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1.  Determinants of breastfeeding indicators among children less than 24 months of age in Tanzania: a secondary analysis of the 2010 Tanzania Demographic and Health Survey 
BMJ Open  2013;3(1):e001529.
To examine the prevalence of key WHO breastfeeding indicators and identify determinants of suboptimal breastfeeding practices among children aged less than 24 months in Tanzania.
Design, setting and participants
Secondary analyses of cross-sectional data from the 2010 Tanzania Demographic and Health Survey. The survey used a stratified two-stage cluster sample of 10 312 households from eight geographical zones of Tanzania. The sample consisted of 3112 children aged 0–23 months.
Main outcome measures
Outcome measures were factors significantly associated with delayed initiation of breastfeeding, non-exclusive breastfeeding and predominant breastfeeding in the first 6 months.
Breastfeeding was initiated within the first hour of birth in 46.1% of mothers. In infants aged less than 6 months, the prevalence of exclusive breastfeeding was 49.9% but only 22.9% were exclusively breastfed at 4–5 months. Seventeen per cent of infants, less than 6 months of age, were ‘predominantly breastfed’. At 12–15 months, 94.0% of infants were still breastfed but the proportion decreased to 51.1% at 20–23 months of age. Multivariate analysis revealed that the risk of delayed initiation of breastfeeding within 1 h after birth was significantly higher among young mothers aged <24 years, uneducated and employed mothers from rural areas who delivered by caesarean section and those who delivered at home and were assisted by traditional birth attendants or relatives. The risk factors associated with non-exclusive breastfeeding, during the first 6 months, were lack of professional assistance at birth and residence in urban areas. The risk of predominant breastfeeding was significantly higher among infants from the Zanzibar geographical zone.
Early initiation of breastfeeding and exclusive breastfeeding indicators were unsatisfactory and are below the national targets for Tanzania. To improve breastfeeding practices, national level programmes will be required, but with a focus on the target groups with suboptimal breastfeeding practices.
PMCID: PMC3549262  PMID: 23299109
Breastfeeding; Determinants; Early initiation of breastfeeding; Exclusive breastfeeding; Predominant breastfeeding; Tanzania
2.  Changing epidemiologic patterns of deliberate self poisoning in a rural district of Sri Lanka 
BMC Public Health  2012;12:593.
Acute poisoning is a major public health issue in many parts of the world. The epidemiology and the mortality rate is higher in low and middle income countries, including Sri Lanka. The aim of this study was to provide details about the epidemiology of acute poisoning in a rural Sri Lankan district and to identify the changing patterns and epidemiology of poisoning.
A prospective study was conducted from September 2008 to January 2010 in all hospitals with inpatient facilities in Anuradhapura district of North Central Province of Sri Lanka. Acute poisoning data was extracted from patient charts. Selected data were compared to the data collected from a 2005 study in 28 hospitals.
There were 3813 poisoned patients admitted to the hospitals in the Anuradhapura district over 17 months. The annual population incidence was 447 poisoning cases per 100,000 population. The total number of male and female patients was approximately similar, but the age distribution differed by gender. There was a very high incidence of poisoning in females aged 15–19, with an estimated cumulative incidence of 6% over these five years. Although, pesticides are still the most common type of poison, medicinal drug poisonings are now 21% of the total and have increased 1.6 fold since 2005.
Acute poisoning remains a major public health problem in rural Sri Lanka and pesticide poisoning remains the most important poison. However, cases of medicinal drug poisoning have recently dramatically increased. Youth in these rural communities remain very vulnerable to acute poisoning and the problem is so common that school-based primary prevention programs may be worthwhile.
Lalith Senarathna, Shaluka F Jayamanna, Patrick J Kelly, Nick A Buckley,michael J Dibley, Andrew H Dawson. These authors contributed equally to this work.
PMCID: PMC3458971  PMID: 22852867
3.  Validity and reliability of a physical activity questionnaire for Vietnamese adolescents 
Accurate assessment of physical activity in adolescents at population level is necessary. In Vietnam, the International Physical Activity Questionnaire (IPAQ) and Physical Activity Questionnaire for Adolescents (PAQA) have been validated against accelerometers for use in adolescents. However, these questionnaires were originally designed for adults and showed poor validity. This study aims to assess the reliability and validity of the Vietnamese Adolescent Physical Activity Recall Questionnaire (V-APARQ).
One hundred and sixty five students were recruited from four junior high schools in Ho Chi Minh City Vietnam in 2004. V-APARQ asked students to report their usual organised and non-organised physical activity during a normal week and moderate- (MPA), vigorous- (VPA and moderate-to-vigorous- (MVPA) physical activity were calculated. Reliability was assessed by test-retest (2 weeks apart). Construct validity was assess by 7-day accelerometry, following the completion of the first V-APARQ.
The construct validity of the V-APARQ showed Spearman correlation of 0.25 and 0.22 for the assessment of the questionnaire when compared to the accelerometer. Test-retest reliability showed a weighted Kappa of 0.75 and the intra-class correlation coefficient for MVPA was 0.57 for the whole group (MPA =0.37 and VPA = 0.62), and were higher in boys than girls. The Bland-Altman plots for reliability show a mean difference of 0.4 minutes (95 % CI = −3.2, 4.0) for daily MVPA (n = 146) and the limits of agreement were −42.6 to 43.4 mins/day. In boys MVPA was lower on the first, compared with second administration of V-APARQ while the reverse was observed among girls.
The reliability and validity of the V-APARQ were low to fair, but are comparable to other self-report physical activity questionnaires used among adolescents. V-APARQ will be useful for population monitoring of change in physical activity among urban Vietnamese adolescents.
PMCID: PMC3487813  PMID: 22853177
Reliability; Validity; Physical activity questionnaire; Adolescents; Vietnam
4.  Temporal trends and correlates of passive commuting to and from school in children from 9 provinces in China 
Preventive medicine  2011;52(6):423-427.
To examine trends and correlates of passive (inactive) commuting to school among Chinese children aged 6–18 years in nine provinces.
The trends analysis used school commuting data from the China Health and Nutrition Surveys in 1997 (n=2454), 2000 (n=1978), 2004 (n=1549) and 2006 (n=1236). Generalised estimating equations examined trends after adjusting for age, sex and region, and also explored the correlates of passive commuting to school in urban and rural areas (n=6935).
An increase in passive commuting to school was noted (3.6% in 1997, 14.1% in 2006, P < 0.0001). Children attending schools not located in their local community were more likely to passively commute. In urban areas, maternal education was associated with increased passive commuting (AOR = 1.41, 95%CI: 1.03–1.92). In rural areas, family income (AOR high/low = 2.12, 95%CI: 1.52–2.96), paternal education (AOR high/low = 1.56, 95%CI: 1.17 – 2.07), motorcycle ownership (AOR = 1.57, 95%CI: 1.19–2.07) were associated with passive commuting.
Passive commuting to school increased in China over a decade and was associated with family socioeconomic status, school location, and in rural children, with access to motorised vehicles.
PMCID: PMC3121931  PMID: 21524662
Children; trend; correlates; commuting; China
5.  School environment factors were associated with BMI among adolescents in Xi'an City, China 
BMC Public Health  2011;11:792.
School environment influences students' behaviours. The purpose of this research was to identify school environment factors associated with BMI.
A cross-sectional study was conducted among 1792 school-aged adolescents from 30 schools in six districts in Xi'an City in 2004. Height and weight were taken from students by trained field staff. School environment characteristics such as physical factors (school facilities, school shops and fast food outlets in school area), school curricula and policies were collected from school doctors using school environment questionnaire. School environment factors were identified in linear mixed effect models with BMI as outcome and adjusted for socio-demographic factors.
After adjusted for socio-demographic factors, BMI was associated with the availability of soft drinks at school shops, the availability and the number of western food outlet in the school vicinity. School curricula such as sports-meeting and health education session were also associated with BMI.
Urgent actions are needed to address the obesogenic elements of school environments. Community and school policy makers should make efforts for students to avoid exposure to fast food outlet in school area and soft drinks at school shops, and to improve school curricula to promote healthy behaviours.
PMCID: PMC3198712  PMID: 21988882
6.  Temporal trends and recent correlates in sedentary behaviours in Chinese children 
Sedentary behaviours (television, video and computer) are related to health outcomes independent of physical activity. Few studies have examined trends and correlates of sedentary behaviours among youth in developing nations. The current study is to examine temporal trends in sedentary behaviours and recent correlates of screen use in Chinese children during a period of economic transition.
Secondary analysis of China Health and Nutrition Surveys. Cross-sectional data on sedentary behaviours including screen use among children aged 6-18 years from four surveys in 1997 (n = 2,469), 2000 (n = 1,838), 2004 (n = 1,382) and 2006 (n = 1,128). Temporal trends in screen use by socio-demographic characteristics were examined. The correlates of spending more than 2 hours per day on screen time in the most recent survey data (2006, n = 986) were analysed using survey logistic regression analysis.
Daily screen time significantly increased in each subgroup by age, sex and urban/rural residence, with the largest increase for urban boys aged 13-18 years from 0.5 hours to 1.7 hours, and for rural boys aged 6-12 years from 0.7 hours to 1.7 hours (p < 0.0001). Daily time in both homework and extracurricular cultural activity increased significantly from 2000 to 2004 but was stable from 2004 to 2006. Boys (OR: 1.41, 95%CI: 1.09 -1.82), having a TV in the bedroom (OR: 1.86, 95%CI: 1.15 - 3.01), having access to internet at home (OR: 1.93, 95%CI: 1.12 - 3.31) or at internet cafés (OR: 2.01, 95%CI: 1.21 - 3.34), or often watching TV with parents (OR: 2.27, 95%CI: 1.37 - 3.74) were all associated with being more likely to be high screen users (≥ 2 hours/day). While children aged 13-18 years (OR: 0.67, 95%CI: 0.46-0.97) were less likely to be high screen users. Children whose parents often have rules on their TV viewing (OR: 0.64, 95%CI: 0.37 - 1.10) were slightly but not significantly less likely to be high screen users.
This study confirms sedentary behaviour has increased over the last decade in Chinese children. Efforts to ensure Chinese youth meet screen time guidelines include limiting access to screen technologies and encouraging parents to monitor their own screen time and to set limits on their child's screen time.
PMCID: PMC3182955  PMID: 21867565
sedentary; screen; trends; children; adolescents; correlates; China
7.  Effect of a Brief Outreach Educational Intervention on the Translation of Acute Poisoning Treatment Guidelines to Practice in Rural Sri Lankan Hospitals: A Cluster Randomized Controlled Trial 
PLoS ONE  2013;8(8):e71787.
In developing countries, including Sri Lanka, a high proportion of acute poisoning and other medical emergencies are initially treated in rural peripheral hospitals. Patients are then usually transferred to referral hospitals for further treatment. Guidelines are often used to promote better patient care in these emergencies. We conducted a cluster randomized controlled trial (ISRCTN73983810) which aimed to assess the effect of a brief educational outreach (‘academic detailing’) intervention to promote the utilization of treatment guidelines for acute poisoning.
Methods and Findings
This cluster RCT was conducted in the North Central Province of Sri Lanka. All peripheral hospitals in the province were randomized to either intervention or control. All hospitals received a copy of the guidelines. The intervention hospitals received a brief out-reach academic detailing workshop which explained poisoning treatment guidelines and guideline promotional items designed to be used in daily care. Data were collected on all patients admitted due to poisoning for 12 months post-intervention in all study hospitals. Information collected included type of poison exposure, initial investigations, treatments and hospital outcome. Patients transferred from peripheral hospitals to referral hospitals had their clinical outcomes recorded. There were 23 intervention and 23 control hospitals. There were no significant differences in the patient characteristics, such as age, gender and the poisons ingested. The intervention hospitals showed a significant improvement in administration of activated charcoal [OR 2.95 (95% CI 1.28–6.80)]. There was no difference between hospitals in use of other decontamination methods.
This study shows that an educational intervention consisting of brief out-reach academic detailing was effective in changing treatment behavior in rural Sri Lankan hospitals. The intervention was only effective for treatments with direct clinician involvement, such as administering activated charcoal. It was not successful for treatments usually administered by non-professional staff such as forced emesis for poisoning.
Trial Registration ISRCTN73983810 ISRCTN73983810
PMCID: PMC3747188  PMID: 23990989
8.  Determinants of exclusive breastfeeding in Nigeria 
Exclusive breast feeding (EBF) has important protective effects on the survival of infants and decreases risk for many early-life diseases. The purpose of this study was to assess the factors associated with EBF in Nigeria.
Data on 658 children less than 6 months of age were obtained from the Nigeria Demographic and Health Survey (NDHS) 2003. The 2003 NDHS was a multi-stage cluster sample survey of 7864 households. EBF rates were examined against a set of individual, household and community level variables using a backward stepwise multilevel logistic regression method.
The average EBF rate among infants younger than 6 months of age was 16.4% (95%CI: 12.6%-21.1%) but was only 7.1% in infants in their fifth month of age. After adjusting for potential confounders, multivariate analyses revealed that the odds of EBF were higher in rich (Adjusted Odds Ratios (AOR) = 1.15, CI = 0.28-6.69) and middle level (AOR = 2.45, CI = 1.06-5.68) households than poor households. Increasing infant age was associated with significantly less EBF (AOR = 0.65, 95%CI: 0.51-0.82). Mothers who had four or more antenatal visits were significantly more likely to engage in EBF (AOR = 2.70, 95%CI = 1.04-7.01). Female infants were more likely to be exclusively breastfed than male infants (AOR = 2.13, 95%CI = 1.03-4.39). Mothers who lived in the North Central geopolitical region were significantly more likely to exclusively breastfeed their babies than those mothers who lived in other geopolitical regions.
The EBF rate in Nigeria is low and falls well short of the expected levels needed to achieve a substantial reduction in child mortality. Antenatal care was strongly associated with an increased rate of EBF. Appropriate infant feeding practises are needed if Nigeria is to reach the child survival Millennium Development Goal of reducing infant mortality from about 100 deaths per 1000 live births to a target of 35 deaths per 1000 live births by the year 2015.
PMCID: PMC3025918  PMID: 21219659
9.  Why don't some women attend antenatal and postnatal care services?: a qualitative study of community members' perspectives in Garut, Sukabumi and Ciamis districts of West Java Province, Indonesia 
Antenatal, delivery and postnatal care services are amongst the recommended interventions aimed at preventing maternal and newborn deaths worldwide. West Java is one of the provinces of Java Island in Indonesia with a high proportion of home deliveries, a low attendance of four antenatal services and a low postnatal care uptake. This paper aims to explore community members' perspectives on antenatal and postnatal care services, including reasons for using or not using these services, the services received during antenatal and postnatal care, and cultural practices during antenatal and postnatal periods in Garut, Sukabumi and Ciamis districts of West Java province.
A qualitative study was conducted from March to July 2009 in six villages in three districts of West Java province. Twenty focus group discussions (FGDs) and 165 in-depth interviews were carried out involving a total of 295 respondents. The guidelines for FGDs and in-depth interviews included the topics of community experiences with antenatal and postnatal care services, reasons for not attending the services, and cultural practices during antenatal and postnatal periods.
Our study found that the main reason women attended antenatal and postnatal care services was to ensure the safe health of both mother and infant. Financial difficulty emerged as the major issue among women who did not fulfil the minimum requirements of four antenatal care services or two postnatal care services within the first month after delivery. This was related to the cost of health services, transportation costs, or both. In remote areas, the limited availability of health services was also a problem, especially if the village midwife frequently travelled out of the village. The distances from health facilities, in addition to poor road conditions were major concerns, particularly for those living in remote areas. Lack of community awareness about the importance of these services was also found, as some community members perceived health services to be necessary only if obstetric complications occurred. The services of traditional birth attendants for antenatal, delivery, and postnatal care were widely used, and their roles in maternal and child care were considered vital by some community members.
It is important that public health strategies take into account the availability, affordability and accessibility of health services. Poverty alleviation strategies will help financially deprived communities to use antenatal and postnatal health services. This study also demonstrated the importance of health promotion programs for increasing community awareness about the necessity of antenatal and postnatal services.
PMCID: PMC2964562  PMID: 20937146
10.  Factors associated with underutilization of antenatal care services in Indonesia: results of Indonesia Demographic and Health Survey 2002/2003 and 2007 
BMC Public Health  2010;10:485.
Antenatal care aims to prevent maternal and perinatal mortality and morbidity. In Indonesia, at least four antenatal visits are recommended during pregnancy. However, this service has been underutilized. This study aimed to examine factors associated with underutilization of antenatal care services in Indonesia.
We used data from Indonesia Demographic and Health Survey (IDHS) 2002/2003 and 2007. Information of 26,591 singleton live-born infants of the mothers' most recent birth within five years preceding each survey was examined. Twenty-three potential risk factors were identified and categorized into four main groups, external environment, predisposing, enabling, and need factors. Logistic regression models were used to examine the association between all potential risk factors and underutilization of antenatal services. The Population Attributable Risk (PAR) was calculated for selected significant factors associated with the outcome.
Factors strongly associated with underutilization of antenatal care services were infants from rural areas and from outer Java-Bali region, infants from low household wealth index and with low maternal education level, and high birth rank infants with short birth interval of less than two years. Other associated factors identified included mothers reporting distance to health facilities as a major problem, mothers less exposed to mass media, and mothers reporting no obstetric complications during pregnancy. The PAR showed that 55% of the total risks for underutilization of antenatal care services were attributable to the combined low household wealth index and low maternal education level.
Strategies to increase the accessibility and availability of health care services are important particularly for communities in rural areas. Financial support that enables mothers from poor households to use health services will be beneficial. Health promotion programs targeting mothers with low education are vital to increase their awareness about the importance of antenatal services.
PMCID: PMC2933719  PMID: 20712866
11.  Why do some women still prefer traditional birth attendants and home delivery?: a qualitative study on delivery care services in West Java Province, Indonesia 
Trained birth attendants at delivery are important for preventing both maternal and newborn deaths. West Java is one of the provinces on Java Island, Indonesia, where many women still deliver at home and without the assistance of trained birth attendants. This study aims to explore the perspectives of community members and health workers about the use of delivery care services in six villages of West Java Province.
A qualitative study using focus group discussions (FGDs) and in-depth interviews was conducted in six villages of three districts in West Java Province from March to July 2009. Twenty FGDs and 165 in-depth interviews were conducted involving a total of 295 participants representing mothers, fathers, health care providers, traditional birth attendants and community leaders. The FGD and in-depth interview guidelines included reasons for using a trained or a traditional birth attendant and reasons for having a home or an institutional delivery.
The use of traditional birth attendants and home delivery were preferable for some community members despite the availability of the village midwife in the village. Physical distance and financial limitations were two major constraints that prevented community members from accessing and using trained attendants and institutional deliveries. A number of respondents reported that trained delivery attendants or an institutional delivery were only aimed at women who experienced obstetric complications. The limited availability of health care providers was reported by residents in remote areas. In these settings the village midwife, who was sometimes the only health care provider, frequently travelled out of the village. The community perceived the role of both village midwives and traditional birth attendants as essential for providing maternal and health care services.
A comprehensive strategy to increase the availability, accessibility, and affordability of delivery care services should be considered in these West Java areas. Health education strategies are required to increase community awareness about the importance of health services along with the existing financing mechanisms for the poor communities. Public health strategies involving traditional birth attendants will be beneficial particularly in remote areas where their services are highly utilized.
PMCID: PMC2928756  PMID: 20701762
12.  Influence of Zinc Supplementation in Acute Diarrhea Differs by the Isolated Organism 
Zinc supplementation is recommended in all acute diarrheas in children from developing countries. We aimed to assess whether zinc supplementation would be equally effective against all the common organisms associated with acute diarrheas. We used data on 801 children with acute diarrhea recruited in a randomized, double blind controlled trial (ISRCTN85071383) of zinc and copper supplementation. Using prespecified subgroup analyses, multidimensionality reduction analyses, tests of heterogeneity, and stepwise logistic regression for tests of interactions, we found that the influence of zinc on the risk of diarrhea for more than 3 days depended on the isolated organism—beneficial in Klebsiella, neutral in Esherichia coli and parasitic infections, and detrimental in rotavirus coinfections. Although we found similar results for the outcome of high stool volume, the results did not reach statistical significance. Our findings suggest that the current strategy of zinc supplementation in all cases of acute diarrheas in children may need appropriate fine tuning to optimize the therapeutic benefit based on the causative organism, but further studies need to confirm and extend our findings.
PMCID: PMC2879540  PMID: 20592753
13.  Therapeutic Value of Zinc Supplementation in Acute and Persistent Diarrhea: A Systematic Review 
PLoS ONE  2010;5(4):e10386.
For over a decade, the importance of zinc in the treatment of acute and persistent diarrhea has been recognized. In spite of recently published reviews, there remain several unanswered questions about the role of zinc supplementation in childhood diarrhea in the developing countries. Our study aimed to assess the therapeutic benefits of zinc supplementation in the treatment of acute or persistent diarrhea in children, and to examine the causes of any heterogeneity of response to zinc supplementation.
Methods and Findings
EMBASE®, MEDLINE ® and CINAHL® databases were searched for published reviews and meta-analyses on the use of zinc supplementation for the prevention and treatment of childhood diarrhea. Additional RCTs published following the meta-analyses were also sought. The reviews and published RCTs were qualitatively mapped followed by updated random-effects meta-analyses, subgroup meta-analyses and meta-regression to quantify and characterize the role of zinc supplementation with diarrhea-related outcomes. We found that although there was evidence to support the use of zinc to treat diarrhea in children, there was significant unexplained heterogeneity across the studies for the effect of zinc supplementation in reducing important diarrhea outcomes. Zinc supplementation reduced the mean duration of diarrhea by 19.7% but had no effect on stool frequency or stool output, and increased the risk of vomiting. Our subgroup meta-analyses and meta-regression showed that age, stunting, breast-feeding and baseline zinc levels could not explain the heterogeneity associated with differential reduction in the mean diarrheal duration. However, the baseline zinc levels may not be representative of the existing zinc deficiency state.
Understanding the predictors of zinc efficacy including the role of diarrheal disease etiology on the response to zinc would help to identify the populations most likely to benefit from supplementation. To improve the programmatic use of zinc, further evaluations of the zinc salts used, the dose, the frequency and duration of supplementation, and its acceptability are required. The significant heterogeneity of responses to zinc suggests the need to revisit the strategy of universal zinc supplementation in the treatment children with acute diarrhea in developing countries.
PMCID: PMC2860998  PMID: 20442848
14.  Validity of self-reported weight, height and resultant body mass index in Chinese adolescents and factors associated with errors in self-reports 
BMC Public Health  2010;10:190.
Validity of self-reported height and weight has not been adequately evaluated in diverse adolescent populations. In fact there are no reported validity studies conducted in Asian children and adolescents. This study aims to examine the accuracy of self-reported weight, height, and resultant BMI values in Chinese adolescents, and of the adolescents' subsequent classification into overweight categories.
Weight and height were self-reported and measured in 1761 adolescents aged 12-16 years in a cross-sectional survey in Xi'an city, China. BMI was calculated from both reported values and measured values. Bland-Altman plots with 95% limits of agreement, Pearson's correlation and Kappa statistics were calculated to assess the agreement.
The 95% limits of agreement were -11.16 and 6.46 kg for weight, -4.73 and 7.45 cm for height, and -4.93 and 2.47 kg/m2 for BMI. Pearson correlation between measured and self-reported values was 0.912 for weight, 0.935 for height and 0.809 for BMI. Weighted Kappa was 0.859 for weight, 0.906 for height and 0.754 for BMI. Sensitivity for detecting overweight (includes obese) in adolescents was 56.1%, and specificity was 98.6%. Subjects' area of residence, age and BMI were significant factors associated with the errors in self-reporting weight, height and relative BMI.
Reported weight and height does not have an acceptable agreement with measured data. Therefore, we do not recommend the application of self-reported weight and height to screen for overweight adolescents in China. Alternatively, self-reported data could be considered for use, with caution, in surveillance systems and epidemiology studies.
PMCID: PMC2864211  PMID: 20384994
15.  Association between physical activity and metabolic syndrome: a cross sectional survey in adolescents in Ho Chi Minh City, Vietnam 
BMC Public Health  2010;10:141.
The emerging epidemic of overweight/obesity in adolescents in Ho Chi Minh City, Vietnam underlines the importance of studying the metabolic syndrome in Vietnamese adolescents who are becoming progressively more inactive. No study in Vietnam has examined the association of metabolic syndrome with moderate to vigorous physical activity (PA) levels among adolescents. We aimed to examine this association in a sample of urban adolescents from Ho Chi Minh City.
A cross-sectional assessment was conducted in 2007 on a representative sample of 693 high-school students from urban districts in Ho Chi Minh City. Metabolic syndrome was defined according to the International Diabetes Federation criteria and physical activity was measured with Actigraph accelerometers. The association between physical activity and metabolic syndrome was assessed by using multiple logistic regression models.
Overall 4.6% of the adolescents and 11.8% of the overweight/obese adolescents had metabolic syndrome. Elevated BP was the most common individual component of the metabolic syndrome (21.5%), followed by hypertriglyceridemia (11.1%). After adjusting for other study factors, the odds of metabolic syndrome among youth in the lowest physical activity group (<43 minutes of physical activity/day) were five times higher than those in the highest physical activity group (>103 minutes/day) (AOR = 5.3, 95% CI: 1.5, 19.1). Metabolic syndrome was also positively associated with socioeconomic status (AOR = 9.4, 95% CI: 2.1, 42.4).
A more physically active lifestyle appears to be associated with a lower odds of metabolic syndrome in Vietnamese adolescents. Socio-economic status should be taken into account when planning interventions to prevent adolescent metabolic syndrome.
PMCID: PMC2847981  PMID: 20236509
16.  Prevalence and risk factors for stunting and severe stunting among under-fives in North Maluku province of Indonesia 
BMC Pediatrics  2009;9:64.
Adequate nutrition is needed to ensure optimum growth and development of infants and young children. Understanding of the risk factors for stunting and severe stunting among children aged less than five years in North Maluku province is important to guide Indonesian government public health planners to develop nutrition programs and interventions in a post conflict area. The purpose of the current study was to assess the prevalence of and the risk factors associated with stunting and severe stunting among children aged less than five years in North Maluku province of Indonesia.
The health and nutritional status of children aged less than five years was assessed in North Maluku province of Indonesia in 2004 using a cross-sectional multi-stage survey conducted on 750 households from each of the four island groups in North Maluku province. A total of 2168 children aged 0-59 months were used in the analysis.
Prevalence of stunting and severe stunting were 29% (95%CI: 26.0-32.2) and 14.1% (95%CI: 11.7-17.0) for children aged 0-23 months and 38.4% (95%CI: 35.9-41.0) and 18.4% (95%CI: 16.1-20.9) for children aged 0-59 months, respectively. After controlling for potential confounders, multivariate analysis revealed that the risk factors for stunted children were child's age in months, male sex and number of family meals per day (≤2 times), for children aged 0-23 months, and income (poorest and middle-class family), child's age in months and male sex for children aged 0-59 months. The risk factors for severe stunting in children aged 0-23 months were income (poorest family), male sex and child's age in months and for children aged 0-59 months were income (poorest family), father's occupation (not working), male sex and child's age in months.
Programmes aimed at improving stunting in North Maluku province of Indonesia should focus on children under two years of age, of male sex and from families of low socioeconomic status.
PMCID: PMC2765943  PMID: 19818167
17.  Reproducibility and comparative validity of a food frequency questionnaire for Australian children and adolescents 
Dietary intake during childhood and adolescence is of increasing interest due to its influence on adult health, particularly obesity, cardiovascular disease and diabetes. There is a need to develop and validate dietary assessment methods suitable for large epidemiologic studies of children and adolescents. Limited large scale dietary studies of youth have been undertaken in Australia, due partly to the lack of a suitable dietary intake tool. A self-administered, semi-quantitative food-frequency questionnaire (FFQ), the 'Australian Child and Adolescent Eating Survey' (ACAES), was developed for youth aged 9-16 years. This study evaluated reproducibility and comparative validity of the ACAES FFQ using assisted food records (FRs) as the reference method.
The ACAES FFQ was completed twice (FFQ1 and FFQ2) at an interval of 5 months, along with four one-day assisted FRs. Validity was evaluated by comparing the average of the FRs with FFQ2 (n = 113) as well as with the average of FFQ1 and FFQ2 (n = 101). Reproducibility was evaluated by comparing FFQ1 and FFQ2 (n = 101). The two methods were compared using correlations, Kappa statistics and Bland-Altman plots.
Correlation coefficients for comparative validity ranged from 0.03 for retinol to 0.56 for magnesium for transformed, energy-adjusted, deattenuated nutrient data, with correlation coefficients greater than 0.40 for total fat, saturated fat, monounsaturated fat, carbohydrate, sugars, riboflavin, vitamin C, folate, beta-carotene, magnesium, calcium and iron. Correlation coefficients for reproducibility ranged from 0.18 for vitamin A to 0.50 for calcium for transformed, energy-adjusted, deattenuated nutrient data. The ACAES FFQ ranked individuals reasonably accurately, with the comparative validity analysis showing that over 50% of participants were classified within one quintile for all nutrients, with only a small percentage grossly misclassified (0-7%).
The ACAES FFQ is the first child and adolescent specific FFQ available for ranking the dietary intakes of Australian children and adolescents for a range of nutrients in epidemiologic research and public health interventions.
PMCID: PMC2758826  PMID: 19744349
18.  Assessment of dietary intake among pregnant women in a rural area of western China 
BMC Public Health  2009;9:222.
Adequate maternal nutrient intake during pregnancy is important to ensure satisfactory birth outcomes. There are no data available on the usual dietary intake among pregnant women in rural China. The present study describes and evaluates the dietary intake in a cohort of pregnant women living in two counties of rural Shaanxi, western China.
1420 pregnant women were recruited from a trial that examined the effects of micronutrient supplementation on birth outcomes. Dietary information was collected at the end of their trimester or after delivery with an interviewed-administrated semi-quantitative food frequency questionnaire (FFQ). Nutrients intake was calculated from the FFQ and compared to the Estimated Average Requirements (EAR). The EAR cut-offs based on the Chinese Nutrition Society Dietary Reference Intakes (DRIs) were used to assess the prevalence of inadequate dietary intakes of energy, protein, calcium, zinc, riboflavin, vitamin C and folate. Mann-Whitney U and Kruskal Wallis tests were used to compare nutrient intakes across subgroups.
The mean nutrient intakes assessed by the FFQ was similar to those reported in the 2002 Chinese National Nutrition and Health Survey from women living in rural areas except for low intakes of protein, fat, iron and zinc. Of the participants, 54% were at risk of inadequate intake of energy. There were high proportions of pregnant women who did not have adequate intakes of folate (97%) and zinc (91%). Using the "probability approach", 64% of subjects had an inadequate consumption of iron.
These results reveal that the majority of pregnant women in these two counties had low intakes of nutrients that are essential for pregnancy such as iron and folate.
Trial registration
PMCID: PMC2716336  PMID: 19589154
19.  Zinc and copper supplementation in acute diarrhea in children: a double-blind randomized controlled trial 
BMC Medicine  2009;7:22.
Diarrhea causes an estimated 2.5 million child deaths in developing countries each year, 35% of which are due to acute diarrhea. Zinc and copper stores in the body are known to be depleted during acute diarrhea. Our objectives were to evaluate the efficacy of zinc and copper supplementation when given with standard treatment to children with acute watery or bloody diarrhea.
We conducted a double-blind randomized controlled clinical trial in the Department of Pediatrics at Indira Gandhi Government Medical College Nagpur, India. Eight hundred and eight children aged 6 months to 59 months with acute diarrhea were individually randomized to placebo (Pl), zinc (Zn) only, and zinc and copper (Zn+Cu) together with standard treatment for acute diarrhea.
The mean duration of diarrhea from enrolment and the mean stool weight during hospital stay were 63.7 hours and 940 grams, respectively, and there were no significant differences in the adjusted means across treatment groups. Similarly, the adjusted means of the amount of oral rehydration solution or intravenous fluids used, the proportion of participants with diarrhea more than 7 days from onset, and the severity of diarrhea indicated by more than three episodes of some dehydration or any episode of severe dehydration after enrolment, did not differ across the three groups.
The expected beneficial effects of zinc supplementation for acute diarrhea were not observed. Therapeutic Zn or Zn and Cu supplementation may not have a universal beneficial impact on the duration of acute diarrhea in children.
Trial registration
The study was registered as an International Standard Randomized Controlled Trial (ISRCTN85071383).
PMCID: PMC2684117  PMID: 19416499
20.  Impact of micronutrient supplementation during pregnancy on birth weight, duration of gestation, and perinatal mortality in rural western China: double blind cluster randomised controlled trial 
Objective To examine the impact of antenatal supplementation with multiple micronutrients or iron and folic acid compared with folic acid alone on birth weight, duration of gestation, and maternal haemoglobin concentration in the third trimester.
Design Cluster randomised double blind controlled trial.
Setting Two rural counties in north west China.
Participants 5828 pregnant women and 4697 live births.
Interventions Villages were randomised for all pregnant women to take either daily folic acid (control), iron with folic acid, or multiple micronutrients with a recommended allowance of 15 vitamins and minerals.
Main outcome measures Birth weight, length, and head circumference measured within 72 hours after delivery. Neonatal survival assessed at the six week follow-up visit.
Results Birth weight was 42 g (95% confidence interval 7 to 78 g) higher in the multiple micronutrients group compared with the folic acid group. Duration of gestation was 0.23 weeks (0.10 to 0.36 weeks) longer in the iron-folic acid group and 0.19 weeks (0.06 to 0.32 weeks) longer in the multiple micronutrients group. Iron-folic acid was associated with a significantly reduced risk of early preterm delivery (<34 weeks) (relative risk 0.50, 0.27 to 0.94, P=0.031). There was a significant increase in haemoglobin concentration in both iron-folic acid (5.0 g/l, 2.0 to 8.0 g/l, P=0.001) and multiple micronutrients (6.9 g/l, 4.1 to 9.6 g/l, P<0.001) groups compared with folic acid alone. In post hoc analyses there were no significant differences for perinatal mortality, but iron-folic acid was associated with a significantly reduced early neonatal mortality by 54% (relative risk 0.46, 0.21 to 0.98).
Conclusion In rural populations in China antenatal supplementation with iron-folic acid was associated with longer gestation and a reduction in early neonatal mortality compared with folic acid. Multiple micronutrients were associated with modestly increased birth weight compared with folic acid, but, despite this weight gain, there was no significant reduction in early neonatal mortality. Pregnant women in developing countries need sufficient doses of iron in nutrient supplements to maximise reductions in neonatal mortality.
Trial registration ISRCTN08850194.
PMCID: PMC2577799  PMID: 18996930
21.  Energy and macronutrient intakes in preschool children in urban areas of Ho Chi Minh City, Vietnam 
BMC Pediatrics  2008;8:44.
An increasing prevalence of overweight and obesity has been documented in preschool children in Ho Chi Minh City (HCMC), Vietnam. However, little is known about what preschool children in HCMC eat or how well their nutrient intake meets nutrient recommendations. This study aims to describe the energy and macronutrient intake and compare these nutrient intakes with the recommendations for Vietnamese children aged four to five years.
The data comes from the baseline measurement of a one year follow-up study on obesity in 670 children attending kindergartens in HCMC. Dietary information for each child at the school and home settings was collected using Food Frequency Questionnaires (FFQs), by interviewing teachers and parents or main caregivers. The average energy and nutrient intake in a day was calculated. The proportion of children with energy intake from macronutrients meeting or exceeding the recommendations was estimated based on the 2006 recommended daily allowance (RDA) for Vietnamese children in this age group.
The dietary intake of the participants contained more energy from protein and fat, particularly animal protein and fat, and less energy from carbohydrates, than the RDA. Most children (98.1%) had mean energy intake from protein greater than the recommended level of 15%, and no child obtained energy from animal fat that was in accordance with the recommendation of less than 30% of the total fat intake. Nearly one half of children (46.5%) consumed less than the advised range of mean energy intake from carbohydrate (60%–70%).
In this preschool child population in HCMC, in which obesity is emerging as major public health problem, there is an imbalance in dietary intake. Healthy eating programs need to be developed as a part of an obesity prevention program for young children in HCMC.
PMCID: PMC2575195  PMID: 18928562
22.  Determinants of neonatal mortality in Indonesia 
BMC Public Health  2008;8:232.
Neonatal mortality accounts for almost 40 per cent of under-five child mortality, globally. An understanding of the factors related to neonatal mortality is important to guide the development of focused and evidence-based health interventions to prevent neonatal deaths. This study aimed to identify the determinants of neonatal mortality in Indonesia, for a nationally representative sample of births from 1997 to 2002.
The data source for the analysis was the 2002–2003 Indonesia Demographic and Health Survey from which survival information of 15,952 singleton live-born infants born between 1997 and 2002 was examined. Multilevel logistic regression using a hierarchical approach was performed to analyze the factors associated with neonatal deaths, using community, socio-economic status and proximate determinants.
At the community level, the odds of neonatal death was significantly higher for infants from East Java (OR = 5.01, p = 0.00), and for North, Central and Southeast Sulawesi and Gorontalo combined (OR = 3.17, p = 0.03) compared to the lowest neonatal mortality regions of Bali, South Sulawesi and Jambi provinces. A progressive reduction in the odds was found as the percentage of deliveries assisted by trained delivery attendants in the cluster increased. The odds of neonatal death were higher for infants born to both mother and father who were employed (OR = 1.84, p = 0.00) and for infants born to father who were unemployed (OR = 2.99, p = 0.02). The odds were also higher for higher rank infants with a short birth interval (OR = 2.82, p = 0.00), male infants (OR = 1.49, p = 0.01), smaller than average-sized infants (OR = 2.80, p = 0.00), and infant's whose mother had a history of delivery complications (OR = 1.81, p = 0.00). Infants receiving any postnatal care were significantly protected from neonatal death (OR = 0.63, p = 0.03).
Public health interventions directed at reducing neonatal death should address community, household and individual level factors which significantly influence neonatal mortality in Indonesia. Low birth weight and short birth interval infants as well as perinatal health services factors, such as the availability of skilled birth attendance and postnatal care utilization should be taken into account when planning the interventions to reduce neonatal mortality in Indonesia.
PMCID: PMC2478684  PMID: 18613953
23.  The prevalence and correlates of physical inactivity among adults in Ho Chi Minh City 
BMC Public Health  2008;8:204.
Socioeconomic changes have led to profound changes in individuals' lifestyles, including the adoption of unhealthy food consumption patterns, prevalent tobacco use, alcohol abuse and physical inactivity, especially in large cities like Ho Chi Minh City (HCMC). The Stepwise Approach to Surveillance of Non-communicable Disease Risk Factors survey was conducted to identify physical activity patterns and factors associated with 'insufficient' levels of physical activity for health in adults in HCMC.
A cross-sectional survey was conducted in 2005 among 1906 adults aged 25–64 years using a probability proportional to size cluster sampling method to estimate the prevalence of non-communicable disease risk factors including physical inactivity. Data on socioeconomic status, health behaviours, and time spent in physical activity during work, commuting and leisure time were collected. Physical activity was measured using the validated Global Physical Activity Questionnaire (GPAQ). Responders were classified as 'sufficiently active' or 'insufficiently active' using the GPAQ protocol. Correlates of insufficient physical activity were identified using multivariable logistic regression.
A high proportion of adults were physically inactive, with only 56.2% (95% CI = 52.1–60.4) aged 25–64 years in HCMC achieving the minimum recommendation of 'doing 30 minutes moderate-intensity physical activity for at least 5 days per week'. The main contributors to total physical activity among adults were from working and active commuting. Leisure-time physical activity represented a very small proportion (9.4%) of individuals' total activity level. Some differences in the pattern of physical activity between men and women were noted, with insufficient activity levels decreasing with age among women, but not among men. Physical inactivity was positively associated with high income (OR = 1.77, 95% CI = 1.05–2.97) and high household wealth index (OR = 1.86, 95% CI = 1.29–2.66) amongst men.
Public health policies and programs to preserve active commuting in HCMC and to promote time spent in recreational physical activity in both genders and across all age groups, but especially among young adults, will be critical in any comprehensive national plan to tackle inactivity. Clear and consistent national recommendations about how much physical activity Vietnamese people need for preventing and managing non-communicable diseases should also be part of this population-wide promotional effort.
PMCID: PMC2435539  PMID: 18541020
24.  Prevalence of Exclusive Breastfeeding in Bangladesh and Its Association with Diarrhoea and Acute Respiratory Infection: Results of the Multiple Indicator Cluster Survey 2003 
The objective of this study was to investigate the association between the prevalence of exclusive breastfeeding and morbidity (diarrhoeal diseases and acute respiratory infection) in infants aged 0-3 month(s) using the Multiple Indicator Cluster Survey (MICS) 2003 data from Bangladesh. The study population included 1,633 infants aged 0-3 month(s). The prevalence of diarrhoea and acute respiratory infection was compared using the chi-square tests between infants aged 0-3 month(s) who were exclusively breastfed and infants who were not exclusively breastfed. Logistic regression was used to adjust for confounders and for calculating adjusted odds ratios. To adjust for cluster sampling and reduced variability, the adjusted chi-square value was divided by the design effect, and a re-estimated p value was calculated. The prevalence of diarrhoea and acute respiratory infection in this sample of 0-3-month old infants in Bangladesh was 14.3% and 31.2% respectively. The prevalence of both illnesses was significantly associated with lack of exclusive breastfeeding. The adjusted odds ratio for diarrhoea was 0.69 (95% confidence interval [CI] 0.49-0.98, p=0.039), and the adjusted odds ratio for acute respiratory infection was also 0.69 (95% CI 0.54-0.88, p=0.003). Only 192 infants (11.7% of total sample) were exclusively breastfed at the time of interview, and 823 infants (50.3%) were never exclusively breastfed. The prevalence of prelacteal feeding was 66.6%. The results confirmed a protective effect of exclusive breastfeeding against infectious diseases-related morbidity in infancy and showed that frequently-collected cross-sectional datasets could be used for estimating effects. The low prevalence of exclusive breastfeeding in Bangladesh needs to be improved to decrease child morbidity.
PMCID: PMC2753993  PMID: 17985821
Acute respiratory infections; Breastfeeding; Cluster surveys; Cross-sectional studies; Diarrhoea; Diarrhoea, Infantile; Infant-feeding practices; Bangladesh
25.  Trends in dietary energy, fat, carbohydrate and protein intake in Chinese children and adolescents from 1991 to 2009 
The British Journal of Nutrition  2012;108(7):1292-1299.
Few studies have examined nutrition transition in children in China. Our aim, in the present study, was to examine temporal trends in dietary energy, fat, carbohydrate and protein intake in Chinese children aged 7–17 years. The analysis used individual level, consecutive 3 d dietary recall data from seven rounds of the China Health and Nutrition Surveys in 1991 (n 2714), 1993 (n 2542), 1997 (n 2516), 2000 (n 2142), 2004 (n 1341), 2006 (n 1072) and 2009 (n 996). Mixed-effect models were constructed to obtain adjusted means and to examine trends after adjusting for intra-class correlation within clusters and for covariates including age, sex, urban/rural residence and income. From 1991 to 2009, daily energy intake steadily declined from 9511·0 to 7658·2 kJ (P < 0·0001). There was a steady decline in daily carbohydrate intake from 382·5 to 254·1 g (P < 0·0001), and in the proportion of energy from carbohydrate from 66·7 to 56·8 % (P < 0·0001). In contrast, daily fat intake steadily increased from 54·8 to 66·0 g (P < 0·0001), as did the proportion of energy from fat from 21·5 to 30·0 % (P < 0·0001). The proportion of children who consumed a diet with more than 30 % of energy from fat increased from 20·1 to 49·4 % (P < 0·0001). The proportion of energy from protein increased from 11·8 to 13·1 % (P < 0·0001), although daily protein intake dropped from 66·2 to 58·0 g (P < 0·0001). Our data suggest that Chinese children have been undergoing a rapid nutrition transition to a high-fat diet.
PMCID: PMC3488814  PMID: 22244308
Children and adolescents; Nutrition transition; Macronutrients; China

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