Drivers of under-five stunting trend in 14 low- and middle-income countries since the turn of the millennium : a multilevel pooled analysis of 50 demographic and health surveys

Background: Understanding the drivers contributing to the decreasing trend in stunting is paramount to meeting the World Health Assembly's global target of 40% stunting reduction by 2025. Methods: We pooled data from 50 Demographic and Health Surveys since 2000 in 14 countries to examine the relationships between the stunting trend and potential factors at distal, intermediate, and proximal levels. A multilevel pooled trend analysis was used to estimate the association between the change in potential drivers at a country level and stunting probability for an individual child while adjusting for time trends and child-level covariates. A four-level mixed-effects linear probability regression model was fitted, accounting for the clustering of data by sampling clusters, survey-rounds, and countries. Results: Stunting followed a decreasing trend in all countries at an average annual rate of 1.04 percentage points. Among the distal factors assessed, a decrease in the Gini coefficient, an improvement in women's decision-making, and an increase in urbanization were significantly associated with a lower probability of stunting within a country. Improvements in households' access to improved sanitation facilities and drinking water sources, and children's access to basic vaccinations were the important intermediate service-related drivers, whereas improvements in early initiation of breastfeeding and a decrease in the prevalence of low birthweight were the important proximal drivers. Conclusions: The results reinforce the need for a combination of nutrition-sensitive and -specific interventions to tackle the problem of stunting. The identified drivers help to guide global efforts to further accelerate stunting reduction and monitor progress against chronic childhood undernutrition

A reinforcement sensitivity perspective on adolescents' susceptibility to the influence of soap opera viewing on alcohol attitudes

Previous research found support for an association between exposure to alcohol-related media content and alcohol attitudes, intentions and behavior. Nevertheless, research on what makes young people susceptible to the occurrence of this relationship is scarce. The current study examined the behavioral activation (BAS) and inhibition system (BIS) as moderators of the relationship between soap opera viewing and alcohol attitudes. A cross-sectional survey was carried out among a sample of 922 adolescents (M-age=14.96years, SD=.85, 56% girls). Regression analyses showed no association between total television viewing and alcohol attitudes, but did confirm that soap opera viewing is associated with positive attitudes towards alcohol use. Moderation analyses indicated that BAS did not moderate this relationship, while BIS did; the relationship between soap opera viewing and positive attitudes toward alcohol was only significant for adolescents with a low BIS-profile. These results provide support for the premise that an elevated BIS protects adolescents from the effect of soap opera viewing frequency on their alcohol attitudes

Adding a reward increases the reinforcing value of fruit

Adolescents' snack choices could be altered by increasing the reinforcing value (RV) of healthy snacks compared with unhealthy snacks. This study assessed whether the RV of fruit increased by linking it to a reward and if this increased RV was comparable with the RV of unhealthy snacks alone. Moderation effects of sex, hunger, BMI z-scores and sensitivity to reward were also explored. The RV of snacks was assessed in a sample of 165 adolescents (15.1 (SD 1.5) years, 39.4% boys and 17.4% overweight) using a computerised food reinforcement task. Adolescents obtained points for snacks through mouse clicks (responses) following progressive ratio schedules of increasing response requirements. Participants were (computer) randomised to three experimental groups (1: 1: 1): fruit (n 53), fruit + reward (n 60) or unhealthy snacks (n 69). The RV was evaluated as total number of responses and breakpoint (schedule of terminating food reinforcement task). Multilevel regression analyses (total number of responses) and Cox's proportional hazard regression models (breakpoint) were used. The total number of responses made were not different between fruit + reward and fruit (b -473; 95% CI -1152, 205, P=0.17) or unhealthy snacks (b 410; 95% CI -222, 1043, P = 0.20). The breakpoint was slightly higher for fruit than fruit + reward (HR 1.34; 95% CI 1.00, 1.79, P=0.050), whereas no difference between unhealthy snacks and fruit + reward (HR 0.86; 95% CI 0.62, 1.18, P=0.34) was observed. No indication of moderation was found. Offering rewards slightly increases the RV of fruit and may be a promising strategy to increase healthy food choices. Future studies should however, explore if other rewards, could reach larger effect sizes

Sensitivity to reward and adolescents’ unhealthy snacking and drinking behavior: the role of hedonic eating styles and availability

Background: Although previous research found a positive association between sensitivity to reward (SR) and adolescents' unhealthy snacking and drinking behavior, mechanisms explaining these associations remain to be explored. The present study will therefore examine whether the associations between SR and unhealthy snack and/or sugar-sweetened beverage (SSB) intake are mediated by external and/or emotional eating and if this mediation is moderated by availability at home or at school. Methods: Cross-sectional data on snacking, availability of snacks at home and at school, SR (BAS drive scale) and external and emotional eating (Dutch eating behavior questionnaire) of Flemish adolescents (n = 1104, mean age = 14.7 +/- 0.8 years; 51 % boys; 18.0 % overweight) in 20 schools spread across Flanders were collected. Moderated mediation analyses were conducted using generalized structural equation modeling in three steps: (1) direct association between SR and unhealthy snack or SSB intake, (2) mediation of either external or emotional eating and (3) interaction of home or school availability and emotional or external eating. Results: Partial mediation of external eating (a*b = 0.69, p < 0.05) and of emotional eating (a*b = 0.92, p < 0.01) in the relation between SR and intake of unhealthy snacks was found (step 2). The relation between SR and SSB intake was not mediated by external or emotional eating (step 2). No moderation effects of home or school availability were found (step 3). Conclusion: Our findings indicate that the association between SR and the consumption of unhealthy snacks is partially explained by external and emotional eating in a population-based sample of adolescents irrespective of the home or school availability of these foods

Use of fitness and nutrition apps : associations with body mass index, snacking, and drinking habits in adolescents

Background: Efforts to improve snacking and drinking habits are needed to promote a healthy body mass index (BMI) in adolescents. Although commercial fitness and nutrition mobile phone apps are widely used, little is known regarding their potential to improve health behaviors, especially in adolescents. In addition, evidence on the mechanisms through which such fitness and nutrition apps influence behavior is lacking. Objectives: This study assessed whether the use of commercial fitness or nutrition apps was associated with a lower BMI and healthier snacking and drinking habits in adolescents. Additionally, it explored if perceived behavioral control to eat healthy; attitudes to eat healthy for the good taste of healthy foods, for overall health or for appearance; social norm on healthy eating and social support to eat healthy mediated the associations between the frequency of use of fitness or nutrition apps and BMI, the healthy snack, and beverage ratio. Methods: Cross-sectional self-reported data on snack and beverage consumption, healthy eating determinants, and fitness and nutrition app use of adolescents (N=889; mean age 14.7 years, SD 0.8; 54.8% [481/878] boys; 18.1% [145/803] overweight) were collected in a representative sample of 20 schools in Flanders, Belgium. Height and weight were measured by the researchers. The healthy snack ratio and the healthy beverage ratio were calculated as follows: gram healthy snacks or beverages/(gram healthy snacks or beverages+ gram unhealthy snacks or beverages) x100. Multilevel regression and structural equation modeling were used to analyze the proposed associations and to explore multiple mediation. Results: A total of 27.6% (245/889) of the adolescents used fitness, nutrition apps or both. Frequency of using nutrition apps was positively associated with a higher healthy beverage ratio (b=2.96 [1.11], P=.008) and a higher body mass index z-scores (zBMI; b=0.13 [0.05], P=.008. A significant interaction was found between the frequency of using nutrition and for the zBMI (b=-0.03 [0.02], P=.04) and the healthy snack ratio (b=-0.84 [0.37], P=.03). Attitude to eat healthy for appearance mediated both the fitness app use frequency-zBMI (a x b=0.02 [0.01], P=.02) and the nutrition app use frequency-zBMI (a x b= 0.04 [0.01], P=.001) associations. No mediation was observed for the associations between the frequency of use of fitness or nutrition apps and the healthy snack or beverage ratio. Conclusions: Commercial fitness and nutrition apps show some association with healthier eating behaviors and BMI in adolescents. However, effective behavior change techniques should be included to affect key determinants of healthy eating

Correlation of esophageal pressure-flow analysis findings with bolus transit patterns on videofluoroscopy

This is a pre-copyedited, author-produced version of an article accepted for publication in Diseases of the Esophagus following peer review. The version of record Omari TI, Szczesniak MM, Maclean J, Myers JC, Rommel N, Cock C and Cook IJ. Correlation of esophageal pressure-flow analysis findings with bolus transit patterns on videofluoroscopy. Dis Esophagus. 2016 Feb-Mar;29(2):166-73. and is available online at: http://dx.doi.org/10.1111/dote.12300 Copyright © 2017 The International Society for Diseases of the EsophagusPressure-flow analysis quantifies the interactions between bolus transport and pressure generation. We undertook a pilot study to assess the interrelationships between pressure-flow metrics and fluoroscopically determined bolus clearance and bolus transport across the esophagogastric junction (EGJ). We hypothesized that findings of abnormal pressure-flow metrics would correlate with impaired bolus clearance and reduced flow across the EGJ. Videofluoroscopic images, impedance, and pressure were recorded simultaneously in nine patients with dysphagia (62–82 years, seven male) tested with liquid barium boluses. A 3.6 mm diameter solid-state catheter with 25 × 1 cm pressure/12 × 2 cm impedance was utilized. Swallowed bolus clearance was assessed using a validated 7-point radiological bolus transport scale. The cumulative period of bolus flow across the EGJ was also fluoroscopically measured (EGJ flow time). Pressure only parameters included the length of breaks in the 20 mmHg iso-contour and the 4 second integrated EGJ relaxation pressure (IRP4s). Pressure-flow metrics were calculated for the distal esophagus, these were: time from nadir impedance to peak pressure (TNadImp to PeakP) to quantify bolus flow timing; pressure flow index (PFI) to integrate bolus pressurization and flow timing; and impedance ratio (IR) to assess bolus clearance. When compared with controls, patients had longer peristaltic breaks, higher IRs, and higher residual EGJ relaxation pressures (break length of 8 [2, 13] vs. 2 [0, 2] cm, P = 0.027; IR 0.5 ± 0.1 vs. 0.3 ± 0.0, P = 0.019; IRP4s 11 ± 2 vs. 6 ± 1 mmHg, P = 0.070). There was a significant positive correlation between higher bolus transport scores and longer peristaltic breaks (Spearman correlation r = 0.895, P < 0.001) and with higher IRs (r = 0.661, P < 0.05). Diminished EGJ flow times correlated with a shorter TNadImp to PeakP (r = −0.733, P < 0.05) and a higher IR (r = −0.750, P < 0.05). Longer peristaltic breaks and higher IR correlate with failed bolus clearance on videofluoroscopy. The metric TNadImp to PeakP appears to be a marker of the period of time over which the bolus flows across the EGJ

Inter-rater reliability and validity of automated impedance manometry analysis and fluoroscopy in dysphagic patients after head and neck cancer radiotherapy

This article may be used for non-commercial purposes in accordance With Wiley Terms and Conditions for self-archiving'.Copyright © 2015 John Wiley & Sons, Inc. All rights reserved.Introduction: Automated Impedance manometry (AIM) pressure-flow analysis is novel non-radiological method to analyse swallowing function based on impedance-pressure recordings of pharyngeal swallows. In a population of dysphagic head and neck cancer patients, we evaluated the reliability and validity of the AIM-derived swallow risk index (SRI) and a novel measure of post-swallow residue (iZn/Z) by comparing it against videofluoroscopy as the gold standard for assessing aspiration and post-swallow residue risk. Materials and Methods: Three blinded experts classified 88 videofluoroscopic swallows from 16 patients for aspiration and the degree of post-swallow residue using validated videofluroscopy scales. Pressure-impedance recordings of the swallows were also analysed using automated analysis software by one expert and two novice observers who derived the SRI and iZn/Z. Inter-observer concordance for videofluoroscopic and AIM measures was assessed using intraclass correlation coefficients (ICC). Patient SRI and iZn/Z measurements were compared with videofluoroscopy scores and control subjects to determine validity for detecting clinically relevant swallowing dysfunction. . Results: Among individual swallows, agreement among observers assessing presence of penetration and aspiration on videofluoroscopy was modest (ICC 0.57). Agreement among observers for AIM-derived swallow risk index (SRI) and the iZn/Z was good (ICC of 0.71 and ICC of 0.82 respectively). When compared with age-matched controls the SRI was higher in patients with aspiration (mean diff. 28.6, 95% CI [55.85 1.355], p<0.05). The iZn/Z was increased, suggesting greater post-swallow residues, in both patients with aspiration (Δ244 [419.7, 69.52, p<0.05]) and penetration (Δ240 [394.3, 85.77, p<0.05]) compared to controls. Discussion: AIM based measures of swallowing function have better inter-rater reliability than comparable fluoroscopically-derived measures. These measures can be easily determined and are objective markers of clinically relevant features of disordered swallowing following head and neck cancer therapy

Characterization of Esophageal Physiology Using Mechanical State Analysis

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution and reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.The esophagus functions to transport swallowed fluids and food from the pharynx to the stomach. The esophageal muscles governing bolus transport comprise circular striated muscle of the proximal esophagus and circular smooth muscle of the distal esophagus. Longitudinal smooth muscle contraction provides a mechanical advantage to bolus transit during circular smooth muscle contraction. Esophageal striated muscle is directly controlled by neural circuits originating in the central nervous system, resulting in coordinated contractions. In contrast, the esophageal smooth muscle is controlled by enteric circuits modulated by extrinsic central neural connections resulting in neural relaxation and contraction. The esophageal muscles are modulated by sensory information arising from within the lumen. Contraction or relaxation, which changes the diameter of the lumen, alters the intraluminal pressure and ultimately inhibits or promotes flow of content. This relationship that exists between the changes in diameter and concurrent changes in intraluminal pressure has been used previously to identify the "mechanical states" of the circular muscle; that is when the muscles are passively or actively, relaxing or contracting. Detecting these changes in the mechanical state of the muscle has been difficult and as the current interpretation of esophageal motility is based largely upon pressure measurement (manometry), subtle changes in the muscle function during peristalsis can be missed. We hypothesized that quantification of mechanical states of the esophageal circular muscles and the pressure-diameter properties that define them, would allow objective characterization of the mechanisms that govern esophageal peristalsis. To achieve this we analyzed barium swallows captured by simultaneous videofluoroscopy and pressure with impedance recording. From these data we demonstrated that intraluminal impedance measurements could be used to determine changes in the internal diameter of the lumen comparable with measurements from videofluoroscopy. Our data indicated that identification of mechanical state of esophageal muscle was simple to apply and revealed patterns consistent with the known neural inputs activating the different muscles during swallowing