The 3C Nutrition Ancillary Study: describing the integration of diet and disease self-management among adolescents and adults with type 1 diabetes in China

The incidence of type 1 diabetes (T1D) is increasing in China and morbidity and mortality may be substantially higher there than in the U.S. While results of clinical trials support intensive disease self-management to reduce the risk of complications, our knowledge of self-management practices in China is limited in scope and outdated. In order to address this gap, a cross-sectional study was conducted in Beijing from January-August 2013. Data collection entailed a fasting blood draw, a questionnaire, and three 24-hour dietary recalls. Telephone administration of the 24-hour recalls was validated against in-person administration in a pilot study. Data on individuals without diabetes were from the China Health and Nutrition Survey. The aims were three-fold: among individuals with T1D in Beijing, 1) to describe the contribution of nutrition education to disease self-management and diet, 2) to compare their dietary intake to individuals without diabetes in Beijing, and 3) to use reduced rank regression to identify dietary pattern(s) that maximize the explained variation in key cardiometabolic risk factors. Participants (n=100) averaged 41.7 ±16.3 years old, diabetes duration, 11.8 ±9.7 years. Fewer than half of participants had "ever" met with a dietitian and only 18% had attended a diabetes education session that covered nutrition in the past 12 months. Nutrition therapy for T1D typically involved matching fixed insulin doses to a diet that was rigid with respect to amount and timing, rather than an individualized, flexible approach recommended by international Diabetes Associations. One effect of this was that participants with T1D had a significantly lower mean percentage of energy from carbohydrates and higher mean percentages of energy from fat and protein compared to a cohort of individuals without diabetes in Beijing. Finally, we identified a dietary pattern characterized by high intakes of wheat products and low-sugar cakes, and low intakes of beans and pickled vegetables that was significantly associated with lower HbA1c and LDL cholesterol. Together, these results highlight an important need for nutrition counseling for individuals with T1D in China that is consistent with current clinical practice guidelines to promote health and reduce risk for complications of diabetes.Doctor of Philosoph

Maternal and paternal employment in agriculture and early childhood development: a cross-sectional analysis of Demographic and Health Survey data

Considerable literature from low- and lower-middle-income countries (LLMICs) links maternal employment to child nutritional status. However, less is known about the role of parental employment and occupation type in shaping child development outcomes. Additionally, little empirical work has examined the mechanisms through which parental occupation influences child outcomes. Our objective was to investigate the associations between maternal and paternal employment (comparing agricultural and non-agricultural employment) and child development and to examine childcare practices and women's empowerment as potential mechanisms. We pooled nine Demographic and Health Surveys (Benin, Burundi, Cambodia, Congo, Haiti, Rwanda, Senegal, Togo, and Uganda) with data on 8,516 children aged 36-59 months. We used generalised linear models to estimate associations between parental employment and child development, child stimulation (number of activities provided by the mother, father, and other household members), child supervision (not left alone or with older child for >1 hour), early childhood care and education programme (ECCE) attendance, and women's empowerment. In our sample, all fathers and 85% of mothers were employed. In 40% of families, both parents were employed in agriculture. After adjusting for child, parental and household confounders, we found that parental agricultural employment, relative to non-agricultural employment, was associated with poorer child development (relative risk (RR) 0.86 (95% CI 0.80, 0.92), more child stimulation provided by other household members (mean difference (MD) 0.26 (95% CI 0.09, 0.42)), less adequate child supervision (RR, 0.83 (95% 0.78, 0.80)), less ECCE attendance (RR 0.46 (95% CI 0.39, 0.54)), and lower women's empowerment (MD -1.01 (95% CI -1.18, -0.84)). Parental agricultural employment may be an important risk factor for early childhood development. More research using more comprehensive exposure and outcome measures is needed to unpack these complex relationships and to inform interventions and policies to support working parents in the agricultural sector with young children

India’s Poshan Tracker: Data-driven Tool for Maternal and Child Nutrition

Early detection and intervention are key for addressing undernutrition in children.1 Increased global coverage of mobile phones could be a game-changer for nutrition surveillance. By reducing the cost and increasing the coverage and speed of nutrition information systems, technology-enabled solutions hold the promise of transforming data-informed decision making. It also has the potential to improve the accuracy of nutrition monitoring data by automating complex calculations, such as the calculation of z-scores from the WHO Growth Tables. The Government of India’s ‘Poshan Tracker’ is the largest mobile phone-based nutrition surveillance system in the world. It provides transparent data on anthropometric outcomes, functioning of Anganwadi Centres (AWCs) and receipt of care services, namely the provision of supplementary food to women, children and adolescent girls. AWCs are centres established as part of the Integrated Child Development Services Scheme, a flagship government programme aimed at improving the nutritional and health outcomes of mothers and children. We analysed Poshan Tracker data to understand how this innovation in accountability may be influencing real-time monitoring of target beneficiaries and the provision of nutritional services in India. Comprehensive data are publicly available from July 2022 to September 2023 across all states and union territories from AWCs. Over the past 15 months, the proportion of the country’s more than 1.39 million AWCs that are open for at least 15 days a month has increased dramatically: from only 35% in July 2022 to 89% in September 2023. Likewise, the proportion open for at least 21 days a month has increased from 24% to 78%. This may be partially attributable to improved reporting by AWC workers. One of the key nutritional services provided by AWCs is the provision of supplementary food, given that food distribution programmes to pregnant women have been shown to lower the risk of stunting and wasting in infants.2 All pregnant women and lactating mothers, children aged 6 months to 3 years, all children with severe acute malnutrition, and adolescent girls aged 14-18 years in north-eastern states and aspirational districts are entitled to receive supplementary food.3 Supplementary food includes take home rations, which are distinct from raw rations provided through other government services such as the public distribution system. In September 2023, 20.9 million beneficiaries received take home rations for at least 21 days. This is in comparison to 4.1 million in July 2022.In addition to providing supplemental nutrition, AWCs are the focal point for child growth monitoring in India. In September 2023, 83.55 million children aged 0-6 years had their height and weight measured, representing 94% of children registered at AWCs. This represents a substantial increase since July 2022, when 40.1 million (45%) children aged 0-6 years were measured. As with other indicators, the increase could partially reflect improved reporting. Looking at the most recent national data from September 2023, the Poshan Tracker indicated that 39% of children beneficiaries aged 0-6 years experienced stunting and 18% were underweight. Among children 0-5 years, 6% experienced wasting and 6% were overweight. The latest population-based anthropometric data for children in India, the National Family Health Survey (NFHS-5, 2019-21), measured children under 5 years. To improve comparability to Poshan Tracker, we restricted our analysis to the subpopulation of NFHS-5 children who reported being measured at least once in the past year at an AWC (56% of the sample of children). Results indicate that the Poshan Tracker often estimates a lower prevalence of undernutrition than the subset of children in NFHS-5 who report having their weight measured at an AWC in the past year. On average, stunting was estimated to be 1.86% lower in Poshan Tracker data than NFHS-5; underweight was 13.72% lower; and wasting was 12.16% lower. Overweight, in contrast, was 0.68% higher in Poshan Tracker, on average, than in NFHS-5. There was substantial variability amongst states, and this variability was not consistent across measures (Figure). For example, in Maharashtra, the prevalence of stunting was 9.34% higher in the Poshan Tracker data than NFHS-5, but the prevalence of wasting was 19.27% lower. These differences could be attributable to a combination of factors. The true prevalence of undernutrition may differ between 2019-2021 (NFHS-5) and 2023 (Poshan Tracker). It is possible, for example, that real-time community-based monitoring using the Poshan Tracker has resulted in improved delivery of intervention services, though further evaluations are needed. Future rounds of NFHS will overlap with ongoing Poshan Tracker monitoring and facilitate a more accurate comparison. The training of data collectors and instruments used differs between NFHS-5 and Poshan Tracker. For example, NFHS-5 uses a SECA digital scale whereas most AWCs use spring scales. Moreover, there may be a bias in reporting for Poshan Tracker as data are collected by workers who are tasked with addressing undernutrition in their communities. The data suggest this may be especially true for child weight, which was systematically higher in the Poshan Tracker than in NFHS-5 across all states and union territories, whereas height was higher in some and lower in others. While not a replacement for routine population-based surveys, real-time community-based monitoring such as the Poshan Tracker can provide a snapshot of the current situation thus allowing for timely identification of areas that require improvement and the potential need to adjust programmatic action to achieve the stated targets. Such systems increase accountability and help ensure that nutrition interventions reach the last mile. Future work should test the pathways by which Poshan Tracker impacts nutritional outcomes. The Poshan Tracker therefore represents an unprecedented opportunity to evaluate the transformative potential of large-scale real-time nutrition monitoring. <br/

Let food be thy medicine:linking local food and health systems to address the full spectrum of malnutrition in low-income and middle-income countries

Hippocrates (fifth century BCE), the father of medicine and namesake of the Oath many medical students swear by to this day, was among the first to recognise the centrality of diet in disease prevention and treatment. In that Oath, the statement, ‘I will apply dietetic measures for the benefit of the sick according to my ability and judgement’, comes before statements about drugs and surgery. Unfortunately, the importance of diet and nutrition in medicine is lost in most discussions of health system reform today, especially in low-income and middle-income countries (LMICs).Moreover, few food system researchers and policymakers consider the myriad opportunities for improving health through forging partnerships between local food, agriculture and health systems.<br/