Elisabetta Aurino

Investment in child and adolescent health and development: key messages from Disease Control Priorities, 3rd Edition

The realisation of human potential for development requires age-specific investment throughout the 8000 days of childhood and adolescence. Focus on the first 1000 days is an essential but insufficient investment. Intervention is also required in three later phases: the middle childhood growth and consolidation phase (5-9 years), when infection and malnutrition constrain growth, and mortality is higher than previously recognised; the adolescent growth spurt (10-14 years), when substantial changes place commensurate demands on good diet and health; and the adolescent phase of growth and consolidation (15-19 years), when new responses are needed to support brain maturation, intense social engagement, and emotional control. Two cost-efficient packages, one delivered through schools and one focusing on later adolescence, would provide phase-specific support across the life cycle, securing the gains of investment in the first 1000 days, enabling substantial catch-up from early growth failure, and leveraging improved learning from concomitant education investments.

School Feeding Programs in Middle Childhood and Adolescence

Almost every country in the world has a national school feeding program to provide daily snacks or meals to school-attending children and adolescents. The interventions reach an estimated 368 million children and adolescents globally. The total investment in the intervention is projected to be as much as US

Identifying an Essential Package for School-Age Child Health: Economic Analysis

75 billion annually (WFP 2013), largely from government budgets. School feeding may contribute to multiple objectives, including social safety nets, education, nutrition, health, and local agriculture. Its contribution to education objectives is well recognized and documented, while its role as a social safety net was underscored following the food and fuel crises of 2007 and 2008 (Bundy and others 2009). In terms of health and nutrition, school feeding contributes to the continuum of development by building on investments made earlier in the life course, including maternal and infant health interventions and early child development interventions (see chapter 7 in this volume, Alderman and others 2017). School feeding may also help leverage global efforts to enhance the inclusiveness of education for out-of-school children, adolescent girls, and disabled persons, as called for in the Sustainable Development Goals (see chapter 17 in this volume, Graham and others 2017). Although the Disease Control Priorities series focuses on lowand middle-income countries (LMICs), evidence from high-income countries (HICs) is included because of the near universality of school feeding and the insights that inclusion can provide as economies develop. For example, the design of school feeding in countries undergoing the nutrition transition1 may provide some lessons on how to shift from providing access to sufficient calories to promoting healthful diets and dietary behaviors for children and adolescents (WFP 2013). Agricultural development has increasingly gained attention. It is clear that to enable the transition to sustainable, scalable government-run programs, the inclusion of the agricultural sector is essential (Bundy and others 2009; Drake and others 2016). Accounting for the full benefits of school feeding through costeffectiveness and benefit-cost analysis is challenging, similar to other complex interventions, but undertaking this accounting is critical for assessing the tradeoffs with competing investments. This chapter reviews the evidence about how school feeding meets these objectives and provides some indication of costs in relation to benefits. The costs of the intervention are well established; estimates that encompass all the benefits of school feeding are more challenging. The benefits must be quantified and translated to the same unit to allow for aggregation. Moreover, how school feeding interventions are designed and implemented varies significantly across

A free lunch or a walk back home? The school food environment and dietary behaviours among children and adolescents in Ghana

This chapter presents the investment case for providing an integrated package of essential health services for children attending primary schools in lowand middleincome countries (LMICs). In doing so, it builds on chapter 20 in this volume (Bundy, Schultz, and others 2017), which presents a range of relevant health services for the schoolage population and the economic rationale for administering them through educational systems. This chapter identifies a package of essential health services that lowand middle-income countries (LMICs) can aspire to implement through the primary and secondary school platforms. In addition, the chapter considers the design of such programs, including targeting strategies. Uppermiddle-income countries and high-income countries (HICs) typically aim to implement such interventions on a larger scale and to include and promote additional health services relevant to their populations. Studies have documented the contribution of school health interventions to a range of child health and educational outcomes, particularly in the United States (Durlak and others 2011; Murray and others 2007; Shackleton and others 2016). Health services selected for the essential package are those that have demonstrated benefits and relevance for children in LMICs. The estimated costs of implementation are drawn from the academic literature. The concept of a package of essential school health interventions and its justification through a cost-benefit perspective was pioneered by Jamison and Leslie (1990). As chapter 20 notes, health services for school-age children can promote educational outcomes, including access, attendance, and academic achievement, by mitigating earlier nutrition and health deprivations and by addressing current infections and nutritional deficiencies (Bundy, Schultz, and others 2017). This age group is particularly at risk for parasitic helminth infections (Jukes, Drake, and Bundy 2008), and malaria has become prevalent in school-age populations as control for younger children delays the acquisition of immunity from early childhood to school age (Brooker and others 2017). Furthermore, school health services are commonly viewed as a means for building and reinforcing healthy habits to lower the risk of noncommunicable disease later in life (Bundy 2011). This chapter focuses on packages and programs to reach school-age children, while the previous chapter, chapter 24 (Horton and Black 2017), focuses on early childhood interventions, and the next chapter, chapter 26 (Horton and others 2017), focuses on adolescent interventions. These packages are all part of the same continuum of care from age 5 years to early adulthood, as discussed in chapter 1 (Bundy, de Silva, and others 2017). A particular emphasis of the economic rationale for targeting school-age children is to promote their health and education while they are in the process of learning; many of the interventions that are part of the package have been shown to yield substantial benefits in educational outcomes (Bundy 2011; Jukes, Drake, and Bundy 2008). They might be viewed as health interventions that leverage the investment in education.

Agro-ecological zone and farm diversity are factors associated with haemoglobin and anaemia among rural school-aged children and adolescents in Ghana

Food environments can play important roles in shaping nutrition and health outcomes. One such environment that has potential to affect youth is the school food environment. In contrast to higher-income countries, however, there is a critical evidence gap on the role of school food environments on children and adolescents in low- and middle-income countries. This mixed-methods study contributes to filling this gap by investigating the role of school food environments on dietary behaviours of children and adolescents in Ghana. It draws on data from household and school questionnaires as well as focus group discussions collected as part of the baseline for an impact evaluation of the Ghana School Feeding Programme (GSFP). Multi-level regression models were fitted with random intercepts at the individual, household and community levels. Excerpts from the focus group discussions provided a deeper understanding of quantitative findings. Children and adolescents who received free school meals provided by the GSFP or who lived further away from school were less likely to go home for lunch. More than half of sampled schools reported offering foods for sale by independent vendors, the most common being meals followed by confectionery, fruit and sugar-sweetened beverages. Predictors of bringing money to school to buy food included non-receipt of free school meals, adolescence, greater commuting distance from home, household asset score, and urban location. Policy efforts focusing on the school food environment may contribute to healthy dietary behaviours for children and adolescents with positive impacts over the lifecourse.

Adolescent mothers’ anthropometrics and grandmothers’ schooling predict infant anthropometrics in Ethiopia, India, Peru, and Vietnam

Abstract Understanding contextual risk factors for haemoglobin (Hb) status and anaemia of rural school‐aged children (SAC) and adolescents is critical in developing appropriate interventions to prevent anaemia. We analysed secondary data from the baseline of an impact evaluation of the Ghana School Feeding Programme to determine the severity of anaemia and contextual factors associated with anaemia and Hb status among rural SAC (6–9 years; n = 323) and adolescents (10–17 years; n = 319) in Ghana. We used regression models with variable selection based on backward elimination in our analyses. The mean Hb was 113.8 ± 13.1 g/L, and the overall prevalence of anaemia was 52.3%, being 55.1% and 49.5% among SAC and adolescents, respectively. We identified childs age (β = 2.21, P < 0.001); farm diversity score (β = 0.59, P = 0.036); and agro‐ecological zone (P trend <0.001) as the main predictors of Hb of SAC. Household asset index (P trend = 0.042) and agro‐ecological zone (P trend <0.001) were predictors of Hb in adolescents. Agro‐ecological zone and age were predictors of anaemia, but the effect of age was only significant for girls and not boys (prevalence odds ratio [POR] = 1.35, 95% CI [1.04, 1.76] vs. POR = 1.14, 95% CI [0.88, 1.46]). SAC in households with maize stock were less likely to be anaemic (POR = 0.55, 95% CI [0.32, 0.97]). Household dietary diversity score (β = 0.59, P = 0.033) was associated with Hb status for the full sample only. Anaemia is a severe public health problem among SAC and adolescents in rural Ghana irrespective of sex. Farm diversity score, availability of maize stock in the household, household asset index, and agro‐ecological zone were the main predictors of Hb and anaemia among the rural SAC and adolescents.

Birth weight and prepubertal body size predict menarcheal age in India, Peru, and Vietnam

We investigated intergenerational associations of adolescent mothers’ and grandmothers’ anthropometrics and schooling with adolescent mothers’ offsprings anthropometrics in Ethiopia, India, Peru, and Vietnam. We examined birthweight (n = 283), birthweight Z‐score (BWZ), conditional growth in weight‐for‐age Z‐score (cWAZ, residuals from a regression of WAZ at last survey round on BWZ, sex, and age), and height‐for‐age Z‐score (HAZ) of children born to older cohort adolescent girls in the Young Lives study. Our key independent variables were adolescent mothers’ body size: HAZ and body‐mass‐index‐for‐age Z‐score (BMIZ) at age 8, conditional HAZ (cHAZ, residuals from a regression of HAZ at the end of a growth period on prior HAZ, age, and sex), conditional BMIZ growth (cBMIZ, calculated analogously), and grandmaternal BMIZ, HAZ, and schooling. We adjusted for child, maternal, and household characteristics. Adolescent mothers’ cHAZ (ages 8–15) predicted birthweight ( β = 130 g, 95% confidence interval (CI) 31–228), BWZ ( β = 0.31, CI 0.09–0.53), and cWAZ ( β = 0.28, CI 0.04–0.51). Adolescent mothers’ BMIZ at age 8 predicted birthweight ( β = 79 g, CI 16–43) and BWZ ( β = 0.22, CI 0.08–0.36). Adolescent mothers’ cBMIZ (ages 12–15) predicted child cWAZ and HAZ. Grandmothers’ schooling predicted grandchild birthweight ( β = 22 g, CI 1–44) and BWZ ( β = 0.05, CI 0.01–0.10).

Erratum to: Roads to interdisciplinarity – working at the nexus among food systems, nutrition and health

Evidence on the associations of birth weight and prepubertal nutritional status with menarcheal age for low‐ and middle‐income countries is limited. We investigated these relationships using the Young Lives younger cohort for 2001 Indian, Peruvian, and Vietnamese girls born in 2001–2002. Girls were followed at approximately ages 1, 5, 8, and 12 years. Weibull survival models estimated hazards of earlier menarche on the basis of birth weight Z‐scores (BWZ), and age‐8 BMI‐for‐age Z‐scores (BMIZ) and height‐for‐age Z‐scores (HAZ). Estimates controlled for potential individual‐, mother‐, and household‐level confounders and for changes in anthropometry between 1 and 8 years. In adjusted models, BWZ predicted later age at menarche (hazard ratio (HR) = 0.90, 95% CI: 0.83–0.97). Conversely, HAZ (HR = 1.66, 95% CI 1.5–1.83) and BMIZ at 8 years (HR = 1.28, 95% CI: 1.18–1.38) predicted earlier menarche. Changes in HAZ and BMIZ between 1 and 8 years were not associated with earlier menarche. Associations were consistent across countries, though with variation in estimated magnitudes. Maternal height and age were associated with later menarche. This evidence points to consistently robust and opposite associations of birth weight versus prepubertal attained height and body mass index with menarcheal age in three diverse settings with regard to nutrition, ethnicity, and socioeconomic status.

The impact of food assistance on food insecure populations during conflict: Evidence from a quasi-experiment in Mali

The article Roads to interdisciplinarity – working at the nexus among food systems, nutrition and health: 1st annual Agriculture, Nutrition and Health (ANH) Academy Week, Addis Ababa (Ethiopia), 20–24 June 2016, written by [F. Picchioni, E. Aurino, L. Aleksandrowicz, M. Bruce, S. Chesterman, P. Dominguez-Salas, Z. Gersten, S. Kalamatianou, C. Turner and J. Yates], was originally published Online First without open access. After publication in volume [9], issue [1], page [181–189] the author decided to opt for Open Choice and to make the article an open access publication. Therefore, the copyright of the article has been changed to