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Objective:To examine the prevalence of and factors associated with different forms of household-level double burden of malnutrition (DBM) in Ethiopia.Design:We defined DBM using anthropometric measures for adult overweight (BMI ≥ 25 kg/m2), child stunting (height-for-age Z-score sd) and overweight (weight-for-height Z-score ≥2 sd). We considered sixteen biological, environmental, behavioural and socio-demographic factors. Their association with DBM forms was assessed using generalised linear models.Setting:We used data from two cross-sectional studies in an urban (Addis Ababa, January–February 2018), and rural setting (Kersa District, June–September 2019).Participants:Five hundred ninety-two urban and 862 rural households with an adult man, adult woman and child Results:In Addis Ababa, overweight adult and stunted child was the most prevalent DBM form (9 % (95 % CI 7, 12)). Duration of residence in Addis Ababa (adjusted OR (aOR) 1·03 (95 % CI 1·00, 1·06)), Orthodox Christianity (aOR 1·97 (95 % CI 1·01, 3·85)) and household size (aOR 1·24 (95 % CI 1·01, 1·54)) were associated factors. In Kersa, concurrent child overweight and stunting was the most prevalent DBM form (11 % (95 % CI 9, 14)). Housing quality (aOR 0·33 (95 % CI 0·20, 0·53)), household wealth (aOR 1·92 (95 % CI 1·18, 3·11) and sanitation (aOR 2·08 (95 % CI 1·07, 4·04)) were associated factors. After adjusting for multiple comparisons, only housing quality remained a significant factor.Conclusions:DBM prevalence was low among urban and rural Ethiopian households. Environmental, socio-economic and demographic factors emerged as potential associated factors. However, we observed no common associated factors among urban and rural households.

The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented public health crisis globally. Understanding healthcare providers’ (HCPs’) knowledge and perceptions of COVID-19 is crucial to identifying effective strategies to improve their ability to respond to the pandemic in sub-Saharan Africa. A phone-based survey of 900 HCPs in Burkina Faso, Ethiopia, and Nigeria (300 per country) was conducted to assess knowledge, perceptions, COVID-19 prevention measures, stigma, and mental health of HCPs. Modified Poisson regression models were used to evaluate predictors of knowledge, perceptions, and prevention measures; adjusted risk ratios (ARRs) and 95% confidence intervals (CIs) were calculated. Three-fourths of the HCPs had adequate knowledge, and over half had correct perceptions of risk and high levels of self-reported prevention measures. The majority of the HCPs (73.7%) reported self-perceived social stigma. There was relatively low prevalence of depression (6.6%), anxiety (6.6%), or psychological distress (18%). Compared with doctors, being a nurse was associated with lower levels of knowledge (ARR: 0.83; 95% CI: 0.77–0.90) and was also negatively associated with having correct perceptions toward COVID-19 (AOR: 0.82; 95% CI: 0.73–0.92). HCPs treating COVID-19 patients had higher likelihood of having high levels of prevention measures (AOR: 1.37; 95% CI: 1.23–1.53). Despite high levels of knowledge among HCPs in sub-Saharan Africa, there is a need to improve COVID-19 perceptions and compliance with prevention measures as well as address social stigma toward HCPs to better ensure their safety and prepare them to deliver health services.

Coronavirus disease 2019 (COVID-19) is a public health emergency affecting the lives of millions of people globally. Different measures and extraordinary steps are being taken to contain the transmission of the virus. The levels of knowledge and implementation of preventive practices related to COVID-19 in sub-Saharan African countries are unclear. Additionally, there is a lack of evidence regarding the impacts of the pandemic on mental health. This study aimed to describe knowledge and practices related to COVID-19 and to assess mental health status among adults in three sub-Saharan African countries: Burkina Faso, Ethiopia, and Nigeria. A total of 1,797 adults were included in the survey, and data were collected using computer-assisted telephone interviews. The proportions of adults who identified more than 80% of COVID-19 symptoms, transmission methods, and prevention mechanisms were 69.9%, 79.2%, and 90.7%, respectively. The practice of preventive measures was relatively lower for avoiding social gatherings and disinfecting contaminated surfaces. Better education, urban residence, and believing the pandemic is real were factors associated with good knowledge on COVID-19 symptoms, transmission methods, and preventive actions. Additionally, being male was associated with good knowledge on symptoms and transmission methods, whereas being in an older age group was associated with knowledge of transmission methods. Mild, moderate, and severe psychological distress was reported by 20.6%, 5.9%, and 1.1% of the participants, respectively. Although this study found high levels of knowledge regarding COVID-19, interventions are needed to increase the uptake of recommended preventive practices among adults in sub-Saharan Africa.

Background: Tanzania has a double burden of malnutrition, including a high prevalence of undernutrition and an increasing prevalence of overweight and obesity among adolescents. Schools present a valuable opportunity to reach a large section of the country’s adolescent population with nutrition-oriented interventions. Objective: The objective of this study was to assess the current state of adolescent school nutrition interventions in Dodoma, Tanzania, with emphasis on 3 potential school-based nutrition interventions, school vegetable gardens, school meals, and education (on nutrition, agriculture, and water, sanitation, and hygiene). Methods: Focus group discussions were conducted with several regional and district-level governmental stakeholders, including health, education, and agricultural officers. Ten public secondary schools were visited, and interviews with school administrators, teachers, students, and parents were conducted. Results: All stakeholders interviewed supported interventions to improve school-based nutrition, including school gardens, school feeding, and nutrition education. All 10 schools visited had some experience providing school meals, but parents’ contributions were essential for the program’s sustainability. Most schools visited had land available for a school garden program, but water availability could be challenging during certain times of the year. The teachers interviewed expressed that the curriculum on nutrition education was highly theoretical and did not allow students to practice the knowledge and skills they learned in the classroom. Conclusions: The current school-based approach to tackling the double burden of adolescent malnutrition in Dodoma is localized and ad hoc. To leverage the potential of schools as a platform for nutrition interventions, integrated and policy-mandated interventions are needed.

The coronavirus disease 2019 (COVID-19) pandemic has significant health and economic ramifications across sub-Saharan Africa (SSA). Data regarding its far-reaching impacts are severely lacking, thereby hindering the development of evidence-based strategies to mitigate its direct and indirect health consequences. To address this need, the Africa Research, Implementation Science, and Education (ARISE) Network established a mobile survey platform in SSA to generate longitudinal data regarding knowledge, attitudes, and practices (KAP) related to COVID-19 prevention and management and to evaluate the impact of COVID-19 on health and socioeconomic domains. We conducted a baseline survey of 900 healthcare workers, 1,795 adolescents 10 to 19 years of age, and 1,797 adults 20 years or older at six urban and rural sites in Burkina Faso, Ethiopia, and Nigeria. Households were selected using sampling frames of existing Health and Demographic Surveillance Systems or national surveys when possible. Healthcare providers in urban areas were sampled using lists from professional associations. Data were collected through computer-assisted telephone interviews from July to November 2020. Consenting participants responded to surveys assessing KAP and the impact of the pandemic on nutrition, food security, healthcare access and utilization, lifestyle, and mental health. We found that mobile telephone surveys can be a rapid and reliable strategy for data collection during emergencies, but challenges exist with response rates. Maintaining accurate databases of telephone numbers and conducting brief baseline in-person visits can improve response rates. The challenges and lessons learned from this effort can inform future survey efforts during COVID-19 and other emergencies, as well as remote data collection in SSA in general.

Background Dietary folate inadequacy is one the most common micronutrient deficiencies that cause neural tube defect (NTD) among infants in Sub-Saharan African countries. This study aims to determine the dietary intake of folate among women of reproductive age (WRA) of Kersa, Eastern Ethiopia. Methods A cross-sectional study took place among voluntary women that were selected from 1140 random households. Using a validated Food Frequency Questionnaire, participant’s weekly dietary intake history of Ethiopian foods and dietary folate intake was worked out. Statistical analysis was done at a 95% confidence interval. Modified Poisson regression was used to identify factors associated with dietary folate consumption. Result The estimated median usual intake of folate was 170 μg/d (IQR: 118.3; 252.2) and about 33% of WRA had low folate intake and 73.9% were at risk for folate inadequacy. From the reported food groups, Beans and Peas, Starchy staples, and Vitamin-A rich dark-green leafy vegetables were the top three ranked foods that contributed much of the dietary folate. The following conditions were statistically related to dietary folate inadequacy; women’s age, being in poor wealth index, low dietary diversity, having seasonal employment, and reliance on market food sources. Conclusions We found that women’s dietary intake of folate in Kersa is very low and cannot protect their offspring from the risk of having NTD. They could also potentially be predisposed to poor health outcomes. Diversifying and fortification of Ethiopian wheats and salts could decrease the burden of folate deficiency in the country.

BACKGROUND: While the causes of anemia at an individual level (such as certain nutritional deficiencies, infections, and genetic disorders) are well defined, there is limited understanding of the relative burden of anemia attributable to each cause within populations. OBJECTIVES: We sought to estimate the proportion of anemia cases attributable to nutrition, infectious diseases, and other risk factors among women, men, and children in 6 regions of Ethiopia. METHODS: A population-based cross-sectional study was conducted. Data were obtained from 2520 women of reproductive age (15–49 y), 1044 adult men (15–49 y), and 1528 children (6–59 mo). Participants provided venous blood samples for assessment of their hemoglobin concentration; ferritin, folate, vitamin B12, and C-reactive protein levels; and the presence of malaria infection. Stool samples were collected to ascertain the helminth infection status. Sociodemographic questionnaires and a 24-h diet recall were administered. Population-weighted prevalences of anemia and risk factors were calculated. Multivariable-adjusted associations of risk factors with anemia and partial population attributable risk percentages were estimated using generalized linear models. RESULTS: The anemia prevalences were 17% (95% CI: 13%–21%) among women, 8% (95% CI: 6%–12%) among men, and 22% (95% CI: 19%–26%) among children. Low serum ferritin contributed to 11% (95% CI: −1% to 23%) of anemia cases among women, 9% (95% CI: 0%–17%) among men, and 21% (95% CI: 4%–34%) among children. The proportions of anemia attributable to low serum folate were estimated at 25% (95% CI: 5%–41%) among women and 29% (95% CI: 11%–43%) among men. Dietary iron intake was adequate for nearly all participants, while inadequacy was common for folate and vitamin B12. Inflammation and malaria were responsible for less than 1 in 10 anemia cases. CONCLUSIONS: Folate deficiency, iron deficiency, and inflammation appear to be important contributors to anemia in Ethiopia. Folic acid food fortification, targeted iron interventions, and strategies to reduce infections may be considered as potential public health interventions to reduce anemia in Ethiopia.

Background Nutritionally inadequate diets in Ethiopia contribute to a persisting national burden of adult undernutrition, while the prevalence of noncommunicable diseases (NCDs) is rising. Objectives To evaluate performance of a novel Global Diet Quality Score (GDQS) in capturing diet quality outcomes among Ethiopian adults. Methods We scored the GDQS and a suite of comparison metrics in secondary analyses of FFQ and 24-hour recall (24HR) data from a population-based cross-sectional survey of nonpregnant, nonlactating women of reproductive age and men (15–49 years) in Addis Ababa and 5 predominately rural regions. We evaluated Spearman correlations between metrics and energy-adjusted nutrient adequacy, and associations between metrics and anthropometric/biomarker outcomes in covariate-adjusted regression models. Results In the FFQ analysis, correlations between the GDQS and an energy-adjusted aggregate measure of dietary protein, fiber, calcium, iron, zinc, vitamin A, folate, and vitamin B12 adequacy were 0.32 in men and 0.26 in women. GDQS scores were inversely associated with folate deficiency in men and women (GDQS Quintile 5 compared with Quintile 1 OR in women, 0.50; 95% CI: 0.31–0.79); inversely associated with underweight (OR, 0.63; 95% CI: 0.44–0.90), low midupper arm circumference (OR, 0.61; 95% CI: 0.45–0.84), and anemia (OR, 0.59; 95% CI: 0.38–0.91) in women; and positively associated with hypertension in men (OR: 1.77, 95% CI: 1.12–2.80). For comparison, the Minimum Dietary Diversity–Women (MDD-W) was associated more positively (P

The coronavirus disease 2019 (COVID-19) pandemic may have short-term and long-term impacts on health services across sub-Saharan African countries. A telephone survey in Burkina Faso, Ethiopia, and Nigeria was conducted to assess the effects of the pandemic on healthcare services from the perspectives of healthcare providers (HCPs) and community members. A total of 900 HCPs (300 from each country) and 1,797 adult community members (approximately 600 from each country) participated in the study. Adjusted risk ratios (ARRs) and 95% confidence intervals (CIs) were computed using modified Poisson regression. According to the HCPs, more than half (56%) of essential health services were affected. Child health services and HIV/surgical/other services had a slightly higher percentage of interruption (33%) compared with maternal health services (31%). A total of 21.8%, 19.3%, and 7.7% of the community members reported that their family members and themselves had difficulty accessing childcare services, maternal health, and other health services, respectively. Nurses had a lower risk of reporting high service interruptions than physicians (ARR, 0.85; 95% CI, 0.56–0.95). HCPs at private facilities (ARR, 0.71; 95% CI, 0.59–0.84) had a lower risk of reporting high service interruptions than those at governmental facilities. Health services in Nigeria were more likely to be interrupted than those in Burkina Faso (ARR, 1.38; 95% CI, 1.19–1.59). Health authorities should work with multiple stakeholders to ensure routine health services and identify novel and adaptive approaches to recover referral services, medical care, maternal and child health, family planning, immunization and health promotion, and prevention during the COVID-19 era.

Objectives COVID-19 has far-reaching consequences for developing countries through the combined effects of infection and mortality and unintended consequences from mitigation measures. COVID-19 can adversely impact food systems and dietary diversity for populations. This cross-sectional study evaluated, using a mobile platform, the effect of COVID-19 on food prices and dietary diversity and quality, among 1797 households in Nouna and Ouagadougou (Burkina Faso), Addis Ababa and Kersa (Ethiopia), and Lagos and Ibadan (Nigeria). Methods Dietary intake was assessed as the frequency of consumption of 20 food groups over the previous 7 days. Dietary diversity scores (DDS; range: 0–10) and Prime Diet Quality Score (PDQS; range: 0–40) assessed dietary diversity and quality. Linear regression models were used to evaluate associations between changes in the prices of staples, pulses, vegetables, fruits, and animal source foods (ASF) with DDS and PDQS during COVID-19. Results Most households reported increases in prices of staples, pulses, fruits, vegetables and ASF, and ≥40% reported decreased consumption of staples, legumes, ASF, other vitamin A rich vegetables, other vegetables and other fruits, and lower DDS and PDQS compared to the period before the COVID-19 emergency. Increases in pulse prices were associated with lower DDS (estimate − 0.35, 95% CI: −0.61, −0.09). Lower crop production (estimate − 0.70, 95% CI: −1.02, −0.37), and skipping meals (estimate − 0.39, 95% CI: −0.56, −0.21) or not eating for a whole day (estimate − 0.23, 95% CI: −0.43, −0.03) were also associated with lower DDS. Conclusions The price increases and worsening dietary diversity and quality call for social protection and other strategies to increase the availability and affordability of nutrient-rich foods during the COVID-19 pandemic and other public health emergencies. Funding Sources The Bill and Melinda Gates Foundation Grant as well as institutional support from the Heidelberg Institute of Global Health, Germany and the Harvard T.H. Chan School of Public Health, USA, supported this work.

Background Anemia remains a public health challenge in Ethiopia, affecting an estimated 56% of children under age 5 years, 23% of women of reproductive age and 18% of adult men. However, anemia etiology and the relative contribution of underlying risk factors for anemia remains unclear and has hindered implementation of anemia control programs. Methods/design Anemia Etiology in Ethiopia (AnemEE) is a population-based cross-sectional survey of six regions of Ethiopia that includes children, women of reproductive age, and men from regionally representative households. The survey will include detailed assessment of anemia, iron, inflammatory and nutritional biomarkers, diet, comorbidities, and other factors. The objectives of AnemEE are 1) to generate evidence for decision-making on the etiology of anemia in Ethiopia among men, women and children and 2) to simulate the potential effect of iron fortification and other interventions on the prevalence of anemia and risk of iron overload. Discussion AnemEE will provide the most comprehensive evaluation of anemia etiology in Ethiopia to date due to its detailed assessment of diet, biomarkers, infections and other risk factors in a population-based sample. By generating evidence and simulating potential interventions, AnemEE will inform the development of high-impact anemia control programs and policies. Trial registration ClinicalTrials.gov, NCT04002466. Registered on 28 June 2019. Retrospectively registered.

Plant-based diets have been widely promoted for cardiovascular disease (CVD) risk reduction. This review discusses the various definitions of plant-based diets and summarizes their associations with CVD risk, specifically distinguishing between healthy and unhealthy plant-based diets. Despite wide variation in definition, most studies suggest that plant-based diets are generally beneficial for cardiovascular health. Many previous studies have defined plant-based diets by the complete exclusion of meat or animal products, while others have accounted for plant-based diets including moderate amounts of animal-source foods. Only a few studies have considered the healthfulness of the specific plant foods included in these dietary patterns. In these studies, plant-based diets containing higher amounts of healthy foods such as whole grains, fruits, vegetables, nuts, legumes, oils, tea, and coffee are associated with lower CVD risk. However, plant-based diets including higher amounts of less healthy plant foods, such as refined grains, potatoes/fries, and foods and beverages high in added sugar, are linked to increased risk. A wide spectrum of plant-based diets can be nutritionally adequate and confer cardiovascular benefits, as long as they are planned appropriately and include high-quality foods. Contrary to popular belief, plant-based diets do not have to be vegan or vegetarian. For most people, complete elimination of meat or animal products is unrealistic and not necessary for cardiovascular health. Quality of the specific components of plant-based diets is also important to consider, as not all plant-source foods have beneficial cardiovascular effects. Healthy plant-based diets can be customized to fit individual and cultural preferences and, with large-scale adoption, could concurrently mitigate threats to both human and environmental health.

OBJECTIVES: Obesity and diet-related noncommunicable diseases are increasing in Ethiopia—often in the same communities where undernutrition remains prevalent. Increasing proportion of energy intake from protein could be a potential strategy to address this double burden; however, this potential has not been examined in sub-Saharan Africa. The objective of this study is to investigate associations of types and food sources of protein with overweight/obesity and underweight in Ethiopia. METHODS: We conducted a cross-sectional dietary survey including 992 women and 632 men aged 18–49 years in Addis Ababa, Ethiopia. Linear regression models were used to assess associations between body mass index (BMI) and % energy intake from total, animal, and plant protein. Logistic regression models were used to examine associations of % energy intake from total, animal, and plant protein and specific food sources of protein with underweight and overweight/obesity. RESULTS: Nearly one third of the sample were overweight or obese. Only 2.5% of total energy intake was derived from animal protein. In multivariable-adjusted linear models in the full sample, BMI was not associated with % energy from total protein, plant protein or animal protein. Total protein and animal protein intake were both associated with lower odds of overweight/obesity (Odds Ratio [OR] per 1% energy increment of total protein 0.92; 95% CI: 0.86, 0.99; P = 0.02; OR per 1% energy increment of animal protein 0.89; 95% CI: 0.82, 0.96; P = 0.004) when substituted for carbohydrate and adjusted for sociodemographic covariates. In food-based analyses, a greater % energy from milk was related to lower odds of underweight but with wide confidence intervals (OR per 5% energy increment 0.54; 95% CI: 0.30, 1.00; P = 0.05). CONCLUSIONS: Increasing the proportion of energy intake from total protein or animal protein in place of carbohydrate could be a strategy to address overweight and obesity in Ethiopia; longitudinal studies are needed to further examine this potential. FUNDING SOURCES: United Kingdom Economic and Social Research Council (ESRC) and Department for International Development (DFID) Joint Fund for Poverty Alleviation Research.

IntroductionVitamin D status may be an important determinant of multidrug-resistant tuberculosis (MDR-TB) infection, progression to disease and treatment outcomes. Novel and potentially cost-effective therapies such as vitamin D supplementation are needed to stem the tide of TB and MDR-TB globally, particularly in India, a country that accounts for the largest fraction of the world’s TB incidence and MDR-TB incidence, and where vitamin D deficiency is endemic. While vitamin D has shown some promise in the treatment of MDR-TB, its role in the context of MDR-TB infection and progression to disease is largely unknown.Methods and analysisThrough a case–control study in Mumbai, India, we aim to examine associations between vitamin D status and active MDR-TB and to investigate vitamin D status and TB infection among controls. Cases are adult outpatient pulmonary patients with MDR-TB recruited from two public TB clinics. Controls are recruited from the cases’ household contacts and from non-respiratory departments of the facilities where cases were recruited. Cases and controls are assessed for serum 25-hydroxyvitamin D concentration, nutrient intake, diet quality, anthropometry and other relevant clinical and sociodemographic parameters. Controls undergo additional clinical assessments to rule out active TB and laboratory assessments to determine presence of TB infection. Statistical analysis investigates associations between vitamin D status and active MDR-TB and between vitamin D status and TB infection among controls, accounting for potential confounding effects of diet, anthropometry and other covariates.Ethics and disseminationThis study has been approved by Harvard T.H. Chan School of Public Health Institutional Review Board; Foundation for Medical Research Institutional Research Ethics Committee and Health Ministry’s Screening Committee of the Indian Council for Medical Research. Permission was granted by the Municipal Corporation of Greater Mumbai, India, a collaborating partner on this research. Outcomes will be disseminated through publication and scientific presentation.Trial registration numberNCT04342598.

Summary Background Few studies have used nationally representative data to describe dietary trends and the related cardiometabolic mortality burden in China. Thus, we aimed to characterise the trends in disease-related dietary factors as well as their associated disease burden among Chinese adults from 1982 to 2012. Methods For this cross-sectional population-based study, we analysed a nationally representative sample of 204 802 adults aged 20 years or older, using data from the 1982, 1992, 2002, and 2010–12 China National Nutrition Surveys (CNNS). We did a comparative risk assessment, in which the effects of suboptimal intakes of 12 dietary factors, individually and collectively, on cardiometabolic mortality were estimated by calculating the population attributable fraction (PAF) to estimate the proportional reduction in cardiometabolic deaths that would occur if exposure to each dietary risk factor was reduced to an alternative optimal level. Findings The overall PAF of mortality from cardiovascular disease and type 2 diabetes that was associated with suboptimal dietary quality was 62·2% in 1982, 57·9% in 1992, 56·2% in 2002, and 51·0% in 2010–12, which accounted for 21·6% of total mortality in China in 1982, 16·6% in 1992, 17·6% in 2002, and 20·8% in 2010–12. The estimated number of cardiometabolic deaths associated with suboptimal dietary intakes was 1·07 million in 1982, 0·93 million in 1992, 1·18 million in 2002, and 1·51 million in 2010–12. Of all 12 dietary factors examined, high sodium intake (17·3%), low fruit consumption (11·5%), and low marine omega-3 fatty acids (9·7%) were associated with the largest numbers of estimated cardiometabolic deaths in 2010–12. Interpretation We observed an improvement in several dietary factors in China in the past few decades. However, current intakes of these dietary factors remain suboptimal. Poor diet quality is estimated to be associated with a substantial proportion of deaths from heart disease, stroke, and type 2 diabetes in China. Funding Ministry of Health, China, and Ministry of Science and Technology, China.

Background: The associations of age-related changes in body weight and waist circumferences with cardiovascular disease (CVD) and mortality remain unclear. Methods: We assessed changes in weight and waist circumference from baseline survey and resurvey among 27 964 participants in the China Kadoorie Biobank (CKB, 2004-2008) and Dongfeng-Tongji Cohort (DF-TJ, 2008-2013). We used Cox proportional hazards models to evaluate the associations between adiposity changes and the subsequent risks of incident CVD, CVD mortality and all-cause mortality. Findings: On average, during a median of 3·4 years from baseline to resurvey, participants experienced a weight loss of 0·6 kg, accompanied by a 2·1 cm increase in waist circumference. We identified 3589 incident CVD cases, 485 CVD deaths, and 1283 all-cause deaths during the follow-up in the CKB (2008-2016) and DF-TJ (2013-2016). Weight loss and waist gain were associated with increased risks of those outcomes in the two cohorts. In particular, compared with participants who had stable waist (waist change -2·0 to 7·0 cm) and weight (weight change -2·5 to 2·5 kg), those who gained waist but lost weight (waist circumference change >7·0 cm, weight change ≤ -2·5 kg) had the highest risk of incident CVD, CVD mortality and all-cause mortality, with the pooled multivariate hazard ratios (HRs) of 1·41 (95% CI, 1·13 to 1·75), 2·48 (1·40 to 4·37), and 1·71 (1·16 to 2·51), respectively. Among the weight-stable participants, waist circumference was linearly associated with CVD risk, with 17% higher risk (HR 1·17, 1·04 to 1·32) for those gained waist while 13% lower risk (HR 0·87, 0·77 to 0·99) for those lost waist compared to waist-stable participants. Interpretation: Increased waist circumference with concurrent weight loss is significantly associated with increased risks of CVD morbidity, CVD mortality, and all-cause mortality among Chinese middle-aged and elderly adults. Funding Statement: This work was partly supported by grants from the Foundation of National Key Programs of Research and Development of China (2016YFC0900800, 2016YFC0900500, 2017YFC0907501 and 2017YFC0907504), the National Natural Science Foundation of China (91643202 and 81390540), the 111 Project and the Program for Changjiang Scholars and Innovative Research Team in University. The China Kadoorie Biobank baseline survey and the first resurvey were supported by the Kadoorie Charitable Foundation in Hong Kong. The long-term follow-up has been supported by the UK Wellcome Trust (grants 088158/Z/09/Z, 104085/Z/14/Z), and the Chinese Ministry of Science and Technology (2011BAI09B01). The British Heart Foundation, UK Medical Research Council, and Cancer Research provide core funding to the Clinical Trial Service Unit and Epidemiological Studies Unit at Oxford University for the project. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The CKB study was approved by the ethics committees or institutional review boards at the University of Oxford, the Chinese Center for Disease Control and Prevention (China CDC), the Chinese Academy of Medical Sciences. The DF-TJ cohort was approved by the ethics committees of Tongji Medical College and the Sinopharm Dongfeng General Hospital. All participants provided written informed consents.

The global obesity and diet-related chronic disease epidemics as well as the food production system’s environmental impacts are serious threats to human and planetary health that will continue to increase if no action is taken. Fortunately, dietary modifications can improve population health and sustainability simultaneously. Healthy dietary patterns (generally higher in plant-based foods, such as vegetables, fruits, whole grains and nuts) can reduce risk of obesity, type 2 diabetes and cardiovascular disease and are more sustainable than animal-based dietary patterns. Compared to plant-based foods, components of animal-based diets such as red and processed meat not only have a larger environmental impact but also have been associated with increased risk of chronic diseases and premature death. To alleviate the growing diet-related disease epidemics and future environmental crises and to shift populations towards dietary patterns higher in healthy plant-based foods and lower in animal-based foods, global interventions and policy changes are crucial.

Summary In this Minireview, we provide an epidemiologist's perspective on the debate and recent advances in determining the relationship between diet and cardiovascular health. We conclude that, in order to reduce the global burden of cardiovascular disease, there should be a greater emphasis on improving overall diet quality and food sources of macronutrients, such as dietary fats and carbohydrates. In addition, building a strong evidence base through high-quality intervention and observational studies is crucial for effective policy changes, which can greatly improve the food environment and population health.