Patrick Kolsteren

Eating out of home and its association with dietary intake: a systematic review of the evidence

During the last decades, eating out of home (OH) has gained importance in the diets worldwide. We document the nutritional characteristics of eating OH and its associations with energy intake, dietary quality and socioeconomic status. We carried out a systematic review of peer‐reviewed studies in eight databases up to 10 March 2011. Of the 7,319 studies retrieved, 29 met the inclusion criteria and were analysed in this review. The quality of the data was assessed and a sensitivity analysis was conducted by isolating nationally representative or large cohort data from 6 and 11 countries, respectively. OH foods were important sources of energy in all age groups and their energy contribution increased in adolescents and young adults. Eating OH was associated with a higher total energy intake, energy contribution from fat in the daily diet and higher socioeconomic status. Two large studies showed how eating OH was also associated with a lower intake of micronutrients, particularly vitamin C, Ca and Fe. Although the studies were cross‐sectional and heterogeneous in the way they classified eating OH, we conclude that eating OH is a risk factor for higher energy and fat intake and lower micronutrient intake.

Mortality risk in preterm and small-for-gestational-age infants in low-income and middle-income countries: a pooled country analysis

BACKGROUND Babies with low birthweight (<2500 g) are at increased risk of early mortality. However, low birthweight includes babies born preterm and with fetal growth restriction, and not all these infants have a birthweight less than 2500 g. We estimated the neonatal and infant mortality associated with these two characteristics in low-income and middle-income countries. METHODS For this pooled analysis, we searched all available studies and identified 20 cohorts (providing data for 2,015,019 livebirths) from Asia, Africa, and Latin America that recorded data for birthweight, gestational age, and vital statistics through 28 days of life. Study dates ranged from 1982 through to 2010. We calculated relative risks (RR) and risk differences (RD) for mortality associated with preterm birth (<32 weeks, 32 weeks to <34 weeks, 34 weeks to <37 weeks), small-for-gestational-age (SGA; babies with birthweight in the lowest third percentile and between the third and tenth percentile of a US reference population), and preterm and SGA combinations. FINDINGS Pooled overall RRs for preterm were 6·82 (95% CI 3·56-13·07) for neonatal mortality and 2·50 (1·48-4·22) for post-neonatal mortality. Pooled RRs for babies who were SGA (with birthweight in the lowest tenth percentile of the reference population) were 1·83 (95% CI 1·34-2·50) for neonatal mortality and 1·90 (1·32-2·73) for post-neonatal mortality. The neonatal mortality risk of babies who were both preterm and SGA was higher than that of babies with either characteristic alone (15·42; 9·11-26·12). INTERPRETATION Many babies in low-income and middle-income countries are SGA. Preterm birth affects a smaller number of neonates than does SGA, but is associated with a higher mortality risk. The mortality risks associated with both characteristics extend beyond the neonatal period. Differentiation of the burden and risk of babies born preterm and SGA rather than with low birthweight could guide prevention and management strategies to speed progress towards Millennium Development Goal 4--the reduction of child mortality. FUNDING Bill & Melinda Gates Foundation.

Risk of childhood undernutrition related to small-for-gestational age and preterm birth in low- and middle-income countries

BACKGROUND Low- and middle-income countries continue to experience a large burden of stunting; 148 million children were estimated to be stunted, around 30-40% of all children in 2011. In many of these countries, foetal growth restriction (FGR) is common, as is subsequent growth faltering in the first 2 years. Although there is agreement that stunting involves both prenatal and postnatal growth failure, the extent to which FGR contributes to stunting and other indicators of nutritional status is uncertain. METHODS Using extant longitudinal birth cohorts (n=19) with data on birthweight, gestational age and child anthropometry (12-60 months), we estimated study-specific and pooled risk estimates of stunting, wasting and underweight by small-for-gestational age (SGA) and preterm birth. RESULTS We grouped children according to four combinations of SGA and gestational age: adequate size-for-gestational age (AGA) and preterm; SGA and term; SGA and preterm; and AGA and term (the reference group). Relative to AGA and term, the OR (95% confidence interval) for stunting associated with AGA and preterm, SGA and term, and SGA and preterm was 1.93 (1.71, 2.18), 2.43 (2.22, 2.66) and 4.51 (3.42, 5.93), respectively. A similar magnitude of risk was also observed for wasting and underweight. Low birthweight was associated with 2.5-3.5-fold higher odds of wasting, stunting and underweight. The population attributable risk for overall SGA for outcomes of childhood stunting and wasting was 20% and 30%, respectively. CONCLUSIONS This analysis estimates that childhood undernutrition may have its origins in the foetal period, suggesting a need to intervene early, ideally during pregnancy, with interventions known to reduce FGR and preterm birth.

Co-occurrence of fumonisins with aflatoxins in home-stored maize for human consumption in rural villages of Tanzania.

This study determined maize-user practices that influence the presence of fumonisin and aflatoxin contamination of maize in food consumed in the rural areas of Tanzania. Samples of the 2005 maize harvest in Tanzania were collected from 120 households and examined for fumonisins and aflatoxins. Information on whether the maize was sorted to remove defective (visibly damaged or mouldy) maize before storage and whether the damaged and mouldy maize or the non-dehulled maize was used as food was also collected. In addition, the percentage of defective kernels in the samples was determined. Ninety per cent of the households sorted out defective maize, 45% consumed the defective maize and 30% consumed non-dehulled maize. In 52% of the samples fumonisins were determined at levels up to 11,048 µg kg−1 (median = 363 µg kg−1) and in 15% exceeded 1000 µg kg−1; the maximum tolerable limit (MTL) for fumonisins in maize for human consumption in other countries. Aflatoxins were detected in 18% of the samples at levels up to 158 µg kg−1 (median = 24 µg kg−1). Twelve per cent of the samples exceeded the Tanzanian limit for total aflatoxins (10 µg kg−1). Aflatoxins co-occurred with fumonisins in 10% of the samples. The percentage defective kernels (mean = 22%) correlated positively (r = 0.39) with the fumonisin levels. Tanzanians are at a risk of exposure to fumonisins and aflatoxins in maize. There is a need for further research on fumonisin and aflatoxin exposure in Tanzania to develop appropriate control strategies.

Effectiveness of preventive school-based obesity interventions in low- and middle-income countries: a systematic review

BACKGROUND The prevalence of childhood obesity is increasing rapidly in low- and middle-income countries, and informed policies to tackle the problem must be defined. OBJECTIVE We systematically reviewed the evidence on the effectiveness of school-based interventions targeting dietary behavior and/or physical activity for the primary prevention of obesity in children and adolescents aged 6-18 y in low- and middle-income countries. DESIGN We searched the MEDLINE, EMBASE, Web of Science, CENTRAL, ERIC, Cochrane Library, and Centre for Reviews and Dissemination databases for peer-reviewed controlled studies published in English, Spanish, French, German, or Dutch between January 1990 and July 2011. The quality of the included studies was appraised independently by 2 authors who used the Effective Public Health Practice Project tool. RESULTS From a total of 7218 unique references, we retained 22 studies. Most of the interventions (82%) had a positive effect on dietary behavior and physical activity behavior (effect size ranged from -0.48 to 1.61). BMI decreased in 8 studies (effect size ranged from -0.7 to 0.0). Effective interventions targeted both diet and physical activity, involved multiple stakeholders, and integrated educational activities into the school curriculum. CONCLUSIONS School-based interventions have the potential to improve dietary and physical activity behavior and to prevent unhealthy body weights in low- and middle-income countries. To reach their full potential, interventions should conduct process evaluations to document program implementation. The effect and the pathways through which interventions have this effect need to be better documented through rigorous evaluation studies.

Prenatal food supplementation fortified with multiple micronutrients increases birth length: a randomized controlled trial in rural Burkina Faso

BACKGROUND Prenatal multiple micronutrient (MMN) or balanced energy and protein supplementation has a limited effect on birth size of the offspring. OBJECTIVE The objective was to determine whether a prenatal MMN-fortified food supplement (FFS) improves anthropometric measures at birth compared with supplementation with an MMN pill alone. DESIGN We conducted a nonblinded, individually randomized controlled trial in 1296 pregnant women in 2 villages in rural Burkina Faso. Supplements were provided on a daily basis, and compliance was closely verified by using a community-based network of home visitors. RESULTS Anthropometric measures at birth were available for analysis for 87% of the 1175 live singleton deliveries enrolled. After adjustment for gestational age at birth, the FFS group had a significantly higher birth length (+4.6 mm; P = 0.001). FFS supplementation resulted in a modestly higher birth weight (+31 g; P = 0.197). Subgroup analyses showed clinically important treatment effects on birth length (+12.0 mm; P = 0.005) and on birth weight (+111 g; P = 0.133) for underweight [body mass index (in kg/m(2)) <18.5] pregnant women. Women with early pregnancy anemia who received FFS gave birth to longer newborns (+7.3 mm; P = 0.002) than did those who received MMN supplementation. CONCLUSIONS The provision of FFS to pregnant women resulted in higher birth length than did MMN supplementation. For women with a suboptimal prepregnancy nutritional status, MMN supplementation should be complemented with a balanced energy and protein supplement to produce a clinical effect on birth size. The trial was registered at clinicaltrials.gov as NCT00909974.

Posting point-of-purchase nutrition information in university canteens does not influence meal choice and nutrient intake

BACKGROUND Growing concern over the relation between out-of-home eating and overweight has triggered the use of point-of-purchase (POP) nutrition information when eating out of the home. In canteens that offer various unhealthy choices, the posting of POP nutrition information has the potential to improve meal choices and dietary intakes. OBJECTIVE The objective of this study was to increase the proportion of consumed meals that comply with recommendations for energy, saturated fat, sodium, and vegetable content by 5%. DESIGN A one-group pretest-posttest design was used. A total of 224 customers of 2 university canteens completed a questionnaire used for consumer profiling and 3-d food records to assess their meal choices and nutrient intakes. The 12 best meal combinations received star ratings and descriptors for nutrients or food groups that did not comply. RESULTS Reported meal choices in canteens and nutrient intakes did not improve after the intervention (P > 0.05). The nutritional profile of the meal choice, obtained from a qualitative and quantitative nutritional assessment of meals, mirrored the nutritional profile of all meals offered (P > 0.05) and not that of the recommended meals offered (P < 0.001). Meal choices were not compensated for later in the day (P > 0.05). The healthiest choices were made by participants with greater objective nutrition knowledge, stronger health and weight-control motives, and a greater openness to change meal choices at baseline (P < 0.05). CONCLUSIONS The posting of nutrition information in university canteens did not effectively change meal choices and nutrient intakes. Despite the intervention, meal choices were largely determined by meals offered. Therefore, nutrition-information interventions in canteens may be more effective with a healthier meal supply. This trial was registered at clinicaltrials.gov as NCT01249508.

Association of out-of-home eating with anthropometric changes : a systematic review of prospective studies

In the present review, the association of out-of-home eating with anthropometric changes was examined. Peer-reviewed studies in eight databases were searched, and 15 prospective studies were included in the review. The quality of the data was assessed by considering risks of bias in sample selection, data collection methods, and the appropriateness of statistical tests. From this, seven studies, which used relatively large samples or had a follow-up period longer than 10 years, were retained for further analysis. It was concluded that eating out-of-home frequently, in the broad sense, is positively associated with the risk of becoming overweight or obese and weight change. With regard to specific out-of-home sources, the review shows that eating at fast-food outlets is associated with a greater increase in body weight and waist circumference over time than eating at restaurants and takeaway foods positively predict BMI change in women. More research is needed on out-of-home foods other than fast-foods and restaurant foods, such as street, canteen, and school foods.

Out-of-pocket healthcare payments on chronic conditions impoverish urban poor in Bangalore, India

BackgroundThe burden of chronic conditions is on the rise in India, necessitating long-term support from healthcare services. Healthcare, in India, is primarily financed through out-of-pocket payments by households. Considering scarce evidence available from India, our study investigates whether and how out-of-pocket payments for outpatient care affect individuals with chronic conditions.MethodsA large census covering 9299 households was conducted in Bangalore, India. Of these, 3202 households that reported presence of chronic condition were further analysed. Data was collected using a structured household-level questionnaire. Out-of-pocket payments, catastrophic healthcare expenditure, and the resultant impoverishment were measured using a standard technique.ResultsThe response rate for the census was 98.5%. Overall, 69.6% (95%CI=68.0-71.2) of households made out-of-pocket payments for outpatient care spending a median of 3.2% (95%CI=3.0-3.4) of their total income. Overall, 16% (95%CI=14.8-17.3) of households suffered financial catastrophe by spending more than 10% of household income on outpatient care. Occurrence and intensity of financial catastrophe were inequitably high among poor. Low household income, use of referral hospitals as place for consultation, and small household size were associated with a greater likelihood of incurring financial catastrophe.The out-of-pocket spending on chronic conditions doubled the number of people living below the poverty line in one month, with further deepening of their poverty. In order to cope, households borrowed money (4.2% instances), and sold or mortgaged their assets (0.4% instances).ConclusionsThis study provides evidence from India that the out-of-pocket payment for chronic conditions, even for outpatient care, pushes people into poverty. Our findings suggest that improving availability of affordable medications and diagnostics for chronic conditions, as well as strengthening the gate keeping function of the primary care services are important measures to enhance financial protection for urban poor. Our findings call for inclusion of outpatient care for chronic conditions in existing government-initiated health insurance schemes.

Strengthening the Reporting of Observational Studies in Epidemiology - nutritional epidemiology (STROBE-nut): An extension of the STROBE statement.

Background Concerns have been raised about the quality of reporting in nutritional epidemiology. Research reporting guidelines such as the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement can improve quality of reporting in observational studies. Herein, we propose recommendations for reporting nutritional epidemiology and dietary assessment research by extending the STROBE statement into Strengthening the Reporting of Observational Studies in Epidemiology—Nutritional Epidemiology (STROBE-nut). Methods and Findings Recommendations for the reporting of nutritional epidemiology and dietary assessment research were developed following a systematic and consultative process, coordinated by a multidisciplinary group of 21 experts. Consensus on reporting guidelines was reached through a three-round Delphi consultation process with 53 external experts. In total, 24 recommendations for nutritional epidemiology were added to the STROBE checklist. Conclusion When used appropriately, reporting guidelines for nutritional epidemiology can contribute to improve reporting of observational studies with a focus on diet and health.