To examine how milk consumption varies by milk choice and measure the association of milk choice on the nutritional and energetic content of National School Lunch Program (NSLP) lunches.

An observational plate waste study using the Digital Photography of Foods Method.

Data were collected from two suburban South Carolina schools in one district during February and March 2013.

Totally, 968 NSLP lunches selected by 619 kindergarten to fifth grade students.

Most students chose chocolate milk (75 %). A multinomial logit model indicated milk choice varied significantly by sociodemographic characteristics. An ordinary least square regression indicated that consumption rates of low-fat white milk were 8·5 % lower than fat-free chocolate milk (P = 0·039) and milk consumption rates varied statistically by sociodemographic characteristics. Ordinary least square regressions found that the consumption of energies and nutrients from NSLP lunches varied with sociodemographic characteristics and milk choice; students selecting chocolate milk consumed 58 more energies (P < 0·001) and 10 more grams of total sugar (P < 0·001) than students selecting low-fat white milk from their NSLP lunches. Students consumed statistically similar energies and nutrients from the non-milk components of their meals.

Students selecting chocolate milk consumed more energies and nutrients from their NSLP lunches with the increases in consumption attributed to the milk component of the meal. The findings have implications for recent changes to NSLP guidelines that allow schools to offer both low-fat and fat-free flavoured milk, reversing the previous ban on low-fat flavoured milk under the Healthy, Hunger-Free Kids Act.

To assess whether exposure to fast-food outlets around schools differed depending on socio-economic status (SES).

Binary logistic regression was used to investigate the presence and zero-inflated Poisson regression was used for the count (due to the excess of zeroes) of fast food within 1000 m and 15000 m road network buffers around schools. The low and middle SES tertiles were combined due to a lack of significant variation as the ‘disadvantaged’ group and compared with the high SES tertile as the ‘advantaged’ group. School SES was expressed using the 2011 Australian Bureau of Statistics, socio-economic indices for areas, index of relative socio-economic disadvantage. Fast-food data included independent takeaway food outlets and major fast-food chains.

Metropolitan Adelaide, South Australia.

A total of 459 schools were geocoded to the street address and 1000 m and 1500 m road network distance buffers calculated.

There was a 1·6 times greater risk of exposure to fast food within 1000 m (OR=1·634; 95 % 1·017, 2·625) and a 9·5 times greater risk of exposure to a fast food within 1500 m (OR=9·524; 95 % CI 3·497, 25·641) around disadvantaged schools compared with advantaged schools.

Disadvantaged schools were exposed to more fast food, with more than twice the number of disadvantaged schools exposed to fast food. The higher exposure to fast food near more disadvantaged schools may reflect lower commercial land cost in low-SES areas, potentially creating more financially desirable investments for fast-food developers.

This study employs a strengths-based approach to assess food access in remote Alaska during the COVID-19 pandemic, identifying both the negative consequences of the pandemic on store-bought and subsistence/traditional food access and compensatory strategies used.

As a part of a larger study on the impacts of COVID-19 on daily life remote Alaskan communities, study data presented here were collected through key informant interviews (KII) and state-wide online surveys from 21 September 2020 to 31 March 2021 among remote Alaska community members.

This study was conducted with residents of remote communities in Alaska, defined as those off the road system. Remote communities often have small or no grocery stores and rely on subsistence or traditional sources of food.

KII participants (n 36) were majority female (78 %) and Alaska Native (57 %). Survey participants (n 615) were also majority female, 25–54 years old and most had had some post-secondary education or training.

Survey and interview data revealed that the pandemic had significant negative impacts on store-bought food access in remote Alaskan communities. Individuals also shared that locally available and wild harvested foods acted as a buffer to some of the loss of access to these store-bought foods, with some people sharing that the harvesting of wild and traditional foods served as a coping strategy during times of pandemic-related stress.

The results from this study demonstrate that the remoteness of some Alaskan communities has been both a source of vulnerability and protection in terms of food access.

Excessive alcohol consumption during reproductive years may impact the integrity of developing eggs and sperm, potentially affecting the life-long health of future children. Inadequate diets could aggravate these preconception effects of alcohol. The aim of the present study was to assess the prevalence of excessive alcohol consumption and explore whether weekly alcohol intake is associated with energy and nutrient intake and adequacy of micronutrient intake among students.

Cross-sectional survey using a validated and reproducibility-tested FFQ.

University of Agder, Norway, in 2018.

622 students (71 % female).

More than 80 % reported having consumed alcoholic beverages the past 4 weeks. One-third of men and 13 % of women exceeded the upper recommended limit of 14 UK alcohol units/week. An inverse association between increasing alcohol intake and energy-adjusted micronutrient intake was evident for thiamine, phosphate, Fe, Zn and Se in men, and for vitamin A, β-carotene, vitamin E and C, thiamine, vitamin B6, folate, P, Mg, K, Fe, Zn and Cu in women. A substantial proportion had vitamin D, folate, Fe and I intakes below average requirement regardless of alcohol consumption level. The combination of prevalent alcohol use, decreasing micronutrient density of diet across alcohol consumption level and a high probability of micronutrient inadequacy indicate reason for concern in a preconception public health perspective.

Our findings call for investigations into young adults’ knowledge, reflections and beliefs regarding diet and alcohol use to understand how these behaviours could be improved ahead of parenthood.

High burden of anaemia exists amongst rural adolescent girls in India. The objective of this study was to characterise anaemia in school going adolescent girls in rural Haryana, India.

Linear and multiple logistic regression analysis of data collected prior to an intervention trial was conducted. Participants were classified into anaemic (haemoglobin <12 g/dl) and non-anaemic group and were further classified into deficiencies of Fe, folate or vitamin B12, mixed, anaemia of other causes and inflammation.

Three schools in Ballabgarh block of Faridabad District, Haryana, India.

One hundered and ninety-eight non-anaemic and 202 anaemic adolescent girls (12–19 years).

Anaemic girls had 29·6 % Fe deficiency, 28·1 % folate or vitamin B12 deficiency, 15·8 % mixed deficiency and 9·7 % acute inflammation. Anaemia of other causes was found in 16·8 % of the anaemic participants. Girls with Fe and isolated folate deficiency had 2·5 times and four times higher odds of developing anaemia, respectively, as compared with non-anaemic girls. Fe deficiency with no anaemia was found amongst 11 % non-anaemic girls. Non-anaemic girls had a high prevalence of combined deficiency of folate or vitamin B12 (29·5 %) and acute inflammation (14·4 %).

The current strategy of Fe and folic acid supplementation alone will not suffice for achieving the desired reduction in the prevalence of anaemia as unknown causes and anaemia of inflammation contribute to a substantial proportion of anaemia. Integrating other nutrition-specific components like improving water, sanitation and hygiene practices with the ongoing micronutrient supplementation program will comprehensively tackle anaemia. Unknown causes of anaemia warrant further research.

The relationship of a diet low in fibre with mortality has not been evaluated. This study aims to assess the burden of non-communicable chronic diseases (NCD) attributable to a diet low in fibre globally from 1990 to 2019.

All data were from the Global Burden of Disease (GBD) Study 2019, in which the mortality, disability-adjusted life-years (DALY) and years lived with disability (YLD) were estimated with Bayesian geospatial regression using data at global, regional and country level acquired from an extensively systematic review.

All data sourced from the GBD Study 2019.

All age groups for both sexes.

The age-standardised mortality rates (ASMR) declined in most GBD regions; however, in Southern sub-Saharan Africa, the ASMR increased from 4·07 (95 % uncertainty interval (UI) (2·08, 6·34)) to 4·60 (95 % UI (2·59, 6·90)), and in Central sub-Saharan Africa, the ASMR increased from 7·46 (95 % UI (3·64, 11·90)) to 9·34 (95 % UI (4·69, 15·25)). Uptrends were observed in the age-standardised YLD rates attributable to a diet low in fibre in a number of GBD regions. The burden caused by diabetes mellitus increased in Central Asia, Southern sub-Saharan Africa and Eastern Europe.

The burdens of disease attributable to a diet low in fibre in Southern sub-Saharan Africa and Central sub-Saharan Africa and the age-standardised YLD rates in a number of GBD regions increased from 1990 to 2019. Therefore, greater efforts are needed to reduce the disease burden caused by a diet low in fibre.

To identify whether there were differences in nutritional quality between organic and conventional ready-to-eat breakfast cereals of similar types, based on NuVal scores.

The current descriptive study analysed NuVal scores for 829 ready-to-eat breakfast cereals and eighteen different cereal types. ANOVA was used to compare the mean NuVal scores of 723 conventional cereals with those of 106 organic cereals.

Ready-to-eat breakfast cereals (n 829) with NuVal scores.

Not applicable.

There was no significant difference in NuVal scores between conventional (mean 28·4 (sd 13·4)) and organic (mean 30·6 (sd 13·2)) cereal types.

Consumers who choose the organic version of a ready-to-eat breakfast cereal believing that nutritional quality is superior may not be making a valid assumption. Public health nutrition educators must help consumers understand that organic cereals are not necessarily more nutritious and their consumption could result in excessive intake of undesirable nutrients, such as fat, sugar and sodium.

Iron and/or iodine deficiencies can have multiple serious adverse health outcomes, but examination of incidence rates of these deficiencies has rarely been conducted in any large population. This study examined incidence rates, temporal trends and demographic factors associated with medically diagnosed iron and iodine deficiencies/disorders in US military service members (SM).

The Defense Medical Epidemiological Database (DMED) was queried for medical visits of active duty SM to obtain specific International Classification of Diseases, Version 9, codes involving clinically diagnosed iron and iodine deficiencies/disorders.

Analysis of existing database (DMED).

Entire population of US military SM from 1997 to 2015 (average n per year = 1 382 266, 15 % women).

Overall incidence rates for iron and iodine were 104 and 36 cases/100 000 person-years, respectively. Over the 19-year period, rates for iron disorders increased steadily (108 % for men, 177 % for women). Rates for iodine disorders also increased steadily for men (91 %), but, for women, there was an initial rise followed by a later decline. Overall, women’s rates were 12 and 10 times higher than men’s for iron and iodine, respectively. Compared with whites, blacks and those of other races had higher rates of deficiencies of both minerals. Incidence rates for iodine deficiency increased substantially with age.

The overall incidence of clinically diagnosed iron and iodine deficiency among SM was low, but increased over the 19 years examined, and certain demographic groups were at significantly greater risk. Given the unexpected increases in incidence of these mineral disorders, increased surveillance may be appropriate.

Clinical Trial Registration No. ISRCTN58987177 (http//:www.isrctn.com/ISRCTN58987177)

This study evaluated the independent and combined environmental impacts of the consumption of beef and ultra-processed foods in Brazil.

Cross-sectional study.

Brazil.

We used food purchases data from a national household budget survey conducted between July 2017 and July 2018, representing all Brazilian households. Food purchases were converted into energy, carbon footprints and water footprints. Multiple linear regression models were used to assess the association between quintiles of beef and ultra-processed foods in total energy purchases and the environmental footprints, controlling for sociodemographic variables.

Both beef and ultra-processed foods had a significant linear association with carbon and water footprints (P < 0·01) in crude and adjusted models. In the crude upper quintile of beef purchases, carbon and water footprints were 47·7 % and 30·8 % higher, respectively, compared to the lower quintile. The upper quintile of ultra-processed food purchases showed carbon and water footprints 14·4 % and 22·8 % higher, respectively, than the lower quintile. The greatest reduction in environmental footprints would occur when both beef and ultra-processed food purchases are decreased, resulting in a 21·1 % reduction in carbon footprint and a 20·0 % reduction in water footprint.

Although the environmental footprints associated with beef consumption are higher, dietary patterns with lower consumption of beef and ultra-processed foods combined showed the greatest reduction in carbon and water footprints in Brazil. The high consumption of beef and ultra-processed foods is harmful to human health, as well as to the environment; thus, their reduction is beneficial to both.

For dietary assessment, mobile devices with a camera can be used as an alternative to hand-written paper records. The Nutritional Tracking Information Smartphone (Nutris-Phone) study aimed to examine relative validity and feasibility of a photo-based dietary record in everyday life.

Parallel to the photo-based technique, a weighed record was performed. Participant satisfaction was assessed by questionnaire. A trained nutrition scientist evaluated portion sizes and nutrient content was calculated (DGExpert). Spearman correlation and Bland–Altman analyses were applied.

Healthy, non-pregnant volunteers (≥18 years) without intent to lose weight recruited at Ulm University, Germany.

Sixty-six participants (36 % males, median age 22·0 (interquartile range 20·0–25·0) years) took pictures of foods and beverages consumed with a commercially available mobile phone.

Significant correlation between the photo-based and weighed record was observed: energy (r=0·991), carbohydrate (r=0·980), fat (r=0·972), protein (r=0·988), fibre (r=0·941). Bland–Altman analyses indicated comparable means and acceptable 95 % limits of agreement (energy: −345·2 to 302·9 kJ (−82·5 to 72·4 kcal); carbohydrate: −15·2 to 13·1 g; fat: −6·4 to 6·4 g; protein: −5·9 to 5·6 g; fibre: −2·7 to 2·5 g). However, with increasing intake level, underestimation by the digital method was present (except for fat, all P<0·01). Over 80 % of participants were satisfied with the photo-based record. In nearly 90 %, technical implementation was without major problems.

Compared with a weighed record, the photo-based dietary record seems to be valid, feasible and user-friendly to estimate energy, macronutrient and fibre intakes, although a systematic bias with increasing levels of intake should be kept in mind.

The development of type 1 diabetes (T1D) is potentially influenced by nutrition. The aim of our study was to assess food and nutrient intakes of children at increased risk of T1D.

Dietary intake of the last 4 weeks was assessed using a diet history interview. The daily nutrient and food intakes were compared with the German Dietary Reference Intakes, the Optimized Mixed Diet recommendations and those of a representative sample of children from the EsKiMo study.

Children included in the analysis participated in the prospective TEENDIAB study.

First-degree relatives of people with T1D (n 268), aged 8–12 years.

The TEENDIAB children consumed 52·0 % of their total energy from carbohydrates, 32·6 % from fat and 14·3 % from protein. Compared with the reference values, their intake was lowest for folate at 61·3 % of the reference, for iodine at 58·1 % and for vitamin D at 8·9 %, and exceeded the reference for vitamin K about 5-fold, for Na about 3·5-fold and for protein about 1·5-fold. Their nutrient intakes were similar to those of a control cohort without increased T1D risk. The consumption of non-desirable food groups (meat products, sweets/snacks) was above the recommendations and the consumption of desirable food groups (fruits, vegetables, carbohydrate-rich foods) was below the recommendations.

The TEENDIAB children had intakes considerably below the recommendations for vitamin D, iodine, folate and plant-based foods, and intakes above for vitamin K, Na, protein, meat products and sweets/snacks. They showed similar dietary patterns to non-risk children.

The present study investigated the risks and benefits of routine Fe–folic acid (IFA) supplementation in pregnant women living in low- and high-groundwater-Fe areas in Bangladesh.

A case-controlled prospective longitudinal study design was used to compare the effect of daily Fe (60 mg) and folic acid (400 μg) supplementation for 3·5 months.

A rural community in Bangladesh.

Pregnant women living in low-groundwater-Fe areas (n 260) and high-groundwater-Fe areas (n 262).

Mean Hb and serum ferritin concentrations at baseline were significantly higher in pregnant women in the high-groundwater-Fe areas. After supplementation, the mean change in Hb concentration in the women in the low-groundwater-Fe areas (0·10 mg/dl) was higher than that in the pregnant women in the high-groundwater-Fe areas (–0·08 mg/dl; P = 0·052). No significant changes in the prevalence of anaemia or Fe deficiency (ID) in either group were observed after IFA supplementation; however, the prevalence of Fe-deficiency anaemia (IDA) decreased significantly in the women in the low-groundwater-Fe areas. The risk of anaemia, ID and IDA after supplementation did not differ significantly between the groups. None of the participants had Fe overload. However, a significant proportion of the women in the high- and low-groundwater-Fe areas remained anaemic and Fe-deficient after supplementation.

IFA supplementation significantly increased the Hb concentration in pregnant women living in the low-groundwater-Fe areas. Routine supplementation with 60 mg Fe and 400 μg folic acid does not pose any significant risk of haemoconcentration or Fe overload. Further research to identify other nutritional and non-nutritional contributors to anaemia is warranted to prevent and treat anaemia.

Sustainable diet is one of the main factors that support food security, and the Mediterranean diet (MD) one of the sustainable diet models associated with low ecological impact and optimum health results has come to the fore. It was aimed to compare the results of the 2010 and 2017 Turkey Nutrition and Health Studies (TNHS) according to the Mediterranean Adequacy Index (MAI) and in order to evaluate the environmental impact of the current nutritional status in Turkey through water footprints (WF).

The MAI score was calculated using the published results of the 2010 and 2017 TNHS, and the WF have been calculated as indicators of environmental impact.

Turkey.

There are no participants.

In the TNHS, there was an increase in the amount of energy provided by foods non-MD in 2017 compared to 2010, with a decrease in the total MAI score. The group with the lowest adherence to the MD in both years was the adult group (MAI20102·74 and MAI20172·31), while the group with the highest adherence was the adolescent group (MAI20103·21 and MAI20172·53). The MAI scores of females were higher than those of males in both years. The males aged 19–64 years had the largest (841 m3/year) WF and the females aged 65+ years had the smallest (483 m3/year). The food group that contributed the most to WF was meat and meat products (21·0–35·0 %).

Adherence to the MD has decreased due to the increase in the consumption of the Western-type diet in Turkey.

To examine the variety of fruits and vegetables lower income households in the USA can buy while meeting Federal dietary recommendations at different levels of expenditure.

Simulation techniques were used to create 3000 market baskets of fruits and vegetables. All baskets contained enough food for a four-person household to meet dietary recommendations for fruits and vegetables over 1 week. Each basket’s retail value was estimated along with the ability of a representative household to afford each basket with different levels of expenditure.

We used data from the US Department of Agriculture’s (USDA) Fruit and Vegetable Prices data product which reports a US household’s costs to buy each of 157 different fruit and vegetable products per edible cup equivalent.

We consider the situation facing a lower income household that receives maximum benefits through the Supplemental Nutrition Assistance Program (SNAP). These benefits are enough for the household to obtain a nutritious and palatable diet without spending any of its own money on food if it approximately follows USDA’s Thrifty Food Plan.

Households receiving maximum SNAP benefits can buy a sufficient variety and quantity of fruits and vegetables if they allocate about 40 % of those benefits to these two food groups. However, if households spend less than that amount, the variety of products they can buy while still satisfying recommendations drops off quickly.

Households that move fruits and vegetables to the centre of their budgets can better afford to meet Federal dietary guidelines.

The present study aimed to evaluate the prevalence of meeting health recommendations on diet and physical activity (having breakfast, eating fruit and vegetables, consumption of milk/yoghurt, performing moderate-to-vigorous physical activity, limiting television watching) and to assess junk snack food consumption in adolescents from southern Italy. The association between healthy behaviours and abdominal adiposity was also examined.

In a cross-sectional protocol, anthropometric data were measured by trained operators while other data were collected through a structured interview.

Three high schools in Naples, Italy.

A sample of 478 students, aged 14–17 years, was studied.

The proportion of adolescents who met each of the health recommendations varied: 55·4 % had breakfast on ≥6 d/week; 2·9 % ate ≥5 servings of fruit and vegetables/d; 1·9 % had ≥3 servings of milk/yoghurt daily; 13·6 % performed moderate-to-vigorous physical activity for ≥60 min/d; and 46·3 % watched television for <2 h/d. More than 65 % of adolescents consumed ≥1 serving of junk snack foods/d. Only 5 % fulfilled at least three recommendations. Healthy habits tended to correlate with each other. As the number of health recommendations met decreased, the percentage of adolescents with high abdominal adiposity (waist-to-height ratio ≥0·5) increased. The trend was not significant when the proportion of overweight/obese adolescents was considered. Logistic regression analysis indicated that male gender and watching television for ≥2 h/d were independently associated with a higher waist-to-height ratio.

Most adolescents failed to meet the five health recommendations considered. Male gender and excessive television watching were associated with abdominal adiposity.

To evaluate the association between weight gain in the first two years of life and the occurrence of wheezing, asthma, serum IgE, skin reactivity and pulmonary function.

Cohort study.

The metropolitan region of Salvador, Bahia, Brazil.

The association was studied between 1997 and 2005 in 669 children up to 11 years of age. Data were collected on asthma and risk factors, both current factors and those present in the first years of life. Weight gain was considered fast when the Z-score was >0·67. Poisson regression was used in the multivariate statistical analysis.

Wheezing was reported in 25·6 % of the children. Weight gain was considered fast (Z-score >0·67) in 29·6 % of the children and slow (Z-score <−0·67) in 13·9 %. Children in the slow weight gain group had 36 % fewer symptoms of asthma (prevalence ratio = 0·65; 95 % CI 0·42, 0·99).

Slower weight gain in the early years of life may constitute a protective factor against symptoms of asthma. The relevance of this finding for public health is not yet certain, since it is known that children with slow and fast weight gain may be more likely to develop adverse health consequences related to both these situations.

Relationships among race/ethnicity, individual socio-economic status (SES), neighbourhood SES and acculturation are complex. We sought to answer whether: (i) race/ethnicity, individual SES and neighbourhood SES have independent effects on women’s fruit and vegetable consumption (FVC); (ii) SES modifies the effects of race/ethnicity on FVC; and (iii) nativity modifies the effect of Latina ethnicity on FVC.

Cross-sectional surveys from the population-based Geographic Research on Wellbeing (GROW) Study were linked with census-tract level data. FVC was indicated by (i) consuming fruits and vegetables less often than daily (LOWFV) and (ii) not having fruits and vegetables in the home very often. Other variables included age, marital status, race/ethnicity, country of birth, educational attainment, family income and longitudinal neighbourhood poverty (based on latent class growth models). Weighted logistic regression models accounting for the complex sample design were constructed.

California, USA, 2012–2013.

Women (n 2669).

In adjusted models, race/ethnicity, education and income were independently associated with FVC, but not neighbourhood poverty. Women of colour, high-school graduates and women with incomes at 301–400 % of the federal poverty level were at higher odds of LOWFV compared with non-Hispanic Whites, college graduates and those with incomes >400 % of the federal poverty level. Little evidence for interactions between race/ethnicity and individual or neighbourhood SES was found; similar patterns were observed for immigrant and US-born Latinas.

Addressing the dietary needs of lower-SES communities requires multilevel interventions that simultaneously provide culturally tailored nutrition education and address the physical and economic accessibility of culturally acceptable fruits and vegetables.

To introduce community-specific modifications in the conventional 24 h recall method for objectively estimating maternal dietary intake and validate it with a reference method.

A modified 24 h recall method was developed with the visit of trained local girls at the subject’s home to weigh portion sizes at each mealtime over the 24 h recall period. This was validated with the reference method in which weighed records of the foods consumed were obtained and their laboratory analysis was done to obtain nutrient intakes.

Rural areas located 40–50 km from Pune City, India.

Forty-one pregnant women participated willingly.

The estimates of intake obtained from the reference method were comparable to those obtained from the modified 24 h recall method for energy (7795 (sd 1841) kJ (1863 (sd 440) kcal) v. 7615 (sd 1824) kJ (1820 (sd 436) kcal), respectively), protein (48·6 (sd 12·9) g v. 45·3 (sd 12·6) g, respectively) and fat (35·3 (sd 16·6) g v. 36·0 (sd 14·2) g, respectively). Significant correlation was observed between the estimates obtained by the two methods for energy (0·75, P < 0·001), protein (0·71, P < 0·001) and fat (0·56, P < 0·001) and differences in nutrient intake did not reveal any systematic bias. When compared with the reference method, the modified method showed >80 % sensitivity and specificity for identifying inadequate maternal energy intakes.

Simple modifications to conventional methods backed by understanding of community specifics and nutritional peculiarities are of immense importance in obtaining objective estimates of daily nutritional intakes of individuals in free-living populations. The approach would be adaptable in similar settings in other developing countries.

Agriculture designed to make best use of landscape and to be maximally sustainable would also provide food of the highest nutritional and gastronomic standards, and would inevitably employ a great many people. Thus it would solve the world's food problems, and its principal social problem, at a stroke. But agriculture in practice is designed for a quite different purpose – to generate wealth, in the cause of ‘economic growth’. The pressing need is not for more science and technology, but to recognise the true cause of the problems and to re-think priorities.

We could all be well fed. Indeed, everyone in the world who is ever likely to be born could be fed to the highest standards of gastronomy as well as of nutrition until humanity itself comes to an end. We already have most of the necessary technique – perhaps all that is needed. We could always do with more excellent science but we need not depend, as we are often told from on high, on the next technological fix. The methods that can provide excellent food would also create a beautiful environment, with plenty of scope for other creatures, and agreeable and stable agrarian economies with satisfying jobs for all.

In reality, in absolute contrast, we have created a world in which almost a billion are chronically undernourished; another billion are horribly overnourished, so that obesity and diabetes are epidemic, and rising; a billion live on less than two dollars a day; and a billion live in urban slums – a figure set to increase and probably at least to double over the next half century; while other species are disappearing so fast that biologists speak of mass extinction.

Stunting (height-for-age < −2 sd) is one of the forms of undernutrition and is frequent among children of low- and middle-income countries. But stunting perse is not a synonym of undernutrition. We investigated association between body height and indicators of energetic undernutrition at three critical thresholds for thinness used in public health: (1) BMI SDS < −2; (2) mid-upper arm circumference divided by height (MUAC (mm) × 10/height (cm) < 1·36) and (3) mean skinfold thickness (SF) < 7 mm and to question the reliability of thresholds as indicators of undernutrition.

Cross-sectional study; breakpoint analysis.

Rural and urban regions of Indonesia and Guatemala – different socio-economic status (SES).

1716 Indonesian children (6·0–13·2 years) and 3838 Guatemalan children (4·0–18·9 years) with up to 50 % stunted children.

When separating the regression of BMI, MUAC or SF, on height into distinguishable segments (breakpoint analysis), we failed to detect relevant associations between height, and BMI, MUAC or SF, even in the thinnest and shortest children. For BMI and SF, the breakpoint analysis either failed to reach statistical significance or distinguished at breakpoints above critical thresholds. For MUAC, the breakpoint analysis yielded negative associations between MUAC/h and height in thin individuals. Only in high SES Guatemalan children, SF and height appeared mildly associated with R2 = 0·017.

Currently used lower thresholds of height-for-age (stunting) do not show relevant associations with anthropometric indicators of energetic undernutrition. We recommend using the catch-up growth spurt during early re-feeding instead as immediate and sensitive indicator of past undernourishment. We discuss the primacy of education and social-economic-political-emotional circumstances as responsible factors for stunting.