To explore anthropometric indicators and mental development in very-low-income children in the second year of life.

Cross-sectional survey.

Low-income areas (income <20th percentile) in semi-urban Mexico (defined as towns or cities with 2500–50 000 inhabitants).

Eight hundred and ninety-six children aged 12.5–23.5 months surveyed from September to December 2001.

Questionnaire survey and anthropometric survey of households. Multivariate regression models evaluated differences across age in anthropometry (height-for-age Z-score (HAZ) and weight-for-height Z-score) and cognitive function (Mental Development Index (MDI) of the Bayley Scales of Infant Development) while controlling for socio-economic and parental characteristics.

There was a significant decline in HAZ and in age-adjusted MDI score across the second year of life. Although the children showed MDI scores close to the mean, normed US values at 13–14 months, the scores were significantly lower than expected in older children (P < 0.0001), even after controlling for socio-economic status and parental characteristics. At 13–14 months, only 3% of children received scores below 70 (less than minus two standard deviations), whereas by 19–20 months, almost 17% of children were performing below this level. No socio-economic or parental characteristics were significant predictors of HAZ or MDI.

Parallel deficits are evident in both height-for-age and cognitive functioning during the second year of life in low-income Mexican infants. The consistency of these growth and development findings further stresses the need for targeted interventions to reduce the vulnerability of low-income Mexican children very early in life.

We estimate attributable fractions, deaths and years of life lost among infants and children ≤2 years of age due to suboptimal breast-feeding in developing countries.

We compare actual practices to a minimum exposure pattern consisting of exclusive breast-feeding for infants ≤6 months of age and continued breast-feeding for older infants and children ≤2 years of age. For infants, we consider deaths due to diarrhoeal disease and lower respiratory tract infections, and deaths due to all causes are considered in the second year of life. Outcome measures are attributable fractions, deaths, years of life lost and offsetting deaths potentially caused by mother-to-child transmission of HIV through breast-feeding.

Developing countries.

Infants and children ≤2 years of age.

Attributable fractions for deaths due to diarrhoeal disease and lower respiratory tract infections are 55% and 53%, respectively, for the first six months of infancy, 20% and 18% for the second six months, and are 20% for all-cause deaths in the second year of life. Globally, as many as 1.45 million lives (117 million years of life) are lost due to suboptimal breast-feeding in developing countries. Offsetting deaths caused by mother-to-child transmission of HIV through breast-feeding could be as high as 242 000 (18.8 million years of life lost) if relevant World Health Organization recommendations are not followed.

The size of the gap between current practice and recommendations is striking when one considers breast-feeding involves no out-of-pocket costs, that there exists universal consensus on best practices, and that implementing current international recommendations could potentially save 1.45 million children's lives each year.

To explore the use of epidemiological modelling for the estimation of health effects of behaviour change interventions, using the example of computer-tailored nutrition education aimed at fruit and vegetable consumption in The Netherlands.

The effects of the intervention on changes in consumption were obtained from an earlier evaluation study. The effect on health outcomes was estimated using an epidemiological multi-state life table model. Input data for the model consisted of relative risk estimates for cardiovascular disease and cancers, data on disease occurrence and mortality, and survey data on the consumption of fruits and vegetables.

If the computer-tailored nutrition education reached the entire adult population and the effects were sustained, it could result in a mortality decrease of 0.4 to 0.7% and save 72 to 115 life-years per 100 000 persons aged 25 years or older. Healthy life expectancy is estimated to increase by 32.7 days for men and 25.3 days for women. The true effect is likely to lie between this theoretical maximum and zero effect, depending mostly on durability of behaviour change and reach of the intervention.

Epidemiological models can be used to estimate the health impact of health promotion interventions.

To provide an overview of research relevant to the Mediterranean diet.

Personal perspectives.

International.

Populations in Europe, North America, Asia.

Approximately 50 years ago, Keys and colleagues described strikingly low rates of coronary heart disease in the Mediterranean region, where fat intake was relatively high but largely from olive oil. Subsequent controlled feeding studies have shown that compared to carbohydrate, both monounsaturated and polyunsaturated fats reduce LDL and triglycerides and increase HDL cholesterol. Importantly, these beneficial metabolic effects are greater in the presence of underlying insulin resistance. In a detailed analysis within the Nurses' Health Study, trans fat from partially hydrogenated vegetable oils (absent in traditional Mediterranean diets) was most strongly related to risk of heart disease, and both polyunsaturated and monounsaturated fat were inversely associated with risk. Epidemiologic evidence has also supported beneficial effects of higher intakes of fruits and vegetables, whole grains, fish, and daily consumption of moderate amounts of alcohol. Together with regular physical activity and not smoking, our analyses suggest that over 80% of coronary heart disease, 70% of stroke, and 90% of type 2 diabetes can be avoided by healthy food choices that are consistent with the traditional Mediterranean diet.

Both epidemiologic and metabolic studies suggest that individuals can benefit greatly by adopting elements of Mediterranean diets.

To identify social, behavioural and cultural factors that explain the thinness of young women relative to their men in rural Maharashtra, India.

Twelve focus group discussions were conducted to explore the villagers' understanding of why women in their area might be thinner than men.

Pabal village and surrounding hamlets, in the Pune district of Maharashtra, India.

Samples of young mothers and fathers, grandmothers and grandfathers were selected from families in the village with children below 10 years of age.

Four factors were identified that the villagers felt contributed to the disparity in thinness. First, marriage isolated girls from their own families and villages, and brought the expectation of early motherhood. Young brides were often unable to relax and eat adequately. Second, marriage increased the workload of young women. They were expected to do the heaviest household chores as well as farm work in this predominantly agricultural community. Third, women had no financial autonomy or freedom of movement, and were therefore denied access to supplementary food sources available to men. Fourth, young women felt responsible for their household's health and success. They were encouraged to fast regularly to ensure this. Despite feeling responsible, young women had no control over factors that might affect the household's well being. This made them anxious and worried a great deal of the time.

Interventions to improve the nutritional status of young women in this region need to recognise the roles and responsibilities taken up by young brides.

The objective of this study was to assess the prevalence of vitamin A deficiency (VAD) in children under 6 years old in China and to identify risk groups for VAD.

A cross-sectional survey was conducted in 14 provinces from coastal, inland and western geographic areas in China.

One city (urban) and two counties (rural) were randomly selected from each province as survey areas.

About 200 children aged 0–6 years were randomly selected in each survey area. A blood sample was collected from each child. Data on sociodemographics and nutrition were obtained by interview of the mother or principal caregiver. Fluorescence microanalysis was used to analyse serum retinol concentration.

VAD (serum retinol < 0.7 μmol l− 1) was observed in 957 out of 7826 children aged 0–6 years (12.2% of the entire study population), whereas severe VAD (serum retinol < 0.35 μmol l− 1) was found in 39 children (0.5%). The highest prevalences of VAD at >1 year of age were observed among children of mothers with minority ethnicity (22.7%) or poor education (19.8%) and in the poor western area (17.4%).

VAD is a nutritional problem in children in China. Children living in the poor western area, having a mother with minority ethnicity or a mother with poor education have a high risk of VAD.

To analyse various aspects of the Mediterranean diet in relation to the risk of several common cancers in Italy.

Data from a series of case-control studies conducted in northern Italy between 1983 and 2004 on over 20 000 cases of several major cancers and 18 000 controls.

For most digestive tract cancers, the risk decreased with increasing vegetable and fruit consumption, with relative risks between 0.3 and 0.7 for the highest level of intake, and the population-attributable risks for low intake of vegetables and fruit ranged between 15 and 40%. Less strong inverse relations were observed for other (epithelial) cancers, too. A number of micronutrients contained in vegetables and fruit showed an inverse relation with cancer risk. In particular, flavones, flavonols and resveratrol were inversely related to breast cancer risk. Olive oil, which is a typical aspect of the Mediterranean diet, has also been inversely related to cancers of the colorectum and breast, and mainly of the upper digestive and respiratory tract. Consumption of pizza, one of the most typical Italian foods, was related to a reduced risk of digestive tract cancers, although pizza may simply be an aspecific indicator of the Italian diet.

Adherence to the Mediterranean diet is a favourable indicator of the risk of several common epithelial cancers in Italy. A score summarising the major characteristics of the Mediterranean diet was related to a priori defined reduced risks of several digestive tract neoplasms by over 50%.

In this review, we will discuss the benefits of diets enriched in virgin olive oil, whose effects are probably due not only to its oleic acid content but also to its other potentially health-promoting components.

Traditionally, the benefits of MD were linked to its effect on lipoprotein metabolism, but today we realise that there exists a whole sheaf of other benefits, including the components of haemostasis: platelet function, thrombogenesis and fibrinolysis.

A diet enriched in virgin olive oil can reduce the sensitivity of platelets to aggregation, decreasing von Willebrand and thromboxane B2 plasma levels. Moreover, a particular interest has aroused about its capacity to decrease fasting factor VII plasma levels and to avoid or modulate its postprandial activation. In addition, tissue factor expression in mononuclear cells could be reduced with the chronic intake of virgin olive oil, and finally, studies performed in different experimental situation have shown that it could also increase fibrinolytic activity, reducing plasma concentration of plasma activator inhibitor type-1 (PAI-1).

The MD is an alimentary model with a high content of monounsaturated fats that is capable of inducing a wide range of biological effects on the cardiovascular system. The application of modern focuses of study will dilucidate in the future the biological and clinical interest of these findings.

To study risk factors for overweight among Brazilian adolescents of low-income families.

Case–control study of obese and non-obese adolescents.

Anthropometric survey including 1420 students (aged 14–19 years) attending a public high school in São Paulo, Brazil.

Selection of 83 overweight (body mass index (BMI) >85th percentile) and 89 non-overweight (BMI >5th percentile and <85th percentile) subjects, frequency-matched by age, gender, pubertal development and socio-economic status. Among the nutritional, familial and behavioural data available, five covariates (parents' obesity, adolescents' past obesity, to have a best friend, dietary restriction and habit of napping) were included in the fitted hierarchical conditional logistic regression models.

Parents or guardians and adolescents were weighed, measured and answered a pre-tested questionnaire applied by trained nutritionists and paediatricians.

The prevalence of overweight was 15.2%. As previous risks, obese parents and obesity during infancy presented odds ratios (OR) and 95% confidence intervals (CI) of 2.23 (1.15–4.35) and 3.60 (1.47–8.80), respectively. As concurrent factors, the habit of napping, to have a best friend and reported dietary restriction presented OR (95% CI) of 3.43 (1.32–8.92), 5.15 (1.76–15.07) and 7.26 (2.95–17.88), respectively. Dietary patterns, frequency of obesogenic foods and other physical activity indicators presented no statistical significance.

In case–control studies, OR may overestimate the true risks. Parents' obesity and previous childhood obesity were identified as risk factors; therefore these factors should be the target for preventive programmes and policies in order to prevent the burden of obesity in the near future.

To investigate what factors relate most strongly to breast-feeding duration in order to successfully support breast-feeding mothers.

Prospective birth cohort study using questionnaires, routinely collected weights and health check at age 13 months.

Gateshead, UK.

Parents of 923 term infants born in a defined geographical area and recruited shortly after birth, 50% of whom were breast-feeding initially.

Only 225 (24%) infants were still breast-fed at 6 weeks, although 136 (15%) continued beyond 4 months. Infants in the most affluent quintile were three times more likely to be initially breast-fed (P < 0.001) and five times more likely to still be feeding at 4 months (P = 0.001) compared with infants in the most deprived quintile. A third of breast-fed infants were given supplementary feeds in the maternity unit and this was associated with a 10-fold increase in odds of giving up breast-feeding by discharge (P = 0.001). Frequent feeding was reported as a reason for giving up in 70% of mothers at 6 weeks and 55% at 4 months. Those infants who stopped breast-feeding earliest showed the most rapid weight gain and were tallest at age 13 months. Non-breast-fed infants had 50% more family doctor contacts up to age 4 months (P = 0.005).

Initiation of breast-feeding in urban Britain remains strongly determined by socio-economic background and early cessation seems to be related to frequent feeding and rapid growth as well as a continuing failure to eradicate health practices that undermine breast-feeding. Those infants not receiving breast milk suffered increased morbidity, but the apparent association between breast-feeding duration and growth probably reflects reverse causation.

The purpose of this paper is to examine the relationship between childhood undernutrition and poverty in urban and rural areas.

Anthropometric and socio-economic data from Multiple Indicator Cluster Surveys in Angola-Secured Territory (Angola ST), Central African Republic and Senegal were used in this analysis. The population considered in this study is children 0–59 months, whose records include complete anthropometric data on height, weight, age, gender, socio-economic level and urban or rural area of residence. In addition to simple urban/rural comparisons, the population was stratified using a wealth index based on living conditions and asset ownership to compare the prevalence, mean Z-score and odds ratios for stunting and wasting.

In all cases, when using a simple urban/rural comparison, the prevalence of stunting was significantly higher in rural areas. However, when the urban and rural populations were stratified using a measure of wealth, the differences in prevalence of stunting and underweight in urban and rural areas of Angola ST, Central African Republic and Senegal disappeared. Poor children in these urban areas were just as likely to be stunted or underweight as poor children living in rural areas. The odds ratio of stunting in the poorest compared with the richest quintile was 3.4, 3.2 and 1.5 in Angola ST, Senegal and Central African Republic, respectively.

This paper demonstrates that simple urban/rural comparisons mask wide disparities in subgroups according to wealth. There is a strong relationship between poverty and chronic undernutrition in both urban and rural areas; this relationship does not change simply by living in an urban environment. However, urban and rural living conditions and lifestyles differ, and it is important to consider these differences when designing programmes and policies to address undernutrition.

A study was conducted among the Onge tribe of the Andaman and Nicobar Islands with the objectives of identifying demographic factors responsible for the decline in their population and assessing their nutritional status, which is an important determinant of child survival.

The study included estimation of indices of fertility and child mortality, and assessment of nutritional status. All individuals of the Onge community settled on Little Andaman Island were included.

The mean total marital fertility rate was estimated to be 5.15 live births per woman and the general fertility rate was 200 live births per 1000 married-woman-years. Although the gross reproduction rate was estimated to be 2.2 female children per married woman, the net reproduction rate was only 0.9 surviving female child per married woman. The mean infant mortality rate during the past 30 years was 192.7 per 1000 live births, and the child survival rate was found to be only 53.2%. A mild to moderate degree of malnutrition was found in 85% of children of pre-school age and severe malnutrition in 10%. The Onges had low intakes of iron, vitamin A and vitamin C. All the screened Onges were found to be infested with one or more intestinal parasites.

High childhood mortality appears to be the predominant demographic factor responsible for the decline in the Onge population. The high prevalence of undernutrition and micronutrient deficiency disorders could be important factors contributing to the high childhood mortality.

The present study was undertaken to assess the impact of drought on the nutritional status of pre-school children aged 0–5 years from a rural population in a desert area facing drought conditions very frequently.

The sampling design for assessment was the three-stage sampling technique.

The study was carried out in 24 villages belonging to six tehsils (sub-units of district) of Jodhpur District, a drought-affected desert district of western Rajasthan, during a drought in 2003.

A total of 914 children were examined at household level, with nutritional status assessed by anthropometry, dietary intake and clinical signs of nutritional deficiency.

The results revealed growth retardation. Stunting (malnutrition of long duration) was observed in 53% of children and underweight in 60%. Wasting, an indicator of short-duration malnutrition, was present in 28% of children. The extent of malnutrition was significantly higher in girls than boys (P < 0.05). Vitamin A and B complex deficiencies were found in 0.7 and 3.0% of children, respectively. Prevalence of marasmus (protein–energy malnutrition, PEM) was 1.7% (2.3% in boys and 1.1% in girls). Overall deficits in mean energy and protein intakes were very high (76 and 54%, respectively). Comparison of the present drought results with earlier studies in desert normal and desert drought conditions showed higher prevalence of PEM and higher dietary energy and protein deficiencies.

The prevalence of wasting was high, greater than the cut-off point of 15% stated by the World Health Organization to indicate that the severity of malnutrition is critical. PEM, vitamin A and B complex deficiencies and anaemia, along with dietary deficits of energy and protein, were observed to be higher than in non-desert areas. This may be due to the harsh environmental conditions in desert areas where drought occurs quite frequently and adversely affects the economy, largely by eroding the coping capacity and economic potential of the people as a result of heavy livestock losses and reduced harvests, leading to increased poverty and poor food intake of the inhabitants. Due to inadequate consumption of daily food the children were suffering from wasting and PEM. Efforts should be made to incorporate measures, such as ensuring the supply of adequate energy and protein to all age groups and especially pre-school children, into ongoing nutrition programmes in order to improve the food security of local inhabitants in this area.

To put the debate on the Mediterranean diet in context by highlighting historical and prospective changes in the level and composition of food consumption in the world and key Mediterranean countries.

Data from FAO's food balance sheets are used to illustrate historical evolution. Projections to 2030 are presented from FAO's recent and ongoing work on exploring world food and agriculture futures.

International.

Many developing countries are undergoing diet transitions bringing them closer to the diets prevalent in the richer countries, i.e. with more energy-dense foods. There follows an increase in the incidence of diet-related non-communicable diseases, which are superimposed on the health problems related to undernutrition that still afflict them. In parallel, many low-income countries are making little progress towards raising food consumption levels necessary for good nutrition and food security. Wider adoption of food consumption patterns akin to those of the Mediterranean diet hold promise of contributing to mitigate adverse effects of such diet transitions. However, the evolution of food consumption in the Mediterranean countries themselves is not encouraging, as these countries have also followed the trend towards higher shares of energy-dense foods. Possible policy responses to these problems include measures to raise awareness of the benefits of healthier diets and/or to change relative food prices in favour of such diets (by taxing fattening foods) or, at the extreme, making individuals who follow ‘bad’ diets, and thus are prone to associated diseases, bear a higher part of the consequent costs borne by the public health systems (tax fat people).

Many health promotion educational interventions assume that increasing knowledge directly influences beliefs, intentions and behaviour, whereas research suggests that knowledge alone is insufficient for behavioural change. Social cognition frameworks such as the Theory of Reasoned Action propose a central role for beliefs and social normative influences. This Scottish study evaluates the role of knowledge and social influences (subjective norms, exposure to breast-feeding, social barriers) on beliefs and future intentions to breast-feed or bottle-feed. Social influences from family and peers are investigated.

A cross-sectional between-subjects observational design was used. A questionnaire was administered to a sample of 229 (46%) male and 267 (54%) female adolescents aged 11–18 years.

Participants completed questionnaires during lessons at three secondary schools in Central Scotland.

Knowledge about health benefits of breast-feeding was generally poor. Analyses found that perceived social barriers to breast-feeding moderated the relationship between knowledge and beliefs. More knowledge, positive beliefs and supportive subjective norms also predicted future intentions to breast-feed. Parental norms exerted greater influence than peer norms on adolescents' breast-feeding beliefs.

Knowledge and social influences are important predictors of positive breast-feeding beliefs and future intentions to breast-feed in adolescents. This has important implications for breast-feeding health promotion interventions in young people.