Homestead food production model contributes to improved household food security and nutrition status of young children and women in poor populations

Micronutrient malnutrition is a serious public health problem among women and children in Bangladesh, Cambodia, Nepal and the Philippines. Helen Keller International has been implementing homestead food production (HFP) programs (coupled with nutrition education) in these countries to increase and ensure year-round availability and intake of micronutrient-rich foods in poor households, particularly among women and children.  Between 2003 and 2007, the HFP program was implemented among ~30,000 households in these four countries. Data collected from representative samples taken for evaluations of HFP programs in these countries illustrated the benefit of the program for households. Data were collected through interviews with households in villages that had the HFP program and from control households in non-HFP program villages. Blood samples collected from ~1000 children aged 6-59 months and ~1200 non-pregnant women before and after program implementation were analyzed for hemoglobin. The review showed that the HFP program significantly improved dietary diversification. The combined data from all four countries showed improved animal food consumption among program households, with liver consumption increasing from 24% at baseline to 46% at endline and the median number of eggs consumed by families per week increasing from 2 to 5.  The sale of HFP products also improved household income. Anemia prevalence among children in program households decreased in all the countries; however, the decrease was only significant in Bangladesh and the Philippines.  Although anemia prevalence also decreased among control households in three countries, the magnitude of change was higher in program households compared with control households.Les carences en micronutriments représentent un grave problème de santé publique chez les femmes et les enfants au Bangladesh, au Cambodge, au Népal et aux Philippines. Helen Keller International met en œuvre dans ces pays un programme de production alimentaire en exploitations familiales (homestead food production - HFP) associé à une éducation à l'alimentation afin d’augmenter et de garantir la disponibilité et la consommation d'aliments riches en micronutriments tout au long de l'année dans les foyers pauvres, et plus particulièrement chez les femmes et les enfants. Entre 2003 et 2007, le programme HFP a été mis en œuvre dans environ 30 000 foyers de ces quatre pays. Les données fournies par les échantillons représentatifs utilisés pour l'évaluation de ce programme mettent en évidence les bénéfices qu'il représente pour les familles. Ces données sont le résultat des entretiens conduits avec des familles appartenant à des villages participant au programme HFP, ainsi qu’avec des familles de contrôle dans des villages non concernés par le programme. Des analyses de l’hémoglobine ont été réalisées sur des échantillons sanguins prélevés avant et après la mise en œuvre du programme sur environ 1 000 enfants âgés de 6 à 59 mois et environ 1 200 femmes (non enceintes). L’évaluation du programme HFP a montré qu’il avait amélioré significativement la diversification alimentaire. Les données combinées des quatre pays montrent une amélioration de la consommation de produits d’origine animale chez les familles du programme. La consommation de foie est passée de 24 % à 46 %, et le nombre médian d’œufs consommés par semaine et par famille est passé de 2 à 5. La vente des produits issus du programme HFP a également amélioré les revenus de ces foyers. La prévalence de l’anémie chez les enfants participant au programme a diminué dans tous les pays. Cette diminution n'était cependant significative qu'au Bangladesh et aux Philippines. Bien que, dans trois pays, la prévalence de l’anémie ait également diminué chez les familles de contrôle, la différence était plus grande chez les familles participant au programme en comparaison avec les familles de contrôle.La malnutrición en micronutrientes es un problema de salud pública serio entre las mujeres y los niños en Bangladesh, Camboya, Nepal y Filipinas. En estos países Helen Keller International ha implementado programas de producción de alimentos en casa (PAC), conjuntamente con una educación en nutrición, para aumentar y asegurar la disponibilidad y el consumo todo el año de alimentos ricos en micronutrientes en hogares desfavorecidos, en particular entre las mujeres y los niños. Entre 2003 y 2007, el programa PAC fue aplicado en unos 30.000 hogares en estos cuatro países. Los datos obtenidos de las muestras representativas tomadas para la evaluación de los programas PAC en dichos países mostraron los beneficios del programa para los hogares. Los datos fueron recogidos a través de entrevistas con hogares en los pueblos en los que se aplicó el programa PAC y con hogares de control en pueblos sin el programa PAC. Antes y después de la implementación del programa, se tomaron muestras de sangre de unos 1000 niños entre 6 y 59 meses de edad y de unas 1200 mujeres no embarazadas; dichas muestras fueron analizadas para ver la hemoglobina. El estudio revela que el programa PAC mejoró de manera significativa la diversificación en la dieta. Los datos combinados de los cuatro países mostraron una mejoría en el consumo de alimentos de origen animal entre los hogares afiliados al programa, con un aumento del consumo de hígado de 24 % al comienzo a 46 % al final, y un aumento de 2 a 5 del número medio de huevos consumidos por familia y por semana. La venta de productos PAC también mejoró los ingresos del hogar. La prevalencia de anemia en los niños de hogares afiliados al programa disminuyó en todos los países; sin embargo, la disminución sólo fue significativa en Bangladesh y Filipinas. Aunque la prevalencia de anemia también disminuyó entre los hogares de control en tres países, la magnitud del cambio fue mayor en hogares del programa que en hogares de control

Homestead food production model contributes to improved household food security and nutrition status of young children and women in poor populations

Micronutrient malnutrition is a serious public health problem among women and children in Bangladesh, Cambodia, Nepal and the Philippines. Helen Keller International has been implementing homestead food production (HFP) programs (coupled with nutrition education) in these countries to increase and ensure year-round availability and intake of micronutrient-rich foods in poor households, particularly among women and children.  Between 2003 and 2007, the HFP program was implemented among ~30,000 households in these four countries. Data collected from representative samples taken for evaluations of HFP programs in these countries illustrated the benefit of the program for households. Data were collected through interviews with households in villages that had the HFP program and from control households in non-HFP program villages. Blood samples collected from ~1000 children aged 6-59 months and ~1200 non-pregnant women before and after program implementation were analyzed for hemoglobin. The review showed that the HFP program significantly improved dietary diversification. The combined data from all four countries showed improved animal food consumption among program households, with liver consumption increasing from 24% at baseline to 46% at endline and the median number of eggs consumed by families per week increasing from 2 to 5.  The sale of HFP products also improved household income. Anemia prevalence among children in program households decreased in all the countries; however, the decrease was only significant in Bangladesh and the Philippines.  Although anemia prevalence also decreased among control households in three countries, the magnitude of change was higher in program households compared with control households.Les carences en micronutriments représentent un grave problème de santé publique chez les femmes et les enfants au Bangladesh, au Cambodge, au Népal et aux Philippines. Helen Keller International met en œuvre dans ces pays un programme de production alimentaire en exploitations familiales (homestead food production - HFP) associé à une éducation à l'alimentation afin d’augmenter et de garantir la disponibilité et la consommation d'aliments riches en micronutriments tout au long de l'année dans les foyers pauvres, et plus particulièrement chez les femmes et les enfants. Entre 2003 et 2007, le programme HFP a été mis en œuvre dans environ 30 000 foyers de ces quatre pays. Les données fournies par les échantillons représentatifs utilisés pour l'évaluation de ce programme mettent en évidence les bénéfices qu'il représente pour les familles. Ces données sont le résultat des entretiens conduits avec des familles appartenant à des villages participant au programme HFP, ainsi qu’avec des familles de contrôle dans des villages non concernés par le programme. Des analyses de l’hémoglobine ont été réalisées sur des échantillons sanguins prélevés avant et après la mise en œuvre du programme sur environ 1 000 enfants âgés de 6 à 59 mois et environ 1 200 femmes (non enceintes). L’évaluation du programme HFP a montré qu’il avait amélioré significativement la diversification alimentaire. Les données combinées des quatre pays montrent une amélioration de la consommation de produits d’origine animale chez les familles du programme. La consommation de foie est passée de 24 % à 46 %, et le nombre médian d’œufs consommés par semaine et par famille est passé de 2 à 5. La vente des produits issus du programme HFP a également amélioré les revenus de ces foyers. La prévalence de l’anémie chez les enfants participant au programme a diminué dans tous les pays. Cette diminution n'était cependant significative qu'au Bangladesh et aux Philippines. Bien que, dans trois pays, la prévalence de l’anémie ait également diminué chez les familles de contrôle, la différence était plus grande chez les familles participant au programme en comparaison avec les familles de contrôle.La malnutrición en micronutrientes es un problema de salud pública serio entre las mujeres y los niños en Bangladesh, Camboya, Nepal y Filipinas. En estos países Helen Keller International ha implementado programas de producción de alimentos en casa (PAC), conjuntamente con una educación en nutrición, para aumentar y asegurar la disponibilidad y el consumo todo el año de alimentos ricos en micronutrientes en hogares desfavorecidos, en particular entre las mujeres y los niños. Entre 2003 y 2007, el programa PAC fue aplicado en unos 30.000 hogares en estos cuatro países. Los datos obtenidos de las muestras representativas tomadas para la evaluación de los programas PAC en dichos países mostraron los beneficios del programa para los hogares. Los datos fueron recogidos a través de entrevistas con hogares en los pueblos en los que se aplicó el programa PAC y con hogares de control en pueblos sin el programa PAC. Antes y después de la implementación del programa, se tomaron muestras de sangre de unos 1000 niños entre 6 y 59 meses de edad y de unas 1200 mujeres no embarazadas; dichas muestras fueron analizadas para ver la hemoglobina. El estudio revela que el programa PAC mejoró de manera significativa la diversificación en la dieta. Los datos combinados de los cuatro países mostraron una mejoría en el consumo de alimentos de origen animal entre los hogares afiliados al programa, con un aumento del consumo de hígado de 24 % al comienzo a 46 % al final, y un aumento de 2 a 5 del número medio de huevos consumidos por familia y por semana. La venta de productos PAC también mejoró los ingresos del hogar. La prevalencia de anemia en los niños de hogares afiliados al programa disminuyó en todos los países; sin embargo, la disminución sólo fue significativa en Bangladesh y Filipinas. Aunque la prevalencia de anemia también disminuyó entre los hogares de control en tres países, la magnitud del cambio fue mayor en hogares del programa que en hogares de control

Storage rot of seed yam resulting from speargrass injuries

Postharvest rot due to injury is a major contributing factor to the declining quality of stored seed yams ( Dioscorea spp.). Among the several known injuries, the piercing effect of speargrass rhizomes has become a serious constraint for yam production in Ghana. The objective of this study was to assess injuries on seed yams resulting from piercing of speargrass rhizomes and their effects on postharvest rots in Ghana. Eighty farmer fields from Mem, Watro, Asanteboa and Abour in the Atebubu-Amantin Municipal in the Bono East Region of Ghana were screened for speargrass incidence and injury on harvested tubers, for laboratory analysis of pathogens in 2016 and 2017. The tubers were sorted into four categories of seed yam based on weight. Thirty seed yams each of two selected white yam cultivars (Dente and Kpamyo) with visible speargrass rhizome-pierced-tubers (VSRPT) and non-speargrass rhizome pierced healthy tubers (NSRPHT) were randomly selected and stored in a ban for weekly assessment of rot. The rotten tissues from the localised area of VPSRT were subjected to pathological investigations in the laboratory. The incidence of injury seemingly increased with increasing tuber weight. It was 0% for < 100 g samples and averagely 14% for > 1 kg samples, irrespective of cultivars and locations. Incidence of rot from NSRPHT sample was observed 5 weeks after storage (WAS) for both cultivars; and 2 WAS from the VSRPT sample and 40% higher than NSRPHT at 8 WAS. Eight and six known rot pathogens were isolated from the rotten tissues of VSRPT of Dente and Kpamyo, respectively. Injury from the piercing of speargrass rhizome significantly contributed to hastening of tuber rots; while tuber injury increased with increasing speargrass density. Appropriate management of speargrass is essential for commercial seed yam growers to reduce tuber damage which affects yam quality, storage and marketing.La pourriture post-r\ue9colte due \ue0 une d\ue9chirure est un facteur majeur contribuant \ue0 la baisse de la qualit\ue9 des ignames des semences stock\ue9es ( Dioscorea spp.). Parmi les nombreuses d\ue9chirures connues, l\u2019effet per\ue7ant des rhizomes de la gerbe d\u2019herbe est devenu une contrainte s\ue9rieuse pour la production d\u2019igname au Ghana. L\u2019objectif de cette \ue9tude \ue9tait d\u2019\ue9valuer les d\ue9chirures sur les ignames de semence r\ue9sultant du per\ue7age des rhizomes de gerbe d\u2019herbe et leurs effets sur les pourritures post-r\ue9colte au Ghana. Quatre-vingts champs d\u2019agriculteurs de Mem, Watro, Asanteboa et Abour dans la municipalit\ue9 d\u2019Atebubu-Amantin dans la region de l\u2018 Est de Bono au Ghana ont \ue9t\ue9 examin\ue9s pour d\ue9terminer l\u2019incidence et les dommages de la gerbe d\u2019herbe sur les tubercules r\ue9colt\ue9s, pour une analyse en laboratoire des agents pathog\ue8nes en 2016 et 2017. Les tubercules ont \ue9t\ue9 tri\ue9s en quatre cat\ue9gories d\u2019igname de semence en fonction du poids. Trente ignames de semence de chacun des deux cultivars s\ue9lectionn\ue9s d\u2019igname blanche (Dente et Kpamyo) avec des tubercules perc\ue9s de rhizome de gerbe d\u2019herbe (VSRPT) et des tubercules sains perc\ue9s de rhizome non- gerbe d\u2019herbe (NSRPHT) ont \ue9t\ue9 s\ue9lectionn\ue9s au hasard et stock\ue9s dans une interdiction pour une \ue9valuation hebdomadaire de la pourriture . Les tissus pourris de la zone localis\ue9e de VPSRT ont \ue9t\ue9 soumis \ue0 des investigations pathologiques en laboratoire. L\u2019incidence des d\ue9chirures a apparemment augment\ue9 avec l\u2019augmentation du poids des tubercules. Il \ue9tait de 0% pour les \ue9chantillons <100 g et de 14% en moyenne pour les \ue9chantillons > 1 kg, quels que soient les cultivars et les emplacements. L\u2019incidence de pourriture de l\u2019\ue9chantillon NSRPHT a \ue9t\ue9 observ\ue9e 5 semaines apr\ue8s stockage (WAS) pour les deux cultivars; et 2 WAS de l\u2019\ue9chantillon VSRPT et 40% plus \ue9lev\ue9s que NSRPHT \ue0 8 WAS. Huit et six agents pathog\ue8nes de la pourriture connus ont \ue9t\ue9 isol\ue9s respectivement dans les tissus pourris du VSRPT de Dente et de Kpamyo. Les d\ue9chirures caus\ue9es par le per\ue7age du rhizome de gerbe d\u2019herbe ont consid\ue9rablement contribu\ue9 \ue0 acc\ue9l\ue9rer la pourriture des tubercules; tandis que les dommages aux tubercules augmentaient avec l\u2019augmentation de la densit\ue9 de la gerbe d\u2019herbe. Une gestion appropri\ue9e de la groseille verte est essentielle pour les producteurs commerciaux d\u2019ignames de semence afin de r\ue9duire les dommages aux tubercules qui affectent la qualit\ue9, le stockage et la commercialisation des ignames

Enhancing productivity of farmer-saved seed yam in Ghana: Positive selection and neem leaf powder factors

Recycling of diseased and pests infested seed yam ( Dioscorea spp.) has resulted in drastic yield reductions in yam production. The objective of this study was to determine the effect of positive selection on the quality of farmer-saved seed yam and also evaluate the effect of neem leaf powder in managing plant parasitic nematodes damage to yam. Two farming systems namely; Positive selection (PS) and Farmer practice (FP) and two soil amendment regimes; neem leaf powder at 20 g stand-1 (NA20) and no neem amendment (NA0) were tested on one variety of yam (Dente). A 2 x 2 x 1 factorial study, mounted on a randomised complete block design in a split plot arrangement was conducted in four replications. Positive selection occupied main plots; while Farmer practice occupied sub-plots. The study was conducted in eight communities located in two municipalities of Ghana, during 2015-2017. Parameters evaluated included Yam Mosaic Virus incidence and severity, incidence and severity of nematode cracks and galling on yam tubers, plant establishment and yield of yam. It was observed that Yam Mosaic Virus (YMV) disease incidence decreased from 38% in 2016 to 31% in 2017 in PS plots as a result of using virus-free planting materials. However, in FP plots, it increased from 67% in 2016 to 72% in 2017. Neem leaf powder amendment resulted in significantly (P< 0.05) low tuber galling (7%) compared with 40% in unamended plots. Similarly, PS plots yielded 7.7 t ha-1 compared to 5.9 t ha-1 in FP fields. In conclusion, Positive selection out-yielded FP by 30.5%; while PS-neem leaf powder interaction resulted in 38.5% over and above FP without neem amendment.Le recyclage des semences d\u2019igname ( Dioscorea spp.) contamin\ue9es par des maladies et des parasites a entra\ueen\ue9 une r\ue9duction drastique du rendement de la production d\u2019igname. L\u2019objectif de cette \ue9tude \ue9tait de d\ue9terminer l\u2019effet de la s\ue9lection positive sur la qualit\ue9 des semences d\u2019igname conserv\ue9es par les agriculteurs et \ue9galement d\u2019\ue9valuer l\u2019effet de la poudre de feuilles de neem dans la gestion des dommages caus\ue9s par les n\ue9matodes parasites des plantes. Deux syst\ue8mes agricoles \ue0 savoir; S\ue9lection positive (PS) et pratique paysanne (PF) et deux r\ue9gimes d\u2019amendement du sol; De la poudre de feuille de neem \ue0 20 g du stand-1 (NA20) et aucun amendement de neem (NA0) ont \ue9t\ue9 test\ue9s sur une vari\ue9t\ue9 d\u2019igname (Dente). Une \ue9tude factorielle de 2 x 2 x 1, mont\ue9e sur une dispositif en\ua0blocs al\ue9atoires complets dans un arrangement en parcelles divis\ue9es, a \ue9t\ue9 men\ue9e en quatre r\ue9p\ue9titions. S\ue9lection positive occup\ue9e parcelles principales; tandis que la pratique paysanne occupait des sous-parcelles. L\u2019\ue9tude a \ue9t\ue9 men\ue9e dans huit communaut\ue9s situ\ue9es dans deux municipalit\ue9s du Ghana en 2015-2017. Les param\ue8tres \ue9valu\ue9s comprenaient l\u2019incidence et la gravit\ue9 du virus de la mosa\uefque de l\u2019igname, l\u2019incidence et la gravit\ue9 des fissures de n\ue9matode et le grippage des tubercules de l\u2019igname, l\u2019\ue9tablissement de la plante et le rendement de l\u2019igname. Il a \ue9t\ue9 observ\ue9 que l\u2019incidence de la maladie caus\ue9e par le virus de la mosa\uefque \ue0 l\u2019igname (YMV) avait diminu\ue9 de 38% en 2016 \ue0 31% en 2017 dans les parcelles PS gr\ue2ce \ue0 l\u2019utilisation de mat\ue9riel de plantation d\ue9pourvu de virus. Cependant, dans les parcelles de PF, il est pass\ue9 de 67% en 2016 \ue0 72% en 2017. L\u2019amendement de poudre de feuille de Neem a entra\ueen\ue9 une r\ue9duction significative du galles des tubercules (P <0,05) (7%) par rapport \ue0 40% dans les parcelles non modifi\ue9es. De m\ueame, les parcelles de PS ont produit 7,7 t ha-1, contre 5,9 t ha-1 dans les champs de PF. En conclusion, la s\ue9lection positive a eu un rendement sup\ue9rieur de 30,5% \ue0 celui de la PF; tandis que l\u2019interaction de la poudre de feuille PS-neem a eu pour r\ue9sultat 38,5% de plus que FP sans amendement de nee

Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019

Background: Accurate and up-to-date assessment of demographic metrics is crucial for understanding a wide range of social, economic, and public health issues that affect populations worldwide. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 produced updated and comprehensive demographic assessments of the key indicators of fertility, mortality, migration, and population for 204 countries and territories and selected subnational locations from 1950 to 2019. Methods: 8078 country-years of vital registration and sample registration data, 938 surveys, 349 censuses, and 238 other sources were identified and used to estimate age-specific fertility. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate age-specific fertility rates for 5-year age groups between ages 15 and 49 years. With extensions to age groups 10–14 and 50–54 years, the total fertility rate (TFR) was then aggregated using the estimated age-specific fertility between ages 10 and 54 years. 7417 sources were used for under-5 mortality estimation and 7355 for adult mortality. ST-GPR was used to synthesise data sources after correction for known biases. Adult mortality was measured as the probability of death between ages 15 and 60 years based on vital registration, sample registration, and sibling histories, and was also estimated using ST-GPR. HIV-free life tables were then estimated using estimates of under-5 and adult mortality rates using a relational model life table system created for GBD, which closely tracks observed age-specific mortality rates from complete vital registration when available. Independent estimates of HIV-specific mortality generated by an epidemiological analysis of HIV prevalence surveys and antenatal clinic serosurveillance and other sources were incorporated into the estimates in countries with large epidemics. Annual and single-year age estimates of net migration and population for each country and territory were generated using a Bayesian hierarchical cohort component model that analysed estimated age-specific fertility and mortality rates along with 1250 censuses and 747 population registry years. We classified location-years into seven categories on the basis of the natural rate of increase in population (calculated by subtracting the crude death rate from the crude birth rate) and the net migration rate. We computed healthy life expectancy (HALE) using years lived with disability (YLDs) per capita, life tables, and standard demographic methods. Uncertainty was propagated throughout the demographic estimation process, including fertility, mortality, and population, with 1000 draw-level estimates produced for each metric. Findings: The global TFR decreased from 2•72 (95% uncertainty interval [UI] 2•66–2•79) in 2000 to 2•31 (2•17–2•46) in 2019. Global annual livebirths increased from 134•5 million (131•5–137•8) in 2000 to a peak of 139•6 million (133•0–146•9) in 2016. Global livebirths then declined to 135•3 million (127•2–144•1) in 2019. Of the 204 countries and territories included in this study, in 2019, 102 had a TFR lower than 2•1, which is considered a good approximation of replacement-level fertility. All countries in sub-Saharan Africa had TFRs above replacement level in 2019 and accounted for 27•1% (95% UI 26•4–27•8) of global livebirths. Global life expectancy at birth increased from 67•2 years (95% UI 66•8–67•6) in 2000 to 73•5 years (72•8–74•3) in 2019. The total number of deaths increased from 50•7 million (49•5–51•9) in 2000 to 56•5 million (53•7–59•2) in 2019. Under-5 deaths declined from 9•6 million (9•1–10•3) in 2000 to 5•0 million (4•3–6•0) in 2019. Global population increased by 25•7%, from 6•2 billion (6•0–6•3) in 2000 to 7•7 billion (7•5–8•0) in 2019. In 2019, 34 countries had negative natural rates of increase; in 17 of these, the population declined because immigration was not sufficient to counteract the negative rate of decline. Globally, HALE increased from 58•6 years (56•1–60•8) in 2000 to 63•5 years (60•8–66•1) in 2019. HALE increased in 202 of 204 countries and territories between 2000 and 2019. Interpretation: Over the past 20 years, fertility rates have been dropping steadily and life expectancy has been increasing, with few exceptions. Much of this change follows historical patterns linking social and economic determinants, such as those captured by the GBD Socio-demographic Index, with demographic outcomes. More recently, several countries have experienced a combination of low fertility and stagnating improvement in mortality rates, pushing more populations into the late stages of the demographic transition. Tracking demographic change and the emergence of new patterns will be essential for global health monitoring. Funding: Bill & Melinda Gates Foundation. © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licens

Global burden of 87 risk factors in 204 countries and territories, 1990�2019: a systematic analysis for the Global Burden of Disease Study 2019

Background: Rigorous analysis of levels and trends in exposure to leading risk factors and quantification of their effect on human health are important to identify where public health is making progress and in which cases current efforts are inadequate. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a standardised and comprehensive assessment of the magnitude of risk factor exposure, relative risk, and attributable burden of disease. Methods: GBD 2019 estimated attributable mortality, years of life lost (YLLs), years of life lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 87 risk factors and combinations of risk factors, at the global level, regionally, and for 204 countries and territories. GBD uses a hierarchical list of risk factors so that specific risk factors (eg, sodium intake), and related aggregates (eg, diet quality), are both evaluated. This method has six analytical steps. (1) We included 560 risk�outcome pairs that met criteria for convincing or probable evidence on the basis of research studies. 12 risk�outcome pairs included in GBD 2017 no longer met inclusion criteria and 47 risk�outcome pairs for risks already included in GBD 2017 were added based on new evidence. (2) Relative risks were estimated as a function of exposure based on published systematic reviews, 81 systematic reviews done for GBD 2019, and meta-regression. (3) Levels of exposure in each age-sex-location-year included in the study were estimated based on all available data sources using spatiotemporal Gaussian process regression, DisMod-MR 2.1, a Bayesian meta-regression method, or alternative methods. (4) We determined, from published trials or cohort studies, the level of exposure associated with minimum risk, called the theoretical minimum risk exposure level. (5) Attributable deaths, YLLs, YLDs, and DALYs were computed by multiplying population attributable fractions (PAFs) by the relevant outcome quantity for each age-sex-location-year. (6) PAFs and attributable burden for combinations of risk factors were estimated taking into account mediation of different risk factors through other risk factors. Across all six analytical steps, 30 652 distinct data sources were used in the analysis. Uncertainty in each step of the analysis was propagated into the final estimates of attributable burden. Exposure levels for dichotomous, polytomous, and continuous risk factors were summarised with use of the summary exposure value to facilitate comparisons over time, across location, and across risks. Because the entire time series from 1990 to 2019 has been re-estimated with use of consistent data and methods, these results supersede previously published GBD estimates of attributable burden. Findings: The largest declines in risk exposure from 2010 to 2019 were among a set of risks that are strongly linked to social and economic development, including household air pollution; unsafe water, sanitation, and handwashing; and child growth failure. Global declines also occurred for tobacco smoking and lead exposure. The largest increases in risk exposure were for ambient particulate matter pollution, drug use, high fasting plasma glucose, and high body-mass index. In 2019, the leading Level 2 risk factor globally for attributable deaths was high systolic blood pressure, which accounted for 10·8 million (95 uncertainty interval UI 9·51�12·1) deaths (19·2% 16·9�21·3 of all deaths in 2019), followed by tobacco (smoked, second-hand, and chewing), which accounted for 8·71 million (8·12�9·31) deaths (15·4% 14·6�16·2 of all deaths in 2019). The leading Level 2 risk factor for attributable DALYs globally in 2019 was child and maternal malnutrition, which largely affects health in the youngest age groups and accounted for 295 million (253�350) DALYs (11·6% 10·3�13·1 of all global DALYs that year). The risk factor burden varied considerably in 2019 between age groups and locations. Among children aged 0�9 years, the three leading detailed risk factors for attributable DALYs were all related to malnutrition. Iron deficiency was the leading risk factor for those aged 10�24 years, alcohol use for those aged 25�49 years, and high systolic blood pressure for those aged 50�74 years and 75 years and older. Interpretation: Overall, the record for reducing exposure to harmful risks over the past three decades is poor. Success with reducing smoking and lead exposure through regulatory policy might point the way for a stronger role for public policy on other risks in addition to continued efforts to provide information on risk factor harm to the general public. Funding: Bill & Melinda Gates Foundation. © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licens

Global Retinoblastoma Presentation and Analysis by National Income Level

Importance: Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale. Objectives: To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis. Design, Setting, and Participants: A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017. Main Outcomes and Measures: Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis. Results: The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4) were female. Most patients (n = 3685 84.7%) were from low-and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 62.8%), followed by strabismus (n = 429 10.2%) and proptosis (n = 309 7.4%). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 95% CI, 12.94-24.80, and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 95% CI, 4.30-7.68). Conclusions and Relevance: This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs. © 2020 American Medical Association. All rights reserved

Sleeping space matters: LLINs usage in Ghana

Long Lasting Insecticidal Net (LLIN) is an effective malaria prevention mechanism. However, ownership of LLIN does not imply its use among households. The availability of enough sleeping space is a natural prerequisite to install and use LLINs. The objective of this study was to explore the effect of sleeping space and other socio-demographic factors of households’ heads on LLINs usage among households. A cross-sectional household-based study was conducted using a quantitative approach. Data was collected exclusively from households that received LLINs at no direct financial cost to them in a mass malaria campaign conducted in the study area using a structured questionnaire. A total of 383 households sampled for the study received 1,181 LLINs with a range of 1 to 15 LLINs per household. Less than 16% of households that received more than 2 LLINs installed all the LLINs they received during the distribution. Among households that received LLINs, 45% of them did not use them at all and 36% of them used them every night including the night before data collection. The number of bedrooms, children and members per household, and the number of occupants per bedroom were also found statistically associated with the use of LLINs among households. The study used a quantitative approach to investigate sleeping space in relation to LLINs usage and malaria control, an area and topic that has not been adequately covered in the literature

Homestead food production model contributes to improved household food security and nutrition status of young children and women in poor populations

Micronutrient malnutrition is a serious public health problem among women and children in Bangladesh, Cambodia, Nepal and the Philippines. Helen Keller International has been implementing homestead food production (HFP) programs (coupled with nutrition education) in these countries to increase and ensure year-round availability and intake of micronutrient-rich foods in poor households, particularly among women and children.  Between 2003 and 2007, the HFP program was implemented among ~30,000 households in these four countries. Data collected from representative samples taken for evaluations of HFP programs in these countries illustrated the benefit of the program for households. Data were collected through interviews with households in villages that had the HFP program and from control households in non-HFP program villages. Blood samples collected from ~1000 children aged 6-59 months and ~1200 non-pregnant women before and after program implementation were analyzed for hemoglobin. The review showed that the HFP program significantly improved dietary diversification. The combined data from all four countries showed improved animal food consumption among program households, with liver consumption increasing from 24% at baseline to 46% at endline and the median number of eggs consumed by families per week increasing from 2 to 5.  The sale of HFP products also improved household income. Anemia prevalence among children in program households decreased in all the countries; however, the decrease was only significant in Bangladesh and the Philippines.  Although anemia prevalence also decreased among control households in three countries, the magnitude of change was higher in program households compared with control households