Supplemental Information 1: Socioeconomic, anthropometric, biochemical and body image data from 113 female subjects.

Background Short stature in adult life, a possible consequence of poor perinatal conditions, is associated with higher risk of mortality and social disabilities. We aimed to determine whether low-income, overweight/obese, short-stature (SS) women show alterations in body composition, self-body-image perception, and biochemical profile compared to their non-short (NS) counterparts. Methods A cross-sectional study was conducted with women living in shantytowns and mother or relatives to undernourished children treated in a center for recuperation and nutritional education. Inclusion criteria were: (1) age, 19–45 years; (2) stature 158.7 cm; and (3) body mass index > 25 kg/m2. Socioeconomic, anthropometric, biochemical, and body image data were collected. We analyzed 56 SS and 57 NS women. Results The SS group showed a higher waist-to-height ratio (WHtR) (mean: 0.63; standard deviation: 0.06 for SS and mean: 0.60; standard deviation: 0.07 for the NS group; p = 0.02), and, in the adjusted analysis, showed lower fat-free mass (Estimated Marginal Mean for the SS group: 45.7 kg 95% confidence intervals (CI) (45.2–46.2) and for the NS group: 46.9 kg 95% CI (46.4–47.4); p < 0.01) and higher fat mass (Estimated Marginal Mean for the SS group: 32.5 95% CI (31.9–33.0) and for the NS group: 31.4 kg 95% CI (30.9–31.9); p < 0.01). Body mass index was a better predictor of current self-body-image perception for NS women. The SS coefficient values were β = 0.141, SE = 0.059, and R2-Nagelkerke = 0.107, and the NS coefficients values were β = 0.307, SE = 0.058, and R2-Nagelkerke = 0.491 (Z = 2.006; p < 0.05). Considering the obese subgroup, six out of 32 (18.8%) SS women and 14 out of 33 (42.4%) NS women perceived themselves as obese (χ2 = 4.27; p = 0.03). This difference remained significant even after adjustment by age, schooling, and number of children (p = 0.04). Only the total thyroxin showed significant differences between groups, lower in SS women (p = 0.04). Discussion Overweight/obese, low-income SS women have more central adiposity and impaired self-body image perception, and the body mass index is a weaker predictor of it, compared to NS women. Misperception about body size may be linked with an overestimation of health and underestimation of risk, which may lead to a lower utilization of the health care system and inadequate physician counseling. These features may account, at least partially, for the higher mortality risk seen in SS adults

Intraindividual double burden of overweight or obesity and micronutrient deficiencies or anemia among women of reproductive age in 17 population-based surveys

Background: Rising prevalence of overweight/obesity (OWOB) alongside persistent micronutrient deficiencies suggests many women face concomitant OWOB and undernutrition. Objectives: We aimed to 1) describe the prevalence of the double burden of malnutrition (DBM) among nonpregnant women of reproductive age, defined as intraindividual OWOB and either ≥1 micronutrient deficiency [micronutrient deficiency index (MDI) \u3e 0; DBM-MDI] or anemia (DBM-anemia); 2) test whether the components of the DBM were independent; and 3) identify factors associated with DBM-MDI and DBM-anemia. Methods: With data from 17 national surveys spanning low- and middle-income countries (LMICs) and high-income countries from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia project (n = 419 to n = 9029), we tested independence of over- and undernutrition using the Rao–Scott chi-square test and examined predictors of the DBM and its components using logistic regression for each survey. Results: Median DBM-MDI was 21.9% (range: 1.6%–39.2%); median DBM-anemia was 8.6% (range: 1.0%–18.6%). OWOB and micronutrient deficiencies or anemia were independent in most surveys. Where associations existed, OWOB was negatively associated with micronutrient deficiencies and anemia in LMICs. In 1 high-income country, OWOB women were more likely to experience micronutrient deficiencies and anemia. Age was consistently positively associated with OWOB and the DBM, whereas the associations with other sociodemographic characteristics varied. Higher socioeconomic status tended to be positively associated with OWOB and the DBM in LMICs, whereas in higher-income countries the association was reversed. Conclusions: The independence of OWOB and micronutrient deficiencies or anemia within individuals suggests that these forms of over- and undernutrition may have unique etiologies. Decision-makers should still consider the prevalence, consequences, and etiology of the individual components of the DBM as programs move towards double-duty interventions aimed at addressing OWOB and undernutrition simultaneously

The Double Burden of Malnutrition: A Systematic Review of Operational Definitions

Background Despite increasing research on the double burden of malnutrition (DBM; i.e., coexisting over- and undernutrition), there is no global consensus on DBM definitions. Objectives To identify published operational DBM definitions, measure their frequency of use, and discuss implications for future assessment. Methods Following a structured search of peer-reviewed articles with terms describing “overnutrition” [e.g., overweight/obesity (OW/OB)] and “undernutrition” (e.g., stunting, micronutrient deficiency), we screened 1920 abstracts, reviewed 500 full texts, and extracted 623 operational definitions from 239 eligible articles. Results We organized three identified DBM dimensions (level of assessment, target population, and forms of malnutrition) into a framework for building operational DBM definitions. Frequently occurring definitions included coexisting: 1) OW/OB and thinness, wasting, or underweight (n = 289 occurrences); 2) OW/OB and stunting (n = 161); 3) OW/OB and anemia (n = 74); and 4) OW/OB and micronutrient deficiency (n = 73). Conclusions Existing DBM definitions vary widely. Putting structure to possible definitions may facilitate selection of fit-for-purpose indicators to meet public health priorities

Global effects of income and income inequality on adult height and sexual dimorphism in height

This paper was accepted for publication in the journal American Journal of Human Biology and the definitive published version is available at http://dx.doi.org/10.1002/ajhb.22980© 2017 Wiley Periodicals, Inc. Objectives: Average adult height of a population is considered a biomarker of the quality of the health environment and economic conditions. The causal relationships between height and income inequality are not well understood. We analyze data from 169 countries for national average heights of men and women and national-level economic factors to test two hypotheses: (1) income inequality has a greater association with average adult height than does absolute income; and (2) neither income nor income inequality has an effect on sexual dimorphism in height. Methods: Average height data come from the NCD-RisC health risk factor collaboration. Economic indicators are derived from the World Bank data archive and include gross domestic product (GDP), Gross National Income per capita adjusted for personal purchasing power (GNI_PPP), and income equality assessed by the Gini coefficient calculated by the Wagstaff method. Results: Hypothesis 1 is supported. Greater income equality is most predictive of average height for both sexes. GNI_PPP explains a significant, but smaller, amount of the variation. National GDP has no association with height. Hypothesis 2 is rejected. With greater average adult height there is greater sexual dimorphism. Conclusions: Findings support a growing literature on the pernicious effects of inequality on growth in height and, by extension, on health. Gradients in height reflect gradients in social disadvantage. Inequality should be considered a pollutant that disempowers people from the resources needed for their own healthy growth and development and for the health and good growth of their children