The double burden of malnutrition and associated factors among south Asian adolescents: Findings from the global school-based student health survey

The health and nutrition of the global adolescent population have been under-researched, in spite of its significant size (1.2 billion). This study investigates the prevalence and associated factors of malnutrition (stunting, thinness and overweight) among adolescents living in South Asia. The sample analysed was 24,053 South Asian schooled adolescents aged 12-15 years that participated in the cross-sectional Global School-Based Student Health Survey (GSHS) between 2009 and 2016. The prevalence of stunting, thinness and overweight was calculated using the World Health Organization (WHO) Child Growth Reference 2007. Associations between the three forms of malnutrition and their possible associated factors were assessed with binary logistic regression analysis using bootstrapping as a resampling method. The overall prevalence of stunting in South Asia was 13%, thinness was 10.8% and overweight was 10.8%. In the logistic regression model of the overall pooled sample, the factors associated with adolescent malnutrition were: age, hygiene behaviours, social support, sedentary behaviour, and tobacco use. A substantial proportion of stunting, thinness and overweight was found among school-going South Asian adolescents, indicating that the double burden of malnutrition is present in this population. Future research should seek to further understand the relationship between all forms of malnutrition and its associated factors in the adolescent population

Adolescent undernutrition in South Asia : a scoping review protocol

Introduction: The aim of the protocol is to present the methodology of a scoping review that aims to synthesise up-to-date evidence on adolescent undernutrition in South Asia. Methods and analysis: The proposed scoping review will be guided by Arksey and O’Malley’s framework and the Joanna Briggs Institute Reviewers’ Manual. The scoping review question, eligibility criteria and search strategy will be based on the Population, Concept and Context strategy. We will conduct the search in electronic bibliographic databases (Medline (OVID), Embase, Cochrane Library, Web of Science, CINAHL, PsycInfo, Scopus) as well as various grey literature sources in order to synthesise and present the findings with descriptive statistics and a narrative description of both quantitative and qualitative evidence. Ethics and dissemination: This study protocol does not require ethical approval. This protocol will accurately describe the proposed scoping review that will map the evidence on adolescent undernutrition in South Asia. The proposed review aims to gather published and unpublished literature to inform policy and healthcare organisations as well as identify future research priorities in South Asia

Choice architecture interventions to improve diet and/or dietary behaviour by healthcare staff in high-income countries : a systematic review

Objectives We were commissioned by the behavioural insights team at Public Health England to synthesise the evidence on choice architecture interventions to increase healthy purchasing and/or consumption of food and drink by National Health Service (NHS) staff. Data sources MEDLINE, EMBASE, CINAHL, Cochrane Central register of Controlled Trials, PsycINFO, Applied Social Sciences Index and Abstracts and Web of Science were searched from inception until May 2017 and references were screened independently by two reviewers. Design A systematic review that included randomised experimental or intervention studies, interrupted time series and controlled before and after studies. Participants Healthcare staff of high-income countries. Intervention Choice architecture interventions that aimed to improve dietary purchasing and/or consumption (outcomes) of staff. Appraisal and synthesis Eligibility assessment, quality appraisal, data abstraction and analysis were completed by two reviewers. Quality appraisal of randomised trials was informed by the Cochrane Handbook, and the Risk of Bias Assessment Tool for Nonrandomized Studies was used for the remainder. Findings were narratively synthesised. Results Eighteen studies met the inclusion criteria. Five studies included multiple workplaces (including healthcare settings), 13 were conducted in healthcare settings only. Interventions in 10 studies were choice architecture only and 8 studies involved a complex intervention with a choice architecture element. Interventions involving a proximity element (making behavioural options easier or harder to engage with) appear to be frequently effective at changing behaviour. One study presented an effective sizing intervention. Labelling alone was generally not effective at changing purchasing behaviour. Interventions including an availability element were generally reported to be successful at changing behaviour but no included study examined this element alone. There was no strong evidence for the effect of pricing on purchasing or dietary intake. Conclusion Proximity, availability and sizing are choice architecture elements that are likely to be effective for NHS organisations. Trial registration number CRD42017064872

Viewpoints of adolescents with overweight and obesity attending lifestyle obesity treatment interventions : a qualitative systematic review

Background Current UK guidance recommends that adolescents with obesity attend a family-based multi-component obesity intervention. However, these programmes suffer from low recruitment and high rates of attrition. Understanding the views of adolescents is necessary for developing future interventions. The aim of this systematic review was to synthesise and explore the views of adolescents who have attended an obesity intervention. Methods Published literature was identified by searching six databases. Studies of adolescents (12-17 years) who attended an obesity intervention were examined. Only studies that collected and analysed data qualitatively were included. Full-texts were analysed using thematic synthesis. Results Twenty-eight studies were included. Thirty-five analytical themes were developed that were broadly divided into seven domains. Key themes included ensuring adolescents receive a ‘tailored intervention’ that involves ‘active engagement’. Support from professionals, family and peers was valued highly. Adolescents expressed ‘prior fears of attending interventions’ and wanted ‘longer-term support’. ‘Enjoyment of sport and physical activity’ was evident and adolescents were strongly motivated by improving body image and social desirability. Discussion Considering the views of adolescents attending obesity interventions may help to inform policy makers in the development of future interventions. This may lead to an improvement in recruitment and attrition rates

Adolescent undernutrition in south Asia: A scoping review

Undernutrition is a growing public health challenge affecting growth and development during adolescence in many low- and middle-income countries. This scoping review maps the evidence on adolescent undernutrition (stunting, thinness and micronutrient deficiencies) in South Asia and highlights gaps in knowledge. Using Arksey and O\u27Malley\u27s framework and the Joanna Briggs Institute Reviewers\u27 Manual, the search included electronic bibliographic databases (Medline (OVID), Embase, Cochrane Library, Web of Science, CINAHL, PsycInfo, and Scopus) as well as various grey literature sources published up to March 2019. In total, 131 publications met the inclusion criteria of this review. All the included evidence used quantitative data and 115 publications used a cross-sectional design. Nearly 70% (n=86) of the included publications were conducted in India. Prevalence of undernutrition was reported based on different growth references and cut-offs. Evidence is divided into publications that included an intervention component (n=12) and publications that did not include an intervention component (n=116), and presented in a narrative synthesis. This scoping review provides a wide range of publications on adolescent undernutrition in South Asia and identifies future research priorities in the field

Dietary factors and Type 2 diabetes in the Middle East : what is the evidence for an association? - A systematic review.

This review aims to search and summarise the available evidence on the association between dietary factors and type 2 diabetes mellitus (T2DM) in Middle Eastern populations, where diabetes prevalence is among the highest in the world. Electronic databases were searched; authors, libraries, and research centres in the Middle East were contacted for further studies and unpublished literature. Included studies assessed potential dietary factors for T2DM in Middle Eastern adults. Two reviewers assessed studies independently. Extensive searching yielded 17 studies which met the inclusion criteria for this review. The findings showed that whole-grain intake reduces the risk of T2DM, and potato consumption was positively correlated with T2DM. Vegetables and vegetable oil may play a protective role against T2DM. Dietary patterns that are associated with diabetes were identified, such as Fast Food and Refined Grains patterns. Two studies demonstrated that lifestyle interventions decreased the risk of T2DM. In summary, the identified studies support an association between some dietary factors and T2DM; however, many of the included studies were of poor methodological quality so the findings should be interpreted with caution. The review draws attention to major gaps in current evidence and the need for well-designed studies in this area

Testing for lynch syndrome in people with endometrial cancer using immunohistochemistry and microsatellite instability-based testing strategies – a systematic review of test accuracy

Background Lynch syndrome is an inherited genetic condition that is associated with an increased risk of cancer, including endometrial and colorectal cancer. We assessed the test accuracy of immunohistochemistry and microsatellite instability-based testing (with or without MLH1 promoter methylation testing) for Lynch syndrome in women with endometrial cancer. Methods We conducted a systematic review of literature published up to August 2019. We searched bibliographic databases, contacted experts and checked reference lists of relevant studies. Two reviewers conducted each stage of the review. Results Thirteen studies were identified that included approximately 3500 participants. None of the studies was at low risk of bias in all domains. Data could not be pooled due to the small number of heterogeneous studies. Sensitivity ranged from 60.7–100% for immunohistochemistry, 41.7–100% for microsatellite instability-based testing, and 90.5–100% for studies combining immunohistochemistry, microsatellite instability-based testing, and MLH1 promoter methylation testing. Specificity ranged from 60.9–83.3% (excluding 1 study with highly selective inclusion criteria) for immunohistochemistry, 69.2–89.9% for microsatellite instability-based testing, and 72.4–92.3% (excluding 1 study with highly selective inclusion criteria) for testing strategies that included immunohistochemistry, microsatellite instability-based testing, and MLH1 promoter methylation. We found no statistically significant differences in test accuracy estimates (sensitivity, specificity) in head-to-head studies of immunohistochemistry versus microsatellite instability-based testing. Reported test failures were rare. Conclusions Sensitivity of the index tests were generally high, though most studies had much lower specificity. We found no evidence that test accuracy differed between IHC and MSI based strategies. The evidence base is currently small and at high risk of bias

Parent-only interventions for childhood overweight or obesity in children aged 5 to 11 years

Background: Child and adolescent overweight and obesity have increased globally, and are associated with short- and long-term health consequences.Objectives: To assess the efficacy of diet, physical activity and behavioural interventions delivered to parents only for the treatment of overweight and obesity in children aged 5 to 11 years.Search methods: We performed a systematic literature search of databases including the Cochrane Library,MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS as well trial registers.We checked references of identified trials and systematic reviews.We applied no language restrictions. The date of the last search was March 2015 for all databases.Selection criteria: We selected randomised controlled trials (RCTs) of diet, physical activity and behavioural interventions delivered to parents only for treating overweight or obesity in children aged 5 to 11 years.Data collection and analysis: Two review authors independently assessed trials for risk of bias and evaluated overall study quality using the GRADE instrument. Where necessary, we contacted authors for additional information.Main results: We included 20 RCTs, including 3057 participants. The number of participants ranged per trial between 15 and 645. Follow-up ranged between 24 weeks and two years. Eighteen trials were parallel RCTs and two were cluster RCTs. Twelve RCTs had two comparisons and eight RCTs had three comparisons. The interventions varied widely; the duration, content, delivery and follow-up of the interventions were heterogeneous. The comparators also differed. This review categorised the comparisons into four groups: parent-only versus parent-child, parent-only versus waiting list controls, parent-only versus minimal contact interventions and parent-only versus other parent-only interventions. Trial quality was generally low with a large proportion of trials rated as high risk of bias on individual risk of bias criteria. In trials comparing a parent-only intervention with a parent-child intervention, the body mass index (BMI) z score change showed a mean difference (MD) at the longest follow-up period (10 to 24 months) of -0.04 (95% confidence interval (CI) -0.15 to 0.08); P = 0.56; 267 participants; 3 trials; low quality evidence. In trials comparing a parent-only intervention with a waiting list control, the BMI z score change in favour of the parent-only intervention at the longest follow-up period (10-12 months) had an MD of -0.10 (95% CI -0.19 to -0.01); P = 0.04; 136 participants; 2 trials; low quality evidence. BMI z score change of parent-only interventions when compared with minimal contact control interventions at the longest follow-up period (9 to 12 months) showed an MD of 0.01 (95% CI -0.07 to 0.09); P = 0.81; 165 participants; 1 trial; low quality evidence. There were few similarities between interventions and comparators across the included trials in the parent-only intervention versus other parent-only interventions and we did not pool these data. Generally, these trials did not show substantial differences between their respective parent-only groups on BMI outcomes. Other outcomes such as behavioural measures, parent-child relationships and health-related quality of life were reported inconsistently. Adverse effects of the interventions were generally not reported, two trials stated that there were no serious adverse effects. No trials reported on all-cause mortality, morbidity or socioeconomic effects. All results need to be interpreted cautiously because of their low quality, the heterogeneous interventions and comparators, and the high rates of non-completion.Authors’ conclusions: Parent-only interventions may be an effective treatment option for overweight or obese children aged 5 to 11 years when compared with waiting list controls. Parent-only interventions had similar effects compared with parent-child interventions and compared with those with minimal contact controls. However, the evidence is at present limited; some of the trials had a high risk of bias with loss to follow-up being a particular issue and there was a lack of evidence for several important outcomes. The systematic review has identified 10 ongoing trials that have a parent-only arm, which will contribute to future updates. These trials will improve the robustness of the analyses by type of comparator, and may permit subgroup analysis by intervention component and the setting. Trial reports should provide adequate details about the interventions to be replicated by others. There is a need to conduct and report cost effectiveness analyses in future trials in order to establish whether parent-only interventions are more cost-effective than parent-child interventions

The influence of the urban food environment on diet, nutrition and health outcomes in low-income and middle-income countries: A systematic review

Introduction: Diet and nutrition are leading causes of global morbidity and mortality. Our study aimed to identify and synthesise evidence on the association between food environment characteristics and diet, nutrition and health outcomes in low-income and middle-income countries (LMICs), relevant to urban settings, to support development and implementation of appropriate interventions.Methods: We conducted a comprehensive search of 9 databases from 1 January 2000 to 16 September 2020 with no language restrictions. We included original peer-reviewed observational studies, intervention studies or natural experiments conducted in at least one urban LMIC setting and reporting a quantitative association between a characteristic of the food environment and a diet, nutrition or health outcome. Study selection was done independently in duplicate. Data extraction and quality appraisal using the National Heart Lung and Blood Institute checklists were completed based on published reports using a prepiloted form on Covidence. Data were synthesised narratively.Results: 74 studies met eligibility criteria. Consistent evidence reported an association between availability characteristics in the neighbourhood food environment and dietary behaviour (14 studies, 10 rated as good quality), while the balance of evidence suggested an association with health or nutrition outcomes (17 of 24 relevant studies). We also found a balance of evidence that accessibility to food in the neighbourhood environment was associated with diet (10 of 11 studies) although evidence of an association with health outcomes was contradictory. Evidence on other neighbourhood food environment characteristics was sparse and mixed. Availability in the school food environment was also found to be associated with relevant outcomes. Studies investigating our other primary outcomes in observational studies of the school food environment were sparse, but most interventional studies were situated in schools. We found very little evidence on how workplace and home food environments are associated with relevant outcomes. This is a substantial evidence gap.Conclusion: \u27Zoning\u27 or \u27healthy food cart\u27 interventions to alter food availability may be appropriate in urban LMIC.Prospero registration number: CRD42020207475

'Good food causes good effects and bad food causes bad effects' : awareness, meanings and perceptions of malnutrition among Pakistani adolescents living in slums through photodiaries and interviews

Around 30 of the urban population of Southern Asia lives in a slum setting where basic necessities such as sanitation, education, employment, infrastructure are lacking, and people are more exposed to health problems. Children living in slums are at high risk of malnutrition. However, there is limited knowledge on adolescents living in slums. We explored awareness and meanings of malnutrition (under and over-nutrition) as well as examining malnutrition risk factors among adolescents living in a slum. A qualitative approach was undertaken using photodiaries and semi-structured interviews with 14 adolescents (13–16 years old) living in a slum in Karachi (Pakistan). An inductive strategy was used moving from open-ended data to patterns using reflexive thematic analysis. We identified widespread malnutrition awareness amongst these adolescents. Food consistently underpinned participants’ narratives and photodiaries, which was reflected in how they made sense of malnutrition: undernutrition was understood as lack of food, while overnutrition as excess of food. This study identified malnutrition drivers: sanitation, exercise, families, peers, wellbeing, gender, nutritional knowledge, media, and most importantly, food. People’s responsibility to eat healthily was highlighted by the participants, implying that people are to be blamed for their poor lifestyle choices. Following this responsibility discourse, most participants contemplated merely individually focused health interventions in order to overcome the problem of malnutrition in their area. It is necessary to study slum food environments better to implement effective nutrition programs and interventions to reduce malnutrition in slum settings