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Abstract Background Research indicates that in the United States, children experience healthier BMI and fitness levels during school vs. summer, but research is limited. The primary goal of this pilot study was to assess where children spend their time during the months that school is not in session and to learn about the different types of activities they engage in within different care settings. A secondary goal of this pilot study was to learn what children eat during the summer months. Methods A nine-week summer study of 57 parents of second and third grade students was conducted in an economically, racial/ethnically and linguistically diverse US urban city. Weekly telephone interviews queried time and activities spent on/in 1) the main caregiver's care 2) someone else's care 3) vacation 4) and camp. Activities were categorised as sedentary, light, moderate, or vigorous (0-3 scale). For each child, a mean activity level was calculated and weighted for proportion of time spent in each care situation, yielding a weighted activity index. On the last phone call, parents answered questions about their child's diet over the summer. Two post-study focus groups were conducted to help interpret findings from the weekly activity interviews. Results The mean activity index was 1.05 ± 0.32 and differed between gender (p = 0.07), education (p = 0.08) and primary language spoken in the household (p = 0.01). Children who spent a greater percentage of time in parent care had on average a lower activity index (β = -0.004, p = 0.01) while children who spent a greater percentage of time in camp had a higher activity index (β = 0.004, p = 0.03). When stratified into type of camp, percentage of time spent in active camp was also positively associated with mean activity index (β = 0.005, p =< 0.001). With regards to diet, after adjusting for maternal education, children who attended less than five weeks of camp were four times more likely to eat their meals in front of the TV often/almost all of the time (OR = 4.0, 95%CI 1.0-16.2, p < 0.06). Conclusions Summer activities and some dietary behaviours are influenced by situation of care and socio-demographic characteristics. In particular, children who spend a greater proportion of time in structured environments appear to be more active. We believe that this pilot study is an important first step in our understanding of what children do during the summer months.

Background. Approximately 1.2 million disabilityadjusted life years (DALYs) are lost annually in Bangladesh due to deficiencies of vitamin A, iron, and zinc. Objective. To provide evidence on the coverage, costs, and cost-effectiveness of alternative fortification interventions to inform nutrition policy-making in Bangladesh. Methods. Combining the 2005 Bangladesh Household Income and Expenditure Survey with a Bangladesh food composition table, apparent intakes of energy, vitamin A, iron, and zinc, and the coverage and apparent consumption levels of fortifiable vegetable oil and wheat flour are estimated. Assuming that fortification levels are those established in official regulations, the costs and cost-effectiveness of the two vehicles are assessed independently and as a two-vehicle portfolio. Results. Vegetable oil has a coverage rate of 76% and is estimated to reduce the prevalence of inadequate vitamin A intake from 83% to 64%. The coverage of wheat flour is high (65%), but the small quantities consumed result in small reductions in the prevalence of inadequate intakes: 1.5 percentage points for iron, less than 1 for zinc, and 2 for vitamin A, while reducing average Estimated Average Requirement (EAR) gaps by 8%, 9%, and 15%, respectively. The most cost-effective 10-micronutrient wheat flour formulation costs US$1.91 million annually, saving 129,212 DALYs at a unit cost of US$14.75. Fortifying vegetable oil would cost US$1.27 million annually, saving 406,877 DALYs at an average cost of US$3.25. Sensitivity analyses explore various permutations of the wheat flour formulation. Divisional variations in coverage, cost, and impact are examined. Conclusions. Vegetable oil fortification is the most cost-effective of the three portfolios analyzed, but all three are very cost-effective options for Bangladesh. [ABSTRACT FROM AUTHOR]

Background: Micronutrient deficiencies continue to constitute a major burden of disease, particularly in Africa and South Asia. Programs to address micronutrient deficiencies have been increasing in number, type, and scale in recent years, creating an ever-growing need to understand their combined coverage levels, costs, and impacts so as to more effectively combat deficiencies, avoid putting individuals at risk for excess intakes, and ensure the efficient use of public health resources.Objective: To analyze combinations of the two current programs--sugar fortification and Child Health Week (CHW)--together with four prospective programs--vegetable oil fortification, wheat flour fortification, maize meal fortification, and biofortified vitamin A maize--to identify Zambia's optimal vitamin A portfolio.Methods: Combining program cost estimates and 30-year Zambian food demand projections, together with the Zambian 2005 Living Conditions Monitoring Survey, the annual costs, coverage, impact, and cost-effectiveness of 62 Zambian portfolios were modeled for the period from 2013 to 2042.Results: Optimal portfolios are identified for each of five alternative criteria: average cost-effectiveness, incremental cost-effectiveness, coverage maximization, health impact maximization, and affordability. The most likely scenario is identified to be one that starts with the current portfolio and takes into account all five criteria. Starting with CHW and sugar fortification, it phases in vitamin A maize, oil, wheat flour, and maize meal (in that order) to eventually include all six individual interventions.Conclusions: Combining cost and Household Consumption and Expenditure Survey (HCES) data provides a powerful evidence-generating tool with which to understand how individual micronutrient programs interact and to quantify the tradeoffs involved in selecting alternative program portfolios. [ABSTRACT FROM AUTHOR]

Background. Since fortification of sugar with vitamin A was mandated in 1998, Zambia's fortification program has not changed, while the country remains plagued by high rates ofmicronutrient deficiencies. Objective. To provide evidence-based fortification options with the hope of reinvigorating the Zambian fortification program. Methods. Zambia's 2006 Living Conditions Monitoring Survey is used to estimate the apparent intakes of vitamin A, iron, and zinc, as well as the apparent consumption levels and coverage of four fortification vehicles. Fourteen alternativefoodfortification portfolios are modeled, and their costs, impacts, average cost-effectiveness, and incremental cost-effectiveness are calculated using three alternative impact measures. Results. Alternative impact measures result in different rank orderings of the portfolios. The most cost-effective portfolio is vegetable oil, which has a cost per disability-adjusted life-year (DALY) saved ranging from 12% to 25% of that of sugar, depending on the impact measure used. The public health impact of fortified vegetable oil, however, is relatively modest. Additional criteria beyond cost-effectiveness are introduced and used to rank order the portfolios. The size of the public health impact, the total cost, and the incremental cost-effectiveness of phasing in multiple vehicle portfolios over time are analyzed. Conclusions. Assessing fortification portfolios by measuring changes in the prevalence of inadequate intakes underestimates impact. A more sensitive measure, which also takes into account change in the Estimated Average Requirement (EAR) gap, is provided by a dose-response-based approach to estimating the number ofDALYs saved. There exist highly cost-effective fortification intervention portfolios with substantial public health impacts and variable price tags that could help improve Zambians' nutrition status. [ABSTRACT FROM AUTHOR]

Background: Observed-Weighed Food Record Surveys (OWFR) are regarded as the most precise dietary assessment methodology, despite their recognized shortcomings, which include limited availability, high cost, small samples with uncertain external validity that rarely include all household members, Hawthorne effects, and using only 1 or 2 days to identify "usual intake." Although Household Consumption and Expenditures Surveys (HCES) also have significant limitations, they are increasingly being used to inform nutrition policyObjective: To investigate differences in fortification simulations based on OWFR and HCES from Bangladesh.Methods: The pre- and postfortification nutrient intake levels from the two surveys were compared.Results: The total population-based rank orderings of oil, wheat flour, and sugar coverage were identical for the two surveys. OWFR found differences in women's and children's coverage rates and average quantities consumed for all three foods that were not detected by HCES. Guided by the Food Fortification Formulator, we found that these differences did not result in differences in recommended fortification levels. Differences were found, however, in estimated impacts: although both surveys found that oil would be effective in reducing the prevalence of inadequate vitamin A intake among both subpopulations, only OWFR also found that sugar and wheat flour fortification would significantly reduce inadequate vitamin A intake among children.Conclusions: Despite the less precise measure of food consumption from HCES, the two surveys provide similar guidance for designing a fortification program. The external validity of these findings is limited. With relatively minor modifications, the precision of HCES in dietary assessment and the use ofHCES in fortification programming could be strengthened. [ABSTRACT FROM AUTHOR]

Background: Zambia was a pioneer when it started fortifying sugar with vitamin A in 1998. Micronutrient deficiencies-especially among young children-have changed little over the past decade. In 2008 an initiative to introduce fortified flours was halted when last-hour questions about the program could not be answered.Objective: To provide information about the need, coverage, and impact of alternative fortification portfolio options to help Zambia overcome its fortification impasse.Methods: Using household data from the 2006 Living Conditions Monitoring Survey, apparent micronutrient intake levels and apparent consumption levels of sugar, vegetable oil, wheat flour and maize meal were estimated. The household level data were used to estimate individual intakes by assuming that food was distributed among household members in direct proportion to their share of the household's total adult consumption equivalent. Intake adequacy was measured relative to age- and gender-specific Estimated Average Requirements. Combining information on the industrial structure and estimated fortifiable quantities consumed of each food, and assuming the nutrient content is that specified in official regulations, simulations were conducted of the coverage and impact of 14 fortification portfolios.Results: Maize, the most commonly consumed food, is consumed in a fortifiable form by only 23% of the population. Sugar fortification is estimated to have reduced inadequate intake of vitamin A from 87% to 79%. Introducing oil fortification could reduce the prevalence of inadequate vitamin A intake to 61%, and fortifying roller and breakfast maize meal would further reduce it to 57%, and reduce inadequate iron and zinc intakes by 2.2% and 5.5%, respectively. Implementing WHO flour guidelines would triple the potential iron and zinc impacts.Conclusion: Analysis of LCMS apparent consumption data have helped address important information gaps and provide better understanding of the coverage and impacts of alternative fortification portfolios. [ABSTRACT FROM AUTHOR]

Obesity is a growth-promoting process as evidenced by its effect on the timing of puberty. Although studies are limited, obesity has been shown to affect the timing of tooth eruption. Both the timing and sequence of tooth eruption are important to overall oral health. The purpose of this study was to examine the association between obesity and tooth eruption. Data were combined from three consecutive cycles (2001-2006) of the National Health and Nutrition Examination Survey (NHANES) and analyzed to examine associations between the number of teeth erupted (NET) and obesity status (BMI z-score >95th percentile BMI relative to the Centers for Disease Control and Prevention (CDC) growth reference) among children 5 up to 14 years of age, controlling for potential confounding by age, gender, race, and socioeconomic status (SES). Obesity is significantly associated with having a higher average NET during the mixed dentition period. On average, teeth of obese children erupted earlier than nonobese children with obese children having on average 1.44 more teeth erupted than nonobese children, after adjusting for age, gender, and race/ethnicity (P < 0.0001). SES was not a confounder of the observed associations. Obese children, on average, have significantly more teeth erupted than nonobese children after adjusting for gender, age, and race. These findings may have clinical importance in the area of dental and orthodontic medicine both in terms of risk for dental caries due to extended length of time exposed in the oral cavity and sequencing which may increase the likelihood of malocclusions. [ABSTRACT FROM AUTHOR]

Background. Globally, there is a scarcity of national food consumption data that could help to assess food patterns and nutrient intakes of population groups. Estimates of food consumption patterns and apparent intakes of energy and nutrients could be obtained from national Household Consumption and Expenditures Surveys (HCES). Objective. To use the HCES conducted in Bangladesh in 2005 (HIES2005) to estimate apparent intakes of vitamin A, iron, and zinc. Methods. Food acquisition data from HIES2005, which surveyed 10,080 households, were transformed into standard measurement units. Intrahousehold food and nutrient distribution was estimated with Adult Male Equivalent (AME) units. Adequacy of intake was assessed by comparing individual nutrient intakes with requirements and was then aggregated by households. Results. The weighted mean energy intake for the population was 2,151 kcal/person/day, with a range among divisions from 1,950 in Barisal to 2,195 in Dhaka division. The apparent intakes of vitamin A and iron were insufficient to satisfy the recommended intakes for more than 80% of the population in Bangladesh, while apparent intakes of zinc, adjusted by bioavailability, satisfied the requirements of approximately 60% of the population Conclusions. Using the HIES2005, we were able to produce estimates of apparent food consumption and intakes of some key micronutrients for the Bangladeshi population and observed wide differences among divisions. However, the methodological approaches reported here, although feasible and promising, need to be validated with other dietary intake methods [ABSTRACT FROM AUTHOR]

Background. The dearth of 24-hour recall and observedweighed food record data--what most nutritionists regard as the gold standard source of food consumption data--has long been an obstacle to evidence-based food and nutrition policy. There have been a steadily growing number of studies using household food acquisition and consumption data from a variety of multipurpose, nationally representative household surveys as a proxy measure to overcome this fundamental information gap. Objective. To describe the key characteristics of these increasingly available Household Consumption and Expenditures Surveys (HCES) in order to help familiarize food and nutrition analysts with the strengths and shortcomings of these data and thus encourage their use in low- and middle-income countries; and to identify common shortcomings that can be readily addressed in the near term in a country-by-country approach, as new HCES are fielded, thereby beginning a process of improving the potential of these surveys as sources of useful data for better understanding food- and nutritionrelated issues. Methods. Common characteristics of key food and nutrition information that is available in HCES and some basic common steps in processing HCES data for food and nutrition analyses are described. Results. The common characteristics of these surveys are documented, and their usefulness in addressing major food and nutrition issues, as well as their shortcomings, is demonstrated. Conclusions. Despite their limitations, the use of HCES data constitutes a generally unexploited opportunity to address the food consumption information gap by using survey data that most countries are already routinely collecting. [ABSTRACT FROM AUTHOR]

Background. Dietary assessment data are essential for designing, monitoring, and evaluating food fortification and other food-based nutrition programs. Planners and managers must understand the validity, usefulness, and cost tradeoffs of employing alternative dietary assessment methods, but little guidance exists. Objective. To identify and apply criteria to assess the tradeoffs of using alternative dietary methods for meeting fortification programming needs. Methods. Twenty-five semistructured expert interviews were conducted and literature was reviewed for information on the validity, usefulness, and cost of using 24-hour recalls, Food Frequency Questionnaires/ Fortification Rapid Assessment Tool (FFQ/FRAT), Food Balance Sheets (FBS), and Household Consumption and Expenditures Surveys (HCES) for program stage-specific information needs. Criteria were developed and applied to construct relative rankings of the four methods. Results. Needs assessment: HCES offers the greatest suitability at the lowest cost for estimating the risk of inadequate intakes, but relative to 24-hour recall compromises validity. Design: HCES should be used to identify vehicles and to estimate coverage and likely impact due to its low cost and moderate-to-high validity. Baseline assessment: 24-hour recall should be applied using a representative sample. Monitoring: A simple, low-cost FFQ can be used to monitor coverage. Impact evaluation: 24-hour recall should be used to assess changes in nutrient intakes. FBS have low validity relative to other methods for all programmatic purposes. Conclusions. Each dietary assessment method has strengths and weaknesses that vary by context and purpose. Method selection must be driven by the program's data needs, the suitability of the methods for the purpos [ABSTRACT FROM AUTHOR]

Background: Micronutrient deficiencies exact an enormous health burden on India. The release of the National Family Health Survey results--showing the relatively wealthy state of Gujarat having deficiency levels exceeding national averages--prompted Gujarat officials to introduce fortified wheat flour in their social safety net programs (SSNPs).Objective: To provide a case study of the introduction of fortified wheat flour in Gujarat's Public Distribution System (PDS), Integrated Child Development Scheme (ICDS), and Mid-Day Meal (MDM) Programme to assess the coverage, costs, impact, and cost-effectiveness of the initiative.Methods: India's 2004/05 National Sample Survey data were used to identify beneficiaries of each of Gujarat's three SSNPs and to estimate usual intake levels of vitamin A, iron, and zinc. Comparing age- and sex-specific usual intakes to Estimated Average Requirements, the proportion of the population with inadequate intakes was estimated. Postfortification intake levels and reductions in inadequate intake were estimated. The incremental cost of fortifying wheat flour and the cost-effectiveness of each program were estimated.Results: When each program was assessed independently, the proportion of the population with inadequate vitamin A intakes was reduced by 34% and 74% among MDM and ICDS beneficiaries, respectively. Both programs effectively eliminated inadequate intakes of both iron and zinc. Among PDS beneficiaries, the proportion with inadequate iron intakes was reduced by 94%. CONCLUSIONS. Gujarat's substitution of fortified wheat flour for wheat grain is dramatically increasing the intake of micronutrients among its SSNP beneficiaries. The incremental cost of introducing fortification in each of the programs is low, and, according to World Health Organization criteria, each program is "highly cost-effective." The introduction of similar reforms throughout India would largely eliminate the inadequate iron intake among persons participating in any of the three SSNPs and would have a significant impact on the global prevalence rate of inadequate iron intake. [ABSTRACT FROM AUTHOR]

Background: Research indicates that in the United States, children experience healthier BMI and fitness levels during school vs. summer, but research is limited. The primary goal of this pilot study was to assess where children spend their time during the months that school is not in session and to learn about the different types of activities they engage in within different care settings. A secondary goal of this pilot study was to learn what children eat during the summer months. Methods: A nine-week summer study of 57 parents of second and third grade students was conducted in an economically, racial/ethnically and linguistically diverse US urban city. Weekly telephone interviews queried time and activities spent on/in 1) the main caregiver's care 2) someone else's care 3) vacation 4) and camp. Activities were categorised as sedentary, light, moderate, or vigorous (0-3 scale). For each child, a mean activity level was calculated and weighted for proportion of time spent in each care situation, yielding a weighted activity index. On the last phone call, parents answered questions about their child's diet over the summer. Two post-study focus groups were conducted to help interpret findings from the weekly activity interviews. Results: The mean activity index was 1.05 ± 0.32 and differed between gender (p = 0.07), education (p = 0.08) and primary language spoken in the household (p = 0.01). Children who spent a greater percentage of time in parent care had on average a lower activity index (β = -0.004, p = 0.01) while children who spent a greater percentage of time in camp had a higher activity index (β = 0.004, p = 0.03). When stratified into type of camp, percentage of time spent in active camp was also positively associated with mean activity index (β = 0.005, p =< 0.001). With regards to diet, after adjusting for maternal education, children who attended less than five weeks of camp were four times more likely to eat their meals in front of the TV often/almost all of the time (OR = 4.0, 95%CI 1.0-16.2, p < 0.06). Conclusions: Summer activities and some dietary behaviours are influenced by situation of care and sociodemographic characteristics. In particular, children who spend a greater proportion of time in structured environments appear to be more active. We believe that this pilot study is an important first step in our understanding of what children do during the summer months. [ABSTRACT FROM AUTHOR]