"Mission impossible"? Midwives' experiences counseling pregnant women with gestational diabetes mellitus

OBJECTIVE

Since not all pregnancy-related complications require hospitalization midwives often provide these women with antenatal care and counseling. This study explored the experiences of midwives providing antenatal care and counseling to pregnant women with gestational diabetes mellitus (GDM).

METHODS

Twelve midwives participated in the interview study performed in the three northernmost counties in Sweden. Grounded theory was used for analysis.

RESULTS

The emerging core category was 'Balancing fear of failure'. The unexpected disease increased the demands and the pressure. Three major conflicting situations were revealed. The midwives believed they were obligated to monitor and control the pregnancy, to initiate and motivate the necessary changes in lifestyle and provide empowering relationships with their patients. The fear of failure with these assignments made the midwives chose different strategies to manage the conflicting situations.

CONCLUSIONS AND PRACTICE IMPLICATIONS

The midwives described conflicting encounters providing antenatal care to pregnant women with GDM. The fear of failing to fulfill the assignments caused by the GDM made the midwives chose strategies to handle the conflicting encounters. Similar conflicting situations might be present for other health care professionals promoting lifestyle changes. The challenges might be addressed with an organization focusing on support and coaching sessions.

Mis-reporting, previous health status and health status of family may seriously bias the association between food patterns and disease

Background

Food pattern analyses are popular tools in the study of associations between diet and health. However, there is a need for further evaluation of this methodology. The aim of the present cross-sectional study was to evaluate the relationship between food pattern groups (FPG) and existing health, and to identify factors influencing this relationship.

Methods

The inhabitants of Västerbotten County in northern Sweden are invited to health check-ups when they turn 30, 40, 50, and 60 years of age. The present study includes data collected from almost 60,000 individuals between 1992 and 2005. Associations between FPG (established using K-means cluster analyses) and health were analyzed separately in men and women.

Results

The health status of the participants and their close family and reporting accuracy differed significantly between men and women and among FPG. Crude regression analyses, with the high fat FPG as reference, showed increased risks for several health outcomes for all other FPGs in both sexes. However, when limiting analysis to individuals without previous ill-health and with adequate energy intake reports, most of the risks instead showed a trend towards protective effects.

Conclusions

Food pattern classifications reflect both eating habits and other own and family health related factors, a finding important to remember and to adjust for before singling out the diet as a primary cause for present and future health problems. Appropriate exclusions are suggested to avoid biases and attenuated associations in nutrition epidemiology.

Trust and ambivalence in midwives' views towards women developing pelvic pain during pregnancy: a qualitative study

BACKGROUND

The Swedish midwife plays a significant role in the antenatal care (ANC) system, and a majority of pregnant women are satisfied with their ANC. Pelvic pain during pregnancy (PP) is prevalent. The study investigated the views, perceptions and attitudes of midwives currently working in ANC regarding PP during pregnancy.

METHODS

The informants were ten midwives between the ages of 35 to 64 years, with a combined experience of 250 years of midwifery. In-depth interviews (n = 4) and one focus group discussion (n = 6) were conducted. The data were interpreted using a qualitative content analysis design.

RESULTS

PP was considered a common, clinical problem that had most likely increased in prevalence in recent decades and could feature prominently in a woman's experience of pregnancy. The informants had developed a strategy for supporting pregnant women affected by PP. The pregnant woman's fear of not being believed concerning her symptoms and the risk of being regarded as a malingerer were acknowledged. Mistrust between a midwife and a woman might occur when the patient's symptoms were vague and ill defined. PP was not considered as something that complicated delivery, and women experiencing it were advised to await 'the natural course of the pregnancy'.

CONCLUSIONS

PP was considered a common, clinical problem and the informants had developed a strategy for supporting pregnant women affected by PP. However, the woman's fear of not being believed concerning her symptoms of PP was acknowledged and mistrust might occur between a midwife and a woman if vague symptoms were reported.

Fish consumption and school grades in Swedish adolescents: a study of the large general population

AIM

To study the associations between fish intake and academic achievement as cognitive parameter among Swedish adolescents.

METHODS

In 2000, a questionnaire including respiratory items, socioeconomic conditions and dietary information was mailed to all schoolchildren (n = 18 158), aged 15 and living in Västra Götaland region of Sweden. The questionnaire was returned by 10 837 subjects. One year later, the total school grades for each subject who had completed the questionnaire and who included their full personal identification number were obtained from the national registers. Multiple linear regression models were applied to evaluate the association between fish intake and academic grades among 9448 schoolchildren, while adjusting for potential confounders, e.g. parents' education.

RESULTS

Grades were higher in subjects with fish consumption once a week compared with subjects with fish consumption of less than once a week (reference group) [increment in estimate 14.5, 95% confidence interval (CI) 11.8-17.1]. Grades were even higher in subjects with fish consumption of more than once a week compared with the reference group (increment in estimate 19.9, 95% CI 16.5-23.3). In the model stratified for parents' education, there were still higher grades among subjects with frequent fish intake in all educational strata (p < 0.01).

CONCLUSION

Frequent fish intake among schoolchildren may provide benefits in terms of academic achievement.

Surprisingly low compliance to local guidelines for risk factor based screening for gestational diabetes mellitus - A population-based study

Background

Screening for gestational diabetes mellitus (GDM) is routine during pregnancy in many countries in the world. The screening programs are either based on general screening offered to all pregnant women or risk factor based screening stipulated in local clinical guidelines. The aims of this study were to investigate: 1) the compliance with local guidelines of screening for GDM and 2) the outcomes of pregnancy and birth in relation to risk factors of GDM and whether or not exposed to oral glucose tolerance test (OGTT).

Methods

This study design was a population-based retrospective cross-sectional study of 822 women. A combination of questionnaire data and data collected from medical records was applied. Compliance to the local guidelines of risk factor based screening for GDM was examined and a comparison of outcomes of pregnancy and delivery in relation to risk factor groups for GDM was performed.

Results

Of the 822 participants, 257 (31.3%) women fulfilled at least one criterion for being exposed to screening for GDM according to the local clinical guidelines. However, only 79 (30.7%) of these women were actually exposed to OGTT and of those correctly exposed for screening, seven women were diagnosed with GDM. Women developing risk factors for GDM during pregnancy had a substantially increased risk of giving birth to an infant with macrosomia.

Conclusion

Surprisingly low compliance with the local clinical guidelines for screening for GDM during pregnancy was found. Furthermore, the prevalence of the risk factors of GDM in our study was almost doubled compared to previous Swedish studies. Pregnant women developing risk factors of GDM during pregnancy were found to be at substantially increased risk of giving birth to an infant with macrosomia. There is a need of actions improving compliance to the local guidelines.

Plasma folate and total homocysteine levels are associated with the risk of myocardial infarction, independently of each other and of renal function

OBJECTIVES

To investigate the relationship between plasma folate, vitamin B12 and total homocysteine concentrations, dietary intake of folate and vitamins B12, B6 and B2, and the risk of first acute myocardial infarction (MI).

DESIGN

Nested case-referent study with up to 13 years of follow-up.

SETTING

The population-based Northern Sweden Health and Disease Study, with 73 879 participants at the time of case ascertainment.

SUBJECTS

A total of 571 MI cases (406 men) and 1569 matched referents. Of the cases, 530 had plasma samples available, and 247 had dietary B-vitamin intake data.

RESULTS

Plasma concentrations of folate were inversely associated, and total homocysteine positively associated, with the risk of MI, independently of each other and of a number of established and novel cardiovascular risk factors, including renal function [multivariate odds ratio for highest vs. lowest quintile of folate 0.52 (95% CI 0.31-0.84), P for trend = 0.036, and homocysteine 1.92 (95% CI 1.20-3.09), P for trend = 0.006]. For plasma vitamin B12 concentrations, and vitamin B12, B6 and B2 intake, no clear risk relationship was apparent. Though not statistically significant, the results for folate intake were consistent with those for plasma concentrations.

CONCLUSIONS

In this large prospective study of a population without mandatory folic acid fortification, both folate and homocysteine were strongly associated with the risk of myocardial infarction, independently of each other and of renal function. Although randomized trials of folic acid supplementation are needed to determine causality, our findings highlight the potential importance of folate, or sources of folate, in incident cardiovascular disease.

Fish intake of Swedish male adolescents is a predictor of cognitive performance

AIM

Fish intake is reported to positively influence cognitive performance in infants and the elderly. In a longitudinal cohort study, we evaluated how fish consumption related to later cognitive performance in healthy young male adolescents.

METHODS

In 2000, all 15-year-olds (n = 18 158; 9260 males) in the western region of Sweden were requested to complete an extensive questionnaire with items on diseases, fish consumption and socioeconomic status. Questionnaire data from the male responders (n = 4792, response rate 52%) were linked with records on subsequent intelligence test performance at age 18 from the Swedish Military Conscription Register (n = 3972). Multivariate linear models were used to estimate associations between fish intake and cognitive performance, adjusting for potential confounders.

RESULTS

There was a positive association between the number of times having fish meals per week at age 15 and cognitive performance measured 3 years later. Fish consumption of more than once per week compared to less than once per week was associated with higher stanine scores in combined intelligence (0.58 units; 95% confidence interval 0.39, 0.76), in verbal performance (0.45; 0.27, 0.63) and in visuospatial performance (0.50; 0.31, 0.69). The association between fish consumption and the 3 intelligence scores was the same in lowly and highly educated groups. This indicates that education did not influence the association between the frequency of fish meals consumed and cognitive performance.

CONCLUSION

Frequent fish intake at age 15 was associated with significantly higher cognitive performance 3 years later.

More distinct food intake patterns among women than men in northern Sweden: a population-based survey

BACKGROUND

The need to promote a healthy diet to curb the current obesity epidemic has today been recognized by most countries. A prerequisite for planning and evaluating interventions on dietary intake is the existence of valid information on long-term average dietary intake in a population. Few large, population-based studies of dietary intake have been carried out in Sweden. The largest to date is the Västerbotten Intervention Program (VIP), which was initiated in 1985, with data collection still ongoing. This paper reports on the first comprehensive analyses of the dietary data and presents dietary intake patterns among over 60,000 women and men in northern Sweden during 1992-2005.

METHODS

Between 1992 and 2005, 71,367 inhabitants in Västerbotten county aged 30, 40, 50, and 60 years visited their local health care center as part of the VIP. Participants of VIP filled in an 84- or 64-item food frequency questionnaire (FFQ) and provided sociodemographic information. Complete and realistic information on consumption frequency was provided by 62,531 individuals. Food intake patterns were analyzed using K-means cluster analyses.

RESULTS

The mean daily energy intake was 6,83 (+/- 1,77) MJ among women and 8,71 (+/- 2,26) MJ among men. More than half of both women and men were classified as Low Energy Reporters (defined as individuals reporting a food intake level below the lower 95% confidence interval limit of the physical activity level). Larger variation in frequency of daily intake was seen among women than among men for most food groups. Among women, four dietary clusters were identified, labeled "Fruit and vegetables", "High fat", "Coffee and sandwich", and "Tea and ice cream". Among men, three dietary clusters were identified, labeled "Fruit and vegetables", "High fat", and "Tea, soda and cookies".

CONCLUSION

More distinct food intake patterns were seen among women than men in this study in northern Sweden. Due to large proportions of Low Energy Reporters, our results on dietary intake may not be suitable for comparisons with recommended intake levels. However, the results on food intake patterns should still be valid and useful as a basis for targeting interventions to groups most in need.

Inverse relation between dietary intake of naturally occurring plant sterols and serum cholesterol in northern Sweden

BACKGROUND

Plant sterols are bioactive compounds, found in all vegetable foods, which inhibit cholesterol absorption. Little is known about the effect of habitual natural dietary intake of plant sterols.

OBJECTIVE

We investigated the relation between plant sterol density (in mg/MJ) and serum concentrations of cholesterol in men and women in northern Sweden.

DESIGN

The analysis included 37 150 men and 40 502 women aged 29-61 y, all participants in the Västerbotten Intervention Program.

RESULTS

Higher plant sterol density was associated with lower serum total cholesterol in both sexes and with lower LDL cholesterol in women. After adjustment for age, body mass index (in kg/m(2)), and (in women) menopausal status, men with high plant sterol density (quintile 5) had 0.15 mmol/L (2.6%) lower total serum cholesterol (P for trend = 0.001) and 0.13 mmol/L (3.1%) lower LDL cholesterol (P = 0.062) than did men with low plant sterol density (quintile 1). The corresponding figures for women were 0.20 mmol/L (3.5%) lower total serum cholesterol (P for trend < 0.001) and 0.13 mmol/L (3.2%) lower LDL cholesterol (P for trend = 0.001).

CONCLUSIONS

The present study is the second epidemiologic study to show a significant inverse relation between naturally occurring dietary plant sterols and serum cholesterol. To the extent that the associations found truly mirror plant sterol intake and not merely a diet high in vegetable fat and fiber, it highlights the importance of considering the plant sterol content of foods both in primary prevention of cardiovascular disease and in the dietary advice incorporated into nutritional treatment of patients with hyperlipidemia.

Interactions between malaria workers and clinical malaria patients in Jepara District, Indonesia

In a one-year longitudinal study of all clinical malaria cases treated by the Village Malaria Workers (VMWs) during 1999-2000, data on health-seeking behavior during a seven-day illness period were collected using a diary; 24 interactions were audiotaped. The results showed that 87% of cases had been treated by the VMWs on day four of the illness period. On day two, the percentage not treated was significantly higher in male as compared with female cases (p = 0.01) and in those below 15 years of age as compared with those 15 years and older (p < 0.001). "Not doing anything" and "using VMWs only" were the two most common actions. Interactions between the VMWs and the patients focused on medical tasks, and low compliance with treatment was a common concern of the VMWs. The concept of preventive measures and the role of mosquitoes were lacking in the interactions.

Paternity leave in Sweden: costs, savings and health gains

OBJECTIVES

The initial objective is to examine the relationship between paternity leave in 1978-1979 and male mortality during 1981-2001, and the second objective is to calculate the cost-effectiveness of the 1974 parental insurance reform in Sweden.

METHODS

Based on a population of all Swedish couples who had their first child together in 1978 (45,801 males), the risk of death for men who took paternity leave, compared with men who did not, was estimated by odds ratios. The cost-effectiveness analysis considered costs for information, administration and production losses, minus savings due to decreased sickness leave and inpatient care, compared to health gains in life-years and quality-adjusted life-years (QALYs).

RESULTS

It is demonstrated that fathers who took paternity leave have a statistically significant decreased death risk of 16%. Costs minus savings (discounted values) stretch from a net cost of EUR 19 million to a net saving of EUR 11 million, and the base case cost-effectiveness is EUR 8000 per QALY.

CONCLUSIONS

The study indicates that that the right to paternity leave is a desirable reform based on commonly stated public health, economic, and feminist goals. The critical issue in future research should be to examine impact from health-related selection.

Low folate levels may protect against colorectal cancer

BACKGROUND AND AIMS

Dietary folate is believed to protect against colorectal cancer (CRC). However, few studies have addressed the role of circulating levels of folate. The aim of this study was to relate prediagnostic plasma folate and homocysteine concentrations and the methylenetetrahydrofolate reductase (MTHFR) 677C>T and 1298A>C polymorphisms to the risk of developing CRC.

SUBJECTS

Subjects were 226 cases and 437 matched referents from the population based Northern Sweden Health and Disease Cohort.

RESULTS

We observed a bell-shaped association between plasma folate concentrations and CRC risk; multivariate odds ratio for middle versus lowest quintile 2.00 (95% confidence interval (CI) 1.13-3.56). In subjects with follow up times greater than the median of 4.2 years however, plasma folate concentrations were strongly positively related to CRC risk; multivariate odds ratio for highest versus lowest quintile 3.87 (95% CI 1.52-9.87; p trend = 0.007). Homocysteine was not associated with CRC risk. Multivariate odds ratios for the MTHFR polymorphisms were, for 677 TT versus CC, 0.41 (95% CI 0.19-0.85; p trend = 0.062), and for 1298 CC versus AA, 1.62 (95% CI 0.94-2.81; p trend = 0.028). Interaction analysis suggested that the result for 1298A>C may have been largely due to linkage disequilibrium with 677C>T. The reduced CRC risk in 677 TT homozygotes was independent of plasma folate status.

CONCLUSIONS

Our findings suggest a decreased CRC risk in subjects with low folate status. This possibility of a detrimental component to the role of folate in carcinogenesis could have implications in the ongoing debate in Europe concerning mandatory folate fortification of foods.

Maternal energy depletion is buffered among malnourished women in Punjab, Pakistan

Women's nutritional status is believed to deteriorate with increasing reproductive stress (so-called maternal depletion). To evaluate this phenomenon, a new theoretical framework has been suggested that incorporates the concepts of a full reproductive cycle, relative lengths of potential depletion and repletion phases, and initial plane of nutrition. We developed the corresponding statistical model and tested predictions provided by the framework about the effect of reproductive pattern on maternal overall weight change (deltaW) during one reproductive cycle. Seventy-six Pakistani women were classified as well-nourished, marginally nourished or malnourished. The relationship between deltaW and length of all phases of the reproductive cycle, each of which is characterized by varying degrees of reproductive stress, was evaluated with multiple regression analysis. Across the reproductive cycle, well-nourished women had a slight weight increase. Surprisingly, malnourished women gained weight in contrast to marginally nourished women. Also surprisingly, for the latter two groups, periods of moderate reproductive stress were associated with weight loss but periods of high reproductive stress were associated with weight gain. Mechanisms such as efficiency and nutrient partitioning are discussed.

Parental share in public and domestic spheres: a population study on gender equality, death, and sickness

STUDY OBJECTIVE

Examine the relation between aspects of gender equality and population health based on the premise that sex differences in health are mainly caused by the gender system.

SETTING/ PARTICIPANTS

All Swedish couples (98 240 people) who had their first child together in 1978.

DESIGN

The exposure of gender equality is shown by the parents' division of income and occupational position (public sphere), and parental leave and temporary child care (domestic sphere). People were classified by these indicators during 1978-1980 into different categories; those on an equal footing with their partner and those who were traditionally or untraditionally unequal. Health is measured by the outcomes of death during 1981-2001 and sickness absence during 1986-2000. Data are obtained by linking individual information from various national sources. The statistical method used is multiple logistic regressions with odds ratios as estimates of relative risks.

MAIN RESULTS

From the public sphere is shown that traditionally unequal women have decreased health risks compared with equal women, while traditionally unequal men tend to have increased health risks compared with equal men. From the domestic sphere is indicated that both women and men run higher risks of death and sickness when being traditionally unequal compared with equal.

CONCLUSIONS

Understanding the relation between gender equality and health, which was found to depend on sex, life sphere, and inequality type, seems to require a combination of the hypotheses of convergence, stress and expansion.

"If we have to die, we just die": challenges and opportunities for tuberculosis and HIV/AIDS prevention and care in northern Thailand

In this study, the authors identify opportunities for and challenges in reducing the risks of tuberculosi (TB) and HIV/AIDS transmission in Thailand. They carried out more than six repeated in-depth interviews with each of 13 participants who have been newly diagnosed with TB, 7 of whom were HIV positive, and their caregivers, until the patient recovered from TB or died. They performed extensive observations during relevant private and public activities and analyzed the data using grounded theory, focusing on behaviors affecting risk of transmission. Out of strong virtue, many caregivers felt a responsibility to care for their ill loved ones, thus putting themselves at risk of transmission. For the older generation, this was unimportant, as they had already completed their life cycle ("let it be"). However, strong human bonds encouraged the patients to complete TB treatment until cured or deceased. The authors discuss strategies to build on appropriate behaviors.

Folate, Vitamin B 12 , and Risk of Ischemic and Hemorrhagic Stroke

Background and Purpose— Folate metabolism has been implicated in stroke. However, the possibility of a role for folate and vitamin B 12 , independent of their effects on homocysteine status, remains to be explored. The aim of this prospective, nested case-referent study was to relate plasma and dietary intake levels of folate and vitamin B 12 to risk of stroke, taking into consideration plasma homocysteine concentrations and methylenetetrahydrofolate reductase polymorphisms.

Methods— Subjects were 334 ischemic and 62 hemorrhagic stroke cases and matched double referents from the population-based Northern Sweden Health and Disease Cohort.

Results— Plasma folate was statistically significantly associated with risk of hemorrhagic stroke in an inverse linear manner, both in univariate analysis and after adjustment for conventional risk factors including hypertension (odds ratio [OR] for highest versus lowest quartile 0.21 (95% confidence interval [CI], 0.06 to 0.71; P for trend=0.008)). Risk estimates were attenuated by inclusion of homocysteine in the model (OR, 0.34; 95% CI, 0.08 to 1.40; P for trend=0.088). A similar pattern was observed for increasing folate intake (multivariate OR, 0.07; 95% CI, 0.01 to 0.55; P for trend=0.031 without homocysteine, and OR, 0.16, 95% CI, 0.02 to 1.23; P for trend=0.118 with homocysteine in the analysis). We found little evidence of an association between plasma or dietary folate and risk of ischemic stroke. Neither plasma nor dietary vitamin B 12 was associated with risk of either stroke subtype.

Conclusions— The results of this study suggest a protective role for folate, possibly in addition to its effects on homocysteine status, in hemorrhagic but not ischemic stroke.

The importance of eating rice: changing food habits among pregnant Indonesian women during the economic crisis

This article presents qualitative and quantitative research findings on food habits of pregnant Indonesian women in relation to the economic crisis that arose in 1997. Between 1996 and 1998, dietary intakes were estimated for 450 pregnant women in Central Java. Between January and June 1999, four focus group discussions, 16 in-depth interviews and four non-participant observations were held with women, two in-depth interviews were held with traditional birth attendants, and four with midwives. Women were categorized as urban or rural, rich or poor, and according to rice field ownership. The women reported that before the crisis they bought more foods and cooked more meals and snacks. During the crisis, cooking methods became simpler and cooking tasty foods was more important than cooking nutritious foods. This involved using plenty of spices and cooking oil, but reducing the use of expensive nutritious foods. The herbal drink jamu was drunk by 15% of pregnant women; its consumption was lower during than before the economic crisis. Twenty-six percent of the women avoided certain foods due to food taboos, and most of these women avoided beneficial foods; this phenomenon decreased during the crisis among the rich and the rural, poor, landless women. In spite of increased prices for rice, women did not decrease their rice consumption during the crisis because rice was believed to have the highest value for survival, to provide strength during pregnancy and delivery, and to be easier to store and cook. Finally, children and husbands had highest priority in being served food, and women were the last to eat.

Nutrient intake and iron status of urban poor and rural poor without access to rice fields are affected by the emerging economic crisis: the case of pregnant Indonesian women

OBJECTIVE

We evaluated the adequacy of nutrient intake in comparison with the Indonesian Estimated Average Requirement (EARs) among pregnant Indonesian women and explain the short-term effect of economic crisis on nutrient intake and iron status.

DESIGN

Cross-sectional study.

SETTING

Purworejo District, Central Java, located 60 km west of Yogyakarta Province, Indonesia.

SUBJECTS

During the period from 1996 to 1998, up to six 24 h recalls were performed during the second trimester of pregnancy among 450 women. Nutrient intake and iron status was evaluated in relation to date of data collection relative to the economic crisis that emerged in August 1997. A computer program (Inafood) was developed to calculate nutrient intake.

RESULTS

: Forty percent of the pregnant women were at risk of inadequate intake of energy and protein, and 70% were at risk of inadequate intake of vitamin A, calcium and iron even before the crisis. Our results also demonstrate an effect of short-term economic crisis on nutrient intake and iron status. When the crisis emerged, urban poor experienced a decrease in intake of most nutrients. During the crisis, rich women experienced a significant decrease in fat (P<0.05). Negative changes in fat density during crisis were experienced by the rich and the rural, poor, and access to rice field subgroups (P<0.01). A significant increase in carbohydrate densities was seen for the rich and rural, poor, and access to rice fields groups (P<0.05). Urban poor experienced decreased serum ferritin concentration (P<0.05), whereas rich women experienced a significant increase (P<0.05).

CONCLUSIONS

Urban poor and rural poor landless women were most directly affected by the emerging economic crisis.

Rye, lignans and human health

Rye bran contains a high content not only of dietary fibre, but also of plant lignans and other bioactive compounds in the so-called dietary fibre complex. Blood concentrations of lignans such as enterolactone have been used as biomarkers of intake of lignan-rich plant food. At present,evidence from studies in human subjects does not warrant the conclusion that rye, whole grains orphyto-oestrogens protect against cancer. Some studies, however, have pointed in that direction,especially in relation to cancers of the upper digestive tract. A number of prospective epidemiological studies have clearly shown a protective effect of wholegrain cereals against myocardial infarctions. A corresponding protective effect against diabetes and ischaemic stroke(brain infarct) has also been demonstrated. It seems reasonable to assume that these protective effects are associated with one or more factors in the dietary fibre complex.

Rapid assessment procedures of malaria in low endemic countries: community perceptions in Jepara district, Indonesia

Most studies on community perceptions toward malaria have been undertaken in high-endemic countries, and studies from low-endemic countries have only recently been published. Similar information is also needed for hypoendemic countries such as Indonesia, to cope with the persistence of foci-endemic malaria in these regions. An applied qualitative method, Rapid Assessment Procedures, was employed during a 3-month intensive data collection period in Jepara district, Central Java province. Data were retrieved from 38 free-listings, 28 in-depth interviews, seven focus group discussions and unstructured observation. Qualitative thematic content analysis was applied. In this community, malaria (known as katisen or panas tis) was considered a common but minor illness. Insufficient understanding of malaria signs and symptoms in the subvillages likely leads to delay in illness recognition and treatment; not surprisingly self-treatment is common and the dosage most likely below the recommended dose. The health center was used but when it did not work, most people would shift back to traditional services due to cost considerations. Low understanding and acceptance of the causal link between the mosquito and malaria, likely leading to poor comprehension of preventive activities, as well as confusion of malaria with dengue fever, were identified. In conclusion, this study highlights a consistent gap between the common understanding and the biomedical description of malaria. If case management continues to be the main strategy in malaria control program, the emic perspective of the people must be well-integrated into the program. Likewise, interventions to improve home-treatment should also be developed.

Associations between reproduction and maternal body weight: examining the component parts of a full reproductive cycle

OBJECTIVE

Many transitional societies currently face both extremes of nutritional status, undernutrition and overnutrition. Women of reproductive age are at high risk of these conditions. The purpose of this review is to consider evidence for relationships between reproduction and nutritional status in women from societies of varying economic development, using body weight or weight-for-height as indicators of maternal nutritional status.

DESIGN

The conceptual framework guiding this review is that the duration of the reproductive cycle varies as a function of its component parts, which include (i) pregnancy, (ii) lactation, (iii) the non-pregnant/non-lactating (NP/NL) interval or, possibly, (iv) an overlap between lactation and next pregnancy. All component parts of the complete cycle vary in length and are associated with changes in nutritional status. A variety of factors ('proximal and distal determinants') influence the duration of the component parts of the reproductive cycle. This framework is used to examine current knowledge of changes in maternal nutritional status during each of these parts.

RESULTS

Women in affluent societies retain some weight with each pregnancy, beyond that of non-pregnant women. Women in less affluent societies retain less weight with each pregnancy. During lactation, women in both affluent and less affluent societies experience only modest weight loss. During the NP/NL interval, women in affluent societies tend to gain weight, whereas weight of women in less affluent societies is likely to fluctuate.

CONCLUSIONS

We conclude that there is a dearth of information on certain parts of the cycle, particularly the periods of overlap of lactation with pregnancy and the NP/NL interval.

Diversity of dietary patterns observed in the European Prospective Investigation into Cancer and Nutrition (EPIC) project

OBJECTIVE

To describe the diversity in dietary patterns existing across centres/regions participating in the European Prospective Investigation into Cancer and Nutrition (EPIC).

DESIGN AND SETTING

Single 24-hour dietary recall measurements were obtained by means of standardised face-to-face interviews using the EPIC-SOFT software. These have been used to present a graphic multi-dimensional comparison of the adjusted mean consumption of 22 food groups.

SUBJECTS

In total, 35 955 men and women, aged 35-74 years, participating in the EPIC nested calibration study.

RESULTS

Although wide differences were observed across centres, the countries participating in EPIC are characterised by specific dietary patterns. Overall, Italy and Greece have a dietary pattern characterised by plant foods (except potatoes) and a lower consumption of animal and processed foods, compared with the other EPIC countries. France and particularly Spain have more heterogeneous dietary patterns, with a relatively high consumption of both plant foods and animal products. Apart from characteristics specific to vegetarian groups, the UK 'health-conscious' group shares with the UK general population a relatively high consumption of tea, sauces, cakes, soft drinks (women), margarine and butter. In contrast, the diet in the Nordic countries, The Netherlands, Germany and the UK general population is relatively high in potatoes and animal, processed and sweetened/refined foods, with proportions varying across countries/centres. In these countries, consumption of vegetables and fruit is similar to, or below, the overall EPIC means, and is low for legumes and vegetable oils. Overall, dietary patterns were similar for men and women, although there were large gender differences for certain food groups.

CONCLUSIONS

There are considerable differences in food group consumption and dietary patterns among the EPIC study populations. This large heterogeneity should be an advantage when investigating the relationship between diet and cancer and formulating new aetiological hypotheses related to dietary patterns and disease.