Public Health Nutrition

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.

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.

BackgroundDietary data gaps limit the effectiveness of food policies and programmes in low-and middle-income countries (LMICs). Automated mobile phone-based tools could fill data gaps at reduced time and cost compared with face-to-face methods, especially for high-frequency dietary quality monitoring in resource-constrained environments. ObjectiveThis study assessed the validity of automated participant-recorded Interactive Voice Response (IVR) 24-hour dietary recalls to assess dietary quality amongst marginalised rural women in a sub-Sahara African context, against same-day gold standard observed weighed food records (WFR). MethodsAutomated IVR with push-button response on basic mobile phones collected semi-quantitative list-based 24-hour dietary recalls from 156 randomly selected women in rural Northern Uganda during the wet season. Inter-method agreement was assessed by comparing mean womens dietary diversity scores (WDDS), the percentage achieving minimum DDS for women (MDD-W), and consumption of unhealthy foods and beverages. ResultsMost women (74.4%) completed the IVR. Compared with the WFR, agreement for the IVR was moderate for MDD-W (21.6% vs. 15.5%; kappa=0.52; area under the curve=0.80), mean WDDS (3.3 vs. 3.5; weighted kappa=0.41), and unhealthy food (34.5% vs 23.3%; kappa=0.44) and beverage consumption (32.8% vs 31.9%; kappa=0.43). ConclusionThis is the first study to validate the use of IVR via basic mobile phones to collect dietary data to estimate population-level MDD-W, WDDS and percentage consuming unhealthy foods and beverages amongst marginalised rural women in sub-Saharan Africa. With provision of short participant training, results indicate this innovative automated method can be used in place of enumerator-administered methods for monitoring key dietary quality indicators widely used in LMICs with low-literate, rural women in Uganda. HighlightsO_LIThis is the first study to validate the use of Interactive Voice Response (IVR) to collect dietary data from digitally marginalised rural women in a sub-Saharan African context, for estimating key international dietary quality indicators widely used in LMICs - MDD-W, WDDS, and the percentage consuming unhealthy foods and beverages C_LIO_LIThis innovative method can be used in place of conventional enumerator-administered methods, after contextualisation and training participants on its use C_LIO_LISuch methods can help fill critical data gaps on dietary quality with low-literate women in resource-scarce settings C_LI O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=117 SRC="FIGDIR/small/25333742v1_ufig1.gif" ALT="Figure 1"> View larger version (55K): org.highwire.dtl.DTLVardef@bcff11org.highwire.dtl.DTLVardef@dda65org.highwire.dtl.DTLVardef@17d565corg.highwire.dtl.DTLVardef@1b0c124_HPS_FORMAT_FIGEXP M_FIG O_FLOATNOFigure 0:C_FLOATNO Graphical abstract C_FIG

BackgroundHealthy diets during childhood and adolescence are paramount for growth, development, and long-term health. However, there is a lack of low-burden standardized metrics to assess and monitor healthy diets among children and adolescents aged 2-19 years of age on a global scale. ObjectiveThis critical review aimed to identify and evaluate existing metrics for assessing healthy diets in this age group and to determine their suitability for global monitoring based on feasibility and adaptability across different contexts. MethodsA systematic search was conducted across three global databases, encompassing both peer-reviewed and grey literature. ResultsA total of 127 distinct healthy diet metrics were identified many of which were developed or adapted based on national dietary guidelines across various geographical contexts. Only five were deemed suitable for global monitoring due to their feasibility and adaptability: the Individual Dietary Diversity Score, 7 food group Minimum Dietary Diversity, 10 food group Minimum Dietary Diversity, Healthy Plate Variety Score, and Adapted ultra-processed food (UPF) Nova Score. Among these metrics, diversity was the most commonly measured sub-construct of a healthy diet, while only the Adapted Nova Score aimed to capture moderation. These five metrics were further evaluated for construct validity, reliability, and cross-context equivalence, which revealed large evidence gaps, particularly regarding sensitivity to change and test-retest reliability. ConclusionsThese findings highlight the need for additional research to validate healthy diet metrics globally to ensure their accuracy, sensitivity, and reliability to differentiate populations and changes over time. Developing robust, low-burden metrics is essential for informing effective, timely nutrition policies and interventions aimed at improving the diets of children and adolescents worldwide. Statement of significanceThis review is the first to systematically evaluate the feasibility and adaptability of existing healthy diet metrics for global monitoring among children and adolescents, identifying key gaps in their validity and reliability, particularly regarding sensitivity to change and test-retest reliability.

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.

ObjectivesTo examine whether complete absence of vegetable and fruit consumption (Zero Vegetable or Fruit - ZVF) independently associates with anemia among children aged 0-59 months in Tajikistan, and to identify key maternal and socioeconomic determinants of childhood anemia. DesignCross-sectional analysis using recent 2023, nationally representative Demographic and Health survey data from Tajikistan. SettingNational population based study across all regions of Tajikistan (urban and rural areas) using two stage stratified cluster sampling. Participants2,355 children in age group 0-59 months with complete data on hemoglobin levels and dietary intake in the preceding 24 hours residing in households selected from 2023 Tajikistan Demographic and Health Survey were included in this study. Main Outcome MeasuresPrimary outcome, childhood anemia status (hemoglobin <10.5g/dl for 6-23 months, <11g/dl for 24-59 months, altitude-adjusted per WHO 2024 criteria). ResultsAmong Tajik children under 5 years, 36.1% of children consumed no vegetables or fruits in the preceding 24 hours and the prevalence of anemia was 33.2%. Adjusted odds in our study revealed no association of ZVF consumption with anemia (OR=0.85, 95% CI: 0.63 to 1.14). Significant associations emerged for maternal anemia which increased child anemia odds by 48% (OR=1.48, 95% CI: 1.16 to 1.88), richest index had 60% lower anemia odds compared to the poorest (OR=0.39, 95% CI: 0.27 to 0.56) and low birth size increased anemia risk two fold (OR=1.92, 95% CI: 1.31 to 2.81).Each additional daily meal consumption reduced anemia odds by 14% (OR=0.86, 95% CI: 0.76 to 0.98). ConclusionsChild anemia in Tajikistan is not primarily driven by specific dietary factors but maternal nutritional status during pregnancy, birth outcomes, and socioeconomic disparities are main drivers. This novel null finding on ZVF intake, underscores that non dietary drivers predominate, informing targeted interventions aligned with SDG2 (Zero hunger). Thus integrated approaches aim to address maternal nutrition, antenatal care, wealth inequalities, and feeding frequency promotion. What is already known on this topicOver 40% of children under five globally are affected by childhood anemia with dietary factors like low fruit and vegetable intake considered important contributors. However, the specific impact of complete absence (zero consumption) of vegetables and fruits on childhood anemia needs to be explored particularly in Central Asian countries like Tajikistan as here the dietary pattern differ from other low- and middle-income settings. What this study addsThis first nationally representative Central Asian study showed that downstream factor thats the zero vegetable or fruit consumption had no association with childhood anemia in Tajikistan. Instead upstream factors like maternal anemia during pregnancy, household wealth disparities, small birth size, and meal frequency emerged as primary determinants, challenging dietary-centric intervention approaches. How this study might affect research, practice or policyThese findings redirect anemia prevention strategies towards integrated interventions addressing maternal nutrition during pregnancy, poverty alleviation, improved antenatal care for fetal growth monitoring, and feeding frequency promotion rather than focusing solely on vegetable or fruit consumption. This evidence informs sustainable development goals (SDG) aligned nutrition policies requiring upstream determinants to be prioritized alongside dietary diversity programs in similar settings. Key PointsO_ST_ABSCore IssuesC_ST_ABSThis study explored whether complete absence of vegetable and fruit consumption (ZVF) associates with childhood anemia (below five years) in Tajikistan thereby challenging dietary-centric intervention approaches by examining maternal and socioeconomic determinants. FindingsThe research found no significant association between zero vegetable or fruit consumption with childhood anemia, but identified maternal anemia during pregnancy, household wealth disparities, small birth size, and meal frequency as primary drivers. MeaningThis novel null finding of our research redirects anemia prevention strategies from dietary diversity alone toward integrated upstream interventions addressing maternal nutrition, poverty alleviation, antenatal care quality, and feeding frequency informing SDG-aligned policies in Central Asia and similar Lower-and Middle-income countries.

IntroductionChildhood obesity is a major global public health issue globally and in Brazil. The impacts of childhood obesity include higher risk of disease during childhood and of obesity and non-communicable diseases in adulthood and represent an important epidemiological and economic burden to countries. MethodsThis study is based on the modeling of total costs of hospitalizations and the additional costs attributable to childhood obesity in the Brazilian National Health System. ResultsThe hospitalizations of children and adolescents with obesity as a primary cause totaled R$5.5 million to the Brazilian National Health System from 2013 to 2022, demonstrating that obesity is rarely considered as a cause of hospitalization especially among children and adolescents. The additional costs of hospitalizations attributable to childhood obesity totaled R$213.1 million during the same period. Considering the additional non-hospital, outpatient and medication cost attributable to childhood obesity in Brazil, the total costs were estimated at R$225.7 million in the last decade. ConclusionThis study highlight that the costs of childhood obesity are not limited to the impacts on adult health and represent a relevant economic burden to the Brazilian National Health System and to families because of additional costs during childhood. Therefore, the prevention and control of childhood obesity is a public health priority that demands immediate and robust policies.

BackgroundUnhealthy diets are a major public health concern. However, a lack of available and up-to-date quantitative dietary intake data, accurate low-burden data collection methods, and valid and interpretable metrics across contexts has hindered frequent monitoring of diets globally. MethodsIn this multi-country validation study, we compared the relationships between low-burden metrics of a healthy diet, identified by the FAO, UNICEF, and WHO Healthy Diets Monitoring Initiative, and a suite of reference metrics of dietary intake. To this end, we used harmonized open access quantitative 24-hour recall and food record data collected from 77,118 adolescent and adult females across 27 countries. FindingsOn any given day, non-consumption of sweet foods or sweet beverages was associated with greater population-level adherence to <10% energy from free sugars in available upper-middle income countries [odds ratio (95% CI): 5.35 (5.05, 5.66)]. Food group diversity score (FGDS) was positively associated with mean adequacy ratio of micronutrients [{beta} of 1-SD change (95% CI): [~]11 percentage points (9, 12)], while NCD-Protect score best predicted consumption of [&ge;]400 g/day of fruits and vegetables [range odds ratio of 1-SD changes (95% CI): 2.56 to 3.01 (2.40 to 3.13) in lower-middle and high income countries, respectively]. FGDS and Global Diet Quality Score Positive were associated with achieving [&ge;]25 g/day of fibre and [&ge;]3,510 mg/day of potassium across contexts. No indicator accurately predicted adherence to WHO guidelines for sodium intake or energy intake ranges for carbohydrates, lipids, and proteins. InterpretationAccurate low-burden dietary assessment methods can provide valid metrics that enable timely monitoring of key characteristics of healthy diets globally. Specifically, avoiding sweet foods or sweet beverages serves as an indicator for population-level adherence to the WHO guideline for free sugar intake, while metrics reflecting nutritious food group diversity are strongly predictive of better micronutrient adequacy and adherence to WHO guidelines for fruits and vegetables, fibre, and potassium intakes across settings. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSUnhealthy diets are a common cause of all forms of malnutrition and are the major risk factor for non-communicable diseases. However, a lack of up-to-date nationally representative quantitative dietary intake data, and a lack of consensus on fit-for-purpose lower-burden data collection methods and metrics, based on comparative epidemiological evidence, has hindered monitoring of healthy diets globally. Added value of this studyUsing open access quantitative 24-hour recall and food record data collected in 27 countries, our validation analyses compared the relationships between measures of a healthy diet, deemed most promising for global surveillance by the FAO, UNICEF, and WHO Healthy Diets Monitoring Initiative, and a suite of reference metrics of dietary intake, both within and across countries. Implications of all the available evidenceNationally representative quantitative dietary intake assessments remain the reference for nutrition. Nevertheless, complementary low-burden methods can yield metrics that are suitable for high-frequency monitoring of healthy diets. Specifically, on any given day, avoiding sweet foods or sweet beverages is an accurate population-level indicator for achieving the WHO guideline of <10% kcal/day from free sugars, while metrics capturing nutritious food group diversity are associated with better micronutrient adequacy, as well as, higher probabilities of reaching WHO guidelines of [&ge;]400 and [&ge;]25 g/day for fruits and vegetables and fibre, respectively, and [&ge;]3,510 mg/day of potassium across contexts.

BackgroundIn low- and middle-income countries (LMICs), food insecurity has traditionally been associated with undernutrition. However, as many LMICs undergo a rapid nutrition transition, greater access to inexpensive, energy-dense, and nutrient-poor foods is contributing to rising rates of overweight and obesity. These shifts may be altering the relationship between food insecurity and excess weight, a link that has been more widely documented in high-income countries. This systematic review aims to synthesize evidence on the association between food insecurity and overweight/obesity among adults in LMICs, and to identify proposed mechanisms and contextual factors that may influence this relationship. MethodsPrimary observational studies focused on the association between food insecurity and overweight/obesity among adults in LMICs will be systematically searched from multiple electronic databases, including PubMed, EMBASE, Global Health, Scopus, and LILACS. Grey literature will be explored using Google Scholar and ProQuest Dissertations & Theses Global. Reference lists of included studies and relevant reviews will also be manually screened to identify additional studies. Extracted data will include measures of food insecurity, overweight/obesity outcomes, and any reported mechanisms or contextual factors influencing their relationship. DiscussionThis review will contribute to a deeper understanding of the complex and evolving relationship between food insecurity and overweight/obesity in LMICs. Where data allow, we will explore how this association varies across country income levels, urban and rural settings, sex, age groups, and exposure to extreme events. Identified mechanisms and contextual modifiers will be synthesized to provide insights into the pathways that may underlie these associations. The findings will help identify knowledge gaps and inform future research and policy efforts aimed at addressing the dual burden of malnutrition in LMICs. RegistrationThis systematic review protocol is registered in PROSPERO under the registration number: CRD420251076653.

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.

Plant-based diets have grown in popularity in recent years, in part because of the perceived health benefits; higher consumption of vegetables and other healthy foods is associated with better nutrition and reduced risk of disease. In this study, we estimate the potential impact of higher uptake of a 100% plant-based (vegan) diet in England from the perspective of the National Health Service (NHS). We estimate the impact in terms of quality-adjusted life years (QALYs), health care expenditure, and total net benefit compared to the current level of uptake. This model-based analysis combines estimates for disease prevalence, the relative risk of disease associated with a vegan diet, and disease-specific health state utility values (HSUVs) and health care costs. We conducted a literature review to identify the most suitable inputs to the model, which included estimates for cancer, coronary heart disease, cataracts, diverticular disease, bone fractures, stroke, and type 2 diabetes. The model is open-source and implemented in an interactive online dashboard, allowing for further extension and exploration of the findings. In our base case analysis with 100% adoption of a plant-based diet in England, the total health care cost savings across all considered diseases is around {pound}6.7 billion per year, with 172,735 additional QALYs, and a total net benefit to the NHS of around {pound}18.8 billion when QALYs are valued at {pound}70,000. The majority of potential savings are realised through the avoidance of almost 1.3 million cases of type 2 diabetes. Numerous challenges are associated with estimating the impact of widespread dietary changes in society. However, strong evidence shows that plant-based diets are associated with better health outcomes for some of Englands most significant causes of disease burden. Higher rates of plant-based diet adoption may bring considerable cost savings for the NHS and generate substantial health benefits for the population. Policymakers should consider the relevance of these estimates to their settings and the potential for interventions that support healthy dietary changes that contribute to population health. Future research should seek to identify the causal effects of plant-based diet adoption on health outcomes, and health care resource use across different populations. FundingThis study was funded by a grant from The Vegan Society. Author DeclarationsThe authors are employees of the Office of Health Economics, a registered charity and independent research organisation that receives funding from a variety of sources. Both authors identify as vegan. CS is a member of The Vegan Society.

BackgroundAccurate 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. ObjectiveTo 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. MethodsIn 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. ResultsThe 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. ConclusionsCulturally 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.

BackgroundSub-Saharan Africa faces prolonged COVID-19 related impacts on economic activity, livelihoods, nutrition, and food security, with recovery slowed down by lagging vaccination progress. ObjectiveThis study investigated the economic impacts of COVID-19 on food prices, consumption and dietary quality in Burkina Faso, Ethiopia, Ghana, Nigeria, and Tanzania. MethodsWe conducted a repeated cross-sectional study and used a mobile platform to collect data. Data collected from round 1 (July-November, 2020) and round 2 (July-December, 2021) were considered. We assessed participants dietary intake of 20 food groups over the previous seven days. The studys primary outcome was the Prime Diet Quality Score (PDQS), with higher scores indicating better dietary quality. We used linear regression and generalized estimating equations to assess factors associated with diet quality during COVID-19. ResultsMost of the respondents were male and the mean age ({+/-}SD) was 42.4 ({+/-}12.5) years. Mean PDQS ({+/-}SD) was low at 19.1 ({+/-}3.8) before COVID-19, 18.6({+/-}3.4) in Round 1, and 19.4({+/-}3.8) in Round 2. A majority of respondents (80%) reported higher than expected prices for all food groups during the pandemic. Secondary education or higher (estimate: 0.73, 95% CI: 0.32, 1.15), older age (estimate: 30-39 years: 0.77, 95% CI: 0.35, 1.19, or 40 years or older: 0.72, 95% CI: 0.30, 1.13), and medium wealth status (estimate: 0.48, 95% CI: 0.14, 0.81) were associated with higher PDQS. Farmers and casual laborers (estimate: -0.60, 95% CI: -1.11, - 0.09), lower crop production (estimate: -0.87, 95% CI: -1.28, -0.46) and not engaged in farming (estimate: -1.38, 95% CI: -1.74, -1.02) associated with lower PDQS. ConclusionDiet quality which had declined early in the pandemic had started to improve. However, consumption of healthy diets remained low, and food prices remained high. Efforts should continue to improve diet quality for sustained nutrition recovery through mitigation measures, including social protection.

Background and objectivesThe consumption of unprocessed or minimally processed whole plant foods and of ultra-processed foods, as defined by the Nova food classification system, are associated in opposite ways with diet quality and risk of diseases. However, it can be difficult to evaluate and monitor the consumption of these foods in some contexts due to lack of resources and time constraints for data collection. This study aimed to describe two simple and easily derived diet quality scores and evaluate their performance in reflecting the dietary share of unprocessed or minimally processed whole plant foods and ultra-processed foods. MethodsA total of 812 adults (18 years old or older) answered the Nova24h screener, a 2-minute self-administered questionnaire that measures the consumption of a set of foods on the day before the interview. Food items included in this tool belong to two main groups of Nova classification: unprocessed or minimally processed whole plant foods (WPF, 33 food items) and ultra-processed foods (UPF, 23 food items). Two scores are obtained from this tool by summing the number of items checked - the Nova-WPF and the Nova-UPF. We compared the Nova-WPF and the Nova-UPF scores with the dietary intake (% of total energy) of all unprocessed or minimally processed whole plant foods and all ultra-processed foods, respectively, obtained through a full self-administered web-based 24-hour recall, applied on the same day. We evaluated the relationship between the approximate quintiles or intervals of each score and the corresponding % of energy intake by linear regression, and the agreement between the intervals of each score with the intervals of the corresponding % of energy intake, using the Prevalence-Adjusted and Bias-Adjusted Kappa (PABAK). ResultsApproximate quintiles of each score presented a direct and linear relationship with the corresponding % of energy intake (p-value for linear trend <0.001). We found a substantial agreement between the intervals of each score and of the corresponding % of energy intake (PABAK 0.72, 95% CI 0.64-0.81 for the Nova-WPF score and PABAK 0.79, 95% CI 0.69-0.88, for the Nova-UPF score). ConclusionsThese two scores performed well against the dietary share of unprocessed or minimally processed whole plant foods and ultra-processed foods in Brazil and can thus be used to evaluate and monitor diet quality.

ObjectiveThe COVID-19 pandemic was accompanied by varying movement restriction measures across populations worldwide. These restrictions altered daily activities at all levels, including food access and intake, as well as psychological feelings during lockdown. The main objective of the present study was to evaluate health, and nutrition behaviors during confinement during the first wave of the COVID-19 pandemic. MethodWe conducted a cross-sectional study using an online survey for data collection; a total of 1,561 surveys were validated. ResultsThe majority of respondents were women (74.2%) between 18 and 49 years old. Among the respondents, 83.3% indicated a university education level, and 49.9% reported a monthly family income equal to or less than 1,000 USD. In addition, more than 50% self-reported overweight or obesity. Responses were analyzed using k-means algorithms to identify food intake patterns; we found three patterns: a healthy food intake pattern, a non-healthy food intake pattern and a mixed food intake pattern. The respondents with healthy food intake and non-healthy food intake patterns reported better socioeconomic conditions. Individuals classified as having mixed food intake patterns had lower incomes, less education and higher unemployment rates. Regarding emotions, we found that women experienced more negative emotions, such as fear, worry and anxiety, during the lockdown period. ConclusionsTaken together, these results suggest that the mobility restriction measures imposed during the COVID-19 pandemic affected food intake patterns by exacerbating existing inequalities. We believe that directing resources towards strategies with the greatest positive impacts on public health remains key, especially in critical situations such as the COVID-19 pandemic.

This longitudinal study examined the association of food insecurity with anthropometric changes, incident hypertension and diabetes over three years in Filipino women. Data were drawn from 1,562 participants in the 2012 and 2015 Cebu Longitudinal Health and Nutrition Survey (CLHNS). Food security was measured using the 7-item Radimer-Cornell scale. Linear and logistic regression models assessed the association between 2012 food insecurity and 2015 outcomes, including BMI, waist circumference (WC), % body fat (%BF), and incident hypertension and diabetes. Higher food insecurity scores in 2012 were significantly associated with lower BMI ({beta} = -0.14, p < 0.001), WC ({beta} = - 0.36, p < 0.001), and %BF ({beta} = -0.34, p < 0.001) in 2015, after adjusting for age, wealth, urbanicity, and other covariates. No statistically significant associations were found between food insecurity and incidence of hypertension (OR = 1.05, 95% CI: 0.89-1.24) or diabetes (OR = 0.92, 95% CI: 0.72-1.18). Unlike trends in high income countries (HIC), where food insecurity is linked to obesity and chronic diseases, these findings underscore the need to examine food insecuritys effects in LMICs undergoing a nutrition transition. Future studies should include longer follow-up periods and detailed dietary assessments to clarify the role of diet as a mediator between food insecurity and disease outcomes.

BackgroundInterventions are needed to promote responsive infant feeding (RIF) to assist caregivers recognize infant hunger/satiety cues and overcome barriers to using RIF. The Learning Early Infant Feeding Cues (LEIFc) intervention was designed to fill this gap by using a validated coaching approach to promote RIF. Guided by the ORBIT model, this multimodal, proof-of-concept (POC) study evaluated the clinical significance, feasibility, and fidelity of LEIFc in mother-infant dyads. MethodsMother-infant dyads were followed from the 3rd trimester of pregnancy to 4 months postpartum. Coaching during a feeding session was provided using the SS-OO-PP-RR ("super," Setting the Stage, Observation & Opportunities, Problem Solving & Planning, Reflection & Review). RIF was measured pre-post via the Infant Feeding Questionnaire subscales: awareness of infant cues (Aware), feeding on a schedule (Schedule), and using food to calm (Calm). Qualitative data from participants was collected at study conclusion. Results21 dayds completed all study visits. Suggesting RIF, there was a 28.5% increase in Aware and a 40% decrease in Calm. Schedule increased 4.8%, not suggestive of RIF. Three themes emerged from the qualitative data: LEIFc offered additional support, recognition of infant feeding cues, and identification of additional needs ConclusionsThis POC study supports that the LEIFc intervention was feasible to implement and acceptable by participants. LEIFc was effective at increasing RIF except feeding on a schedule. The study concluded at 4 months postpartum when many mothers return to work and/or have other caregivers feeding their infant which may contribute to feeding on a schedule. Mixed methods analyses may explain the results. Consistent with the ORBIT model, the next steps are to refine the intervention then test in a larger sample at highest risk for poor infant outcomes associated with feeding (i.e., rapid infant weight gain, childhood obesity).

1ObjectiveMonitoring dietary habits is crucial for identifying shortcomings and delineating countermeasures. About 20 years after the last population-based surveys in Bavaria and Germany, dietary habits were assessed to describe the intake distributions and compare these with recommendations at food and nutrient level. MethodsThe 3rd Bavarian Food Consumption Survey (BVS III) was designed as a diet survey representative of adults in Bavaria; from 2021 to 2023, repeated 24-hour diet recalls were collected by telephone using the software GloboDiet(C). Food (sub-)group and nutrient intake data were modeled with the so-called NCI method, weighted for the deviation from the underlying population. Intake distributions in men and women were described as percentiles. These data were used to estimate the proportion of persons meeting dietary intake recommendations. In addition, food consumption data were compared with the results reported 20 years ago collected by the same methodology (2nd Bavarian Food Consumption Survey, BVS II). ResultsUsing 24-hour diet recalls of 550 male and 698 female participants, we estimated intake distributions for food (sub-)groups and nutrients. A major proportion of the adult population does not meet the food-based dietary guidelines; this refers to a series of food groups, including fruit and vegetables, legumes, nuts, cereal products, and especially whole grain products, as well as fresh and processed meat. Regarding selected essential nutrients, a considerable proportion of the population was at higher risk of insufficiency from iron (women), zinc (men), and folic acid (both men and women), as already described in previous studies. ConclusionA major proportion of the adult Bavarian population does not meet the current food-based dietary guidelines. Compared to BVS II data, favorable changes refer to lower consumption of total meat (especially processed meat) and soft drinks, and an increased intake of vegetables. The conclusions based on the intake of selected essential nutrients hardly changed over time. From a public health perspective, the still low intake of vegetables, fruit, nuts, cereal products, and particularly of whole grain products, and associated higher risks of insufficient supply of several vitamins and minerals call for action for improvement.

BackgroundThere is increasing global focus on malnutrition in infants aged under 6 months (u6m) but evidence on how best to identify and manage at-risk individuals is sparse. Our objectives were to: explore data quality of commonly used anthropometric indicators; describe prevalence and disease burden of infant u6m malnutrition; compare wasting and underweight as measures of malnutrition by determining the strength and consistency of associations with biologically plausible risk factors. MethodsWe performed a cross-sectional secondary analysis of Demographic and Health Survey (DHS) datasets, focussing on infants u6m. We calculated underweight (low weight-for-age), wasting (low weight-for-length), stunting (low length-for-age), and concurrent wasting and stunting. We explored data quality by recording extreme (flagged, as per standard criteria) or missing values. We calculated the population-weighted prevalence of each type of malnutrition and extrapolated the burden to all low- and middle-income countries (LMICs). We explored associations between infant, maternal and household risk factors with underweight and wasting using logistic regression models. ResultsWe analysed 54 DHS surveys. Data quality in terms of refusals and missingness was similar for both weight and length. There were more extreme (flagged) values for length-based measures (6.1% flagged for weight-for-length, 4.8% for length-for-age) than for weight-for-age (1.0% flagged). Overall, 20.1% of infants (95% CI: 19.5, 20.7) were underweight, 21.3% (95% CI: 20.7, 22.3) were wasted, 17.6% (95% CI: 17.0, 18.2) were stunted, and 2.0% (95% CI: 1.8, 2.2) were concurrently wasted and stunted. This corresponds to an estimated burden in LMICs of 23.8m underweight infants, 24.5m wasted infants, 21.5m stunted infants and 2.2m concurrently wasted and stunted. Logistic regression models showed that numerous risk factors were associated with wasting and underweight. Effect sizes of risk factors tended to be stronger and more consistently associated with underweight compared to wasting. ConclusionMalnutrition in infants u6m is a major problem in LMICs. This is true whether assessed by underweight, wasting or stunting. Our data build on other evidence suggesting that underweight may be a better anthropometric case definition than wasting: data quality is better when length is not involved; biologically plausible risk factors are better reflected by an infant being underweight. Future research, ideally from intervention trials, should further explore how best to identify malnourished (small and nutritionally at-risk) infants u6m. For now, treatment programmes should note that many factors might underlie problems in this age group: services should thus consider how to address maternal health and wider social circumstances as well as caring for infants themselves.

Objectives: To characterize prevalence and secular trends in stunting, thinness, overweight, obesity, and the double burden of malnutrition (DBM) in urban Vietnamese children. Methods: We analyzed 249,745 annual health check visits from 97,111 children aged 18 months to 18 years attending a private school system in Hanoi, Ho Chi Minh City, and Haiphong from 2018 to 2025. Temporal trends in stunting, thinness, and obesity were modelled using generalized estimating equation (GEE) logistic regression. Results: A total of 51,034 males and 46,077 females were included. Stunting prevalence was low but rose significantly in both sexes (males: 0.7% to 1.3%, p=0.006, females: 0.7% to 1.7%, p<0.001), concentrated in children under 10 years (GEE OR/year=1.076 and 1.089, both p<0.05), females exceeded males by 2025. Obesity declined overall in males (21.4% to 17.0%) and females (6.2% to 5.0%, both p<0.001), but rose significantly among males aged 15-18 years (OR=1.055, p=0.021). Overweight increased in males (19.7% to 20.5%, p=0.010) but declined in females (18.0% to 14.8%, p<0.001). Individual-level DBM (concurrent stunting with overweight/obesity) was uncommon (<0.2%). City-level heterogeneity was marked, with Haiphong showing the highest male obesity (22.7% in 2025) and individual-level DBM. Conclusion: Vietnamese urban schoolchildren experienced simultaneous, divergent nutritional burdens from 2018-2025: rising stunting and thinness under age 10, declining early childhood obesity, and rising adolescent male obesity. Individual-level DBM was rare, but a population-level double burden was evident across age groups. City, age, and sex specific nutrition and school health policies are needed to address this complex malnutrition transition.