Burden Of Malnutrition In Children Research Articles

Policy analysis of the triple burden of malnutrition in children below 5 years of age in Oman

Background: Oman faces the triple burden of malnutrition (TBM) among children under 5 years of age, characterized by stunting, overweight, and wasting. This critical issue impacts children’s healthy development and the country’s progress toward the UN Sustainable Development Goal three addressing good health and well-being. Methods: This study employs secondary data analysis to investigate the prevalence and trends of stunting, overweight, and wasting among children under 5 years of age in Oman, compared with selected Gulf Cooperation Council countries and the Organization for Economic Co-operation and Development (OECD) countries. Data sources include the United Nations International Children’s Emergency Fund, the World Health Organization, and the World Bank Group. Kingdon’s Multiple Streams Framework (MSF) and Howlett’s Policy Implementation Theory are used to critically analyze Oman’s strategies for improving child malnutrition. Results: The prevalence of stunting in Oman decreased from 12.3% in 2012 to 11.6% in 2022. The percentage of children who are overweight increased significantly from 2.9% in 2012 to 6.5% in 2022, surpassing trends in OECD countries. The incidence of wasting was 9.3% in 2017. Conclusion: The three critical aspects to address TBM in Oman are (1) policy gaps (the need for regular follow-up of children under the age of 5 years), (2) implementation barriers (need for regular program review and stakeholder engagement), and (3) the need for tailored interventions. These challenges can be rectified by (1) implementing an expansion of nutrition programs through early education in childcare facilities, (2) increasing parental awareness, and (3) increasing collaboration with healthcare providers (through childcare health programs) for continuous monitoring and support.

Epidemiological study of pediatric nutritional deficiencies: an analysis from the global burden of disease study 2019

BackgroundNutritional deficiencies (ND) continue to threaten the lives of millions of people around the world, with children being the worst hit. Nevertheless, no systematic study of the epidemiological features of child ND has been conducted so far. Therefore, we aimed to comprehensively assess the burden of pediatric ND.MethodsWe analyzed data on pediatric ND between 1990 and 2019 from the Global Burden of Disease study (GBD) 2019 at the global, regional, and national levels. In addition, joinpoint regression models were used to assess temporal trends.ResultsIn 2019, the number of prevalent cases of childhood malnutrition increased to 435,071,628 globally. The global age-standardized incidence, prevalence, and DALY rates showed an increasing trend between 1990 and 2019. Meanwhile, the burden of child malnutrition was negatively correlated with sociodemographic index (SDI). Asia and Africa still carried the heaviest burden. The burden and trends of child malnutrition varied considerably across countries and regions. At the age level, we found that malnutrition was significantly more prevalent among children < 5 years of age.ConclusionPediatric ND remains a major public health challenge, especially in areas with low SDI. Therefore, primary healthcare services in developing countries should be improved, and effective measures, such as enhanced pre-school education, strengthened nutritional support, and early and aggressive treatment, need to be developed.

Nutritional status and growth of children and adolescents with and without cerebral palsy in eastern Uganda: A longitudinal comparative analysis.

There is a need to understand the growth and burden of malnutrition in children with cerebral palsy (CP) in order to design appropriate inclusive nutrition strategies. We compared the nutritional status and four-year longitudinal growth of a population-based cohort of children and adolescents (C&A) with CP (n = 97; 2-17 years; 55/42 M/F), and an age and sex matched group without CP (n = 91; 2-17y; 50/41 M/F) in rural Uganda. The cohorts were assessed in 2015 and 2019 for weight, height, social demographic characteristics, and feeding related factors. Nutritional status was determined using the World Health Organization (WHO) Z-scores. Wilcoxon sign rank and Mann-Whitney tests were used to test within and between group differences. Multivariable linear regression was used to determine predictors of the change in growth. Approximately two thirds (62/97 (64%)) of C&A with CP were malnourished (with <-2SD in any of the WHO Z-scores), especially those with feeding difficulties (OR = 2.65; P = 0.032), and those who needed to be fed (OR = 3.8; P = 0.019). Both the CP and non-CP groups deviated negatively from the WHO reference growth curve for height, with a significantly slower growth in the CP group (median change score of height-for-age Z score (HAZ) between assessments = -0.80(-1.56, 0.31), p<0.01), than the non-CP group (median HAZ change score = -0.27(-0.92,0.34, p = 0.034). There was a statistically significant group difference in the median HAZ change score between the CP and non-CP groups (z = -2.21, p = 0.026). Severity of motor impairment measured by the Gross Motor Function Classification System (GMFCS-level) correlated negatively (r = -1.37,95%CI -2.67, -0.08) with the change in HAZ scores among the CP group. Children and adolescents with severe motor impairments exhibit an increased risk of malnutrition and growth retardation compared to their age matched peers without CP, which underscores the need to develop inclusive community-based nutrition strategies for children with cerebral palsy.

Spatial distribution and determinants of stunting, wasting and underweight in children under-five in Ethiopia

BackgroundThe burden of malnutrition in children under five remains an important child health issue where significant regional variations are observed in Ethiopia. The main aim of the current study was to explore the spatial distribution of stunting, wasting, and underweight in children under five in Ethiopia.MethodsThe secondary data from EDHS, 2016, was employed, and a total of 7960 under-five children were included in the analysis. The general spatial analysis was performed to explore the spatial distribution of malnutrition among under-five within and between the regions of Ethiopia. The Spatial Lag and Spatial Error models were used to examine the spatial dependence between stunting, wasting, and being underweight. The Geographically weighted regression analysis was performed to estimate the types and strength of relationships between malnutrition and associated determinant factors across the regions and within the clusters or Zones of each region.ResultsAmong the under-five children included in the study, 36.6% were stunted, 12.2% were wasted and 25.2% were underweight. The Global Moran Index's value indicates (Stunting, I = 0.3135, p-value < 0.00001, Wasting, I = 0.1948, p-value < 0.0001 and Underweight, I = 0.5291, p-value < 0.0001) that there was a significant spatial variation of malnutrition across the regions and Zones of Ethiopia. The significant source of spatial variation of malnutrition in children under five was associated with the mother's education level, drinking water facility, toilet facilities, number of children under-five in the household, household’s wealth index, breastfeeding duration of the child, child size at birth, Body Mass Index of Mothers (BMI), region, and place of residence.ConclusionsThe spatial association and spatial patterns of stunting, wasting, and being underweight were clustered within and between the regions of Ethiopia. The hotspot areas of stunting, wasting, and being underweight were detected in the regions where there were poor health facilities and limited socioeconomic indicators.

Contextual factors and spatial trends of childhood malnutrition in Zambia.

Understanding the national burden and epidemiological profile of childhood malnutrition is central to achieving both national and global health priorities. However, national estimates of malnutrition often conceal large geographical disparities. This study examined the prevalence of childhood malnutrition across provinces in Zambia, changes over time, and identified factors associated with the changes. We analyzed data from the 2013/4 and 2018 Zambia demographic and health surveys (ZDHS) to examine the spatial heterogeneity and mesoscale correlates of the dual burden of malnutrition in children in Zambia. Maps illustrating the provincial variation of childhood malnutrition were constructed. Socio-demographic and clinical factors associated with childhood malnutrition in 2013 and 2018 were assessed independently using a multivariate logistic model. Between 2013/4 and 2018, the average prevalence of stunting decreased from 40.1% (95% CI: 39.2-40.9) to 34.6% (95% CI:33.6-35.5), wasting decreased from 6.0% (95% CI: 5.6-6.5) to 4.2% (95% CI: 3.8-4.7), underweight decreased from 14.8% (95% CI: 14.1-15.4) to 11.8% (95% CI: 11.2-12.5) and overweight decreased from 5.7% (95% CI: 5.3-6.2) to 5.2% (95% CI: 4.8-5.7). High variability in the prevalence of childhood malnutrition across the provinces were observed. Specifically, stunting and underweight in Northern and Luapula provinces were observed in 2013/14, whereas Lusaka province had a higher degree of variability over the two survey periods. The study points to key sub-populations at greater risk and provinces where malnutrition was prevalent in Zambia. Overall, these results have important implications for nutrition policy and program efforts to reduce the double burden of malnutrition in Zambia.

Exploring the prevalence of multiple forms of malnutrition in children 6–18 years living in the Eastern Cape, South Africa

Background: The existence of multiple forms of malnutrition is a growing problem in developing countries. Children living in the Eastern Cape have a relatively high prevalence of cardiovascular disease (CVD) risk factors and food insecurity, suggesting the possibility of the several coexisting forms of malnutrition. Due to the negative long-term consequences of undernutrition, overnutrition and, to a greater extent, a combination of both, it is important for this issue to be identified early in children and addressed. Aim: This study was undertaken to investigate the prevalence of the different forms of malnutrition in children living in the Eastern Cape province. Methods: Secondary analysis of a cross-sectional sample of 237 school-aged children, aged 6–18 years, in the Eastern Cape province of South Africa was conducted. The variables included in the analysis were the demographic data, anthropometric data and biochemical data, specifically blood profiles related to micronutrient deficiencies and CVD risk factors. Fisher’s exact test was used to compare the prevalence rates of several coexisting forms of malnutrition in the children. All data analysis was conducted in R version 4.0.3 and statistical significance was set at 0.05. Results: In children with overweight/obesity, 13.6% had a micronutrient deficiency, while 37.71% of the children within the normal weight range had coexisting micronutrient deficiencies and CVD risk factors. The prevalence of folate deficiency was 73.0%, iron deficiency 6.3%, and hyperglycaemia was at 10.6%. Fisher’s exact test was used to compare the prevalence rates between genders and no statistically significant differences were observed. Conclusion: Further research is needed to understand the relatively high prevalence of CVD risk factors in these children within the normal weight range and to investigate how dietary intake contributes to the overall double burden of malnutrition in children.

Lifetime impact of being underweight or overweight/obese during childhood in Vietnam

BackgroundThere is limited evidence about lifetime burden of child malnutrition. This study aimed to estimate the lifetime impact of being underweight or overweight/obese during childhood in Vietnam.MethodsWe developed a life table model in combination with a Markov model for Vietnamese children aged 5–19 years and simulated until they reached 75 years of age or died using published data. The starting year was 2019 and the model estimated number of deaths, years of life lived and quality-adjusted life years (QALY) with an annual discount rate of 3%. We performed scenario, one-way, and probabilistic sensitivity analyses to assess the impact of uncertainties in input parameters.ResultsThe model estimated 9.68 million deaths (6.44 million men and 3.24 million women), 622 million years of life lived (317 million men and 305 million women), and 601 million QALYs (308 million men and 293 million women). Scenario analyses showed that the reduction in either underweight or overweight/obesity alone, and reduction in both underweight and overweight/obesity resulted in fewer deaths, more years of life lived and more QALYs gained. In the scenario where everyone was a healthy weight, the model estimated 577,267 fewer deaths (6.0% less), 2 million more years of life lived (0.3% more), and 3 million QALYs gained (0.6% more) over base-case results which represents current situation in Vietnam.ConclusionsOur results suggest that addressing underweight and overweight/obesity will contribute to reducing deaths and increasing years of life lived and QALYs. Policies and interventions in alignment with Sustainable Development Goals to address underweight and overweight/obesity are necessary to achieve health for all.

Hala Ghattas

Scars from a protracted war, and the inevitable political instability following years of civil military conflict, have afflicted Lebanon for decades. Recent events—the economic crisis of 2019, the fatal explosion at Beirut's port in August, 2020, and the global pandemic—have deepened the country's already fragile predicament. On top of that, Lebanon hosts the most refugees per capita in the world, mostly from Syria and the “permanently temporary” Palestinian refugee community. Hala Ghattas (American University of Beirut [AUB], Lebanon) and her family live in Beirut, where she is a public health nutritionist. She was born there, emigrated to Australia as a child, and returned when the war was officially declared over. But the instability continued: “I was, I suppose, a child of war, and that has determined my interests, how I look at these kinds of crises and how they influence health”, she says. Double burden of malnutrition in children and adolescents in the Arab regionAmid the social and political challenges faced by the Arab region in recent decades, a rapid nutrition transition has also been evolving. With accelerated urbanisation and food system transitions, the region has consistently witnessed increases in the numbers of people who are overweight and obese, including among children and adolescents. At the same time, child stunting and acute malnutrition burdens linger inequitably across the region and remain particularly high in populations affected by conflict. Full-Text PDF

Double burden of malnutrition in children and adolescents in the Arab region

Double burden of malnutrition in children and adolescents in the Arab region

Malnutrition and the mental health of children: the sub-Saharan Africa perspective

Child malnutrition has been a notably significant health challenge over the years especially in Africa where the prevalence is high. The World Health Organization has defined malnutrition as deficiencies or excesses in the intake of nutrients, imbalance of essential nutrients or impaired use of nutrients. Studies have further shown that the burden of malnutrition in children in Africa can be traced to the sub-Saharan region of Africa. A lot of factors are responsible for this some of which include; poverty, ignorance, inaccessibility of quality food items, among others. And although malnutrition in children is associated with a number of non-communicable diseases, it has a significant association with mental health affecting motor, cognitive and behavioural development, etcetera. Several researches have highlighted the relationship between malnutrition in children and mental health disorders. Hence, this paper discusses the relationship between malnutrition and the mental health of children in sub-Saharan Africa, the prevalence of malnutrition-induced mental health disorders in this region, factors affecting this prevalence as well as suggestions involving the government at various levels in the region, not-for-profit organizations, individuals and the entire society at large in addressing this very serious issue as it affects the future of the next generation.

Simposio 18: Programas e intervenciones en el niño con obesidad y situación de crisis

Simposio 18: Factores psicosociales, diabetes, epidemias y pandemias vigentesProgramas e intervenciones en el niño con obesidad y situación de crisisHoy en nuestro país, más que nunca, el concepto de doble carga de malnutrición en niños/as está muy vigente. Nos encontramos con un 32% de inseguridad alimentaria1 y con un 41% de exceso de peso en niño/as de 5 a 12 años2. También se sabe, de acuerdo con esta misma encuesta, que los chicos comen peor que los adultos.Frente a esta situación de dificultades en el acceso, y sabiendo que los determinantes de la obesidad son múltiples (alta exposición al marketing, insuficiente educación alimentaria, inadecuada oferta a alimentos frescos, alta disponibilidad y fácil acceso a alimentos con exceso de azúcar, grasas y sal, entornos escolares obesogénicos, etiquetado de alimentos incomprensible para los consumidores), las estrategias de salud pública también deben serlo.

The presence of the double burden of malnutrition in children and their mothers in Grand-Popo, Benin.

Malnutrition is a public health problem, with 45% of child deaths attributed to undernutrition. The aim of this study was to investigate the presence of the double burden of malnutrition in children-mother pairs in Benin. An analytical cross-sectional approach was used to collect data from 408 randomly selected children aged 0-59 months and their mothers. A pretested questionnaire was used to collect information on demographic and socioeconomic status, and anthropometric measurements were used to estimate the nutritional status of children and body mass indexes of the mothers. The World Health Organization Anthro software was used to estimate Z-scores whereas SPSS version 25 was used for statistical analysis. Descriptive and regression analysis were carried out on the data. The mean age of children was 24.45 ± 14.9 months and 53.2% were girls. The mean age of mothers was 27.99 ± 6.99, 93.1% were married and approximately 91.7% of households had a monthly income of US$60. Prevalence of wasting in children was 9.8% and stunting was 29.7%. The mean waist circumference of mothers was 79.95 ± 10.35 cm and 19.3% were classified as high metabolic risk. Body mass index measurements showed that 16.9% of mothers were overweight and 7.4% obese. Stunting and wasting were highly prevalent. There is a coexistence of underweight and overweight in Grand-Popo, Benin. The results drew attention to the need for coordination of preventive interventions to focus on the household food distribution.

Assessing inequalities and regional disparities in child nutrition outcomes in India using MANUSH \u2013 a more sensitive yardstick

BackgroundIndia is strongly committed to reducing the burden of child malnutrition, which has remained a persistent concern. Findings from recent surveys indicate co-existence of child undernutrition, micronutrient deficiency and overweight/obesity, i.e. the triple burden of malnutrition among children below 5 years. While considerable efforts are being made to address this challenge, and several composite indices are being explored to inform policy actions, the methodology used for creating such indices, i.e., linear averaging, has its limitations. Briefly put, it could mask the uneven improvement across different indicators by discounting the ‘lagging’ indicators, and hence not incentivising a balanced improvement. Signifying negative implications on policy discourse for improved nutrition. To address this gap, we attempt to develop a composite index for estimating the triple burden of malnutrition in India, using a more sensitive measure, MANUSH.MethodologyData from publicly available nation-wide surveys - National Family Health Survey (NFHS) and Comprehensive National Nutrition Survey (CNNS), was used for this study. First, we addressed the robustness of MANUSH method of composite indexing over conventional aggregation methods. Second, using MANUSH scores, we assessed the triple burden of malnutrition at the subnational level over different periods NHFS- 3(2005–06), NFHS-4 (2015–16) and CNNS (2106–18). Using mapping and spatial analysis tools, we assessed neighbourhood dependency and formation of clusters, within and across states.ResultMANUSH method scores over other aggregation measures that use linear aggregation or geometric mean. It does so by fulfilling additional conditions of Shortfall and Hiatus Sensitivity, implicitly penalising cases where the improvement in worst-off dimension is lesser than the improvement in best-off dimension, or where, even with an overall improvement in the composite index, the gap between different dimensions does not reduce. MANUSH scores helped in revealing the gaps in the improvement of nutrition outcomes among different indicators and, the rising inequalities within and across states and districts in India. Significant clusters (p < 0.05) of high burden and low burden districts were found, revealing geographical heterogeneities and sharp regional disparities. A MANUSH based index is useful in context-specific planning and prioritising different interventions, an approach advocated by the newly launched National Nutrition Mission in India.ConclusionMANUSH based index emphasises balanced development in nutritional outcomes and is hence relevant for diverse and unevenly developing economy like India.

Tackling child malnutrition in Jamaica, 1962\u20132020

On the eve of independence in 1962, malnutrition was the largest single cause of death in Jamaica for children under one. Although child malnutrition rates have rapidly declined since 1962, today Jamaica experiences a double burden of malnutrition: the coexistence of pockets of high child malnutrition with rising levels of childhood obesity. Based on a wide range of sources, including public documents, newspaper reports, scientific studies and reports by international agencies, this article examines a gradual decline in child malnutrition and the rise of the double burden of malnutrition in Jamaica from independence to the present. It will first of all show that changes in the global economy and overseas loans and aid both aided and limited the ability of the Jamaican government to lower child malnutrition levels and also contributed to a rise in childhood obesity. Second, it will illustrate that a traditional deficit-led approach to child malnutrition was followed in post-independent Jamaica, focussing on the public and individuals as targets for intervention and using quantitative measures to trace progress. And third, it will question whether the double burden of child malnutrition will give rise to ‘healthy publics’—‘dynamic collectives of people, ideas and environments that can enable health and well-being’.

The Use of Anthropometrics, BMI and Isotope Dilution Methods in Assessing the Double Burden of Malnutrition in Children (3-5 Years) in the Southern and Northern Regions of Botswana

The Use of Anthropometrics, BMI and Isotope Dilution Methods in Assessing the Double Burden of Malnutrition in Children (3-5 Years) in the Southern and Northern Regions of Botswana

Socio-cultural practices, eating patterns and presence of double burden of malnutrition in mothers and their children in Grand-popo, Benin

AbstractThe world faces today a double burden of malnutrition which includes both undernutrition and overweight, especially in developing countries. Managing these two aspects of malnutrition in developing countries is a heavy burden for their failing health systems. Data from FAO show that 161 million children under five years are stunted and at the same time 3.4 million people die each year due to overweight and obesity (FAO, 2013). The aim of this study is to investigate the sociocultural influence, feeding practices and the presence of double burden of malnutrition in children and their mothers in Grand-popo's community in Benin. A cross-sectional, descriptive and analytical approach was used. A sample of 408 children between 0- 59 months and their mothers were selected. A questionnaire was developed to get information on demographic and socio-economic status of the household, breastfeeding and infant feeding practices. Food frequency questionnaire was administrated to assess dietary patterns and four focus groups with mothers were held to determine care practices and food taboos. Weight and height measurements for children and weight, height and waist circumference for their mothers were taken. Height for Age and Weight for Height z scores were determined for children and body mass index (BMI) measurements were calculated for women. For statistics analysis, IBM SPSS 25 was used. The mean age of children was 24.45 ± 14.9 months with 53.2% of girls in the sample. The mean age of mothers was 27.99 ± 6.99 years. Majority of mothers (93.1%) are married or living with the spouse. About 91.7% of household had a monthly income of $60 and spent on average $24 ± $11.2 on food. Prevalence of wasting was 9.8% and stunting 29.7%. Waist circumference mean of mothers was 79.95 ± 10.35 cm and 19.3% were classified to be at high metabolic risk. BMI assessments revealed 16.9% of mothers were overweight and 7.4% obese. All children were breastfed. Children were introduced to family foods at 5 months on average with very low consumption of animal protein and fruits, and a high consumption of vegetables and maize based meals. Food taboos particularly during pregnancy were revealed and those cultural beliefs were still followed by some mothers. The findings showed the need for more effort on cultural sensitive interventions to reduce double burden of malnutrition.

Role of Optimized Plant Protein Combinations as a Low-Cost Alternative to Dairy Ingredients in Foods for Prevention and Treatment of Moderate Acute Malnutrition and Severe Acute Malnutrition.

Tackling the global burden of acute malnutrition in children remains a major public health challenge and is essential for achieving sustainable development. Despite having effective treatment options, most wasted children go untreated; treatment coverage for severe acute malnutrition (SAM) children is only about 20%. Milk is currently an essential component of effective SAM treatment, incorporated into ready-to-use therapeutic food (RUTF). Reaching the untreated children, as well as preventing SAM, requires investment in innovative and cost-efficient approaches. To date, attempts to replace or remove milk from RUTF have been either unsuccessful or unpersuasive. This is likely because milk provides the highest protein quality and density of all typical RUTF ingredients. However, alternative protein sources could provide cost savings. Alternative protein sources, especially plant-based protein alternatives, have had shown more promising progress for the treatment of children with moderate acute malnutrition. Acknowledging that cost is a major barrier to the scale-up of treatment of acute malnutrition and that alternative protein sources are a practical means to reduce cost, continued research focusing on alternative proteins is necessary.

Combating Triple Burden of Malnutrition in Children

Combating Triple Burden of Malnutrition in Children

Estimating the Double Burden of Malnutrition among 595,975 Children in 65 Low- and Middle-Income Countries: A Meta-Analysis of Demographic and Health Surveys.

Introduction: Given the changing global nutrition landscape, the double burden of malnutrition is a major public health challenge in many developing countries. The main aim of this study is to estimate the double burden of malnutrition among children in low- and middle-income countries (LMICs). Methods: This study used cross-sectional data from Demographic and Health Surveys (2001–2016). A meta-analysis was conducted to estimate the prevalence of malnutrition indicators in 595,975 children under five years from 65 LMICs. Significant heterogeneity was detected among the various surveys (I2 >50%), hence a random-effect model was used. Sensitivity analysis was also performed, to examine the effects of outliers. Results: The pooled estimate for stunting, wasting, underweight, and overweight/obesity was 29.0%, 7.5%, 15.5%, and 5.3% respectively. Countries with the highest coexistence of undernutrition and overweight/obesity were: South Africa (stunting 27.4% (95% CI: 25.1, 29.8); overweight/obesity 13.3% (95% CI: 11.5, 15.2)), Sao Tome and Principe (stunting 29.0% (95% CI: 26.8, 31.4); overweight/obesity 10.5% (95% CI: 9.0, 12.1)), Swaziland (stunting 28.9% (95% CI: 27.3, 30.6); overweight/obesity 10.8% (95% CI: 9.7, 12.0)), Comoros (stunting 30.0% (95% CI: 28.3, 31.8); overweight/obesity 9.3% (95% CI: 8.3, 10.5)), and Equatorial Guinea (stunting 25.9% (95% CI: 23.4, 28.7); overweight/obesity 9.7% (95% CI: 8.0, 11.6)). Conclusions: There is an urgent need to strengthen existing policies on child malnutrition to integrate and scale up opportunities for innovative approaches which address the double burden of malnutrition in children under five years in LMICs.

A Review of the Nutritional Quality of School Canteen Foods in South Asia

In Schools, canteens play a crucial role in ensuring nutritional well-being of adolescents. Regular consumption of unhealthy food items purchased from the school canteens may add to the existing burden of malnutrition in children, especially adolescents. A narrative review was conducted to comprehensively summarize the nutritional quality of food products served in South Asian school canteens. Three electronic scientific databases were searched for articles and selected articles were analyzed. Literature review indicated the absence of school food policy/guidelines, unhygienic school canteens, high availability and accessibility of unhealthy foods in school canteens and lack of awareness regarding healthy school food environment among parents, teachers, students, and principals. Further, well-designed studies to assess the nutritional quality of foods served in school canteens using appropriate indices are required.