evidence-based blog of Filippo Dibari

Posts Tagged ‘scientific paper’

Breastfeeding: NOT good news in developing countries

In Under-nutrition on September 30, 2012 at 6:13 am

Global trends in exclusive breastfeeding

by Xiaodong Cai, Tessa Wardlaw and David W Brown

International Breastfeeding Journal 2012, 7:12 

(entire doc)




Infant and young child feeding is critical for child health and survival. Proportion of infants 0–5 months who are fed exclusively with breast milk is a common indicator used for monitoring and evaluating infant and young child feeding in a given country and region. Despite progress made since 1990, a previous review in 2006 of global and regional trends found improvement to be modest. The current study provides an update in global and regional trends in exclusive breastfeeding from 1995 to 2010, taking advantage of the wealth of data from recent household surveys.


Using the global database of infant and young child feeding maintained by the United Nations Children’s Fund, the authors examined estimates from 440 household surveys in 140 countries over the period between 1995 and 2010 and calculated global and regional averages of the rate of exclusive breastfeeding among infants 0–5 months for the two time points to assess the trends.


Trend data suggest the prevalence of exclusive breastfeeding among infants younger than six months in developing countries increased from 33% in 1995 to 39% in 2010. The prevalence increased in almost all regions in the developing world, with the biggest improvement seen in West and Central Africa.


In spite of the well-recognized importance of exclusive breastfeeding, the practice is not widespread in the developing world and increase on the global level is still very modest with much room for improvement. Child nutrition programmes worldwide continue to require investments and commitments to improve infant feeding practices in order to have maximum impact on children’s lives.

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Famine Exposure in the Young and the Risk of Type 2 Diabetes in Adulthood (n=7,837)

In Under-nutrition on September 28, 2012 at 9:26 am

Annet F.M. van AbeelenSjoerd G. EliasPatrick M.M. BossuytDiederick E. GrobbeeYvonne T. van der SchouwTessa J. Roseboom and Cuno S.P.M. Uiterwaal

in Diabetes. 2012 Sep;61(9):2255-60


The developmental origins hypothesis proposes that undernutrition during early development is associated with an increased type 2 diabetes risk in adulthood.

We investigated the association between undernutrition during childhood and young adulthood and type 2 diabetes in adulthood. We studied 7,837 women from Prospect-EPIC (European Prospective Investigation Into Cancer and Nutrition) who were exposed to the 1944-1945 Dutch famine when they were between age 0 and 21 years. We used Cox proportional hazards regression models to explore the effect of famine on the risk of subsequent type 2 diabetes in adulthood. We adjusted for potential confounders, including age at famine exposure, smoking, and level of education.

Self-reported famine exposure during childhood and young adulthood was associated with an increased type 2 diabetes risk in a dose-dependent manner. In those who reported moderate famine exposure, the age-adjusted type 2 diabetes hazard ratio (HR) was 1.36 (95% CI [1.09-1.70]); in those who reported severe famine exposure, the age-adjusted HR was 1.64 (1.26-2.14) relative to unexposed women. These effects did not change after adjustment for confounders.

This study provides the first direct evidence, using individual famine exposure data, that a short period of moderate or severe undernutrition during postnatal development increases type 2 diabetes risk in adulthood.

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Effects of Ramadan fasting on cardiovascular risk factors: a prospective observational study

In Over-nutrition on September 24, 2012 at 3:47 pm

by Mohsen Nematy, Maryam Alinezhad-Namaghi, Masoud mahdavi Rashed, Mostafa Mozhdehifard, Seyedeh Sania Sajjadi, Saeed Akhlaghi, Maryam Sabery, Seyed Amir R Mohajeri, Neda Shalaey, Mohsen Moohebati and Abdolreza Norouzy

Nutrition Journal 2012, 11:69 – Published: 10 September 2012

(download the provisional entire paper)

Abstract (provisional)


Previous research has shown that Ramadan fasting has beneficial effects on cardiovascular risk factors, however there are controversies. In the present study, the effect of Ramadan fasting on cardiovascular risk factors has been investigated.


This is a prospective observational study that was carried out in a group of patients with at least one cardiovascular risk factor (including history of documented previous history of either coronary artery disease (CAD), metabolic syndrome or cerebro-vascular disease in past 10 y). Eighty two volunteers including 38 male and 44 female, aged 29–70 y, mean 54.0 [PLUS-MINUS SIGN] 10 y, with a previous history of either coronary artery disease, metabolic syndrome or cerebro-vascular disease were recruited. Subjects attended the metabolic unit after at least 10 h fasting, before and after Ramadan who were been fasting for at least 10 days. A fasting blood sample was obtained, blood pressure was measured and body mass index (BMI) was calculated. Lipids profile, fasting blood sugar (FBS) and insulin, homocysteine (hcy), high-sensitivity C-reactive protein (hs-CRP) and complete blood count (CBC) were analyzed on all blood samples.


A significant improvement in 10 years coronary heart disease risk (based on Framingham risk score) was found (13.0 [PLUS-MINUS SIGN] 8 before Ramadan and 10.8 [PLUS-MINUS SIGN]7 after Ramadan, P <0.001, t test).There was a significant higher HDL-c, WBC, RBC and platelet count (PLT), and lower plasma cholesterol, triglycerides, LDL-c, VLDL-c, systolic blood pressure, body mass index and waist circumference after Ramadan (P <0.05, t test). The changes in FBS, insulin,Homeostasis Model Assessment Insulin Resistance (HOMA-IR), hcy, hs-CRP and diastolic blood pressure before and after Ramadan were not significant (P >0.05, t test).


This study shows a significant improvement in 10 years coronary heart disease risk score and other cardiovascular risk factors such as lipids profile, systolic blood pressure, weight, BMI and waist circumference in subjects with a previous history of cardiovascular disease.

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Unexpected evidence: “Hunter-Gatherer Energetics and Human Obesity”

In Over-nutrition on September 21, 2012 at 9:31 am

Herman Pontzer, David A. Raichlen, Brian M. Wood,Audax Z. P. Mabulla, Susan B. Racette, Frank W. Marlowe

PLoS ONE 7(7) 2012 

(download the entire paper)


Western lifestyles differ markedly from those of our hunter-gatherer ancestors, and these differences in diet and activity level are often implicated in the global obesity pandemic. However, few physiological data for hunter-gatherer populations are available to test these models of obesity.

In this study, we used the doubly-labeled water method to measure total daily energy expenditure (kCal/day) in Hadza hunter-gatherers to test whether foragers expend more energy each day than their Western counterparts.

As expected, physical activity level, PAL, was greater among Hadza foragers than among Westerners. Nonetheless, average daily energy expenditure of traditional Hadza foragers was no different than that of Westerners after controlling for body size. The metabolic cost of walking (kcal kg−1 m−1) and resting (kcal kg−1 s−1) were also similar among Hadza and Western groups.

The similarity in metabolic rates across a broad range of cultures challenges current models of obesity suggesting that Western lifestyles lead to decreased energy expenditure. We hypothesize that human daily energy expenditure may be an evolved physiological trait largely independent of cultural differences.


Find more about obesity on this blog.

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Development of a crossover-randomized trial method to determine the acceptability and safety of novel ready-to-use therapeutic foods (ahead of print)

In Under-nutrition on September 19, 2012 at 5:07 pm

by Dibari F, Bahwere P, Huerga H, Irena AH, Owino V, Collins S, Seal A.

Nutrition (article in press).


Objective: To develop a method for determining the acceptability and safety of ready-to-use therapeutic foods (RUTF) before clinical trialing. Acceptability was defined using a combination of three consumption, nine safety, and six preference criteria. These were used to compare a soy/maize/sorghum RUTF (SMS-RUTFh), designed for the rehabilitation of human immunodeficiency virus/tuberculosis (HIV/TB) wasted adults, with a peanut-butter/milk-powder paste (P-RUTF; brand: Plumpy’nut) designed for pediatric treatment.

Methods: A cross-over, randomized, controlled trial was conducted in Kenya. Ten days of repeated measures of product intake by 41 HIV/TB patients, >18 y old, body mass index (BMI) 18-24 kg/m^2, 250 g were offered daily under direct observation as a replacement lunch meal. Consumption, comorbidity, and preferences were recorded.

Results: The study arms had similar age, sex, marital status, initial BMI, and middle upper-arm circumference. No carryover effect or serious adverse events were found. SMS-RUTFh energy intake was not statistically different from the control, when adjusted for BMI on day 1, and the presence of throat sores. General preference, taste, and sweetness scores were higher for SMS-RUTFh compared to the control (P < 0.05). Most consumption, safety, and preference criteria for SMS-RUTFh were satisfied except for the average number of days of nausea (0.16 versus 0.09 d) and vomiting (0.04 versus 0.02 d), which occurred with a higher frequency (P < 0.05).

Conclusion: SMS-RUTFh appears to be acceptable and can be safely clinically trialed, if close monitoring of vomiting and nausea is included. The method reported here is a useful and feasible approach for testing the acceptability of ready-to-use foods in low income countries.

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Obesity in sub-Saharan Africa: development of an ecological theoretical framework

In Over-nutrition on September 1, 2012 at 3:09 pm

Alison ScottChinwe Stella EjikemeEmmanuel Nii Clottey and Joy Goens Thomas

Health Promot. Int. (2012) – August 29, 2012


The prevalence of overweight and obesity is increasing in sub-Saharan Africa (SSA). There is a need for theoretical frameworks to catalyze further research and to inform the development of multi-level, context-appropriate interventions. In this commentary, we propose a preliminary ecological theoretical framework to conceptualize factors that contribute to increases in overweight and obesity in SSA. The framework is based on a Causality Continuum model [Coreil et al. Social and Behavioral Foundations of Public Health. Sage Publications, Thousand Oaks] that considers distant, intermediate and proximate influences. The influences incorporated in the model include globalization and urbanization as distant factors; occupationsocial relationshipsbuilt environment andcultural perceptions of weight as intermediate factors and caloric intake, physical inactivity and genetics as proximate factors. The model illustrates the interaction of factors along a continuum, from the individual to the global marketplace, in shaping trends in overweight and obesity in SSA. The framework will be presented, each influence elucidated and implications for research and intervention development discussed. There is a tremendous need for further research on obesity in SSA. An improved evidence base will serve to validate and develop the proposed framework further.

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Maternal Multiple Micronutrient Supplements and Child Cognition: A Randomized Trial in Indonesia

In Under-nutrition on September 1, 2012 at 7:20 am

Elizabeth L. PradoKatherine J. AlcockHusni MuadzMichael T. UllmanAnuraj H. Shankar, for the SUMMIT Study Group

Pediatrics. August 20, 2012


OBJECTIVES: We investigated the relative benefit of maternal multiple micronutrient (MMN) supplementation during pregnancy and until 3 months postpartum compared with iron/folic acid supplementation on child development at preschool age (42 months).

METHODS: We assessed 487 children of mothers who participated in the Supplementation with Multiple Micronutrients Intervention Trial, a cluster-randomized trial in Indonesia, on tests adapted and validated in the local context measuring motor, language, visual attention/spatial, executive, and socioemotional abilities. Analysis was according to intention to treat.

RESULTS: In children of undernourished mothers (mid-upper arm circumference <23.5 cm), a significant benefit of MMNs was observed on motor ability (B = 0.39 [95% confidence interval (CI): 0.08–0.70]; P = .015) and visual attention/spatial ability (B = 0.37 [95% CI: 0.11–0.62]; P = .004). In children of anemic mothers (hemoglobin concentration <110 g/L), a significant benefit of MMNs on visual attention/spatial ability (B = 0.24 [95% CI: 0.02–0.46]; P = .030) was also observed. No robust effects of maternal MMN supplementation were found in any developmental domain over all children.

CONCLUSIONS: When pregnant women are undernourished or anemic, provision of MMN supplements can improve the motor and cognitive abilities of their children up to 3.5 years later, particularly for both motor function and visual attention/spatial ability. Maternal MMN but not iron/folic acid supplementation protected children from the detrimental effects of maternal undernutrition on child motor and cognitive development.

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Literature Review and Institutional Analysis: Toward an Integrated Approach for Addressing Malnutrition in Zambia (IFPRI)

In Under-nutrition on August 28, 2012 at 8:09 pm

by Jody Harris and Scott Drimie

IFPRI Discussion Paper 01200 – August 2012



Due to the predominance of direct, specific interventions in nutrition for development, the health sector tends to own nutrition, with interventions customarily implemented through health programs. That the agriculture sector should also be a vehicle for improved nutrition is intuitive, but this sector often delivers neither good nutrition nor food security to the most vulnerable in the population. The complex and multisectoral nature of malnutrition may explain why it has not been effectively addressed, even though we know many of the solutions; intersectoral action is critical to addressing this complexity, but to date there is no consensus on how intersectoral solutions are best implemented or institutionalized. This review brings together experiences from across Sub-Saharan Africa in order to draw out recommendations for improved intersectoral implementation going forward, and assesses how these findings apply specifically to the Zambian context.

The experiences reviewed suggest three broad barriers to intersectoral collaboration for nutrition: low political commitment and mobilization; sector-bound organizational structures and weak coordinating bodies; and lack of human resources and capacity. Key lessons for improved intersectoral implementation include the role of advocacy in framing the problem in context and highlighting mutual gains for different sectors, to create the political will and working space for nutrition action; the importance of organizational arrangements, including convening or coordinating bodies with multisectoral credibility to facilitate mobilizing and resourcing power; and the importance of building not only technical but also strategic capacity to manage multisectoral relationships for improved nutrition outcomes. Ultimately, these solutions will have to be tailored to country contexts.

Zambia is an ideal candidate for a country that could make a significant impact on its malnutrition problem. With the emergence of the Scaling Up Nutrition (SUN) movement in the country, nutrition has received some high-level political attention, and the multi-sectoral nature of nutrition is recognized in overarching development policies and strategies. However, political attention has not moved into concrete action, and nutrition strategies, policies, and plans are essentially wish lists noting best practice, confined mainly to the health sector, created with substantial input from external actors, and without the backing of political commitment, budgetary or human resources, or capacity; implementation of these grand ideas is severely lacking. Several vital but attainable processes would improve intersectoral coordination for nutrition in Zambia and enable its potentially strong policy to be implemented across sectors. These include strategic lobbying for real political and social commitment to nutrition in sectors outside of health; strengthening the National Food and Nutrition Commission both in terms of its power to convene the different actors and the strategic capacity of its leadership; and improved technical training outside of core nutrition competencies in nutrition workers in general. These recommendations are interlinked; one cannot happen without the other, and all are necessary but not sufficient to improve the nutrition situation in Zambia. Movement should start in all areas at once, and the high-level momentum created by the SUN movement is an opportunity, providing the potential for cross-sectoral dialogue and increased resources, that should not be missed.

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The evolution of human adiposity and obesity: where did it all go wrong?

In Over-nutrition on August 22, 2012 at 7:57 pm

by Jonathan C. K. Wells

Dis. Model. Mech.September 2012, vol. 5; no. 5; pages: 595-607

(download the entire paper)


Because obesity is associated with diverse chronic diseases, little attention has been directed to the multiple beneficial functions of adipose tissue.

Adipose tissue not only provides energy for growth, reproduction and immune function, but also secretes and receives diverse signaling molecules that coordinate energy allocation between these functions in response to ecological conditions. Importantly, many relevant ecological cues act on growth and physique, with adiposity responding as a counterbalancing risk management strategy.

The large number of individual alleles associated with adipose tissue illustrates its integration with diverse metabolic pathways. However, phenotypic variation in age, sex, ethnicity and social status is further associated with different strategies for storing and using energy. Adiposity therefore represents a key means of phenotypic flexibility within and across generations, enabling a coherent life-history strategy in the face of ecological stochasticity.

The sensitivity of numerous metabolic pathways to ecological cues makes our species vulnerable to manipulative globalized economic forces. The aim of this article is to understand how human adipose tissue biology interacts with modern environmental pressures to generate excess weight gain and obesity.

The disease component of obesity might lie not in adipose tissue itself, but in its perturbation by our modern industrialized niche.

Efforts to combat obesity could be more effective if they prioritized ‘external’ environmental change rather than attempting to manipulate ‘internal’ biology through pharmaceutical or behavioral means.

Find other posts related to obesity on this blog.


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The effectiveness of interventions to treat severe acute malnutrition in young children: a systematic review

In Under-nutrition on August 19, 2012 at 11:55 am

Picot J, Hartwell D, Harris P, Mendes D, Clegg AJ, Takeda A

Health Technology Assessment 2012; Vol. 16: No. 19

(download the entire paper)



Severe acute malnutrition (SAM) arises as a consequence of a sudden period of food shortage and is associated with loss of a person’s body fat and wasting of their skeletal muscle. Many of those affected are already undernourished and are often susceptible to disease. Infants and young children are the most vulnerable as they require extra nutrition for growth and development, have comparatively limited energy reserves and depend on others. Undernutrition can have drastic and wide-ranging consequences for the child’s development and survival in the short and long term. Despite efforts made to treat SAM through different interventions and programmes, it continues to cause unacceptably high levels of mortality and morbidity. Uncertainty remains as to the most effective methods to treat severe acute malnutrition in young children.


To evaluate the effectiveness of interventions to treat infants and children aged < 5 years who have SAM.

Data source:

Eight databases (MEDLINE, EMBASE, MEDLINE In-Process & Other Non-Indexed Citations, CAB Abstracts Ovid, Bioline, Centre for Reviews and Dissemination, EconLit EBSCO and The Cochrane Library) were searched to 2010. Bibliographies of included articles and grey literature sources were also searched. The project expert advisory group was asked to identify additional published and unpublished references.

Review methods:

Prior to the systematic review, a Delphi process involving international experts prioritised the research questions. Searches were conducted and two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to the full texts of retrieved papers by one reviewer and checked independently by a second. Included studies were mapped to the research questions. Data extraction and quality assessment were undertaken by one reviewer and checked by a second reviewer. Differences in opinion were resolved through discussion at each stage. Studies were synthesised through a narrative review with tabulation of the results.


A total of 8954 records were screened, 224 full-text articles were retrieved, and 74 articles (describing 68 studies) met the inclusion criteria and were mapped. No evidence focused on treatment of children with SAM who were human immunodeficiency virus sero-positive, and no good-quality or adequately reported studies assessed treatments for SAM among infants < 6 months old. One randomised controlled trial investigated fluid resuscitation solutions for shock, with none adequately treating shock. Children with acute diarrhoea benefited from the use of hypo-osmolar oral rehydration solution (H-ORS) compared with the standard World Health Organization-oral rehydration solution (WHO-ORS). WHO-ORS was not significantly different from rehydration solution for malnutrition (ReSoMal), but the safety of ReSoMal was uncertain. A rice-based ORS was more beneficial than glucose-based ORSs, and provision of zinc plus a WHO-ORS had a favourable impact on diarrhoea and need for ORS. Comparisons of different diets in children with persistent diarrhoea produced conflicting findings. For treating infection, comparison of amoxicillin with ceftriaxone during inpatient therapy, and routine provision of antibiotics for 7 days versus no antibiotics during outpatient therapy of uncomplicated SAM, found that neither had a significant effect on recovery at the end of follow-up. No evidence mapped to the next three questions on factors that affect sustainability of programmes, long-term survival and readmission rates, the clinical effectiveness of management strategies for treating children with comorbidities such as tuberculosis and Helicobacter pylori infection and the factors that limit the full implementation of treatment programmes. Comparison of treatment for SAM in different settings showed that children receiving inpatient care appear to do as well as those in ambulatory or home settings on anthropometric measures and response time to treatment. Longer-term follow-up showed limited differences between the different settings. The majority of evidence on methods for correcting micronutrient deficiencies considered zinc supplements; however, trials were heterogeneous and a firm conclusion about zinc was not reached. There was limited evidence on either supplementary potassium or nicotinic acid (each produced some benefits), and nucleotides (not associated with benefits). Evidence was identified for four of the five remaining questions, but not assessed because of resource limitation.


The systematic review focused on key questions prioritised through a Delphi study and, as a consequence, did not encompass all elements in the management of SAM. In focusing on evidence from controlled studies with the most rigorous designs that were published in the English language, the systematic review may have excluded other forms of evidence. The systematic review identified several limitations in the evidence base for assessing the effectiveness of interventions for treating young children with severe acute malnutrition, including a lack of studies assessing the different interventions; limited details of study methods used; short follow-up post intervention or discharge; and heterogeneity in participants, interventions, settings, and outcome measures affecting generalisability.


For many of the most highly ranked questions evidence was lacking or inconclusive. More research is needed on a range of topic areas concerning the treatment of infants and children with SAM. Further research is required on most aspects of the management of SAM in children < 5 years, including intravenous resuscitation regimens for shock, management of subgroups (e.g. infants < 6 months old, infants and children with SAM who are human immunodeficiency virus sero-positive) and on the use of antibiotics.

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