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Mapping local patterns of childhood overweight and wasting in low- and middle-income countries between 2000 and 2017

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A double burden of malnutrition occurs when individuals, household members or communities experience both undernutrition and overweight. Here, we show geospatial estimates of overweight and wasting prevalence among children under 5 years of age in 105 low- and middle-income countries (LMICs) from 2000 to 2017 and aggregate these to policy-relevant administrative units. Wasting decreased overall across LMICs between 2000 and 2017, from 8.4% (62.3 (55.1–70.8) million) to 6.4% (58.3 (47.6–70.7) million), but is predicted to remain above the World Health Organization’s Global Nutrition Target of <5% in over half of LMICs by 2025. Prevalence of overweight increased from 5.2% (30 (22.8–38.5) million) in 2000 to 6.0% (55.5 (44.8–67.9) million) children aged under 5 years in 2017. Areas most affected by double burden of malnutrition were located in Indonesia, Thailand, southeastern China, Botswana, Cameroon and central Nigeria. Our estimates provide a new perspective to researchers, policy makers and public health agencies in their efforts to address this global childhood syndemic. Fine-scale geospatial mapping of overweight and wasting (two components of the double burden of malnutrition) in 105 LMICs shows that overweight has increased from 5.2% in 2000 to 6.0% in children under 5 in 2017. Although overall wasting decreased over the same period, most countries are not on track to meet the World Health Organization’s Global Nutrition Target of <5% in over half of LMICs by 2025.
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https://doi.org/10.1038/s41591-020-0807-6
*A list of authors and their affiliations appears online. e-mail: sihay@uw.edu
The profound impacts of childhood malnutrition, including
both undernutrition and overweight, affect the economic,
social and medical well-being of individuals, families, com-
munities and nations1,2. Undernutrition has been the most common
form of malnutrition in LMICs3, but as populations experience
economic growth, urbanization and demographic change, over-
weight is an emerging problem, leading to a double burden of mal-
nutrition (DBM). DBM may be manifested at the individual level
as stunting in childhood followed by overweight in adulthood4. At
the household level, research has focused on maternal and child
indicators of malnutrition, whereas at the population level, preva-
lence of both undernutrition with overweight has been reported5.
In children, DBM can be defined using different combinations of
the various indicators of undernutrition (wasting and/or stunting)
and overweight, obesity and diet-related noncommunicable dis-
eases (NCDs)6. While the most studied type of double burden is
that of stunting and obesity, it is mostly applicable at the individual
level among overweight adults who were previously stunted from
chronic undernutrition during childhood. Wasting is associated
with high rate of child mortality, whereas stunting has significant
negative impact across the life course and is highly predictive of
economic outcomes7. Public health nutrition programs designed to
address undernutrition may exacerbate overweight8, thus a compre-
hensive understanding of DBM at the population level is crucial for
the design of effective interventions.
Our aim was to determine the prevalence of overweight among
children under 5 years old in LMICs (N = 105) for policy-relevant
administrative units (district, state, and national level) and deter-
mine DBM by combining these estimates with those of wasting
prevalence. As there is no broad consensus on the preferred interna-
tional child growth standards for assessing overweight and obesity
among children under 5 (refs. 9,10), we used weight-for-height above
established cutoff points defined by the World Health Organization
(WHO). This was to analyze overweight estimates in relation to
the Global Nutrition Targets (GNTs), which were developed based
on WHO standards. Prevalence of early childhood overweight
(including obesity) is defined as the proportion of children under
5 with a weight-for-height z score (WHZ) more than two standard
deviations (s.d.) above the WHO sex- and age-specific median
growth reference standards10. This is different from the definition
for children between the ages of 5–18 years, which is above one s.d.
for overweight and above two s.d. for obese. We selected wasting as
the comparative indicator against overweight, as both share recom-
mended population prevalence ranges, which can be used to create
bivariate categories for DBM. Child wasting prevalence is defined as
the proportion of children under 5 with a WHZ more than two s.d.
below the median WHO growth standards10. Using WHZs allowed
modeling of the three categories in the same distribution and thus
enabled us to reliably determine the relative proportions for each
category using an ordinal approach. Based on WHO and United
Nations Children’s Fund (UNICEF)-defined thresholds, a moderate
level of separate or dual conditions is defined as >5–10%, a high
level as >10–15% and a very high level as >15% estimated preva-
lence11. Finally, we have defined DBM in this study as the simultane-
ous occurrence of >5% estimated prevalence for both wasting and
overweight within the same locations in the same year.
Reversing the rise in childhood overweight is indicated in the
United Nations (UN) Sustainable Development Goal 2.2 (ref. 12) and
WHO’s GNTs to improve maternal, infant and young child nutri-
tion13. WHO has also set an international target to reduce wasting
to <5% by 2025 (ref. 14). Quantifying changes in childhood over-
weight and wasting prevalence can be used to measure progress
toward these targets, while identifying locales with simultaneous
overweight and wasting will better inform intervention planning.
In addition, mapping changes in DBM prevalence will provide a
deeper understanding of the impact of past intervention strategies,
including insight into overweight in children under 5.
Global and local variation in malnutrition trends
Globally in 2017, an estimated 38.3 million (5.6%) children under 5
were overweight and 50.5 million (7.5%) were wasted15. The major-
ity (91%) of children under 5 affected by wasting and nearly half
Mapping local patterns of childhood overweight
and wasting in low- and middle-income countries
between 2000 and 2017
LBD Double Burden of Malnutrition Collaborators*
A double burden of malnutrition occurs when individuals, household members or communities experience both undernutrition
and overweight. Here, we show geospatial estimates of overweight and wasting prevalence among children under 5 years of
age in 105 low- and middle-income countries (LMICs) from 2000 to 2017 and aggregate these to policy-relevant administra-
tive units. Wasting decreased overall across LMICs between 2000 and 2017, from 8.4% (62.3 (55.1–70.8) million) to 6.4%
(58.3 (47.6–70.7) million), but is predicted to remain above the World Health Organization’s Global Nutrition Target of <5%
in over half of LMICs by 2025. Prevalence of overweight increased from 5.2% (30 (22.8–38.5) million) in 2000 to 6.0% (55.5
(44.8–67.9) million) children aged under 5 years in 2017. Areas most affected by double burden of malnutrition were located in
Indonesia, Thailand, southeastern China, Botswana, Cameroon and central Nigeria. Our estimates provide a new perspective to
researchers, policy makers and public health agencies in their efforts to address this global childhood syndemic.
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(48%) of overweight children lived in LMICs, with Africa and Asia
accounting for the largest shares of the global burden (25% and 46%
of overweight and 27% and 69% of wasted children, respectively)16.
Direct comparisons of population-level trends of childhood over-
weight and wasting generally provide regional- or country-level
estimates5,1620, potentially masking important subnational differ-
ences. Previously, we mapped 2000–2017 prevalence and trends in
wasting, stunting and underweight among children under 5 across
LMICs21 using Bayesian model-based geostatistical techniques22.
Building from this approach and using data from 420 household
surveys representing more than 3 million children, we mapped the
relative burdens of overweight and wasting among children under 5
in 105 LMICs from 2000 to 2017. Mapping with a continuous model
allows us to incorporate geolocated data and covariates and produce
gridded cell-level estimates that can be aggregated to intervention-
or policy-relevant geographical areas as boundaries change over
time. We present estimates at this local grid cell-level and aggregate
to first administrative (such as states and provinces), second admin-
istrative (such as districts and departments) and national levels.
On the basis of 2000 to 2017 weighted annualized rates of change
(AROC), which apply more weight to recent data, we predict preva-
lence of overweight and wasting and estimate their double burden
in 2025. The full array of outputs are available at the Global Health
Data Exchange (http://ghdx.healthdata.org/record/ihme-data/lmic-
double-burden-of-malnutrition-geospatial-estimates-2000-2017)
and can be further explored with our customized visualization tools
(https://vizhub.healthdata.org/lbd/dbm).
Prevalence and trends in early childhood overweight
Across LMICs, the prevalence of early childhood overweight
increased from 5.2% (95% uncertainty interval, 4.5–5.4%) to
6.0% (4.8–6.1%) in the modeled study period. Between 2000 and
2017, there were noticeable differences in estimated levels by area
(Fig. 1a,b). Although levels varied broadly across LMICs, every
modeling region had areas with high estimated prevalence in 2017
(Fig. 1b and Extended Data Fig. 1). These included large contiguous
areas across most Central American, Caribbean and South American
countries and areas with 15% estimated prevalence in central
Cuba, southern Panama, western Paraguay, scattered throughout
several eastern Brazilian states (for example, in Rio Grande do Sul,
Minas Gerais, Santa Catarina, Paraná and São Paulo) and Peru’s
coastal cities of Tacna, Ilo, Islay, Callao, Trujillo and Lima. In Africa,
most countries bordering the Sahel had low overweight prevalence
(0–5%); areas with >15% estimated prevalence were concentrated
in North Africa throughout Morocco, Algeria, Tunisia, Egypt and
select areas of Libya, as well as along South Africa’s southern coast
and in pockets in Botswana and Zambia. Large areas in eastern
and northern China and throughout Mongolia had an estimated
overweight prevalence >15%. Countries in the Oceania region
had moderate to high levels, with estimates over 15%, such as in
Indonesia’s Jakarta Pusat and Jakarta Barat regencies (in Jakarta
Raya; 17.7% (15.3–18.4%)). The North Africa, Central Asia and
Southeast Asia regions showed vast differences across nations; for
example, Afghanistan, Sudan and Laos had <5% estimated national
prevalence, whereas Egypt, Uzbekistan, Morocco, Kyrgyzstan and
Thailand had 15%. South Asia’s estimated levels ranged from <5%
in Bangladesh to 10% Bhutan. Estimated prevalence in Karbala
city in Karbala, Iraq, increased from 13.6% (12.4–14.1%) in 2000 to
29.3% (22.9–29.1%) in 2017. Thailand’s southern areas experienced
large increases in estimated prevalence levels; Sathorn district,
Bangkok Metropolis, had 24.1% (20.1–24.8%) overweight in 2000
and 33.9% (27.5–35.5%) in 2017. Areas with the greatest decrease
included Churcampa district, Huancavelica, Peru, decreasing
from 17.5% (17.4–17.6%) in 2000 to 10.3% (10.2–10.4%) in 2017.
Similarly, overweight in Al Gash district, Kassala, Sudan, declined
from 14.1% (13.6–14.5%) to 6.1% (5.2–6.2%).
Within-country differences in estimated overweight levels were
found in 37 (35.2%) LMICs, including South Africa, Peru and
Indonesia, which had twofold differences in estimated prevalence
across second administrative units in 2017. South Africa had high
estimated national levels (24.9% (23.9–25.2%)); however, the prov-
ince of Northern Cape had moderate levels (14.6% (13.6–14.9%)),
whereas the southeastern province of Eastern Cape had very high
levels (32.7% (30.8–33.9%)). Disparities were further pronounced at
the district level. Siyanda (Northern Cape) had 12.5% (11.6–12.9%)
prevalence, whereas Ugu (KwaZulu-Natal) had 36.7% (34.0–38.2%).
Nearly every modeling region had areas with overweight preva-
lence that ranked among the highest decile in 2000, 2017 or both
years (Fig. 1c).
Overall, the number of overweight children under 5 in LMICs
also showed a significant increase from 30.0 million (22.8–38.5) to
55.5 million (44.8–67.9) in the study period (Fig. 2a,b). By 2017,
26.2 million (24.1–27.2 million; 36.0%) of those affected lived in
eastern Asia, northern Africa or South America. An estimated
8.6% (8.5–9.9%) of first administrative units had fewer than 1,000
overweight children under 5, 47.5% (47.2–49.5%) had 1,000 to
<10,000, 43.8% (40.6–44.3%) had 10,000 to <100,000 and just 3.8%
(3.7–3.9%) had 100,000 or more. Some areas, such as northern
and central parts of Bolivia, experienced large annualized declines
such that their ranking among the highest estimated prevalence
decile in 2000 no longer applied in 2017. In contrast, a large area in
India, south of the Tropic of Cancer, experienced large annualized
increases in overweight; its ranking among the lowest prevalence
decile in 2000 was not maintained in 2017. All modeled regions
had areas that experienced average annualized increases of 1% in
overweight prevalence (Fig. 2c). Unless current trajectories change,
prevalence of overweight will continue to increase to 2025 (Fig. 2d).
Prevalence and trends in child wasting
The estimated prevalence of early childhood wasting decreased over-
all across LMICs between 2000–2017, from 8.4% (7.9–9.9%) to 6.4%
(4.9–7.9%). The most notable relative reductions were seen across
North Africa and in select countries in sub-Saharan African (SSA)
regions, Central and Andean America and Southeast Asia regions.
In Burkina Faso’s Ganzourgou district, estimated levels declined
from 20.2% (19.1–21.3%) in 2000 to 11.6% (10.9–12.1%) in 2017,
in Yemen’s Ash Shaikh Outhman district from 25.1% (22.2–26.3%)
to 21.3% (18.9–22.2%) and in Sudan’s Al Mahagil district from
31.9% (31.4–32.6%) to 12.2% (10.5–12.9%). Increases in estimated
prevalence also occurred, such as in Pakistan’s Makran district
(Baluchistan), from 7.4% (6.7–7.6%) to 11.4% (10.4–11.8%).
In 2017, there were several instances of contrasting geographic
patterns of child wasting compared to those of overweight. Many
Central American, Caribbean and South American countries (46%;
11 of 24) affected by overweight (>15% prevalence) met the WHO
GNTs for <5% prevalence of wasting across all districts based on
estimated prevalence (Fig. 3a,b and Extended Data Fig. 2). Estimated
wasting prevalence was 15% in 31.9% (850 of 2,661) and 20% in
12.9% (342) of second administrative units across Central and South
Asian countries, contributing to high prevalence at the national
level in India (15.7% (15.4–15.9%)), Pakistan (12.2% (11.8–12.4%))
and Sri Lanka (11.2% (10.5–11.5%)); Afghanistan and Bangladesh
maintained high levels (estimated prevalence 10%) across many
areas. Local-level estimates delineate very high wasting prevalence
(15%) along the African Sahel from Mauritania to Sudan, in the
northeastern Horn of Africa and neighboring countries of Eritrea,
Ethiopia, Somalia, Kenya, South Sudan and Yemen, in select areas
in Algeria and Egypt, and across Madagascar. In the Middle East,
Syria exceeded 15% estimated prevalence throughout most areas
and Iraq’s southeastern districts exceeded 10%. Estimated levels
of wasting were relatively uniform and low across East Asia, with
the exception of a few focal areas exceeding 10% or 20% in central
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pockets of east China. Most areas in Southeast Asia and Oceania
experienced moderate-to-high estimated wasting levels (~10%),
whereas some areas in Indonesia’s southern-most islands in Nusa
Tenggara (Timur state) exceeded 15% prevalence. Meanwhile, some
areas in Myanmar, Thailand, northern Laos and Vietnam had very
low levels, approaching the WHO GNTs.
a
b
c
d
35
26.25
17.5
8.75
0
Overweight
prevalence (%)
Overweight
prevalence (%)
35
26.25
17.5
8.75
0
2000
2017
2000–2017
2017
Lowest in 2000
Lowest in 2017
Lowest in 2000
and 2017
Highest in 2000
Highest in 2017
Highest in 2000 and 2017
Largest AROC
Smallest AROC
HighLow
HighLow
Relative uncertainty
Overweight prevalence
Fig. 1 | Prevalence of overweight children under 5 in LMICs (2000–2017). a,b, Prevalence of overweight among children under 5 at 5×5-km resolution
in 2000 (a) and 2017 (b). c, Overlapping population-weighted lowest and highest 10% of grid cells and AROC in overweight from 2000 to 2017.
d, Overlapping population-weighted quartiles of overweight and relative 95% uncertainty in 2017. Maps reflect administrative boundaries, land cover,
lakes and population; gray colored areas have grid cells classified as ‘barren or sparsely vegetated’ and had fewer than ten people per 1×1-km grid cell
in 2017 or were not included in this analysis3945. Maps were generated using ArcGIS Desktop 10.6.
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Between 2000 and 2017, the number of children under 5
affected by wasting decreased from 62.3 (55.1–70.8) million to 58.3
(47.6–70.7) million, 28.4% (28.2–28.5) of whom were in Africa
and 65.4% (63.6–67.3) in South Asia in 2017 (Fig. 3c,d). Despite
maintaining high estimated prevalence in many areas, all regions
in Africa had areas that experienced among the highest rates of
annualized declines in 2000–2017; only a few areas in Chad, Sudan,
South Sudan, Ethiopia and Kenya were among the highest decile
of estimated prevalence levels in both 2000 and 2017 (Fig. 4a,b).
Progress differed across and within African countries, with some
a
b
c
d
2017
2017
2000–2017
2025
35
17.5
8.75
0
–2.5
0
2.5
>5
< –5
10
0
>1,000
10
0
>1,000
Overweight
prevalence counts
Overweight prevalence
counts (thousands)
Relative annualized
change in overweight (%)
Overweight
prevalence (%)
26.25
Fig. 2 | Number of overweight children under 5 in LMICs (2000–2017) and progress toward 2025. a,b, Number of children under 5 affected by
overweight at a 5×5-km resolution (a) and by first administrative units (b). c, Annualized decrease (AD) in overweight prevalence from 2000 to 2017.
d, Grid cell-level predicted overweight prevalence in 2025 based on AD achieved from 2000 to 2017 and projected from 2017. Maps reflect administrative
boundaries, land cover, lakes and population; gray colored areas have grid cells classified as ‘barren or sparsely vegetated’ and had fewer than ten people
per 1×1-km grid cell in 2017 or were not included in this analysis3945. Maps were generated using ArcGIS Desktop 10.6.
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nations, such as Nigeria, Ethiopia and Namibia, experiencing both
annualized decreases and increases in wasting within their borders
(Fig. 4c). Overall, South America and South SSA demonstrated
the largest annualized declines (5%) across most of their areas
and regions of Latin America and the Caribbean, the Middle
East, South Asia, Southeast Asia and Oceania experienced mostly
Lowest in 2000
Highest in 2000
Largest AROC
Smallest AROC
Highest in 2017
Lowest in 2000
and 2017
Highest in 2000 and 2017
Lowest in 2017
Wasting
prevalence (%)
8.75
35
0
26.25
17.5
8.75
35
0
26.25
17.5
Wasting prevalence
Relative uncertainty
Low
Low
High
High
2000
2017
2000–2017
2017
Wasting
prevalence (%)
a
b
c
d
Fig. 3 | Prevalence of wasted children under 5 in LMICs (2000–2017). a–c, Prevalence of moderate and severe wasting among children under 5 at a
5×5-km resolution in 2000 (a) and 2017 (b). c, Overlapping population-weighted lowest and highest 10% of grid cells and AROC in wasting from 2000
to 2017. d, Overlapping population-weighted quartiles of wasting and relative 95% uncertainty in 2017. Maps reflect administrative boundaries, land cover,
lakes and population; gray colored areas have grid cells classified as ‘barren or sparsely vegetated’ and had fewer than ten people per 1×1-km grid cell in
2017 or were not included in this analysis3945. Maps were generated using ArcGIS Desktop 10.6.
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annualized increases. Large areas of India and parts of central
Pakistan experienced some of the highest prevalence levels through-
out the study period, as well as annualized increases. Nearly all
South Asian countries had large contiguous areas of stagnation or
annualized increases in wasting; given recent rates of progress, few
will meet the WHO GNTs in all their locations by 2025 (Fig. 4d). By
2025, 68 (64.8%) of LMICs are predicted to fail to meet the <5% tar-
get nationally, all of which are in Africa, Asia and the Middle East.
a
b
c
d
Wasting
prevalence (%)
Relative annualized
change in wasting (%)
Wasting prevalence
counts (thousands)
Wasting
prevalence counts
>1,000
10
0
>1,000
10
0
>5
2.5
0
–2.5
< –5
35
26.25
17.5
8.75
0
2025
2000–2017
2017
2017
Fig. 4 | Number of wasted children under 5 in LMICs (2000–2017) and progress toward 2025. a,b, Number of children under 5 affected by wasting
at the 5×5-km resolution (a) and by first administrative units (b). c, AD in wasting prevalence from 2000 to 2017. d, Grid cell-level predicted stunting
prevalence in 2025 based on AD achieved from 2000 to 2017 and projected from 2017. Maps reflect administrative boundaries, land cover, lakes and
population; gray colored areas have grid cells classified as ‘barren or sparsely vegetated’ and had fewer than ten people per 1×1-km grid cell in 2017 or
were not included in this analysis3945. Maps were generated using ArcGIS Desktop 10.6.
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Based on subnational estimates, 88 (83.8%) and 94 (89.5%) will fail
to meet the wasting WHO GNTs in all first and second administra-
tive units, respectively.
Double burden of wasting and overweight
Nearly every modeling region had subnational areas with at least
moderate co-occurrence of wasting and overweight (5% estimated
prevalence of both conditions) in 2017 (Fig. 5 and Extended Data
Fig. 3). Exceptions were Central and South America, where Guyana
was the only example of moderate DBM (5%–10% of both condi-
tions). In Africa, much of the Democratic Republic of the Congo,
Cameroon, Republic of Congo, Zambia and southern Botswana
demonstrated high DBM (10% of both overweight and wasting).
Areas in central Morocco reached some of the highest levels of
DBM (15% overweight, 10–15% wasting), whereas much of the
rest of North Africa had high estimated overweight (10–15%) and
moderate estimated wasting (5–10%). Locations scattered through-
out Iraq, India and in Southeast Asia mostly experienced moder-
ate wasting (such as Myanmar at 5–10%) or moderate DBM (such
as Indonesia at 5–10%), reaching moderate-to-high DBM levels in
select areas (such as central Papua New Guinea and Cambodia at
5–10% overweight, 10–15% wasting; Thailand, 10–15% overweight,
5–10% wasting). Relatively rare in East Asia, DBM was at moder-
ate levels at most (5–10% both conditions), such as in provinces in
southeastern China. At the national level, 25.7% (27 of 105) LMICs
were moderately affected and 5.7% (6 of 105) were highly affected
by both overweight and wasting (5% and 10% prevalence of
both conditions, respectively). Subnationally, however, 70.5% (74 of
105) of LMICs had moderately affected districts, 11.4% (12 of 105)
had highly affected districts and 2.9% (3 of 105) had districts with
very high DBM (5%, 10% and 15% prevalence of both condi-
tions, respectively).
Although childhood nutritional status generally improved
over 2000–2017, subnational variation in childhood overweight,
wasting and DBM was apparent. Declines in wasting and over-
weight prevalence in South Africa’s western areas led to a decrease
in DBM prevalence, from high levels in Siyanda district in 2005
(10–15% estimated wasting and overweight) to moderate levels
in 2017 (5–10% both conditions); overweight remains very high,
however, on the southern coast (15%). On the basis of annu-
alized trends, 25.7% (27 of 105) of LMICs are predicted to have
districts with at least moderate DBM by 2025 and 34.3% (36 of
105) are predicted to have high DBM districts (Fig. 5). Between
2000 and 2017, 8.6% (9 of 105) of LMICs had first administrative
units that experienced transition from high estimated prevalence
of wasting (10%) to normal weight (<5% both wasting and over-
weight). Nearly one-third, 32.3% (34 of 105) of LMICs had first
administrative units that transitioned from normal weight to high
overweight and 7.6% (8 of 105) transitioned from high wasting to
high DBM.
Discussion
This study provides overweight estimates and combines them with
wasting estimates to highlight DBM across LMICs at a fine geospa-
tial scale. This enables efficient targeting of local-level interventions
to improve nutrition outcomes in vulnerable populations. The fig-
ures presented here, as well as our online visualization tools, allow
for comparing overweight and wasting levels and trends across and
within countries for each year from 2000 to 2017, leveraging the
spatially resolved underlying data and covariates to produce detailed
spatial estimates across all modeled regions. Our estimates show the
global trend in early childhood wasting is declining, but areas with
high prevalence and little progress, such as in the Sahel and South
Asia, remain. Meanwhile, childhood overweight prevalence has
increased, especially in tropical South America and regions in the
Middle East, Central Asia and Africa.
Across LMICs, trends in childhood overweight have increased
while wasting decreased by different magnitudes from 2000–2017,
leading to the emergence of DBM in several areas. As countries
experience economic growth, they may undergo nutritional transi-
tions wherein the challenges of undernutrition are replaced by those
of overweight or the co-occurrence of both conditions4. Overall,
food security has improved across LMICs in the past decade, which
has led to increased availability of calories at the population level23.
Although overweight is a reflection of excess calorie intake and
reduced energy expenditure, there is a growing recognition that at
the root of the rising rates of overweight are complex interactions
between societal, environmental, food industry and individual fac-
tors, including biological, psychological and economical factors24.
Understanding the factors underpinning these trends is key to pre-
dicting how nutrition programs can accelerate amelioration of wast-
ing without incurring high rates of childhood overweight.
Although we included urbanicity as a covariate in our models,
we were unable to reliably stratify our results by urban and rural
areas. Urbanization is widely viewed as a key driver of the rise in
overweight, but an increase in rural body mass index has recently
been recognized as a main driver of the global epidemic of obe-
sity in adults25. Such an analysis would thus add important context
to our estimates. Case studies in China, Egypt, India, Mexico, the
Philippines and South Africa have demonstrated a consistent trend
of increased energy content of diets26. Relatively rural areas in China
have experienced an increase in the intake of animal source foods
and edible oils, likely due to the decreasing cost of these products.
Further, increased use of motor vehicles and labor-saving technolo-
gies in agriculture have caused a decrease in energy expenditure
in all these countries. In Brazil, household consumption of high-
calorie ultra-processed foods has steadily replaced that of fresh or
minimally processed foods27. Nutritious diets consisting of the latter
can help prevent both wasting and stunting, thus work is needed
to identify how dietary patterns differ between wasted and over-
weight children and the underlying factors causing those differ-
ences. Widespread collection and assembly of nutrition data from
older children and adults would also contribute to a more complete
understanding of longitudinal nutrition patterns.
In addition to tracking progress, child nutrition measurements
are important for predicting and averting morbidity and mortal-
ity. Wasting is often indicative of short-term weight loss due to
food shortages, famine or diseases such as diarrhea2830 and puts
children at greater risk of succumbing to common infections28.
Childhood overweight is likely to progress into adulthood and is
associated with NCDs24, including cardiovascular disease, type
2 diabetes, sleep apnea and cancer31,32. Routine monitoring and
reporting of child nutrition status can highlight trends and act as
an early warning for health systems, particularly in the context of
epidemiological transitions4.
Although overall spending on development assistance and
investments to address malnutrition from government donors have
remained steady, those from multilateral institutions have increased
since 2013, amounting to US$856 million in overseas development
assistance in 2016 (ref. 15). These investments, however, fall short
of the estimated US$3.5 trillion per year that malnutrition costs
society, US$500 billion of which is attributable to overweight and
obesity33. By focusing on prevention and early action, healthcare
costs can be reduced and human capital increased. One difficulty,
however, is addressing the different forms of malnutrition in tan-
dem. Multiple forms of malnutrition are the new normal, accord-
ing to the GNR15 and Scaling Up Nutrition34,35. Double-duty actions
that could simultaneously combat undernutrition, overweight,
obesity, and diet-related NCDs have been proposed to address this
problem3638. Despite progress in identifying such actions, such as
the promotion of breastfeeding, double-duty approaches have not
been widely adopted. To better respond to the diverse and rapidly
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756
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evolving nutrition challenges facing LMICs, sustainable and health-
promoting food systems are needed to slow the development of
DBM. Due to the multiple causality of malnutrition, multisector
collaboration is required, including agriculture, trade and industry,
environment, communication and education, all working towards
policy and intervention coherence8,24.
OVR prevalence
MSW prevalence
Low High
Low High
a
b
c
d
2025
5 × 5-km
2025
2017
Admin 1
5 × 5-km
2017
Admin 1
Fig. 5 | Overlapping population-weighted quartiles of overweight and wasting prevalence in children under 5 across LMICs in 2017 and 2025.
ad, Prevalence of moderate-to-severe overweight (OVR) and wasting (MSW) among children under 5 years of age in 2017 at the first administrative
unit (a) and at a 5×5-km resolution (b). c,d, Estimated prevalence of moderate to severe OVR and MSW among children under 5 years of age in 2025 at
the first administrative unit (c) and at a 5×5-km resolution (d). Quartile cutoffs were 0–5%, 5–10%, 10–15% and 15%. Maps reflect administrative
boundaries, land cover, lakes and population; gray colored areas have grid cells classified as ‘barren or sparsely vegetated’ and had fewer than ten people
per 1×1-km grid cell in 2017 or were not included in these analyses3945. Maps were generated using ArcGIS Desktop 10.6.
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There are several limitations to these analyses, mainly concern-
ing the quantity and quality of the underlying data in the models,
as shown in our uncertainty maps (Figs. 1f and 2f). Missing or
improbable values in the primary data may contribute bias in the
estimates and thus we have incorporated covariates to improve the
estimates in areas where data are sparse. Additionally, differences in
measurement techniques between surveys, scale miscalibration or
equipment failure and poor training and standardization of mea-
surers may contribute bias. Although our estimates were produced
at a high spatial resolution, they were limited to prevalence by area,
rather than the co-occurrence of wasting and overweight experi-
enced by the same households or individuals. Additional work is
required to identify the immediate and basic causes that lead to
both wasting and obesity coexisting in the same geographical areas
so that appropriate solutions can be identified. Future studies will
consider maternal indicators associated with child nutritional out-
comes, such as anemia and examine the co-distribution of over-
weight and stunting to broaden our assessment. New modeling
approaches are currently in development to provide full distribu-
tions of height, weight and age, for more complete assessments of
DBM using all important indicators of undernutrition.
Commendable gains have been made globally against child
malnutrition over the past two decades. Our mapped estimates,
however, show that high rates of wasting persist and overweight is
increasing among young children in many LMICs. Identifying the
causes underlying the presence of wasting or overweight in children
living in the same community is necessary to formulate appropriate
solutions. The estimates provided by this study can aid in the iden-
tification of specific areas where further insight can be gathered and
trials of policy interventions administered, ultimately contributing
to the UN Decade of Action on Nutrition process of sustained and
coherent implementation of policies and programs37.
Online content
Any methods, additional references, Nature Research reporting
summaries, source data, extended data, supplementary informa-
tion, acknowledgements, peer review information; details of author
contributions and competing interests; and statements of data and
code availability are available at https://doi.org/10.1038/s41591-
020-0807-6.
Received: 25 October 2019; Accepted: 20 February 2020;
Published online: 20 April 2020
References
1. Ng, M. etal. Global, regional, and national prevalence of overweight and
obesity in children and adults during 1980–2013: a systematic analysis for the
global burden of disease study 2013. Lancet 384, 766–781 (2014).
2. Black, R. E. etal. Maternal and child undernutrition and overweight in
low-income and middle-income countries. Lancet 382, 427–451 (2013).
3. Black, R. E. etal. Maternal and child undernutrition: global and regional
exposures and health consequences. Lancet 371, 243–260 (2008).
4. World Health Organization. Double burden of malnutrition http://www.who.
int/nutrition/double-burden-malnutrition/en/ (2018).
5. de Onis, M., Blössner, M. & Borghi, E. Global prevalence and trends of
overweight and obesity among preschool children. Am. J. Clin. Nutr. 92,
1257–1264 (2010).
6. Popkin, B. M., Corvalan, C. & Grummer-Strawn, L. M. Dynamics of the
double burden of malnutrition and the changing nutrition reality. Lancet 395,
65–74 (2020).
7. UNICEF, WHO & e World Bank. Joint child malnutrition estimates - levels
and trends (2017 edition) https://www.who.int/nutgrowthdb/estimates2016/
en/ (2017)
8. Hawkes, C., Demaio, A. R. & Branca, F. Double-duty actions for ending
malnutrition within a decade. Lancet Glob. Health 5, e745–e746 (2017).
9. Cole, T. J., Bellizzi, M. C., Flegal, K. M. & Dietz, W. H. Establishing a
standard denition for child overweight and obesity worldwide: international
survey. Brit. Med. J. 320, 1240 (2000).
10. World Health Organization. Training course on child growth assessment
http://www.who.int/childgrowth/training/en/ (2008).
11. de Onis, M. etal. Prevalence thresholds for wasting, overweight and stunting
in children under 5 years. Public Health Nutr. 22, 175–179 (2019).
12. United Nations. Goal 2: sustainable development knowledge platform https://
sustainabledevelopment.un.org/sdg2.
13. World Health Organization. Global nutrition targets 2025: childhood
overweight policy brief http://www.who.int/nutrition/publications/
globaltargets2025_policybrief_overweight/en/ (2014).
14. World Health Organization. Global nutrition targets 2025: wasting policy
brief http://www.who.int/nutrition/publications/globaltargets2025_
policybrief_wasting/en/ (2014).
15. Development Initatives. 2018 Global nutrition report: shining a light to spur
action on nutrition https://globalnutritionreport.org/reports/global-nutrition-
report-2018/ (2018).
16. United Nations Children’s Fund, World Health Organization & e World
Bank. Levels and trends in child malnutrition: key ndings of the 2018
edition https://www.who.int/nutgrowthdb/2018-jme-brochure.pdf?ua=1
(2018).
17. World Health Organization. Data: nutrition - joint child malnutrition
estimates (2018 edition) http://apps.who.int/gho/tableau-public/tpc-frame.
jsp?id=402 (2018)
18. Tzioumis, E., Kay, M. C., Bentley, M. E. & Adair, L. S. Prevalence and trends
in the childhood dual burden of malnutrition in low- and middle-income
countries, 1990–2012. Public Health Nutr. 19, 1375–1388 (2016).
19. Abarca-Gómez, L. etal. Worldwide trends in body-mass index, underweight,
overweight and obesity from 1975 to 2016: a pooled analysis of 2,416
population-based measurement studies in 128.9 million children, adolescents
and adults. Lancet 390, 2627–2642 (2017).
20. Humbwavali, J. B., Giugliani, C., Silva, I. C. Mda & Duncan, B. B. Temporal
trends in the nutritional status of women and children under ve years of age
in sub-Saharan African countries: ecological study. Sao Paulo Med. J. Rev.
Paul. Med. 136, 454–463 (2018).
21. Kinyoki, D. K. etal. Mapping child growth failure across low- and middle-
income countries. Nature 577, 231–234 (2020).
22. Diggle, P. & Ribeiro, P. J. Model-based Geostatistics (Springer, 2007); https://
doi.org/10.1007/978-0-387-48536-2
23. FAO, IFAD, UNICEF, WFP & WHO. e State of Food Security and
Nutrition in the World 2019. Safeguarding Against Economic Slowdowns and
Downturns (FAO, 2019).
24. Wells, J. C. etal. e double burden of malnutrition: aetiological pathways
and consequences for health. Lancet 395, 75–88 (2020).
25. Bixby, H. etal. Rising rural body-mass index is the main driver of the global
obesity epidemic in adults. Nature 569, 260–264 (2019).
26. Food and Agriculture Organization of the United Nations. e double burden
of malnutrition. Case studies from six developing countries. FAO Food Nutr.
Pap. 84, 1–334 (2006).
27. Monteiro, C. A., Levy, R. B., Claro, R. M., de Castro, I. R. R. & Cannon, G.
Increasing consumption of ultra-processed foods and likely impact on human
health: evidence from Brazil. Public Health Nutr. 14, 5–13 (2010).
28. Wang, Y. & Chen, H.-J. in Handbook of Anthropometry (ed. Preedy, V. R.)
29–48 (Springer, 2012).
29. WHO. Physical status: the use and interpretation of anthropometry: report of
a WHO Expert Committee http://apps.who.int/iris/bitstream/
handle/10665/37003/WHO_TRS_854.pdf;jsessionid=2FE8F4F177D025F64336
56F4F7577F3F?sequence=1 (1995).
30. Neufeld, L. M. & Osemdar, S. J. M. World nutrition situation: global, regional
and country trends in underweight and stunting as indicators of nutrition
and health of populations. Internat. Nutr. 78, 11–19 (2013).
31. CDC. Causes and consequences of childhood obesity https://www.cdc.gov/
obesity/childhood/causes.html (2016).
32. Ong, K. K. L., Ahmed, M. L., Emmett, P. M., Preece, M. A. & Dunger, D. B.
Association between postnatal catch-up growth and obesity in childhood:
prospective cohort study. Brit. Med. J. 320, 967 (2000).
33. Global Panel on Agriculture and Food Systems for Nutrition. e cost of
malnutrition: why policy action is urgent https://glopan.org/sites/default/les/
pictures/CostOfMalnutrition.pdf (2016).
34. Scaling Up Nutrition Civil Society Network. SUN Movement Strategy &
Roadmap 2016–2020. http://docs.scalingupnutrition.org/wp-content/
uploads/2016/09/SR_20160901_ENG_web_pages.pdf (2016).
35. Scaling Up Nutrition (SUN) Movement: Annual Progress Report 2016.
https://scalingupnutrition.org/wp-content/uploads/2016/11/SUN_Report_
20161129_web_All.pdf (2016).
36. Hawkes, C. etal. Double-duty actions: seizing programme and policy
opportunities to address malnutrition in all its forms. Lancet 395,
142–155 (2020).
37. World Health Organization. United Nations decade of action on nutrition
2016–2025: towards country-specic SMART commitments for action on
nutrition http://www.fao.org/3/a-i6130e.pdf (2016).
38. Nugent, R. etal. Economic eects of the double burden of malnutrition.
Lancet 395, 156–165 (2020).
NATURE MEDICINE | VOL 26 | MAY 2020 | 750–759 | www.nature.com/naturemedicine
758
Content courtesy of Springer Nature, terms of use apply. Rights reserved
Articles
NATurE MEDICINE
39. Global Administrative Areas. GADM database of global administrative areas
http://www.gadm.org (2018).
40. Land Processes Distributed Active Archive Center. Combined MODIS 5.1.
MCD12Q1 | LP DAAC: NASA Land Data Products and Services. https://
lpdaac.usgs.gov/products/mcd12q1v006/ (2017).
41. Lehner, B. & Döll, P. Development and validation of a global database of
lakes, reservoirs and wetlands. J. Hydrol. 296, 1–22 (2004).
42. World Wildlife Fund. Global lakes and wetlands database, level 3 https://
www.worldwildlife.org/pages/global-lakes-and-wetlands-database (2004).
43. Tatem, A. J. WorldPop, open data for spatial demography. Sci. Data 4,
170004 (2017).
44. WorldPop. WorldPop dataset http://www.worldpop.org.uk/data/get_data/ (2017).
45. GeoNetwork. e Global Administrative Unit Layers (GAUL) http://www.fao.
org/geonetwork/srv/en/main.home (2015).
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Methods
Overview. Our study follows the Guidelines for Accurate and Transparent Health
Estimates Reporting48 (Supplementary Table 1). e analyses used model-based
geostatistics to generate local-, administrative- and national-level estimates of
children under 5 overweight, wasting prevalence and double burden in LMICs
over time. Using an ensemble modeling framework that fed into a Bayesian
generalized linear mixed-eects model with a correlated space–time random
eect and 1,000 draws from an approximate posterior distribution, we generated
annual prevalence estimates for overweight and wasting on a 5 × 5-km grid over
105 LMICs from 2000 to 2017 and aggregated these to administrative and national
levels (Supplementary Table 2). Countries were selected for inclusion in this study
using the socio-demographic index (SDI), a summary measure of development
that combines education, fertility and poverty47. Selected countries were in the low,
lower-middle and middle SDI quintiles, with several exceptions (Supplementary
Table 2). China, Libya, Malaysia, Panama and Turkmenistan were included despite
higher-middle SDIs for geographic continuity with other included countries.
Albania, Bosnia-Herzegovina and Moldova were excluded due to geographic
discontinuity and lack of available survey data. We did not conduct estimates
for the island nations of American Samoa, Federated States of Micronesia, Fiji,
Kiribati, Marshall Islands, Samoa, Solomon Islands or Tonga, as no survey data
could be sourced.
Data. Surveys and child anthropometry data. We extracted individual-level height,
weight and age data for children under 5 from household survey series including
the Demographic and Health Surveys, Multiple Indicator Cluster Surveys, Living
Standards Measurement Study and Core Welfare Indicators Questionnaire, among
other country-specic child health and nutrition surveys4952 (Supplementary
Tables 3 and 4). Included in our models were 420 georeferenced household
surveys representing over 3 million children under 5. Each individual child record
was associated with a cluster, a group of neighboring households or a ‘village’
that acted as a primary sampling unit. Approximately 185 surveys with height,
weight and age data included geographic coordinates or precise place names
for each cluster within that survey. In the absence of geographic coordinates for
each cluster, we assigned data to the smallest available administrative areal unit
in the survey (polygon) while accounting for the survey sample design (15,781
survey polygons for overweight and wasting)53,54. Boundary information for these
administrative units was obtained as shapeles either directly from the surveys or
by matching to shapeles in the Global Administrative Unit Layers55 database or
the Database of Global Administrative Areas56. In select cases, shapeles provided
by the survey administrator were used or custom shapeles were created based on
survey documentation. ese areal data were resampled to point locations using
a population-weighted sampling approach over the relevant areal unit with the
number of locations set proportionally to the number of grid cells in the area and
the total weights of all the resampled points summing to one43.
Select data sources were excluded for the following reasons: missing survey
weights for areal data, missing sex or age variable, incomplete sampling (for
example, only children ages 0–3 years measured) or untrustworthy data (as
determined by the survey administrator or by inspection). Details on the survey
data excluded for each country can be found in Supplementary Table 5. Data
extraction and processing methods have been described previously21.
Child anthropometry. Using height, weight, age and sex data for each individual,
WHZs were calculated using the age-, sex- and indicator-specific lambda-mu-
sigma values from the 2006 WHO Child Growth Standards10,57. The lambda-mu-
sigma methodology allows for Gaussian z score calculations and comparisons
to be applied to skewed, non-Gaussian distributions58. A child was classified as
overweight or wasted if their weight-for-height/length was more than two s.d.
(z scores) above or below the WHO growth reference population, respectively59.
These individual-level data observations were then collapsed to cluster-level totals
for the number of children sampled and total number of children under 5 affected
by overweight and the total number of children who are wasted out of the children
who were not overweight.
Temporal resolution. We estimated prevalence of overweight and wasting annually
from 2000 to 2017 using a model that allowed us to account for data points
measured across survey years, and as such, allows us to predict at monthly or finer
temporal resolutions. We were limited, however, both computationally and by the
temporal resolution of covariates (Supplementary Table 6) and thus produced only
annual estimates.
Seasonality adjustment. WHZs were used to calculate individual child wasting
status. As a data preprocessing step, we performed a seasonality adjustment on
individual-level child weights in order to account for differences in observed child
weight that may have been due to food scarcity during the month in which the
survey was conducted. To adjust weight measurements, we fitted a model for each
region with a 12-month seasonal spline, a country-level fixed effect and a smooth
spline over the duration of our data collection using the mgcv package in R and the
following formula:
WHZ
scc month
ð Þþ
stp t
ðÞþ
as:factor country
ðÞ:
I
Month is the integer-valued month of the year (1, , 12), t is the time of
the interview in integer months since the earliest observation of any child in
the dataset and country is a factor variable representing the country where the
observation was recorded. We modeled the periodic component on months using
12 cyclic cubic (cc) regression splines basis functions and we accounted for a
smooth longer time temporal trend using four thin-plate (tp) splines. The country
effects and the long-term temporal spline were included only to avoid confounding
during fitting of the seasonal spline fit and neither country effects nor the long-
term trend was used in the seasonal adjustment. We then adjusted all observations
to account for the difference in the seasonal period between the month of the
interview and an average day of the year as determined by which days aligned with
the mean of the periodic spline.
Spatial covariates. In order to leverage strength from locations with observations
to the entire spatial–temporal domain, we compiled several 5 × 5-km raster
layers of putative socioeconomic and environmental correlates of malnutrition in
the 105 LMICs (Supplementary Table 6). These covariates were selected based on
their potential to be predictive for overweight and wasting, according to literature
review and plausible hypothesis as to their influence. Acquisition of temporally
dynamic datasets, where possible, was prioritized to best match our observations
and thus predict the changing dynamics of the two indicators. Of the 12 covariates
included, 6 were temporally dynamic and were reformatted as a synoptic mean
over each estimation period or as a mid-period year estimate. These included
average daily mean rainfall (precipitation), educational attainment in women of
reproductive age (15–49 years old), enhanced vegetation index, fertility, urbanicity
and population. The remaining six covariate layers were static throughout the
study period and were applied uniformly across all modeling years; these covariates
included growing season length, irrigation, nutritional yield for vitamin A,
nutritional yield for protein, nutritional yield for iron and travel time to nearest
settlement >50,000 inhabitants.
To select covariates and capture possible nonlinear effects and complex
interactions between them, an ensemble covariate modeling method was
implemented60. For each region, three submodels were fitted to our dataset, using
all of our covariate data as explanatory predictors: generalized additive models,
boosted regression trees and lasso regression. Each submodel was fitted using
fivefold cross-validation to avoid overfitting and the out-of-sample predictions
from across the five holdouts were compiled into a single comprehensive set of
out-of-sample predictions from that model. Additionally, the same submodels
were also run using 100% of the data and a full set of in-sample predictions were
created. The three sets of out-of-sample submodel predictions were fed into the
full geostatistical model as the explanatory covariates when performing the model
fitting. The in-sample predictions from the submodels were used as covariates
when generating predictions using the fitted full geostatistical model. A recent
study has shown that this ensemble approach can improve predictive validity by up
to 25% over an individual model60.
Analysis. Geostatistical model. In this study, wasting was dened as the proportion
of children under 5 below negative 2 WHZ (<−2 WHZ); normal category, the
proportion of children under 5 between negative 2 and positive 2 WHZ z score
(>−2 and <2 WHZ); and overweight was dened as the proportion of children
under 5 above positive 2 WHZ z score (>2 WHZ) as dened in the WHO growth
reference population59. To model the full distribution of possible indicators of
nutritional status in WHZ (wasting (<−2 WHZ), normal (>−2 and <2 WHZ) and
overweight (>2 WHZ)), we used an ordinal modeling approach61,62 to estimate the
relative proportion of each indicator. A similar modeling approach was used to
estimate vaccine coverage in Africa63.
We used a continuation ratio model to estimate the prevalence of three
categories: wasting, normal weight and overweight. We first modeled the
proportion of wasting children within a Bayesian hierarchical framework using
logistic regression with a spatially and temporally explicit generalized linear
mixed-effects model. Second, we modeled the proportion of the children that were
overweight conditioned on not being wasted using the same Bayesian modeling
framework. The estimates from the second conditional model were then combined
with the wasting estimates to compute the proportion of overweight children in the
full distribution.
At each cluster, j, where j = 1, 2, n, and time t, where t = 2000, 2001, 2017, the
prevalence of wasting was modeled using the observed number of children in cluster
d, who were found to be wasted as a binomial count data Cd among a sample size Nd.
C
dj
p
idðÞ;tdðÞ
;
N
d
Binomial p
idðÞ;tdðÞ
;
N
d
�
8
observe clusters d logit p
i;t
�
¼β0þXi;tβþZi;tþϵctrðiÞþϵi;tþZi;t8i2spatial domain 8t2time domain
P
3
h¼1
βh¼1
ϵctr iid Normal 0;γ2
ðÞ
ϵi;tiid Normal 0;σ2
ðÞ
ZGPð0;Σspace ΣtimeÞ
Σspace ¼ω2
ΓνðÞ2v1´κDðÞ
ν
´KνκDðÞ
Σtime
j;k¼
ρjkjj
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For indices d, i and t, *(index) is the value of * at the index. The annual
prevalence of wasting, pi,t, in cluster i, in time t, was modeled as a linear
combination of the three submodels, (generalized additive models, boosted
regression trees and lasso regression), rasterized covariate values, Xi,t, a correlated
spatiotemporal random effect term Zi,t, country random effects
ϵctrðiÞ
I
, with one
unstructured country random effect fitted for each country in the modeling
region and all
ϵctr
I
sharing a common variance parameter, γ2, and an independent
nugget random effect
;
, with variance parameter, σ2. Coefficients βh in the
three submodels h = 1, 2, 3 represent their respective predictive weighting in
the logit link, while the joint error term Zi,t accounts for residual spatiotemporal
autocorrelation between individual data points that remain after accounting for
the predictive effect of the submodel covariates, the country-level random effect
ϵ
ctr
ð
i
Þ
I
and the nugget,
. The residuals Zi,t, were modeled as a three-dimensional
Gaussian process in space–time centered at zero and with a covariance matrix
constructed from a Kronecker product of spatial and temporal covariance kernels.
The spatial covariance, Σspace, was modeled using an isotropic and stationary
Matérn function64 and temporal covariance, Σtime, as an annual autoregressive
(AR1) function over the 18 years represented in the model. In the stationary
Matérn function, Γ is the gamma function, Kv is the modified Bessel function of
order v > 0, κ > 0 is a scaling parameter, D denotes the Euclidean distance and ω2 is
the marginal variance. The scaling parameter, κ, is defined to be
κ¼ffiffiffiffi
8v
p
=
δ
I
,
where δ is a range parameter (about the distance where the covariance function
approaches 0.1) and v is a scaling constant, which is set to 2 rather than fitted from
the data. The number of rows and the number of columns of the spatial Matérn
covariance matrix are both equal to the number of spatial mesh points for a given
modeling region. The number of rows and the number of columns of the spatial
Matérn covariance matrix are both equal to the number of spatial mesh points for
a given modeling region. In the AR1 function, ρ is the autocorrelation function
and k and j are points in the time series where |kj| defines the lag. The number
of rows and the number of columns of the AR1 covariance matrix are both equal
to the number of temporal mesh points (18). The number of rows and the number
of columns of the space–time covariance matrix, Σspace⊗Σtime, for a given modeling
region are both equal to the number of spatial mesh points × the number of
temporal mesh points.
This approach leverages the residual correlation structure to more
accurately predict prevalence estimates for locations with no data, while also
propagating the dependence in the data through to uncertainty estimates65. The
posterior distributions were fitted using computationally efficient and accurate
approximations in R-INLA66,67 (integrated nested Laplace approximation) with the
stochastic partial differential equations68 approximation to the Gaussian process
residuals using R project v.3.5.1. The stochastic partial differential equations
approach using INLA has been demonstrated elsewhere, including the estimation
of health indicators, particulate air matter and population age structure6971.
Uncertainty intervals were generated from 1,000 draws (statistically plausible
candidate maps)72 created from the posterior-estimated distributions of
modeled parameters.
Post estimation. To transform grid cell-level estimates into a range of information
useful to a wide constituency of potential users, estimates were aggregated at
first and second administrative units specific to each country and at national
levels73. Although the models can predict all locations covered by available raster
covariates, all final model outputs for which land cover was classified as ‘barren or
sparsely vegetated’ on the basis of Moderate Resolution Imaging Spectroradiometer
(MODIS) satellite data (2013) were masked74. Areas where the total population
density was less than ten individuals per 1 × 1-km grid cell in 2015 were also
masked in the final outputs.
Model validation. Models were validated using spatially stratified fivefold
out-of-sample cross-validation. In order to offer a more stringent analysis by
accounting for some of the spatial correlation in the data, holdout folds were
created by combining sets of all data falling with first administrative level
areas. Validation was performed by calculating bias (mean error), variance
(root-mean-square error), 95% data coverage within prediction intervals and
correlation between observed data and predictions. All validation metrics
were calculated on the out-of-sample predictions from the fivefold cross-
validation. All validation procedures and corresponding results are provided in
Supplementary Tables 7–18.
Projections. To compare our estimated rates of improvement in overweight
and wasting prevalence over the last 18 years with the improvements needed
between 2017 and 2025 to meet WHO GNTs, we performed a simple projection
using estimated AROC applied to the final year of our estimates. Both AROC
and projections were calculated at the draw-level to obtain the uncertainty of
the estimates.
For each indicator i, we calculated AROC at each grid cell (m) by calculating
the AROC between each pair of adjacent years t:
AROCu;m;t
¼
logit
p
u;m;t
pu;m;t1

We then calculated a weighted AROC for each indicator by taking a weighted
average across the years, where more recent AROCs were given more weight in the
average. We defined the weights to be:
Wt¼ðt2000 þ1γÞ;
where γ may be chosen to give varying amounts of weight across the years. For each
indicator, we then calculated the average AROC to be:
AROCu;m¼
X
2017
2001
Wt´AROCu;m;t
!
Finally, we calculated the projections (Proj) by applying the AROC in
our 2017 mean prevalence estimates to produce estimates in 8 years from 2017
to 2025.
Proju;m;2025 ¼logit1logit p
u;m;2017

þAROC
u;m
´8

:
This projection scheme is analogous to the methods used in the Global Burden
of Disease 2017 study47 for measurement of progress and projected attainment
of health-related Sustainable Development Goals. Our projections are based on
the assumption that areas will sustain the current AROC, and the precision of
the AROC estimates is dependent on the level of uncertainty emanating from the
estimation of annual prevalence.
Priors. The following priors were used for our overweight and wasting models:
β
0
Nμ
¼
0
;
σ2
¼
32
ðÞ;
βiid Nμ¼1
no:ensemble models ;σ2¼32

;
log 1þρ
1ρ

Nðμ¼4;σ2¼1:22Þ;
log 1
σ2
nug

loggamma α¼1;γ¼5´105
ðÞ
:
log 1
σ2
country

loggamma α¼1;γ¼5´105
ðÞ
:
θ1¼log σ2
k

Nðμθ1;σ2
θ1Þ
θ
2¼
log κ
ðÞ
N
ð
μ
θ2
;σ2
θ2Þ
Given that our covariates used in INLA (the predicted outputs from the
ensemble models) should be on the same scale as our predictive target, we
believe that the intercept in our model should be close to zero and that the
regression coefficients should sum to 1. As such, we chose the prior for our
intercept to be N(0,σ2 = 32) and the prior for the fixed-effect coefficients to be
N
1
no:ensemble models
;σ2
¼
32

I
. The prior on the temporal correlation parameter,
ρ, was chosen to be mean zero, showing no prior preference for either positive or
negative autocorrelation structure and with a distribution wide enough such that
within three s.d. of the mean, the prior includes values of ρ ranging from 0.95
to 0.95. The priors on the random effect variances were chosen to be relatively
loose given that we believe our fixed-effects covariates should be well correlated
with our outcome of interest, which might suggest relatively small random effects
values. At the same time, we wanted to avoid using a prior that was so diffuse as
to actually put high prior weight on large random effect variances. For stability,
we used the uncorrelated multivariate normal priors that INLA automatically
determines (based on the finite elements mesh) for the log-transformed spatial
hyperparameters κ and τ. In our parameterization, we represent α and γ in the log
gamma distribution as shape and inverse-scale, respectively.
Prior sensitivity analysis. Sensitivity analysis was undertaken to assess the impact
of the hyper-priors for the nugget, country random effects, and space–time
correlation. We considered two different sets of priors related to the nugget and
country random effects and three set related to space–time correlation, resulting in
six different combinations of hyper-priors as outlined below.
Model 1: In this model, we used the default hyper-priors in INLA75 (for both
nugget and country random effects. The hyper-prior for the AR1 rho, ρ, was
retained as shown below.
log 1
σ2
nugget

loggamma α¼1;γ¼5´105
ðÞand
log 1
σ2
counry

loggamma α¼1;γ¼5´105
ðÞ:
log 1þρ
1
ρ

Normal
ð
μ
¼
4;σ2
¼
1:22
Þ
Model 2: The hyper-priors for nugget were changed as indicated below, where
hyper-priors for country random effect were the default hyper-priors in INLA. The
hyper-priors for the AR1 rho, ρ, were retained the same as model 1.
log 1
σ2
nugget

loggamma α¼1;γ¼2ðÞand
log 1
σ2
counry

loggamma α¼1;γ¼5´105
ðÞ
:
log 1þρ
1
ρ

Normal
ð
μ
¼
4;σ2
¼
1:22
Þ
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Model 3: In this model the hyper-priors for country random effects and nugget
were exchanged, where hyper-priors for nugget were the default hyper-priors in
INLA. The hyper-priors for the AR1 rho, ρ, were retained the same as model 1.
log 1
σ2
nug

loggamma α¼1;γ¼5´105
ðÞand
log 1
σ2
counry

loggamma α¼1;γ¼2ðÞ:
log 1þρ
1
ρ

Normal
ð
μ
¼
4;σ2
¼
1:22
Þ
Model 4: In this model, we used the default hyper-priors in INLA for less
informative nugget and country random effects. The hyper-priors for the AR1 rho,
ρ, were changed.
log 1
σ2
nugget

loggamma α¼1;γ¼5´105
ðÞand
log 1
σ2
counry

loggamma α¼1;γ¼5´105
ðÞ:
log 1þρ
1
ρ

Normal
ð
μ
¼
0;σ2
¼
1:22
Þ
Model 5: In this model, we used the default hyper-priors in INLA for both
nugget and country random effects. The hyper-priors for the AR1 rho, ρ, were the
default in INLA.
log 1
σ2
nugget

loggamma α¼1;γ¼5´105
ðÞand
log 1
σ2
counry

loggamma α¼1;γ¼5´105
ðÞ:
log 1þρ
1
ρ

Normal
ð
μ
¼
0;σ2
¼
2:582
Þ
The predicted estimates for all models with different sets of hyper-priors were
highly correlated at the grid-cell level and yielded low mean absolute differences
(Supplementary Table 7). We ultimately selected the less informative priors for
nugget and country random effects as they are default priors in the INLA package
and have been applied widely76,77 and selected a more stringent parameterization of
our space–time correlation, as indicated in model 1.
Mesh construction. We constructed the finite elements mesh for the stochastic
partial differential equation approximation to the Gaussian process regression
using a simplified polygon boundary (in which coastlines and complex boundaries
were smoothed) for each of the regions within our model. We set the inner mesh
triangle maximum edge length (the mesh size for areas over land) to be 0.75
degrees and the buffer maximum edge length (the mesh size for areas over the
ocean) to be 5 degrees. An example finite elements mesh constructed for Eastern
SSA mesh is described by Kinyoki etal.21.
Reporting Summary. Further information on research design is available in the
Nature Research Reporting Summary linked to this article.
Data availability
Our study follows the Guidelines for Accurate and Transparent Health Estimates
Reporting48 (Supplementary Table 1). The findings of this study are supported by
data available in public online repositories, data publicly available upon request
of the data provider and data not publicly available due to restrictions by the
data provider. Nonpublicly available data were used under license for the current
study but may be available from the authors upon reasonable request and with
permission of the data provider. Details of data sources and availability can be
found in Supplementary Tables 2–5. The full output of the analyses are publicly
available in the Global Health Data Exchange (http://ghdx.healthdata.org/record/
ihme-data/lmic-double-burden-of-malnutrition-geospatial-estimates-2000-2017)
and can further be explored via customized data visualization tools (https://vizhub.
healthdata.org/lbd/dbm.). Administrative boundaries were retrieved from the
Database of Global Administrative Areas39. Land cover was retrieved from the
online Data Pool, courtesy of the NASA EOSDIS Land Processes Distributed
Active Archive Center, USGS/Earth Resources Obser vation and Science Center,
Sioux Falls, South Dakota40. Lakes were retrieved from the Global Lakes and
Wetlands Database, courtesy of the World Wildlife Fund and the Center for
Environmental Systems Research, University of Kassel41,42. Populations were
retrieved from WorldPop43,44.
Code availability
All code used for these analyses is publicly available online at http://ghdx.
healthdata.org/record/ihme-data/lmic-double-burden-of-malnutrition-geospatial-
estimates-2000-2017 and at http://github.com/ihmeuw/lbd/tree/dbm-lmic-2020.
References
47. Dicker, D. etal. Global, regional, and national age-sex-specic mortality and
life expectancy, 1950–2017: a systematic analysis for the global burden of
disease study 2017. Lancet 392, 1684–1735 (2018).
48. Stevens, G. A. etal. Guidelines for accurate and transparent
health estimates reporting: the GATHER statement. PLoS Med. 13,
e1002056 (2016).
49. USAID. Demographic and health surveys (DHS) http://dhsprogram.com/.
50. UNICEF. Multiple indicator cluster surveys (MICS) http://mics.unicef.org.
51. World Bank Group. Living standards measurement survey (LSMS) http://
go.worldbank.org/UK1ETMHBN0.
52. World Bank Group. Core welfare indicators questionnaire survey (CWIQ)
http://ghdx.healthdata.org/series/core-welfare-indicators-questionnaire-
survey-cwiq.
53. Lumley, T. in Complex Surveys: A Guide to Analysis Using R. (Wiley, 2010).
54. Lumley, T. Analysis of complex survey samples. J. Stat. Sow. 9,
1–19 (2004).
55. FAO. e global administrative unit layers (GAUL): technical aspects http://
www.fao.org/geonetwork/srv/en/main.home.
56. Global Administrative Areas (GADM). GADM database of global
administrative areas http://www.gadm.org.
57. WHO Multicentre Growth Reference Study Group. WHO child growth
standards based on length/height, weight and age. Acta Paediatr. Suppl, 450,
76–85 (2006).
58. Indrayan, A. Demystifying LMS and BCPE methods of centile
estimation for growth and other health parameters. Indian Pediatr. 51,
37–43 (2014).
59. WHO Multicentre Growth Reference Study Group. WHO child growth
standards based on length/height, weight and age. Acta Paediatr 95,
76–85 (2006).
60. Bhatt, S. etal. Improved prediction accuracy for disease risk mapping
using Gaussian process stacked generalization. J. R. Soc. Interface 14,
20170520 (2017).
61. Fienberg, S. E. e Analysis of Cross-Classied Categorical Data
(Springer, 2007); https://doi.org/10.1007/978-0-387-72825-4
62. Ananth, C. V. & Kleinbaum, D. G. Regression models for ordinal responses: a
review of methods and applications. Int. J. Epidemiol. 26, 1323–1333 (1997).
63. Mosser, J. F. etal. Mapping diphtheria-pertussis-tetanus vaccine coverage in
Africa, 2000–2016: a spatial and temporal modelling study. Lancet 393,
1843–1855 (2019).
64. Stein, M. L. Interpolation of Spatial Data (Springer, 1999).
65. Diggle, Peter J. & Ribeiro, Paulo J. Model-based Geostatistics (Springer, 2007);
https://doi.org/10.1007/978-0-387-48536-2.
66. Rue, H., Martino, S. & Chopin, N. Approximate Bayesian inference for
latent Gaussian models by using integrated nested Laplace approximations.
J. R. Stat. Soc. Ser. B Stat. Methodol. 71, 319–392 (2009).
67. Martins, T. G., Simpson, D., Lindgren, F. & Rue, H. Bayesian computing with
INLA: new features. Comput. Stat. Data Anal. 67, 68–83 (2013).
68. Lindgren, F., Rue, H. & Lindström, J. An explicit link between
Gaussian elds and Gaussian Markov random elds: the stochastic partial
dierential equation approach. J. R. Stat. Soc. Ser. B Stat. Methodol.73,
423–498 (2011).
69. Golding, N. etal. Mapping under-5 and neonatal mortality in Africa,
2000–15: a baseline analysis for the sustainable development goals. Lancet
390, 2171–2182 (2017).
70. Osgood-Zimmerman, A. etal. Mapping child growth failure in Africa
between 2000 and 2015. Nature 555, 41–47 (2018).
71. Alegana, V. A. etal. Fine resolution mapping of population age-structures for
health and development applications. J. R. Soc. Interface 12,
20150073–20150073 (2015).
72. Patil, A. P., Gething, P. W., Piel, F. B. & Hay, S. I. Bayesian geostatistics
in health cartography: the perspective of malaria. Trends Parasitol. 27,
246–253 (2011).
73. Gething, P. W., Patil, A. P. & Hay, S. I. Quantifying aggregated uncertainty in
Plasmodium falciparum malaria prevalence and populations at risk via
ecient space-time geostatistical joint simulation. PLoS Comput. Biol. 6,
e1000724 (2010).
74. Scharlemann, J. P. W. etal. Global data for ecology and epidemiology:
a novel algorithm for temporal Fourier processing MODIS data. PLoS ONE 3,
e1408 (2008).
75. Blangiardo, M. & Cameletti, M. in Spatial and Spatio‐temporal Bayesian
Models with R‐INLA 235–258 (John Wiley & Sons, 2015).
76. Cameletti, M., Lindgren, F., Simpson, D. & Rue, H. Spatio-temporal
modeling of particulate matter concentration through the SPDE approach.
AStA Adv. Stat. Anal. 97, 109–131 (2013).
77. Blangiardo, M., Cameletti, M., Baio, G. & Rue, Havard Spatial and
spatio-temporal models with R-INLA. Spat. Spatio-Temporal Epidemiol. 7,
39–55 (2013).
Acknowledgements
This work was primarily supported by grant OPP1132415 from the Bill & Melinda Gates
Foundation awarded to S.I.H. The corresponding author had full access to data in the
study and had final responsibility for the decision to submit the study for publication.
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LBD Double Burden of Malnutrition Collaborators
Damaris K. Kinyoki1,2, Jennifer M. Ross1,3,4, Alice Lazzar-Atwood1, Sandra B. Munro1,
Lauren E. Schaeffer1, Mahdieh Abbasalizad-Farhangi5, Masoumeh Abbasi6, Hedayat Abbastabar7,
Ahmed Abdelalim8, Amir Abdoli9, Mohammad Abdollahi10, Ibrahim Abdollahpour11,
Rizwan Suliankatchi Abdulkader12, Nebiyu Dereje Abebe13,14, Teshome Abuka Abebo15,
Kedir Hussein Abegaz16,17, Hassan Abolhassani18,19, Lucas Guimarães Abreu20, Michael R. M. Abrigo21,
Abdelrahman I. Abushouk22, Manfred Mario Kokou Accrombessi23, Dilaram Acharya24,25,
Maryam Adabi26, Akindele Olupelumi Adebiyi27,28 , Isaac Akinkunmi Adedeji29, Victor Adekanmbi30,
Abiodun Moshood Adeoye31,32, Olatunji O. Adetokunboh33,34, Davoud Adham35,
Posi Emmanuel Aduroja36, Shailesh M. Advani3 7,38 , Mohsen Afarideh39, Mohammad Aghaali40,
Anurag Agrawal41,42, Tauseef Ahmad43,44, Keivan Ahmadi45, Sepideh Ahmadi46,
Muktar Beshir Ahmed47, Rushdia Ahmed48,49, Olufemi Ajumobi50,51, Chalachew Genet Akal52,
Temesgen Yihunie Akalu53, Tomi Akinyemiju54,55, Blessing Akombi56, Ziyad Al-Aly57,58, Samiah Alam59,
Genet Melak Alamene60, Turki M. Alanzi61, Jacqueline Elizabeth Alcalde Rabanal62,
Niguse Meles Alema63, Beriwan Abdulqadir Ali64,65, Muhammad Ali66, Mehran Alijanzadeh67,
Cyrus Alinia68, Vahid Alipour69,70, Hesam Alizade71,72, Syed Mohamed Aljunid73,74, Afshin Almasi75,
Amir Almasi-Hashiani76, Hesham M. Al-Mekhlafi77,78, Rajaa M. Al-Raddadi79, Khalid Altirkawi80,
Nelson Alvis-Guzman81,82, Nelson J. Alvis-Zakzuk83,84, Azmeraw T. Amare85,86,
Adeladza Kofi Amegah87, Saeed Amini88, Mostafa Amini Rarani89, Fatemeh Amiri90,
Arianna Maever Loreche Amit91,92, Nahla Hamed Anber93, Catalina Liliana Andrei94,
Fereshteh Ansari95,96, Alireza Ansari-Moghaddam97, Zelalem Alamrew Anteneh98,
Carl Abelardo T. Antonio99,100, Ernoiz Antriyandarti101, Davood Anvari102,103, Razique Anwer104,
Author contributions
D.K.K., J.M.R., A.A. and S.I.H. conceived and planned the study. A.L.-A. and D.K.K.
obtained, extracted, processed and geopositioned data. D.K.K. carried out statistical
analyses. The first draft of the manuscript was written by D.K.K, J.M.R., S.B.M., L.E.S.,
A.A. and S.I.H.; D.K.K., S.B.M. and J.M.R. finalized the manuscript based on comments
from other authors and reviewer feedback. D.K.K., A.L.-A. and S.B.M. managed the
Supplementary Information. All authors provided intellectual input into aspects of this
study. Additional details on author contributions are in the Supplementary Information.
Competing interests
This study was funded by the Bill & Melinda Gates Foundation. Co-authors employed
by the Bill & Melinda Gates Foundation provided feedback on initial maps and drafts
of this manuscript. Otherwise, the funders of the study had no role in study design,
data collection, data analysis, data interpretation, writing of the final report or the
decision to publish. The corresponding author had full access to all data in the study
and had final responsibility for the decision to submit for publication. DrUddin reports
personal fees from Deakin University Institute for Physical Activity and Nutrition,
Australia, outside the submitted work. DrLorkowski reports personal fees from Akcea
Therapeutics, Amedes MVZ für Laboratoriumsdiagnostik und Mikrobiologie, AMGEN,
Berlin-Chemie, Boehringer Ingelheim Pharma, Daiichi Sankyo, MSD Sharp & Dohme,
Novo Nordisk, Sanofi-Aventis, Synlab, Unilever and Upfield, as well as nonfinancial
support from Preventicus outside the submitted work. Prof. Postma reports grants and
personal fees from various pharmaceutical industries, all outside the submitted work.
Prof. Postma holds stocks in Ingress Health and Pharmacoeconomics Advice Groningen
and is advisor to Asc Academics, all pharmacoeconomic consultancy companies.
DrRemuzzi reports personal fees and nonfinancial support from Alnylam, personal fees
and nonfinancial support from Boehringer Ingelheim, personal fees and nonfinancial
support from Handock Inc., personal fees and nonfinancial support from Inception
Sciences Canada and personal fees and nonfinancial support from Achillion, outside
the submitted work. Dr.Jakovljevic reports grants from Ministry of Education Science
and Technological Development of the Republic of Serbia outside the submitted work.
DrFlohr reports grants from European Union IMI grant scheme (Horizon 2020) outside
the submitted work. DrJozwiak reports personal fees from ALAB LABORATORIA,
nonfinancial support from SERVIER, nonfinancial support from MICROLIFE, personal
fees from TEVA POLSKA, nonfinancial support from SUPERPHARM and nonfinancial
support from MEDICOVER, outside the submitted work. W. Mendoza is currently
Program Analyst Population and Development at the United Nations Population
Fund-UNFPA Country Office in Peru, which does not necessarily endorse this study.
Prof. Saxena reports grants from NIHR School for Public Health Research, grants from
NIHR Applied Research Collaboration and grants from The Daily Mile Foundation
supported by INEOS, outside the submitted work. DrDunachie reports grants from The
Fleming Fund at UK Department of Health and Social Care, during the conduct of the
study. DrMozaffarian reports research funding from the National Institutes of Health
and the Gates Foundation; personal fees from GOED, Nutrition Impact, Bunge, Indigo
Agriculture, Motif FoodWorks, Amarin, Acasti Pharma, Cleveland Clinic Foundation,
America’s Test Kitchen and Danone; scientific advisory board, Brightseed, DayTwo,
Elysium Health and Filtricine; and chapter royalties from UpToDate; all outside the
submitted work. DrJ. Singh reports personal fees from Crealta/Horizon, Medisys, Fidia,
UBM LLC, Medscape, WebMD, Clinical Care Options, Clearview Healthcare Partners,
Putnam Associates, Spherix, the National Institutes of Health and the American College
of Rheumatology, stock options in Amarin Pharmaceuticals and Viking Pharmaceuticals
and participates in the steering committee of OMERACT, an international organization
that develops measures for clinical trials receives arm’s length funding from 12
pharmaceutical companies and is also on the speaker’s bureau of Simply Speaking.
Additional information
Extended data is available for this paper at https://doi.org/10.1038/s41591-020-0807-6.
Supplementary information is available for this paper at https://doi.org/10.1038/
s41591-020-0807-6.
Correspondence and requests for materials should be addressed to S.I.H.
Peer review information Jennifer Sargent was the primary editor on this article and
managed its editorial process and peer review in collaboration with the rest of the
editorial team.
Reprints and permissions information is available at www.nature.com/reprints.
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Maha El Tantawi287, Iffat Elbarazi288, Demelash Abewa Elemineh289, Shaimaa I. El-Jaafary8,
Ziad El-Khatib290,291, Aisha Elsharkawy292, Yasser Mohamed El-Sherbiny286,293, Iqbal R. F. Elyazar294,
Mohammad Hassan Emamian295, Shymaa Enany296, Daniel Adane Endalew297,
Melese Linger Endalifer298, Khalil Eskandari299,300, Sharareh Eskandarieh301, Saman Esmaeilnejad302,
Alireza Esteghamati39, Arash Etemadi303,304, Atkilt Esaiyas Etisso305, Jessica Fanzo306,307,
Mohammad Farahmand308, Anwar Faraj309, Sajjad Farashi310, Mohammad Fareed311, Andrea Farioli312,
Andre Faro313, Farshad Farzadfar119, Hossein Farzam6, Syeda Sadia Fatima314, Nazir Fattahi75,
Nelsensius Klau Fauk315,316, Ali Akbar Fazaeli317, Netsanet Fentahun318, Tomas Y. Ferede319,
Seyed-Mohammad Fereshtehnejad110,320, Eduarda Fernandes321, João C. Fernandes322,
Garumma Tolu Feyissa323,324, Irina Filip325,326, Florian Fischer327, Carsten Flohr328, Nataliya A. Foigt329,
Morenike Oluwatoyin Folayan330, Artem Alekseevich Fomenkov331, Masoud Foroutan332,
Jana Förster333, Joel Msafiri Francis334, Takeshi Fukumoto335,336, Reta Tsegaye Gayesa337,
Biniyam Sahiledengle Geberemariyam338, Tsegaye Tewelde Gebrehiwot47, Hadush Gebremariam165,
Kidane Tadesse Gebremariam339, Ketema Bizuwork Bizuwork Gebremedhin340,
Gebreamlak Gebremedhn Gebremeskel120,341, Assefa Ayalew Ayalew Gebreslassie339,
Gebretsadkan G. G. Gebretsadik165, Getnet Azeze Gedefaw86,342, Yilma Chisha Dea Geramo164,
Hailay Abrha Gesesew47,315, Birhanu Geta343, Agegnehu Bante Getenet344, Kebede Embaye Gezae345,
Fatemeh Ghaffarifar346, Mansour Ghafourifard347, Alireza Ghajar39,348, Mahsa Ghajarzadeh349,
Ahmad Ghashghaee350, Hesam Ghiasvand351, Asadollah Gholamian352,353, Syed Amir Gilani354,355,
Tiffany K. Gill356, Ibrahim Abdelmageed Ginawi357, Srinivas Goli225,358, Nelson G. M. Gomes321,359,
Sameer Vali Gopalani360,361, Houman Goudarzi362,363, Alessandra C. Goulart364,365,
Arunkumar Govindakarnavar366, Ayman Grada367, Michal Grivna288, Rafael Alves Guimarães368,
Rashid Abdi Guled369, Yuming Guo233,370, Rahul Gupta371,372, Rajeev Gupta373,374,
Nima Hafezi-Nejad375,376, Michael Tamene Haile377, Arvin Haj-Mirzaian378,379, Arya Haj-Mirzaian375,378,
Brian J. Hall380, Iman Halvaei381, Randah R. Hamadeh382, Yadollah Hamidi383,
Demelash Woldeyohannes Handiso338, Graeme J. Hankey384,385, Hamidreza Haririan386,
Ninuk Hariyani387,388, Ahmed I. Hasaballah389, Md. Mehedi Hasan390, Milad Hasankhani5,
Edris Hasanpoor391, Amir Hasanzadeh392,393, Maryam Hashemian394, Soheil Hassanipour395,396,
Hamid Yimam Hassen397,398, Rasmus Havmoeller399, Corinna Hawkes400, Khezar Hayat401,402,
Desta Haftu Hayelom164, Behnam Heidari39, Reza Heidari-Soureshjani403, Delia Hendrie404,
Andualem Henok397, Nathaniel J. Henry1, Mario Herrero405, Claudiu Herteliu124,
Fatemeh Heydarpour406, Hagos D. de Hidru407, Chi Linh Hoang270, Hans W. Hoek408,409,
Michael K. Hole410, Ramesh Holla411, Gillian Hollerich1, Enayatollah Homaie Rad412,413,
Sung Hwi Hong414,415, Praveen Hoogar416, Masako Horino417, Naznin Hossain418,419, Mostafa Hosseini420,
Mehdi Hosseinzadeh421,422, Mihaela Hostiuc423,424, Sorin Hostiuc425,426, Mowafa Househ427,
Mohamed Hsairi428, Guoqing Hu429, Tanvir M. Huda430,431, Ayesha Humayun432, Bing-Fang Hwang433,
Segun Emmanuel Ibitoye36, Olayinka Stephen Ilesanmi27, Milena D. Ilic434,
Mohammad Hasan Imani-Nasab435, Leeberk Raja Inbaraj436, Usman Iqbal437,
Seyed Sina Naghibi Irvani438, Sheikh Mohammed Shariful Islam439,440, Chidozie C. D. Iwu441,
Chinwe Juliana Iwu442,443, Neda Izadi444, Jalil Jaafari445, Anelisa Jaca446,447, Farhad Jadidi-Niaragh448,
Nader Jafari Balalami449, Morteza Jafarinia450, Mohammad Ali Jahani113, Mihajlo Jakovljevic451,
Amir Jalali452, Farzad Jalilian453,454, Achala Upendra Jayatilleke455,456, Panniyammakal Jeemon457,
Fyezah Jehan458, Ensiyeh Jenabi459, Ravi Prakash Jha460, Vivekanand Jha461,462, John S. Ji463,464,
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Peng Jia465, Oommen John462, Yetunde O. John-Akinola36, Kimberly B. Johnson1, Jost B. Jonas466,467,
Nitin Joseph468, Farahnaz Joukar395, Jacek Jerzy Jozwiak469, Suresh Banayya Jungari470,
Mikk Jürisson471, Ali Kabir472, Zubair Kabir473, Amaha Kahsay165, Molla Kahssay184, Hamed Kalani474,
Leila L. Kalankesh475, Rohollah Kalhor67,476, Zahra Kamiab477, Tanuj Kanchan478, Umesh Kapil479,
Neeti Kapoor137, Manoochehr Karami480, Behzad Karami Matin75, André Karch481, Mohd A. Karim163,431,
Surendra Karki56,482, Amir Kasaeian483,484, Gebremicheal Gebreslassie Kasahun251,
Habtamu Kebebe Kasaye337, Tesfaye Dessale Kassa485, Hagazi Gebremedhin Kassaye63,
Nicholas J. Kassebaum1,486, Ali Kazemi Karyani75,487, Andre Pascal Kengne488,489,
Daniel Bekele Ketema490, Yousef Saleh Khader491, Morteza Abdullatif Khafaie492,
Mojtaba Khaksarian493, Nauman Khalid494, Ibrahim A. Khalil3, Rovshan Khalilov495, Asad Khan496,
Ejaz Ahmad Khan497, Md Nuruzzaman Khan498,499, Mohammad Saud Khan500,
Muhammad Shahzeb Khan501,502, Khaled Khatab503,504, Amir Khater505, Mona M. Khater506,
Mahalqua Nazli Khatib507, Maryam Khayamzadeh508,509, Maryam Khazaei-Pool510,
Mohammad Khazaei133, Salman Khazaei480, Mohammad Taghi Khodayari511,
Mohammad Hossein Khosravi512, Roba Khundkar513, Ali Kiadaliri514, Neda Kianipour487,
Daniel N. Kiirithio515, Yun Jin Kim516, Ruth W. Kimokoti517, Adnan Kisa518, Sezer Kisa519, Tufa Kolola520,
Hamidreza Komaki521,522, Shivakumar K. M. Kondlahalli523, Ali Koolivand524, Parvaiz A. Koul525,
Ai Koyanagi526, Moritz U. G. Kraemer527,528, Kewal Krishan529, Kris J. Krohn1, Nuworza Kugbey530,531,
Manasi Kumar532,533, Pushpendra Kumar225, Vivek Kumar534, Om P. Kurmi535,536, Oluwatosin Kuti537,
Carlo La Vecchia538, Ben Lacey163,539, Deepesh P. Lad540, Aparna Lal182, Dharmesh Kumar Lal541,
Faris Hasan Lami542, Prabhat Lamichhane543, Justin J. Lang544, Van C. Lansingh545,546, Savita Lasrado547,
Georgy Lebedev548,549, Paul H. Lee550, Shaun Wen Huey Lee551,552, Mostafa Leili133, Ian D. Letourneau1,
Sonia Lewycka277,553, Shanshan Li233, Lee-Ling Lim554,555, Shai Linn556, Shiwei Liu557, Simin Liu558,
Rakesh Lodha559, Joshua Longbottom560, Jaifred Christian F. Lopez561,562, Stefan Lorkowski563,564,
Erlyn Rachelle King Macarayan565,566, Mohammed Madadin567, Hassan Magdy Abd El Razek568,
Muhammed Magdy Abd El Razek569, Dhaval P. Maghavani570, Phetole Walter Mahasha34,
Narayan Bahadur Mahotra571, Venkatesh Maled572,573, Afshin Maleki574, Shokofeh Maleki575,
Deborah Carvalho Malta576, Ali Manafi577, Farzad Manafi578, Navid Manafi579,580,
Narendar Dawanu Manohar581, Fariborz Mansour-Ghanaei395, Borhan Mansouri582,
Mohammad Ali Mansournia420, Chabila Christopher Mapoma583, Dadi Marami143, Laurie B. Marczak1,
Carlos Alberto Marrugo Arnedo584,585, Francisco Rogerlândio Martins-Melo586, Anthony Masaka587,
Benjamin Ballard Massenburg588, Pallab K. Maulik589,590, Benjamin K. Mayala1,591, Mohsen Mazidi592,
Man Mohan Mehndiratta593,594, Freshteh Mehri595, Kala M. Mehta596,
Wahengbam Bigyananda Meitei597, Fantahun Ayenew Mekonnen53, Teferi Mekonnen598,
Gebrekiros Gebremichael Meles164, Hagazi Gebre Meles599, Addisu Melese52, Walter Mendoza600,
Ritesh G. Menezes601, Meresa Berwo Mengesha602, George A. Mensah489,603, Tuomo J. Meretoja604,605,
Tomasz Miazgowski606, Neda Milevska Kostova607, Ted R. Miller404,608, Edward J. Mills609,
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Mehdi Mirzaei-Alavijeh453,454, Prasanna Mithra468, Babak Moazen151, Efat Mohamadi620,
Amjad Mohamadi-Bolbanabad621, Karzan Abdulmuhsin Mohammad65,622, Yousef Mohammad623,
Dara K. Mohammad624,625, Aso Mohammad Darwesh626, Naser Mohammad Gholi Mezerji627,
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Abbas Mosapour611,647, Jonathan F. Mosser1, Simin Mouodi113, Amin Mousavi Khaneghah648,
Dariush Mozaffarian649, Ulrich Otto Mueller650,651, Christopher J. L. Murray1,2, G. V. S. Murthy652,
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Mehdi Naderi575, Girish N. Nadkarni658, Ahamarshan Jayaraman Nagarajan659,660, Mohsen Naghavi1,2,
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Cuong Tat Nguyen673, Huong Lan Thi Nguyen673, Dabere Nigatu162, Yeshambel T. Nigatu674,675,
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Vuong Minh Nong673, Jean Jacques Noubiap489, Christoph Nowak681, Bogdan Oancea682,
Richard Ofori-Asenso683,684, Onome Bright Oghenetega685, In-Hwan Oh686, Olanrewaju Oladimeji687,688,
Morteza Oladnabi689, Andrew T. Olagunju690,691, Tinuke O. Olagunju535,
Bolajoko Olubukunola Olusanya692, Jacob Olusegun Olusanya693, Mojisola Morenike Oluwasanu36,
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Orish Ebere Orisakwe699, Alberto Ortiz700,701, Osayomwanbo Osarenotor702,
Aaron E. Osgood-Zimmerman1, Mayowa Ojo Owolabi703, Mahesh P. A.704, Jagadish Rao Padubidri705,
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Sergio I. Prada733, Liliana Preotescu734,735, Dimas Ria Angga Pribadi736, Zahiruddin Quazi Syed175,
Mohammad Rabiee737, Navid Rabiee738, Amir Radfar739,740, Alireza Rafiei741,742, Fakher Rahim743,744,
Vafa Rahimi-Movaghar745 , Muhammad Aziz Rahman746,747, Sajjad ur Rahman748 ,749,
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Vahid Rashedi761, Prateek Rastogi705, Priya Rathi762, Salman Rawaf763,764, David Laith Rawaf765,766,
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Serge Resnikoff771,772, Nima Rezaei19,773, Shahab Rezaeian6, Mohammad Sadegh Rezai774,
Aziz Rezapour69, Seyed Mohammad Riahi444,775, Ana Isabel Ribeiro776, Jennifer Rickard777,778,
Alina Rodriguez779,780, Leonardo Roever781, Elias Merdassa Roro782,783, Gholamreza Roshandel732,784,
Ali Rostami785, Enrico Rubagotti786,787, Anas M. Saad788, Seyedmohammad Saadatagah789,
Yogesh Damodar Sabde790, Siamak Sabour444, Ehsan Sadeghi75, Masoumeh Sadeghi791,
Saeed Safari792, Yahya Safari75, Hamid Safarpour793, Rajesh Sagar794, Amirhossein Sahebkar795,796,
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Yahya Salimi453,454,663, Hamideh Salimzadeh732, Hossein Samadi Kafil805, Evanson Zondani Sambala34,
Abdallah M. Samy806, Itamar S. Santos807, Bruno Piassi Sao Jose808,
Sivan Yegnanarayana Iyer Saraswathy809,810, Abdur Razzaque Sarker811, Benn Sartorius2,812,
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Masood Ali Shaikh826, Ali S. Shalash827, Mehran Shams-Beyranvand828, Amir Shamshirian829,
Morteza Shamsizadeh830, Mohammed Shannawaz831, Kiomars Sharafi75, Mehdi Sharif832,833,
Rajesh Sharma834, Hatem Samir Shehata8, Abbas Sheikhtaheri69,835, Kenji Shibuya836,
Wondimeneh Shibabaw Shiferaw131, Mika Shigematsu837, Jae Il Shin838,839, Rahman Shiri840,
Reza Shirkoohi841,842, Ivy Shiue843, Kerem Shuval556, Soraya Siabani844,845, Tariq J. Siddiqi502,
Inga Dora Sigfusdottir846,847, Diego Augusto Santos Silva848, Biagio Simonetti849, Ambrish Singh850,851,
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Maryam Zamanian76, Hamed Zandian960,963, Hadi Zarafshan964, Nejimu Biza Zepro184,339,
Taddese Alemu Zerfu965,966, Taye Abuhay Zewale98, Yunquan Zhang967,968, Zhi-Jiang Zhang969,
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Simon I. Hay1,2 ✉
1Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. 2Department of Health Metrics Sciences, School of Medicine,
University of Washington, Seattle, WA, USA. 3Department of Global Health, University of Washington, Seattle, WA, USA. 4Department of Medicine,
University of Washington, Seattle, WA, USA. 5School of Nutrition and Food Sciences, Tabriz University of Medical Sciences, Tabriz, Iran. 6Kermanshah
University of Medical Sciences, Kermanshah, Iran. 7Advanced Diagnostic and Interventional Radiology Research Center, Tehran University of Medical
Sciences, Tehran, Iran. 8Department of Neurology, Cairo University, Cairo, Egypt. 9Department of Parasitology and Mycology, Jahrom University of Medical
Sciences, Jahrom, Iran. 10The Institute of Pharmaceutical Sciences (TIPS), Toxicology and Diseases Group, Tehran University of Medical Sciences, Tehran,
Iran. 11Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran. 12Department of Public Health, Ministry of Health, Riyadh, Saudi
Arabia. 13School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia. 14Public Health, Wachemo University, Hosanna, Ethiopia. 15College of
Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia. 16Biostatistics and Health Informatics, Madda Walabu University, Bale Robe,
Ethiopia. 17Radiotherapy Center, Addis Ababa University, Addis Ababa, Ethiopia. 18LABMED, Karolinska University Hospital, Huddinge, Sweden. 19Research
Center for Immunodeficiencies, Tehran University of Medical Sciences, Tehran, Iran. 20Department of Pediatric Dentistry, Federal University of Minas
Gerais, Belo Horizonte, Brazil. 21Research Department, Philippine Institute for Development Studies, Quezon City, Philippines. 22Cardiovascular Medicine,
Ain Shams University, Abbasia, Egypt. 23Bénin Clinical Research Institute (IRCB), Cotonou, Benin. 24Department of Preventive Medicine, Dongguk
University, Gyeongju, South Korea. 25Department of Community Medicine, Kathmandu University, Devdaha, Nepal. 26Hamadan University of Medical
Sciences, Hamadan, Iran. 27Department of Community Medicine, University of Ibadan, Ibadan, Nigeria. 28Department of Community Medicine, University
College Hospital, Ibadan, Ibadan, Nigeria. 29Department of Sociology, Olabisi Onabanjo University, Ago-Iwoye, Nigeria. 30School of Medicine, Cardiff
University, Cardiff, UK. 31College of Medicine, University of Ibadan, Ibadan, Nigeria. 32Community Cardiovascular Research Unit, Elyon Heart Rehabilitation
Center, Ibadan, Nigeria. 33Department of Global Health, Stellenbosch University, Stellenbosch, South Africa. 34Cochrane South Africa, South African
Medical Research Council, Cape Town, South Africa. 35School of Health, Ardabil University of Medical Science, Ardabil, Iran. 36Department of Health
Promotion and Education, University of Ibadan, Ibadan, Nigeria. 37Social Behavioral Research Branch, National Institute of Health, Bethesda, MD, USA.
38Cancer Prevention and Control, Georgetown University, Washington, DC, USA. 39Endocrinology and Metabolism Research Center (EMRC), Tehran
University of Medical Sciences, Tehran, Iran. 40Epidemiology, Qom University of Medical Sciences, Qom, Iran. 41 Research Area for Informatics and Big Data,
CSIR Institute of Genomics and Integrative Biology, Delhi, India. 42Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA.
43Department of Epidemiology and Health Statistics, School of Public Health, Southeast University Nanjing, Nanjing, China. 44Microbiology Department,
Hazara University Mansehra, Mansehra, Pakistan. 45Lincoln Medical School, Universities of Nottingham & Lincoln, Lincoln, UK. 46School of Advanced
Technologies in Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 47Department of Epidemiology, Jimma University, Jimma, Ethiopia.
48James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh. 49Health Systems and Population Studies Division, International Centre for
Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh. 50School of Community Health Sciences, University of Nevada, Reno, NV, USA. 51National
Malaria Elimination Program, Federal Ministry of Health, Abuja, Nigeria. 52Department of Medical Laboratory Sciences, Bahir Dar University, Bahir Dar,
Ethiopia. 53Department of Epidemiology and Biostatistics, University of Gondar, Gondar, Ethiopia. 54Department of Population Health Sciences, Duke
University, Durham, NC, USA. 55Duke Global Health Institute, Duke University, Durham, NC, USA. 56School of Public Health and Community Medicine,
University of New South Wales, Sydney, New South Wales, Australia. 57John T. Milliken Department of Internal Medicine, Washington University in St.
Louis, St Louis, MO, USA. 58Clinical Epidemiology Center, VA Saint Louis Health Care System, Department of Veterans Affairs, St Louis, MO, USA.
59Department of Medicine, Dalhousie University, Halifax, NS, Canada. 60School of Health Sciences, Madda Walabu University, Bale Goba, Ethiopia.
61Department of Health Information Management and Technology, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia. 62Centre of Health
System Research, National Institute of Public Health, Cuernavaca, Mexico. 63Department of Pharmacy, Adigrat University, Adigrat, Ethiopia. 64Medical
Technical Institute, Erbil Polytechnic University, Erbil, Iraq. 65Ishik University, Erbil, Iraq. 66Department of Biotechnology, Quaid-i-Azam University
Islamabad, Islamabad, Pakistan. 67Social Determinants of Health Research Center, Qazvin University of Medical Sciences, Qazvin, Iran. 68Department of
Health Care Management and Economics, Urmia University of Medical Science, Urmia, Iran. 69 Health Management and Economics Research Center, Iran
University of Medical Sciences, Tehran, Iran. 70Health Economics Department, Iran University of Medical Sciences, Tehran, Iran. 71Department of
Microbiology, Kerman University of Medical Sciences, Kerman, Iran. 72Department of Microbiology, Hormozgan University of Medical Sciences, Bandar
Abbas, Iran. 73Department of Health Policy and Management, Kuwait University, Safat, Kuwait. 74International Centre for Casemix and Clinical Coding,
National University of Malaysia, Bandar Tun Razak, Malaysia. 75Research Center for Environmental Determinants of Health (RCEDH), Kermanshah
University of Medical Sciences, Kermanshah, Iran. 76Department of Epidemiology, Arak University of Medical Sciences, Arak, Iran. 77Medical Research
Center, Jazan University, Jazan, Saudi Arabia. 78Department of Medical Parasitology, Sana’a University, Sana’a, Yemen. 79Department of Family and
Community Medicine, King Abdulaziz University, Jeddah, Saudi Arabia. 80King Saud University, Riyadh, Saudi Arabia. 81Research Group in Health
Economics, University of Cartagena, Cartagena, Colombia. 82Research Group in Hospital Management and Health Policies, University of the Coast,
Barranquilla, Colombia. 83Departamento de Ciencias Económicas, Universidad dela Costa, Barranquilla, Colombia. 84Observatorio Nacional de Salud,
National Institute of Health, Bogotá, Colombia. 85Sansom Institute, South Australian Health and Medical Research Institute, Adelaide, South Australia,
Australia. 86Bahir Dar University, Bahir Dar, Ethiopia. 87Biomedical Science, University of Cape Coast, Cape Coast, Ghana. 88Health Services Management
Department, Arak University of Medical Sciences, Arak, Iran. 89Health Services Management, Isfahan University of Medical Sciences, Isfahan, Iran.
90Department of Radiology, Kermanshah University of Medical Sciences, Kermanshah, Iran. 91Department of Epidemiology and Biostatistics, University of
the Philippines Manila, Manila, Philippines. 92Online Programs for Applied Learning, Johns Hopkins University, Baltimore, MD, USA. 93Mansoura University,
Mansoura, Egypt. 94Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. 95Research Center for Evidence Based Medicine-Health
Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran. 96Razi Vaccine and Serum Research Institute,
Agricultural Research Education and Extension Organization (AREEO), Tehran, Iran. 97Department of Epidemiology and Biostatistics, Health Promotion
Research Center, Zahedan, Iran. 98Department of Epidemiology and Biostatistics, Bahir Dar University, Bahir Dar, Ethiopia. 99Department of Health Policy
and Administration, University of the Philippines Manila, Manila, Philippines. 100Department of Applied Social Sciences, Hong Kong Polytechnic University,
Hong Kong, China. 101Department of Agribusiness, Universitas Sebelas Maret, Surakarta, Indonesia. 102Department of Parasitology, Mazandaran University
of Medical Sciences, Sari, Iran. 103Department of Microbiology and Immunology, Iranshahr University of Medical Sciences, Iranshahr, Iran. 104Department of
Pathology, Al-Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia. 105Department of Sociology and Social Work, Kwame Nkrumah
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University of Science and Technology, Kumasi, Ghana. 106Center for International Health, Ludwig Maximilians University, Munich, Germany. 107Social
Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran. 108Department of Health Promotion and Education, Tehran
University of Medical Sciences, Tehran, Iran. 109School of Health Sciences, Birmingham City University, Birmingham, UK. 110Department of Neurobiology,
Karolinska Institutet, Stockholm, Sweden. 111School of Health and Social Studies, Dalarna University, Falun, Sweden. 112School of Nursing and Midwife, Babol
University of Medical Sciences, Babol, Iran. 113Babol University of Medical Sciences, Babol, Iran. 114Preventive Medicine and Public Health Research Center,
Iran University of Medical Sciences, Tehran, Iran. 115Neurology, Shiraz University of Medical Sciences, Shiraz, Iran. 116Prevention of Metabolic Disorders
Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 117Department of Microbiology, Hamedan University of Medical Sciences,
Hamedan, Iran. 118Department of Clinical Chemistry, University of Gondar, Gondar, Ethiopia. 119Non-Communicable Diseases Research Center, Tehran
University of Medical Sciences, Tehran, Iran. 120Department of Nursing, Aksum University, Aksum, Ethiopia. 121Department of Health System and Health
Economics, Bahir Dar University, Bahir Dar City, Ethiopia. 122School of Nursing, , University of Nottingham, Amman, Jordan. 123School of Business, University
of Leicester, Leicester, UK. 124Department of Statistics and Econometrics, Bucharest University of Economic Studies, Bucharest, Romania. 125Bénin Clinical
Research Institute (IRCB), Abomey-Calavi, Benin. 126Contrôle des Maladies Infectieuses, Laboratory of Studies and Research-Action in Health, Porto Novo,
Benin. 127Indian Institute of Public Health, Public Health Foundation of India, Gurugram, India. 128The Judith Lumley Centre, La Trobe University, Melbourne,
Victoria, Australia. 129General Office for Research and Technological Transfer, Peruvian National Institute of Health, Lima, Peru. 130Department of Health
Policy Planning and Management, University of Health and Allied Sciences, Ho, Ghana. 131Department of Nursing, Debre Berhan University, Debre Berhan,
Ethiopia. 132Cellular and Molecular Biology Research Center, Babol University of Medical Sciences, Babol, Iran. 133Department of Environmental Health
Engineering, Hamadan University of Medical Sciences, Hamadan, Iran. 134Department of Reproductive Health, University of Gondar, Gondar, Ethiopia.
135Public Health Risk Sciences Division, Public Health Agency of Canada, Toronto, Ontario, Canada. 136Department of Nutritional Sciences, University of
Toronto, Toronto, Ontario, Canada. 137Department of Forensic Science, Government Institute of Forensic Science, Nagpur, India. 138Healthcare Management
Department, Shiraz University of Medical Sciences, Shiraz, Iran. 139Biochemistry Unit, Universiti Sultan Zainal Abidin, Kuala Terengganu, Malaysia.
140Biomedicine Department, Universiti Sultan Zainal Abidin Gongbedak, Kuala Terengganu, Malaysia. 141Health Policy and Management Department,
Tehran University of Medical Sciences, Tehran, Iran. 142Department of Forensic Medicine and Toxicology, , Manipal Academy of Higher Education, Manipal,
India. 143Department of Medical Laboratory Science, Haramaya University, Harar, Ethiopia. 144School of Public Health, Haramaya University, Harar, Ethiopia.
145Department of Hypertension, Medical University of Lodz, Lodz, Poland. 146Polish Mothers’ Memorial Hospital Research Institute, Lodz, Poland.
147Department of Noncommunicable Diseases, Bangladesh University of Health Sciences (BUHS), Dhaka, Bangladesh. 148Department of Animal Pathology
and Epidemiology, Razi Vaccine and Serum Research Institute, Karaj, Iran. 149Department of Neurosciences, Costa Rican Department of Social Security, San
Jose, Costa Rica. 150School of Medicine, University of Costa Rica, San Pedro, Costa Rica. 151Heidelberg Institute of Global Health (HIGH), Heidelberg
University, Heidelberg, Germany. 152T.H. Chan School of Public Health, Harvard University, Boston, MA, USA. 153University of Aden, Aden, Yemen. 154School
of Public Health, Imperial College London, London, UK. 155Health Human Resources Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
156Department of Applied Human Nutrition, Bahir Dar University, Bahir Dar, Ethiopia. 157University of Gondar, Gondar, Ethiopia. 158Department of
Community Medicine, Gandhi Medical College Bhopal, Bhopal, India. 159Jazan University, Jazan, Saudi Arabia. 160Social Determinants of Health Research
Center, Lorestan University of Medical Sciences, Khorramabad, Iran. 1 61Department of Epidemiology and Biostatistics, Lorestan University of Medical
Sciences, Khorramabad, Iran. 162Department of Reproductive Health and Population Studies, Bahir Dar University, Bahir Dar, Ethiopia. 163Nuffield
Department of Population Health, University of Oxford, Oxford, UK. 164Department of Public Health, Arba Minch University, Arba Minch, Ethiopia.
165Department of Nutrition and Dietetics, Mekelle University, Mekelle, Ethiopia. 166Adigrat University, Adigrat, Ethiopia. 167 School of Public Health, Wolaita
Sodo University, Addis Ababa, Ethiopia. 168Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA, USA. 169Hubert
Department of Global Health, Emory University, Atlanta, GA, USA. 170Department of Global Health, University of South Florida, Tampa, FL, USA.
171Department of Health Information Management, Manipal Academy of Higher Education, Manipal, Manipal, India. 172School of Public Health, University
of Adelaide, Adelaide, South Australia, Australia. 173Public Health Research Laboratory, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.
174 Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, India. 175Department of Community
Medicine, Datta Meghe Institute of Medical Sciences, Deemed University, Wardha, India. 176Department of Statistical and Computational Genomics,
National Institute of Biomedical Genomics, Kalyani, India. 177Department of Statistics, University of Calcutta, Kolkata, India. 178Social Determinants of
Health Research Center, Babol University of Medical Sciences, Babol, Iran. 179Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy. 180Health
Economics & Outcomes Research, Creativ-Ceutical (Huntsworth Health), London, UK. 181Woldia University, Woldia, Ethiopia. 182National Centre for
Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory, Australia. 183Department of Clinical Pharmacy
and Pharmacology, University of Dhaka, Dhaka, Bangladesh. 184Department of Public Health, Samara University, Samara, Ethiopia. 185Debretabor University,
Addis Ababa University, Debretabor, Ethiopia. 186Department of Pediatrics and Child Health Nursing, Bahir Dar University, Bahir Dar, Ethiopia. 187Transport
and Road Safety (TARS) Research Center, , University of New South Wales, Sydney, New South Wales, Australia. 188School of Health Sciences, Swinburne
University of Technology, Melbourne, Victoria, Australia. 189Department of Nutrition, Saint Paul’s Hospital Millennium Medical College, Addis Ababa,
Ethiopia. 190Department of Veterinary Medicine, Islamic Azad University, Kermanshah, Iran. 191Department of Biomedical Sciences, Nazarbayev University,
Nur-Sultan City, Kazakhstan. 192Department of Internal Medicine, Manipal Academy of Higher Education, Mangalore, India. 193Department of General
Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy. 194 School of Medicine, Hamadan University of Medical Sciences, Hamadan,
Iran. 195Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK. 196University of Genoa, Genoa, Italy.
197Division of Hematology and Oncology, Georgetown University, Washington, DC, USA. 198Epidemiology and Evidence Based Medicine, I.M. Sechenov First
Moscow State Medical University, Moscow, Russia. 199Gorgas Memorial Institute for Health Studies, Panama City, Panama. 200Department of Research,
Golden Community, Kathmandu, Nepal. 201Department of Community Medicine, Employees’ State Insurance Model Hospital, Bangalore, India.
202Department for Health Care Management, Technical University of Berlin, Berlin, Germany. 203School of Public Health and Health Systems, University of
Waterloo, Waterloo, Ontario, Canada. 204Al Shifa School of Public Health, Al Shifa Trust Eye Hospital, Rawalpindi, Pakistan. 205Internal Medicine
Department, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina. 206Comisión Directiva, Argentine Society of
Medicine, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina. 207National Institute of Public Health, Cuernavaca, Mexico. 208Department of
Disease Control, London School of Hygiene & Tropical Medicine, London, UK. 209Centre for Population Health Sciences, Nanyang Technological University,
Singapore, Singapore. 210Global eHealth Unit, Imperial College London, London, UK. 211Department of Population and Health, Metropolitan Autonomous
University, Mexico City, Mexico. 212Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden. 213Research Unit on
Applied Molecular Biosciences (UCIBIO), University of Porto, Porto, Portugal. 214Department of Psychiatry, University of São Paulo, São Paulo, Brazil.
215Colombian National Health Observatory, National Institute of Health, Bogota, Colombia. 216Epidemiology and Public Health Evaluation Group, National
University of Colombia, Bogota, Colombia. 217Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia.
218School of Public Health, University of Hong Kong, Hong Kong, China. 219Health, Nutrition and Population, World Bank, Lusaka, Zambia. 220Institute for
Global Health, Heidelberg University, Heidelberg, Germany. 221Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, India.
222Division of Epidemiology, National Institute of Cholera and Enteric Diseases, Kolkata, India. 223Department of Medicine, University of Toronto, Toronto,
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Ontario, Canada. 224Population Research Centre, Gokhale Institute of Politics and Economics, Pune, India. 225International Institute for Population Sciences,
Mumbai, India. 226Department of Medical Entomology and Vector Control, Urmia University of Medical Science, Urmia, Iran. 227Department of Biostatistics
and Epidemiology, Babol University of Medical Sciences, Babol, Iran. 228Epidemiology Research Center, Royan Institute, Tehran, Iran. 229Department of
Nursing, Wolaita Sodo University, Sodo, Ethiopia. 230Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria,
Australia. 231Department of Pulmonary Medicine, Christian Medical College and Hospital (CMC), Vellore, India. 232Hanoi National University of Education,
Hanoi, Vietnam. 233School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia. 234School of Medicine and Surgery,
University of Milan Bicocca, Monza, Italy. 235Institute of Public Health, University of Gondar, Gondar, Ethiopia. 236Discipline of Public Health, Flinders
University, Adelaide, South Australia, Australia. 237Department of Human Physiology, University of Gondar, Gondar, Ethiopia. 238Department of
Environmental Health, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia. 239Department of Dermatology, Case Western Reserve
University, Cleveland, OH, USA. 24 0Department of Dermatology, University of Milan, Milan, Italy. 24 1Department of Pediatrics, Tanta University, Tanta,
Egypt. 242Toxoplasmosis Research Center, Mazandaran University of Medical Sciences, Sari, Iran. 243Division of Women and Child Health, Aga Khan
University, Karachi, Pakistan. 24 4Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC,
USA. 245Population and Development, Facultad Latinoamericana de Ciencias Sociales Mexico, Mexico City, Mexico. 246Australian Institute for Suicide
Research and Prevention, Griffith University, Mount Gravatt, Queensland, Australia. 247Department of Nursing, Woldia University, Woldia, Ethiopia.
248Department of Nursing, Jimma University, Jimma, Ethiopia. 249Department of Neonatal Nursing, St. Paul’s Hospital Millennium Medical College, Addis
Ababa, Ethiopia. 250Ambo University, Ambo, Ethiopia. 251School of Pharmacy, Aksum University, Aksum, Ethiopia. 252Addis Ababa University,, Addis Ababa,
Ethiopia. 253Center for Nutrition and Health Research, National Institute of Public Health, Cuernavaca, Mexico. 254Department of Global Health and
Infection, Brighton and Sussex Medical School, Brighton, UK. 255Division of Cardiology, Atlanta Veterans Affairs Medical Center, Decatur, GA, USA.
256School of Nutrition, Food Science and Technology, Hawassa University, Hawassa, Ethiopia. 257School of Nursing and Midwifery, Haramaya University,
Harar, Ethiopia. 258Centre for Atmospheric Sciences, Indian Institute of Technology Delhi, New Delhi, India. 259Department of Community Medicine,
University of Peradeniya, Peradeniya, Sri Lanka. 260Mathematical Demography and Statistics, International Institute for Population Sciences, Mumbai, India.
261Health Research Section, Nepal Health Research Council, Kathmandu, Nepal. 262Department of Microbiology, Far Western University, Mahendranagar,
Nepal. 263Department of Epidemiology, Shiraz University of Medical Sciences, Shiraz, Iran. 264Center of Complexity Sciences, National Autonomous
University of Mexico, Mexico City, Mexico. 265Facultad de Medicina Veterinaria y Zootecnia, Autonomous University of Sinaloa, Culiacan, Mexico.
266Department of Nursing, Bank Melli, Tehran, Iran. 267Fenot Project, Harvard University, Addis Ababa, Ethiopia. 268Ministry of Health and Medical
Education, Tehran, Iran. 269Center of Excellence in Public Health Nutrition, Nguyen Tat Thanh University, Ho Chi Minh, Vietnam. 270Center of Excellence in
Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam. 271School of Nursing and Midwifery, University of Cape Coast, Cape Coast,
Ghana. 272Iran University of Medical Sciences, Tehran, Iran. 273Department of Health Policy and Economy, Tabriz University of Medical Sciences, Tabriz,
Iran. 274World Food Programme, New Delhi, India. 275Public Health Department, Hawassa University, Hawassa, Ethiopia. 276Curtin University, Perth,
Western Australia, Australia. 277Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK. 278Mahidol-Oxford Tropical Medicine
Research Unit, Bangkok, Thailand. 279Postgraduate Program in Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil. 280School of
Medicine, Federal University of Bahia, Salvador, Brazil. 281Medicina Interna, Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil. 282Department of
Bacteriology and Virology, Tabriz University of Medical Sciences, Tabriz, Iran. 283Department of Pharmacology and Toxicology, Maragheh University of
Medical Sciences, Maragheh, Iran. 284Department of Pharmacology and Toxicology, Tabriz University of Medical Sciences, Tabriz, Iran. 285Biomedical
Informatics and Medical Statistics, Alexandria University, Alexandria, Egypt. 286Department of Clinical Pathology, Mansoura University, Mansoura, Egypt.
287Pediatric Dentistry and Dental Public Health, Alexandria University, Alexandria, Egypt. 288Institute of Public Health, United Arab Emirates University, Al
Ain, United Arab Emirates. 289Department of Statistics, Debre Markos University, Debre Markos, Ethiopia. 290Department of Public Health Sciences,
Karolinska Institutet, Stockholm, Sweden. 291World Health Programme, Université du Québec en Abitibi-Témiscamingue, Rouyn-Noranda, Quebec, Canada.
292Endemic Medicine and Hepatogastroentrology Department, Cairo University, Cairo, Egypt. 293Department of Biosciences, Nottingham Trent University,
Nottingham, UK. 294Eijkman-Oxford Clinical Research Unit, Eijkman Institute for Molecular Biology, Jakarta, Indonesia. 295Ophthalmic Epidemiology
Research Center, Shahroud University of Medical Sciences, Shahroud, Iran. 296Department of Microbiology and Immunology, Suez Canal University,
Ismailia, Egypt. 297Department of Midwifery, Wolkite University, Wolkite, Ethiopia. 298Department of Midwifery, Woldia University, Woldia, Ethiopia.
299Department of Medicinal Chemistry, Kerman University of Medical Sciences, Kerman, Iran. 300Pharmaceutics Research Center, Kerman University of
Medical Sciences, Kerman, Iran. 301Multiple Sclerosis Research Center, Tehran University of Medical Sciences, Tehran, Iran. 302Department of Physiology,
Tarbiat Modares University, Tehran, Iran. 303Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA. 304Tehran
University of Medical Sciences, Tehran, Iran. 305Unit of Medical Physiology, Hawassa University, Hawassa, Ethiopia. 306Berman Institute of Bioethics, Johns
Hopkins University, Baltimore, MD, USA. 307 Nutrition and Food Systems Division, Food and Agriculture Organization of the United Nations, Rome, Italy.
308School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. 309Department of Political Science, University of Human Development,
Sulaimaniyah, Iraq. 310Deputy of Research and Technology, Hamadan University of Medical Sciences, Hamadan, Iran. 311College of Medicine, Imam
Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia. 312Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
313Department of Psychology, Federal University of Sergipe, Sao Cristovao, Brazil. 314Department of Biological and Biomedical Sciences, Aga Khan
University, Karachi, Pakistan. 315College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia. 316Institute of Resource
Governance and Social Change, Kupang, Indonesia. 317Social Determinants of Health Research Center, Hamadan University of Medical Sciences, Hamadan,
Iran. 318Department of Public Health Nutrition, Bahir Dar University, Bahir Dar, Ethiopia. 319School of Nursing and Midwifery, Hawassa University, Hawassa,
Ethiopia. 320Division of Neurology, University of Ottawa, Ottawa, Ontario, Canada. 321REQUIMTE/LAQV - Network of Chemistry and Technology, University
of Porto, Porto, Portugal. 322Center for Biotechnology and Fine Chemistry, Catholic University of Portugal, Porto, Portugal. 323Department of Health
Education & Behavioral Sciences, Jimma University, Jimma, Ethiopia. 3 24Jimma University, Jimma, Ethiopia. 325Psychiatry Department, Kaiser Permanente,
Fontana, CA, USA. 326School of Health Sciences, A.T. Still University, Mesa, AZ, USA. 327 Department of Population Medicine and Health Services Research,
Bielefeld University, Bielefeld, Germany. 328Unit for Population-Based Dermatology Research, King’s College London, London, UK. 329Institute of
Gerontology, National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine. 330Department of Child Dental Health, Obafemi Awolowo University, Ile-Ife,
Nigeria. 331Timiryazev Institute of Plant Physiology (IPPRAS), Russian Academy of Sciences, Moscow, Russia. 332Abadan School of Medical Sciences,
Abadan University of Medical Sciences, Abadan, Iran. 333Department of Research, Center for Population and Health, Wiesbaden, Germany. 334Department
of Family Medicine and Primary Care, University of the Witwatersrand, Johannesburg, South Africa. 335Department of Dermatology, Kobe University, Kobe,
Japan. 336Gene Expression & Regulation Program, The Wistar Institute, Philadelphia, PA, USA. 337School of Nursing and Midwifery, Wollega University,
Nekemte, Ethiopia. 338Public Health Department, Madda Walabu University, Bale-Robe, Ethiopia. 339School of Public Health, Mekelle University, Mekelle,
Ethiopia. 340Department of Nursing and Midwifery, Addis Ababa University, Addis Ababa, Ethiopia. 341Nursing Department, Mekelle University, Mekelle,
Ethiopia. 342Haramaya University, Dire Dawa, Ethiopia. 343Pharmacy, Wollo University, Dessie, Ethiopia. 344Department of Nursing, Arba Minch University,
Arba Minch, Ethiopia. 345Department of Biostatistics, Mekelle University, Mekelle, Ethiopia. 346Department of Parasitology and Entomology, Tarbiat
Modares University, Tehran, Iran. 347Department of Medical Surgery, Tabriz University of Medical Sciences, Tabriz, Iran. 348Department of Medicine,
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Massachusetts General Hospital, Boston, MA, USA. 349Neuroscience Institute, Academy of Medical Science, Tehran, Iran. 350Department of Health
Services Management, Iran University of Medical Sciences, Tehran, Iran. 351Social Determinants of Health Research Center, University of Social Welfare and
Rehabilitation Sciences, Tehran, Iran. 352Science and Research Branch, Islamic Azad University, Tehran, Iran. 353Young Researchers and Elite Club, Islamic
Azad University, Rasht, Iran. 354University of Lahore, Lahore, Pakistan. 355Afro-Asian Institute, Lahore, Pakistan. 356Adelaide Medical School, University of
Adelaide, Adelaide, South Australia, Australia. 357Department of Family and Community Medicine, University of Hail, Hail, Saudi Arabia. 358Center for the
Study of Regional Development, Jawahar Lal Nehru University, New Delhi, India. 359Department of Chemistry, University of Porto, Porto, Portugal.
360Department of Biostatistics and Epidemiology, University of Oklahoma, Oklahoma City, OK, USA. 361Department of Health and Social Affairs,
Government of the Federated States of Micronesia, Palikir, Federated States of Micronesia. 362Department of Respiratory Medicine, Hokkaido University,
Sapporo, Japan. 363Center for Environmental and Health Sciences, Hokkaido University, Sapporo, Japan. 364Center for Clinical and Epidemiological Research,
University of São Paulo, Sao Paulo, Brazil. 365Internal Medicine Department, University of São Paulo, São Paulo, Brazil. 366Manipal Institute of Virology,
Manipal Academy of Higher Education, Manipal, India. 367Department of Dermatology, Boston University, Boston, MA, USA. 368Instituto de Patologia
Tropical e Saúde Pública, Federal University of Goiás, Goiânia, Brazil. 369College of Medicine and Health Science, Jigjiga University, Jigjiga, Ethiopia.
370Department of Epidemiology and Biostatistics, Zhengzhou University, Zhengzhou, China. 371March of Dimes, Arlington, VA, USA. 372School of Public
Health, West Virginia University Morgantown, Morgantown, WV, USA. 373Academics and Research Department, Rajasthan University of Health Sciences,
Jaipur, India. 374Department of Medicine, Mahatma Gandhi University of Medical Sciences & Technology, Jaipur, India. 375Department of Radiology and
Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA. 376School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
377Department of Nursing, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia. 378Department of Pharmacology, Tehran University of
Medical Sciences, Tehran, Iran. 379Obesity Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 380Global and Community Mental
Health Research Group, University of Macau, Macao, China. 381Department of Anatomical Sciences, Tarbiat Modares University, Tehran, Iran.
382Department of Family and Community Medicine, Arabian Gulf University, Manama, Bahrain. 383Department of Health Management and Economics,
Hamadan University of Medical Sciences, Hamadan, Iran. 384School of Medicine, University of Western Australia, Perth, Western Australia, Australia.
385Neurology Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia. 386Tabriz University of Medical Sciences, Tabriz, Iran.
387Department of Dental Public Health, Universitas Airlangga Indonesia, Surabaya, Indonesia. 388Australian Research Centre for Population Oral Health,
University of Adelaide, Adelaide, South Australia, Australia. 389Department of Zoology, Al-Azhar University, Cairo, Egypt. 390Institute for Social Science
Research, The University of Queensland, Indooroopilly, Queensland, Australia. 391Department of Healthcare Management, Maragheh University of Medical
Sciences, Maragheh, Iran. 392Department of Microbiology, Maragheh University of Medical Sciences, Maragheh, Iran. 393Department of Microbiology,
Tehran University of Medical Sciences, Tehran, Iran. 394Department of Biology, Utica College, Utica, NY, USA. 395Gastrointestinal and Liver Disease
Research Center, Guilan University of Medical Sciences, Rasht, Iran. 396Guilan University of Medical Sciences, Rasht, Iran. 397Department of Public Health,
Mizan-Tepi University, Tepi, Ethiopia. 398Unit of Epidemiology and Social Medicine, University Hospital Antwerp, Wilrijk, Belgium. 399Department of Clinical
Sciences, Karolinska University Hospital, Stockholm, Sweden. 400School of Health Sciences, City University of London, London, UK. 401Institute of
Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan. 402Department of Pharmacy Administration and Clinical
Pharmacy, Xian Jiaotong University, Xian, China. 403Shahrekord University of Medical Sciences, Shahrekord, Iran. 404School of Public Health, Curtin
University, Perth, Western Australia, Australia. 405Agriculture and Food, Commonwealth Scientific and Industrial Research Organisation, St. Lucia,
Queensland, Australia. 406Medical Biology Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran. 407Department of Biostatistics
and Epidemiology, Adigrat University, Adigrat, Ethiopia. 408Department of Psychiatry, University Medical Center Groningen, Groningen, the Netherlands.
409Department of Epidemiology, Columbia University, New York, NY, USA. 410Department of Pediatrics, Dell Medical School, University of Texas Austin,
Austin, TX, USA. 411Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India. 412Guilan Road Trauma Research Center, Guilan
University of Medical Sciences, Rasht, Iran. 413Social Determinants of Health Research Center, Guilan University of Medical Sciences, Rasht, Iran.
414Department of Pediatrics, Yonsei University, Seoul, South Korea. 415Research Department, Electronic Medical Records for the Developing World, York,
UK. 416Transdisciplinary Centre for Qualitative Methods, Manipal Academy of Higher Education, Manipal, India. 417Nevada Division of Public and Behavioral
Health, Carson City, NV, USA. 418Department of Pharmacology and Therapeutics, Dhaka Medical College, Dhaka, Bangladesh. 419Department of
Pharmacology, Bangladesh Industrial Gases Limited, Tangail, Bangladesh. 420Department of Epidemiology and Biostatistics, Tehran University of Medical
Sciences, Tehran, Iran. 421Department of Computer Engineering, Islamic Azad University, Tehran, Iran. 422Computer Science Department, University of
Human Development, Sulaymaniyah, Iraq. 423Department of General Surgery, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
424Department of Internal Medicine, Bucharest Emergency Hospital, Bucharest, Romania. 425Faculty of Dentistry, Department of Legal Medicine and
Bioethics, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. 426Clinical Legal Medicine Department, National Institute of
Legal Medicine, Bucharest, Romania. 427College of Science and Engineering, Hamad Bin Khalifa University, Doha, Qatar. 428Medicine School of
Tunis, Baab Saadoun, Tunisia. 429Department of Epidemiology and Health Statistics, Central South University, Changsha, China. 430School of Public Health,
University of Sydney, Sydney, New South Wales, Australia. 431Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research,
Dhaka, Bangladesh. 432Department of Public Health and Community Medicine, Shaikh Khalifa Bin Zayed Al-Nahyan Medical College at Shaikh Zayed
Medical Complex, Lahore, Pakistan. 433Department of Occupational Safety and Health, China Medical University, Taichung, Taiwan. 434Department of
Epidemiology, University of Kragujevac, Kragujevac, Serbia. 435Department of Public Health, Lorestan University of Medical Sciences, Khorramabad, Iran.
436Department of Family Medicine, Bangalore Baptist Hospital, Bangalore, India. 437Global Health and Development Department, Taipei Medical University,
Taipei City, Taiwan. 438Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 439Institute for Physical
Activity and Nutrition, Deakin University, Burwood, Victoria, Australia. 440Sydney Medical School, University of Sydney, Sydney, New South Wales,
Australia. 441School of Health Systems and Public Health, University of Pretoria, Hatfield, South Africa. 442Cochrane Center, South African Medical Research
Council, Parow Valley, South Africa. 443Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa. 444Department of
Epidemiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 445Department of Environmental Health Engineering, Guilan University of
Medical Sciences, Rasht, Iran. 446Medical Research Council South Africa, Cape Town, South Africa. 447Centre for Evidence Based Health Care, Stellenbosch
University, Cape Town, South Africa. 448Department of Immunology, Tabriz University of Medical Sciences, Tabriz, Iran. 449Department of Psychosis, Babol
Noshirvani University of Technology, Babol, Iran. 450Department of Immunology, Isfahan University of Medical Sciences, Isfahan, Iran. 451Department for
Health Care and Public Health, Sechenov First Moscow State Medical University, Moscow, Russia. 452Department of Psychiatry, Kermanshah University of
Medical Sciences, Kermanshah, Iran. 453Social Development & Health Promotion Research Center, Kermanshah University of Medical Sciences,
Kermanshah, Iran. 454Kermanshah University of Medical Sciences, Kermanshah, Iran. 455Institute of Medicine, University of Colombo, Colombo, Sri Lanka.
456University of Colombo, Colombo, Sri Lanka. 457Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and
Technology, Trivandrum, India. 458Department of Pediatrics & Child Health, Aga Khan University, Karachi, Pakistan. 459Autism Spectrum Disorders Research
Center, Hamadan University of Medical Sciences, Hamadan, Iran. 460Department of Community Medicine, Banaras Hindu University, Varanasi, India.
461Manipal Academy of Higher Education, Manipal, India. 462The George Institute for Global Health, University of New South Wales, New Delhi, India.
463Environmental Research Center, Duke Kunshan University, Kunshan, China. 464Nicholas School of the Environment, Duke University, Durham, NC, USA.
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465Department of Earth Observation Science, University of Twente, Enschede, the Netherlands. 466Department of Ophthalmology, Heidelberg University,
Mannheim, Germany. 467Beijing Ophthalmology & Visual Science Key Laboratory, Beijing Tongren Hospital, Beijing, China. 468Department of Community
Medicine, Manipal Academy of Higher Education, Mangalore, India. 469Department of Family Medicine and Public Health, University of Opole, Opole,
Poland. 470School of Health Sciences, Savitribai Phule Pune University, Pune, India. 471 Institute of Family Medicine and Public Health, University of Tartu,
Tartu, Estonia. 472 Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran. 473School of Public Health, University
College Cork, Cork, UK. 474Infectious Diseases Research Center, Golestan University of Medical Sciences, Gorgan, Iran. 475Department of Medical
Informatics, Tabriz University of Medical Sciences, Tabriz, Iran. 476 Health Services Management Department, School of Health Qazvin University of
Medical Sciences Qazvin, Qazvin, Iran. 477Community Medicine Department, Rafsanjan University of Medical Sciences, Iran, Rafsanjan, Iran. 47 8Department
of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Jodhpur, India. 479All India Institute of Medical Sciences, New Delhi, India.
480Department of Epidemiology, Hamadan University of Medical Sciences, Hamadan, Iran. 481Institute for Epidemiology and Social Medicine, University of
Münster, Münster, Germany. 482Research and Development, Australian Red Cross Blood Service, Sydney, New South Wales, Australia. 483Hematology-
Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran. 484Pars Advanced and Minimally Invasive
Medical Manners Research Center, Iran University of Medical Sciences, Tehran, Iran. 485Clinical Pharmacy Unit, Mekelle University, Mekelle, Ethiopia.
486Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA. 487Department of Public Health, Kermanshah University
of Medical Sciences, Kermanshah, Iran. 488Non-Communicable Diseases Research Unit, Medical Research Council South Africa, Cape Town, South Africa.
489Department of Medicine, University of Cape Town, Cape Town, South Africa. 490 Department of Public Health, Debre Markos University, Debre Markos,
Ethiopia. 491Department of Public Health, Jordan University of Science and Technology, Irbid, Jordan. 492Social Determinants of Health Research Center,
Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. 493Department of Physiology, Lorestan University of Medical Sciences, Khorramabad, Iran.
494School of Food and Agricultural Sciences, University of Management and Technology, Lahore, Pakistan. 495Department of Physiology, Baku State University,
Baku, Azerbaijan. 496School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia. 4 97Epidemiology and
Biostatistics Department, Health Services Academy, Islamabad, Pakistan. 498Department of Population Sciences, Jatiya Kabi Kazi Nazrul Islam University,
Mymensingh, Bangladesh. 499Department of Public Health, University of Newcastle, Newcastle, New South Wales, Australia. 500Department of Hospital
Medicine, Miriam Hospital, Brown University, Providence, RI, USA. 501Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County,
Chicago, IL, USA. 502Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan. 503Faculty of Health and Wellbeing,
Sheffield Hallam University, Sheffield, UK. 504College of Arts and Sciences, Ohio University, Zanesville, OH, USA. 505Internal Medicine and
Gastroenterology Department, National Hepatology and Tropical Research Institute, Cairo, Egypt. 506Department of Medical Parasitology, Cairo University,
Cairo, Egypt. 507Division of Evidence Synthesis, Datta Meghe Institute of Medical Sciences, Wardha, India. 508Cancer Research Center, Shahid Beheshti
University of Medical Sciences, Tehran, Iran. 509Academy of Medical Science, Tehran, Iran. 510Department of Public Health, Mazandaran University of
Medical Sciences, Sari, Iran. 511Department of Biostatistics, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 512Department of Neurosurgery,
Iran University of Medical Sciences, Tehran, Iran. 513Oxford University Global Surgery Group, University of Oxford, Oxford, UK. 514Clinical Epidemiology Unit,
Lund University, Lund, Sweden. 515Research and Data Solutions, Synotech Consultant, Nairobi, Kenya. 516School of Medicine, Xiamen University Malaysia,
Sepang, Malaysia. 517Department of Nutrition, Simmons University, Boston, MA, USA. 518School of Health Sciences, Kristiania University College, Oslo,
Norway. 519Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway. 520Department of Public Health, Ambo University,
Ambo, Ethiopia. 521Neurophysiology Research Center, Hamadan University of Medical Sciences, Hamadan, Iran. 522Brain Engineering Research Center,
Institute for Research in Fundamental Sciences, Tehran, Iran. 523Department of Public Health Dentistry, Deemed University, Karad, India. 524Department of
Environmental Health Engineering, Arak University of Medical Sciences, Arak, Iran. 525Department of Internal and Pulmonary Medicine, , Sheri Kashmir
Institute of Medical Sciences, Srinagar, India. 526CIBERSAM, San Juan de Dios Sanitary Park, Sant Boi de Llobregat, Spain. 527Department of Zoology,
University of Oxford, Oxford, UK. 528Harvard Medical School, Harvard University, Boston, MA, USA. 529Department of Anthropology, Panjab University,
Chandigarh, India. 530Department of Family and Community Health, University of Health and Allied Sciences, Ho, Ghana. 531Department of Psychology and
Health Promotion, University of KwaZulu-Natal, Durban, South Africa. 532Department of Psychiatry, University of Nairobi, Nairobi, Kenya. 533Division of
Psychology and Language Sciences, University College London, London, UK. 534Department of Medicine Brigham and Women’s Hospital, Harvard
University, Boston, MA, USA. 535Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada. 536Institute of
Occupational and Environmental Medicine, University of Birmingham, Birmingham, UK. 537Health and Nutrition Section, United Nations Childrens’ Fund
(UNICEF), Accra, Ghana. 538Clinical Medicine and Community Health, University of Milan, Milano, Italy. 539National Institute for Health Research (NIHR),
Oxford Biomedical Research Centre, Oxford, UK. 540Department of Internal Medicine, Post Graduate Institute of Medical Education and Research,
Chandigarh, India. 541Public Health Foundation of India, Gurugram, India. 542Department of Community and Family Medicine, University of Baghdad,
Baghdad, Iraq. 543School of Medicine, Deakin University, Geelong, Victoria, Australia. 544Health Promotion and Chronic Disease Prevention Branch, Public
Health Agency of Canada, Ottawa, Ontario, Canada. 545HelpMeSee, New York, NY, USA. 546International Relations, Mexican Institute of Ophthalmology,
Queretaro, Mexico. 547Department of Otorhinolaryngology (ENT) & Head and Neck Surgery, Father Muller Medical College, Mangalore, India.
548Department of Information and Internet Technologies, I.M. Sechenov First Moscow State Medical University, Moscow, Russia. 549Federal Research
Institute for Health Organization and Informatics of the Ministry of Health (FRIHOI), Moscow, Russia. 550School of Nursing, Hong Kong Polytechnic
University, Hong Kong, China. 551School of Pharmacy, Monash University, Bandar Sunway, Malaysia. 552School of Pharmacy, Taylor’s University Lakeside
Campus, Subang Jaya, Malaysia. 553Oxford University Clinical Research Unit, Wellcome Trust Asia Programme, Hanoi, Vietnam. 554Department of
Medicine, University of Malaya, Kuala Lumpur, Malaysia. 555Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong,
China. 556School of Public Health, University of Haifa, Haifa, Israel. 557Centre for Chronic Disease Control, Beijing, China. 558Department of Epidemiology,
Brown University, Providence, RI, USA. 559Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India. 560Vector Biology, Liverpool
School of Tropical Medicine, Liverpool, UK. 561Department of Nutrition, University of the Philippines Manila, Manila, Philippines. 562Alliance for Improving
Health Outcomes, Inc., Quezon City, Philippines. 563Institute of Nutrition, Friedrich Schiller University Jena, Jena, Germany. 564Competence Cluster for
Nutrition and Cardiovascular Health (nutriCARD), Jena, Germany. 565Ariadne Labs, Harvard University, Boston, MA, USA. 566Development and
Communication Studies, University of the Philippines Los Baños, Laguna, Philippines. 567Pathology Department, Imam Abdulrahman Bin Faisal University,
Dammam, Saudi Arabia. 568Radiology Department, Mansoura University Hospital, Mansoura, Egypt. 569Ophthalmology Department, Aswan Faculty of
Medicine, Aswan, Egypt. 570Department of Internal Medicine, Grant Medical College & Sir J.J. Group of Hospitals, Mumbai, India. 571Institute of Medicine,
Tribhuvan University, Kathmandu, Nepal. 572Health Education and Research Department, SDM College of Medical Sciences & Hospital, Dharwad, India.
573Health University, Rajiv Gandhi University of Health Sciences, Bangalore, India. 574Environmental Health Research Center, Kurdistan University of
Medical Sciences, Sanandaj, Iran. 575Clinical Research Development Center, Kermanshah University of Medical Sciences, Kermanshah, Iran. 576Department
of Maternal and Child Nursing and Public Health, Federal University of Minas Gerais, Belo Horizonte, Brazil. 577Plastic Surgery Department, Iran University
of Medical Sciences, Tehran, Iran. 578Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada. 579Ophthalmology Department, Iran
University of Medical Sciences, Tehran, Iran. 580Ophthalmology Department, University of Manitoba, Winnipeg, Manitoba, Canada. 581School of Science
and Health, Western Sydney University, Sydney, New South Wales, Australia. 582Substance Abuse Prevention Research Center, Kermanshah University of
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Medical Sciences, Kermanshah, Iran. 583Department of Population Studies, University of Zambia, Lusaka, Zambia. 584Research Department, Grupo de
Investigación Fundovida - Fundovida IPS, Cartagena, Colombia. 585Grupo de Investigación en Economía dela Salud, University of Cartagena, Cartagena,
Colombia. 586Campus Caucaia, Federal Institute of Education, Science and Technology of Ceará, Caucaia, Brazil. 587Public Health Department, Botho
University-Botswana, Gaborone, Botswana. 588Division of Plastic Surgery, University of Washington, Seattle, WA, USA. 589Research Department, The
George Institute for Global Health, New Delhi, India. 590School of Medicine, University of New South Wales, Sydney, New South Wales, Australia. 591ICF
International, DHS Program, Rockville, MD, USA. 592Department of Twin Research and Genetic Epidemiology, King’s College London, London, UK.
593Neurology Department, Janakpuri Super Specialty Hospital Society, New Delhi, India. 594Neurology Department, Govind Ballabh Institute of Medical
Education and Research, New Delhi, India. 595Pharmacology and Toxicology, Hamadan University of Medical Sciences, Hamadan, Iran. 596 Department of
Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA. 597Public Health and Mortality, International Institute for
Population Sciences, Mumbai, India. 598Department of Nutrition, University of Oslo, Oslo, Norway. 599Mekelle University, Mekelle, Ethiopia. 600Peru Country
Office, United Nations Population Fund (UNFPA), Lima, Peru. 601Forensic Medicine Division, Imam Abdulrahman Bin Faisal University, Dammam, Saudi
Arabia. 602Department of Midwifery, Adigrat University, Adigrat, Ethiopia. 603Center for Translation Research and Implementation Science, National
Institutes of Health, Bethesda, MD, USA. 604Breast Surgery Unit, Helsinki University Hospital, Helsinki, Finland. 605University of Helsinki, Helsinki, Finland.
606Department of Propedeutics of Internal Diseases & Arterial Hypertension, Pomeranian Medical University, Szczecin, Poland. 607Health Policy and
Management, Centre for Regional Policy Research and Cooperation ‘Studiorum’, Skopje, Macedonia. 608Pacific Institute for Research & Evaluation,
Calverton, MD, USA. 609Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada. 610Global
Institute of Public Health (GIPH), Ananthapuri Hospitals and Research Centre, Trivandrum, India. 611Department of Clinical Biochemistry, Babol University
of Medical Sciences, Babol, Iran. 612Golestan University of Medical Sciences, Gorgan, Iran. 613Department of Environmental Health, Sabzevar University of
Medical Sciences, Sabzevar, Iran. 614Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases,
Shahid Beheshti University of Medical Sciences, Tehran, Iran. 615Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan. 616Department of Atherosclerosis and
Coronary Heart Disease, National Center of Cardiology and Internal Disease, Bishkek, Kyrgyzstan. 617Research Center for Biochemistry and Nutrition in
Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran. 618Department of Rehabilitation and Sports Medicine, Kermanshah University of
Medical Sciences, Kermanshah, Iran. 619Deputy of Social Health, Iran University of Medical Sciences, Tehran, Iran. 620Health Equity Research Center, Tehran
University of Medical Sciences, Tehran, Iran. 621Social Determinants of Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran.
622Research Center, Salahaddin University, Erbil, Iraq. 623Internal Medicine Department, King Saud University, Riyadh, Saudi Arabia. 624Department of Food
Technology, Salahaddin University, Erbil, Iraq. 625Department of Medicine, Karolinska Institutet, Stockholm, Sweden. 6 26Department of Information
Technology, University of Human Development, Sulaymaniyah, Iraq. 627Department of Biostatistics, Hamadan University of Medical Sciences, Hamadan,
Iran. 628Department of Epidemiology and Biostatistics, Shahrekord University of Medical Sciences, Shahrekord, Iran. 629Department of Immunology, Babol
University of Medical Sciences, Babol, Iran. 630Clinical Biochemistry, Tarbiat Modares University, Tehran, Iran. 631Department of Nursing, Shahroud
University of Medical Sciences, Shahroud, Iran. 632Department of Biomolecular Sciences, University of Mississippi, Oxford, MS, USA. 633Department of
Pharmacy, Mizan-Tepi University, Mizan, Ethiopia. 634Health Systems and Policy Research Unit, Ahmadu Bello University, Zaria, Nigeria. 635School of
Pharmacy, Haramaya University, Harar, Ethiopia. 636Iran National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Iran.
637Community Nutrition, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 638Health Systems Research Center, National Health Research
Institutes, Cuernavaca, Mexico. 639Department of Public Health Sciences, University of Miami, Miami, FL, USA. 640Department of Public Health Medicine,
University of KwaZulu-Natal, Durban, South Africa. 641Department of Molecular Medicine, Birjand University of Medical Sciences, Birjand, Iran.
642Department of Epidemiology and Biostatistics, Kurdistan University of Medical Sciences, Sanandaj, Iran. 643Department of Epidemiology, Iran University
of Medical Sciences, Tehran, Iran. 644Department of Economics and Management Sciences for Health, Tehran University of Medical Sciences, Tehran, Iran.
645Department of Mathematical Sciences, University of Bath, Bath, UK. 646Department of Surgery, University of Washington, Seattle, WA, USA.
647Department of Clinical Biochemistry, Tarbiat Modares University, Tehran, Iran. 648Food Science, University of Campinas, Campinas, Brazil. 649Friedman
School of Nutrition Science and Policy, Tufts University, Boston, MA, USA. 650Federal Institute for Population Research, Wiesbaden, Germany. 651Center for
Population and Health, Wiesbaden, Germany. 652Indian Institute of Public Health - Hyderabad, Public Health Foundation of India, Hyderabad, India.
653School of Medical Sciences, Science University of Malaysia, Kubang Kerian, Malaysia. 654Department of Pediatric Medicine, Nishtar Medical University,
Multan, Pakistan. 655Department of Pediatrics & Pediatric Pulmonology, Institute of Mother & Child Care, Multan, Pakistan. 656Department of Microbiology
and Immunology, Mekelle University, Mekelle, Ethiopia. 657Department of Urology, Tehran University of Medical Sciences, Tehran, Iran. 658Department of
Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA. 659Research and Analytics, Initiative for Financing Health and Human
Development, Chennai, India. 660Research and Analytics, Bioinsilico Technologies, Chennai, India. 661Initiative for Non Communicable Diseases,
International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh. 662Comprehensive Cancer Center, University of Alabama at Birmingham,
Birmingham, AL, USA. 663Department of Epidemiology & Biostatistics, Kermanshah University of Medical Sciences, Kermanshah, Iran. 664Department of
Disease, Epidemics, and Pandemics Control, Ministry of Public Health, Yaoundé, Cameroon. 665Department of Public Heath, University of Yaoundé I,
Yaoundé, Cameroon. 666Hospital of the Federal University of Minas Gerais, Federal University of Minas Gerais, Belo Horizonte, Brazil. 667Department of
Pediatrics, Arak University of Medical Sciences, Arak, Iran. 668Iranian Ministry of Health and Medical Education, Tehran, Iran. 669General Surgery, Emergency
Hospital of Bucharest, Bucharest, Romania. 670Anatomy and Embryology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
671Cardiology, Cardio-Aid, Bucharest, Romania. 672Department of Biological Sciences, University of Embu, Embu, Kenya. 673 Institute for Global Health
Innovations, Duy Tan University, Hanoi, Vietnam. 674Institute of Mental Health Research, University of Ottawa, Ottawa, Ontario, Canada. 675Department of
Clinical Epidemiology, Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada. 676Department of Pharmacology of Tehran University of Medical
Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 677Heidelberg University Hospital, Heidelberg, Germany. 678Public Health
Department, Universitas Negeri Semarang, Kota Semarang, Indonesia. 679Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei
City, Taiwan. 680School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa. 681Department of Neurobiology, Care
Sciences and Society (NVS), H1, Division of Family Medicine and Primary Care, Karolinska Institutet, Huddinge, Sweden. 682Administrative and Economic
Sciences, University of Bucharest, Bucharest, Romania. 683Centre of Cardiovascular Research and Education in Therapeutics, Monash University,
Melbourne, Victoria, Australia. 684Independent Consultant, Accra, Ghana. 685Department Obstetrics and Gynecology, University of Ibadan, Ibadan, Nigeria.
686Department of Preventive Medicine, Kyung Hee University, Dongdaemun-gu, South Korea. 687HAST, Human Sciences Research Council, Durban, South
Africa. 688School of Public Health, University of Namibia, Osakhati, Namibia. 689Department of Medical Genetics, School of Advanced Technologies in
Medicine, Golestan University of Medical Sciences, Gorgan, Iran. 690Department of Psychiatry and Behavioural Neurosciences, McMaster University,
Hamilton, Ontario, Canada. 691Department of Psychiatry, University of Lagos, Lagos, Nigeria. 692Centre for Healthy Start Initiative, Lagos, Nigeria. 693Centre
for Healthy Start Initiative, Phonics Hearing Centre, Lagos, Nigeria. 694Public Health and School of Graduates Studies, Jigjiga University, Jig-Jiga, Ethiopia.
695Department of Pharmacology and Therapeutics, University of Nigeria Nsukka, Enugu, Nigeria. 696Department of Psychology, University of Ghana, Accra,
Ghana. 697Graduate School of Public Health, San Diego State University, San Diego, CA, USA. 698University of Washington, Seattle, WA, USA. 699University
of Port Harcourt, Port Harcourt, Nigeria. 700School of Medicine, Autonomous University of Madrid, Madrid, Spain. 701Department of Nephrology and
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Hypertension, The Institute for Health Research Foundation Jiménez Díaz University Hospital, Madrid, Spain. 702Department of Environmental
Management and Toxicology, University of Benin, Benin City, Nigeria. 703Institute for Advanced Medical Research and Training, University of Ibadan,
Ibadan, Nigeria. 704Department of Respiratory Medicine, Jagadguru Sri Shivarathreeshwara Academy of Health Education and Research, Mysore, India.
705Department of Forensic Medicine and Toxicology, Manipal Academy of Higher Education, Mangalore, India. 706Department of Medical Mycology and
Parasitology, Shiraz University of Medical Sciences, Shiraz, Iran. 707Center for Health Outcomes & Evaluation, Bucharest, Romania. 708Augenpraxis Jonas,
Heidelberg University, Heidelberg, Germany. 709Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. 710Research and
Evaluation, Population Council, New Delhi, India. 711Indian Institute of Health Management Research University, Jaipur, India. 712Department of Pediatircs,
RD Gardi Medical College, Ujjain, India. 713Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. 714Research & Publication Cell, Kalinga Institute
of Medical Sciences, Bhubaneswar, Bhubaneswar, India. 715Regional Medical Research Centre, Indian Council of Medical Research, Bhubaneswar, India.
716Department of Population Studies, International Institute for Population Sciences, Mumbai, India. 717International Institute of Health Management
Research, New Delhi, India. 718Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia. 719Population Health, Murdoch Childrens
Research Institute, Melbourne, Victoria, Australia. 720Wolaita Sodo University, Sodo, Ethiopia. 721Department of Physiology, Iran University of Medical
Sciences, Tehran, Iran. 722Center for Research and Innovation, Ateneo De Manila University, Pasig City, Philippines. 723Istituto di Ricerche Farmacologiche
Mario Negri IRCCS, Bergamo, Italy. 7 24School of Medicine, University of Virginia, Charlottesville, VA, USA. 725HIV and Mental Health Department,
Integrated Development Foundation Nepal, Kathmandu, Nepal. 726University Medical Center Groningen, University of Groningen, Groningen, the
Netherlands. 727Faculty of Economics and Business, University of Groningen, Groningen, the Netherlands. 728Department of Public Health, Maragheh
University of Medical Sciences, Maragheh, Iran. 729Department of Nutrition and Food Sciences, Maragheh University of Medical Sciences, Maragheh, Iran.
730School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada. 731Paramedic Department, Kermanshah
University of Medical Sciences, Kermanshah, Iran. 732Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
733Fundación Valle del Lili, Cali, Colombia. 734Infectious Diseases, National Institute of Infectious Diseases, Bucuresti, Romania. 735Department of Infectious
Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. 736Health Sciences Department, Muhammadiyah University of
Surakarta, Sukoharjo, Indonesia. 737Biomedical Engineering Department, Amirkabir University of Technology, Tehran, Iran. 738Department of Chemistry,
Sharif University of Technology, Tehran, Iran. 739College of Medicine, University of Central Florida, Orlando, FL, USA. 740College of Graduate Health
Sciences, A.T. Still University, Mesa, AZ, USA. 741Department of Immunology, Mazandaran University of Medical Sciences, Sari, Iran. 742 Molecular and Cell
Biology Research Center, Mazandaran University of Medical Sciences, Sari, Iran. 743Thalassemia and Hemoglobinopathy Research Center, Ahvaz
Jundishapur University of Medical Sciences, Ahvaz, Iran. 744Metabolomics and Genomics Research Center, Tehran University of Medical Sciences, Tehran,
Iran. 745Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran. 746 School of Nursing and Healthcare Professions,
Federation University, Heidelberg, Victoria, Australia. 747National Centre for Farmer Health, Deakin University, Waurn Ponds, Victoria, Australia.
748 Department of Clinical Pediatrics, Sweidi Hospital, Riyadh, Saudi Arabia. 74 9Department of Pediatrics, North-West University, Peshawar, Pakistan.
750Society for Health and Demographic Surveillance, Suri, India. 751Department of Economics, University of Göttingen, Göttingen, Germany. 752Birjand
University of Medical Sciences, Birjand, Iran. 753Department of Pharmacology, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 754University
Institute of Public Health, University of Lahore, Lahore, Pakistan. 75 5Public Health Department, University of Health Sciences, Lahore, Pakistan. 756Policy
Research Institute, Kathmandu, Nepal. 757Institute for Poverty Alleviation and International Development, Yonsei University, Wonju, South Korea.
758Department of Oral Pathology, Srinivas Institute of Dental Sciences, Mangalore, India. 75 9Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador,
Brazil. 760Institute of Public Health, Federal University of Bahia, Salvador, Brazil. 761School of Behavioral Sciences and Mental Health, Tehran Institute of
Psychiatry, Tehran, Iran. 762Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, India. 763Department of Primary Care and Public
Health, Imperial College London, London, UK. 764Academic Public Health Department, Public Health England, London, UK. 765WHO Collaborating Centre
for Public Health Education and Training, Imperial College London, London, UK. 766University College London Hospitals, London, UK. 767School of Health,
Medical and Applied Sciences, Central Queensland University, Sydney, New South Wales, Australia. 768Neurology Department, Sree Chitra Tirunal Institute
for Medical Sciences and Technology, Thiruvananthapuram, India. 769School of Social Sciences and Psychology, Western Sydney University, Penrith, New
South Wales, Australia. 770Translational Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia. 771Brien Holden Vision
Institute, Sydney, New South Wales, Australia. 772Organization for the Prevention of Blindness, Paris, France. 773Network of Immunity in Infection,
Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran. 774 Pediatric Infectious Diseases
Research Center, Mazandaran University of Medical Sciences, Sari, Iran. 775Department of Epidemiology, Birjand University of Medical Sciences, Birjand,
Iran. 776EPIUnit - Public Health Institute University Porto (ISPUP), University of Porto, Porto, Portugal. 777Surgery Department, University of Minnesota,
Minneapolis, MN, USA. 778Surgery Department, University Teaching Hospital of Kigali, Kigali, Rwanda. 779School of Psychology, University of Lincoln,
Lincoln, UK. 780Department of Epidemiology and Biostatistics, Imperial College London, London, UK. 781Department of Clinical Research, Federal University
of Uberlândia, Uberlândia, Brazil. 782Department of Public Health, Wollega University, Nekemte, Ethiopia. 783Public Health Department, Addis Ababa
University, Addis Ababa, Ethiopia. 784Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan,
Iran. 785Infectious Diseases and Tropical Medicine Research Center, Babol University of Medical Sciences, Babol, Iran. 786Centro de Investigación Palmira,
Agrosavia, Palmira, Colombia. 787Department of Ocean Science and Engineering, Southern University of Science and Technology, Shenzhen, China. 788Ain
Shams University, Cairo, Egypt. 789Department of Cardiology, Tehran University of Medical Sciences, Tehran, Iran. 790National Institute for Research in
Environmental Health, Indian Council of Medical Research, Bhopal, India. 791Cardiovascular Research Institute, Isfahan University of Medical Sciences,
Isfahan, Iran. 792Emergency Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 793Department of Health in Disasters and
Emergencies, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 794Department of Psychiatry, All India Institute of Medical Sciences, New Delhi,
India. 795Halal Research Center of IRI, FDA, Tehran, Iran. 796Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad,
Iran. 797Nanobiotechnology Center, Soran University, Soran, Iraq. 798Department of Anatomical Sciences, Kermanshah University of Medical Sciences,
Kermanshah, Iran. 799Department of Pathology, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia. 800Taleghani Hospital, Kermanshah
University of Medical Sciences, Kermanshah, Iran. 801Radiology and Nuclear Medicine Department, Kermanshah University of Medical Sciences,
Kermanshah, Iran. 802Taleghani Hospital, Kermanshah, Iran. 803Urology Department, Cairo University, Cairo, Egypt. 804Public Health and Community
Medicine, Cairo University, Giza, Egypt. 805Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. 806Department of Entomology,
Ain Shams University, Cairo, Egypt. 807Department of Internal Medicine, University of São Paulo, São Paulo, Brazil. 808Department of Infectious Diseases
and Tropical Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil. 809Department of Community Medicine, PSG Institute of Medical
Sciences and Research, Coimbatore, India. 810PSG-FAIMER, South Asia Regional Institute, Coimbatore, India. 811Health Economics and Financing Research
Group, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh. 812Faculty of Infectious and Tropical Diseases, London School
of Hygiene & Tropical Medicine, London, UK. 813Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran. 814Surgery Department,
Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar. 815Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, UK.
816UGC Centre of Advanced Study in Psychology, Utkal University, Bhubaneswar, India. 817Udyam-Global Association for Sustainable Development,
Bhubaneswar, India. 818Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa. 819Unit for Hypertension and
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Cardiovascular Disease, South African Medical Research Council, Cape Town, South Africa. 820Department of Psychology, University of Alabama at
Birmingham, Birmingham, AL, USA. 821Department of Food Science and Nutrition, Jigjiga University, Jigjiga, Ethiopia. 822Emergency Department, Manian
Medical Centre, Erode, India. 823Microbiology Service, National Institutes of Health, Bethesda, MD, USA. 8 24Department of Health Promotion and
Education, Alborz University of Medical Sciences, Karaj, Iran. 825Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
826Independent Consultant, Karachi, Pakistan. 827Department of Neuropsychiatry, Ain Shams University, Cairo, Egypt. 828School of Medicine, Alborz
University of Medical Sciences, Karaj, Iran. 829Medical Laboratory Sciences, Mazandaran University of Medical Sciences, Sari, Iran. 830Chronic Diseases
(Home Care) Research Center, , Hamadan University of Medical Sciences, Hamadan, Iran. 831Department of Development Studies, International Institute
for Population Sciences, Mumbai, India. 832Department of Basic Sciences, Islamic Azad University, Sari, Iran. 833Department of Laboratory Sciences, Islamic
Azad University, Sari, Iran. 834University School of Management and Entrepreneurship, Delhi Technological University, New Delhi, India. 835Department of
Health Information Management and Informatics, Iran University of Medical Sciences, Tehran, Iran. 836Institute for Population Health, King’s College
London, London, UK. 837National Institute of Infectious Diseases, Tokyo, Japan. 838College of Medicine, Yonsei University, Seodaemun-gu, South Korea.
839Division of Cardiology, Emory University, Atlanta, GA, USA. 840Finnish Institute of Occupational Health, Helsinki, Finland. 841Cancer Research Institute,
Tehran University of Medical Sciences, Tehran, Iran. 842Cancer Biology Research Center, Tehran University of Medical Sciences, Tehran, Iran. 843Institute of
Medical Epidemiology, Martin Luther University Halle-Wittenberg, Halle, Germany. 844Department of Health Education & Promotion, Kermanshah
University of Medical Sciences, Kermanshah, Iran. 845School of Health, University of Technology Sydney, Sydney, New South Wales, Australia.
846Department of Psychology, Reykjavik University, Reykjavik, Iceland. 847Department of Health and Behavior Studies, Columbia University, New York, NY,
USA. 848Department of Physical Education, Federal University of Santa Catarina, Florianopolis, Brazil. 849Department of Law, Economics, Management and
Quantitative Methods, University of Sannio, Benevento, Italy. 850Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania,
Australia. 851Global Patient Outcome and Real World Evidence, Eli Lilly and Company, Indianapolis, IN, USA. 852Department of Humanities and Social
Sciences, Indian Institute of Technology, Roorkee, Roorkee, India. 853Department of Pulmonary Medicine, Asthma Bhawan, Jaipur, India. 854Department of
Medicine, University of Alabama at Birmingham, Birmingham, AL, USA. 855Medicine Service, US Department of Veterans Affairs, Birmingham, AL, USA.
856Department of Forensic Medicine, Kathmandu University, Dhulikhel, Nepal. 857 Department of Epidemiology, School of Preventive Oncology, Patna, India.
858Department of Epidemiology, Healis Sekhsaria Institute for Public Health, Mumbai, India. 859Department of Midwifery, Haramaya University, Harar,
Ethiopia. 860Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, Denmark. 861Medical Surgical
Nursing Department, Urmia University of Medical Science, Urmia, Iran. 862Emergency Nursing Department, Semnan University of Medical Sciences,
Semnan, Iran. 863Midwifery Department, Hamadan University of Medical Sciences, Hamadan, Iran. 864Research Center for Environmental Determinants of
Health, Academy of Medical Science, Kermanshah, Iran. 865Hospital Universitario dela Princesa, Autonomous University of Madrid, Madrid, Spain.
866Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Madrid, Spain. 867Department of Research Development, Federal
Research Institute for Health Organization and Informatics of the Ministry of Health (FRIHOI), Moscow, Russia. 868Laboratory of Public Health Indicators
Analysis and Health Digitalization, Moscow Institute of Physics and Technology, Moscow, Russia. 869Hull York Medical School, University of Hull, Hull City,
UK. 870Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK. 871Department of Parasitology and Mycology,
Tabriz University of Medical Sciences, Tabriz, Iran. 872Division of Community Medicine, International Medical University, Kuala Lumpur, Malaysia.
873Research Management, Policy, Planning and Coordination, Indian Council of Medical Research, New Delhi, India. 874 Clinical Department, Nutrition and
Dietetics Department, Federal Research Institute of Nutrition, Biotechnology and Food Safety, Moscow, Russia. 875Department of Internal Disease, Pirogov
Russian National Research Medical University, Moscow, Russia. 876Department of Nursing, Muhammadiyah University of Surakarta, Surakarta, Indonesia.
877Department of Public Health, China Medical University, Taichung City, Taiwan. 878Department of Community Medicine, Ahmadu Bello University, Zaria,
Nigeria. 879Department of Agriculture and Food Systems, University of Melbourne, Melbourne, Victoria, Australia. 880Norwegian Institute of Public Health,
Bergen, Norway. 881Department of Community Health, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania. 882Muhimbili
University of Health and Allied Sciences, Dar Es Salaam, Tanzania. 883Department of Criminology, Law and Society, University of California Irvine, Irvine,
CA, USA. 884Department of Medicine, University of Valencia, Valencia, Spain. 885Carlos III Health Institute, Biomedical Research Networking Center for
Mental Health Network (CiberSAM), Madrid, Spain. 886Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan. 887Department of
Pediatrics, Hawassa University, Hawassa, Ethiopia. 888International Vaccine Institute, Seoul, South Korea. 889Research Center for Molecular Medicine,
Hamadan University of Medical Sciences, Hamadan, Iran. 890School of Pharmacy, Mekelle University, Mekelle, Ethiopia. 891University Institute ‘Egas Moniz’,
Monte da Caparica, Portugal. 892Research Institute for Medicines, University of Lisbon, Lisbon, Portugal. 893Department of Public Health, Adigrat University,
Adigrat, Ethiopia. 894Pharmacognosy, Mekelle University, Mekelle, Ethiopia. 895Department of Pediatrics, King Saud University, Riyadh, Saudi Arabia.
896College of Medicine, Alfaisal University, Riyadh, Saudi Arabia. 897Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University,
Standford, CA, USA. 898Department of Anesthesiology, King Fahad Medical City, Riyadh, Saudi Arabia. 899Department of Endocrinology, Christian Medical
College and Hospital (CMC), Vellore, India. 900Biology Department, Moscow State University, Moscow, Russia. 901HIV/STI Surveillance Research Center,
and WHO Collaborating Center for HIV Surveillance, Kerman University of Medical Sciences, Kerman, Iran. 902Department of Medicine, University of
Calgary, Calgary, Alberta, Canada. 903Department of Pathology and Legal Medicine, University of São Paulo, Ribeirão Preto, Brazil. 904Clinical Epidemiology
and Public Health Research Unit, Burlo Garofolo Institute for Maternal and Child Health, Trieste, Italy. 905Molecular Medicine and Pathology, University of
Auckland, Auckland, New Zealand. 906Clinical Hematology and Toxicology, Military Medical University, Hanoi, Vietnam. 907Department of Neurology, All
India Institute of Medical Sciences, Delhi, India. 908Department of Pharmacy, Stamford University Bangladesh, Dhaka, Bangladesh. 909Gomal Center of
Biochemistry and Biotechnology, Gomal University, Dera Ismail Khan, Pakistan. 910TB Culture Laboratory, Mufti Mehmood Memorial Teaching Hospital
Dera Ismail Khan, Dera Ismail Khan, Pakistan. 911Amity Institute of Biotechnology, Amity University Rajasthan, Jaipur, India. 912Lifestyle Diseases Research
Entity, North-West University, Mmabatho, South Africa. 913Division of Health Sciences, University of Warwick, Coventry, UK. 914Department of
Epidemiology and Biostatistics, Umeå University, Umeå, Sweden. 915Argentine Society of Medicine, Buenos Aires, Argentina. 916Velez Sarsfield Hospital,
Buenos Aires, Argentina. 917Central Research Institute of Cytology and Genetics, Federal Research Institute for Health Organization and Informatics of the
Ministry of Health (FRIHOI), Moscow, Russia. 918Christian Medical College and Hospital (CMC), Vellore, India. 919UKK Institute, Tampere, Finland.
920Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran. 921National AIDS Control Organisation, Ministry of Health, New
Delhi, India. 922Raffles Neuroscience Centre, Raffles Hospital, Singapore, Singapore. 923Yong Loo Lin School of Medicine, National University of Singapore,
Singapore, Singapore. 924Community & Family Medicine, All India Institute of Medical Sciences, Bathinda, India. 925Department of Neurology & Stroke Unit,
Sant’Anna Hospital, Como, Italy. 926Occupational Health Unit, Sant’Orsola Malpighi Hospital, Bologna, Italy. 927Department of Health Care Administration
and Economics, National Research University Higher School of Economics, Moscow, Russia. 928Department of Global Health and Population, Harvard
University, Boston, MA, USA. 929School of Medicine, University of Belgrade, Belgrade, Serbia. 930Department of Pediatric Endocrinology, Mother and Child
Healthcare Institute of Serbia ‘DrVukan Cupic’, Belgrade, Serbia. 931Foundation University Medical College, Foundation University, Islamabad, Pakistan.
932Department of Epidemiology and Biostatistics, Wuhan University, Wuhan, China. 933Demographic Change and Ageing Research Area, Federal Institute
for Population Research, Wiesbaden, Germany. 934Department of Physical Therapy, Naresuan University, Meung District, Thailand. 935Department of
Psychology and Counselling, University of Melbourne, Melbourne, Victoria, Australia. 936Department of Medicine, University of Melbourne, St Albans,
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Victoria, Australia. 937Department of Pharmacology and Toxicology, Mekelle University, Mekelle, Ethiopia. 938Department of Pharmacology, Addis Ababa
University, Addis Ababa, Ethiopia. 939Department of Nursing, Wollo University, Dessie, Ethiopia. 940Department of Orthopaedics, Wenzhou Medical
University, Wenzhou, China. 941School of Medicine, Nanjing University, Nanjing, China. 942Medical Physics Department, Ahvaz Jundishapur University of
Medical Sciences, Ahvaz, Iran. 943Clinical Cancer Research Center, Milad General Hospital, Tehran, Iran. 944Department of Diabetes and Metabolic
Diseases, University of Tokyo, Tokyo, Japan. 945Department of Preventive Medicine, Northwestern University, Chicago, IL, USA. 946School of International
Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada. 947Health Services Management Research Center, Kerman University of
Medical Sciences, Kerman, Iran. 948Department of Health Management, Policy and Economics, Kerman University of Medical Sciences, Kerman, Iran.
949Wolkite University, Wolkite, Ethiopia. 950Centre for Suicide Research and Prevention, University of Hong Kong, Hong Kong, China. 951Department of
Social Work and Social Administration, University of Hong Kong, Hong Kong, China. 952Department of Psychopharmacology, National Center of Neurology
and Psychiatry, Tokyo, Japan. 953Department of Preventive Medicine, Korea University, Seoul, South Korea. 954Department of Sociology, Yonsei University,
Seoul, South Korea. 955Department of Health Policy & Management, Jackson State University, Jackson, MS, USA. 956School of Medicine, Tsinghua
University, Beijing, China. 957Department of Environmental Health, Mazandaran University of Medical Sciences, Sari, Iran. 958Environmental Health,
Academy of Medical Science, Sari, Iran. 959Global Health Institute, Wuhan University, Wuhan, China. 960Social Determinants of Health Research Center,
Ardabil University of Medical Science, Ardabil, Iran. 961Department of Medicine, Monash University, Melbourne, Victoria, Australia. 962Student Research
Committee, Babol University of Medical Sciences, Babol, Iran. 963Department of Community Medicine, Ardabil University of Medical Science, Ardabil, Iran.
964Psychiatry and Psychology Research Center, Tehran University of Medical Sciences, Tehran, Iran. 965Maternal and Child Wellbeing Unit, African
Population Health Research Centre, Nairobi, Kenya. 966Public Health Department, Dilla University, Dilla, Ethiopia. 967School of Public Health, Wuhan
University of Science and Technology, Wuhan, China. 968Hubei Province Key Laboratory of Occupational Hazard Identification and Control, Wuhan
University of Science and Technology, Wuhan, China. 969Department of Preventive Medicine, Wuhan University, Wuhan, China. 970School of Biology and
Pharmaceutical Engineering, Wuhan Polytechnic University, Wuhan, China. e-mail: sihay@uw.edu
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Extended Data Fig. 1 | Prevalence of under-5 childhood overweight in LMICs in 2017 at administrative levels 0, 1, 2, and at 5 × 5-km resolution.
Prevalence of overweight among children under 5 at administrative level 0 (national-level estimates) (a), first administrative unit (b), second
administrative unit (c), and at the 5 × 5-km resolution (d). Maps reflect administrative boundaries, land cover, lakes, and population; grey-coloured grid
cells were classified as “barren or sparsely vegetated” and had fewer than ten people per 1 × 1-km grid cell3945, or were not included in this analysis. Maps
were generated using ArcGIS Desktop 10.6.
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Extended Data Fig. 2 | Prevalence of under-5 child wasting in LMICs at administrative levels 0, 1, 2, and at 5 × 5-km resolution in 2017. Prevalence of
wasting among children under 5 at administrative level 0 (national-level estimates) (a), first administrative unit (b), second administrative unit (c), and at
the 5 × 5-km resolution (d). Maps reflect administrative boundaries, land cover, lakes, and population; grey-coloured grid cells were classified as “barren
or sparsely vegetated” and had fewer than ten people per 1 × 1-km grid cell3945, or were not included in this analysis. Maps were generated using ArcGIS
Desktop 10.6.
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Extended Data Fig. 3 | Modelling regions. Modelling regions46 were based on geographic and socio-demographic index (SDI) regions from the Global
Burden of Disease47, defined as: Andean South America, Central America and the Caribbean, Central sub-Saharan Africa (SSA), East Asia, Eastern SSA,
Middle East, North Africa, Oceania, Southeast Asia, South Asia, South SSA, Central Asia, Tropical South America, and Western SSA. Regions in grey (Stage
3) were not included in our models due to high-middle and high SDI. Map was generated using ArcGIS Desktop 10.6.
46. Murray, C. J. etal. GBD 2010: design, denitions and metrics. Lancet 380, 2063–2066 (2012).
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nature research | reporting summary October 2018
Corresponding author(s): Simon I. Hay
Last updated by author(s): 01/10/2020
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nature research | reporting summary October 2018
Field-specific reporting
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Sample size Sample size was calculated as the number of unique data source-location pairs with observations of overweight and wasting prevalence. This
sample size is reported in the main text under Global and location variation in malnutrition trends,"...using data from 420 household surveys
representing more than 3 million children, we map the relative burdens of overweight and wasting among under-5 children in 105 LMICs from
2000 to 2017."
Data exclusions
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