Background: Circular migration is the dominant pattern of movement in India, and is a livelihood strategy used by many food insecure rural households. Repeated shifts in food environments have important implications on household food security and dietary patterns, but have not been studied. Objective: To explore differences in the food environment, food security, and food availability between home and destination spaces. Methods: Mixed-methods research was conducted among circular migrant families working and residing on brick kilns in the state of Bihar. Utilizing stratified cluster sampling, two rounds of cross-sectional data were collected from 2564 families. Additionally, 25 in-depth interviews were conducted with circular migrant parents, kiln owners, and labor contractors. The Food Insecurity Experience Scale (FIES) was validated for use in our study population. Bivariate analyses were conducted to estimate the association of food insecurity with sociodemographic variables. Qualitative data were analyzed using descriptive thematic methods. Results: 70 percent of respondents utilized at least one non-market source of food at the origin; at the destination, sources of food were limited to the private market. Despite higher food prices at the destination, perceived food affordability was higher during periods of migration, resulting in improved food security. Tubers, rice, and wheat were typically available in the household daily, whereas fruits, eggs, and dairy were typically unavailable during the week. Conclusions: Circular migration can enable short-term food security by improving food affordability. Policy frameworks must address the root causes of chronic food insecurity, especially among rural-to-rural circular migrant families.

Women comprise two-thirds of the global-health (GH) workforce but are underrepresented in leadership. GH departments are platforms to advance gender equality in GH leadership. Using a survey of graduates from one GH department, we compared women's and men's post-training career agency and GH employment and assessed whether gender gaps in training accounted for gender gaps in career outcomes. Master-of-Public-Health (MPH) and mid-career-fellow alumni since 2010 received a 31-question online survey. Forty-four per cent of MPH alum and 24% of fellows responded. Using logistic regression, we tested gender gaps in training satisfaction, career agency, and GH employment, unadjusted and adjusted for training received. Women (N = 293) reported lower satisfaction with training (M7.6 vs 8.2) and career agency (leadership ability: M6.3 vs 7.4) than men (N = 60). Women more often than men acquired methods-related skills (95% vs 78%), employment recommendations (42% vs 18%), and group membership. Men more often than women acquired leadership training (43% vs 23%), award recommendations (53% vs 17%), and conference support (65% vs 35%). Women and men had similar odds of GH employment. Accounting for confounders and gender-gaps in training eliminated gender gaps in five of six career-agency outcomes. Panel studies of women's and men's career trajectories in GH are needed.

Intake of dietary docosahexaenoic acid (DHA 22:6n-3) is very low among Indian pregnant women. Maternal supplementation during pregnancy and lactation may benefit offspring neurodevelopment. We conducted a double-blind, randomized, placebo-controlled trial to test the effectiveness of supplementing pregnant Indian women (singleton gestation) from ≤20 weeks through 6 months postpartum with 400 mg/d algal DHA compared to placebo on neurodevelopment of their offspring at 12 months. Of 3379 women screened, 1131 were found eligible; 957 were randomized. The primary outcome was infant neurodevelopment at 12 months, assessed using the Development Assessment Scale for Indian Infants (DASII). Both groups were well balanced on sociodemographic variables at baseline. More than 72% of women took >90% of their assigned treatment. Twenty-five serious adverse events (SAEs), none related to the intervention, (DHA group = 16; placebo = 9) were noted. Of 902 live births, 878 were followed up to 12 months; the DASII was administered to 863 infants. At 12 months, the mean development quotient (DQ) scores in the DHA and placebo groups were not statistically significant (96.6 ± 12.2 vs. 97.1 ± 13.0, p = 0.60). Supplementing mothers through pregnancy and lactation with 400 mg/d DHA did not impact offspring neurodevelopment at 12 months of age in this setting.

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.

Background: Prenatal exposure to environmental pollutants such as mold, lead, pesticides, tobacco, and air pollutants has been suggested to impair cognitive development. Evidence is needed from longitudinal studies to understand their joint impact on child development across time. Objective: To study associations between exposure to indoor environmental pollutants or outdoor air pollution during pregnancy and offspring cognitive development trajectories through 7 years. Methods: We included 718 Mexican mother-child pairs. Prenatal exposure to indoor environmental pollutants (mold, ventilation, pesticides, tobacco smoke, and use of vidiartred clay pots) was self-reported by the mothers and integrated into an index, or objectively measured in the case of outdoor air pollutants (nitrogen oxides, benzene, toluene, and xylene). Child global cognitive development was measured at 12, 18, 60, or 84 months. Using Latent Class Growth Analysis, we identified three developmental trajectories (positive = 108, average = 362, low = 248). We used multinomial logistic models to test associations between environmental pollutant score (EPS) or outdoor air pollutants, and cognitive development trajectories. Results: After adjustment for sociodemographic covariates, EPS was associated with the average (OR = 1.26 95%CI = 1.01, 1.55) and low (OR = 1.41 95%CI = 1.11, 1.79) trajectories compared to positive; where a unit increase in EPS means an additional prenatal exposure to a pollutant. There was no association between outdoor air pollutants and cognitive development trajectories. Conclusion: Children of women who reported higher exposure to indoor environmental pollutants during pregnancy were more likely to follow worse developmental trajectories through 7 years. These results support the development and testing of interventions to reduce exposure to environmental pollutants during pregnancy and early childhood as a potential strategy to improve long-term cognitive development.

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.

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.

Aims Clinical trials show lifestyle change programs are beneficial, yet large-scale, successful translation of these programs is scarce. We investigated the association between participation in the largest U.S. lifestyle change program, MOVE!, and diabetes control outcomes. Methods This longitudinal, retrospective cohort study used Veterans Health Administration databases of patients with diabetes who participated in MOVE! between 2005 and 2012, or met eligibility criteria (BMI ≥ 25 kg/m2) but did not participate. Main outcomes were diabetic eye disease, renal disease, and medication intensification. Results There were 400,170 eligible patients with diabetes, including 87,366 (22%) MOVE! participants. Included patients were 96% male, 77% white, with mean age 58 years and BMI 34 kg/m2. Controlling for baseline measurements and age, race, sex, BMI, and antidiabetes medications, MOVE! participants had lower body weight (− 0.6 kg), random plasma glucose (− 2.8 mg/dL), and HbA1c (− 0.1%) at 12 months compared to nonparticipants (each p < 0.001). In multivariable Cox models, MOVE! participants had lower incidence of eye disease (hazard ratio 0.80, 95% CI 0.75–0.84) and renal disease (HR 0.89, 95% CI 0.86–0.92) and reduced medication intensification (HR 0.82, 95% CI 0.80–0.84). Conclusions If able to overcome participation challenges, lifestyle change programs in U.S. health systems may improve health among the growing patient population with diabetes.

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.