Validity of an FFQ to measure nutrient and food intakes in Tanzania

Validity and Reproducibility of a Semiquantitative Food Frequency Questionnaire and Food Picture Book in Nigeria

Background

Increasing noncommunicable diseases in Nigeria are partly related to dietary factors. However, the lack of validated nutrition assessment tools hinders the conduct of nutritional epidemiology research in this population.

Objectives

To develop a Food Frequency Questionnaire (FFQ) and Food Picture Book (FPB) for Nigerian adults, and to assess its reproducibility and validity compared with 24-h dietary recalls (24DRs) during different seasons in the year.

Methods

We compiled 202 foods for the FFQ through focus groups and consultations with local dietitians. We created an FPB with standardized food portion images to enhance the accuracy of reports of dietary intakes. We administered the FFQs to 205 purposively selected adults in Ibadan, Nigeria at ∼6 monthly intervals between November 2018 and October 2020. We evaluated the FFQ's reproducibility and validity compared with 24DR across the dry and rainy seasons by examining the consumption of common food and mixed dishes. We computed the Spearman's correlation coefficients (SCC), intraclass correlation coefficients (ICC), and Wilcoxon signed-rank tests, and generated Bland and Altman plots.

Results

Overall, we studied 110 women (53.7%) and 95 men (46.3%) with a mean age of 45.0 ± 13.4 y (mean ± SD). The reproducibility tests showed a mean ± SD SCC of 0.39 ± 0.14 and mean ± SD ICC of 0.32 ± 0.12. Higher mean ± SD SCC values were noted for cereal products (0.43 ± 0.09), starchy roots and tubers (0.45 ± 0.17), and soups (0.44 ± 0.20). Conversely, lower mean ± SD SCC values were observed for milk products (0.29 ± 0.02), solid fats (0.29 ± 0.26), and fish (0.22 ± 0.19). Regarding validity tests, the overall mean ± SD SCC was 0.27 ± 0.16 and mean ± SD ICC was 0.26 ± 0.16. We observed seasonal variations in intakes of fruits, cassava flour-based products, and nuts, although most foods did not show significant differences in intakes between seasons.

Conclusions

Our FFQ and FPB demonstrated moderate correlations and seasonal variations in intakes of certain foods, emphasizing the need to account for seasonality in dietary intakes in nutritional studies in Nigeria and similar countries.

Dietary Intake Assessment Using a Novel, Generic Meal-Based Recall and a 24-Hour Recall: Comparison Study

BACKGROUND

Dietary intake assessment is an integral part of addressing suboptimal dietary intakes. Existing food-based methods are time-consuming and burdensome for users to report the individual foods consumed at each meal. However, ease of use is the most important feature for individuals choosing a nutrition or diet app. Intakes of whole meals can be reported in a manner that is less burdensome than reporting individual foods. No study has developed a method of dietary intake assessment where individuals report their dietary intakes as whole meals rather than individual foods.

OBJECTIVE

This study aims to develop a novel, meal-based method of dietary intake assessment and test its ability to estimate nutrient intakes compared with that of a web-based, 24-hour recall (24HR).

METHODS

Participants completed a web-based, generic meal-based recall. This involved, for each meal type (breakfast, light meal, main meal, snack, and beverage), choosing from a selection of meal images those that most represented their intakes during the previous day. Meal images were based on generic meals from a previous study that were representative of the actual meal intakes in Ireland. Participants also completed a web-based 24HR. Both methods were completed on the same day, 3 hours apart. In a crossover design, participants were randomized in terms of which method they completed first. Then, 2 weeks after the first dietary assessments, participants repeated the process in the reverse order. Estimates of mean daily nutrient intakes and the categorization of individuals according to nutrient-based guidelines (eg, low, adequate, and high) were compared between the 2 methods. P values of less than .05 were considered statistically significant.

RESULTS

In total, 161 participants completed the study. For the 23 nutrient variables compared, the median percentage difference between the 2 methods was 7.6% (IQR 2.6%-13.2%), with P values ranging from <.001 to .97, and out of 23 variables, effect sizes for the differences were small for 19 (83%) variables, moderate for 2 (9%) variables, and large for 2 (9%) variables. Correlation coefficients were statistically significant (P<.05) for 18 (78%) of the 23 variables. Statistically significant correlations ranged from 0.16 to 0.45, with median correlation of 0.32 (IQR 0.25-0.40). When participants were classified according to nutrient-based guidelines, the proportion of individuals who were classified into the same category ranged from 52.8% (85/161) to 84.5% (136/161).

CONCLUSIONS

A generic meal-based method of dietary intake assessment provides estimates of nutrient intake comparable with those provided by a web-based 24HR but with varying levels of agreement among nutrients. Further studies are required to refine and improve the generic recall across a range of nutrients. Future studies will consider user experience including the potential feasibility of incorporating image recognition of whole meals into the generic recall.

Women's input and decision-making in agriculture are associated with diet quality in rural Tanzania

Background

Women's empowerment is one critical pathway through which agriculture can impact women's nutrition; however, empirical evidence is still limited. We evaluated the associations of women's participation, input, and decision-making in key agricultural and household activities with women's diet quality.

Methods

We analyzed data from a cross-sectional study of 870 women engaged in homestead agriculture. We used food frequency questionnaires to assess women's diets and computed women's diet quality using the Prime Diet Quality Score (PDQS) (range 0-42), which captures healthy and unhealthy foods. We evaluated women's decision-making in 8 activities, food crop farming, cash crop farming, livestock raising, non-farm economic activities, wage/salary employment, fishing, major household expenditures, and minor household expenditures. Generalized estimating equations (GEE) linear models were used to evaluate associations between (a) women's participation, (b) decision-making, (c) adequate input, (d) adequate extent of independence in decision-making in agriculture, and (e) adequate input in use of agricultural income with their PDQS. Adequate input was defined as input into some, most or all decisions compared to input into few decisions or none. Adequate extent of independence was defined as input to a medium or high extent compared to input to a small extent or none.

Findings

Median PDQS was 19 (IQR: 16-21). Women's adequate input in decision-making on wage and salary employment (estimate: 4.19, 95% CI: 2.80, 5.57) and minor expenditures were associated with higher PDQS vs. inadequate input. Women with independence in decision-making on livestock production (estimate: 0.97, 95% CI: 0.05, 1.90) and minor household expenditures, and women with adequate decision-making in the use of income from wages/salaries (estimate: 3.16, 95% CI: 2.44, 3.87) had higher PDQS. Participation in agricultural activities was positively associated with PDQS.

Conclusions

Women's participation and input in decision-making in wage and salary employment, livestock production, and minor household expenditures were strongly associated with the consumption of better-quality diets. Women participating in multiple farm activities were also likely to have better diet quality. This study adds to the growing evidence on the pathways through which women's empowerment may influence women's nutrition in rural Tanzania.

Dietary Iron Intake and HIV-Related Outcomes Among Adults Initiating Antiretroviral Therapy in Tanzania

OBJECTIVE

Anemia is highly prevalent among people living with HIV (PLWHIV) and is often due to iron deficiency. This study evaluated the relationship of dietary iron intake levels and sources with mortality and clinical outcomes among adults initiating HAART.

DESIGN

We conducted a secondary analysis of a multivitamin supplementation trial among 2293 PLWHIV initiating HAART in Dar es Salaam, Tanzania.

METHODS

Dietary iron intake was assessed with a food frequency questionnaire at HAART initiation, and participants followed until death or censoring. Total, animal-, and plant-sourced iron were categorized into quartiles. Intake of food groups was categorized into 0-1, 2-3, and ≥4 servings/wk. Cox proportional hazards models estimated hazard ratios for mortality and incident clinical outcomes.

RESULTS

There were 175 deaths (8%). Red meat intake was associated with a lower risk of all-cause mortality (HR: 0.54; 95% CI: 0.35 to 0.83), AIDS-related mortality (HR: 0.49; 95% CI: 0.28 to 0.85), and severe anemia (HR: 0.57; 95% CI: 0.35 to 0.91), when intake ≥4 servings/wk, compared with 0-1 servings/wk. Legume intake was a lower risk of associated with all-cause mortality (HR: 0.49; 95% CI: 0.31 to 0.77) and AIDS-related mortality (HR: 0.37; 95% CI: 0.23 to 0.61), when intake ≥4 servings/wk, compared with 0-1 servings/wk. Although total dietary iron and overall plant-sourced iron intake were not associated with the risk of mortality or HIV-related outcomes, the highest quartile of animal-sourced iron intake was associated with a lower risk of all-cause mortality (HR: 0.56; 95% CI: 0.35 to 0.90) and a lower risk of AIDS-related mortality (HR: 0.50; 95% CI: 0.30 to 0.90), compared with the lowest quartile.

CONCLUSION

Intake of iron-rich food groups may be associated with a lower risk of mortality and critical HIV-related outcomes among adults initiating HAART.

TRIAL REGISTRATION

The parent trial was registered at Clinicaltrials.gov . Identifier: NCT00383669.

Validating a semi-quantitative food frequency questionnaire to assess regional diet in a study of cancer in South West Nigeria

PURPOSE

Cancer burden is rising rapidly in Nigeria, the most populous country in sub-Saharan Africa; this trend may in part be attributable to diet. We developed and validated a semi-quantitative food frequency questionnaire (FFQ) to assess regional diet in Nigeria.

METHODS

We recruited 68 adult participants from rural and urban settings in South West Nigeria. We developed an FFQ administered at baseline and assessed its validity using 3 dietary recalls (baseline, 7 days post baseline, 3 months post baseline). We calculated Spearman's rank correlation coefficients and energy-adjusted de-attenuated correlation coefficients for food items and macronutrients. We evaluated cross-classification using quartiles of macronutrient intake.

RESULTS

Energy-adjusted de-attenuated food item correlations between the FFQ and dietary recalls ranged from -0.08 (smoked beef/goat) to 0.73 (fried snacks) for the average intake from the first 2 recalls (2DR) and from -0.05 (smoked beef/goat) to 0.75 (smoked fish) for the average of all 3 recalls (3DR). Macronutrient correlations ranged from 0.15 (fat) to 0.37 (fiber) for the 2DR and from 0.08 (fat) to 0.41 (carbohydrates) for the 3DR. The percent of participants classified in the same quartile ranged from 16.4% (fat) to 32.8% (fiber, protein) for the 2DR and from 25.6% (fat) to 34.9% (carbohydrates) for the 3DR. Agreement improved when including adjacent quartiles, from 65.5% (carbohydrates) to 70.5% (fat, fiber) for the 2DR and from 62.8% (protein) to 76.8% (carbohydrate) for the 3DR.

CONCLUSION

Our semi-quantitative FFQ was reasonably valid for ranking intake of certain foods and macronutrients in adults in South West Nigeria.

Associations of percentage energy intake from total, animal and plant protein with overweight/obesity and underweight among adults in Addis Ababa, Ethiopia

OBJECTIVE

This study investigated associations between types and food sources of protein with overweight/obesity and underweight in Ethiopia.

DESIGN

We conducted a cross-sectional dietary survey using a non-quantitative FFQ. Linear regression models were used to assess associations between percentage energy intake from total, animal and plant protein and BMI. Logistic regression models were used to examine the associations of percentage energy intake from total, animal and plant protein and specific protein food sources with underweight and overweight/obesity.

SETTING

Addis Ababa, Ethiopia.

PARTICIPANTS

1624 Ethiopian adults (992 women and 632 men) aged 18-49 years in selected households sampled using multi-stage random sampling from five sub-cities of Addis Ababa.

RESULTS

Of the surveyed adults, 31 % were overweight or obese. The majority of energy intake was from carbohydrate with only 3 % from animal protein. In multivariable-adjusted linear models, BMI was not associated with percentage energy from total, plant or animal protein. Total and animal protein intake were both associated with lower odds of overweight/obesity (OR per 1 % energy increment of total protein 0·92; 95 % CI: 0·86, 0·99; P = 0·02; OR per 1 % energy increment of animal protein 0·89; 95 % CI: 0·82, 0·96; P = 0·004) when substituted for carbohydrate and adjusted for socio-demographic covariates.

CONCLUSION

Increasing proportion of energy intake from total protein or animal protein in place of carbohydrate could be a strategy to address overweight and obesity in Addis Ababa; longitudinal studies are needed to further examine this potential association.

Validity and reliability of a semi-quantitative food frequency questionnaire for assessing dietary vitamin D and calcium intakes in Iranian childbearing age women

This study aimed to examine the validity and reliability of a semi-quantitative food frequency questionnaire (FFQ) designed to estimate dietary vitamin D and Calcium (Ca) intakes in a sample of Iranian childbearing age women. An 87-item FFQ was developed and 84 healthy childbearing age women completed it. FFQ was validated by comparing its results with the 24-h dietary recall (24-h recall) and serum 25-hydroxyvitamin D (S-25(OH)D) as the references methods. The FFQ was completed for the second time after 4 weeks to assess the reliability of the questionnaire. Data were analyzed using spearman’s correlation, cross-classification analysis, Bland–Altman plots, the weighted κ, intraclass classification, and the method of triads. Spearman’s correlations between vitamin D and Ca intakes by the FFQ and 24-h recalls and between vitamin D intakes and S-25(OH)D were significant (r: 0.706, r: 0.959, and r: 0.682, respectively, all, P < 0.001). Cross-classification for vitamin D and Ca between two dietary methods and for vitamin D intake of FFQ and S-25(OH)D demonstrated that most of the quartiles were categorized into the same or adjacent quartiles. The Bland Altman plots for these nutrients also demonstrated good agreement. For vitamin D, the validity coefficients (VCs) calculated by the method of the triad for three methods were in the range of 0.808–0.843. The weighted κ for agreement of vitamin D and Ca by FFQ1 and FFQ2 were 0.18 and 0.638, respectively. The findings indicated that the developed FFQ has acceptable validity for estimating vitamin D and Ca. Its reliability for Ca was stronger than vitamin D.

Validity and reproducibility of a FFQ for assessing dietary intake among residents of northeast China: northeast cohort study of China

The study was to evaluate the reproducibility and validity of the FFQ for residents of northeast China. A total of 131 participants completed two FFQ (FFQ1 and FFQ2) within a 3-month period, 125 participants completed 8-d weighed diet records (WDR) and 112 participants completed blood biomarker testing. Reproducibility was measured by comparing nutrient and food intake between FFQ1 and FFQ2. The validity of the FFQ was assessed by WDR and the triad method. The Spearman correlation coefficients (SCC) and intraclass correlation coefficients (ICC) for reproducibility ranged from 0·41 to 0·69 (median = 0·53) and from 0·18 to 0·68 (median = 0·53) for energy and nutrients and from 0·37 to 0·73 (median = 0·59) and from 0·33 to 0·86 (median = 0·60) for food groups, respectively. The classifications of same or adjacent quartiles ranged from 73·64 to 93·80 % for both FFQ. The crude SCC between the FFQ and WDR ranged from 0·27 to 0·55 (median = 0·46) for the energy and nutrients and from 0·26 to 0·70 (median = 0·52) for food groups, and classifications of the same or adjacent quartiles ranged from 65·32 to 86·29 %. The triad method indicated that validation coefficients for the FFQ were above 0·3 for most nutrients, which indicated a moderate or high level of validity. The FFQ that was developed for residents of northeast China for the Northeast Cohort Study of China is reliable and valid for assessing the intake of most foods and nutrients.

Are home gardening programs a sustainable way to improve nutrition? Lessons from a cluster-randomized controlled trial in Rufiji, Tanzania

Homestead food production (HFP) programs may improve diet and nutrition outcomes by increasing availability of nutrient dense foods such as vegetables and supporting livelihoods. We conducted a pair-matched cluster-randomized controlled trial to investigate whether vegetable home gardens could improve women's dietary diversity, household food security, maternal and child iron status, and the probability of women consuming nutrient-rich food groups. We enrolled 1,006 women of reproductive age (18-49 years) in ten villages in Pwani Region, Eastern Tanzania, matched the villages into pairs according to village characteristics, and randomly allocated villages to intervention or control. Households in the intervention villages received agricultural training, inputs to promote home production of nutritious crops, and nutrition and health education. Data were collected in 2016, 2017, and 2019 and analyzed using linear regression models with propensity score weighting adjusting for individual-level confounders, differential loss to follow-up, and fixed effects for village pairs to accommodate the pair-matched design. Results after one year of the intervention (previously published) found significant improvements in dietary diversity. However, three years after the start of the intervention the difference in dietary diversity disappeared, even though the number of women who grew at least one crop was significantly higher (75 percentage points, 95% CI: 72, 81) in treatment households compared to controls. Barriers to maintaining a home garden, including lack of irrigation opportunities and fencing materials, and social disruption may have precluded sustained impacts from home gardening in this context. Future home garden programs should carefully consider mechanisms and investments needed for sustained impact over time.

Lack of an association between dietary patterns and adiposity among primary school children in Kilimanjaro Tanzania

Introduction

Healthy dietary habits prevent childhood overweight and obesity and the risk of non-communicable diseases (NCDs) later in life. We examined dietary patterns and their association with adiposity among primary school children in northern Tanzania.

Methods

Dietary data was collected by 24-h recall and food frequency questionnaire (FFQ) for 1170 primary school children aged 9 – 11 years from 20 primary schools in the Kilimanjaro region. Factor analysis and FFQ data were used to identify dietary patterns. Children were categorized into terciles of their adherence to each dietary pattern. Multilevel logistic regression was used to evaluate the association of dietary pattern terciles with adiposity indicators: body mass index z–scores (BMI z scores), body fat percentage by bioelectrical impedance, triceps, subscapular skinfold thicknesses, and waist circumference.

Results

Fifteen percent of children had BMI Z > 1.0, indicating overweight or obesity. Two dietary patterns were identified by factor analysis: a healthy pattern characterized by frequent consumption of fruits and vegetables; and a mixed dietary pattern characterized by intake of fatty snacks, sweets and sugar snacks, sugary beverages, meat and alternatives, milk, and milk products. After adjusting for potential confounders, for both models: model 1 (age and sex), and model 2 (age, sex, school type, time spent walking to school, district [urban/ rural], availability of television and electronic gadgets at home and neighbourhood playground); we found no significant associations between dietary patterns and adiposity measures.

Conclusion

Dietary patterns were not associated with adiposity in Tanzanian primary school children, possibly because of limitations of the FFQ, which did not record information on portion sizes. Future research should focus on understanding the key foods / snacks consumed by school children, portion sizes and their long-term effects on adiposity in children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40795-022-00529-4.

Role of dietary quality and diversity on overweight and obesity among women of reproductive age in Tanzania

This study aimed to examine associations of dietary quality and diversity among reproductive-aged women with overweight and obesity. We conducted a cross-sectional study in the Health and Demographic Surveillance System of the Dar es Salaam Urban Cohort Study (DUCS) in Tanzania. A random sample of 1004 non-pregnant women was selected from the DUCS population database and interviewed about dietary information using the FFQ. Women were aged 30.2 (±8.1) years; 27.8% were overweight and 22.6% were obese. All 1004 women in the study consumed starchy staple foods. Of all the women studied, 10.5%, 1.7% and 3.8% consumed vitamin A rich dark green vegetables, nuts and seeds, and beans and peas, respectively. Compared with women in the lowest quintile of Prime Dietary Quality Score (PDQS), those who were in the highest quintile were significantly less likely to be overweight or obese (Adjusted Prevalence Ratio (APR) = 0.76, 95%CI: 0.62, 0.89) (F for trend = 0.029). Dietary diversity score (DDS) was not significantly associated with overweight and obesity. Risk factors included the highest consumption of animal foods (APR = 2.81, 95% CI: 1.51-3.51) and fast food (APR = 2.57, 95% CI: 1.24-4.34). Consumption of legumes and whole grains was associated with lower risk (APR = 0.59; 95% CI: 0.38-0.2). Dietary quality is an important predictor of overweight and obesity among women of reproductive age. Nutrition interventions may be warranted to support women of reproductive age to enter pregnancy with healthier weight to prevent adverse pregnancy outcomes and future risk of chronic diseases.

Gender and Age Differences in Meal Structures, Food Away from Home, Chrono-Nutrition, and Nutrition Intakes among Adults and Children in Tanzania Using a Newly Developed Tablet-Based 24-Hour Recall Tool

Background

In many regions of the world, little is known about meal structures, meal patterns, and nutrient intake because the collection of quantitative dietary intake is expensive and labor-intensive.

Objectives

We describe the development and field feasibility of a tablet-based Tanzania 24-h recall tool (TZ-24hr-DR) and dietary intakes collected from adults and children in rural and urban settings.

Methods

Using the Tanzanian food-composition table, the TZ-24hr-DR tool was developed on an Android platform using the Open Data Kit. The module provides food lists, meal lists, ingredient lists, quantity and amount consumed, breastfeeding frequency, and a recipe feature. Similar to the USDA Automated Multiple Pass Method, this TZ-24hr-DR contains review features such as time in-between meals, a summary of meals, and portion sizes.

Results

Dietary intake using TZ-24hr-DR was collected among 1) 845 children 0-18 mo of age enrolled in the Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS) trial (ClinicalTrials.gov identifier: NCT03759821) in Mara, Tanzania, and 2) 312 adult families from the Diet, Environment, and Choices of positive living (DECIDE) observational study in peri-urban Dar es Salaam. Interviewers were trained on paper-based methods with food models and tablet-based collection. Conversion to nutrient intake was readily linked and accessible, enabling rapid review and analysis. Overall, 2158 and 8197 dietary meal records were collected from the DECIDE study and EFFECTS trial, respectively. Among adults, 63% of men and 92% of women reported eating at home, and there were differences in protein, fat, and zinc. Food consumed outside the home typically occurs for the first 2 meals. Children's intake of nutrients increased with age; however, median micronutrient intakes for calcium, iron, zinc, and vitamin A remained below recommended nutrient intakes.

Conclusions

The TZ-24hr-DR is a field- and user-friendly tool that can collect large samples of dietary intakes. Further validation is needed. The tool is available freely for research purposes and can be further adapted to other contexts in East Africa.

Validating Accuracy of a Mobile Application against Food Frequency Questionnaire on Key Nutrients with Modern Diets for mHealth Era

In preparation for personalized nutrition, an accurate assessment of dietary intakes on key essential nutrients using smartphones can help promote health and reduce health risks across vulnerable populations. We, therefore, validated the accuracy of a mobile application (app) against Food Frequency Questionnaire (FFQ) using artificial intelligence (AI) machine-learning-based analytics, assessing key macro- and micro-nutrients across various modern diets. We first used Bland and Altman analysis to identify and visualize the differences between the two measures. We then applied AI-based analytics to enhance prediction accuracy, including generalized regression to identify factors that contributed to the differences between the two measures. The mobile app underestimated most macro- and micro-nutrients compared to FFQ (ranges: -5% for total calories, -19% for cobalamin, -33% for vitamin E). The average correlations between the two measures were 0.87 for macro-nutrients and 0.84 for micro-nutrients. Factors that contributed to the differences between the two measures using total calories as an example, included caloric range (1000-2000 versus others), carbohydrate, and protein; for cobalamin, included caloric range, protein, and Chinese diet. Future studies are needed to validate actual intakes and reporting of various diets, and to examine the accuracy of mobile App. Thus, a mobile app can be used to support personalized nutrition in the mHealth era, considering adjustments with sources that could contribute to the inaccurate estimates of nutrients.

Development and validation of food frequency questionnaire for food and nutrient intakes of adults in Butajira, Southern Ethiopia

We developed a culturally-specific Food Frequency Questionnaire (FFQ) to the Ethiopian context and evaluate its validity in comparison to two 24-h dietary recalls (24-HRs) of food and nutrient intake. To evaluate the validity of a culturally-specific FFQ against two 24-HRs, we used a paired t-test, Wilcoxon-signed-rank test, Correlation coefficients, cross-classification, κ and Bland-Altman analysis. The FFQ was obtained 15 d after the second 24-HR was completed. A total of 105 adults, of which 43 (41 %) were men and 62 (59 %) women, aged 20–65 years participated in this present study. Mean energy and macronutrient intake obtained from the FFQ were significantly higher than those obtained from the mean of two 24-HRs. For energy and nutrient intakes, the crude correlation ranged from 0⋅05 (total fat) to 0⋅49 (vitamin B1). The de-attenuated correlation ranged from to 0⋅10 (total fat) to 0⋅80 (vitamin A). For the majority of food groups, no significant difference was observed in the median intake of food and nutrients. Crude correlation for food groups ranged from 0⋅12 (egg) to 0⋅78 (legumes). The de-attenuated correlation ranged from 0⋅24 (egg) to 1⋅00 (meat/poultry/fish and dairy). The FFQ is valid to assess and rank individuals in terms of intake of most food groups according to high and low intake categories.

Household-level double burden of malnutrition in Ethiopia: a comparison of Addis Ababa and the rural district of Kersa

OBJECTIVE

To examine the prevalence of and factors associated with different forms of household-level double burden of malnutrition (DBM) in Ethiopia.

DESIGN

We defined DBM using anthropometric measures for adult overweight (BMI ≥ 25 kg/m2), child stunting (height-for-age Z-score <-2 sd) and overweight (weight-for-height Z-score ≥2 sd). We considered sixteen biological, environmental, behavioural and socio-demographic factors. Their association with DBM forms was assessed using generalised linear models.

SETTING

We used data from two cross-sectional studies in an urban (Addis Ababa, January-February 2018), and rural setting (Kersa District, June-September 2019).

PARTICIPANTS

Five hundred ninety-two urban and 862 rural households with an adult man, adult woman and child <5 years.

RESULTS

In Addis Ababa, overweight adult and stunted child was the most prevalent DBM form (9 % (95 % CI 7, 12)). Duration of residence in Addis Ababa (adjusted OR (aOR) 1·03 (95 % CI 1·00, 1·06)), Orthodox Christianity (aOR 1·97 (95 % CI 1·01, 3·85)) and household size (aOR 1·24 (95 % CI 1·01, 1·54)) were associated factors. In Kersa, concurrent child overweight and stunting was the most prevalent DBM form (11 % (95 % CI 9, 14)). Housing quality (aOR 0·33 (95 % CI 0·20, 0·53)), household wealth (aOR 1·92 (95 % CI 1·18, 3·11) and sanitation (aOR 2·08 (95 % CI 1·07, 4·04)) were associated factors. After adjusting for multiple comparisons, only housing quality remained a significant factor.

CONCLUSIONS

DBM prevalence was low among urban and rural Ethiopian households. Environmental, socio-economic and demographic factors emerged as potential associated factors. However, we observed no common associated factors among urban and rural households.

Consumption of dietary folate estimates and its implication for reproductive outcome among women of reproductive age in Kersa: cross-sectional survey

Background

Dietary folate inadequacy is one the most common micronutrient deficiencies that cause neural tube defect (NTD) among infants in Sub-Saharan African countries. This study aims to determine the dietary intake of folate among women of reproductive age (WRA) of Kersa, Eastern Ethiopia.

Methods

A cross-sectional study took place among voluntary women that were selected from 1140 random households. Using a validated Food Frequency Questionnaire, participant’s weekly dietary intake history of Ethiopian foods and dietary folate intake was worked out. Statistical analysis was done at a 95% confidence interval. Modified Poisson regression was used to identify factors associated with dietary folate consumption.

Result

The estimated median usual intake of folate was 170 μg/d (IQR: 118.3; 252.2) and about 33% of WRA had low folate intake and 73.9% were at risk for folate inadequacy. From the reported food groups, Beans and Peas, Starchy staples, and Vitamin-A rich dark-green leafy vegetables were the top three ranked foods that contributed much of the dietary folate. The following conditions were statistically related to dietary folate inadequacy; women’s age, being in poor wealth index, low dietary diversity, having seasonal employment, and reliance on market food sources.

Conclusions

We found that women’s dietary intake of folate in Kersa is very low and cannot protect their offspring from the risk of having NTD. They could also potentially be predisposed to poor health outcomes. Diversifying and fortification of Ethiopian wheats and salts could decrease the burden of folate deficiency in the country.

Validity of the food frequency questionnaire for adults in nutritional epidemiological studies: A systematic review and meta-analysis

As the most widely used tool for assessing dietary intake, the validity of food frequency questionnaires (FFQs) should be evaluated before application. A comprehensive search of the PubMed and Web of Science databases was conducted for publications from January 2000 to April 1, 2020. Pooled estimates were calculated for correlation coefficients and mean differences for energy and 61 nutrients between FFQs and standard methods. The literature search identified 130 articles that included 21,494 participants. Subgroup analyses according to the number of administrations of the reference method, sample size, administration methods, FFQ items, reference periods, quality of the studies, gender, and regions were also performed. We conducted a meta-analysis by summarizing the available evidence to comprehensively assess the validity of FFQs stratified by the reference method type (24-hour recall (24HRs) and food records (FRs). We also performed subgroup analyses to examine the impact on the final summary estimates. After a meta-analysis of the FFQs' validity correlation coefficients of the included studies, this study showed that the range (median) of the validity coefficients of the 24HRs as reference methods was 0.220-0.770 (0.416), and for the FRs, it was 0.173-0.735 (0.373), which indicated that FFQs were suitable to assess the overall dietary intake in nutritional epidemiological studies. The results of the subgroup analysis showed that the number of administrations of the reference method, administration mode, number of items, reference periods, sample size, and gender mainly affected the validity correlation of FFQs.Supplemental data for this article is available online at https://doi.org/10.1080/10408398.2021.1966737 .

Design and validation of a food frequency questionnaire to assess the dietary intake for adults in pastoral settings in Northern Tanzania

OBJECTIVE

Food frequency questionnaires are widely used as a dietary assessment tool in nutritional epidemiology to determine the relationship between diet and diseases. In Tanzania, there are several cultural variations in food intake which makes it necessary to design and validate a culture-specific food frequency questionnaire (CFFQ). Therefore, we designed a 27-items CFFQ and examine its validity in pastoral communities. Validity of CFFQ was assessed by comparing nutrient intake estimated from the CFFQ against the average from two 24-h diet recall (2R24). Spearman's correlation coefficients, cross classification and Bland-Altman's methods were used to assess the validity of CFFQ.

RESULTS

A total of 130 adults aged 18 years and above completed both CFFQ and 2R24. Correlation coefficients between CFFQ and 2R24 ranged from low (r = - 0.07) to moderate (r = 0.37). The correlation coefficients were moderately significant for kilocalories (r = 0.31, p < 0.001), carbohydrate (r = 0.33, p < 0.001), magnesium (r = 0.37, p < 0.001), and iron (r = 0.34, p < 0.001). On average, about 69% of participants were correctly classified into the same or adjacent quartile of energy and nutrient intake, while 9% were misclassified by the CFFQ. Bland-Altman's plot demonstrated that the CFFQ had acceptable agreement with the 2R24.

Risk factors for overweight and obesity among women of reproductive age in Dar es Salaam, Tanzania

Background

Overweight and obesity have increased considerably in low- and middle-income countries over the past few decades, particularly among women of reproductive age. This study assessed the role of physical activity, nutrient intake and risk factors for overweight and obesity among women in Dar es Salaam, Tanzania.

Methods

We conducted a cross-sectional survey among 1004 women aged 15–49 years in the Dar es Salaam Urban Cohort Study (DUCS) from September 2018 to January 2019. Dietary intake was assessed using a food frequency questionnaire (FFQ). Physical activity was assessed using the Global Physical Activity Questionnaire (GPAQ) using metabolic equivalent tasks (MET). Modified poison regression models were used to evaluate associations between physical activity and nutrient intake with overweight/obesity in women, controlling for energy and other factors.

Results

The mean (±SD) age of study women was 30.2 (±8.1) years. Prevalence of overweight and obesity was high (50.4%), and underweight was 8.6%. The risk of overweight/obesity was higher among older women (35–49 vs 15–24 years: PR 1.59; 95% CI: 1.30–1.95); women of higher wealth status (PR 1.24; 95% CI: 1.07–1.43); and informally employed and married women. Attaining moderate to high physical activity (≥600 MET) was inversely associated with overweight/obesity (PR 0.79; 95% CI: 0.63–0.99). Dietary sugar intake (PR 1.27; 95% CI: 1.03–1.58) was associated with increased risk, and fish and poultry consumption (PR 0.78; 95% CI: 0.61–0.99) with lower risk of overweight/obesity.

Conclusion

Lifestyle (low physical activity and high sugar intake), age, wealth status, informal employment and marital status were associated with increased risk of overweight/obesity, while consumption of fish and poultry protein was associated with lower risk. The study findings underscore the need to design feasible and high-impact interventions to address physical activity and healthy diets among women in Tanzania.

Hart K, Engel B. A Cross-Sectional Analysis of Dietary Intake and Nutritional Status of Patients on Haemodialysis Maintenance Therapy in a Country of Sub-Saharan Africa

Malnutrition is common among dialysis patients, but there is insufficient literature on the problem from resource-poor settings of the sub-Saharan region. We conducted a cross-sectional investigation of dietary intake and nutritional status of haemodialysis (HD) patients to inform the current status of this population group in the region. HD patients aged ≥18 years, with dialysis vintage of ≥3 months, at one nephrology unit in Tanzania were assessed for their habitual diet and nutrient intake. Anthropometric measures and biochemistry tests were also performed. The diet was predominantly starchy food based, accompanied by a limited selection of vegetables. Fruits and animal protein were also minimally consumed (1 portion/day each). Fruit consumption was higher in females than males (median (25th, 75th) = 2 (1, 2.3) versus 0.5 (0, 1.7) portions, p = 0.008). More than 70% of participants had suboptimal measures for protein and energy intake, dietary iron, serum albumin, muscle mass, and hand grip strength (HGS). Inadequacies in protein and energy intake and dialysis clearance (URR) increased with the increase in body weight/BMI and other specific components (MAMC and FMI). Consumption of red meats correlated significantly and positively with serum creatinine (r = 0.46, p = 0.01), potassium (r = 0.39, p = 0.03), and HGS (r = 0.43, p = 0.02) and was approaching significance for a correlation with serum iron (r = 0.32, p = 0.07). C-RP correlated negatively with albumin concentration (r = -0.32, p = 0.02), and participants with C-RP within acceptable ranges had significantly higher levels of haemoglobin (p = 0.03, effect size = -0.28). URR correlated negatively with haemoglobin concentration (r = -0.36, p = 0.02). Patients will benefit from improved nutritional services that deliver individually tailored and culturally practical dietary advice to enable them to make informed food choices whilst optimizing disease management.

Prevalence and correlates of overweight and obesity among primary school children in Kilimanjaro, Tanzania

BACKGROUND

Prevalence of childhood overweight and obesity in low- and middle-income countries is on the rise. We focused on multiple factors which could influence body mass index.

METHODS

A cross sectional school-based study was conducted in Moshi, Tanzania. Primary school children aged 9-11 years were recruited from 20 schools through a multistage sampling technique. Questionnaires were used to collect information on physical activity and diet by food frequency questionnaire. Height and weight measurements were taken and body mass index z scores for age and sex (BMIZ) calculated using the WHO AnthroPlus. Children were considered thin if BMIZ was <-2 standard deviations and overweight or obese if BMIZ was >1 SD. Information on school policies and environment was obtained from headteachers. Correlates of overweight and obesity were examined using a multinomial multilevel logistic regression.

RESULTS

A total of 1170 primary school children, of whom 636 (54%) were girls, were recruited from 20 schools. The prevalence of overweight and obesity was 15% overall (overweight 9% and obesity 6%) and most prevalent in urban areas (23%) and in private schools (24%). Moreover, thinness was found to be (10%) overall, most prevalent in rural areas (13%) and in government schools (14%). At school level, residing in urban (adjusted relative risk ratio [aRRR] 3.76; 95% confidence interval [CI] 2.49,5.68) and being in private school (aRRR 4.08; 95% CI 2.66,6.25) were associated with a higher risk of overweight and obesity while availability of playgrounds in schools (aRRR 0.68; 95% CI 0.47, 0.97) was associated with a lower risk of overweight and obesity. At home level, availability of sugary drinks (aRRR 1.52; 95% CI 1.01,2.28) was associated with a higher risk of overweight and obesity.

CONCLUSION

Overweight and obesity are common in private schools and in urban settings. Efforts should be taken to ensure availability of playgrounds in schools and encouraging children to engage in physical activities.

Risks of aflatoxin exposure among adolescents in boarding schools in Kilimanjaro region, Tanzania

School feeding in low-income countries is dominated by cereals and legumes, which are susceptible to aflatoxin contamination but are usually not assessed for aflatoxins. A cross sectional study was conducted to assess aflatoxin exposure among adolescents through consumption of school meals in Kilimanjaro region. Food frequency questionnaires and 24 h dietary recalls were used to collect information on food consumption. At least four samples of common food used in school meals were collected. A deterministic approach was used to estimate the dietary aflatoxin exposure. High Performance Liquid chromatography (HPLC) was used to analyse presence of aflatoxin contamination. Results showed that, maize based food and beans were consumed on daily basis. The intake of maize flour and dehulled maize ranged from 17.5 to 738.2 g and 28.2 to 272 g per person per day respectively. Furthermore, consumption of beans and rice were in the range of 121.1 to 595.2 g and 15.7 to 42.2 g per person per day respectively. Total aflatoxins ranged 0.20-438.53 μg/kg (median 2.30 μg/kg). The highest contamination range (0.59-438.53 μg/kg) was in maize while the lowest (0.20-3.41 μg/kg) was found in rice. Similarly, the highest aflatoxin B1 (AFB1) concentration (35.88 μg/kg) was in dehulled maize while the lowest (0.44 μg/kg) was in rice. The highest dietary exposure to total aflatoxins and AFB1 due to consumption of maize ranged from 0.70 to 973.45 ng/kg/bodyweight (bw)/day, and from 0.05-81.06 ng/kg/bw/day, respectively. This pronounced risk of exposure to aflatoxins might have been contributed by a monotonous maize based diet in boarding schools. These findings call for institutions immediate interventions, such as the use of appropriate storage technologies, sorting, cleaning and winnowing in order to remove damaged grains, thereby reducing the risk of dietary exposure to aflatoxins. Likewise, the relevant ministries should consider food diversification and routine risk assessments of the susceptible crops throughout the value chain as a long-term intervention plan at policy level.

Life expectancy and agricultural environmental impacts in Addis Ababa can be improved through optimized plant and animal protein consumption

In Ethiopia, children and adults face a double burden of malnutrition, with undernutrition and stunting coexisting with non-communicable diseases. Here we use a framework of comparative risk assessment, local dietary surveys and relative risks from large observational studies to quantify the health and environmental impacts of meeting adult and child recommended daily protein intakes in urban Addis Ababa. We find that plant-based foods, especially legumes, would have the lowest environmental impact and substantially increase life expectancy in adults, while animal-source proteins could be beneficial for children. This context-specific approach-accounting for regional constraints and trade-offs-could aid policymakers in developing culturally appropriate, nutritionally adequate and sustainable dietary recommendations.

Validity and reproducibility of a Food Frequency Questionnaire for German descendants living in Brazil

ABSTRACT Objective This study evaluated reproducibility, relative validity, using a 24-hour recall questionnaire as a reference standard, and estimated calibration factors for a food frequency questionnaire adapted for use with German descendants living in Brazil. Methods The target population consisted of 50 volunteers, of both genders, aged over 20 years, living in a German colonization city in southern Brazil. The food frequency questionnaire was applied twice, in the first and third months of the investigation. During this period, three 24-hour recalls were applied, with an interval of one month between them. Reproducibility was estimated by the intraclass correlation coefficient. Validity was tested by the intraclass correlation coefficient, weighted kappa test and Bland-Altman method. Calibration factors were estimated using linear regression. Results Among the food frequency questionnaires, there was a strong correlation for energy and most of the nutrients corrected for energy. There was a weak correlation between a food frequency questionnaire and a 24-hour dietary recall. However, the exact concordance in the categorization in tertiles among the instruments ranged from 28% (vitamin A) to 52% (fiber and potassium). Gross values of the food frequency questionnaire were reduced with the calibration and approached the consumption data estimated by the 24-hour dietary recall. Conclusions The food frequency questionnaire showed good reproducibility, however, weak correlation with the 24-hour dietary recall. The calibration of the data obtained by the food frequency questionnaire brought them closer to the reference method.

Home gardening improves dietary diversity, a cluster-randomized controlled trial among Tanzanian women

Homestead food production (HFP) programmes improve the availability of vegetables by providing training in growing nutrient-dense crops. In rural Tanzania, most foods consumed are carbohydrate-rich staples with low micronutrient concentrations. This cluster-randomized controlled trial investigated whether women growing home gardens have higher dietary diversity, household food security or probability of consuming nutrient-rich food groups than women in a control group. We enrolled 1,006 women of reproductive age in 10 villages in Pwani Region in eastern Tanzania, split between intervention (INT) and control (CON) groups. INT received (a) agricultural training and inputs to promote HFP and dietary diversity and (b) nutrition and public health counselling from agricultural extension workers and community health workers. CON received standard services provided by agriculture and health workers. Results were analysed using linear regression models with propensity weighting adjusting for individual-level confounders and differential loss to follow up. Women in INT consumed 0.50 (95% CI [0.20, 0.80], p = 0.001) more food groups per day than women in CON. Women in INT were also 14 percentage points (95% CI [6, 22], p = 0.001) more likely to consume at least five food groups per day, and INT households were 6 percentage points (95% CI [-13, 0], p = 0.059) less likely to experience moderate-to-severe food insecurity compared with CON. This home gardening intervention had positive effects on diet quality and food security after 1 year. Future research should explore whether impact is sustained over time as well as the effects of home garden interventions on additional measures of nutritional status.

Food Crop Diversity, Women's Income-Earning Activities, and Distance to Markets in Relation to Maternal Dietary Quality in Tanzania

BACKGROUND

Women's dietary diversity and quality are limited in low- and middle-income countries (LMICs). Nutrition-sensitive interventions that promote food crop diversity and women's access to income could improve diets and address the double burden of malnutrition in LMICs.

OBJECTIVES

We examined the associations among food crop diversity and women's income-earning activities with women's diet quality, as well as effect modification by access to markets, in the context of small-holder food production in rural Tanzania.

METHODS

Data from a cross-sectional study of 880 women from Rufiji, Tanzania, were analyzed. Women's dietary intake was assessed using a food frequency questionnaire. The prime diet quality score (PDQS; 21 food groups; range, 0-42), a unique diet-quality metric for women that captures the healthy and unhealthy aspects of diet, was computed. Generalized estimating equation linear models were used to evaluate the associations of food crop diversity and women's income-earning activities with PDQS, while controlling for socio-economic factors.

RESULTS

Maternal overweight (24.3%) and obesity (13.1%) were high. The median PDQS was 19 (IQR, 17-21). Households produced 2.0 food crops (SD ± 1.0) yearly. Food crop diversity was positively associated with PDQS (P < 0.001), but the association was strengthened by proximity to markets (P for interaction = 0.02). For women living close (<1.1 km) to markets, producing 1 additional food crop was associated with a 0.67 (95% CI, 0.22-1.12) increase in PDQS, versus a 0.40 (95% CI, 0.24-0.57) increase for women living farther away. The PDQS increased with women's salaried employment (estimate, 0.96; 95% CI, 0.26-1.67).

CONCLUSIONS

Household food production may interact with access to markets for sales and purchases, while nonfarm income also improves women's diet quality in rural Tanzania. Programs to improve women's diet quality should consider improving market access and women's access to income (source of empowerment), in addition to diversifying production.

Validation of semiquantitative FFQ administered to adults: a systematic review

Objective:

To conduct a systematic review of studies for the validation of semiquantitative FFQ (SFFQ) that assess food intake in adults.

Design:

The authors conducted a systematic search in PubMed for articles published as late as January 2020 in Spanish, English, French and Portuguese. Individual searches (twelve in total) paired three hyphenated and non-hyphenated variations of ‘semiquantitative food frequency questionnaire’ with both ‘validity’ and ‘validation’ using the ‘all fields’ and the ‘title/abstract’ retrieval categories. Independent extraction of articles was performed by four authors using predefined data fields.

Setting:

We searched for original SFFQ validation studies that analysed general diet composition (nutrients with or without food groups or energy analysis) in healthy adults, in any setting, and that also reported correlation coefficients.

Participants:

Healthy adults.

Results:

Sixty articles were included. The preferred comparison standard for validation was food records (n 37). The main correlation coefficients used were Pearson’s (n 41), and validity coefficients varied from −0·45 to 1. Most correlation coefficients were adjusted by energy (twelve studies presented only crude values). The elements mentioned most frequently were energy, macronutrients, cholesterol, SFA, PUFA, fibre, vitamin C, Ca and Fe.

Conclusions:

Although all these SFFQ are reported as validated, coefficients may vary across groups of foods and nutrients. Based on our findings, we suggest researchers to consult our revision before choosing a SFFQ and to review important issues about them, such as their validation, number of items, number of participants, etc. Systematic Review Registration: PROSPERO number CRD42017064716. Available at: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42017064716.

Dietary Practices, Nutrient Adequacy, and Nutrition Status among Adolescents in Boarding High Schools in the Kilimanjaro Region, Tanzania

A cross-sectional study was conducted to assess dietary practices, nutrient adequacy, and nutrition status among 164 adolescents aged between 16 and 19 years in boarding secondary schools in the Kilimanjaro region. In-depth interviews and a survey guided by a semistructured and structured questionnaire, including 24-hour recall and food frequency questionnaire techniques, were used to collect information. Nutrition status was assessed using anthropometric measurements and hemoglobin levels. WHO AnthroPlus software and NutriSurvey software were used to analyze anthropometry and dietary data, respectively. Diet in boarding schools was monotonous comprising mainly of cereal-legume meal with low intake of animal sources, fruits, and vegetables. Mean intake of energy, vitamin C, iron, calcium, and zinc was 1392 kcal, 24.8 mg, 9.2 mg, 134.5 mg, and 4.3 mg, respectively, which were below the Recommended Daily Allowance. The average carbohydrate, fat, and protein intake of 471.9 g, 73.7 g, and 80.7 g, respectively, were slightly higher than the Recommended Daily Allowance in both sexes. Male had a significantly higher intake of protein and carbohydrates (P < 0.001). Female had a significantly (P < 0.001) high intake of fat compared to male adolescents. Overall, 23.1% of the adolescents were anaemic, 25% were overweight, and 6.1% were obese. Boarding secondary schools' diet is monotonous and are inadequate in key micronutrients, iron, zinc, calcium, and vitamin C. There is a coexistence of undernutrition and overnutrition among adolescents in boarding schools. Therefore, monitoring adolescents' dietary intake and nutrition status is a key in preventing adolescents' malnutrition in the short term and diet-related diseases in the long term.

Relative validity of a computer-based semi-quantitative FFQ for use in the Pelotas (Brazil) Birth Cohort Studies

OBJECTIVE

To assess the relative validity of a FFQ developed for the Pelotas Birth Cohort Studies.

DESIGN

Participants completed a ninety-two-food-item FFQ and then answered two 24-h recalls (24HR), one in-person interview and a second one by telephone, administered 14-28 d apart. Median and relative differences of energy, fifteen nutrients and eleven food groups were estimated based on the FFQ and the average of two 24HR. Nutrients were log-transformed and energy-adjusted using residual method. Validity was assessed by crude, energy-adjusted and de-attenuated Pearson and Lin's concordance correlation coefficients. Agreement of quartiles and weighted κ were performed. Differences in energy and nutrient estimations between methods were plotted in Bland-Altman graphs.

SETTING

Pelotas, southern Brazil.

PARTICIPANTS

Two hundred fifty-four participants randomly selected from the 1993 Pelotas Birth Cohort during the 22-year follow-up (2015).

RESULTS

The FFQ overestimated energy and most nutrients and food groups compared with the two 24HR. Energy-adjusted and de-attenuated Pearson correlation coefficients ranged from 0·21 to 0·66. The highest energy-adjusted and de-attenuated concordance correlation coefficients were observed for Ca (0·48), niacin (0·32), Na (0·29), vitamin C (0·28) and riboflavin (0·25). The percentage of nutrients classified into the same and opposite quartiles ranged from 36·5 to 60·3 %, and from 4·8 to 19·1 %, respectively. Weighted κ was moderate for Ca (0·51), beans and legumes (0·50) and milk and dairies (0·49).

CONCLUSIONS

The FFQ provides a reasonable dietary intake assessment for habitual food consumption. However, the relative validity was weak for specific nutrients and food groups.

Cross-country comparison of dietary patterns and overweight and obesity among adult women in urban Sub-Saharan Africa

OBJECTIVE

To derive dietary patterns (DP) among women of reproductive age (WRA) and older women in urban Sub-Saharan Africa (SSA), and to examine their association with body mass index (BMI), overweight and obesity.

DESIGN

We used principal component analysis to derive DP. Their association with BMI, overweight and obesity was assessed using linear and multinomial logistic regression models controlling for age, marital status, education and wealth.

SETTING

Cross-sectional data from prospective studies in Accra, Ghana (2008-2009), Dar es Salaam, Tanzania (2014) and Lilongwe and Kasungu, Malawi (2017-2018) were used.

PARTICIPANTS

We compared WRA in Ghana (18-54 years, n 1762) and Malawi (19-48 years, n 137), and older women in Ghana (≥55 years, n 514) and Tanzania (≥50 years, n 134).

RESULTS

Among WRA, protein and healthy DP were identified in both Ghana and Malawi. In Ghana, the protein DP was associated with higher odds of overweight or obesity (adjusted OR 1·82, 95 % CI 1·27, 2·60 for quintile 2). Among older women, three DP were identified in Ghana (cereal, protein and healthy) and two DP in Tanzania (protein and healthy). The protein DP was associated with higher BMI in Ghana (adjusted mean difference 2·83, 95 % CI 0·95, 4·71 for quartile 3).

CONCLUSIONS

Higher quintiles of the protein DP were associated with higher BMI and odds of overweight or obesity among women in urban Ghana, but not in Malawi or Tanzania. Further research is needed to understand how DP influence overweight and obesity among adult women in urban SSA.

Effects of school-based physical activity and multi-micronutrient supplementation intervention on growth, health and well-being of schoolchildren in three African countries: the KaziAfya cluster randomised controlled trial protocol with a 2 × 2 factorial design

BACKGROUND

In low- and middle-income countries, infectious diseases remain a key public health issue. Additionally, non-communicable diseases are a rapidly growing public health problem that impose a considerable burden on population health. One way to address this dual disease burden, is to incorporate (lifestyle) health promotion measures within the education sector. In the planned study, we will (i) assess and compare physical activity, physical fitness, micronutrient status, body composition, infections with soil-transmitted helminths, Schistosoma mansoni, malaria, inflammatory and cardiovascular health risk markers, cognitive function, health-related quality of life, and sleep in schoolchildren in Côte d'Ivoire, South Africa and Tanzania. We will (ii) determine the bi- and multivariate associations between these variables and (iii) examine the effects of a school-based health intervention that consists of physical activity, multi-micronutrient supplementation, or both.

METHODS

Assuming that no interaction occurs between the two interventions (physical activity and multi-micronutrient supplementation), the study is designed as a cluster-randomised, placebo-controlled trial with a 2 × 2 factorial design. Data will be obtained at three time points: at baseline and at 9 months and 21 months after the baseline assessment. In each country, 1320 primary schoolchildren from grades 1-4 will be recruited. In each school, classes will be randomly assigned to one of four interventions: (i) physical activity; (ii) multi-micronutrient supplementation; (iii) physical activity plus multi-micronutrient supplementation; and (iv) no intervention, which will serve as the control. A placebo product will be given to all children who do not receive multi-micronutrient supplementation. After obtaining written informed consent from the parents/guardians, the children will be subjected to anthropometric, clinical, parasitological and physiological assessments. Additionally, fitness tests will be performed, and children will be invited to wear an accelerometer device for 7 days to objectively assess their physical activity. Children infected with S. mansoni and soil-transmitted helminths will receive deworming drugs according to national policies. Health and nutrition education will be provided to the whole study population independently of the study arm allocation.

DISCUSSION

The study builds on the experience and lessons of a previous study conducted in South Africa. It involves three African countries with different social-ecological contexts to investigate whether results are generalisable across the continent.

TRIAL REGISTRATION

The study was registered on August 9, 2018, with ISRCTN. https://doi.org/10.1186/ISRCTN29534081.

Effects of school-based physical activity and multi-micronutrient supplementation intervention on growth, health and well-being of schoolchildren in three African countries: the KaziAfya cluster randomised controlled trial protocol with a 2 × 2 factorial design

BACKGROUND

In low- and middle-income countries, infectious diseases remain a key public health issue. Additionally, non-communicable diseases are a rapidly growing public health problem that impose a considerable burden on population health. One way to address this dual disease burden, is to incorporate (lifestyle) health promotion measures within the education sector. In the planned study, we will (i) assess and compare physical activity, physical fitness, micronutrient status, body composition, infections with soil-transmitted helminths, Schistosoma mansoni, malaria, inflammatory and cardiovascular health risk markers, cognitive function, health-related quality of life, and sleep in schoolchildren in Côte d'Ivoire, South Africa and Tanzania. We will (ii) determine the bi- and multivariate associations between these variables and (iii) examine the effects of a school-based health intervention that consists of physical activity, multi-micronutrient supplementation, or both.

METHODS

Assuming that no interaction occurs between the two interventions (physical activity and multi-micronutrient supplementation), the study is designed as a cluster-randomised, placebo-controlled trial with a 2 × 2 factorial design. Data will be obtained at three time points: at baseline and at 9 months and 21 months after the baseline assessment. In each country, 1320 primary schoolchildren from grades 1-4 will be recruited. In each school, classes will be randomly assigned to one of four interventions: (i) physical activity; (ii) multi-micronutrient supplementation; (iii) physical activity plus multi-micronutrient supplementation; and (iv) no intervention, which will serve as the control. A placebo product will be given to all children who do not receive multi-micronutrient supplementation. After obtaining written informed consent from the parents/guardians, the children will be subjected to anthropometric, clinical, parasitological and physiological assessments. Additionally, fitness tests will be performed, and children will be invited to wear an accelerometer device for 7 days to objectively assess their physical activity. Children infected with S. mansoni and soil-transmitted helminths will receive deworming drugs according to national policies. Health and nutrition education will be provided to the whole study population independently of the study arm allocation.

DISCUSSION

The study builds on the experience and lessons of a previous study conducted in South Africa. It involves three African countries with different social-ecological contexts to investigate whether results are generalisable across the continent.

TRIAL REGISTRATION

The study was registered on August 9, 2018, with ISRCTN. https://doi.org/10.1186/ISRCTN29534081.

Dietary Micronutrients and Gender, Body Mass Index and Viral Suppression Among HIV-Infected Patients in Kampala, Uganda

BACKGROUND

HIV/AIDS is a hallmark of immune suppression. Micronutrient deficiencies in diet and recurrent opportunistic infections play major roles in the lives of people living with HIV. Although benefits of providing adequate diet to HIV positive persons are well documented, the demand for key elements still remain unclear in particular settings, especially in low and middle-income countries.

METHODS

This was a cross sectional analysis of baseline data collected from HIV-infected adults initiating antiretroviral therapy, and who were enrolled in a multivitamin supplementation trial. A food frequency questionnaire was used and intake were obtained as a product of quantities consumed. Adequacy was calculated as the proportion of Recommended Dietary Allowances (RDA). A chi square test and logistic regression analysis were used at p-value 0.05 to show significant associations.

RESULTS

Mean intakes were above minimum requirements for analyzed micronutrients with the exception of Calcium and Iron. Participants who met RDA intakes were as follows: highest (≥ 80%) for Magnesium, Selenium, Zinc and Vitamins B2, B6, B9, C and E; moderate (50% to <80%) for Vitamins B3, and A; and lowest (≤50%) for Iron (30%), Calcium (14.9%), Vitamins B12 and B1. Gender differences in met RDA were observed for Iron, Selenium, Zinc, Vitamins A, B1, B3 and E. In multivariable analyses, nutritional status and CD4 count had no influence on meeting RDA for majority of micronutrients such as magnesium, Selenium, B class vitamins (B1, B2, B3, B6, B9, B12), vitamin (A, C, and E), Zinc and Calcium, but not including iron.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Diets consumed by the study participants were low in most protective nutrients (Iron, Calcium, Zinc, Vitamin A, B1, B3, and B12). This deficiency was more common among females than males, and irrespective of BMI or CD 4 count. Findings warrant further investigation on the impact and cost implications for suplementation interventions that target the elements lacking in the diets of people living with HIV in similar low-resourced settings.

The Relationship Between Dietary Diversity Among Women of Reproductive Age and Agricultural Diversity in Rural Tanzania

BACKGROUND

Agriculture can influence diets through consumption of home-produced foods or increased purchasing power derived from sale of agricultural commodities.

OBJECTIVE

This article explores cross-sectional relationships between agricultural diversification and dietary diversity (a proxy for micronutrient adequacy) among women of reproductive age in rural Tanzania.

METHODS

Dietary diversity was measured using the women's minimum dietary diversity score indicator. Data were analyzed from the baseline survey of a cluster randomized control trial in Rufiji, Tanzania. One woman of reproductive age was randomly surveyed from each eligible household, totaling 1006 individuals. Generalized linear mixed-effects models were used to estimate the relationship between agricultural indicators and dietary diversity.

RESULTS

Median dietary diversity score for women was 3.00 (interquartile range: 2-3). Approximately 73% of households grew at least 1 crop in the previous year. Women's dietary diversity score was positively associated with cropping diversity (P for trend = .04), ownership of livestock (adjusted coefficient: 0.30; 95% confidence interval [CI]: 0.08-0.44; P = .005), cash crop production (adjusted coefficient: 0.22; 95% CI: 0.03-0.41; P = .02), and production of pulses (adjusted coefficient: 0.50; 95% CI: 0.27-0.74; P < .0001) and other vegetables (adjusted coefficient: 0.64; 95% CI: 0.11-1.17; P = .02).

CONCLUSIONS

Average dietary diversity is well below the recommended 5 food groups per day, a widely used indicator of micronutrient adequacy. Since the majority of households participate in agriculture, the efforts to promote agricultural diversification and/or specialization and sale of agricultural goods may positively influence dietary diversity and associated health and nutrition outcomes.

Neighbour home gardening predicts dietary diversity among rural Tanzanian women

OBJECTIVE

The present study's aim was to assess the impact of a nutrition-sensitive intervention on dietary diversity and home gardening among non-participants residing within intervention communities.

DESIGN

The study was a cross-sectional risk factor analysis using linear and logistic multivariate models.

SETTING

In Tanzania, women and children often consume monotonous diets of poor nutritional value primarily because of physical or financial inaccessibility or low awareness of healthy foods.ParticipantsParticipants were women of reproductive age (18-49 years) in rural Tanzania.

RESULTS

Mean dietary diversity was low with women consuming three out of ten possible food groups. Only 23·4 % of respondents achieved the recommended minimum dietary diversity of five or more food groups out of ten per day. Compared with those who did not, respondents who had a neighbour who grew crops in their home garden were 2·71 times more likely to achieve minimum dietary diversity (95 % CI 1·60, 4·59; P=0·0004) and 1·91 times more likely to grow a home garden themselves (95 % CI 1·10, 3·33; P=0·02). Other significant predictors of higher dietary diversity were respondent age, education and wealth, and number of crops grown.

CONCLUSIONS

These results suggest that there are substantial positive externalities of home garden interventions beyond those attained by the people who own and grow the vegetables. Cost-effectiveness assessments of nutrition-sensitive agriculture, including home garden interventions, should factor in the effects on the community, and not just on the individual households receiving the intervention.