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Prior observational studies have reported the potential protective effect of n-3 fatty acids on the prognosis of acute pancreatitis (AP). However, the causal impact of n-3 fatty acids on AP is unclear. We aimed to investigate further the association of n-3 fatty acids with AP. We performed a meta-analysis and Mendelian randomisation (MR) to explore the association between n-3 fatty acids and the prognosis of AP from clinical observation and genetics perspectives, respectively. Nine randomised controlled trials were included in this study. The result meta-analysis showed that complementary therapy of n-3 fatty acids significantly decreased mortality (Relative Risk (RR): 0·30; 95 % CI 0·14, 0·65, P < 0·05) and infectious complications in AP (RR: 0·45; 95 % CI 0·27, 0·77, P < 0·05). Compared with the control groups, the hospital stays (MD: −1·02; 95 % CI −1·85, −0·20, P < 0·05) in AP patients with n-3 fatty acids treatment were statistically reduced. However, the ICU stay (MD: −0·49; 95 % CI −1·29, −0·31, P > 0·05) between control groups and AP patients with n-3 fatty acids treatment was insignificant. Utilising genetic susceptibility analysis in the MR approach, the MR showed n-3 fatty acids have a significant causal effect on the AP risk (OR, 0·887; 95 % CI 0·797, 0·986, P = 0·027, fixed-effect; OR, 0·887; 95 % CI 0·792, 0·993, P = 0·037, random-effect). n-3 fatty acids complementary therapy may improve the prognosis of AP. Furthermore, genetically predicted serum levels of n-3 fatty acids can significantly lower AP risk.
To assess associations between dietary fat quality indices and risk of pre-diabetes and type 2 diabetes mellitus (T2DM) among Iranian adults.
Design:
Daily intakes of fatty acids were estimated using a validated FFQ with 168 food items. Adjusted hazard ratios (HR) and 95 % CI for pre-diabetes and T2DM were calculated across tertile categories of dietary fat quality indices including the atherogenic index, thrombogenic index, health-promoting index, ratio of PUFA to SFA (PUFA:SFA) and ratio of hypo- and hypercholesterolaemia (h:H).
Setting:
Tehran Lipid and Glucose Study.
Participants:
Iranian men and women.
Results:
The mean (sd) age of the 2042 pre-diabetes-free participants in pre-diabetes analysis was 38·84 (12·97), and 55·2 % were women. In T2DM analysis, the mean (sd) age of the 2295 T2DM-free participants was 40·06 (13·42), and 54·6 % of them were women. In the crude model, the PUFA:SFA ratio was positively associated with T2DM incidence (HR = 1·43; 95 % CI 1·04, 1·98). However, after adjustment for confounding variables, there were no significant associations between dietary fat quality indices and risk of pre-diabetes and T2DM.
Conclusions:
We found no significant association between fat quality indices and risk of pre-diabetes and T2DM. Further prospective and clinical trial studies are needed to clarify the issue.
To co-design support strategies to enable sustainable, healthy, affordable food provision, including waste mitigation practices, in Australian Early Childhood Education and Care (ECEC) settings.
Design:
Based on the co-design IDEAS framework (Ideate, DEsign, Assess & Share), this co-design process involved iterative interviews and focus groups with ECEC centre staff and workshops with Nutrition Australia. Interview and workshop themes were coded to the Theoretical Domains Framework (TDF) to develop initial prototypes for support strategies that were further developed and refined in focus groups.
Setting:
ECEC with onsite food provision, in Victoria, Australia.
Participants:
ECEC staff and a Victorian Government-funded programme delivered through Nutrition Australia that provides nutrition support to ECEC services.
Results:
ECEC staff interviews (n 17) suggested a lack of knowledge on the topic of sustainable healthy food provision and a need for resources and support for all staff and children. Workshops with Nutrition Australia built on interviews and suggested a focus on lower intensity strategies and a suggestion to embed knowledge-related activities into the children’s curriculum. Focus groups (n 8) further informed co-design of strategies, producing a visual representation of sustainable healthy food provision with supporting tips and a whole-of-centre approach that includes children through a classroom activity.
Conclusions:
The co-designed resources could provide feasible strategies for the adoption of sustainable, healthy and affordable provision practices in the ECEC setting. Involvement of a local government-funded health promotion service provides valuable research-to-practice contribution as well opportunity for scalable dissemination of resources through existing infrastructure.
The aim of this study was to explore and identify why young adults aged between 18 and 30 years in the UK and France do or do not consume dairy products. Several studies have associated dairy products with a healthy diet, and the production of soft dairy, i.e. milk, yoghurt, and soft cheese, as more environmentally friendly than some other animal-based products. Yet recent reports highlight that dairy intake is lower than recommended for health, especially among young adults. Using a qualitative methodology, forty-five participants aged 18–30 years (UK: n = 22; France: n = 23) were asked about their reasons for (non)consumption of a wide range of dairy products. Audio-recorded focus groups and individual interviews were conducted in English in the UK and in French in France, transcribed and coded. A thematic analysis found four themes and sixteen sub-themes (theme product-related: sub-themes sensory, non-sensory, composition; theme individual-related: sub-themes mode of consumption, preferences, personal reasons, knowledge, attitudes and concerns, needs or cravings; theme cultural aspects: sub-themes product categorization, social norms, use; theme market offering: sub-themes alternative, packaging, value for money, availability) to influence participants’ dairy (non)consumption in both countries. A seventeenth sub-theme (theme cultural aspects: sub-theme structure of the meal) was found to influence dairy consumption only in France. Further studies are needed to investigate these themes within larger samples, but these findings contribute to understanding dairy (non)consumption in young adults in the UK and France and may aid the development of strategies to improve young adults’ diets.
Randomised controlled trials are the ‘gold standard’ approach in nutrition research to show a causal relationship between a dietary intervention and clinically relevant outcomes at the population level. Here we review why different study designs are needed to establish the efficacy of dietary interventions at the individual level and to better account for relevant factors that can also influence the outcomes. Over the past decade, precision nutrition approaches have been developed as a new way to measure the effectiveness of dietary interventions at the individual and population level. Precision nutrition aims to determine the individual factors that are associated with differences in responses to dietary interventions. This is complex, typically needing studies with a large number of participants and using advanced statistical approaches and machine-learning algorithms to identify predictors that can explain why individuals do or do not respond to consuming specific foods, meals or diets, for a given outcome. N-of-1 study designs, which are new to nutrition science, offer a robust alternative approach to assess how an intervention and everyday behaviours affect individual health outcomes. They utilise repeated measures within individuals, rather than baseline and end measures in a larger number of participants, to provide the statistical power required to determine an individual’s responsiveness to an intervention. The adoption of new study designs and modelling approaches, particularly the N-of-1 approach, to examine responses to interventions within individuals, will help to further the understanding of the relationships between diet and health within individuals more effectively and accurately.
The workplace is a key environmental determinant of health and well-being. Food choices can be influenced by several workplace-related factors including, but not limited to, working hours, the workplace food environment, job roles and workplace culture. Therefore, the workplace is increasingly viewed as an important place for public health nutrition interventions. However, research in this area is fragmented and heterogeneous due to the wide range of workplace settings and occupational groups. This editorial summarises the research presented at The Nutrition Society Workplace Diet and Health Special Interest Group Satellite Symposium in July 2024 as part of the inaugural Nutrition Society Congress.
Machine learning is increasingly being utilised across various domains of nutrition research due to its ability to analyse complex data, especially as large datasets become more readily available. However, at times, this enthusiasm has led to the adoption of machine learning techniques prior to a proper understanding of how they should be applied, leading to non-robust study designs and results of questionable validity. To ensure that research standards do not suffer, key machine learning concepts must be understood by the research community. The aim of this review is to facilitate a better understanding of machine learning in research by outlining good practices and common pitfalls in each of the steps in the machine learning process. Key themes include the importance of generating high-quality data, employing robust validation techniques, quantifying the stability of results, accurately interpreting machine learning outputs, adequately describing methodologies, and ensuring transparency when reporting findings. Achieving this aim will facilitate the implementation of robust machine learning methodologies, which will reduce false findings and make research more reliable, as well as enable researchers to critically evaluate and better interpret the findings of others using machine learning in their work.
For the past three decades, India has implemented several nutrition programmes to address malnutrition in the under-fives. To understand the programme’s impact, this study assesses the prevalence of acute malnutrition, moderate acute malnutrition (MAM) and severe acute malnutrition (SAM), using mid-upper arm circumference (MUAC) among tribal children.
Design:
The survey was conducted in two tribal blocks (Desaiganj and Bhamragad) of the Gadchiroli district in Maharashtra to identify children registered in the ‘Anganwadi’ program.
Setting:
A community-based cross-sectional survey was carried out.
Participants:
The total sample size was 1055 children (aged 0–59 months).
Results:
The overall prevalence of SAM and MAM was 1·4 % (n 15) and 9·8 % (n 103). A higher prevalence of MAM was found in males (38·5 %, n 40) and females (27·1 %, n 28) in below 6 months. Additionally, a higher prevalence of MAM was observed in females (10·7 %, n 113) compared with males (9·0 %, n 95). The prevalence of SAM was significantly (P < 0·001) higher in females (1·7 %, n 18) than in males (1·0 %, n 11). Children aged between 12 and 17 months were sixteen times more likely (OR = 16·9, P < 0·001, CI = 4·8, 59·6) to have MAM (MUAC < 12·5 cm) than children aged between 6 and 11 months. Children from the Desaiganj block were significantly less likely (OR = 0·4, P < 0·001, CI = 0·2, 0·7) to have MAM compared with children from Bhamragad. Approximately 4 % (n 42) of children were classified as critically malnourished.
Conclusion:
There is an urgent need for block-level monitoring of MAM and SAM, as well as evaluation of existing nutrition programmes, to address the disparity in the sex-specific prevalence of MAM and SAM in tribal areas.
Animal source foods (ASFs) are diverse and heterogeneous, including unprocessed red meat, processed meat, poultry, eggs, seafood, milk, cheese, and yoghurt. It is essential for preventing malnutrition and its consequences among vulnerable populations, including infants, young children, adolescents, women of reproductive age, and pregnant and lactating women. Understanding the intakes of ASF among adolescents and associated factors is critical for establishing priorities to promote its consumption and enhance growth and development during this period. Consequently, the purpose of the current study is to examine the current levels of not consuming ASF among school-aged adolescent girls and the relationship between anaemia and not consuming ASF. A facility-based cross-sectional study design was conducted among 516 school adolescent girls in Silti District, Central Ethiopia, spanning from October 2 to 20, 2023. Data were entered into Epi-data 3.1 and exported to SPSS version 25 for further analysis. Adjusted odds ratios, along with their corresponding 95% confidence intervals, were calculated to examine the association between not consuming ASF and anaemia status after adjusting for age, residence, menstrual status, and morbidity. Statistical significance was defined as a p-value less than 0.05 in the final model. In this study, the prevalence of not consuming any form of ASF was 51.1% (95 CI: 44.6%–53.2%) and the prevalence of anaemia was 29% (95% CI: 25.2, 33.3). Moreover, unlikely consumption of ASF was significantly associated with anaemia (AOR = 3.2, 95% CI:2, 5.1) after adjusting for age, place of residence, experience of morbidity symptoms and menstrual status. The current study found a significant prevalence of adolescent girls in the area not consuming ASF while attending school. Moreover, the prevalence of anaemia was moderate. Unlikely consumption of ASF was significantly associated with anaemia. Hence, enhancing ASF consumption is one of the key actions to fight against anaemia.
Online 24-h dietary recall tools are commonly used in nationwide nutrition surveys to assess population diets. With a steep rise in the development of new and more advanced 24-h dietary recall tools, the decision of which tool to use for a national nutrition survey becomes increasingly challenging. Therefore, this short communication outlines the process of selecting a 24-h dietary recall tool for a national nutrition survey in New Zealand.
Design:
To identify suitable 24-h dietary recall tools, a review of peer-reviewed and grey literature was conducted (2019–2022). Data on functionalities, validation, usability and adaptability were extracted for eighteen pre-specified tools, which were used in the subsequent evaluation process.
Results:
Six of the eighteen tools had new relevant publications since 2019. The fourteen new publications described six validation studies and eight usability studies. Based on pre-selection criteria (e.g. availability, adaptability, previous use in national surveys), three tools were shortlisted: ASA24, Intake24 and MyFood24. These tools were further evaluated, and expert advice was sought to determine the most suitable tool for use in the New Zealand context.
Conclusions:
A comprehensive yet time- and cost-efficient approach was undertaken to identify the potential use of online 24-h dietary recall tools for a national nutrition survey. The selection process included key evaluation criteria to determine the tools’ suitability for adaptation within the New Zealand context and ultimately to select a preferred tool. A similar approach may be useful for other countries when having to select 24-h dietary recall tools for use in national nutrition surveys.
This study used the Behaviour Change Wheel (BCW) and Theoretical Domains Framework (TDF) to identify parental factors that are associated with increasing their child’s fruit and vegetable consumption. The information gathered enabled a behavioural diagnosis and the identification of intervention functions to increase fruit and vegetable consumption in children.
Design:
A qualitative design using open-ended online survey methodology was utilised.
Setting:
United Kingdom.
Participants:
Twenty-eight parents of primary school-aged children (4–11 years) aged 29–51 years participated.
Results:
Thematic and summative analysis identified skills in preparation and cooking, awareness of and desire to increase fruit and vegetable intake, knowledge of the recommendations and better health for their child as the main facilitators. The main barriers were time and financial constraints, their child’s food preferences and refusal to eat fruit and vegetables, negative role modelling from parents and grandparents and beliefs that fruit and vegetable intake will increase with age. For behaviour change to occur, ‘knowledge’, ‘social influences’, ‘environmental context and resources’, ‘beliefs about consequences’ and ‘beliefs about capabilities’ need to be altered.
Conclusions:
Novel findings suggest that future intervention development should focus on parental beliefs and skills around how to increase fruit and vegetable consumption as their child ages and expanding parental knowledge on the benefits of fruit and vegetable consumption such as mental and future health. The use of the TDF and BCW identified appropriate intervention functions that will guide future behaviour change techniques, modes of delivery and policy categories that best target increasing children’s fruit and vegetable consumption.
Rheumatoid arthritis (RA) is a prevalent autoimmune disease, and there is growing evidence suggesting a potential correlation between dietary factors and the pathogenesis of this condition. In order to investigate the causal relationship between diet and RA, we conducted a two-sample Mendelian randomisation (MR) analysis to examine the causal associations between twenty-two dietary factors and RA. Summary data from genome-wide association studies (GWAS) of RA were obtained from large GWAS meta-analyses. GWAS summary data for twenty-two dietary factors were obtained from UK Biobank. Random-effects inverse variance weighted was used as the primary method for assessing causality, and analyses of heterogeneity and horizontal pleiotropy were performed to ensure the accuracy of the results. Research indicates a negative genetic causal relationship between cereal intake (OR = 0·64, 95 % CI: 0·41, 0·99, P = 0·048) and oily fish intake (OR = 0·70, 95 % CI: 0·52, 0·95, P = 0·020) with the risk of RA. Other dietary factors were not causally related to RA. Sensitivity analysis shows that our results are reliable. This study provides genetic evidence suggesting that cereal intake and oily fish intake are protective factors for RA, indicating that RA patients and individuals at high risk should make appropriate dietary adjustments.
We investigated associations between ‘healthy dietary pattern’ scores, at ages 36, 43, 53 and 60–64 years, and body composition at age 60–64 years among participants from the MRC National Survey of Health and Development (NSHD). Principal component analyses of dietary data (food diaries) at age 60–64 years were used to calculate diet scores (healthy dietary pattern scores) at each age. Higher scores indicated healthier diets (higher consumption of fruit, vegetables and wholegrain bread). Linear regression was used to investigate associations between diet scores at each age and height-adjusted dual-energy X-ray absorptiometry-measured fat and lean mass measures at age 60–64 years. Analyses, adjusting for sex and other potential confounders (age, smoking history, physical activity and occupational class), were implemented among 692 men and women. At age 43, 53 and 60–64 years, higher diet scores were associated with lower fat mass index (FMI) and android:gynoid fat mass ratio; for example, in fully adjusted analyses, a standard deviation (sd) increase in diet score at age 60–64 years was associated with an SD difference in mean FMI of −0·18 (95 % CI: −0·25, −0·10). In conditional analyses, higher diet scores at ages 43, 53 and 60–64 years (than expected from diet scores at younger ages) were associated with lower FMI and android:gynoid fat mass ratio in fully adjusted analyses. Diet scores at age 36 years had weaker associations with the outcomes considered. No associations regarding appendicular lean mass index were robust after full adjustment. This suggests that improvements in diet through adulthood are linked to beneficial effects on adiposity in older age.
Numerous public initiatives aim to influence individual food choices by informing about what is considered ‘healthy’, ‘climate-friendly’, and generally ‘sustainable’ food. However, research suggests that rather than public authorities, social influence is more likely to affect people’s behaviour. Using a randomised controlled trial, this study investigated if and how the two kinds of influences (factual versus social) could affect the real-life, self-reported intake of plant- and animal-based foods. In a four-month randomised controlled trial, a self-selected sample of adults living in Sweden (N = 237) tracked their daily food consumption several times per week using a tailored mobile phone app. Participants were randomised into one of three groups: two treatment groups receiving factual or social information about plant- and animal-based food consumption, or a control group receiving no information. Pre- and post-questionnaires provided additional background information about the participants. Participants’ food habits varied from week to week, and an explorative analysis pointed to a slight decrease in the consumption of animal-based food in the group that received social information. However, the longer-term patterns remained relatively constant in all groups, showing no substantial shift regardless of the kind of cues that the participants received. By investigating the roles of two common types of information about food and dietary change, the results contribute to discussions about how and by whom effective and efficient measures can be implemented to transform food habits. The results suggest there is limited potential for sustained and substantial behavioural changes through both social and factual information campaigns.
To quantify and compare concurrent within-person trends in lifestyle risks, nutrition status and drivers of food choice among urban migrants in Central Asia.
Design:
We collected panel data on household structure, drivers of food choice, nutrition knowledge and diverse measures of nutrition status and lifestyle risk from urban migrants at 0, 3, 6 and 9 months using harmonised methodology in two cities. Trends were analysed using mixed-effects models and qualitatively compared within and between cities.
Setting:
Ulaanbaatar, Mongolia, and Almaty, Kazakhstan.
Participants:
200 adults (22–55 years) who migrated to these cities within the past 2 years.
Results:
Adjusting for age and sex, each month since migration was positively associated with fasting TAG in Almaty (0·55 mg/dl; 95 % CI: 0·13, 0·94) and BMI (0·04 kg/m2; 95 % CI: 0·01, 0·07), body fat (0·14 %; 95 % CI: 0·01, 0·26) and fasting glucose (0·04 mmol/l; 95 % CI: 0·02, 0·05) and lipids in Ulaanbaatar (P < 0·05). In Almaty, nutrition knowledge (measured using an objective 20-point scale) declined despite improvements in diet quality (measured by Prime Diet Quality Score). The influence of food availability, price and taste on food choice increased in Almaty (P < 0·05). Upon multivariable adjustment, nutrition knowledge was positively associated with diet quality in Almaty and adherence to ‘acculturated’ diet patterns in both cities (P < 0·05). Different trends in smoking, sleep quality and generalised anxiety were observed between cities.
Conclusions:
Findings indicate heterogeneous shifts in nutrition, lifestyles and drivers of food choice among urban migrants in Central Asia and provide an evidence base for focused research and advocacy to promote healthy diets and enable nutrition-sensitive food environments.
While there is evidence that long-chain n-3 PUFA supplementation benefits mood, the extent to which a single high dose of n-3 PUFA can induce acute mood effects has not been examined. The present study investigated whether a single dose of a DHA-rich powder affects self-reported mood in middle-aged males during elevated cognitive demand. In a randomised, double-blind, placebo-controlled trial with a balanced crossover design, twenty-nine healthy males (age M = 52.8 years, sd = 5.3) were administered a powder (in a meal) containing 4·74 g n-3 PUFA (DHA 4020 mg; EPA 720 mg) or placebo in random order on two different testing days separated by a washout period of 7 ± 3 d. Participants completed mood assessments before and after completing two cognitive test batteries at baseline and again 3·5–4·0 h following the consumption of the active treatment or placebo. While completion of the cognitive test batteries increased negative mood, differential effects for alertness (P = 0·008) and stress (P = 0·04) followed consumption of the DHA-rich powder compared with placebo. Although alertness declined when completing the cognitive batteries, it was higher following consumption of the DHA-rich powder compared with placebo (P = 0·006). Conversely, stress was lower following consumption of the DHA-rich powder relative to placebo, though this difference only approached significance (P = 0·05). Overall, results from this pilot study demonstrate that a single high dose of n-3 PUFA may deliver acute mood benefits following elevated cognitive demand in healthy middle-aged males.
Feeding is an interactive process between parents and children and is related to children’s healthy nutrition, growth, and feelings about the child or parent. The effectiveness of the interaction between feeding and behaviour is strongly influenced by how well this reciprocal procedure is stimulated and supported.
The current study aimed to cross-culturally adapt and validate the About Your Child’s Eating (AYCE) questionnaire in its Greek language version for Greek-Cypriot parents and caregivers of children aged six months to 16 years with or without feeding and swallowing problems.
One hundred Greek-Cypriot parents/caregivers of children with feeding and swallowing difficulties and 100 Greek-Cypriot parents/caregivers of children without feeding and swallowing difficulties participated in this study. This study was conducted at mainstream schools and private speech-language therapy clinics in Cyprus. According to WHO, the AYCE questionnaire was translated and culturally tailored for Greek speakers.
The analysis revealed a statistically significant difference between the AYCE total mean scores of parents in the Typical Development of Feeding Behaviors group (c-TDFB) (M = 44.03, SD = 11.18) and parents in the Atypical Development of Feeding Behaviors group (c-ADFB) (M = 63.56, SD: 16.22) (P < 0.001), with c-ADFB scoring significantly higher. The overall evaluation of the scale yielded a Cronbach’s α coefficient of 0.916.
The validity of the AYCE questionnaire in Cyprus was also assessed. The findings demonstrate that the AYCE can be a beneficial tool for determining critical facets of the feeding parent–child interaction for preschool- and school-aged Greek-Cypriot children in Cyprus.
To construct an evidence-based practice programme for the nutrition management of older adults in nursing homes. The programme will provide a basis for improving or solving the nutrition management problems of older adults in nursing homes.
Design:
The study is based on guideline evidence and Delphi method. The evidence was comprehensively searched, assessed and summarized, and the best evidence and a preliminary programme for nutrition management of older adults in nursing homes were aggregated. Then, the Delphi method was used to assess the applicability of the preliminary programme and the obstacle factors to modify, supplement and improve the nutrition management programme.
Setting:
Baseline survey data were collected from three nursing homes in Ningxia, China, and guideline evidence was obtained through systematic searches of the Cochrane Library, PubMed and other scientific databases, as well as relevant official websites.
Participants:
A total of 350 older adults residing nursing homes and 160 nurses participated in the baseline survey. To ensure the programme’s applicability and identify potential implementation obstacles, fifteen experts from local grade A hospitals, nursing homes and community health centres were consulted for review.
Results:
A fourteen-item, fifty-six-best-evidence nutrition management programme for older adults in nursing homes was developed based on five guideline evidences and baseline survey findings.
Conclusions:
This is a systematic and comprehensive nutritional management programme for older adults in nursing homes based on guideline evidence, which can provide a standardised basis for the implementation of scientific nutritional management in nursing homes in Ningxia. Managers should promote the translation of evidence into practice in accordance with the specific circumstances of individual nursing homes.
Neural tube defects (NTD) are serious, life-threatening birth defects. Staple food fortification with folic acid (vitamin B9) is a proven, effective intervention to reduce NTD birth prevalence. Mandatory food fortification with folic acid was implemented in South Africa (SA) in 2003. This article provides an overview of NTD birth prevalence in SA, pre- and post-fortification, and evaluates current folic acid fortification regulations.
Design:
Fortification effectiveness data in SA were reviewed using published studies and national reports on NTD birth prevalence pre- and post-folic acid fortification. Current folic acid fortification regulations in SA were evaluated by experts.
Setting:
Regulations were assessed using national health guidelines, legislation and regulations. NTD birth prevalence data were sourced from the published literature.
Participants:
None.
Results:
Significant reductions in the birth prevalence of spina bifida and anencephaly and improved maternal folate levels have been achieved following the introduction of folic acid fortification in SA. However, there is poor overall regulatory compliance in some instances and a gap in current regulations that excludes the fortification of cake flour in SA.
Conclusions:
While the SA NTD birth prevalence has decreased by 30% post-fortification, the regulatory exclusion of cake flour fortification is a significant and growing issue. Proposed 2016 regulatory amendments to address this gap urgently require finalisation and enactment by government to prevent negating benefits achieved to date and to ensure continued improvement. Fortification monitoring requires strengthening to ensure widespread compliance with policies, particularly in underserved areas.