Background: Worldwide, the awareness about childhood obesity as a public health concern is increasing, particularly in developing countries like Pakistan. Obesity during early childhood may persist into later ages, increasing the risk of chronic illnesses such as diabetes and hypertension. Objective: The aim of this study was to examine the relationship of different types of food groups with obesity among children with normal and stunted growth trajectories in Pakistan. Methods: This cross-sectional study conducted a secondary analysis of Pakistan Demographic and Health Surveys (PDHSs) conducted in the years 2012–2013 and 2017–2018. Data of 1230 healthy and obese children with either normal or stunted growth were analysed after excluding those who were aged below six months, wasted, underweight, or had missing anthropometric or dietary data. The relationship of different food groups with obesity among the children with normal and stunted growth was analysed by bivariate logistic regression. Results: The prevalence of paediatric obesity dropped from 7.3% in 2012–2013 to 2.4% in 2017–2018. However, the coexistence of stunting with obesity—termed the nutritional paradox—slightly increased from 2.8% in 2012–2013 to 3% in 2017–2018. Among the different food groups, the continuation of breastmilk was associated with lowering the odds of obesity by 69% (25% to 88%) among children with normal growth. Conversely, among children with stunted growth, the continuation of breastmilk was associated with an increase in the odds of obesity by 3.71 (1.08 to 12.62) times. Conclusion: Despite the 4.9% reduction in paediatric obesity, cases of the nutritional paradox are still escalating in Pakistan. This reflects an urgent need for targeted nutritional interventions to mitigate the impact of obesogenic diets and reduce the prevalence of childhood obesity in Pakistan.

Objectives: To examine whether complete absence of vegetable and fruit consumption (Zero Vegetable or Fruit - ZVF) independently associates with anemia among children aged 0-59 months in Tajikistan, and to identify key maternal and socioeconomic determinants of childhood anemia. Design: Cross-sectional analysis using recent 2023, nationally representative Demographic and Health survey data from Tajikistan. Setting: National population based study across all regions of Tajikistan (urban and rural areas) using two stage stratified cluster sampling. Participants: 2,355 children in age group 0-59 months with complete data on hemoglobin levels and dietary intake in the preceding 24 hours residing in households selected from 2023 Tajikistan Demographic and Health Survey were included in this study. Main Outcome Measures: Primary outcome, childhood anemia status (hemoglobin <10.5g/dl for 6-23 months, <11g/dl for 24-59 months, altitude-adjusted per WHO 2024 criteria). Results: Among Tajik children under 5 years, 36.1% of children consumed no vegetables or fruits in the preceding 24 hours and the prevalence of anemia was 33.2%. Adjusted odds in our study revealed no association of ZVF consumption with anemia (OR=0.85, 95% CI: 0.63 to 1.14). Significant associations emerged for maternal anemia which increased child anemia odds by 48% (OR=1.48, 95% CI: 1.16 to 1.88), richest index had 60% lower anemia odds compared to the poorest (OR=0.39, 95% CI: 0.27 to 0.56) and low birth size increased anemia risk two fold (OR=1.92, 95% CI: 1.31 to 2.81).Each additional daily meal consumption reduced anemia odds by 14% (OR=0.86, 95% CI: 0.76 to 0.98). Conclusions: Child anemia in Tajikistan is not primarily driven by specific dietary factors but maternal nutritional status during pregnancy, birth outcomes, and socioeconomic disparities are main drivers. This novel null finding on ZVF intake, underscores that non dietary drivers predominate, informing targeted interventions aligned with SDG2 (Zero hunger). Thus integrated approaches aim to address maternal nutrition, antenatal care, wealth inequalities, and feeding frequency promotion. What is already known on this topic: Over 40% of children under five globally are affected by childhood anemia with dietary factors like low fruit and vegetable intake considered important contributors. However, the specific impact of complete absence (zero consumption) of vegetables and fruits on childhood anemia needs to be explored particularly in Central Asian countries like Tajikistan as here the dietary pattern differ from other low- and middle-income settings. What this study adds: This first nationally representative Central Asian study showed that downstream factor that’s the zero vegetable or fruit consumption had no association with childhood anemia in Tajikistan. Instead upstream factors like maternal anemia during pregnancy, household wealth disparities, small birth size, and meal frequency emerged as primary determinants, challenging dietary-centric intervention approaches. How this study might affect research, practice or policy: These findings redirect anemia prevention strategies towards integrated interventions addressing maternal nutrition during pregnancy, poverty alleviation, improved antenatal care for fetal growth monitoring, and feeding frequency promotion rather than focusing solely on vegetable or fruit consumption. This evidence informs sustainable development goals (SDG) aligned nutrition policies requiring upstream determinants to be prioritized alongside dietary diversity programs in similar settings. Key Points: Core Issues: This study explored whether complete absence of vegetable and fruit consumption (ZVF) associates with childhood anemia (below five years) in Tajikistan thereby challenging dietary-centric intervention approaches by examining maternal and socioeconomic determinants. Findings: The research found no significant association between zero vegetable or fruit consumption with childhood anemia, but identified maternal anemia during pregnancy, household wealth disparities, small birth size, and meal frequency as primary drivers. Meaning: This novel null finding of our research redirects anemia prevention strategies from dietary diversity alone toward integrated upstream interventions addressing maternal nutrition, poverty alleviation, antenatal care quality, and feeding frequency informing SDG-aligned policies in Central Asia and similar Lower-and Middle-income countries.