Background Earlier age at menarche is associated with behavioral and noncommunicable disease risks. The influence of birth weight (BW) (intrauterine) and postnatal growth on age at menarche is not well studied in low- and middle-income countries (LMICs). Objective Therefore, we investigated these associations in 5 LMIC birth cohorts. Methods We analyzed data from Brazil, Guatemala, India, the Philippines, and South Africa (n = 3983). We derived stunting (< −2 SD scores) at 24 mo using the WHO child growth standards. We generated interaction terms with categorized BW and conditional weight (lighter < 0 or heavier ≥ 0), and height (shorter < 0 or taller ≥ 0) z-scores. We categorized early-, modal-, and late-onset menarche and used multilevel ordinal regression. We used multilevel linear regression on continuous age at menarche. Results Mean age at menarche was 12.8 y (95% CI: 12.7 12.9). BW was not associated with age at menarche. Conditional height at 24 mo and mid-childhood (OR: 1.35; 95% CI: 1.27, 1.44 and 1.32; 1.25, 1.41, respectively) and conditional weight at 24 mo and mid-childhood (OR: 1.15; 1.08, 1.22 and 1.18; 1.11, 1.25, respectively) were associated with increased likelihood of early-onset menarche. Being heavier at birth and taller at 24 mo was associated with a 4-mo (95% CI: 0.8, 7.6) earlier age at menarche than being lighter at birth and shorter at 24 mo. Being heavier at birth but lighter in mid-childhood was associated with a 3-mo (95% CI: 0.8, 4.8) later age at menarche than being lighter at birth and mid-childhood. Age at menarche was 7 mo later in stunted than nonstunted girls. Conclusion Age at menarche is inversely related to relative weight gain but also to rapid linear growth among those born shorter but remained stunted, and those born taller and grew excessively. These findings do not deter the global health goal to reduce growth faltering but emphasize the potential adverse effects of an obesogenic environment on adolescent development.

Importance The impact of adolescent pregnancy on offspring birth outcomes has been widely studied, but less is known about its impact on the growth of the young mother herself. Objective To determine the association between adolescent pregnancy and attained height. Design Prospective birth cohort study. Setting Cohort members followed from birth to age 20 y in Soweto, South Africa. Participant From among 840 Black females with sufficient data, we identified 54 matched pairs, in which a girl who became pregnant before the age of 17 years was matched with a girl who did not have a pregnancy by age 20 y. Pairs were matched on age at menarche and heightfor-Age z scores in the year before the case became pregnant (mean 15.0 y). Main Outcome Measures The two groups were compared with respect to attained height, measured at mean age 18.5 y. Results Mean age at conception was 15.9 years (range: 13.7 to 16.9 y). Mean height at matching was 159.4 cm in the adolescent pregnancy group and 159.3 cm in the comparison group (p = 0.3). Mean attained height was 160.4 cm in the adolescent pregnancy group and 160.3 cm in the comparison group (p = 0.7). Conclusions Among Black females in Soweto, South Africa, adolescent pregnancy was not associated with attained height.

Anthropometric data collected in clinics and surveys are often inaccurate and unreliable due to measurement error. The Body Imaging for Nutritional Assessment Study (BINA) evaluated the ability of 3D imaging to correctly measure stature, head circumference (HC) and arm circumference (MUAC) for children under five years of age. This paper describes the protocol for and the quality of manual anthropometric measurements in BINA, a study conducted in 2016-17 in Atlanta, USA. Quality was evaluated by examining digit preference, biological plausibility of z-scores, z-score standard deviations, and reliability. We calculated z-scores and analyzed plausibility based on the 2006 WHO Child Growth Standards (CGS). For reliability, we calculated intra- and inter-observer Technical Error of Measurement (TEM) and Intraclass Correlation Coefficient (ICC). We found low digit preference; 99.6% of z-scores were biologically plausible, with z-score standard deviations ranging from 0.92 to 1.07. Total TEM was 0.40 for stature, 0.28 for HC, and 0.25 for MUAC in centimeters. ICC ranged from 0.99 to 1.00. The quality of manual measurements in BINA was high and similar to that of the anthropometric data used to develop the WHO CGS. We attributed high quality to vigorous training, motivated and competent field staff, reduction of non-measurement error through the use of technology, and reduction of measurement error through adequate monitoring and supervision. Our anthropometry measurement protocol, which builds on and improves upon the protocol used for the WHO CGS, can be used to improve anthropometric data quality. The discussion illustrates the need to standardize anthropometric data quality assessment, and we conclude that BINA can provide a valuable evaluation of 3D imaging for child anthropometry because there is comparison to gold-standard, manual measurements.

Objectives: We aimed to assess the associations of socioeconomic factors with dietary patterns in a Guatemalan population. Methods: Cross-sectional data of 1076 participants (42 % men, mean age 32.6 ± 4.2 years) collected between 2002 and 2004 in four rural villages in Guatemala. Dietary patterns were derived using principal component analysis. Chi-square and Poisson regression models were used to assess associations between socioeconomic factors and dietary patterns. Results: Three dietary patterns were identified: “Western” (high in processed foods), “traditional” (high in traditional foods) and “coffee and sugar”, explaining 11, 7 and 6 % of the variance, respectively. Annual expenditures were associated with a higher adherence to the “Western” pattern: prevalence ratios [(PR) (95 % confidence interval)] 1.92 (1.17–3.15) for the highest vs. lowest expenditure group in men and 8.99 (3.57–22.64) in women. A borderline significant (p = 0.06) negative association was found between the “traditional” pattern and higher household expenditures [0.71 (0.49–1.02) in men] and with schooling [0.23 (0.05–1.02)] in women (p = 0.05). Conclusions: Dietary patterns in Guatemala are predicted by socioeconomic factors. In particular, high annual expenditures are associated with a more westernized, less traditional diet.

Background Guatemala has experienced a substantial increase in overweight and obesity in recent years, yet physical activity patterns and consequent energy expenditure are largely unexplored in this population. Methods To describe overall physical activity levels (PAL) and activities contributing to daily energy expenditure, we analyzed time spent in daily activities as reported by 985 women and 819 men, living in rural and urban areas of Guatemala in 2002–04. Results Physical activity levels recommended to prevent obesity (PAL ≥ 1.70) differed by residence/occupation among men (agricultural-rural: 77%; nonagricultural-rural: 36%; urban: 24%; P < 0.01), but not women (rural: 2%; urban: 3%; P = 0.5). Median energy expenditure was higher among agricultural-rural men (44 MET*h/d; MET = metabolic equivalent) compared to nonagricultural-rural (37 MET*h/d) and urban men (35 MET*h/d; P < 0.01); energy expenditure was slightly lower among rural compared to urban women (34 MET*h/d vs. 35 MET*h/d; P < 0.01). Occupation was the largest contributor to energy expenditure (19–24 MET*h/d); among women and nonagricultural-rural and urban men this was primarily of a light intensity. Energy expenditure in sedentary activities ranged from 2 MET*h/d among rural women to 6 MET*h/d among agricultural-rural men. Any sports/exercise time was reported by 35% and 5% of men and women, respectively. Nevertheless, the majority of participants believed they were significantly active to stay healthy. Conclusion Overall, energy expenditure was low in the population not dedicated to agricultural occupations; an increased focus on active leisure-time behaviors may be needed to counterbalance reductions in energy expenditure consequent to sedentarization of primary occupations.

Growing evidence supports the role of preconception maternal nutritional status (PMNS) on birth outcomes; however, evidence of relationships with child growth are limited. We examined associations between PMNS (height, weight and body mass index- BMI) and offspring growth during the first 1000 days. We used prospective cohort data from a randomized-controlled trial of preconception micronutrient supplementation in Vietnam, PRECONCEPT (n = 1409). Poisson regression models were used to examine associations between PMNS and risk of offspring stunting (<-2 HAZ) at 2 years. We used path analytic models to examine associations with PMNS on fetal growth (ultrasound measurements) and offspring HAZ at birth and 2 years. All models were adjusted for child age, sex, gestational weight gain, education, socioeconomic status and treatment group. A third of women had a preconception height < 150cm or weight < 43 kg. Women with preconception height < 150 cm or a weight < 43 kg were at increased risk of having a stunted child at 2 years (incident risk ratio IRR: 1.85, 95% CI 1.51–2.28; IRR 1.35, 95% CI 1.10–1.65, respectively). While the traditional low BMI cut-off (< 18.5 kg/m2) was not significant, lower BMI cut-offs (< 17.5 kg/m2or < 18.0 kg/m2) were significantly associated with 1.3 times increased risk of child stunting. In path models, PMNS were positively associated with fetal growth (ultrasound measurements) and offspring HAZ at birth and 2 years. For each 1 standard deviation (SD) increase in maternal height and weight, offspring HAZ at 2 years increased by 0.30 SD and 0.23 SD, respectively. In conclusion, PMNS influences both offspring linear growth and risk of stunting across the first 1000 days. These findings underscore the importance of expanding the scope of current policies and strategies to include the preconception period in order to reduce child stunting.

Anemia is an important public health challenge and accurate prevalence estimates are needed for program planning and tracking progress. While venous blood assessed by automated hematology analyzers is considered gold standard, most population-based surveys use point-of-care diagnostics and capillary blood to estimate population prevalence of anemia. Several factors influence hemoglobin (Hb) concentration, including human and analytic error, analysis method, and type of instrument, but it is unclear whether biological variability exists between venous and capillary blood. The objective of this paper was to systematically review sources of Hb variability and the potential biological basis for venous and capillary differences. We use data from a recent survey in the state of Uttar Pradesh, India, to illustrate the implications on anemia prevalence estimates. Significant differences in Hb concentration between capillary and venous blood samples are common. Most but not all find capillary Hb concentration to be higher than venous. Instrument/method variability and human error play an important role, but cannot fully explain these differences. A normative guide to data collection, analysis, and anemia diagnosis is needed to ensure consistent and appropriate interpretation. Further research is needed to fully understand the biological implications of venous and capillary Hb variability.

Anaemia is a public health problem in Ghana. We sought to identify factors associated with haemoglobin concentration (Hb) and anaemia among schoolattending adolescents. We analysed data from 2948 adolescent girls and 609 boys (10 19 years) selected from 115 schools from regions of Ghana as a secondary analysis of baseline surveys conducted at two time-points. We measured Hb, malaria from capillary blood, anthropometry and used a modified food frequency questionnaire to assess diet. Multivariable linear and Poisson regression models were used to identify predictors of Hb and anaemia. The prevalence of anaemia, malaria and geophagy were 24, 25, and 24 %, respectively, among girls and 13, 27 and 6 %, respectively, among boys. Girls engaging in geophagy had a 53 % higher adjusted prevalence of anaemia and 0 39 g/dl lower Hb. There were similar results among those who tested positive for malaria (+52 % anaemia; -0 42 g/dl Hb). Among girls, lower anaemia prevalence and higher Hb were associated with consumption of foods rich in haeme iron (-22 %; +0 18 g/dl), consumption of iron-fortified cereal/beverages consumed with citrus (-50 %; +0 37 g/dl) and being overweight (-22 %; +0 22 g/dl). Age was positively associated with anaemia among girls, but negatively associated among boys. Boys who tested positive for malaria had 0 31 g/dl lower Hb. Boys who were overweight or had obesity and consumed flour products were also more likely to be anaemic (119 and 56 %, respectively). Factors associated with Hb and anaemia may inform anaemia reduction interventions among school-going adolescents and suggest the need to tailor them uniquely for boys and girls.

Background: From conception to 6 months of age, an infant is entirely dependent for its nutrition on the mother: via the placenta and then ideally via exclusive breastfeeding. This period of 15 months - about 500 days - is the most important and vulnerable in a child's life: it must be protected through policies supporting maternal nutrition and health. Those addressing nutritional status are discussed here. Objective and design: This paper aims to summarize research on policies and programs to protect women's nutrition in order to improve birth outcomes in low- and middle-income countries, based on studies of efficacy from the literature, and on effectiveness, globally and in selected countries involving in-depth data collection in communities in Ethiopia, India and Northern Nigeria. Results of this research have been published in the academic literature (more than 30 papers). The conclusions now need to be advocated to policy-makers. Results: The priority problems addressed are: intrauterine growth restriction (IUGR), women's anemia, thinness, and stunting. The priority interventions that need to be widely expanded for women before and during pregnancy, are: supplementation with iron-folic acid or multiple micronutrients; expanding coverage of iodine fortification of salt particularly to remote areas and the poorest populations; targeted provision of balanced protein energy supplements when significant resources are available; reducing teenage pregnancies; increasing interpregnancy intervals through family planning programs; and building on conditional cash transfer programs, both to provide resources and as a platform for public education. All these have known efficacy but are of inadequate coverage and resourcing. The next steps are to overcome barriers to wide implementation, without which targets for maternal and child health and nutrition (e.g. by WHO) are unlikely to be met, especially in the poorest countries. Conclusions: This agenda requires policy decisions both at Ministry and donor levels, and throughout the administrative system. Evidence-based interventions are established as a basis for these decisions, there are clear advocacy messages, and there are no scientific reasons for delay.

Background: Evidence suggests a strong association between nutrition during the first 1000days (conception to 2years of life) and cognitive development. Maternal docosahexaenoic acid (DHA) supplementation has been suggested to be linked with cognitive development of their offspring. DHA is a structural component of human brain and retina, and can be derived from marine algae, fatty fish and marine oils. Since Indian diets are largely devoid of such products, plasma DHA levels are low. We are testing the effect of pre- and post-natal DHA maternal supplementation in India on infant motor and mental development, anthropometry and morbidity patterns. Methods: DHANI is a double-blinded, parallel group, randomized, placebo controlled trial supplementing 957 pregnant women aged 18-35years from ≤20weeks gestation through 6months postpartum with 400mg/d algal-derived DHA or placebo. Data on the participant's socio-demographic profile, anthropometric measurements and dietary intake are being recorded at baseline. The mother-infant dyads are followed through age 12months. The primary outcome variable is infant motor and mental development quotient at 12months of age evaluated by Development Assessment Scale in Indian Infants (DASII). Secondary outcomes are gestational age, APGAR scores, and infant anthropometry. Biochemical indices (blood and breast-milk) from mother-child dyads are being collected to estimate changes in DHA levels in response to supplementation. All analyses will follow the intent-to-treat principle. Two-sample t test will be used to test unadjusted difference in mean DASII score between placebo and DHA group. Adjusted analyses will be performed using multiple linear regression. Discussion: Implications for maternal and child health and nutrition in India: DHANI is the first large pre- and post-natal maternal dietary supplementation trial in India. If the trial finds substantial benefit, it can serve as a learning to scale up the DHA intervention in the country.