Unhealthy Food and Beverage Consumption in Children and Risk of Overweight and Obesity: A Systematic Review and Meta-Analysis.

This WHO-commissioned review contributed to the update of complementary feeding recommendations, synthesizing evidence on effects of unhealthy food and beverage consumption in children on overweight and obesity. We searched PubMed (Medline), Cochrane CENTRAL, and Embase for articles, irrespective of language or geography. Inclusion criteria were: 1) randomized controlled trials (RCTs), non-RCTs, cohort studies, and pre/post studies with control; 2) participants aged ≤10.9 y at exposure; 3) studies reporting greater consumption of unhealthy foods/beverages compared with no or low consumption; 4) studies assessing anthropometric and/or body composition; and 5) publication date ≥1971. Unhealthy foods and beverages were defined using nutrient- and food-based approaches. Risk of bias was assessed using the ROBINS-I (risk of bias in nonrandomized studies of interventions version I) and RoB2 [Cochrane RoB (version 2)] tools for nonrandomized and randomized studies, respectively. Narrative synthesis was complemented by meta-analyses where appropriate. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation. Of 26,542 identified citations, 60 studies from 71 articles were included. Most studies were observational (59/60), and no included studies were from low-income countries. The evidence base was low quality, as assessed by ROBINS-I and RoB2 tools. Evidence synthesis was limited by the different interventions and comparators across studies. Evidence indicated that consumption of sugar-sweetened beverages (SSBs) and unhealthy foods in childhood may increase BMI/BMI z-score, percentage body fat, or odds of overweight/obesity (low certainty of evidence). Artificially sweetened beverages and 100% fruit juice consumption make little/no difference to BMI, percentage body fat, or overweight/obesity outcomes (low certainty of evidence). Meta-analyses of a subset of studies indicated a positive association between SSB intake and percentage body fat, but no association with change in BMI and BMI z-score. High-quality epidemiological studies that are designed to assess the effects of unhealthy food consumption during childhood on risk of overweight/obesity are needed to contribute to a more robust evidence base upon which to design policy recommendations. This protocol was registered at https://www.crd.york.ac.uk/PROSPERO as CRD42020218109.

The effect of a school-based iron intervention on the haemoglobin concentration of school children in north-west Pakistan.

BACKGROUND/OBJECTIVE: To assess the effectiveness of iron supplements administered to school children through a longitudinal school health intervention in terms of child haemoglobin concentration and anaemia prevalence. SUBJECTS/METHODS: Children and adolescents aged 5-17 years were selected from 30 schools in north-west Pakistan for a longitudinal iron supplement intervention. Children received once-weekly iron supplements (200 mg ferrous sulphate containing 63 mg of elemental iron) for 24 weeks (n=352); or the same supplements twice-weekly for 12 weeks (n=298) or received no tablets (n=298). Haemoglobin concentration was estimated in finger-prick blood samples at baseline, 12 and 24 weeks. Follow-up samples were taken at 36 weeks. RESULTS: A non-significant increase in haemoglobin concentration was observed in children receiving iron supplements after 12 weeks (mean 1.4 g/l s.d. 15.0 g/l in once-weekly versus 2.5 g/l s.d. 14.5 g/l in twice-weekly) compared with the group receiving no iron supplements. There was no significant reduction in the prevalence of anaemia in the once-weekly or twice-weekly group compared with the unsupplemented group. The prevalence of anaemia increased in all three groups during the follow-up period (24-36 weeks). CONCLUSIONS: Once-weekly and twice-weekly iron supplements were not associated with significant increases in haemoglobin concentration compared with unsupplemented children. In all groups, baseline haemoglobin concentration was the strongest predictor of haemoglobin increase. The lack of improvement may stem from the moderate baseline prevalence of anaemia (33%); other micronutrient deficiencies; variable compliance; or the worsening of haemoglobin status owing to seasonal changes in dietary iron and other nutrients.

Socio-economic status and body composition outcomes in urban South African children.

OBJECTIVE: To determine which aspects of socio-economic status (SES) measured at birth and at ages 9 or 10 years, are associated with body composition at ages 9 or 10 years. DESIGN: Mixed longitudinal cohort. SETTING: Johannesburg-Soweto South Africa. PARTICIPANTS: A sub-sample of the Birth to Twenty (Bt20) cohort (n = 281) with data on birth weight, height, weight, fat and lean tissue (whole body dual-energy x ray absorptiometry (DXA)), and birth and ages 9 or 10 years SES measures. MAIN OUTCOME MEASURES: Linear regression was used to estimate the influence of birth and ages 9 or 10 years SES measures on three outcomes: fat mass index (FMI) (fat mass (kg)/height (m)4), lean mass index (LMI) (lean mass (kg)/height (m)2), and body mass index (BMI) at ages 9 or 10 years controlling for sex, age, birth weight and pubertal status. RESULTS: Compared to the lowest SES tertile, being in the highest birth SES tertile was associated with increased LMI at ages 9 or 10 years (beta = 0.43, SE = 0.21 for white and black children and beta = 0.50, SE = 0.23 for black children only), whereas children in the high SES tertile at ages 9 or 10 years had increased FMI (beta = 0.46, SE = 0.22 for white and black children, and beta = 0.65, SE = 0.23 for black children only). SES at birth and at ages 9 or 10 years accounted for 8% and 6% of the variance in FMI and BMI, respectively (black children). CONCLUSIONS: These findings underline the importance of examining SES across childhood ages when assessing nutrition inequalities. Results emphasise the need to consider lean and fat mass as well as BMI when studying SES and body composition in children.

Significant changes in physical activity among pregnant women in the UK as assessed by accelerometry and self-reported activity.

OBJECTIVE: Research on the impact of maternal physical activity on pregnancy outcomes has often employed subjective measures of physical activity obtained by diary or questionnaire. This study investigates the feasibility of using accelerometry as an objective measure of physical activity of pregnant women compared with subjective data obtained via activity recall among pregnant women. DESIGN: Activity data were collected prospectively on 57 women at 12, 16, 25, 34 and 38 weeks of gestation. Total daily physical activity was assessed by ambulatory accelerometer and activity interview (self-report). Maternal personality variables (health value, extroversion) were assessed by established scales. SETTING: Leicestershire, UK. SUBJECTS: Pregnant women were recruited by voluntary participation via antenatal booking clinics. In all, 64 pregnant women with low-risk pregnancy were enrolled onto the study, of whom 57 completed the study. RESULTS: Mean 24 h physical activity levels (PAL) decreased significantly from second to third trimester as assessed by self-report interview (1.51-1.29 Metabolic Equivalent TEE-h/day, P<0.01) and accelerometry (200.05-147.42 counts/min, P<0.01). The correlation between the two measures declined as pregnancy progressed (r value ranging from 0.55 to 0.08). Compliance with the accelerometers declined from 90% at 12 weeks to 47% at 34 weeks (P<0.01). Compliance with the self-report interviews was 100%. Those who fully complied with the accelerometry demonstrated a significantly higher health value (P<0.05) and a significantly greater level of extroversion (P<0.05) than those who did not. CONCLUSIONS: Accelerometers and self-reported activity interviews both indicated a significant decline in PAL during pregnancy. Although subjects showed a willingness to use both methods, accelerometers resulted in variable compliance with 72 h monitoring. Both techniques may be limited by the need to measure low levels of physical activity during the third trimester. SPONSORSHIP: Cambridge Neurotechnology Ltd, UK, assisted with the provision of Actiwatch accelerometers.

Activity patterns and time allocation during pregnancy: a longitudinal study of British women.

OBJECTIVE: Few studies provide data regarding the integrated everyday activities of Western pregnant women. The study aimed to quantify changes in the daily activity of women during pregnancy and to examine whether pregnancy has a differential impact on different activity domains. DESIGN: A prospective, longitudinal study of maternal time allocation and activity was carried out. METHODS: The time allocation patterns of 57 healthy nulliparous pregnant women were assessed at 16, 25, 34 and 38 weeks gestation by semi-structured interview. Mean total daily activity levels (DALs) were estimated according to the intensity and duration of each activity reported. Self-reported activity was sub-divided into occupational, recreational, domestic and nocturnal activity ratios. RESULTS: From 16 to 34 weeks gestation mean self-reported DAL declined significantly from 1.54 to 1.40 METS (Metabolic Equivalent TEE Score, where TEE is total energy expenditure) (p < 0.001). In the different activity domains, mean occupational activity ratio decreased (p < 0.002) whilst nocturnal activity ratio increased (p < 0.002) from 16 to 34 weeks. Mean recreational activity ratio decreased significantly between 25 and 38 weeks (p < 0.001) but no significant changes were observed in mean domestic activity ratio. CONCLUSIONS: Low-risk pregnancy has a differential impact on occupational, recreational and domestic domains. Economies in energy expenditure appear to be made in occupational and recreational activity while domestic activities are largely maintained during pregnancy. Changes in physical activity may be influenced more by the type of activity rather than the intensity of activity.

Factors affecting birthweight of rural Australian Aborigines.

AIM: To examine factors affecting birthweight of Aboriginal infants in the Kimberley region of north-west Australia. RESEARCH DESIGN: A retrospective study of maternal and infant health records obtained through routine data collection. SUBJECTS AND METHODS: Birthweight and length of 2959 infants born to 1822 women from 1986 to 1994 were analysed. Mothers and infants were matched using unique identification codes. Index births and subsequent births to the same mother were collated in order to examine relative birth order effects and to calculate birth intervals. RESULTS: Regression analysis showed significant associations between weight of the index birth and maternal age (p < 0.001), remoteness of locality (p < 0.01), sex of the infant (p < 0.001) and maternal height (p < 0.001). Length at birth was significantly associated with ethnicity of infant (Aboriginal vs Aboriginal/non-Aboriginal admixture, p < 0.05), sex (p < 0.001), remoteness (p < 0.01) and maternal height (p < 0.001). Similar associations were observed for second and subsequent births. Birth interval was not associated with birthweight or length. Low birthweight was also more common to Aboriginal mothers compared with mothers of Aboriginal/non-Aboriginal admixture (13.1% vs 9.2%; chi(2) = 5.1, p < 0.025) even though there were no differences in height between these two groups. Teenage mothers (< or =19 years) were no more likely to have low birthweight babies than older mothers. Of the variables examined, the only significant predictor of low birthweight was a previous low birthweight baby (relative risk = 4.45, p < 0.001). CONCLUSIONS: Short birth intervals and teenage births were not significant contributors to low birthweight in the present study. The high prevalence and duration of breastfeeding in the Kimberley may contribute to long average birth intervals. Pre-term birth, rather than intrauterine growth retardation, is likely to be the most common cause of low birthweight in this population.

Anthelmintic treatment of rural Bangladeshi children: effect on host physiology, growth, and biochemical status.

BACKGROUND: The effect of helminth infestation on the nutrition, growth, and physiology of the host is still poorly understood. Anthelmintic treatment of children in developing countries has had varying success in terms of growth improvements. OBJECTIVE: The objective of this study was to assess the effect of regular deworming on child growth, physiology, and biochemical status. DESIGN: The study was a 12-mo longitudinal intervention in 123 Bangladeshi children aged 2-5 y. Treatment (mebendazole) or placebo tablets were administered every 2 mo for 8 mo and again at 12 mo. Weight, height, midupper arm circumference, intestinal permeability, plasma albumin, alpha(1)-antichymotrypsin, and total protein concentration were assessed every 2 mo. RESULTS: Treatment with mebendazole reduced the prevalence of Ascaris lumbricoides from 78% to 8%, of Trichuris trichiura from 65% to 9%, and of hookworm from 4% to 0%. There was no significant difference in the growth of treated children compared with those given placebo tablets. No changes in intestinal permeability or plasma albumin were observed after deworming. Significant decreases in total protein (P<0.001) and alpha(1)-antichymotrypsin (P<0.001) were observed in the treatment group, indicating possible reductions in inflammation and immunoglobulin concentration after deworming. A significant increase in the prevalence of Giardia intestinalis (from 4% to 49%) in the treatment group was associated with a short-term reduction in weight (P = 0.02) and higher intestinal permeability (P <0.001) in infected subjects. No long-term effects of G. intestinalis on growth were observed. CONCLUSION: Low-intensity helminth infections, predominantly of A. lumbricoides and T. trichiura, do not contribute significantly to the poor growth and biochemical status of rural Bangladeshi children.

Seasonality of low birthweight in indigenous Australians: an increase in pre-term birth or intrauterine growth retardation?

We have analysed birthweights of 4,508 Aboriginal and Torres Strait Islander livebirths in the Kimberley region of Western Australia from 1981-93. Mean birthweight varied significantly according to month of birth (F(11) = 2.57, p = 0.003) and low birthweight babies were more common during the wet season. A significant increase in the proportion of very low birthweight (VLBW) babies was observed during the wet season compared with the dry season (OR 2.73; 95% CI 2.3-3.67; p < 0.001); whereas babies weighing 1,500-2,499 g were not significantly more common during the wet season (OR 1.06; 95% CI 0.96-1.17; p = ns). The results indicate that adverse environmental conditions may be associated with increased risk of VLBW. Since newborns weighing less than 1500 g are very likely to be pre-term (< 37 weeks' gestation), the findings also suggest that seasonality of birthweight may be due to an increase in pre-term births rather than an increase in intrauterine growth retardation. Further research is required to identify the underlying causes of an increase in VLBW babies during the wet season.

Differences in growth among remote and town-dwelling aboriginal children in the Kimberley region of Western Australia.

This paper documents the growth of Aboriginal children in remote communities and gazetted towns of the Kimberley region in the far north of Western Australia over the past 20 years. The study's specific aim was to compare the height and weight growth of children in different environments from birth to five years of age. From 1979 to 1983, children living in towns were significantly taller and heavier than their counterparts in remote communities. From 1984 to 1988 and thereafter, there were no significant differences in the growth patterns of children in towns and remote communities. Overall, weight-for-age and height-for-age of children in remote communities has improved since the 1970s relative to their town-dwelling counterparts. These changes in growth shed light on the quality of the social and physical environment over the past 20 years and may assist with the development of future programs for child health.

Maternal reports of child illness and the biochemical status of the child: the use of morbidity interviews in rural Bangladesh.

In a longitudinal study of child growth and nutritional status in Bangladesh, child morbidity was recorded using health interviews with the mother. The aim of the present study was to establish whether maternal reports of child illness were associated with the biochemical health status of the child. Children aged 2-5 years (n 117) took part in the study and their mothers were interviewed every fortnight by Bangladeshi fieldworkers. Maternal reports of diarrhoea were associated with significantly lower plasma albumin concentrations (P < 0.001), poorer intestinal permeability (P < 0.001), higher plasma immunoglobulin A levels (P < 0.005) and higher alpha-1-antichymotrypsin (ACT) levels (P < 0.05) compared with children reported to be healthy. Children with fever had significantly higher ACT (P < 0.001) and lower albumin (P < 0.05) levels compared with their healthy counterparts. Respiratory infections (RI) were not associated with any significant changes; however, reports of RI with fever were associated with significantly higher levels of ACT than either illness individually (interaction P < 0.05). These highly significant associations between maternal reports of illness and biochemical profiles of child health support the use of health interviews in developing countries.

Persistent growth faltering among aboriginal infants and young children in north-west Australia: a retrospective study from 1969 to 1993.

The objective was to examine long-term changes in the growth of Aboriginal infants and young children in the Kimberley region in the far north-west of Australia from 1969 to 1993. A retrospective analysis of anthropometric data (weight and length) routinely collected on 0-5-year-old children in 5-year cohorts from 1969 to 1993 was carried out. From 1974-78 to 1989-93 there has been a significant increase in mean birthweight (ANOVA p < 0.05). The percentage of low birthweight infants (< 2500 g) declined from 14% in 1979-83 to 10% in 1989-93 (p < 0.001). There were no consistent improvements in the growth patterns of infants from birth to 60 months. All cohorts displayed pronounced growth faltering in weight-for-age and height-for-age from 6 to 12 months of age and fell significantly below both the NCHS reference values and mean values for healthy breastfed infants. In conclusion, reductions in Aboriginal infant mortality and infectious disease rates over the past 20 years have not been accompanied by improved growth. The persistence of child malnutrition in these communities may warrant a shift in attention from disease treatment and prevention to a better understanding of nutritional influences, particularly weaning practices, during infancy and early childhood.

Socio-economic influences on gender inequalities in child health in rural Bangladesh.

OBJECTIVE: To investigate gender inequalities in child growth and nutritional status in relation to socio-economic status in Bangladesh. DESIGN: A 16-month longitudinal study of child growth measuring anthropometric and socio-economic status. SETTING: A rural area of Jamalpur district, northern Bangladesh. SUBJECTS: 1366 children from 2 to 6 years of age. METHODS: Child height and weight were measured monthly. Morbidity, food intake and health-seeking behaviours were assessed fortnightly. Multivariable analyses were performed on the growth and nutritional status of male and female children in relation to socio-economic factors including father's occupation, parental education, birth order and family size. RESULTS: There was no evidence of gender bias in farming and trading/employee households but landless female children had significantly poorer height-for-age (P < 0.001) and weight-for-age (P < 0.001) than their male counterparts. During a period of natural disaster, a statistically significant interaction was observed between father's occupation and sex (P < 0.05) such that the combination of being female and being landless was more detrimental to nutritional status than either variable alone. Over the following 16-months, catch-up-growth was apparent in landless female children who grew significantly more in height-for-age (P < 0.001) and weight-for-age (P < 0.001) than their male counterparts. CONCLUSIONS: Gender inequalities in health in Bangladesh varied significantly according to occupational status, such that the effect of sex was dependent upon occupation. These effects were statistically significant during the period of natural disaster but became insignificant as local conditions improved. This demonstrates both temporal and socio-economic variation in gender inequalities in health.

PIP: During February 1989-June 1990 in Bangladesh, local field assistants collected data on 1366 children 2-6 years old, attending maternal and child health clinics operated by a nongovernmental organization, and living in 13 villages in Jamalpur District situated on the banks of the Jamuna River. The field assistants made home visits to record child morbidity every 2 weeks and to measure child height and weight once a month. During January-April 1989, this area suffered from extensive food shortages due to a prolonged drought and one of the worst floods recorded in Bangladesh. Gender bias was not apparent in farming and trading/employee households. In landless households (i.e., fathers' occupation was laborer), girls were significantly shorter and less heavy than boys (p 0.001), however. During a natural disaster, fathers' occupation significantly interacted with sex (p 0.05). Specifically, children who were both female and living in a landless household were more likely to have poor nutritional status than children who were female and living in a farming or trading/employee household and children who were male and living in a landless household. This interaction was not apparent as local conditions improved. Over the 16 months following the natural disaster, landless girls grew significantly more in height-for-age and weight-for-age than landless boys (p 0.001). In other words, these girls experienced more catch-up growth than the boys. At the end of the study, nutritional status varied only according to socioeconomic status but not according to gender. These findings suggest that gender bias within this population depends on changes in food availability and the rural economy. Thus, child nutrition programs should target landless girls, who are at highest risk of gender discrimination and malnutrition during economic adversity.

Seasonality and child morbidity in rural Bangladesh.

This study examined seasonal variation in the impact of infection on child nutritional status. Maternal reports of child illness were examined in relation to monthly changes in weight, weight-for-age, and midupper arm circumference (MUAC) of children aged 2-6 years of age. The greatest deterioration in short-term nutritional status was associated with episodes of fever, followed by episodes of diarrhea and respiratory infections. The monsoon season was associated with the highest prevalence of fever, respiratory infection, and diarrheal diseases. Irrespective of the prevalence of infection, the relationship between infection and nutritional status varied across seasons. Weight loss and decreases in MUAC associated with infection in the dry and monsoon seasons were statistically significantly greater than those in the winter months. The observed seasonal variation in morbidity is an important consideration for studies of infection and malnutrition in children. © 1995 Wiley-Liss, Inc.

An increase in Giardia duodenalis infection among children receiving periodic Anthelmintic treatment in Bangladesh.

During a deworming study in northern Bangladesh, the prevalence of Giardia duodenalis increased significantly among three groups of children receiving periodic treatment with mebendazole. This was first observed in the treatment group (Group A) of a 12-month study. Giardia increased from 5 to 31 per cent in Group A (n = 49 chi 2 = 10.42, P < 0.005), but did not increase significantly in the placebo group (Group B) (11 to 18 per cent; chi 2 = 0.4, P = NS). The prevalence of Giardia in the treatment and placebo groups was not significantly different at the beginning of the study (n = 89, chi 2 = 0.8, P = NS). During a 6-month follow-up study, children in Groups A and B received 2-monthly treatment with mebendazole. Within 6 months the prevalence of Giardia increased significantly in Group B from 18 to 44 per cent (chi 2(1) = 6.14, P < 0.05). The prevalence of Giardia was also examined in 265 children at the end of an 18-month deworming study in the same area and found to be significantly higher among the treatment group (Group C) compared with the placebo group (Group D) (38 v. 21 per cent, chi 2 = 8.87, P < 0.005). Finally, the prevalence of Giardia was significantly higher in Group B after being treated than in Group D which had not been treated (44 and 21 per cent, respectively, chi 2 = 9.08, P < 0.005). These children were from the same villages and measured during the same month of the monsoon season.(ABSTRACT TRUNCATED AT 250 WORDS)

Perceptions and treatment of intestinal worms in rural Bangladesh: local differences in knowledge and behaviour.

A survey was conducted on 131 mothers in rural Bangladesh to examine knowledge and perceptions of helminth infection in relation to use of health facilities and treatment-seeking behaviour. Almost all respondents considered worms to be a cause of bad health and a high percentage of mothers had obtained deworming treatment for their children. However, marked differences were found in mothers' descriptions of the causes and prevention of helminth infection in two adjacent areas; Pullakandi and Shekpara. The discrepancies in biomedical knowledge corresponded with differences in treatment-seeking behaviour in the two areas. All households in the area had access to free deworming treatment provided by a health clinic, but this facility was predominantly used by women living nearby in Pullakandi. Because of the cultural and social constraints on female activities, women living further from the clinic, in Shekpara, preferred to send their husbands to a pharmacy in the nearby town to buy deworming treatment. As a consequence, these households were at a relative disadvantage in respect of the low exposure of women to health education and the greater financial cost of deworming treatment. The study highlights the influences of social and cultural factors on treatment-seeking behaviour, which in turn affect women's exposure to health education and biomedical knowledge of helminths. Further questions are raised, however, on the ability of women to implement preventive measures and the impact of health education on rates of parasitic infection.

An 18-month study of the effect of periodic anthelminthic treatment on the growth and nutritional status of pre-school children in Bangladesh.

An 18-month study was conducted from February 1989 to August 1990 to examine the effect of regular deworming on child growth and nutritional status. A sample of 1402 children, from 2 to 6 years old, were divided into a treatment group and a control group. The 688 children in the treatment group received a 500 mg single dose of mebendazole, while the 714 children in the control group were given a placebo. Height, weight and mid-upper arm circumference (MUAC) were measured on monthly household visits. Growth was measured in terms of the change in height-for-age, weight-for-age, weight-for-height and MUAC over 18 months. The initial prevalence of infection was estimated from a random sample of 96 children (49 treated, 47 control). The initial overall prevalence of Ascaris lumbricoides, Trichuris trichiura and hookworm was 71, 44 and 10% respectively. The final prevalence of infection, estimated from a random sample of 265 children, was A. lumbricoides 6%, T. trichiura 6% and hookworm 2% in the mebendazole group compared with 64, 18 and 19% respectively in the placebo group. Despite the successful treatment of helminths, there was no significant improvement in the growth of treated children compared with their untreated counterparts in terms of the change in z-scores of height-for-age, weight-for-age, weight-for-height and MUAC. The factors which may have contributed to this outcome are discussed.