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To examine how home food inventories and food procurement practices changed due to the COVID-19 pandemic.
Design:
Cross-sectional baseline data from a randomised controlled trial of a home food environment intervention. Telephone interviews were conducted from October 2020 to December 2022.
Setting:
Four 2–1–1 United Way agencies in Georgia, USA.
Participants:
2–1–1 clients (n 602); 80·6 % identified as Black and 90·9 % as women. Mean age was 42·8 (sd = 11·80). The majority were food insecure (73·4 %) and received Supplemental Nutrition Assistance Program (SNAP) benefits (65·8 %).
Results:
A majority of participants reported smaller inventories of fresh fruits and vegetables (65·1 %) and unhealthy snacks (61·6 %) in the home relative to before COVID-19. The majority (55·8 %) also reported decreased shopping for fruits and vegetables and decreased use of fast food for family meals (56·1 %). Over half (56·2 %) started to use a food pantry, and 44·9 % started ordering groceries online due to COVID-19. A COVID-19 stressors scale was significantly associated with decreased odds of a smaller fresh fruit and vegetable inventory (OR = 0·61, CI 0·51, 0·73) and a smaller unhealthy snack inventory (OR = 0·86, CI 0·74, 0·99). COVID-19 stressors were also associated with changed food procurement practices, including increased online grocery shopping (OR = 1·19, CI 1·03, 1·37), and starting to use a food pantry (OR = 1·31, CI 1·13, 1·51).
Conclusions:
The pandemic had a significant impact on home food inventories and procurement practices. Understanding how major events such as pandemics affect home food environments may help to stave off negative nutritional outcomes from similar events in the future.
To cognitively test questions for inclusion in a national nutrition survey, ensuring the questions are interpreted as intended, and to inform further improvements.
Design:
A draft nutrition survey questionnaire was developed based on existing questionnaires and expert input. Twelve questions on dietary habits and food security were selected for cognitive testing as these were newly developed, amended from existing questions or identified to no longer reflect the current food environment or concepts. Cognitive interviews were conducted using both think-aloud and probing techniques to capture respondents’ thought processes used to arrive at an answer. Interviews were audio-recorded and transcribed verbatim. Qualitative data were analysed for recurring patterns and unique discoveries across the survey questions.
Setting:
New Zealand.
Participants:
Sixty-eight participants aged 11 years and older, representing diverse socio-demographics including gender, ethnicity and education level.
Results:
Three main cognitive challenges were identified: (1) interpreting ambiguous terms, (2) understanding dietary or technical terms and (3) following complex or unclear instructions. Questions were refined based on the study findings and further advice from experts in nutrition and survey design to enhance participant understanding and accuracy.
Conclusions:
The cognitive testing findings and expert input led to the refinement and potential improvement of selected questions for inclusion in a national nutrition survey. Changes included simplified terminology, clearer instructions, improved examples and better question order. Our methodological approach and findings may be valuable for those designing similar questions for dietary surveys.
Bubble tea is known to have adverse health impacts due to its high sugar content. However, the influence of digital marketing on its consumption, especially among young people, remains unclear. This study aimed to describe the digital marketing strategies of Chinese bubble tea brands.
Design:
A content analysis of all marketing posts made by the top three Chinese bubble tea brands (by market share) – XIXUE, HEYTEA and NAYUKI – on Bilibili between 1 January 2023 and 31 December 2023.
Setting:
Bilibili, a popular social media platform among Chinese young people, in 2023.
Participants:
Not applicable.
Results:
Branding is central to the digital marketing strategies of bubble team brands, with the majority of posts using brand logos (99 %), branded effects (80·1 %) and branded characters (63 %), including children’s characters (19 %). Marketing strategies promoting user interaction were also common, reflected in the frequent use of hashtag campaigns (63 %), general engagement strategies (43 %) and competitions (10 %). Cultural elements that are integrated into the marketing message to resonate with the audience’s cultural identity were present in 47 % of posts.
Conclusions:
Bubble tea brands are using a range of digital marketing strategies to engage consumers and build brand presence in the competitive bubble tea market in China. Measures to protect young consumers from the exposure of such marketing should be considered as a way of improving population diets and reducing excess weight gain.
Using serum biomarkers that reflect fruit and vegetable (FV) intake offers a significant advantage over traditional dietary assessments by providing a more objective, accurate measure, meaningfully minimising recall bias and misreporting common in self-reported dietary data. This study investigated the relationship between these serum biomarkers and mortality risk using data from 19 168 adults aged 30 years and older who participated in the National Health and Nutrition Examination Survey from 1988 to 2006. Mortality follow-up was determined by linkage to the National Death Index through 31 December 2019 and diet by 24-h recalls. Cox proportional hazards models were employed to calculate hazard ratios (HR) and 95 % CI for mortality outcomes by tertiles of serum biomarkers of FV intake. Higher serum concentrations of total carotenoids were associated with a reduced risk of all-cause (tertile 3 v. tertile 1 HR = 0·69, 95 % CI = 0·61, 0·78) and cancer mortality (HR = 0·53, 95 % CI = 0·39, 0·71). Greater serum concentrations of individual carotenoids, such as α-carotene, β-carotene, β-cryptoxanthin, lycopene, lutein and zeaxanthin, were also linked to lower risks of all-cause and cancer mortality. Higher serum potassium concentrations showed a trend towards an association with a greater risk of all-cause mortality. No significant associations were found between serum vitamin C concentrations and mortality outcomes in the overall analysis; however, in sex-stratified analyses, higher vitamin C concentrations were associated with reduced risk of all-cause and cancer mortality in women. These findings suggest that specific serum biomarkers of FV intake, particularly carotenoids and vitamin C, may serve as indicators of reduced mortality risk.
Arabinoxylans (AX), the primary hemicellulose found in cereals and grasses, play a crucial role in regulating immunity, metabolism and various physiological processes, underscoring their value as essential components in dietary nutrition. Considering the extensive research on AX in piglet nutrition, this paper systematically reviews their impacts on gut health and microbiota in piglets, as well as the underlying mechanisms of action. AX have been shown to mediate gut barrier fortification through tight junction protein upregulation and orchestrate mucosal immunity homeostasis, consequently ameliorating early-weaning-associated diarrheal pathogenesis in piglets. Additionally, AX function as microbial ecological modulators through selective enrichment of beneficial commensal microbiota (e.g. Bifidobacterium spp. and Lactobacillus spp.), while simultaneously stimulating microbial biosynthesis of SCFA and ferulic acid exhibiting potent antioxidant and anti-inflammatory activity, thereby maintaining the intestinal health of piglets. This review offers valuable insights into their potential as a dietary intervention to support gut health and immune function in early-weaned piglets. However, most studies focus on single-source AX such as wheat or maize, with limited exploration of novel sources or comparative effects of source combinations. Future research should systematically investigate the molecular mechanisms of AX action, provide data-driven guidance for selecting AX sources in feed formulations and establish optimal inclusion levels in practical feeding regimens. Such efforts will further solidify the precision nutrition potential of AX in promoting sustainable and healthy growth in piglets.
Management of moderate wasting (MW) is an important component of country-level strategies to address wasting, given high caseloads and susceptibility to illness and death. However, many countries experience challenges in providing targeted supplementary feeding programmes with specially formulated foods involved in managing MW. Some implementing agencies have developed a community-based programme using locally available foods (LF) for MW management known as Tom Brown. This study assessed the costs and cost-efficiency of three Tom Brown programmes (two with an 8-week supplementation duration, one with a 10-week duration).
Design:
We assessed institutional costs and selected estimates of societal costs to households and community volunteers.
Setting:
Northeast Nigeria
Participants:
Programme staff
Results:
Total cost per child ranged from $155 to $184 per 8-week programme and $493 per 10-week programme. Monthly LF supplementation cost per child ranged from $5 to $21. Unit costs were influenced by implementation duration and variations in programme features including storage and transportation models, the inclusion of voucher transfers and volunteer cadre models. Opportunity costs to beneficiaries and volunteers in preparing recipes were substantial. Cash/voucher components, when used, represented a cost driver for institutional and societal costs.
Conclusions:
An updated WHO guideline emphasises the role of LF for supplementing MW children who lack other risk factors. Given that specially formulated foods are not necessary for all MW children to recover, programme approaches using LF are important options for managing MW. This study from Nigeria provides the first cost estimates for using LF to manage MW. Future research is needed on the effectiveness and cost-effectiveness of these approaches.
Lipids are essential for child development. Nutritional recommendations are numerous, evolving over time and are often based on expert opinions more than evidence-based medicine. The objective of this review is to critically analyse the evolution of current nutritional recommendations, identify existing knowledge gaps and propose avenues for improvement to optimise infant nutrition and development. A narrative literature review on Pubmed, EMBASE and Cochrane databases (2001–22) was conducted with the keywords: ‘alpha-linolenic acid, arachidonic acid, children, cholesterol, docosahexaenoic acid, eicosapentaenoic acid, guidelines, infant, long-chain (LC) PUFA, linoleic acid, lipids and dietary intakes, newborn, palmitic acid and toddler’. Among 861 articles identified, 133 were selected. The main current recommendations are issued by the French Agency for Food Safety (AFSSA), French Agency for Food, Environmental and Occupational Health and Safety (ANSES) and the Food and Agriculture Organization and World Health Organization (FAO-WHO). In infants from 0 to 3 years of age the main challenge is to increase lipid intake while maintaining an optimal omega 6/omega 3 ratio. Current recommendations are focused on polyunsaturated fatty acids, emphasising the intake of linoleic, eicosapentaenoic and docosahexaenoic acids without any specific recommendation for arachidonic acid before the age of 6 months. Points of interest, but without any recommendation, are the incorporation of milk fat, cholesterol, monounsaturated fatty acids, and saturated fatty acids for infants under 6 months. In conclusion, this article identifies knowledge gaps regarding the structural aspect of lipids and the integration of new categories of lipids in future recommendations to promote the quality of infant formulas.
To propose nutrition-related corporate reporting metrics for Australian packaged food manufacturers, retailers and quick-service restaurants and explore their feasibility of implementation.
Design:
Proposed metrics were developed based on (1) a review of current corporate reporting frameworks and relevant literature to collate nutrition-related recommendations, metrics and principles of best-practice reporting and (2) adaptation of existing recommendations into reporting metrics. Interviews with representatives from fifteen food companies were conducted to understand implementation considerations.
Setting:
Australia
Results:
There is a wide range of existing globally applicable nutrition-related recommendations and reporting metrics for food companies. Based on nine key principles identified for best-practice corporate reporting on nutrition, we devised forty-one reporting metrics (including five flagged as priorities) tailored to food companies operating in Australia across five focus areas: ‘corporate strategy and governance’, ‘product formulation’, ‘nutrition labelling and information’, ‘promotion practices’ and ‘product accessibility and affordability’. Company representatives expressed support for the proposed metrics, noting that additional information technology infrastructure and resources would be required for their routine reporting by companies.
Conclusions:
The proposed set of reporting metrics offers evidence-based guidance for the disclosure of nutrition-related actions by Australian food companies. The proposed metrics can inform government, public health groups and investors on best-practice approaches to monitor corporate nutrition practices and guide related policy decisions. Widespread implementation of the reporting metrics would be facilitated by integration with mandatory corporate sustainability reporting standards, with routine monitoring and enforcement by government, coupled with fit-for-purpose tools for comparing the healthiness of company product portfolios.
Several epidemiological studies have shown that consumption of coffee and green tea is inversely associated with risks of death and disability; however, the relationship between caffeine consumption and these outcomes remains unclear. We examined these associations in Japanese older adults. This was a prospective study of 7708 adults (aged ≥ 65 years) recruited from the Kyoto–Kameoka study. Dietary intake was estimated using a validated FFQ. Caffeine consumption was classified into four categories. Disability and mortality data were collected between 15 February 2012 and 30 November 2016. Hazard ratios (HR) and 95 % CI of outcomes were calculated using multivariable Cox proportional hazard models. During the median 4·75-year follow-up period, a total of 593 deaths and 1379 disability incidents were recorded. After adjusting for confounders, caffeine consumption was inversely associated with the incidence of disability (< 100 mg/d: reference; 100–149 mg/d: HR, 0·91 (95 % CI 0·80, 1·04); 150–199 mg/d: HR, 0·84 (95 % CI 0·72, 0·99); ≥ 200 mg/d: HR, 0·75 (95 % CI 0·63, 0·89), Pfor trend = 0·001) but not all-cause mortality. High coffee consumption was inversely associated with mortality (≥ 3 cups/d: HR, 0·62 (95 % CI 0·43, 0·88)) and disability (≥ 3 cups/d: HR, 0·81 (95 % CI 0·65, 0·99)) compared with non-consumption. However, green tea consumption was not associated with mortality or disability. Caffeine and coffee consumption was inversely associated with disability and/or mortality. Further research is needed to clarify whether high caffeine intake is safe and effective for older adults.
Food refusal behaviours in preschool children can significantly impact their nutritional status and overall quality of life. This study investigated the relationship between food refusal behaviours, compliance with the Mediterranean diet and quality of life in preschool children. Conducted as a cross-sectional study, it included 400 children aged 4–6 years and their parents. The Child Food Rejection Scale measured food refusal behaviours, The Children’s Mediterranean Diet Quality Scale (KIDMED) assessed compliance with the Mediterranean Diet and the Children Quality of Life-Questionnaire (Kiddy-KINDL) scale evaluated quality of life. The mean age of the children was 4·80 (sd 0·71) years. According to age-based BMI-Z scores, 71·0 % were normal, 15·5 % underweight, 9·0 % slightly overweight and 4·5 % obese. Parents’ average age was 34·65 (sd 5·35) years; 96·8 % were married, 88·8 % had a nuclear family structure, 58·0 % were university graduates and 69·8 % rated their income level as moderate. Girls had higher food refusal scores than boys (P < 0·05). Children who frequently fell ill also scored higher in food refusal (P < 0·05). Food refusal decreased with higher family income, larger family size and older parental age (P < 0·05). Parental nutrition education significantly reduced food refusal scores (P < 0·05). Higher KIDMED scores were associated with lower food refusal (P < 0·01), and children with low Kiddy-KINDL scores exhibited higher food refusal behaviours (P < 0·01). A positive correlation was found between KIDMED and Kiddy-KINDL scores (P < 0·01). No significant associations were detected between BMI Z scores and food rejection and its subscales. The findings suggest that compliance with the Mediterranean diet reduces food refusal behaviours in preschool children and increases quality of life, while low quality of life is associated with increased food refusal behaviours.
Increasing prevalence of diet-related non-communicable diseases in India is attributed to overconsumption of energy-dense, nutrient-poor diets and ultra processed foods (UPF) may potentially contribute to this consumption pattern. Applying standard UPF definition and developing appropriate tools can better capture its consumption among Indians. This cross-sectional study aimed to validate the ‘Nova-UPF Screener (for India)’ and explore its potential to objectively capture UPF consumption among Indian adults. The screener, adapted in prior formative research study from a tool for Brazilian population, was subjected to content, face and concurrent criterion validation. Subject matter experts (n 74) participated in online consultations to determine its content validity. Adults (18–60 years) from different geographical regions of India were included for face (n 70) and concurrent criterion (n 304) validations. The screener comprised twenty-four UPF categories specific to Indian food environment. Critical inputs from experts on screener’s appropriateness were incorporated to enhance its content. For face validation, overall percentage agreement of 99·4 % for all questions indicated a strong agreement for retaining screener attributes in each question. Half the participants (49·4 %) who were administered the finalised screener had Nova-UPF scores between 2 and 4 out of 24. There was almost perfect agreement (Pabak index = 0·85) between distribution of participants based on Nova-UPF scores and fifths of dietary share of UPF (as energy %) assessed by 24-h dietary recall. Nova-UPF Screener (for India) is a valid tool to capture UPF consumption in India that can be used for rapid assessment of UPF consumption and informing policies to improve Indian diets.
An integrative approach addressing diet and other lifestyle factors is warranted in studying obesity and its related diseases. The objective of this study is to examine the associations of lifestyle patterns with overweight/obesity among children in the United Arab Emirates. Data were derived from a cross-sectional survey of children aged 4–9 years living in Dubai, Sharjah and Abu Dhabi (n 426). Dietary intake was collected using a 24-h dietary recall and evaluated with the Healthy Eating Index. The Youth Physical Activity Questionnaire assessed physical activity, while other lifestyle factors included the presence of a live-in household helper, number of electronic devices in the child’s bedroom, eating while watching TV, family dinner frequency, fast-food and breakfast consumption and hours of sleep. Factor analysis was used to identify the lifestyle patterns. Two lifestyle patterns emerged: an unhealthy pattern marked by higher fast-food intake, eating while watching TV, having a live-in household helper and lower family dinners and a healthy pattern with higher physical activity, better Healthy Eating Index, more sleep, micronutrient supplements and breakfast consumption. The healthy lifestyle pattern was linked to a 30 % reduction in overweight/obesity odds (OR = 0·7, 95 % CI: 0·53, 0·93). A healthy lifestyle pattern, characterised by higher physical activity, better dietary quality, adequate sleep and breakfast consumption, is associated with lower odds of overweight/obesity among children in the United Arab Emirates. These findings highlight the importance of promoting comprehensive lifestyle interventions to effectively address childhood obesity in this population.
Thyroglobulin (Tg) has been considered a measure of iodine status, but there is no global guidance. This analysis examines the relationship between serum Tg and spot urinary iodine concentration (UIC) data to identify Tg concentrations that correspond to current WHO thresholds for population iodine status. We analysed data from 730 non-pregnant Guatemalan women aged 15–49 years who had both UIC and Tg measurements. Correlations were examined. Bootstrap stratified finite sampling with replacement was used to generate cluster k-medians of UIC (mUIC) and Tg (mTg) that served as the population unit of analyses. Non-linear restricted cubic spline regression dose–response curve functions and ordinary differential equations were then used to derive the Tg threshold corresponding to WHO definitions for UIC. Mean age was 30·2 (sd 9·3) years. mTg was 10·4 ng/ml (9·9, 10·8), and mUIC was 148·7 μg/l (139·1, 161·0). Correlations between spot UIC and Tg were NS at the individual level, but correlations based on population k-medians were significant (Spearman r = −0·21 to −0·06, each P < 0·0001) and demonstrated a U-shaped relationship according to WHO categories. Derived mTg cutoffs were 14·2 ng/ml predictive of UIC insufficiency, 10·2 ng/ml for UIC adequacy, 8·5 ng/ml for UIC above adequate and 10·8 ng/ml for UIC excess. The significant and graded mUIC–mTg correlations suggest that Tg concentrations predictive of UIC categories are obtainable for non-pregnant Guatemalan women aged 15–49 years. The newly derived mTg cutoff may be more discriminant at a lower spectrum of UIC in terms of identifying iodine-deficient women, more so than in the UIC excess category.
Although guidelines recommend targeted vitamin D testing for high-risk populations, testing has increased globally. Limited studies have examined real-world testing patterns and their relationship with deficiency outcomes. This study investigates trends, demographic determinants and deficiency outcomes associated with voluntary vitamin D testing among Taiwanese adults.
Design:
A retrospective cohort study analysing electronic medical records to assess vitamin D testing trends, demographic predictors of deficiency and status changes following consecutive tests within 2 years. Vitamin D status was classified based on serum 25-hydroxyvitamin D levels as deficient (< 20 ng/ml), insufficient (20–29·9 ng/ml) or sufficient (≥ 30 ng/ml).
Setting:
A tertiary medical centre in Taiwan.
Participants:
Between 2013 and 2022, 13 381 outpatients underwent voluntary vitamin D testing. After excluding those aged < 18 years, with advanced renal disease, osteomalacia, rickets or hyperparathyroidism, 8383 were included in the final analysis.
Results:
Testing increased sharply after 2019. Although women underwent twice as many tests, men had a higher deficiency prevalence (56·94 % v. 53·01 %). Adults aged 18–34 years had the highest prevalence (67·81 %). Obstetrics and Gynecology specialists ordered the most tests, particularly for female infertility, with 65·73 % of patients deficient. Among those with repeat tests, deficiency prevalence decreased from 59.32 % to 43·25 %.
Conclusions:
The increase in voluntary vitamin D testing with demographic disparities highlights the importance of understanding testing behaviours and public health implications. Improved vitamin D status at follow-up suggests potential benefits in identifying high-risk individuals and emphasises the need for further research to evaluate outcomes and guide prevention strategies.
During the COVID-19 pandemic, the US Department of Agriculture allowed all US schools to offer meals at no cost regardless of family income, a policy known as Universal Free Meals (UFM). Despite the recognised benefits of UFM, the policy expired in June 2022. The goal of this study was to gather perceptions of school staff in Arizona about school meals, UFM and the discontinuation of UFM.
Design:
This mixed-method study collected data using an online survey. Open-ended survey questions were analysed using qualitative thematic analysis, and closed-ended questions were analysed using descriptive analysis.
Setting:
The survey was distributed to school staff in the two major metropolitan areas in Arizona between September and October 2022, soon after the UFM policy expired.
Participants:
Survey responses were received from 1255 school staff, including teachers, cafeteria staff, administrators and other staff.
Results:
Most school staff (93 %) were supportive of UFM, and the support was consistent across all staff categories and across different political leanings. Thematic analysis demonstrated that staff felt UFM helped to meet students’ basic needs, reduced stigma and lessened the burden on teachers to use their own resources to provide food to students. Despite strong support, some staff reported concerns about food quality, programme waste and time available for lunch.
Conclusions:
UFM policies were strongly supported by school staff, despite some concerns about programme implementation. Understanding these views is important to the discussion of expanding UFM policies in the USA and globally.
To investigate the associations among income from work, the gender of the reference person, family and food insecurity (FI).
Design:
This quantitative study used nationally representative data from the 2018 Brazilian Family Budget Survey.
Setting:
The analyses estimated levels of food security and insecurity measured by the Brazilian Food Insecurity Scale according to labour income determined by the minimum wage per capita and the sex of the reference person (female/male). The logistic regression model measured the interaction between work income and gender in association with household FI.
Participants:
Brazilian families living in permanent households with at least one resident earning income from employment (n 48 625).
Results:
Households headed by women and with labour income ≤ ¼ minimum wage per capita had the highest percentage of moderate/severe FI (29·7 %). In these families and households with lower levels of employment income headed by men, the highest probabilities of moderate/severe FI were observed, at 10·8 and 9·6, respectively, compared with families with higher levels of employment income headed by men.
Conclusions:
Lower employment income contributes to FI in families, especially those that are headed by women. The socialisation of care work and the reduction in paid labour hours contribute to greater access to the labour market for women and a lower likelihood of FI.
To examine the intra- and inter-device reliability of devices using pressure-mediated reflection spectroscopy (the Veggie Meter®).
Design:
A cross-sectional research study was conducted across eight sites in the USA. Using two Veggie Meters® at each site, participants completed five, counter-balanced pairs of finger scans. Intra-device comparisons included intra-class correlation coefficients (ICC) and calculation of the CV and 95 % CI of each device/site; hypothesised to be ≤ 6 %. Inter-device comparisons included ICC, absolute relative differences (ARD) and 95 % CI, and equivalence; both hypothesised to be ≤ 10 %.
Setting:
Eight sites across the USA.
Participants:
Across sites, participants’ (n 282) average age ranged 24·7–39·0 years; sex ranged 60·0–85·7 % women and Non-Hispanic White ranged 20·0–94·3 %.
Results:
Intra-device ICC ranged from 0·77 to 0·99. The CV ranged from 6·2 to 14·2 %, with an average of 8·8 %. A majority (63 %; n 10) of the Veggie Meter® devices had significantly higher CV from the hypothesised 6 %. Inter-device ICC ranged from 0·58 to 0·94. The ARD ranged from 7·5 to 22·0 %, with an average of 13·9 %. ARD in a majority (n 5) of sites was significantly higher than the hypothesised 10 %. Five sites (63 %) demonstrated equivalence below the hypothesised 10 %.
Conclusions:
Our study demonstrates the intra-device and inter-device reliability to be moderate to high, as per ICC. The observed margin of difference within a device was up to 14 %, with an average of 9 %. The observed margin of difference between devices was up to 22 %, with an average of 14 % between devices.
This study compared dietary diversity and nutrient adequacy across age groups and seasons within an indigenous Karen community.
Design:
Cross-sectional survey.
Setting:
Dietary intake was assessed using a single-day 24-h dietary recall among Karen community members living in two villages of Laiwo subdistrict, Sangkhlaburi district, Kanchanaburi province, Thailand.
Participants:
In total, 312 Karen people participated during the rainy season and 344 during the dry season, including school-age children (6–12 years), working-age people (19–59 years) and older people (≥ 60 years).
Results:
Dietary diversity scores and food variety scores significantly differed across age groups for both seasons. However, seasonal dietary diversity score differences were not observed within any group, except for the food variety scores of school-age children. Over 70 % of participants in all age groups had inadequate intake of key micronutrients – Ca, Fe, vitamin A, vitamin C, Zn, vitamin B6 and vitamin B12 – as indicated by nutrient adequacy ratios < 0·75. Moderate to strong positive correlations between dietary diversity scores and nutrient adequacy ratios for energy, vitamin B2, vitamin C, niacin and mean adequacy ratio (r = 0·418–0·691, P < 0·001) were observed exclusively in the dry season and across all age groups.
Conclusions:
Among the Karen people, who are also facing triple burden malnutrition, dietary diversity is limited, micronutrient inadequacy is prevalent and overall dietary quality is insufficient despite frequent vegetable consumption. Findings highlight the need to address systemic challenges related to food variety and to promote education on appropriate food quantities, preparation methods and sustainable traditional food systems to improve nutrition.