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Objective:To collect context-specific insights into maternal and child health and nutrition issues, and to explore potential solutions in Nanoro, Burkina Faso.Design:Eleven focus groups with men and women from eleven communities, facilitated by local researchers.Setting:The study took place in the Nanoro Health district, in the West-Central part of Burkina Faso.Participants:Eighty-six men (18–55 years) and women by age group: 18–25; 26–34 and 35–55 years, participated in the group discussions.Results:Participants described barriers to optimal nutrition of mothers and children related to a range of community factors, with gender inequality as central. Major themes in the discussions are related to poverty and challenges generated by socially and culturally determined gender roles. Sub-themes are women lacking access to food whilst pregnant and having limited access to health care and opportunities to generate income. Although communities believe that food donations should be implemented to overcome this, they also pointed out the need for enhancing their own food production, requiring improved agricultural technologies. Given the important role that women could play in reducing malnutrition, these communities felt they needed to be empowered to do so and supported by men. They also felt that this had to be carried out in the context of an enhanced health care system.Conclusions:Findings reported here highlight the importance of nutrition-sensitive interventions and women’s empowerment in improving maternal and child nutrition. There is a need to integrate a sustainable multi-sectorial approach which goes beyond food support.

Objective:Despite efforts to improve maternal and child nutrition, undernutrition remains a major public health challenge in Ghana. The current study explored community perceptions of undernutrition and context-specific interventions that could improve maternal and child nutrition in rural Northern Ghana.Design:This exploratory qualitative study used ten focus group discussions to gather primary data. The discussions were recorded, transcribed and coded into themes using Nvivo 12 software to aid thematic analysis.Setting:The study was conducted in rural Kassena-Nankana Districts of Northern Ghana.Study participants:Thirty-three men and fifty-one women aged 18–50 years were randomly selected from the community.Results:Most participants reported poverty, lack of irrigated agricultural land and poor harvests as the main barriers to optimal nutrition. To improve maternal and child nutrition, study participants suggested that the construction of dams at the community level would facilitate all year round farming including rearing of animals. Participants perceived that the provision of agricultural materials such as high yield seedlings, pesticides and fertiliser would help boost agricultural productivity. They also recommended community-based nutrition education by trained health volunteers, focused on types of locally produced foods and appropriate ways to prepare them to help improve maternal and child nutrition.Conclusion:Drawing on these findings and existing literature, we argue that supporting community initiated nutrition interventions such as improved irrigation for dry season farming, provision of agricultural inputs and community education could improve maternal and child nutrition.

Objective:To identify peri-conceptional diet patterns among women in Bangalore and examine their associations with risk of gestational diabetes mellitus (GDM).Design:BAngalore Nutrition Gestational diabetes LifEstyle Study, started in June 2016, was a prospective observational study, in which women were recruited at 5–16 weeks’ gestation. Peri-conceptional diet was recalled at recruitment, using a validated 224-item FFQ. GDM was assessed by a 75-g oral glucose tolerance test at 24–28 weeks’ gestation, applying WHO 2013 criteria. Diet patterns were identified using principal component analysis, and diet pattern–GDM associations were examined using multivariate logistic regression, adjusting for ‘a priori’ confounders.Setting:Antenatal clinics of two hospitals, Bangalore, South India.Participants:Seven hundred and eighty-five pregnant women of varied socio-economic status.Results:GDM prevalence was 22 %. Three diet patterns were identified: (a) high-diversity, urban (HDU) characterised by diverse, home-cooked and processed foods was associated with older, more affluent, better-educated and urban women; (b) rice-fried snacks-chicken-sweets (RFCS), characterised by low diet diversity, was associated with younger, less-educated, and lower-income, rural and joint families; and (c) healthy, traditional vegetarian (HTV), characterised by home-cooked vegetarian and non-processed foods, was associated with less-educated, more affluent, and rural and joint families. The HDU pattern was associated with a lower GDM risk (adjusted odds ratio (aOR): 0·80/sd, 95 % CI (0·64, 0·99), P = 0·04) after adjusting for confounders. BMI was strongly related to GDM risk and possibly mediated diet–GDM associations.Conclusions:The findings support global recommendations to encourage women to attain a healthy pre-pregnancy BMI and increase diet diversity. Both healthy and unhealthy foods in the patterns indicate low awareness about healthy foods and a need for public education.

Background: Maternal nutrition influences fetal development and may permanently alter ("program") offspring body composition and metabolism, thereby influencing later risk of diabetes and cardiovascular (cardiometabolic) disease. The prevalence of cardiometabolic disease is rising rapidly in India. Objectives: To test the hypothesis that supplementing low-income Indian women with micronutrient-rich foods preconceptionally and during pregnancy has a beneficial impact on the children's body composition and cardiometabolic risk marker profiles. Methods: Follow-up of 1255 children aged 5-10 y whose mothers took part in the Mumbai Maternal Nutrition Project [Project "SARAS"; International Standard Randomised Controlled Trial Number (ISRCTN)62811278]. Mothers were randomly assigned to receive a daily micronutrient-rich snack or a control snack of lower micronutrient content, both made from local foods, in addition to normal diet, from before pregnancy until delivery. Children's body composition was assessed using anthropometry and DXA. Their blood pressure, plasma glucose, insulin, and lipid concentrations were measured. Outcomes were compared between allocation groups with and without adjustment for confounding factors. Results: Overall, 15% of children were stunted, 34% were wasted, and 3% were overweight. In the intention-To-Treat analysis, there were no differences in body composition or risk markers between children in the intervention and control groups. Among children whose mothers started supplementation ≥3 mo before conception (the "per protocol"sample) the intervention increased adiposity among girls, but not boys. BMI in girls was increased relative to controls by 2% (95% CI: 1, 4; P = 0.01); fat mass index by 10% (95% CI: 3, 18; P = 0.004); and percent fat by 7% (95% CI: 1, 13; P = 0.01) unadjusted, with similar results in adjusted models. Conclusions: Overall, supplementing women with micronutrient-rich foods from before pregnancy until delivery did not alter body composition or cardiometabolic risk markers in the children. Subgroup analyses showed that, if started ≥3 mo before conception, supplementation may increase adiposity among female children.

Objective:To determine whether food security, diet diversity and diet quality are associated with anthropometric measurements and body composition among women of reproductive age. The association between food security and anaemia prevalence was also tested.Design:Secondary analysis of cross-sectional data from the Healthy Life Trajectories Initiative (HeLTI) study. Food security and dietary data were collected by an interviewer-administered questionnaire. Hb levels were measured using a HemoCue, and anaemia was classified as an altitude-adjusted haemoglobin level < 12·5 g/dl. Body size and composition were assessed using anthropometry and dual-energy x-ray absorptiometry.Setting:The urban township of Soweto, Johannesburg, South Africa.Participants:Non-pregnant women aged 18–25 years (n 1534).Results:Almost half of the women were overweight or obese (44 %), and 9 % were underweight. Almost a third of women were anaemic (30 %). The prevalence rates of anaemia and food insecurity were similar across BMI categories. Food insecure women had the least diverse diets, and food security was negatively associated with diet quality (food security category v. diet quality score: B = –0·35, 95 % CI –0·70, –0·01, P = 0·049). Significant univariate associations were observed between food security and total lean mass. However, there were no associations between food security and body size or composition variables in multivariate models.Conclusions:Our data indicate that food security is an important determinant of diet quality in this urban-poor, highly transitioned setting. Interventions to improve maternal and child nutrition should recognise both food security and the food environment as critical elements within their developmental phases.

Objective:To obtain a community perspective on key nutrition-specific problems and solutions for mothers and children.Design:A qualitative study comprising nine focus group discussions (FGD) following a semi-structured interview guide.Setting:The township of Soweto in South Africa with a rising prevalence of double burden of malnutrition.Participants:Men and women aged ≥18 years (n 66). Three FGD held with men, six with women.Results:Despite participants perceived healthy diet to be important, they felt their ability to maintain a healthy diet was limited. Inexpensive, unhealthy food was easier to access in Soweto than healthier alternatives. Factors such as land use, hygiene and low income played a fundamental role in shaping access to foods and decisions about what to eat. Participants suggested four broad areas for change: health sector, social protection, the food system and food environment. Their solutions ranged from improved nutrition education for women at clinic visits, communal vegetable gardens and government provision of food parcels to regulatory measures to improve the healthiness of their food environment.Conclusions:South Africa’s current nutrition policy environment does not adequately address community-level needs that are often linked to structural factors beyond the health sector. Our findings suggest that to successfully address the double burden of malnutrition among women and children, a multifaceted approach is needed combining action on the ground with coherent policies that address upstream factors, including poverty. Further, there is a need for public engagement and integration of community perspectives and priorities in developing and implementing double-duty actions to improve nutrition.

Objective:To explore the perceptions of adolescents and their caregivers on drivers of diet and physical activity in rural India in the context of ongoing economic, social and nutrition transition.Design:A qualitative study comprising eight focus group discussions (FGD) on factors affecting eating and physical activity patterns, perceptions of health and decision-making on food preparation.Setting:Villages approximately 40–60 km from the city of Pune in the state of Maharashtra, India.Participants:Two FGD with adolescents aged 10–12 years (n 20), two with 15- to 17- year-olds (n 18) and four with their mothers (n 38).Results:Dietary behaviour and physical activity of adolescents were perceived to be influenced by individual and interpersonal factors including adolescent autonomy, parental influence and negotiations between adolescents and caregivers. The home food environment, street food availability, household food security and exposure to television and digital media were described as influencing behaviour. The lack of facilities and infrastructure was regarded as barriers to physical activity as were insufficient resources for public transport, safe routes for walking and need for cycles, particularly for girls. It was suggested that schools take a lead role in providing healthy foods and that governments invest in facilities for physical activity.Conclusions:In this transitioning environment, that is representative of many parts of India and other Lower Middle Income Countries (LMIC), people perceive a need for interventions to improve adolescent diet and physical activity. Caregivers clearly felt that they had a stake in adolescent health, and so we would recommend the involvement of both adolescents and caregivers in intervention design.

Objective:To explore community perceptions on maternal and child nutrition issues in Sub-Saharan Africa.Design:Thirty focus groups with men and women from three communities facilitated by local researchers.Setting:One urban (Soweto, South Africa) and two rural settings (Navrongo, Ghana and Nanoro, Burkina Faso) at different stages of economic transition.Participants:Two hundred thirty-seven men and women aged 18–55 years, mostly subsistence farmers in Navrongo and Nanoro and low income in Soweto.Results:Differences in community concerns about maternal and child health and nutrition reflected the transitional stage of the country. Community priorities revolved around poor nutrition and hunger caused by poverty, lack of economic opportunity and traditional gender roles. Men and women felt they had limited control over food and other resources. Women wanted men to take more responsibility for domestic chores, including food provision, while men wanted more involvement in their families but felt unable to provide for them. Solutions suggested focusing on ways of increasing control over economic production, family life and domestic food supplies. Rural communities sought agricultural support, while the urban community wanted regulation of the food environment.Conclusions:To be acceptable and effective, interventions to improve maternal and child nutrition need to take account of communities’ perceptions of their needs and address wider determinants of nutritional status and differences in access to food reflecting the stage of the country’s economic transition. Findings suggest that education and knowledge are necessary but not sufficient to support improvements in women’s and children’s nutritional status.

Objective:To explore, from the perspectives of adolescents and caregivers, and using qualitative methods, influences on adolescent diet and physical activity in rural Gambia.Design:Six focus group discussions (FGD) with adolescents and caregivers were conducted. Thematic analysis was employed across the data set.Setting:Rural region of The Gambia, West Africa.Participants:Participants were selected using purposive sampling. Four FGD, conducted with forty adolescents, comprised: girls aged 10–12 years; boys aged 10–12 years; girls aged 15–17 years, boys aged 15–17 years. Twenty caregivers also participated in two FGD (mothers and fathers).Results:All participants expressed an understanding of the association between salt and hypertension, sugary foods and diabetes, and dental health. Adolescents and caregivers suggested that adolescent nutrition and health were shaped by economic, social and cultural factors and the local environment. Adolescent diet was thought to be influenced by: affordability, seasonality and the receipt of remittances; gender norms, including differences in opportunities afforded to girls, and mother-led decision-making; cultural ceremonies and school holidays. Adolescent physical activity included walking or cycling to school, playing football and farming. Participants felt adolescent engagement in physical activity was influenced by gender, seasonality, cultural ceremonies and, to some extent, the availability of digital media.Conclusions:These novel insights into local understanding should be considered when formulating future interventions. Interventions need to address these interrelated factors, including misconceptions regarding diet and physical activity that may be harmful to health.

Objective:To describe the anthropometry, socioeconomic circumstances, diet and screen time usage of adolescents in India and Africa as context to a qualitative study of barriers to healthy eating and activity.Design:Cross-sectional survey, including measured height and weight and derived rates of stunting, low BMI, overweight and obesity. Parental schooling and employment status, household assets and amenities, and adolescents’ dietary diversity, intake of snack foods, mobile/smartphone ownership and TV/computer time were obtained via a questionnaire.Setting:Four settings each in Africa (rural villages, West Kiang, The Gambia; low-income urban communities, Abidjan, Cote D’Ivoire; low/middle-class urban communities, Jimma, Ethiopia; low-income township, Johannesburg, South Africa) and India (rural villages, Dervan; semi-rural villages, Pune; city slums, Mumbai; low-middle/middle-class urban communities, Mysore).Participants:Convenience samples (n 41–112 per site) of boys and girls, half aged 10–12 years and another half aged 15–17 years, were recruited for a qualitative study.Results:Both undernutrition (stunting and/or low BMI) and overweight/obesity were present in all settings. Rural settings had the most undernutrition, least overweight/obesity and greatest diet diversity. Urban Johannesburg (27 %) and Abidjan (16 %), and semi-rural Pune (16 %) had the most overweight/obesity. In all settings, adolescents reported low intakes of micronutrient-rich fruits and vegetables, and substantial intakes of salted snacks, cakes/biscuits, sweets and fizzy drinks. Smartphone ownership ranged from 5 % (West Kiang) to 69 % (Johannesburg), higher among older adolescents.Conclusions:The ‘double burden of malnutrition’ is present in all TALENT settings. Greater urban transition is associated with less undernutrition, more overweight/obesity, less diet diversity and higher intakes of unhealthy/snack foods.

Objective:To explore influences on adolescent diet and physical activity, from the perspectives of adolescents and their caregivers, in Jimma, Ethiopia.Design:Qualitative design, using focus group discussions (FGD).Setting:A low-income setting in Jimma, Ethiopia.Participants:Five FGD with adolescents aged 10–12 years and 15–17 years (n 41) and three FGD with parents (n 22) were conducted.Results:Adolescents displayed a holistic understanding of health comprising physical, social and psychological well-being. Social and cultural factors were perceived to be the main drivers of adolescent diet and physical activity. All participants indicated that caregivers dictated adolescents’ diet, as families shared food from the same plate. Meals were primarily determined by caregivers, whose choices were driven by food affordability and accessibility. Older adolescents, particularly boys, had opportunities to make independent food choices outside of the home which were driven by taste and appearance, rather than nutritional value. Many felt that adolescent physical activity was heavily influenced by gender. Girls’ activities included domestic work and family responsibilities, whereas boys had more free time to participate in outdoor games. Girls’ safety was reported to be a concern to caregivers, who were fearful of permitting their daughters to share overcrowded outdoor spaces with strangers.Conclusions:Adolescents and caregivers spoke a range of social, economic and cultural influences on adolescent diet and physical activity. Adolescents, parents and the wider community need to be involved in the development and delivery of effective interventions that will take into consideration these social, economic and cultural factors.

Objective:To explore adolescents’ perceptions, knowledge and behaviours regarding nutrition and physical activity in low-income districts of Abidjan, Côte d’Ivoire, taking into consideration their caregivers’ perspectives.Design:Two investigators conducted six focus group discussions.Setting:The study was carried out in two low-income suburbs, Yopougon and Port-Bouët, in Abidjan, Côte d’Ivoire.Participants:Adolescents and their caregivers were recruited into the study via local head teachers and heads of settlement.Results:Overall, seventy-two participants, including forty-six adolescents and twenty-six caregivers, took part. Participants demonstrated good nutrition knowledge, relating nutritional health to a balanced diet and hygiene. Sustained physical activity was reported. However, adopting good practices was challenging due to participant’s economic circumstances. Their environment was a barrier to improving health due to dirtiness and violence, with a lack of space limiting the possibility to practice sport. Adolescents and their caregivers differed in their response to these constraints. Many caregivers felt powerless and suggested that a political response was the solution. Alternatively, adolescents were more likely to suggest new creative solutions such as youth-friendly centres within their community.Conclusions:Participants were aware that their nutritional habits were not in line with what they had learnt to be good nutritional practices due to socio-economic constraints. Physical activity was part of adolescent life, but opportunities to exercise were restricted by their environment. Strategies for improving adolescent health in these settings need to be developed in collaboration with adolescents in a manner that accommodates their opinions and solutions.

Objective:To explore, adolescents’ and caregivers’ perspectives, about shaping of diet and physical activity habits in rural Konkan, India.Design:Five focus group discussions (FGD) were conducted with adolescents and two with caregivers. Data were analysed using thematic analysis.Setting:FGD were conducted in secondary schools located in remote rural villages in the Ratnagiri district, Konkan region, Maharashtra, India.Participants:Forty-eight adolescents were recruited including twenty younger (10–12 years) and twenty-eight older (15–17 years) adolescents. Sixteen caregivers (all mothers) were also recruited.Results:Three themes emerged from discussion: (i) adolescents’ and caregivers’ perceptions of the barriers to healthy diet and physical activity, (ii) acceptance of the status quo and (iii) salience of social and economic transition. Adolescents’ basic dietary and physical activity needs were rarely met by the resources available and infrastructure of the villages. There were few opportunities for physical activity, other than performing household chores and walking long distances to school. Adolescents and their caregivers accepted these limitations and their inability to change them. Increased use of digital media and availability of junk foods marked the beginning of a social and economic transition.Conclusion:FGD with adolescents and their caregivers provided insights into factors influencing adolescent diet and physical activity in rural India. Scarcity of basic resources limited adolescent diet and opportunities for physical activity. To achieve current nutritional and physical activity recommendations for adolescents requires improved infrastructure in these settings, changes which may accompany the current Indian social and economic transition.

Background Adolescence is an important transitional period in which major physical, psychological and cognitive changes occur. Lifestyle habits during this time, particularly related to dietary behaviour and physical activity, strongly influence overall health and non-communicable disease risk in adulthood. There are gaps in knowledge about the determinants of food choices and physical activity habits of adolescents in low and middle income countries. Objectives To identify factors which influence the food choices and physical activity habits of adolescents in the South Indian city of Mysore, India. Methods Six focus group discussions were conducted in selected urban neighbourhoods of Mysore. Thirty volunteers were recruited by purposive sampling method to include younger (10-12 years old, n=12) and older (15-17 years old, n=12) adolescents, and caregivers of adolescents (n=6). The focus group discussions were conducted by investigators who were native to the region Results Despite revealing a propensity for consuming fast foods, adolescents ate home cooked meals regularly, and both young people and their parents were satisfied with the quality of the adolescents’ diets. Also, all participant groups reported that adolescents regularly played and enjoyed games and sports, and did household chores as part of their physical activity. However, the pressure of schoolwork and the increasing amounts of time spent on digital devices including mobile phones were major constraints to being active. Conclusions Adolescents and caregivers perceive that Mysore adolescents’ dietary habits remain satisfactory. Academic study was found to be the priority in adolescents’ lives. This is recognized and accepted both socially and culturally as the right choice by parents and young people alike. Therefore, not much time or effort is spent on being active. A contradiction is that although time is considered to be a scarce commodity that necessitates careful partitioning, any surplus time is preferentially spent in playing digital games and interacting on social media. Interventions are needed to increase the amount of physical activity undertaken by Mysore adolescents.

This study examined associations between a maternal “mixed, high sugar” dietary pattern during pregnancy and ultrasound‐determined fetal growth in 495 urban African women and explored whether these associations were independent of maternal baseline body mass index (BMI) and gestational weight gain (GWG). Linear mixed effects modelling (LMM) was used to test the associations between maternal mixed, high sugar dietary pattern score, baseline BMI (kg/m2), and GWG (kg/week) and the following fetal growth outcomes: (a) biparietal diameter (cm), (b) head circumference (cm), (c) abdominal circumference (cm), and (d) femur length (cm). In the pooled LMM, a +1 standard deviation (SD) increase in the mixed, high sugar dietary pattern score was associated with higher biparietal diameter (0.03 cm/+1 SD; p = .007), head circumference (0.07 cm/+1 SD; p = .026), abdominal circumference (0.08 cm/+1 SD; p = .038), and femur length (0.02 cm/+1 SD; p = .015). Although these associations were independent of maternal BMI and GWG, higher baseline BMI was independently and positively associated with abdominal circumference (0.03 cm/+1 kg/m2; p = .011) and femur length (0.01 cm/+1 kg/m2; p = .007) and 1 kg/week greater GWG was associated with a 0.82 cm increase in abdominal circumference (p = .007). In urban African settings, where preconception maternal obesity prevalence is high and processed, high sugar diets are common, improving maternal dietary intake and BMI prior to conception should be prioritised for optimising pregnancy and birth outcomes as well as longer‐term offspring health. In addition, dietary management strategies during pregnancy may be beneficial in facilitating healthy fetal growth.

Background: Diets in rural India are cereal based with low intakes of micronutrient-rich foods. The value chains for nutrition approach aims to study supply and demand of such foods. This may aid in development of interventions to improve diets and livelihoods. Objectives: (1) To identify how fruit and vegetables are accessed, (2) to describe and map the structure of value chains for exemplar foods, (3) to understand how foods are priced, and (4) to explore factors that affect decisions about which crops are grown, marketed, and sold. Methods: After stakeholder consultation, we identified 2 fruits (mango and guava) and 2 vegetables (shepu and spinach) as exemplar foods. Criteria for these exemplar foods were that they should be known to participants and there should be variability in intakes. We held 24 interviews with value chain actors including farmers, wholesalers, and vendors of the exemplar foods. Data collection was stopped when no new information emerged. We used inductive thematic coding for our analysis. Results: The value chains for each of the exemplar foods were relatively simple and involved farmers, middlemen, and vendors at either city or village level. The main themes identified as being factors considered when making decisions about which foods to grow and sell were (1) farming resources and assets, (2) quality of produce, (3) environmental conditions, (4) financial factors, (5) transport availability, and (6) consumer demand. Conclusions: There are opportunities to intervene within fruit and vegetable value chains to increase availability, affordability, and access to produce in rural India. Future research is required to determine which interventions will be feasible, effective, and acceptable to the community and other stakeholders.

Background: Micronutrient insufficiencies are a serious public health problem among women of reproductive age in Low and Middle Income Countries including India, adversely affecting maternal health and economic productivity, and child growth and educational outcomes. Fruit and vegetables are important sources of micronutrients and consumption of these foods is less than recommendations. Objective: To identify perceived barriers and facilitators to fruit and vegetable consumption among women of reproductive age living in rural communities in Eastern Maharashtra, India.Methods: We used qualitative methods and held 9 focus group discussions and 12 one to one interviews. The data collection was stopped when no new information emerged. We used inductive thematic coding to analyse the data. Women aged 18-40 years were recruited from eight villages surrounding the city of Wardha, Maharashtra, India.Results: Women knew that fruit and vegetables were beneficial to health and expressed that they wanted to increase intakes of these foods for themselves and their children. Seven main themes were identified as being barriers or facilitators to fruit and vegetable consumption: 1) Personal factors; 2) Household dynamics; 3) Social and Cultural Norms; 4) Workload; 5) Time pressures; 6) Environmental Factors; 7) Cost. Conclusions: Rural Indian women consumed fruit and vegetables infrequently and said they would like to consume more. Several potentially modifiable factors affecting intakes were identified. Value chain analyses of fruit and vegetables in these communities are important to identify opportunities to intervene to increase consumption.

Background:Physical inactivity in children and youth in India is a major public health problem. The 2016 Indian Report Card on Physical Activity for Children and Youth has been conceptualized to highlight this epidemic by appraising behaviors, contexts, strategies, and investments related to physical activity of Indian children and youth.Methods:An international research collaboration resulted in the formation of a Research Working Group (RWG). RWG determined key indicators; identified, synthesized, and analyzed existing evidence; developed criteria for assigning grades; and, finally, assigned grades to indicators based on consensus.Results:Overall Physical Activity Levels were assigned a grade of C-. Active Transportation and Sedentary Behaviors were both assigned a grade of C. Government Strategies and Investments was assigned a grade of D. Six other indicators, including the country-specific indicator Physical Fitness, were graded as INC (incomplete) due to the lack of nationally representative evidence.Conclusions:Based on existing evidence, it appears that most Indian children do not achieve recommended levels of physical activity and spend most of their day in sedentary pursuits. The report card identifies gaps in both investments and research that need to be addressed before understanding the complete picture of active living in children and youth in India.

Background The aim of this study was to determine whether physical activity volume and intensity in mid-childhood and early adolescence were associated with cardiometabolic risk factors at 13.5 years. Methods Participants were recruited from the Mysore Parthenon observational birth cohort. At ages 6–10 and 11–13 years, volume and intensity of physical activity were assessed using AM7164 or GT1M actigraph accelerometers worn for ≥4 days, and expressed as mean counts per day and percentage time spent in light, moderate and vigorous physical activity according to criteria defined by Evenson et al. At 13.5 years, fasting blood samples were collected; lipids, glucose and insulin concentrations were measured and insulin resistance (HOMA) was calculated. Systolic and diastolic blood pressure were measured at the left arm using a Dinamap (Criticon). Anthropometry and bio-impedance analysis were used to assess body size and composition. Metabolic and anthropometric measures were combined to produce a metabolic syndrome risk score. Results At 6–10 years, boys and girls respectively spent a median (IQR) of 1.1 (0.5, 2.0) % and 0.8 (0.4, 1.3) % of recorded time vigorously active. At 11–13 years, boys and girls respectively spent a median (IQR) of 0.8 (0.4, 1.7) % and 0.3 (0.1, 0.6) % of time vigorously active. All of the physical activity parameters were positively correlated between the 6–10 year and the 11–13 year measurements indicating that physical activity tracked from childhood to early adolescence. There were no associations between physical activity at 6–10 years and individual 13.5 year risk factors but % time vigorously active was inversely associated with metabolic syndrome score (B = −0.40, 95% CI −0.75, 0.05). Volume of physical activity at 11–13 years was inversely associated with 13.5 year HOMA and fat percentage and vigorous physical activity was associated with HOMA, fat percentage, sum of skinfolds, waist circumference and total: HDL cholesterol ratio. Vigorous physical activity was inversely associated with metabolic syndrome score (B = −0.51, 95% CI −0.94, −0.08). Conclusions Volume and intensity of physical activity in early adolescence were negatively associated with metabolic and anthropometric risk factors. Interventions that aim to increase adolescent physical activity, especially vigorous, may prevent cardiometabolic disease in later life.

Background: Young maternal age is associated with poorer birth outcomes, but the mechanisms are incompletely understood. Using data from a prospective cohort of pregnant women living in Mumbai slums, India, we tested whether lower maternal age was associated with adverse fetal growth. Methods: Fetal crown-rump length (CRL) was recorded at a median (interquartile range, IQR) of 10 weeks' gestation (9-10 weeks). Head circumference (HC), biparietal diameter (BPD), femur length (FL), and abdominal circumference (AC) were recorded at 19 (19-20) and 29 (28-30) weeks. Newborns were measured at a median (IQR) of 2 days (1-3 days) from delivery. Gestation was assessed using prospectively collected menstrual period dates. Results: The sample comprised 1653 singleton fetuses without major congenital abnormalities, of whom 1360 had newborn measurements. Fetuses of younger mothers had smaller CRL (0.01 standard deviation [SD] per year of maternal age; 95% confidence interval CI: 0.00-0.02(1); P = .04), and smaller HC, FL, and AC at subsequent visits. Fetal growth of HC (0.04 cm; 95% CI: 0.02-0.05; P < .001), BPD (0.01 cm; 95% CI: 0.00-0.01; P = .009), FL (0.04 cm; 95% CI: 0.02-0.06; P < .001), and AC (0.01 cm; 95% CI: 0.00-0.01; P = .003) up to the third trimester increased with maternal age. Skinfolds, head, and mid-upper arm circumferences were smaller in newborns of younger mothers. Adjusting for maternal prepregnancy socioeconomic status, body mass index, height, and parity attenuated the associations between maternal age and newborn size but did not change those with fetal biometry. Conclusion: Fetuses of younger mothers were smaller from the first trimester onward and grew slower, independently of known confounding factors.

Objectives To (1) describe micronutrient intakes among women of reproductive age living in Mumbai slums; (2) assess the adequacy of these intakes compared with reference values; (3) identify important dietary sources of micronutrients. Subjects/methods Participants were 6426 non-pregnant women aged 16–39 years, registered in a randomised controlled trial of a food-based intervention set in the Bandra, Khar and Andheri areas of Mumbai, India. Cross-sectional quantified food frequency questionnaire (FFQ) data were collected. Vitamin (n = 9) and mineral (n = 6) intakes were calculated and analysed in relation to dietary reference values (DRVs). Important dietary sources were identified for each micronutrient. Results Median intakes of all micronutrients, except vitamin E, were below the FAO/WHO reference nutrient intake (RNI). Intakes of calcium, iron, vitamin A and folate were furthest from the RNI. For seven of the micronutrients, over half of the women had intakes below the lower reference nutrient intake (LRNI); this figure was over 75% for calcium and riboflavin. The majority of women (93%) had intakes below the EAR for 5 or more micronutrients, and 64% for 10 or more. Adolescents had lower intakes than women aged >19 years. Less than 1% of adult women and no adolescents met the EAR for all micronutrients. Animal source foods and micronutrient-rich fruit and vegetables were consumed infrequently. Conclusions These women had low intakes of multiple micronutrients, increasing their risk of insufficiency. There is a need to determine the factors causing poor intakes, to direct interventions that improve diet quality and nutritional sufficiency.

Background:Early life nutrition may affect individuals’ susceptibility to adult non-communicable diseases (NCD). Psychological stress is a well-recognised NCD risk factor. Recent evidence suggests that impaired foetal nutrition alters neuro-endocrine pathways, and hypothalamic-pituitary-adrenal axis feedback systems, resulting in abnormal stress responses, and NCD risk. This study aims to examine adolescent cortisol and cardiovascular stress responses in relation to maternal nutrition and contemporaneous NCD risk markers.Methods: The study sample will be drawn from three well-established birth cohorts in India; the Parthenon cohort, Mysore (N=550, age~20y), the SARAS KIDS prenatal intervention cohort, Mumbai (N=300, age~10-12y) and the Pune Rural Intervention in Young Adults/ PRIYA cohort, Pune (N=100, age~22y). We will perform the ‘Trier Social Stress Test (TSST)’, a well-accepted stress-test module which involves participants performing 5-minutes each of public speaking and mental arithmetic tasks in front of unfamiliar ‘judges’ (stressor). Repeated measures of salivary cortisol and autonomic cardiovascular outcomes relative to the stressor will be assessed. Measures of psychological stress, cognitive function, blood pressure, glucose-insulin metabolism and depression will be carried out. Mechanistic studies including DNA methylation in gluco-corticoid receptor (NR3C1) and11β-HSD2gene loci and neuroimaging will be carried out in a subsample. Qualitative interviews and focus group discussions in a subsample of the Parthenon cohort will explore the perception of stress and stressors among the youth.We will convert repeated measures into time-weighted averages before analysis. We will carry out multivariable regression analysis to test the associations. We will further refine the analyses using the mixed-model regression and conditional analyses for the association with repeated measures. Ethics and dissemination:This study has been approved by the research ethics committee of CSI Holdsworth Memorial Hospital, Mysore. The findings will be disseminated locally and at international meetings, and reports will be submitted to open access peer reviewed journals.

Religion has played an important role in shaping the dietary habits of the population in different parts of the world. Vegetarianism is strongly associated with a number of religions that originated in ancient India, which advocate nonviolence. Although vegetarian diet has been shown to be associated with several health benefits in traditionally meat eating societies, in predominantly vegetarian populations such as in India, vegetarian lifestyle may confer nutritional imbalances and consequent effects on long-term health in children. These effects may be due to maternal macro- and micronutrient deficiencies and excesses leading to compromised fetal growth. Impaired postnatal and childhood growth due to nutritional imbalances in the unsupplemented vegetarian diet may further exacerbate these effects. The future focus should be on devising religion- and culture-appropriate intervention methods to prevent the adverse effects of vegetarian diets on health in children.

Improving micronutrient intakes of under‐nourished mothers in low‐ and middle‐income countries increases birth weight, but there is little data on the nature and timing during gestation of any effects on fetal growth. Ultrasound measures of fetal size were used to determine whether and when a food‐based supplement affected fetal growth. Non‐pregnant women living in Mumbai slums, India (N = 6,513), were randomly assigned to receive either a daily micronutrient‐rich snack containing green leafy vegetables, fruit, and milk (treatment) or a snack made from lower‐micronutrient vegetables (control) in addition to their usual diet from before pregnancy until delivery. From 2,291 pregnancies, the analysis sample comprised 1,677 fetuses (1,335 fetuses of women supplemented for ≥3 months before conception). First‐trimester (median: 10 weeks, interquartile range: 9–12 weeks) fetal crown‐rump length was measured. Fetal head circumference, biparietal diameter, femur length, and abdominal circumference were measured during the second (19, 19–20 weeks) and third trimesters (29, 28–30 weeks). The intervention had no effect on fetal size or growth at any stage of pregnancy. In the second trimester, there were interactions between parity and allocation group for biparietal diameter (p = .02) and femur length (p = .04) with both being smaller among fetuses of primiparous women and larger among those of multiparous women, in the treatment group compared with the controls. Overall, a micronutrient‐rich supplement did not increase standard ultrasound measures of fetal size and growth at any stage of pregnancy. Additional ultrasound measures of fetal soft tissues (fat and muscle) may be informative.

Background: Prospective observational studies suggest that maternal diets rich in leafy green vegetables and fruit may help prevent gestational diabetes mellitus (GDM). Objective: Our objective was to test whether increasing women’s dietary intake of leafy green vegetables, fruit, and milk before conception and throughout pregnancy reduced their risk of GDM. Methods: Project SARAS (“excellent”) (2006–2012) was a nonblinded, individually randomized, controlled trial in women living in slums in the city of Mumbai, India. The interventions included a daily snack made from leafy green vegetables, fruit, and milk for the treatment group or low-micronutrient vegetables (e.g., potato and onion) for the control group, in addition to the usual diet. Results for the primary outcome, birth weight, have been reported. Women were invited to take an oral-glucose-tolerance test (OGTT) at 28–32 wk gestation to screen for GDM (WHO 1999 criteria). The prevalence of GDM was compared between the intervention and control groups, and Kernel density analysis was used to compare distributions of 120-min plasma glucose concentrations between groups. Results: Of 6513 women randomly assigned, 2291 became pregnant; of these, 2028 reached a gestation of 28 wk, 1008 (50%) attended for an OGTT, and 100 (9.9%) had GDM. In an intention-to-treat analysis, the prevalence of GDM was reduced in the treatment group (7.3% compared with 12.4% in controls; OR: 0.56; 95% CI: 0.36, 0.86; P = 0.008). The reduction in GDM remained significant after adjusting for prepregnancy adiposity and fat or weight gain during pregnancy. Kernel density analysis showed that this was explained by the fact that fewer women in the treatment group had a 2-h glucose concentration in the range 7.5–10.0 mmol/L. Conclusions: In low-income settings, in which women have a low intake of micronutrient-rich foods, improving dietary micronutrient quality by increasing intake of leafy green vegetables, fruit, and/or milk may have an important protective effect against the development of GDM. This trial was registered at www.controlled-trials.com as ISRCTN62811278.

Background The mother is the only source of nutrition for fetal growth including brain development. Maternal nutritional status (anthropometry, macro- and micro-nutrients) before and/or during pregnancy is therefore a potential predictor of offspring cognitive function. The relationship of maternal nutrition to offspring cognitive function is unclear. This review aims to assess existing evidence linking maternal nutritional status with offspring cognitive function. Methods Exposures considered were maternal BMI, height and weight, micronutrient status (vitamins D, B12, folate and iron) and macronutrient intakes (carbohydrate, protein and fat). The outcome was any measure of cognitive function in children aged