risk ratios (RR), respectively. Four models were run: unadjusted, sociodemographic-adjusted, total energy (TE) intake-adjusted and fully adjusted (including sociodemographic information and TE intake). For longitudinal analyses of incident depression, baseline depression cases were additionally excluded (n=403). ResultsParticipants (average age 24.55 years) had a balanced distribution of sex (51.4% female) and race (48.6% Black), and a 29.45% baseline prevalence of depression. Higher milk intake was associated with a lower risk of incident depression (RR=0.94, 95% CI 0.91-0.98) in the TE-adjusted longitudinal model. Cross-sectionally, higher sugar-sweetened beverage consumption associated with higher odds of depression, while higher calcium intake (OR=0.48, 95% CI 0.31; 0.76) and vegetable consumption (OR=0.74, 95% CI 0.61, 0.91) were associated with lower odds of depression after TE intake adjustment. Higher fibre intake was associated with lower odds of depression in the unadjusted model. ConclusionHigher daily milk intake was associated with a lower risk of depression, while higher calcium, vegetable, and fibre intake were associated with a lower prevalence of depression in young adults. These findings suggest that prevention strategies for common mental disorders could include dietary approaches within mental health care.

BackgroundRandomized trials have shown that a healthy Nordic diet (HND) improves liver steatosis, but there is limited evidence on the effects of Nordic dietary patterns on the risk of major adverse liver outcomes (MALO). We specified a hypothetical target trial protocol to estimate the effects of adhering to a HND or the Nordic Nutrition Recommendations 2023 (NNR23) on the 24-year risk of MALO in a middle-aged to elderly Swedish population. MethodsTwo pooled population-based cohorts including n=64,406 men and women (Cohort of Swedish Men (COSM) and the Swedish Mammography Cohort (SMC)) with repeated measurements on diet and confounders in 1997, 2008/2009 and 2019 were used to emulate population-adapted versions of the diets. Under the assumptions of no unmeasured confounding, selection bias or measurement error, the parametric g-formula was used to estimate 24-year risks of MALO from each hypothetical intervention. Secondary analyses included comparing the HND and NNR23 with a low-adherence group; reducing alcohol as an additional hypothetical intervention; and assessing risk of all-cause mortality. ResultsThe estimated 24-year risk of MALO in the HND was 0.53% (95% CI: 0.38, 0.73), in the NNR23 diet 0.70% (95% CI: 0.57, 0.90) and in no intervention 0.64% (95% CI: 0.56, 0.77). Estimated risk differences (RDs) of MALO for HND versus no intervention and NNR23 versus no intervention were -0.11% (95% CI: -0.27, 0.07) and 0.06% (95% CI: -0.04, 0.15), respectively. Compared to NNR23, the estimated RD for the HND was -0.17% (95% CI: -0.38, 0.05). Meaningful risk reductions following the HND were estimated when compared to a low-adherence diet group (-1.50% (95% CI: -9.53, -0.05)), when including reducing alcohol, and for all-cause mortality (-2.67% (95% CI: -3.51, -1.85) versus no intervention; -1.68% (95% CI: - 2.75, -0.62) versus NNR23)). ConclusionWe estimated no clear risk reductions from a population-adapted HND or a NNR23 diet on the 24-year risk of MALO when compared to each other or no intervention. However, when either compared to a low-adherence group or when including reducing alcohol as a hypothetical intervention or when specifying all-cause mortality as the outcome, we estimated meaningful risk differences following the HND.

BackgroundSevere acute malnutrition (SAM) among children under 5 years of age is generally treated in outpatient settings providing caregivers with weekly ready-to-use therapeutic food (RUTF) rations to be administered at home. Recent updates to global treatment guidelines suggest that RUTF dose can be reduced once children progress to moderate stage (MAM). No evidence exists on the optimal timing of the dosage reduction or on ideal visit frequency. ObjectivesWe aimed to test the impact of 1) immediate RUTF dose reduction (1a) versus including a 2-week transition (1b) among children admitted with SAM and 2) fortnightly (2a) versus weekly (2b) visit frequency during MAM phase among children admitted with SAM and MAM. Methods and findingsThis prospective cluster-randomized controlled non-inferiority trial followed a 2 x 2 factorial design and divided 39 health areas (clusters) of Nara, Mali, into 4 groups implementing: A) 1a+2a B) 1a+2b, C) 1b+2a, and D) 1b+2b. Simplified, combined treatment was used providing 2 daily RUTF sachets to children admitted as SAM (mid-upper arm-circumference=MUAC<115mm or edema) and 1 daily RUTF sachet to children admitted with MAM (MUAC 115-124mm). Recovery was declared when a child reached MUAC [&ge;]125mm and absence of edema for 2 consecutive visits. Depending on the randomization arm, children admitted with SAM transitioned into receiving 1 daily RUTF sachet immediately upon reaching MUAC[&ge;]115mm (A+B) or after 3 consecutive visits (2 weeks) with MUAC[&ge;]115mm (C+D). Weekly visits were applied for all children with MUAC<115mm and then depending on randomization arm, visits continued weekly (A+C) or fortnightly (B+D) in the MAM phase. The main outcome was recovery and a non-inferiority margin of 10% was applied. Between April and December 2023, a total of 6249 children with MUAC<125mm or edema were admitted to treatment including 1451 children with SAM. On average 98% of children recovered with a mean duration of treatment of 6 weeks. Immediate transition resulted in non-inferior recovery compared to 2-week transition from SAM to MAM and no differences were observed in program outcomes (proportion of recovered, defaulted, non-recovered, transferred to inpatient care and deceased). However, we observed a non-significant trend of slight increase in the proportion of children regressing back to SAM after being MAM among children following immediate transition compared to those benefitting from 2-week transition. Fortnightly visit frequency in MAM phase resulted in non-inferior recovery compared to weekly visits throughout and no differences were observed in program outcomes. Duration of treatment was 2.5 weeks longer with fortnightly visits during MAM phase resulting in 23 sachets higher RUTF consumption compared to weekly visits throughout. ConclusionsWe recommend applying weekly visits throughout treatment where feasible for both children with MAM and SAM at admission and including a 2-week transition period before reducing the RUTF dose for children admitted with SAM once they reach MAM criteria. Trial registrationThe study was registered to clinicaltrials.gov (NCT06594341).

Child stunting is still a global public health challenge, with a greater impact in developing countries. In Tanzania, an estimate of 30% of children are stunted. This study estimated childcare practices associated with stunting in the agro-pastoral community of Izazi ward in Iringa District. A cross-sectional study was employed to collect both quantitative and qualitative anthropometric data from 377 mother-child pairs of children aged 6-59 months. Three focus group discussions were carried out with mothers, and interviews were conducted with community leaders. Respondents were selected using systematic and snowball sampling methods. Data collection involved a structured questionnaire, where ENA for SMART software was used to generate the index for height-for-age. The findings confirm that stunting is still a public health problem among agro-pastoral communities of Izazi ward, 34.7% of respondents were stunted. A multivariate binary logistic regression was used to assess the childcare practices associated with stunting; factors associated with stunting included: being female (AOR=0.66; 95% CI:0.40-0.99, p=0.048), breastfeeding for 1 year (AOR=19.75; 95% CI:8.99-43.39, p=0.001), breastfeeding for less than two years (AOR=7.08; 95% CI:4.03-12.45, p=0.001), non-exclusive breastfeeding (AOR=2.599; 95% CI:1.23-5.47, p=0.012), and having one disease (AOR=5.36; 95% CI:1.88-15.27, p=0.02). This study highlights the importance of promoting exclusive breastfeeding and treating childhood illnesses to improve health outcomes among children.

IntroductionBreastfeeding supports multiple aspects of child development and maternal health. However, research findings are often inconsistent due to methodological limitations, including inadequate control for sociodemographic factors, variation in feeding practices, health conditions across the life course, and heterogeneity in human milk (HM) composition. The Manitoba Interdisciplinary Lactation Center (MILC) is a globally accessible, bench-to-population research platform that enables integrated study of HM composition, maternal-child health, and the societal and structural determinants of lactation and HM feeding. Methods and AnalysisMILC combines cross-sectional questionnaire data and HM sample collection with longitudinal administrative data derived from provincial government databases. MILC recruits lactating parents currently feeding their HM to at least one child. Participants follow a standardized full breast expression protocol. All collected HM samples have their macronutrient profiles characterized and are bio-banked for unspecified future research. Questionnaires capture child and parent demographic, dietary and health characteristics, and detailed HM feeding practices. Administrative data include over 90 databases spanning health and social services utilization and education; these de-identified records are housed at the Manitoba Population Research Data Repository and linked with MILC study samples and data. MILC questionnaires and HM collection protocols can be customized to accommodate specific research projects (e.g. additional surveys or questions; snap freezing, addition of preservatives, cell or extra-cellular vesicle isolation, etc.). MILC began recruiting participants in October 2024 and is currently ongoing. Researchers may access MILC data and biospecimens subject to appropriate ethical approvals and data-sharing agreements. Ethics and disseminationMILC is approved by the University of Manitoba Human Research Ethics Board and the Provincial Health Research Privacy Committee. Participation is voluntary and based on informed consent. Research updates and findings will be disseminated via peer-reviewed journal publications, academic and clinical conferences, social media, public knowledge sharing events (e.g. information booths and virtual "Ask Me Anything" sessions), the MILC website (https://www.milcresearch.com) and the MILC Club (monthly meetings among researchers, trainees, healthcare providers, and community partners). MILC members also engage with agenda-setting organizations (e.g. Breastfeeding Committee for Canada, North American Board for Breastfeeding and Lactation Medicine) to accelerate translation of research knowledge into policy and practice. STRENGTHS AND LIMITATIONS OF THIS STUDYO_LIMILC combines low-burden cross-sectional human milk samples and questionnaire data with lifelong/longitudinal administrative data. C_LIO_LIParent-child dyad human milk feeding practices and history are captured in a high level of detail, filling a gap frequently experienced in human milk and lactation research. C_LIO_LIOur questionnaires have been partially harmonized with other biorepositories and/or utilize valid and reliable measurement scales. C_LIO_LIThe initial MILC study pilot population lacks diversity; this will be intentionally addressed going forward. C_LIO_LIThe cost to maintain a long-term biorepository facility is high. C_LI

BackgroundHuman milk (HM) bioactive components can have immune modulatory functions, impact the gut microbiome, and may result in functional benefits when added to infant formula (IF). In this single-arm, prospective, intervention study, we tested the effectiveness of an IF with a whey protein concentrate co-enriched in -lactalbumin, milk fat globule membrane (MFGM), and Sn-2 palmitate resulting in protein and lipid profiles observed in HM. The outcomes tested were feeding tolerance, Bifidobacteria abundance, and intestinal and immune health of Chinese infants. MethodsPredominantly formula-fed (FF) and breastfed (BF) infants were enrolled between 3 and 28 days and assigned to the FF (N= 60) or BF (N=60) group, per their feeding practice, for 6 weeks. The primary endpoint was Infant Gastrointestinal Symptom Questionnaire (IGSQ) index score assessed using a validated IGSQ-13 questionnaire after 6 weeks of intervention; non-inferiority of FF vs BF was tested. Secondary endpoints included fecal Bifidobacteria abundance assessed using shotgun metagenomics sequencing; fecal short chain fatty acids (SCFAs) analyzed by ultra-performance liquid chromatography-tandem mass spectrometry; fecal markers of immune response, inflammation, intestinal barrier integrity (secretory immunoglobulin A sIgA), cytokines, calprotectin, 1 antitrypsin, lipocalin-2) assessed using enzyme-linked immunosorbent assay; stool consistency assessed using gastrointestinal (GI) diary; anthropometric assessments; quality of life; physician reported adverse events; and use of medications. ResultsGood GI tolerance was observed in both groups at V2 (mean{+/-}SD IGSQ score FF: 19.9{+/-}7.4; BF: 16.8{+/-}4.2); difference of means 1.35 [95% CI: -1.312, 4.012]). After 6 weeks, Bifidobacterium genus relative abundance was not significantly different between the groups. Total SCFAs were significantly higher (p<0.05) in the FF versus BF group, driven by increased levels of valeric and propanoic acids (p<0.05 for both). The IGSQ domain scores, stool consistency, fecal markers of immunity, inflammation, and intestinal barrier integrity (except lipocalin-2 which was significantly higher in BF vs FF), anthropometric Z-scores, common illnesses, antibiotic use, and adverse events were not significantly different between groups at week 6. ConclusionsOur results support the effectiveness of this tested infant formula in supporting good GI tolerance, growth, specific intestinal and immune health markers, and Bifidobacteria abundance similar to that of the BF group. Trial registrationNCT04880083 (2021-05-06)

BackgroundHIV and malnutrition act synergistically to weaken the immune system, increasing susceptibility to opportunistic infections, morbidity, and mortality. HIV destroys the body ability to fight infections, while malnutrition hinders recovery, accelerating the progression of AIDS related illnesses. This combination also undermines the adherence to and effectiveness of antiretroviral therapy (ART), particularly in resource limited settings. Accordingly, this study assessed the prevalence of malnutrition and associated factors among women attending prevention of mother to child transmission programs in public hospitals in Addis Ababa, Ethiopia, in 2024. MethodsA cross sectional study was undertaken from April 1st to 20th, 2024. The study enrolled 193 women receiving PMTCT care at six public hospitals in Addis Ababa, selected through a simple random sampling method. Data were collected via face to face interviews using a standardized, structured questionnaire. Additionally, participants mid upper arm circumference (MUAC), weight, and height were measured to assess nutritional status. Data analysis was performed using SPSS version 26. Binary logistic regression was employed to examine the strength of associations, with results expressed as odds ratios alongside 95% confidence intervals. A p value score of 0.05 was considered statistically significant. ResultsThe overall prevalence of malnutrition was 29% (19% undernutrition, 8% overweight, 2% obesity). In the adjusted analysis, younger age (25 to 34 years) was protective (AOR: 0.25), whereas experiencing eating problems (AOR: 13.70) and gastrointestinal symptoms (AOR: 3.52), immunosuppression (AOR: 8.13), anemia (AOR: 5.03), low meal frequency (AOR: 4.12), poor adherence (AOR: 3.60) were significant risk factors. ConclusionThe prevalence of malnutrition among women receiving PMTCT at public hospitals in Addis Ababa was high. Moving forward, integrating routine nutritional screening and evidence based supportive interventions, including dietary support for women with low meal frequency and targeted management for those with anemia or low CD4 counts, should be a priority to improve comprehensive care for this vulnerable population.

Outcomes from the COSMOS trial have reinforced the notion of flavanols as important plant-derived bioactives contributing to cardiovascular health. As discussions continue on whether specific dietary reference values for flavanols are warranted, it is possible that existing dietary guidelines emphasizing fruits and vegetables already yield sufficient flavanol intake levels. If this were the case, developing flavanol specific dietary reference values might be unnecessary. This study therefore aimed at assessing whether adherence to dietary recommendations for fruit and vegetable intake and overall diet quality achieves flavanol intake levels of 500 mg/day, the amount proven to mediate cardiovascular benefits in the COSMOS trial. Flavanol intake was objectively evaluated using two validated and complementary biomarkers, 5-(3{square},4{square}-dihydroxyphenyl)-{gamma}-valerolactone metabolites (gVLMB) and structurally related (-)-epicatechin metabolites (SREMB), in two geographically distinct studies: COSMOS (US; n=6,509) and EPIC-Norfolk (UK; n=24,154). The results showed that higher fruit and vegetable intakes and diet quality (assessed via the alternative healthy eating index-aHEI) were associated with increased flavanol intake in COSMOS. Nevertheless, fewer than 25% of participants meeting dietary guidelines achieved an estimated flavanol intake of [&ge;]500 mg/day. Similar findings were observed in EPIC-Norfolk as well as through flavanol intake simulations considering fruits and vegetables commonly consumed in the US diet. In conclusion, adherence to existing dietary guidelines does not yield flavanol intake levels comparable to those shown to provide cardiovascular benefits in COSMOS. Thus, specific dietary reference values for flavanols may still be necessary if aiming to increase the intake of these dietary compounds. Graphical abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=101 SRC="FIGDIR/small/26346949v1_ufig1.gif" ALT="Figure 1"> View larger version (39K): org.highwire.dtl.DTLVardef@24faeaorg.highwire.dtl.DTLVardef@1d52a29org.highwire.dtl.DTLVardef@1c2ff33org.highwire.dtl.DTLVardef@100a384_HPS_FORMAT_FIGEXP M_FIG C_FIG

Background Acute malnutrition remains a major public health challenge among children under five in Malawi due to undetected and untreated cases. While several policies and programmes are in place, they face significant resource input and implementation constraints. In this study, we evaluate the potential health impact and cost-effectiveness of three interventions designed to address constraints along the care pathway in childhood acute malnutrition management. These include improving early recognition of symptoms by caregivers, increasing attendance at routine growth monitoring visits through community outreach, and scaling up the availability of therapeutic food supplements. Methods and Findings We use a newly developed model representing the natural history and management of acute malnutrition, implemented within the Thanzi La Onse (TLO) dynamic individual-based simulation framework, which captures the public health system in Malawi. Each of the three interventions is assessed both individually and in combination, translated into seven scenarios which we evaluate in comparison to the status quo. The optimal strategy combines two interventions, improved caregiver awareness of early symptoms with increased availability of therapeutic food supplements. Over five years, this strategy is predicted to avert 840,470 (95% CI: 682,057-998,883) DALYs with total incremental costs of $34 million. This corresponds to an annual health expenditure increase of $0.32 per capita. At a cost-effectiveness threshold of $76 per DALY averted, the strategy results in an incremental net health benefit of 394,252 (95% CI: 235,839-552,665) DALYs averted. Conclusions The cost-effective strategy for addressing constraints in childhood acute malnutrition management is simultaneously improving caregiver recognition of early symptoms and expanding therapeutic food supplement availability. Out of the seven scenarios evaluated, this integrated approach was found to be the optimal strategy within the Malawian public health system, yielding substantial health at modest costs. These findings provide critical evidence to inform national policy and guide investment prioritisation for the management of childhood acute malnutrition.