Marko Kerac

Malnutrition is a major global challenge with both short‐ and long‐term health impacts. Studies of historical famines have provided evidence of an association between famine exposure and risk of non‐communicable diseases (NCDs) in later life. However, whether famine exposure has heterogeneous effects on different later‐life NCDs remains unclear. In this study, we investigated whether the effects of exposure to the Chinese Famine of 1959–1961 on later‐life NCDs were disease‐specific, age‐specific, and sex‐specific. We conducted a secondary analysis of data from a large‐scale, nationally representative panel study, i.e., the China Health and Retirement Longitudinal Study (CHARLS, 2011–2020, N = 11,047 adults aged 45 years and older). We measured famine exposure using self‐reported famine experience, life stage using age at famine exposure, and NCDs using 14 chronic conditions. Three main findings emerged. First, the effects of famine exposure for developing NCDs in later life were disease‐specific, with 20%–29% higher odds of digestive disease, memory‐related disease, arthritis, kidney disease and dyslipidemia, versus 10% higher odds of heart disease and diabetes. Second, the effects of famine exposure were age‐specific, with exposure in utero or at ages 0–2 years having the largest impacts on 8 of the 14 later‐life conditions (diabetes, stroke, lung disease, liver disease, digestive disease, cancer, kidney disease, and arthritis), whereas exposure at ages 3–5 years having the largest impact on psychiatric disease and memory‐related disease in later life. Conversely, famine exposure during adulthood was associated with lower odds of various NCDs. This divergence reflects a balance of competing forces: for individuals exposed prior to adulthood, severe developmental damage overshadows the healthy survivor effect, increasing later‐life NCD risk; for individuals exposed during adulthood, completed physiological development minimized programming damage, allowing the healthy survivor effect to dominate. Third, the famine effects were sex‐specific for later‐life cardiometabolic diseases (dyslipidemia, heart disease and stroke), with famine exposure having larger impacts on women than men, pointing to the survivor advantage among men. Future studies should investigate underlying biological mechanisms, intergenerational pathways of transmission, and long‐term growth and body composition in survivors.

Child malnutrition is a major global problem, but in many high‐burden countries, screening and treatment of acute malnutrition called wasting (weight‐for‐length z‐score < −2SD) only begins at age 6 months. Infants under 6 months ‘at risk of poor growth and development’ are, however, increasingly recognised. Latest 2023 WHO guidelines describe anthropometric, feeding and maternal/infant clinical criteria for early detection and treatment. We aimed to explore the value of these criteria to early detect infants at risk of wasting at 6 months. We conducted a secondary analysis of a prospective observational cohort of 789 mother‐infant pairs in Senegal. Several WHO detection criteria were applied to examine the dyads and risk factors for wasting at 6 months, the current malnutrition programme enrolment criterion. Descriptive statistics, Alluvial plots and logistic regression analysis were employed. At birth, 6.8% of infants had low birth weight (weight < 2500 g) and most (99.7%) were breastfed. At age 3 months, 9.4% were underweight (weight‐for‐age z‐score < −2SD) and 10% were wasted; 66% were exclusively breastfed. Many infants transitioned between being malnourished and having normal weight over time. Wasting prevalence at 6 months was 9.5%; risk factors included low birth weight (adjusted odds ratio [aOR] 3.16, 95% CI:1.39, 7.19) and underweight at 3 months (aOR 6.62, 95% CI 2.96, 14.8). Infant feeding and maternal factors were not associated. Applying the 2023 WHO guidelines could detect infants at risk of poor growth and development early. Programme enrolment criteria need further refinement to identify infants requiring follow‐up or treatment.

Malnutrition among infants aged under 6 months (u6m) is a global public health problem. As countries begin implementing 2023 WHO malnutrition guidelines, local prevalence and epidemiology must be well understood. We analysed Bangladesh Demographic Health Survey data (2011–2022), describing the prevalence and time trends of infant u6m wasting (weight‐for‐length z‐score [WLZ] < −2), stunting (length‐for‐age z‐score [LAZ] < −2), and underweight (weight‐for‐age z‐score [WAZ] < −2). In bivariate and multivariate analyses, we tested the association between wasting and underweight and established risk factors for malnutrition. Over the last 10 years, Bangladesh has seen some reduction in stunting and underweight, while wasting has remained relatively stable. In 2022, out of 440 infants u6m, 10.2% were wasted, 11.2% stunted, 11.3% underweight, 0.2% concurrently wasted/stunted. This translates to 178,394 infants u6m being wasted, 195,884 stunted, and 197,633 underweight, in 2022. Between the years 2011 and 2022, 30.3% of participants had at least one form of anthropometric deficit. Length (171) had more missing values than weight (79). WAZ had the lowest percentage of flagged data (0.5%) compared to WLZ (6.1%) and LAZ (2.5%). Underweight was associated with residence, wealth status, maternal age at delivery, maternal BMI, maternal height, maternal level of education, exclusive breastfeeding status and fever in the past 2 weeks. Factors associated with wasting were survey year, the sex of the household head, wealth status, maternal educational level, maternal age at delivery, infant age, and place of delivery. Our findings support the urgent need to roll out the 2023 WHO Guidelines in Bangladesh. They are also consistent with other recent literature highlighting potential advantages of weight‐for‐age (WAZ) as a measure of undernutrition. Given multiple associated factors, packages of care tackling a wide range of potential underlying causes are important for effective local interventions tailored to this age group.

Introduction: Malawi is at a unique time point when infectious disease and undernutrition persist while modern diets, and changes in urbanisation, medical treatments and climate change, non-communicable long-term physical and mental health conditions are emerging. Malawi faces high socioeconomic hardships with 75% of families living in poverty with limited access to basic resources. With these demographic changes, very limited research has been undertaken into the determinants of physical and mental health-related trajectories over time, and in particular the role of prenatal and early life exposures in predetermining long-term conditions in later life. The study will establish a unique multigenerational birth cohort across contrasting rural and urban settings in Malawi to examine how pregnancy, early-life and intergenerational factors shape long-term mental and physical health Methods and analysis: Generation Malawi is based within the open, health and demographic surveillance sites in rural (southern Karonga District) and urban (high-density sectors of Area 25, Lilongwe) Malawi. The study seeks to enrol up to 5000 pregnant women aged 16 years and above, and their spouses, during early pregnancy. Pregnant women and their spouses are followed up until the delivery date at which time their baby is recruited into the study. Children and their parents are then followed up at 1 week, 6 weeks, 4, 12, 24 and 36 months after delivery. At each point, we conduct detailed interviewer-led questionnaires, physical measurements and collection of bio-samples for immediate analysis and long-term storage. The data from this cohort will help us understand the causes of long-term ill health and, in the future, help develop effective interventions to prevent and promptly treat these conditions. Ethics and dissemination: This study protocol was approved by the National Health Science Research Committee in Malawi (number: 21/01/2653) and the Ethics Committee of the College of Medical, Veterinary and Life Sciences at the University of Glasgow, UK (protocol number: 200190183). The formative work for this study was granted ethical clearance by the College of Medicine Research Ethics Committee (protocol number P.11/19/2865). Results will be presented at relevant conferences and published in peer-reviewed journals.

Children with disabilities are often excluded in nutrition policy, programming and practice. A recently established “Feeding and Disability Resource Bank” collates currently available guidelines and training materials for children with disabilities. Our research aims to evaluate these resources to improve quality of care for children with disabilities in nutrition programming and services. Objectives include analysis of resources, evaluating gaps in resources, and barriers and facilitators to their use. Methods include thematic analysis and semi-structured key-informant interviews to identify priority areas for improvement of the resources and provide context to their use. Data were analysed deductively to identify themes around the study’s objectives. Analysis of the Feeding and Disability Resource Bank included 13 training resources, eight programme packages and nine programmatic guidelines which were mapped for coverage and depth of recommendations for 28 key topics. Twelve key informant interviews were conducted. Synthesized key topics were identified by key informants and thematic analysis included identification of disability, feeding difficulties and malnutrition, management of feeding difficulties and malnutrition and integration of care for a child, family and community. Findings indicate there are some high-quality resources to support children with disabilities, but more are needed to provide comprehensive care. Gaps include appropriate assessment of nutritional status (8/30 resources), micronutrient deficiencies (0/30), management of the nutritional quality of a modified diet (6/30) and dehydration (3/30). Resources can be strengthened by filling identified gaps, standardising recommendations and operationalising how these practices can be integrated into programming. The uptake of these recommendations could be maximized by concurrent consideration of the visibility of disability in nutrition agendas, accessibility and dissemination of the resources, and the human and resource capacity of the sector. Unless addressed, children with disabilities will continue to experience systemic exclusion from accessing quality care, treatment and prevention of further disability.

Background: Pregnant adolescents are at higher risk of adverse birth outcomes. Tailoring antenatal care (ANC) to adolescents’ unique needs may be a way to reduce adverse maternal and child outcomes within this population. This systematic review aimed to evaluate ANC services for pregnant adolescents and their impact on maternal and infant outcomes. Methods: Two reviewers independently searched five electronic databases (September 2024) to evaluate existing ANC services that are tailored to adolescents and the impact they have on maternal and infant outcomes. Studies were assessed for quality using the NICE quality appraisal tool and a narrative synthesis was carried out to present the findings. In addition, a survey was disseminated through the Global Adolescent Nutrition Network (GANN) to gain further insights into stakeholder views and experiences of tailored ANC for adolescents. Results: 11,236 articles were reviewed, with 14 studies included for analysis. Interventions as part of ANC for pregnant adolescents included micronutrient supplementation, supplementary feeding, community-based delivery, group-delivery, tailored nutrition education, and additional support and counselling. Outcomes such as birthweight, preterm birth, and gestational age were reported, with most studies (11/14) demonstrating positive effects. Of 103 survey responses, 100% agreed that ANC for pregnant adolescents need to be delivered in a youth-friendly manner, and 57% indicated that providing both youth-friendly delivery and additional support are crucial. Inclusive and supportive care, tailored educational support, tailored nutrition care, and mental health support were most commonly mentioned as key components for tailored ANC. Conclusions: The systematic review and survey data concur in identifying key elements of adolescent-tailored ANC. Some of these have already been shown to be effective; however, due to the high heterogeneity of the study designs, a stronger evidence-base is needed. Specific elements of future ANC packages for pregnant adolescents might include group ANC delivery, community-based services, increased confidentiality measures, mental health support and counselling, health education, and nutrition care tailored to adolescents’ physiological and emotional needs.

Background: As the threat of child malnutrition increases, the focus remains mostly on short-term consequences. Long-term sequelae are increasingly recognised but lack strong evidence, and many studies face methodological limitations. Method: A retrospective cohort of survivors of the 1984–1985 Great-Ethiopian Famine was compared with two novel control groups: born post-famine; and age category- and sex-matched controls. Exposure to famine at different age categories was explored (fetal, 0–2, 2–5, 5–10 and 10–18 years). Follow-up was 40 years later. Outcomes included anthropometry, body composition, arterial stiffness, mental health, and risk of cardiometabolic and non-communicable diseases (NCDs). Adjusted differences and 95% CI between exposed and controls were calculated. Results: Compared with matched and post-famine controls, adjusted differences (95% CI) for exposed group were: height, −1.4 cm (−2.4 to –0.3) and −2.4 cm (−3.7 to –1.1); weight, −1.4 kg (−2.7 to –0.1) and −1.7 kg (−3.3 to –0.1); diastolic blood pressure (DBP), −2.8 mm Hg (−4.4 to –1.1) and 2.8 mmHg (0.9 to 4.7); handgrip strength, −1.7 kg (−2.7 to –0.6) and −4.1 kg (−5.5 to –2.7); brachial augmentation index, 5.4% (0.3% to 10.5%) and 16.1% (10.1% to 22.1%); aortic augmentation index, 6.0% (1.5% to 10.4%) and 11.7% (6.1% to 17.3%); subscapular skinfold thickness, 1.1 mm (0.2 to 1.9) and 1.2 mm (0.1 to 2.3); triceps skinfold thickness, 1.8 mm (0.8 to 2.7) and 2.1 mm (1.0 to 3.3) and waist-to-height ratio, 0.01 (0.003 to 0.02) and 0.01 (0.001 to 0.02), respectively. When comparing risk by timing of exposure, individuals exposed during early childhood (0–2 years), preschool age (2–5 years), and late childhood (5–10 years) had reduced adult stature of −2.8 cm (–4.8 to –0.9), −2.8 cm (−4.7 to -0.9) and −2.1 cm (–4.0 to −0.2), respectively, and increased triceps skinfold of 1.7 mm (−0.5 to 3.8), 3.2 mm (0.8 to 5.6) and 3.8 mm (1.6 to 6.02), respectively. Conclusions: Early-life famine exposure is associated with smaller adult size and several, but not all NCD risks. Lower DBP in survivors compared with matched controls is surprising and might reflect differential susceptibility to specific later-life health risks. Greater arterial stiffness underscores the need to identify both preclinical and clinical risk. In contrast to exposure in utero, risk was higher among those exposed during early childhood (0-2 years), preschool (2–5 years) and late childhood (5–10 years). The study underscores the need for a dual approach in low- and middle-income settings: tackling the immediate undernutrition while also anticipating and mitigating long-term NCD risk in populations exposed to early-life severe malnutrition or famine.

Malnutrition among infants aged under six months (u6m) is a global public health problem. As countries begin implementing 2023 WHO malnutrition guidelines, local prevalence and epidemiology must be well understood. We analysed Bangladesh Demographic Health Survey data (2004 – 2022), describing the prevalence and time trends of infant u6m wasting (weight-for-length z-score [WLZ] <-2), stunting (length-for-age z-score [LAZ] <-2), and underweight (weight-for-age z-score [WAZ] <-2). In bivariate and multivariate analyses, we tested the association between wasting and underweight and established risk factors for malnutrition. Over the last 20 years, Bangladesh has seen a substantial reduction in stunting and underweight while wasting has remained relatively stable. In 2022, out of 476 infants u6m, 10.6% were wasted, 12.8% stunted, 13.7% underweight, 0.5% concurrently wasted/stunted, and 14.8% were reported small at birth. This translates to 185,390 infants u6m being wasted, 223,867 stunted, and 239,608 underweight, in 2022. WAZ had the lowest percentage of flagged data (0.8%) compared to WLZ (6.0%) and LAZ (6.4%). Underweight was associated with delivery place, small birth size, infant sex, post-natal check-ups, fever in the past 2 weeks, drinking water source, maternal BMI, and maternal height. Fewer factors were associated with being wasted, including the sex of the household head. Our findings support the urgent need to roll out 2023 WHO Guidelines in Bangladesh. They also support the superiority of underweight as a measure of undernutrition. Packages of care tackling a wide range of potential underlying causes are important for effective local interventions tailored to this age group.

Background/Objectives: Worldwide, millions of infants under 6 months are at increased risk of poor growth and development, illness, and death. We investigated the coherence of global policy characteristics, vulnerability, and continuity of care, which guides the care of vulnerable infants under 6 months and their mothers. Methods: We conducted a scoping review according to PRISMA-ScR guidance. We included English publications with no time limit, applicable to low- and middle-income countries, sourced through Google Scholar, contacts, WHO and UNICEF databases, global networks, and agency websites. The search was conducted from August 2023 to February 2024. We identified 34 documents for review. We categorised policies into guidelines, namely, WHO evidence-based recommendations and multi-source guidance documents with implementation details. We consolidated 49 vulnerability descriptors into 28 vulnerability factors and four sub-groups. We did not assess policy quality. Results: We found rich but fragmented global policy guidance. Multiple terminologies create superficial differences and mask important ones. Growth appraisal was mostly limited to nutrition-oriented guidance and was lacking in health-centric documents. Continuity of care lacked scope and depth. WHO policies are out of sync with each other and the latest evidence on mortality risk markers. WHO procedures need to accommodate non-UN documents to leverage existing guidance potential. A living policy system to manage evidence-to-policy processes and policy interactions is needed. The WHO-INTEGRATE evidence for decision frameworks could help country-led adaptations, system-sensitive global support, and WHO methodological development. Conclusions: There are immediate opportunities for interdisciplinary policy cooperation. Action is urgently needed to secure coherent evidence-based policies for equitable and effective care.