Double Burden Of Undernutrition Research Articles

Cardiovascular Dynamics in HIV: The Influence of Adrenal Function and Nutritional Status.

This interdisciplinary review explores the intricate nexus between HIV infection, nutrition, adrenal gland function, and cardiovascular health, highlighting a critical aspect of HIV management often overlooked in current literature. With the advent of antiretroviral therapy, the life expectancy of people living with HIV has dramatically improved, transforming HIV into a manageable chronic condition. However, this success brings forth new challenges, notably an increased risk of cardiovascular diseases among people living with HIV. We examine the normal physiology of the adrenal gland, including its role in mineral metabolism, a crucial facet of nutrition. We discuss the evolution of knowledge tying adrenal pathology to cardiovascular disease. We explore the impact of HIV on adrenal gland findings from a gross pathology perspective, as well as the clinical impact of adrenal insufficiency in HIV. The review further elucidates the role of nutrition in this context, considering the double burden of undernutrition and obesity prevalent in regions heavily affected by HIV. By aggregating findings from longitudinal studies and recent clinical trials, the review presents compelling evidence of increased cardiovascular disease among people living with HIV compared with people without HIV. It highlights the critical role of the adrenal glands in regulating nutrient metabolism and its implications for cardiovascular health, drawing attention to the potential for dietary interventions and targeted therapies to mitigate these risks. This review urges a paradigm shift in the management of HIV, advocating for a holistic approach that incorporates nutritional assessment and interventions into routine HIV care to address the complex interplay between HIV, adrenal function, and cardiovascular health. Through this lens, we offer insights into novel therapeutic strategies aimed at reducing cardiovascular risk in people living with HIV, contributing to the ongoing efforts to enhance the quality of life and longevity in this population.

Trends in growth and nutritional status of high school graduates in Hangzhou, China, 2011\u20132020

BackgroundDuring past decades, there was a positive trend in growth and nutrition status of adolescents in China, but there was significant regional disparity. The purpose of this study is to investigate the trends in growth and nutritional status of high school graduates in Hangzhou between 2011 and 2020.Methods High school graduates (Grade 12) who finished the physical examination of the national college entrance examination between 2011 and 2020 (n=481,353)were included in this study. Data were obtained from the database of physical examination of the national college entrance exam. Height and weight were measured; body mass index (BMI) was calculated from height and weight. Thinness, overweight and obesity were defined according to the International Obesity Task Force criteria. For the vast majority of the high school graduates were 18 years old or nearly 18 years old, the cutoffs of 18 years were adopted. Those are 18.5, 25 and 30 kg/m2, for thinness, overweight and obesity respectively.ResultsThere was a significant growth trend in height, weight and BMI in both sexes (P < 0.001). Height increased by 1.80 cm in boys and 1.45 cm in girls. Weight increased by 4.62 kg in boys and 2.51 kg in girls. BMI increased by 1.09 kg/m2 in boys and 0.60 kg/m2 in girls. An increase trend was found in the prevalence of overweight and obesity in both sexes (P < 0.001). Overweight increased by 7.43% (from 9.05 to 16.48%) among boys and 4.05% (from 4.57 to 8.62%) among girls. Obesity increased by 3.85% (from 2.29 to 6.14%) among boys and 1.76% (from 0.64 to 2.40%) among girls. The prevalence of thinness fluctuated in both boys and girls, 12.42–15.59% among boys and 18.97–23.68% among girls. Boys had higher odds of overweight and obesity and lower odds of thinness than girls (P < 0.001).ConclusionsThere is a positive trend in growth and nutritional status of high school graduates in Hangzhou. However, there is still a considerable prevalence of thinness, it indicates a double burden of undernutrition and overnutrition.

FRONTLINE HEALTH PROVIDER'S PERSPECTIVE IN REDUCING CHILD DEATHS DUE TO MALNUTRITION IN A TRIBAL DISTRICT OF MAHARASHTRA: A QUALITATIVE STUDY

Background: Malnutrition is a complex problem with double burden of undernutrition and overweight. India is no exception to it but there is a higher level of malnutrition in tribal blocks and to curb this situation,various activities have been undertaken but the slow pace of decline in malnutrition is a concern.The role of frontline health workers is crucial in strengthening primary health care.They serve as the bridge between the formal government health-care system and the community.The present study helps to seek the perception of primary health care service providers and challenges faced by them in reducing child deaths due to malnutrition. Method: A descriptive cross sectional qualitative study was conducted during August 2019 - February 2020 in three talukas of a tribal district. Focus group discussions (FGD) for each service providers Auxiliary Nurse midwife (ANM), Anganwadi worker (AWW) and Accredited Social Health activist (ASHA) were conducted. All the FGDs were audio recorded and transcripts were prepared,a thematic analysis framework was used for doing the analysis. Results: Most of the service providers were aware regarding their roles and responsibilities in implementation of schemes/ services related to malnutrition. The important factors influencing their performance were superstitions, more reliance on health seeking from unqualified health care providers and faith healers, poor road connectivity, network issues,lack of refresher training,overburdening with work,poor incentives. Conclusion: Specific training programs to tackle malnutrition along with frequent refresher training of the service providers,better infrastructure and human resources will help in achieving the desired results in future in dealing with child malnutrition.

Effect on Child Nutrition of Maternal Counselling Delivered by Community Health Workers: A Cluster Randomised Controlled Trial in Karnataka, India

Background: India suffers a double burden of undernutrition and anaemia. The Karnataka anaemia project indicated that a counselling intervention delivered by community health workers improved anaemia cure. Objective: To evaluate the effect of maternal counselling on overall child nutrition. Methods: Secondary analysis of a cluster randomised controlled trial (55 villages). Mothers in the intervention group received five monthly counselling sessions plus usual care (iron and folic acid supplements), while the control group received usual care only. The study included 1144 children (1-5 years old), of whom 534 were anaemic. 24-hour dietary recall and questionnaires were used to determine children’s dietary intake (primary outcome), maternal knowledge on nutritional aspects of anaemia (secondary outcome). Follow up was conducted at six months. Linear mixed regression models were used to assess between groups differences. Findings: Daily intake of all nutrients, except vitamin C, increased in both groups from baseline to follow up. The increase was higher among children in the intervention group compared to the control group for all nutrients except vitamin B12. Iron and vitamin C intake increased by 0·24 (95%CI -0·67; 1·15) mg/day and 4.61 (95% CI -0·69; 9·91) mg/day in the intervention group compared to the control group, respectively. Furthermore, children of mothers with low education also benefited from the intervention. Interpretation: The intervention resulted in modest improvements in child nutrition, however comparable between maternal education levels. Previously observed enhancement of anaemia cure rate was probably due to improved adherence to iron and folic acid supplements. Trial Registration: ISRCTN identifier: ISRCTN68413407. Funding: Wellcome Trust/DBT India Alliance. Conflict of Interest: Dr. Shet received a grant from the Wellcome Trust/DBT India Alliance while the study was conducted. No other disclosures are reported. Ethical Approval: The study was approved by the St. Johns National Academy of Health Sciences Institutional Ethical Committee (IEC 115/2012). Mothers and caregivers provided written informed consent to participate. An independent committee was employed to act as data safety and management board. This committee conducted an interim analysis looking at the side effects of IFA supplements. The reported side effects were minor.

Factors associated with body mass index among slum dwelling women in India: an analysis of the 2005-2006 Indian National Family Health Survey.

BackgroundUrbanization is increasing around the world, and in India, this trend has translated into an increase in the size of slum dwellings whose environments are suspected of being associated with poor health outcomes, particularly those relating to women’s nutritional status. With this study, we sought to determine the factors associated with Indian women’s body mass index (BMI) in slum environments, with special attention paid to women with tribal status.MethodsA multiple linear regression analysis was performed on data from the Indian National Family Health Survey (2005–2006), modeling demographic and behavioral factors suspected of being associated with BMI, with additional focus on the measures of social class, specifically caste and tribal status.ResultsIncreasing BMI is significantly and positively associated with frequency of watching television, having diabetes, age, wealth index, and residency status in the areas of New Delhi, Andhra Pradesh, or Tamil Nadu.ConclusionAlthough belonging to a scheduled tribe was not associated with changes in BMI, unadjusted rates suggest that tribal status may be worthy of deeper investigation. Among slum dwellers, there is a double burden of undernutrition and overnutrition. Therefore, a diverse set of interventions may be required to improve the health outcomes of these women.

Double Burden of Undernutrition and Obesity in Palestinian Schoolchildren: A Cross-Sectional Study.

The coexistence of underweight and overweight (double burden) remains a major problem in many developing countries. Little is known about the factors associated with the double burden of malnutrition in Palestinian children. To assess factors associated with undernutrition and overnutrition in 1500 schoolchildren aged 5 to 16 years, in the West Bank. We surveyed a sample of 22 schools run by the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) and the Palestinian government. Binary logistic regression was used to examine the factors associated with malnutrition. The hunger index, a composite score from 8 questions, was used to measure food insecurity. In the 1484 children enrolled in UNRWA and government schools in the West Bank, the prevalence of stunting was 7% and underweight 3%. Around 12% of students were overweight and 6% obese. The hunger index was negatively associated with height for age. Factors associated with being underweight were male sex, mother being unemployed, and households not having enough food to eat for at least 2 days in the previous month. Factors associated with obesity were older age and time spent watching television. When overweight and obesity were combined in the analysis, they were inversely associated with increasing number of days spent playing sports. Our results show that the important nutritional risks for school-age children in the West Bank would seem to be the simultaneous occurrence of undernutrition and obesity. The study highlights the need to balance obesity management and prevention with interventions to tackle undernutrition.

The Double Burden of Undernutrition and Overnutrition in Developing Countries: an Update.

Many developing countries have achieved a remarkable improvement in nutrition status in the past decades. However, the prevalence of undernutrition remains a serious problem. At the same time, the prevalence of obesity is increasing substantially, and in some countries, it has approached that of developed countries. This article provides an update on this double burden of malnutrition (DBMN) in developing nations. One hundred countries (lower, middle-lower, and upper-middle income countries) were selected and analysed, and to support the analysis, a systematic review of current published studies was performed. The results show that DBMN already exists in almost all developing countries and that the DBMN ratio (i.e., overweight/underweight) has increased as income per capita has increased. DBMN may manifest within the community, household, or individual. In addition to common factors, poor nutrition in early childhood is suggested as another important driving factor behind the rising obesity rate in most developing countries. A life-course approach has been proposed to prevent undernutrition and overnutrition and should be integrated into the development of health systems to control double burden in developing countries.

Dietary Intake Research in Asian Children: Significance and Challenges.

Food intake studies have a long history. However, until a few decades ago, there was limited quantitative data on feeding patterns and food intake in infants and children living in South Asia. The recent SEANUT study and MING study have provided several new insights into the dietary patterns of children living in China, Indonesia, Malaysia, Thailand and Vietnam. The complexity and variety of Asian diets makes the collation of dietary information a challenge. The double burden of under-nutrition and over-nutrition is prevalent in many Asian countries. Compared to obesity, stunting is widespread in South East Asia. Our future challenge is to develop food intake assessment techniques which can be refined and made available as a common dietary assessment tool across this region. Successful nutritional intervention can only be achieved if we know what Asian children eat. Dietary intake research will be a key factor in realizing our goal to eradicate malnutrition in this region.

Nutrition transition and double burden of undernutrition and excess of weight in Brazil

Brazil, a unique Latin American country recognized as 1 of the 8 major economies of the world, is experiencing a significant deterioration in health equality in the past decade, despite its universal and free-of-charge health service that is governed by its national constitution. The objective was to describe the double burden at the national, household, and individual levels as well as its major trends across all demographic strata in the past 40 y. The data were collected from 6 Brazilian national surveys conducted in 1974-1975, 1989, 1996, 2002-2003, 2006, and 2008-2009. Anthropometric indicators were estimated for all age groups and anemia indicators for children aged <5 y and women aged >15 y according to WHO recommendations. The annual increment rate was calculated for all indicators to assess the different time points among surveys. In 2008-2009, 1 of every 7 citizens was obese. From 1974-1975 to 2008-2009, the annual obesity increment rate for men was 4.7% each year and was 2.5% each year for women. A large decrease in undernutrition in adults was observed from 1974-1975 to 1989. In children <5 y of age, no increase in the prevalence of overweight across the analyzed periods was observed, whereas a major decrease in the prevalence of undernutrition was detected from 1996 to 2006-2007. The prevalence of the obese mother-underweight child pair was low. No association between anemia and any other child anthropometric indicator was detected. Prevalence trends of adult obesity stratified by quintiles of per capita household income showed different trajectories for men and women across the surveys. In the last period, the poorest and richest adults showed positive incremental rates of obesity. In Brazil, the current prevalence of excess weight is at least 3-fold higher than that of undernutrition. The lowest prevalence rate in the last period analyzed was observed in children <5 y of age. Inclusive social policies have succeeded in reducing poverty and in identifying new challenges related to obesity control or reduction.

Double burden of undernutrition and obesity in Uruguay

Uruguay is at an advanced stage of the epidemiologic transition; like other Latin American countries, it bears a nutritional double burden composed of undernutrition and overweight or obesity. The aim was to estimate whether a double burden of nutritional problems exists in Uruguay and to identify if governmental programs and policies for nutrition take this double burden into account. Existing studies were reviewed, and other data were processed specifically for the purpose of this article. Several data sources were used to include a broad, comprehensive population range. The prevalence of stunting in children aged <2 y is 10.9%. There is a high frequency of obesity, which increases with age (9.5% in children <2 y old, 18.8% in those aged 6 y, 20.4% in those aged 11 y, 26.6% in those aged 13-15 y, and 35.3% in adults). In addition, 13.8% of women start pregnancy underweight and the rate of obesity increases during pregnancy from 36.7% at the beginning to 46.5% at the end. Anemia is very frequent in the selected population we examined, as follows: 31% of children <2 y old and 20.9% of pregnant women in their third trimester. An obese mother with a stunted child are present in 6.3% of households; 1.9% of stunted children are obese at age 6 y and 3.1% are obese at the age of 11. Multiple logistic analysis applied to children <2 y showed an association between stunting and obesity (OR: 2.0; 95% CI: 1.2, 3.6). The data suggest that there is a nutritional double burden in Uruguay. This nutritional burden is similar to that of other countries in the region. This important public issue should be tackled, and it should be addressed in early infancy.

The double burden of undernutrition and excess body weight in Mexico

In Mexico, stunting and anemia have declined but are still high in some regions and subpopulations, whereas overweight and obesity have increased at alarming rates in all age and socioeconomic groups. The objective was to describe the coexistence of stunting, anemia, and overweight and obesity at the national, household, and individual levels. We estimated national prevalences of and trends for stunting, anemia, and overweight and obesity in children aged <5 y and in school-aged children (5-11 y old) and anemia and overweight and obesity in women aged 20-49 y by using the National Health and Nutrition Surveys conducted in 1988, 1999, 2006, and 2012. With the use of the most recent data (2012), the double burden of malnutrition at the household level was estimated and defined as the coexistence of stunting in children aged <5 y and overweight or obesity in the mother. At the individual level, double burden was defined as concurrent stunting and overweight and obesity in children aged 5-11 y and concurrent anemia and overweight or obesity in children aged 5-11 y and in women. We also tested if the coexistence of the conditions corresponded to expected values, under the assumption of independent distributions of each condition. At the household level, the prevalence of concurrent stunting in children aged <5 y and overweight and obesity in mothers was 8.4%; at the individual level, prevalences were 1% for stunting and overweight or obesity and 2.9% for anemia and overweight or obesity in children aged 5-11 y and 7.6% for anemia and overweight or obesity in women. At the household and individual levels in children aged 5-11 y, prevalences of double burden were significantly lower than expected, whereas anemia and the prevalence of overweight or obesity in women were not different from that expected. Although some prevalences of double burden were lower than expected, assuming independent distributions of the 2 conditions, the coexistence of stunting, overweight or obesity, and anemia at the national, household, and intraindividual levels in Mexico calls for policies and programs to prevent the 3 conditions.

The double burden of undernutrition and excess body weight in Ecuador

Ecuador's current nutrition policies have not taken adequate notice of the double burden of malnutrition and continue to focus on stunting and to a lesser extent on overweight, without addressing the simultaneous presence of undernutrition, micronutrient deficiencies, and overweight or obesity (OW/OB). The aim of this article was to describe the prevalence and distribution of undernutrition (stunting, anemia, and zinc deficiency), overweight, and obesity in Ecuador to explore the evolving double burden of malnutrition at the national, household, and individual levels and to discuss whether current public health policies are addressing the double burden. Data from the 2012 Ecuadorian National Health and Nutrition Survey (ENSANUT-ECU) was used to estimate the dual burden of malnutrition at the national, household, and individual levels in children <5 y old, school-aged children, and women of reproductive age. In 13.1% of households, mothers with excess body weight coexist with a stunted child <5 y old. Moreover, among households with overweight or obese mothers, 12.6% have an anemic child and 14% have a zinc-deficient child. At the individual levels, the coexistence of OW/OB and stunting, anemia, or zinc deficiency was found in 2.8%, 0.7%, and 8.4% of school-aged children, respectively. In addition, 8.9% and 32.6% of women aged 12-49 y have excess body weight and anemia or zinc deficiency, respectively. This article shows the coexistence of high rates of undernutrition and OW/OB at the individual, household, and national levels in Ecuador. Although integrated approaches to address the emerging double burden are required, public health policies to date have not responded adequately.

The double burden of undernutrition and excess body weight in Mexico (621.5)

Introduction: Stunting (ST) and anemia (AN) have declined but are still high in some regions and subpopulations and overweight and obesity (OW/OB) have increased at alarming rates; therefore, undernutrition and OW/OB coexist. Objective: Describe the coexistence of ST, AN and OW/OB at national (NAT), household (HH) and individual (IND) levels. Methods: Using the Health and Nutrition National Survey 2012 (ENSANUT 2012), prevalences of ST, AN and OW/OB in 0‐59 mo children (&lt;5mo), school‐aged children (5‐11y) and adult women (20‐49y) were obtained at NAT level. Double burden of malnutrition (DB) at HH level was defined as coexistence of a ST &lt; 5y and an OW/OB mother (ST‐OW/OBm). At IND level, DB was defined as concurrent ST and OW/OB (ST‐OW/OB) in 5‐11y, AN and OW/OB (AN‐OW/OB) in 5‐11y and women. To determine if coexistence of the conditions corresponded to expected values, given independent distributions of each of them, observed and expected prevalence were tested statistically. Results: At HH level, the prevalence of ST‐OW/OBm was 8.6%, at IND level prevalence were 1% for ST‐OW/OB in 5‐11y, and 2.9% for AN‐OW/OB and 7.4% for AN‐OW/OB in women. At HH and IND level in 5‐11y, prevalence of DB were significantly lower than expected, while those in women were significantly higher. Conclusion: Although some prevalences of DB were lower than expected, given independent distributions of the two conditions, the coexistence of ST, OW/OB and AN at NAT, HH and IND levels in Mexico call of policies and programs to prevent simultaneously the three conditions.

Double burden of undernutrition and overnutrition in Vietnam in 2011: results of the SEANUTS study in 0·5–11-year-old children

The Vietnamese South East Asian Nutrition Survey (SEANUTS), a cross-sectional study, was undertaken to assess the nutritional status in a nationally representative sample of children aged 0·5-11·9 years. A multi-stage cluster-randomised sampling method was used to recruit 2872 children. Anthropometric measurements included weight, height, mid-upper arm circumference, and waist and hip circumferences. Blood biochemistry involved analyses of Hb, serum ferritin, and vitamins A and D. Dietary intake was assessed using a 24 h recall questionnaire, and nutrient intakes were compared with the Vietnamese RDA. In children aged < 5 years, approximately 14% were stunted, 8·6% underweight and 4·4% thin. A higher prevalence of stunting (15·6%) and underweight (22·2%) was observed in school-aged children. Undernutrition was more prevalent in rural areas than in urban areas. In contrast, almost 29% of the urban children were either overweight or obese when compared with 4% of the overweight children and 1·6% of the obese children in rural areas. A higher percentage of children in the age group 0·5-1·9 years and residing in rural areas had low Hb levels than those in the age group 2·0-5·9 years and residing in urban areas. In children aged 6-11 years, a small percentage had low Hb (11-14%) and vitamin A (5-10%) levels, but almost half the children (48-53%) had vitamin D insufficiency. Food consumption data indicated that the children did not meet the RDA for energy, protein, Fe, vitamin A, vitamin B1 and vitamin C. Results from the SEANUTS highlight the double burden of malnutrition in Vietnam. Information from the SEANUTS can serve as an input for targeted policy development, planning and development of nutrition programmes.

The evaluation of maternal health in rural western China

Objective: The double burden of undernutrition and overnutrition is recognized as a global devastating problem. However, few studies have investigated the maternal nutritional status among different ethnicities and the socio-demographic characteristics in rural areas of western China. This study attempted to fill this gap.Design: Data on 10,495 women with children under three years old were collected using a three-stage probability proportion to size sampling from 45 counties of 10 provinces in western China. Generalized Estimating Equation (GEE) was used to assess the maternal nutrition conditions, including chronic energy deficiency (CED) and overweight/obesity.Results: According to the WHO BMI standard, the prevalences of CED and overweight/obesity were 12.3% (BMI ≤ 18.5 kg/m2) and 12.4% (BMI ≥ 25 kg/m2), respectively, while overweight/obesity rate was 18.5% (BMI ≥ 24 kg/m2) based on the Chinese standard. A significant difference in malnutrition between Han and Minority was not observed. The relationship between breastfeeding and CED was inverse (OR 0.64, 95%CI: 0.48, 0.87), but higher parity were positively correlated with CED (OR 1.57, 95%CI: 1.36, 1.82). The highest odds of CED were observed in the group with 1–5 years of education (OR 1.21, 95%CI: 1.03, 1.43). Higher parity was also associated with overweight/obesity (OR 0.78, 95%CI: 0.67, 0.91), and rural women aged 30–39 years old were more likely to be overweight/obese (OR 2.21, 95%CI: 1.47, 3.32). In addition, higher socioeconomic status was positively related to overweight women (OR 1.19, 95%CI: 1.01, 1.43), and inversely associated with CED (OR 0.83, 95%CI: 0.72, 0.97).Conclusion: The coexistence of undernutrition and overweight among women of reproductive age are determined in rural western China. It appears that socio-demographic factors considerably influence maternal nutritional status in the study. These findings have important policy implications for recommendations on maternal health intervention in China.

Double burden of undernutrition and obesity in Palestinian schoolchildren: a cross-sectional study

Background Previous studies of nutrition were undertaken in adolescent schoolchildren in the West Bank or Gaza Strip, occupied Palestinian territory; most of the children were selected from only a few geographical areas. We assessed factors associated with stunting (height-for-age standardised scores Methods We surveyed a sample of 22 schools run by the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) and Palestinian Government. Using UNRWA's and the government's lists, we selected 1500 students from those attending school at the time the study was undertaken. We selected a set number of students per class from the first (mean age 6·71 years [SD 0·45]), sixth (11·82 years [0·57]), and ninth grades (14·83 years [0·61]), with a 1:1 ratio of boys to girls. The number of classes in each grade was between one and five. Siblings were excluded; we selected one student per household. We stratified the lists of students attending the UNRWA and government schools by location and sex. Within each school, 42 students per grade were selected using random sampling and recruited to the study—eg, if there were two classes A and B, we randomly selected 21 students from the alphabetical list for each class. BMI was defined according to age-specific and sex-specific cutoff values reported as per the 2000 growth charts of the Centers for Disease Control and Prevention, Atlanta, GA, USA, and height and weight measures as per WHO standards. Columbia University's Institutional Review Board, New York, NY, USA, approved the study protocol in December, 2008. Written informed consent and assent were obtained from sixth and ninth grade students and their parents. Findings Data were obtained from 1484 (99%) of 1500 students. Prevalence of stunting was 97 (7%) of 1446 and underweight 94 (7%) of 1444 students. 180 (12%) of 1444 students were overweight and 86 (6%) obese. There were non-significant differences in stunting (52 [7%] of 772 vs 45 [7%] of 674; difference 0·98, 95% CI 0·67–1·44; p=0·96), underweight (25 [3%] of 771 vs 24 [4%] of 673; 0·92, 0·52–1·58; p=0·73), and overweight (99 [13%] vs 81 [12%]; 1·07, 0·81–1·40; p=0·64) between the children in government and UNRWA schools. Obesity was more prevalent in UNRWA schools than in government schools (56 [7%] vs 30 [4%]; 1·63, 1·06–2·51; p=0·0246). The hunger index, which is a composite score from the eight questions on the food insecurity questionnaire, was negatively associated with height for age (p=0·018). Factors associated with underweight were male sex (odds ratio 2·8, 1·5–5·3; p=0·002), mother being unemployed (3·0, 1·0–8·4; p=0·04), and households not having enough food to eat for at least 2 days in the past month (1·8, 1·0–3·3; p=0·05). Factors associated with obesity were age, with children in the ninth grade more likely to be obese (1·1, 1·02–1·2; p=0·01) than were younger children, and time spent watching television (1·1, 1·0–1·3; p=0·014). When overweight and obesity were combined in the analysis, they were significantly and inversely associated with increasing number of days spent playing sports (0·87, 0·77–0·98; p=0·02). Interpretation By contrast with the results of previous studies, our data do not suggest an association between birth order, birthweight, size of the household, maternal education, and the child's nutritional status. Our results show the need to target food insecurity and improve child health in the occupied Palestinian territory, partly through increased awareness and promotion of sustainable healthy lifestyle changes for the prevention and management of undernutrition and obesity. The dissemination of information about the social, emotional, and cognitive effects of regular physical activity should be integral to health and nutrition programmes. We need to focus simultaneously on food insecurity and the establishment of a simple and reliable system for the detection of malnutrition; and we need to implement programmes related to the negative effects of adverse lifestyles. Funding UNRWA, UNICEF, Juzoor for Health and Social Development, Institute of Human Nutrition, Columbia University, and Flagship Project.

Diets, Nutrition and Poverty: The Indian Experience

This chapter focuses on the Indian experience with dietary changes, their nutritional implications, and policy response to alleviate nutritional deprivation. We review the evidence on nutrient intake and dietary changes, particularly the downward shift in calorie, protein and other nutrient intake over the period 1993–2004 and provide a demand based explanation of this shift. We report on eating out as an aspect of dietary transition, examine the relationship between calorie deprivation and poverty, and argue against delinking of the two. We analyse poverty nutrition traps, whether child undernutrition is underestimated and the double burden of undernutrition and obesity. We examine the (potential) contribution of National Rural Guarantee Scheme and Public Distribution System in mitigating the extent and severity of undernutrition. We emphasize that food security entails a right to certain policies to ensure food entitlements, as opposed to a narrow interpretation of the right to food in terms of state provisioning of these entitlements. Conclusions from a broad policy perspective are delineated.