Nutrition transition among adolescents of a south-Mediterranean country: dietary patterns, association with socio-economic factors, overweight and blood pressure. A cross-sectional study in Tunisia

Poor Eating Habits and Low Physical Activity Contribute to Weight Excess and Increase Cardiometabolic Risk in Adolescents Practicing Soccer as a Recreational Sport

BACKGROUND

Monitoring anthropometry, dietary intake, and physical activity (PA) is essential to prevent/counteract childhood obesity. This study examined dietary intake, PA, and anthropometric characteristics in young boys practicing soccer as a recreational sport.

METHODS

A cross-sectional study included 226 boys aged 8 to 13 years participating in soccer as a recreational activity in football academies located in Tunis, Tunisia. Anthropometric measures allowed the calculation of body mass index, fat mass, and peak height velocity as markers of biological maturity. A three-day food record and a food frequency questionnaire estimated nutrient intake and eating habits. The International Physical Activity Questionnaire (IPAQ) was used to estimate the PA level of the participants.

RESULTS

It was found that a high percentage of the children had excess weight (54%) and excess fat mass (47%). The total energy, carbohydrate, and saturated fat intake of the children exceeded the recommended levels by approximately 10%, 15%, and 30%, respectively. However, the intake of unsaturated fat was below the estimated requirements, particularly in obese children. In addition to the unbalanced macronutrient intake, the children also showed an insufficient intake of many essential micronutrients. Around 60% to 70% of the children in all three groups had a low intake of magnesium, n-3 polyunsaturated fatty acids (PUFA), and vitamins B9, B12, and D. Moreover, 20% to 35% of the children in the three groups had an insufficient intake of vitamins A and C. Insufficient vitamin E intake was found in 63% of obese children and 35% of non-obese children. It was observed that the PA level was lower in the overweight/obese group compared to the normal-weight group (p < 0.005). More than three-quarters of overweight/obese children had low PA levels, about 20% were moderately active, and only 1 to 2% were highly active. Conversely, normal-weight children showed moderate to high PA levels.

CONCLUSIONS

Poor eating behavior, an unbalanced diet, and a low PA level are prevalent in Tunisian boys practicing recreational sports. Such a combination is responsible for a disparity between energy intake and expenditure, contributing to weight excess and increased cardiometabolic risk. The study findings provide meaningful information for practitioners and authorities on applying a balanced diet and adequate PA to prevent and fight against obesity and improve cardiometabolic health in youth.

The prevalence of high blood pressure and its determinants among Tunisian adolescents

Hypertension can originate in childhood and remain undetected unless special screening is performed. The burden of hypertension in adolescents in Tunisia is unknown. The aim of this study was to investigate the prevalence of blood pressure (BP) within the hypertension range and its association with other risk factors among Tunisian adolescents. A cross-sectional study that included 1385 secondary school students in Sousse, Tunisia, was performed during 2017-2018. A two-stage cluster sampling strategy was used to obtain a representative sample of the study population. BP within the hypertension range (HBP)was classified following the European guideline recommendations for measuring BP in children and adolescents. Anthropometric indices were measured using a standard protocol. A structured questionnaire collected information about sociodemographic characteristics, lifestyle, mental health status, and addictions. Adjusted logistic regression models were used to assess hypertension-related risk factors. Our study included 39.5% boys and 60.5% girls. The mean age of our population was 17 ± 1.5 years. The prevalence of HBP was 15.4% (13.1-18.0%), and it was significantly higher in boys (22.8%) than in girls (10.6%, p value < 0.001). In the multivariate logistic regression model, overweight [OR = 1.72(1.18-2.51)] and obesity [OR = 3.73(2.55-5.41)] were independent risk factors for HBPrange, (p value < 0.001), whereas female sex [OR = 0.41(0.29-0.56), p value < 0.001] and depression [OR = 0.67(0.51-0.88), p value = 0.008] were independent protective factors. Among Tunisian secondary school adolescents, the prevalence of HBP was high and associated with excess body weight. A comprehensive strategy for the prevention of hypertension and its risk factors among youth is urgently needed.

The association between dietary trajectories across childhood and blood pressure in early adolescence: The Longitudinal Study of Australian Children

BACKGROUND

Cardio-metabolic risk factors, including hypertension, are increasingly appearing in childhood. The aims of this study were to examine the associations between dietary trajectories across childhood and subsequent blood pressure (BP) at age 10/11, and to further determine whether these associations were explained by BMI or fat mass.

METHODS

Data from 4360 participants from the Longitudinal Study of Australian Children were analysed. Dietary scores were computed based on similarity of intake to the Australian Dietary Guidelines. Group-based trajectory modelling was used to identify distinct dietary trajectories based on participant's individual dietary scores at up to four timepoints between age 4 and 11. Linear regression models examined the associations between dietary trajectories and BP measured at age 10/11. Models were adjusted for relevant covariates, and BMI or fat mass.

RESULTS

Four dietary trajectories were identified: "never healthy" (4.3%); "moderately healthy" (23.1%); "becoming less healthy" (14.2%); and "always healthy" (58.4%). Children in the "always healthy" trajectory had a lower systolic (-2.19 mmHg; 95% CI -3.78, -0.59) and diastolic BP (-1.71; -2.95, -0.47), compared with children in the "never healthy" trajectory after covariate adjustment. These associations were attenuated after additional adjustment for BMI or fat mass, but remained significant for diastolic BP.

CONCLUSIONS

A dietary trajectory mostly aligned with the Australian Dietary Guidelines across childhood was associated with slightly lower BP at age 10/11, which was not fully explained by BMI or fat mass. These findings support the need to encourage and enable healthy dietary habits early in childhood to attenuate the increasing burden of cardio-metabolic disease.

Dietary patterns and indicators of cardiometabolic risk among rural adolescents: A cross-sectional study at 15-year follow-up of the MINIMat cohort

Background

Diet being a modifiable factor, its relationship with cardiometabolic risk is of public health interest. The vast majority of studies on associations of dietary patterns with cardiometabolic risk indicators among adolescents are from high-income countries and urban settings. We sought to describe dietary patterns and examine their associations with selected cardiometabolic risk indicators-waist circumference (WC), systolic blood pressure, fasting lipid profile and insulin resistance-along with its gender stratification among adolescents in a low-income, rural setting.

Methods

This cross-sectional study utilized data from the 15-year follow-up of the Maternal and Infant Nutrition Interventions in Matlab (MINIMat) cohort in southeast Bangladesh. The children who were born as singletons to the mothers randomized in the MINIMat trial and had valid birth anthropometrics were eligible for the follow-up. We employed a single, qualitative 24-hour recall to assess diet. Dietary patterns were derived from simple K-means cluster analysis, and calculation of dietary diversity score (DDS) using a validated instrument. Anthropometric parameters and systolic blood pressure were recorded. Fasting plasma triglyceride, total cholesterol, low- and high-density lipoproteins, insulin and glucose levels were measured. We calculated insulin resistance using the Homeostasis Model Assessment equation (HOMA-IR). Three right-skewed outcome variables were natural log (Ln) transformed: WC, triglyceride and HOMA-IR. Omnibus and gender-specific multiple linear regression models were fitted.

Results

Among 2,253 adolescents (52.1% girls, 7.1% overweight/obese), we identified four diet clusters: Traditional, Fish-dominant, Meat-dominant, and High-variety. No significant associations were found between the clusters and indicators. On gender-stratification, triglyceride levels were lower among boys in the Fish-dominant (Ln-triglyceride βadjusted: -0.09; 95% confidence interval (CI): -0.15, -0.02) and Meat-dominant (Ln-triglyceride βadjusted: -0.08; 95% CI: -0.15, -0.004) clusters than among boys in the Traditional cluster. Compared to boys in the bottom quartile of DDS, boys in the top quartile had 2.1 mm of Hg (95% CI: 0.5, 3.6) higher systolic blood pressure and 1.9% (95% CI: 0.01-3.8%) higher WC.

Conclusion

While statistically significant, the gender-specific differences in triglyceride, systolic blood pressure, and waist circumference across dietary patterns were small. Associations between dietary patterns and cardiometabolic risk indicators may require a time lag beyond mid-adolescence to manifest in a rural setting. Prospective studies are warranted to delineate the magnitude and direction of those associations.

Consumption of fruits and vegetables among adolescents in Arab Countries: a systematic review

BACKGROUND

Adolescents' consumption of fruits and vegetables is inadequate in most Arab countries, leading to a higher risk of poor health outcomes. This systematic review evaluates fruits and vegetables intake among adolescents in Arab countries, the proportion of adolescents meeting the dietary guidelines in these countries, and the dietary assessment tools used to assess fruits and vegetables intake.

METHODS

Four databases were searched, MEDLINE, PUBMED, EMBASE, and Web of Science. Studies were eligible if they reported fruit or vegetable consumption among adolescents aged 10 to 19 in 22 Arab countries. The risk of bias in the included studies was assessed by two reviewers independently using the risk of bias tool developed by Hoy et al. Data were extracted and synthesized into three categories; frequency of fruits and vegetables consumption, mean fruits and vegetables consumption, and percentage of adolescents meeting fruits and vegetables consumption recommendations.

RESULTS

The review included 44 articles utilizing 41 cross-sectional studies. Most studies were school-based, and data was collected from both males and females using self-administered questionnaires. Of those, validated questionnaires were used in 28 studies. According to the World Health Organization recommendation, most studies defined five fruits and vegetables servings as the adequacy cutoff point; other definitions were used in some studies. The reported mean consumption ranged between 6.1 times per week and 4.5 servings of fruits and vegetables per day. The proportion of those who met the recommendations of eating five servings per day ranged between 10 and 29%. Fruits were shown to have a lower daily intake than vegetables (4.2 to 53.7% for fruits and 7.8 to 66.3% for vegetables).

DISCUSSION

This review indicated inadequate fruits and vegetables consumption among adolescents in Arab countries and highlighted an increased risk of non-communicable diseases and malnutrition prevalence. A limitation was the incomparability of available data between countries. Further in-depth research on the core reasons behind adolescents' inadequacy in fruits and vegetables consumption is recommended.

Cost-Effectiveness of Bariatric Surgery in Tunisia

PURPOSE

Obesity is a growing global issue with evidence linking it to an increase in loss of disease-free years, reduced quality of life, increased mortality, and additional economic burden. This study sought to establish the cost-effectiveness of gastric bypass and sleeve gastrectomy, compared to conventional therapy in patients with obesity, from a Tunisian healthcare payor perspective.

PATIENTS AND METHODS

A Markov model compared lifetime costs and outcomes of bariatric surgery with conventional treatment among patients with body mass index (BMI) ≥ 40 kg/m², BMI ≥ 35 kg/m² with obesity-related co-morbidities (Group 1), or BMI ≥ 35 kg/m² with type 2 diabetes mellitus (T2DM) (Group 2). Inputs were sourced from the Tunisian Health Examination Survey, local clinician data and literature sources. Health states were associated with different cost and utility decrements. Changes in body mass index, systolic blood pressure, lipid ratio and diabetes remission rates were modelled on a yearly basis. The incremental cost-effectiveness ratio (ICER), quality-adjusted life years (QALYs) and net monetary benefit (NMB) were key outcomes. Sensitivity and scenario analyses were performed to test the model's robustness.

RESULTS

The model showed that the benefits of bariatric surgery were favorable compared to conventional treatment, with an ICER of 1844 TND/QALY in Group 1 patients and 2413 TND/QALY in Group 2 patients. Bariatric surgery resulted in a QALY gain of 3.26 per patient in Group 1 and a gain of 1.77 per patient in Group 2. At a willingness to pay threshold of 31,379 TND/QALY, the incremental NMB was 96,251 TND and 51,123 TND for Group 1 and Group 2, respectively.

CONCLUSION

From the Tunisian healthcare payor perspective, bariatric surgery is cost-effective for patients with obesity and those with T2DM and obesity-related comorbidities. These findings may have impact on future decision-making on funding and reimbursement of bariatric surgery in Tunisia.

Sugar Reduction Initiatives in the Eastern Mediterranean Region: A Systematic Review

This systematic review aims to identify and characterize existing national sugar reduction initiatives and strategies in the Eastern Mediterranean Region. For this purpose, a systematic review of published and grey literature was performed. A comprehensive list of search terms in the title/abstract/keyword fields was used to cover the four following concepts (1) sugar, (2) reduction OR intake, (3) policy and (4) EMR countries. A total of 162 peer-reviewed documents were identified, until the 2nd of August 2022. The key characteristics of the identified national strategies/initiatives included the average sugar intake of each country's population; sugar levels in food products/beverages; implementation strategies (taxation; elimination of subsidies; marketing regulation; reformulation; consumer education; labeling; interventions in public institution settings), as well as monitoring and evaluation of program impact. Twenty-one countries (95%) implemented at least one type of sugar reduction initiatives, the most common of which was consumer education (71%). The implemented fiscal policies included sugar subsidies' elimination (fourteen countries; 67%) and taxation (thirteen countries 62%). Thirteen countries (62%) have implemented interventions in public institution settings, compared to twelve and ten countries that implemented food product reformulation and marketing regulation initiatives, respectively. Food labeling was the least implemented sugar reduction initiative (nine countries). Monitoring activities were conducted by four countries only and impact evaluations were identified in only Iran and Kingdom of Saudi Arabia (KSA). Further action is needed to ensure that countries of the region strengthen their regulatory capacities and compliance monitoring of sugar reduction policy actions.

Trends in prevalence of overweight and obesity among South African and European adolescents: a comparative outlook

BACKGROUND

South Africa has several national surveys with body weight-related data, but they are not conducted regularly. Hence, data on longitudinal trends and the recent prevalence of adolescent obesity are not readily available for both national and international reporting and use. This study collectively analysed nationally representative surveys over nearly 2 decades to investigate trends in prevalence of adolescent obesity in South Africa. Furthermore, it compared these data with similar continental report for 45 countries across Europe and North America including United Kingdom, Norway, Netherland, Sweden, Azerbaijan, etc. to identify at-risk sub-population for overweight and obesity among adolescents.  METHODS: The study included primary data of adolescents (15 - 19 years) from South African national surveys (N = 27, 884; girls = 51.42%) conducted between 1998 and 2016. Adolescents' data extracted include measured weight, height, sex, parent employment status, monthly allowance received, and family socioeconomic-related variables. Data were statistically analysed and visualized using chi-square of trends, Wald statistics, odds ratio and trend plots, and compared to findings from European survey report (N = 71, 942; girls = 51.23%). South African adolescents' obesity and overweight data were categorized based on World Health Organization (WHO)'s growth chart and compared by sex to European cohort and by family socioeconomic status.

RESULTS

By 2016, 21.56% of South African adolescents were either obese or overweight, similar to the 21% prevalence reported in 2018 among European adolescents. Girls in South Africa showed higher trends for obesity and overweight compared to boys, different from Europe where, higher trends were reported among boys. South African Adolescents from upper socioeconomic families showed greater trends in prevalence of overweight and obesity than adolescents from medium and lower socioeconomic families. Mothers' employment status was significantly associated with adolescents' overweight and obesity.

CONCLUSIONS

Our study shows that by 2016, the prevalence of adolescent obesity was high in South Africa - more than 1 in 5 adolescents - which is nearly similar to that in Europe, yet South African girls may be at a greater odd for overweight and obesity in contrast to Europe, as well as adolescents from high earning families. South African local and contextual factors may be driving higher prevalence in specific sub-population. Our study also shows the need for frequent health-related data collection and tracking of adolescents' health in South Africa.

School and community drivers of child diets in two Arab cities: The SCALE protocol and innovative tools to assess children’s food environments

Background

In the context of the rapid nutrition transition experienced by middle-income countries of the Arab region, children and adolescent’s food choices and dietary behaviors are early risk factors for the development of non-communicable diseases. Assessment of factors influencing food choices among this age group is challenging and is usually based on self-reported data, which are prone to information and recall bias. As the popularity of technologies and video gaming platforms increases, opportunities arise to use these tools to collect data on variables that affect food choice, dietary intake, and associated outcomes. This protocol paper describes the SCALE study (School and community drivers of child diets in Arab cities; identifying levers for intervention) which aims to explore the environments at the level of households, schools and communities in which children’s food choices are made and consequently identify barriers and enablers to healthy food choices within these environments.

Methods

Field studies are being conducted in primary schools, among children aged 9–12 years, in Greater Beirut, Lebanon and Greater Tunis, Tunisia. A stratified random sample of 50 primary schools (public and private) are selected and 50 children are randomly selected from grades 4-5-6 in each school. The study includes surveys with children, parents/caregivers, school directors, teachers, and nutrition/health educators to assess individual diets and the contextual factors that influence children’s food choices. Innovative locally adapted tools and methods such as game-based choice experiments, wearable cameras and neighborhood mapping are used to describe the environments in which children’s food choices are made.

Discussion

The SCALE study will generate contextual knowledge on factors in school and neighborhood environments that influence child dietary behaviors and will inform multi-level interventions and policies to address childhood malnutrition (under-and over-nutrition). By integrating methods from various disciplines, including economics, data science, nutrition, and public health and by considering factors at various levels (home, school, and neighborhood), the study will identify levers for intervention with the potential to improve children’s dietary behaviors. This will help fill existing gaps in research on food systems and consequently guide positive change in Lebanon and Tunisia, with the potential for replicability in other contexts.

Infancy Dietary Patterns, Development, and Health: An Extensive Narrative Review

Correct dietary patterns are important for a child’s health from birth to adulthood. Understanding a child’s health as a state of entire physical, mental, and social well-being is essential. However, reaching adulthood in a complete health proper state is determined by feeding and dietary habits during preconception, pregnancy, or children infancy. Different factors, such as the mother’s lifestyle, culture, or socioeconomic status, are crucial during all these phases. In this review, we aimed to assess the long-term associations between infancy dietary patterns and health and their influence on development and growth. To reach this objective, a consensus critical review was carried out using primary sources such as scientific articles, and secondary bibliographic indexes, databases, and web pages. PubMed, SciELO, and Google Scholar were the tools used to complete this research. We found that high-income countries promote high-calorie foods and, consequently, obesity problems among children are rising. However, undernutrition is a global health issue concerning children in low- and middle-income countries; thus, parental socioeconomic status in early life is essential to children’s health and development, showing that biological, social, and environmental influences are increased risk factors for chronic diseases. This narrative review is aimed to collect evidence for early nutritional intervention and future disease prevention.

Association of dietary patterns with blood pressure and body adiposity in adolescents: a systematic review

This paper aimed to systematically review the results of observational studies that investigated the association of dietary patterns with blood pressure and body adiposity markers in adolescents. Articles were searched in July 2020 in PubMed, Scopus, Web of Science, and Scientific Electronic Library Online (SciELO). Of the 3408 studies found, 24 fulfilled the inclusion criteria and were considered in this review. Almost all studies (n = 23) identified at least one unhealthy pattern, predominantly characterized as consumption of confectionery, refined grains, sweets, sweetened drinks, red meats, and processed meats. Fourteen of the twenty-four studies found a significant association between any dietary pattern and blood pressure and/or body adiposity markers. There was a positive association of dietary patterns - characterized by the consumption of foods rich in sodium, animal fat, refined carbohydrates, and low in fiber - with increased blood pressure and body adiposity. Our findings highlight the importance of studies with this scope, whose results can support the surveillance of adolescent's health. However, considering the limited number of studies that found a significant association and their limitations, the present results should be interpreted carefully. More prospective studies are needed to determine how adherence to dietary patterns could influence blood pressure and body adiposity markers in the long term.

Food consumption in Tunisian university students and its association with sociodemographic characteristics and lifestyle behaviours

OBJECTIVE

This study aimed to characterise food consumption among students at the University of Carthage (Tunisia), assessing quality of diet and main dietary patterns, and their association with potential conditioning factors.

DESIGN

Cross-sectional study. Participants self-reported food consumption in two 24-h recalls and information about sociodemographic, anthropometric and lifestyle characteristics such as BMI, birthplace, physical activity, eating places or kitchen appliances. Mediterranean Diet Score (MDS) and the Nutrient Rich Foods (NRF) index (NRF9.3) were used to assess diet quality. Exploratory factor analysis was conducted to identify eating patterns. Linear regression models were used to test the association of dietary patterns with the diet quality markers.

SETTING

Students at the University of Carthage, Tunisia.

PARTICIPANTS

132 students.

RESULTS

Almost 96 % of participants need shifts towards healthier food. Four main food patterns were identified 'Traditional food', 'Transitional food', 'European breakfast' and 'Western food'. 'Traditional food' was the first dietary model, positively associated with MDS and NRF9.3. Women showed higher adherence to 'European breakfast' and higher quality of diet by NRF9.3. Students eating out of home showed higher adherence to 'Western food', those who never kept a regular schedule of meals consumed lower amount of vegetables and tubers, and sedentary or low active students had a higher intake of ready-to-eat products.

CONCLUSIONS

Diet quality of the participating Tunisian students is inadequate, but traditional Mediterranean diet remains the main pattern in spite of the advanced transitional nutrition. Some lifestyle risk behaviours affecting quality of diet were identified in this work, which supports the youth's particular vulnerability.

Successful aging and lifestyle comparison of Greeks living in Greece and abroad: the epidemiological Mediterranean Islands Study (MEDIS)

OBJECTIVES

Comparing lifestyle and successful aging between Greeks living in Greece (GG) and Greeks living abroad (GA) using a multidimensional model of successful aging including both biomedical and non-medical components.

METHODS

Anthropometric, clinical, psychological, socio-demographic, dietary and lifestyle parameters were assessed in a random sample of 252 GG and 252 GA. Successful aging was evaluated using the validated successful aging index (SAI range 0-10).

RESULTS

GA had better financial and educational status and scored higher in all social activity parameters (p's < 0.05). GA were more likely to be physically active (p < 0.001), had higher adherence to the Mediterranean diet (p < 0.001) and were less likely to be smoking (p = 0.008). Depression was more evident among GG compared to GA (p < 0.001). GA was aging significantly more successfully than GG (p < 0.001). Men irrespective of location were aging significantly more successfully than women (p < 0.05).

CONCLUSION

Place of residence and personal choices significantly affect the level of healthy aging among people with similar genetic backgrounds.

Guide de Pratique Clinique. Prise en charge de l’hypertension artérielle chez l’adulte en Tunisie

Ce document a été réalisé dans le cadre d'une collaboration entre l'Instance Nationale de l’Évaluation et de l'Accréditation en Santé (INEAS), la Société Tunisienne de Cardiologie et de Chirurgie Cardiovasculaire (STCCCV) et la Caisse Nationale d’Assurance Maladie (CNAM).

Salt Reduction Initiatives in the Eastern Mediterranean Region and Evaluation of Progress towards the 2025 Global Target: A Systematic Review

This study aims at identifying national salt reduction initiatives in countries of the Eastern Mediterranean Region and describing their progress towards the global salt reduction target. A systematic review of published and grey literature was conducted. Key characteristics of strategies were extracted and classified according to a pre-defined framework: salt intake assessments; leadership and strategic approach; implementation strategies; monitoring and evaluation of program impact. Salt intake levels were estimated in 15 out of the 22 countries (68%), while national salt reduction initiatives were identified in 13 (59%). The majority of countries were found to implement multifaceted reduction interventions, characterized by a combination of two or more implementation strategies. The least common implementation strategy was taxation, while the most common was reformulation (100%), followed by consumer education (77%), initiatives in specific settings (54%), and front of pack labelling (46%). Monitoring activities were conducted by few countries (27%), while impact evaluations were lacking. Despite the ongoing salt reduction efforts in several countries of the region, more action is needed to initiate reduction programs in countries that are lagging behind, and to ensure rigorous implementation and evaluations of ongoing programs. Such efforts are vital for the achievement of the targeted 30% reduction in salt intake.

Epidemiological characteristics of hypertension, impaired fasting capillary glucose and their comorbidity: a retrospective cross-sectional population-based study of rural adolescents in Southeast Nigeria

OBJECTIVE

To assess the prevalence of hypertension, impaired fasting capillary glucose (IFCG) and coexistence of both as well as determinants of these conditions among rural adolescents.

DESIGN

A retrospective cross-sectional population-based study.

SETTING

Three rural communities in southeast Nigeria.

PARTICIPANTS

A total of 401 adolescents (10 - 19 years) selected through a five-stage sampling technique completed the study. Sick adolescents, pregnant and nursing adolescent mothers were excluded.

PRIMARY OUTCOME MEASURES

Prevalence and determinants of hypertension, IFCG and comorbidity of both were assessed through weight, height, blood pressure, fasting capillary glucose measurements and statistical analysis.

RESULTS

Prehypertension (10.7%), hypertension alone (12.7%), IFCG alone (11.0%), diabetes (0.2%) and hypertension with IFCG (6.2%) were prevalent among the adolescents. The adolescents aged 15 - 19 years were less likely to be affected by hypertension alone (adjusted OR (AOR)=0.36, 95% CI 0.18 to 0.74, p<0.01). The likelihood of having hypertension alone was three times higher among those who smoked any substance (AOR=3.43, 95% CI 1.34 to 8.78, p<0.05) and 2.85 times higher among those who consumed alcohol (AOR=2.85, 95% CI 1.33 to 6.10, p<0.01). Meal skipping (AOR=2.69, 95% CI 1.16 to 6.25, p<0.05), consumption of fried/baked snacks (AOR=15.46, 95% CI 1.62 to 147.37, p<0.05) and vegetables (AOR=2.27, 95% CI 1.11 to 4.66, p<0.05) were also significant risk factors of hypertension alone. Skipping meals (AOR=2.15, 95% CI 0. 93 to 4.99, p>0.05) and longer than 7 hours of night sleep (AOR=1.88, 95% CI 0.94 TO 3.73, p>0.05) increased the risk of IFCG alone by twofold. Female adolescents (AOR=0.29, 95% CI 0.10 to 0.78, p<0.05) and those who consumed fried/baked snacks (AOR=0.09, 95% CI 0.02 to 0.37, p<0.01) were less likely to have hypertension with IFPG than males and those who consumed non-fried/baked snacks, respectively.

CONCLUSION

This study reported relatively low prevalence of hypertension alone, IFCG alone, hypertension with IFCG and epidemiological characteristics that can become focus of interventions to curtail the emergence of cardiovascular events at an early age. Awareness creation through health and nutrition education is emphasised.

Unbalanced intakes of sodium and potassium among Tunisian adults: A cross-sectional study

The prevention and management of hypertension are untimely associated with a lowering of sodium intake. The present study aimed to evaluate the sodium and potassium intake levels of Tunisian population through measurement of 24-hr urinary sodium excretions. A randomly, multistage, cross-sectional study was conducted in an urban region (Bizerte) in Tunisia during 2015. The target population involved adults aged from 25 to 64 years. Sodium, potassium, and creatinine concentrations were determined in each urine sample using indirect potentiometric method. From the 420 selected participants, only 194 gave urine samples complying completeness criteria. A multivariate regression model was used to assess the variables related to sodium and potassium excretion. The daily mean excretion of sodium and potassium was 138.3 ± 46.5 mmol/d (corresponding to 8.1 ± 2.7 g/d of salt intake) and 61.0 ± 22.7 mmol/d, respectively. More than 87.1% of the participants (89.8% for men vs. 84.9% for women; p = .31) exceeded the WHO recommendation of 5 g/d. The upper limit of 10 g salt intake per day was still exceeded by 26.3%. After adjusted analysis, sex (for women, coef = -1.6; (95% CI: -2.4, -0.7)), level of instruction (≥30 kg/m2, coef = +1.1; (95% IC: 0.4-2.0)), and body mass index (≥30 kg/m2, coef = +1.1; (95% CI: 0.1, 2.0)) were associated with the sodium excretion. High sodium intake and inadequate potassium intake were found among participants. This consumption profile complies with the diet westernization context occurring in Tunisia. The initiated strategy focused on the downward of sodium in bread (the main source of salt intake) seems to be promising.

Relative Validity of a Semi-Quantitative Food Frequency Questionnaire for Adolescents

<b><i>Introduction:</i></b> A valid food frequency questionnaire (FFQ) is a priority for epidemiological studies. We aimed to perform a relative validity of an FFQ for Portuguese adolescents. <b><i>Methods:</i></b> A semi-quantitative Portuguese FFQ (SQ-PortFood-FQ) was developed and the relative validity performed using the multiple-pass 24-h recall. Eighty adolescents (aged 10–17 years) completed both questionnaires to measure energy intake, macro- and specific micronutrient intake. We used the following methods for the relative validity: (1) Spearman’s correlation coefficient (<i>r</i>); (2) cross-classification into the same third (agreement) and into the opposite third (disagreement); (3) weighted κ-coefficient (κ_W); (4) and the Bland-Altman method. <b><i>Results:</i></b> We obtained acceptable correlation coefficients between questionnaires for energy (<i>r =</i>0.59;<i> p</i> &#x3c; 0.001), protein (<i>r =</i>0.60;<i> p</i>&#x3c; 0.001), fat (<i>r</i> = 0.55;<i> p</i> &#x3c; 0.001), carbohydrates (<i>r =</i>0.51;<i> p</i> &#x3c; 0.001) and sodium (<i>r =</i>0.51;<i> p</i> &#x3c; 0.001). Tertile agreement for energy, protein, fat, carbohydrates and vitamin C intakes classified correctly more than 50% and grossly misclassified less than 10% of participants. Energy and protein produced moderate agreement between methods with a κ_W &#x3e;0.40. The SQ-PortFood-FQ overestimated all analysed data when compared to the 24-h recall, although those estimations were &#x3c;10% for energy, macronutrients and cholesterol. The 95% limits of agreement showed that all the variables (energy, protein, fat, carbohydrates, fibre, calcium, sodium, iron, saturated fatty acids, monounsaturated fatty acids and cholesterol) were within the desirable limits of agreement of 50–200%, with the exception of vitamin C (76–296%) and polyunsaturated fatty acids (PUFA) (75–232%). <b><i>Discussion/Conclusion:</i></b> The SQ-PortFood-FQ showed acceptable relative validity at the individual level for energy, protein, fat, carbohydrates, fibre, calcium, sodium, iron, saturated fatty acids, monounsaturated fatty acids and cholesterol. Non-significant relationships were found for vitamin C and PUFA. Our results are in line with previous studies carried out amongst adolescents. As far as we know this is the first FFQ validated for Portuguese adolescents.

Factors influencing dietary practices in a transitioning food environment: a cross-sectional exploration of four dietary typologies among rural and urban Ugandan women using Photovoice

BACKGROUND

Healthy and sustainable dietary practices offer a possible solution to competing tensions between health and environmental sustainability, particularly as global food systems transition. To encourage such dietary practices, it is imperative to understand existing dietary practices and factors influencing these dietary practices. The aim of this study was to identify multi-level factors in lived rural and urban Ugandan food environments that influence existing dietary practices among women of reproductive age (WRA).

METHODS

A mixed methods study was conducted. Multiple correspondence analysis followed by hierarchical cluster analysis were performed on dietary data collected among a sample (n = 73) of Ugandan WRA in Kampala (urban) and Wakiso (rural) districts to elicit dietary clusters. Dietary clusters, which were labelled as dietary typologies based on environmental impact and nutrition transition considerations, were reflective of dietary practices. Following this, a smaller sample of WRA (n = 18) participated in a Photovoice exercise and in-depth interviews to identify factors in their social, physical, socio-cultural and macro-level environments influencing their enactment of the identified dietary typologies, and therefore dietary practices.

RESULTS

Four dietary typologies emerged: 'urban, low-impact, early-stage transitioners', 'urban, medium-impact, mid-stage transitioners', 'rural, low-impact, early-stage transitioners' and 'rural, low-impact, traditionalists'. Although experienced somewhat differently, the physical environment (access, availability and cost), social networks (parents, other family members and friends) and socio-cultural environment (dietary norms) were cross-cutting influences among both urban and rural dietary typologies. Seasonality (macro-environment) directly influenced consumption of healthier and lower environmental impact, plant-based foods among the two rural dietary typology participants, while seasonality and transportation intersected to influence consumption of healthier and lower environmental impact, plant-based foods among participants in the two urban dietary typologies.

CONCLUSION

Participants displayed a range of dietary typologies, and therefore dietary practices. Family provides an avenue through which interventions aimed at encouraging healthier and lower environmental impact dietary practices can be targeted. Home gardens, urban farming and improved transportation could address challenges in availability and access to healthier, lower environmental impact plant-based foods among urban WRA.

Food Consumption Patterns and Nutrient Intakes of Children and Adolescents in the Eastern Mediterranean Region: A Call for Policy Action

The Eastern Mediterranean Region (EMR) has witnessed significant social and economic changes that may have influenced the diet of children and adolescents, and increased the risk for obesity and malnutrition in this age group. This review aims to characterize and assess food consumption patterns and nutrient intakes amongst school-aged children (5-10 years) and adolescents (10-19 years) in countries of the EMR. Electronic databases (MedLine, PubMed, Scopus, and Google Scholar) were searched for relevant articles published between 2005 and 2020; international organizations and governmental websites were also searched. Available studies documented low intakes of fruits, vegetables and fiber, inadequate consumption of water, milk and dairy products, coupled with high intakes of fat, saturated fat, and sugar sweetened beverages, as well as a frequent consumption of energy-dense, nutrient poor foods such as sweet and savory snacks. Micronutrient inadequacies were also observed, particularly for calcium, iron, zinc and vitamins A, D, C, and folate. Acknowledging the impact that nutrition may have on building societies and transforming the lives of children, adolescents and their families, there is a crucial need for a food system approach in developing and implementing national and regional policies and interventions aimed at improving the diet of children and adolescents.

Modified Mediterranean diet score adapted to a southern Mediterranean population and its relation to overweight and obesity risk

Objectives:

The current study aimed to develop a modified Mediterranean diet (MMD) score adjusted to the southern Mediterranean countries’ cultural specificities and to evaluate associations between adherence to this modified score and overweight/obesity risk in Moroccan adults.

Design:

Population-based cross-sectional study.

Setting:

Rural and urban areas of the five greatest provinces of Morocco.

Participants:

In total, 1516 participants were recruited between September 2009 and February 2017. Dietary assessment was obtained using a validated Moroccan FFQ. We constructed a MMD score focusing on twelve components. The MMD score ranged from 0 (no adherence to the traditional southern Mediterranean diet (MD)) to 12 (maximal adherence) and was categorised as low (scores 0–4), moderate (scores 5–7) and high (scores 8–12).

Results:

Among the whole population, 754 (50·5 %) were women and 738 (49·5 %) were men, and the mean age was about 55·60 ± 13·70. In total, 58 % of participants were moderately active. Regarding educational level, 50·7 % were illiterate. The prevalence of overweight and obesity was 43·3 and 8·6 %, respectively. In multivariate analyses, close adherence to MMD (scores 8–12) was associated with reduced overweight/obesity risk (OR 0·61, 95 % CI 0·44, 0·84).

Conclusion:

The prevalence of overweight and obesity was very high among Moroccan adults. Adherence to the traditional southern MD may help prevent overweight and obesity.

Factors influencing dietary behaviours in urban food environments in Africa: a systematic mapping review

Objective:

To identify factors influencing dietary behaviours in urban food environments in Africa and identify areas for future research.

Design:

We systematically reviewed published/grey literature (protocol CRD4201706893). Findings were compiled into a map using a socio-ecological model on four environmental levels: individual, social, physical and macro.

Setting:

Urban food environments in Africa.

Participants:

Studies involving adolescents and adults (11–70 years, male/female).

Results:

Thirty-nine studies were included (six adolescent, fifteen adolescent/adult combined and eighteen adult). Quantitative methods were most common (twenty-eight quantitative, nine qualitative and two mixed methods). Studies were from fifteen African countries. Seventy-seven factors influencing dietary behaviours were identified, with two-thirds at the individual level (45/77). Factors in the social (11/77), physical (12/77) and macro (9/77) environments were investigated less. Individual-level factors that specifically emerged for adolescents included self-esteem, body satisfaction, dieting, spoken language, school attendance, gender, body composition, pubertal development, BMI and fat mass. Studies involving adolescents investigated social environment-level factors more, for example, sharing food with friends. The physical food environment was more commonly explored in adults, for example, convenience/availability of food. Macro-level factors associated with dietary behaviours were food/drink advertising, religion and food prices. Factors associated with dietary behaviour were broadly similar for men and women.

Conclusions:

The dominance of studies exploring individual-level factors suggests a need for research to explore how social, physical and macro-level environments drive dietary behaviours of adolescents and adults in urban Africa. More studies are needed for adolescents and men, and studies widening the geographical scope to encompass all African countries.

Mediterranean diet adherence and weight status among Sicilian Middle school adolescents

During the last decades, an important modification of dietary habits has been observed in the Mediterranean countries, especially among young people. The aim of this study was to evaluate adherence to the Mediterranean diet (MedDiet) and its relationship with weight status in a group of Italian middle school adolescents by using the KIDMED test. The evaluation of weight status revealed that 61.5, 26.8, and 11.7% were normal weight, overweight, and obese, respectively. MedDiet adherence was high in 13.3%, average in 27.1%, and low in 59.6% of the students with no differences by gender and age. MedDiet adherence was found significatively higher in normal weight and in played sport adolescents, in comparison to the overweight and obese ones (p < .001) who showed incorrect nutritional habits. This cross-sectional study shows a very low MedDiet adherence among adolescent living in the Mediterranean basin and highlights the role of Mediterranean dietary pattern in the fight against obesity.

Gender inequalities in diet quality and their socioeconomic patterning in a nutrition transition context in the Middle East and North Africa: a cross-sectional study in Tunisia

Background

In a context of nutrition transition and major shifts in lifestyle and diet, the Middle East and North Africa features a marked gender excess adiposity gap detrimental to women. In this setting, where gender issues are especially acute, we investigated gender differences in dietary intake with a focus on diet quality, and how the differences varied with the area of residence and socio-demographic characteristics.

Methods

The study was conducted in 2009–2010 in the Greater Tunis region (Tunisia), as a case study of an advanced nutrition transition context in the region. A cross-sectional survey used a random, stratified, clustered sample of households: 1689 women and 930 men aged 20–49 years were analyzed. Dietary intake was assessed using a 3-day food record. Nutrient content was derived from a specific Tunisian food composition database. We analysed the Diet Quality Index-International (DQI-I) and sub-scores (variety, adequacy, moderation and balance). A score of DQI-I > 60 defined good diet quality. Inequality measures were women vs. men differences in means for interval variables and odds-ratios (OR) for DQI-I > 60. Their variation with socio-demographic characteristics was estimated using models featuring gender x covariate interactions.

Results

Mean energy intake/day was 2300 ± 15 kcal for women vs. 2859 ± 32 kcal for men. By 1000 g/kcal/d women consumed more fruits and sweets but less red meat and soft drinks than men. Women had a higher mean moderation sub-score than men (+ 1.8[1.4, 2.2], P < 0.0001) but lower variety (− 2.0[− 2.3, − 1.6], P < 0.0001) and adequacy (− 1.8[− 2.0, − 1.5], P < 0.0001). Thus, the overall mean DQI-I was lower among women than men (58.6 ± 0.3 vs. 60.4 ± 0.3, − 1.8[− 2.6, − 1.0], P < 0.0001) as was the proportion of DQI-I > 60 (45.2% vs. 55.7%, OR = 0.7[0.5, 0.8], P < 0.0001). Adjusted gender differences in DQI-I decreased with age but were higher in larger households and extreme categories of education (no-schooling and university) vs. the middle categories.

Conclusion

In this nutrition transition context with only average diet quality, it was somewhat lower for women. Socioeconomic patterning of gender contrasts was mild. Beyond, that women had lower adequacy and variety scores but better moderation is a possible pathway for gender specific prevention messages.

Electronic supplementary material

The online version of this article (10.1186/s12937-019-0442-6) contains supplementary material, which is available to authorized users.

[Prevalence of overweight and obesity among adolescents in school in Lubumbashi, Democratic Republic of Congo]

INTRODUCTION

overweight and obesity in adolescents are a major global public health issue due to their potential impact on health and increasing frequency. This study aims to determine the prevalence of overweight and obesity among adolescents attending public and private schools in Lubumbashi (DRC).

METHODS

we conducted a cross-sectional study of 5341 adolescents aged 10-19 years, 2858 (53.5%) girls and 2483 (46.5%) boys. Weight and height were measured for each adolescent and then body mass index (BMI) was calculated.

RESULTS

the average weight was 43,78 ± 11.62 kg (42,39 ± 12.11 kg for boys and 44.95 ± 11.04 kg for girls), the average height was 151,30 ± 13,09 cm (151.20 ± 14.64 cm for boys and 151,38 ± 11.58 cm for girls) and BMI was 18,82 ± 3.15 kg/m² (19.39 ± 3.39 kg/m² for boys and 18.17 ± 2.71 kg/m² for girls). The prevalence of overweight was 8% while that of obesity was 1%. The girls were significantly more affected by overweight (10.7% girls against 5% boys) and obesity (1.5% girls against 0.4% boys) than the boys.

CONCLUSION

overweight and obesity in school environment are a reality in Lubumbashi. The prevalence of overweight and obesity in this age group category should be determined in a national evaluation plan in order to implement preventive and therapeutic strategies.

Decreased Oleic Acid and Marine n - 3 Polyunsaturated Fatty Acids in Tunisian Patients with Urothelial Bladder Cancer

Fatty acids (FAs) are thought to impact carcinogenesis by affecting cell signaling. A case-control study including 250 patients with urothelial bladder cancer (UBC) and 250 controls was conducted. Plasma FAs composition was assessed using capillary gas chromatography. Associations of individual and classes of FAs with UBC were controlled for the main risk factors for UBC. Plasma FAs profile was different in patients compared to controls. Higher levels (third tertile vs. first tertile) in palmitic acid (PA) [multi-adjusted OR (95% CI), 1.83 (1.14-2.92)], and n - 6:n - 3 FA ratio [4.13 (2.38-7.16)] were associated with increased risk for UBC [multi-adjusted OR (95% CI), 1.83 (1.14-2.92)]. In contrast, higher levels (third tertile vs. first tertile) in oleic [0.54 (0.34-0.86)], dihomo-γ-linolenic (DGLA) [0.47 (0.29-0.74)], eicosapentaenoic (EPA) [0.32 (0.19-0.52)], and docosahexaenoic (DHA) acids [0.33 (0.20-0.53)] were associated with lower risk for UBC. Although the study design does not allow proving causality, the findings suggest a possible protective role of oleic acid and marine n - 3 polyunsaturated FAs (PUFAs) against bladder carcinogenesis.

A "Fork-to-Farm" Multi-Scale Approach to Promote Sustainable Food Systems for Nutrition and Health: A Perspective for the Mediterranean Region

Mediterranean countries are undergoing dietary and nutritional changes that affect their inhabitants' health, while facing massive environmental challenges. The increasing demand of water in agriculture, the capacity to maintain local food production, and the growing dependence on food imports are interconnected issues that must be addressed to ensure food security and nutrition in the Mediterranean region. Here, we present the conceptual framework and methodologies developed by the MEDINA-Study Group for rethinking food systems toward sustainable consumption and production modes. Based on its multidisciplinary expertise, the MEDINA-Study Group designed a "fork-to-farm" multi-scale approach, stemming from current dietary habits and examining how some options to nutritionally improve these habits might affect the food systems. This approach was developed for research activities in the South of France and Tunisia, two areas with very different diet-agriculture-environment nexus. The conceptual framework is based on the analysis of elements of the food systems (from consumption to production) at different levels (individual, household, regional and national levels). The methods include: (i) modeling options of dietary changes at different scales, in order to nutritionally optimize food consumption-production without increasing the environmental impact, (ii) translating the best-choice changes into possible policy actions, (iii) testing the acceptability and feasibility of these actions with several stakeholders, and (iv) producing guidelines for sustainable food choices and production. The MEDINA-Study Group identified additional issues that could be included in a future framework to help designing ambitious agricultural, food and health policies in the Mediterranean region.

Physical inactivity, gender and culture in Arab countries: a systematic assessment of the literature

Background

Physical inactivity is associated with excess weight and adverse health outcomes. We synthesize the evidence on physical inactivity and its social determinants in Arab countries, with special attention to gender and cultural context.

Methods

We searched MEDLINE, Popline, and SSCI for articles published between 2000 and 2016, assessing the prevalence of physical inactivity and its social determinants. We also included national survey reports on physical activity, and searched for analyses of the social context of physical activity.

Results

We found 172 articles meeting inclusion criteria. Standardized data are available from surveys by the World Health Organization for almost all countries, but journal articles show great variability in definitions, measurements and methodology. Prevalence of inactivity among adults and children/adolescents is high across countries, and is higher among women. Some determinants of physical inactivity in the region (age, gender, low education) are shared with other regions, but specific aspects of the cultural context of the region seem particularly discouraging of physical activity. We draw on social science studies to gain insights into why this is so.

Conclusions

Physical inactivity among Arab adults and children/adolescents is high. Studies using harmonized approaches, rigorous analytic techniques and a deeper examination of context are needed to design appropriate interventions.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5472-z) contains supplementary material, which is available to authorized users.

Dietary patterns and cardiometabolic risk factors among adolescents: systematic review and meta-analysis

This study systematised and synthesised the results of observational studies that were aimed at supporting the association between dietary patterns and cardiometabolic risk (CMR) factors among adolescents. Relevant scientific articles were searched in PUBMED, EMBASE, SCIENCE DIRECT, LILACS, WEB OF SCIENCE and SCOPUS. Observational studies that included the measurement of any CMR factor in healthy adolescents and dietary patterns were included. The search strategy retained nineteen articles for qualitative analysis. Among retained articles, the effects of dietary pattern on the means of BMI (n 18), waist circumference (WC) (n 9), systolic blood pressure (n 7), diastolic blood pressure (n 6), blood glucose (n 5) and lipid profile (n 5) were examined. Systematised evidence showed that an unhealthy dietary pattern appears to be associated with poor mean values of CMR factors among adolescents. However, evidence of a protective effect of healthier dietary patterns in this group remains unclear. Considering the number of studies with available information, a meta-analysis of anthropometric measures showed that dietary patterns characterised by the highest intake of unhealthy foods resulted in a higher mean BMI (0·57 kg/m²; 95 % CI 0·51, 0·63) and WC (0·57 cm; 95 % CI 0·47, 0·67) compared with low intake of unhealthy foods. Controversially, patterns characterised by a low intake of healthy foods were associated with a lower mean BMI (−0·41 kg/m²; 95 % CI −0·46,−0·36) and WC (−0·43 cm; 95 % CI −0·52,−0·33). An unhealthy dietary pattern may influence markers of CMR among adolescents, but considering the small number and limitations of the studies included, further studies are warranted to strengthen the evidence of this relation.

[Relationship between macronutrient and micronutrient intake and nutritional status of active older adults in Chillán, Chile]

INTRODUCTION

Social participation by older adults is a health-protective element that promotes a normal nutritional status through the intake of appropriate nutrients that favour successful aging.

MATERIAL AND METHODS

A cross-sectional analytical study was performed on a sample of 118 older adults. Food intake was measured using a 24-h recall questionnaire. The body mass index was used to evaluate the nutritional status. The information was analysed using uni- and bivariate descriptive statistics. Given the abnormal distribution of the responses, the Mann-Whitney and Kolgomorov-Smirnov statistical test were used to compare data at the significance level α=0.05.

RESULTS

More than half (55%) of the women and 61% of men had a normal nutritional status. The calories and macronutrient intake were within the recommended ranges and unrelated to the nutritional status (P>.05). The micronutrients showed significant differences in relation to the nutritional status, broken down by gender and age, in the majority of vitamins and minerals. (P>.01). The group between 75-90 years old accomplished the recommended dietary allowance in every case.

CONCLUSIONS

The active participation in organised community groups, the educational level of the older adults, and higher income, could be key factors to explain the good nutritional status of the group, and appears to be a good indicator of healthy aging.

Long term effect of a school based intervention to prevent chronic diseases in Tunisia, 2009-2015

BACKGROUND & OBJECTIVES

We aimed to evaluate the long term effect of school based intervention to prevent non- communicable disease risk factors.

METHODS

It was a quasi experimental study conducted during the period of 2009-2015. We involved school children aged from 11 to 16 years old. For the assessment of the program's effectiveness, subjects in both groups were examined at baseline, at the end of the 3-year intervention period and at the follow-up, one year after program's cessation.

RESULTS

In the intervention group, the prevalence of school children who reported to be eating 5 fruits and vegetable sdaily increased significantly from 30.0% at pre-assessment to 33.2% at post-assessment, one year after (p=0.02, p=0.41 respectively). For the control group, this prevalence had significantly decreased from 40.2% at baseline to 35.0% at post-intervention, at the follow up, this proportion increased to 44.5%(p=0.001, p<10-3 respectively). Concerning smoking habits, we observed a decreasing trend in the intervention group from 5.7% at pre-assessment, to 4.8% at post-assessment and to 3.4% at the follow-up (p=0.19 and p=0.25 respectively). There was also a significant decrease in school children who did recommended physical activity in the same group.

CONCLUSION

The present work showed that interventions promoting healthy lifestyles should be maintained. Developing countries should be encouraged and supported to design, conduct, and evaluate robust preventive interventions.

Fiber Patterns in Young Adults Living in Different Environments (USA, Spain, and Tunisia). Anthropometric and Lifestyle Characteristics

Benefits of dietary fiber go beyond its effect on chronic diseases associated with development. Consequently, the pattern of fiber intake has been considered an indicator for diet quality. Young adults are especially vulnerable to a food environment that drives an increase in chronic diseases linked to economic development. The aim of this work was to characterize patterns of fiber intake among university students. A cross-sectional study was conducted on a sample of 730 students enrolled at the University of Castilla-La Mancha (Spain), the University of Carthage (Tunisia), and Florida International University (USA). Mean age was 21.2. Food consumption was self-reported in two 24-h recalls. Mean dietary fiber intake was 17.8 g, not reaching the adequate intake. Contrary to expectations, American participants were the highest consumers (p < 0.001), and also exhibited the highest BMI. Cereals, legumes, vegetables and fruit were the main food sources of fiber. Fiber from appetizers, prepared and precooked meals, sauces, spices and condiments accounted for 16.7% in American participants, 7.4% in Spanish participants and 2.6% in Tunisian participants. Total fiber intake increased with energy intake but did not depend on smoking habits and physical activity in any country. It is essential to improve consumers’ interpretation of guidelines on fiber intake.

Challenges and results of a school-based intervention to manage excess weight among school children in Tunisia 2012-2014

BACKGROUND

Obesity is a serious health issue and predisposes individuals to an increased risk of morbidity and mortality. Its prevalence in children has increased worldwide.

OBJECTIVE

To demonstrate the feasibility and effectiveness of a school-based management program based on healthy lifestyle promotion for obese and overweight adolescents in Sousse, Tunisia.

METHODS

We conducted a quasi-experimental study among overweight and obese school children enrolled in 7th and 8th grades in Sousse, Tunisia with two groups, intervention and control. The 1-year intervention was based on promoting healthy eating and physical activity through a collective intervention for all recruited children and an individual intervention only for obese children who require intensive managing. Data collection was done before, at the end and at a 4-month follow up of the intervention, both in intervention and control groups.

RESULTS

The body mass index Z score decreased significantly from pre-intervention to post-intervention (1.89±0.57 to 1.76±0.63, p<0.001) and from post-intervention to the follow-up (1.76±0.63 to 1.55±0.68, p<0.001) in the intervention group. In the control group, it decreased significantly from pre-intervention to post-intervention but not significantly from post-intervention to follow-up assessment. Calorie intake decreased significantly both in intervention and control groups.

CONCLUSION

This project began with introducing a new culture of health management in schools on one side and with increasing awareness of the importance of obesity prevention and treatment. The support of authorities for this type of action is very important to guarantee its sustainability.

How dietary intake has been assessed in African countries? A systematic review

BACKGROUND

Dietary patterns are often considered as one of the main causes of non-communicable diseases worldwide. It is of utmost importance to study dietary habits in developing countries since this work is scarce.

OBJECTIVE

To summarize the most recent research conducted in this field in African countries, namely the most used methodologies and tools.

METHODS

A systematic review was conducted on MEDLINE®/PubMed, aiming to identify scientific publications focused on studies of dietary intake of different African populations, in a ten-year period. Papers not written in English/Portuguese/Spanish, studies developed among African people but not developed in African countries, studies aiming to assess a particular nutrient/specific food/food toxin and studies that assessed dietary intake among children were excluded.

FINDINGS

Out of 99 included studies, the 24-hour recall and the food-frequency questionnaire were the most used dietary intake assessment tools, used to assess diet at an individual level. It was also observed that often country-unspecific food composition databases are used, and the methodologies employed are poorly validated and standardized.

CONCLUSIONS

There is an emergent need to improve the existing food databases by updating food data and to develop suitable country-specific databases for those that do not have their own food composition table.

Inventory on the dietary assessment tools available and needed in africa: a prerequisite for setting up a common methodological research infrastructure for nutritional surveillance, research, and prevention of diet-related non-communicable diseases

OBJECTIVE

To carry out an inventory on the availability, challenges, and needs of dietary assessment (DA) methods in Africa as a pre-requisite to provide evidence, and set directions (strategies) for implementing common dietary methods and support web-research infrastructure across countries.

METHODS

The inventory was performed within the framework of the "Africa's Study on Physical Activity and Dietary Assessment Methods" (AS-PADAM) project. It involves international institutional and African networks. An inventory questionnaire was developed and disseminated through the networks. Eighteen countries responded to the dietary inventory questionnaire.

RESULTS

Various DA tools were reported in Africa; 24-Hour Dietary Recall and Food Frequency Questionnaire were the most commonly used tools. Few tools were validated and tested for reliability. Face-to-face interview was the common method of administration. No computerized software or other new (web) technologies were reported. No tools were standardized across countries.

CONCLUSIONS

The lack of comparable DA methods across represented countries is a major obstacle to implement comprehensive and joint nutrition-related programmes for surveillance, programme evaluation, research, and prevention. There is a need to develop new or adapt existing DA methods across countries by employing related research infrastructure that has been validated and standardized in other settings, with the view to standardizing methods for wider use.

Development and validation of an Arabic questionnaire to assess psychosocial determinants of eating behavior among adolescents: a cross-sectional study

BACKGROUND

There is a scarcity of studies that evaluate the psychosocial determinants of eating behavior among adolescents in the Eastern Mediterranean region. The availability of such data is limited by the lack of valid culturally appropriate tools. The current study aims to develop and validate an Arabic questionnaire that measures psychosocial determinants of eating behavior among adolescents.

METHODS

A cross-sectional study was carried out to validate a five-scale questionnaire developed to measure nutrition-related knowledge, attitude, practices, and self-efficacy and social norms. Content validity was assessed by Lawshe's method, factor analysis was used to assess construct validity, and Cronbach's α was used to test internal consistency. Temporal stability was assessed by test-retest reliability. A random sample of public and private school students participated in the validation study.

RESULTS

All the five scales demonstrated excellent content validity (content validity ratio, CVR ≥0.778). Factor analysis revealed several dimensions for each scale. Cronbach's α for the identified dimensions or subscales ranged between 0.495 and 0.809 indicating acceptable internal consistency. Cronbach's α for the total scales ranged between 0.759 and 0.836. Test-retest analysis revealed good temporal stability (intraclass correlation, ICC >0.7).

CONCLUSIONS

A psychometrically valid tool to measure psychosocial determinants of eating behavior was developed. This tool can serve as a potential instrument for pretest and impact evaluation of ongoing nutrition education interventions and curricula. Based on results obtained from this tool, efficacious modifications can be instilled for nutrition policies and interventions.

Methodology and Early Findings of the Fifth Survey of Childhood and Adolescence Surveillance and Prevention of Adult Noncommunicable Disease: The CASPIAN-V Study

Background:

This paper presents the methodology and early findings of the fifth survey of a school-based surveillance program in Iran.

Methods:

This nationwide study was conducted in 2015 as the fifth survey of a surveillance program entitled “Childhood and Adolescence Surveillance and PreventIon of Adult Non- communicable disease” (CASPIAN-V) study. The protocol was mainly based on the World Health Organization-Global School student Health Survey. We studied 14400 students, aged 7-18 years, and their parents living in 30 provinces in Iran. Fasting blood was obtained from a sub-sample of 4200 randomly selected students.

Results:

The participation rate for the whole study and for blood sampling were 99% and 91.5%, respectively. The mean (SD) age of participants was 12.3 (3.2) years, consisting of 49.4% girls and 71.4% urban residents. Overall, 16.1% were underweight (17.4% of boys and 14.8% of girls), and 20.8% had excess weight consisting of 9.4% (8.7% of boys and 10.2% of girls) of overweight and 11.4% (12.5% of boys and 10.3% of girls) of obesity. Abdominal obesity was documented in 21.1% of students (21.6% of boys and 20.5% of girls). Low HDL-C was the most prevalent abnormality of the lipid profile (29.5%) followed by high serum triglycerides (27.7%). Of students, 59.9% consumed whole wheat bread; and 57% reported that they never or rarely added salt to table. The reported daily consumption of fresh fruits, vegetables, and milk was about 60%, 32% and 40%, respectively. 13.7% of participants had at least 30-min daily leisure-time physical activity.

Conclusions:

The current findings provide an overview of the current health status and lifestyle habits of children and adolescents. This surveillance program would help planning preventive programs at individual and community levels.

Adequacy Assessment of a Universal Salt Iodization Program Two Decades after Its Implementation: A National Cross-Sectional Study of Iodine Status among School-Age Children in Tunisia

In the framework of a worldwide policy to eliminate iodine deficiency (ID) disorders, universal salt iodization was adopted in Tunisia two decades ago. The present study aims to evaluate this strategy, using both performance and impact indicators. A total of 1560 children, aged 6-12 years, were randomly sampled using a national, two-stage, stratified, cross-sectional cluster survey in 2012. Urinary iodine concentration (UIC) of the subjects, and household salt iodine content, were analyzed. The national median UIC was 220 µg/L (95% confidence interval (CI): 199-241), indicating an acceptable iodine status at the population level. Only 11.4% (95% CI: 8.6-14.9) of the children had UIC <100 µg/L, but with large regional disparities (4.3% to 25.5%, p < 0.01); however, more than a quarter of the subjects were at risk of adverse health consequences due to iodine excess. Children from households of low socio-economic levels were more prone to inadequate UIC. The national median iodine concentration of household salt was 22 mg/kg (95% CI: 21-23). Only half of the households used adequately iodized salt (15-25 ppm), with large regional disparities. National ID rates are now well below the target criteria of WHO (World Health Organization) certification (<20% of children with UIC <50 µg/L and <50% with UIC <100 µg/L). The coverage of adequately iodized salt fell short in meeting the goals of USI (Universal Salt Iodization), i.e., >90% of households. Regular monitoring of iodized salt production lines must be strengthened with involvement by producers.

Mediterranean diet adherence and body composition among Southern Italian adolescents

INTRODUCTION

Adherence to the traditional Mediterranean diet has been associated with health benefits in young populations. The aim of this study was to evaluate the association between adherence to the Mediterranean diet and cardio-metabolic parameters in adolescents living in Sicily, Southern Italy.

METHODS

A cross-sectional study was conducted during two school years (2012-2013 and 2013-2014) on 1643 adolescents of 11-16 years attending 15 secondary schools. Socio-demographic, dietary, lifestyle, and anthropometric data were collected. The KIDMED score was used to evaluate the adherence to the Mediterranean diet. Linear and logistic regression models were used to test the association between the variable of interest and the outcomes.

RESULTS

A higher percentage of boys compared with girls was overweight (30.8% vs. 25.4%) and obese (28.7% vs. 18.5%) and only 9.1% had high adherence to the Mediterranean diet. Vegetable intake was negatively associated with being overweight/obese whereas higher intake of sweets, sugar-sweetened beverages, and fast foods was associated with overweight and obesity. A good adherence to the Mediterranean diet resulted in 30% decreased odds of being overweight or obese (odd ratio 0.70, 95% confidence interval: 0.56-0.87) in both boys and girls. An inverse correlation was found between KIDMED score and BMI, waist circumference and fat mass. No relation with blood pressure was found.

CONCLUSIONS

Mediterranean dietary pattern resulted significantly associated with weight status in adolescents. These results underline the importance of providing lifestyle and dietary habits education to prevent overweight and obesity in adolescent.

Exclusive olive oil consumption and 10-year (2004-2014) acute coronary syndrome incidence among cardiac patients: the GREECS observational study

BACKGROUND

The present study evaluated the association between long-term, exclusive olive oil consumption, in cooking preparation or as a dressing, and the 10-year (2004-2014) incidence of acute coronary syndrome (ACS) among cardiac patients.

METHODS

From October 2003 to September 2004, a sample of 2172 ACS consecutive patients from six major Greek hospitals were enrolled. During 2013-2014, the 10-year follow-up was performed in 1918 patients (88% participation rate). The development of fatal or nonfatal ACS was recorded through medical records or hospital registries. Among other dietary components, added fats (i.e. olive oil, butter, margarine and seed oils) consumption at baseline examination was assessed using a semi-quantitative food frequency questionnaire.

RESULTS

Non-exclusive olive oil consumption on a daily basis was associated with an adverse effect on the ACS incidence after taking into account various potential confounders [odds ratio (OR) = 1.40, 95% confidence interval (CI) = 1.05-1.86, P = 0.024]. However, significant interactions between olive oil consumption and body mass index (BMI) (P = 0.082) and educational level (P = 0.054) led to further stratified analysis. Using BMI as strata (i.e. ≤29.9 versus >29.9 kg m(-2)), the above association remained significant only in obese patients (OR = 1.80, 95% CI = 1.03-3.12, P = 0.038), whereas, on examining the education status (i.e. ≤9 versus >9 years of school), a significant association was observed only among the higher educated patients (OR = 1.83, 95% CI = 1.01-3.32, P = 0.047).

CONCLUSIONS

Exclusive use of olive oil, either as a salad dressing or in cooking, should be promoted through the dietary management of ACS patients, with the aim of reducing the likelihood of recurrent cardiac episodes.

Gender inequalities in excess adiposity and anaemia combine in a large double burden of malnutrition gap detrimental to women in an urban area in North Africa

OBJECTIVE

The nutrition transition has exacerbated the gender gap in health in the Middle East and North Africa region as the increase in excess adiposity has been much higher among women than men. This is not exclusive of the persistence of anaemia, generally also more prevalent among women. We assessed the magnitude and sociodemographic factors associated with gender inequality vis-à-vis the double burden of excess adiposity and anaemia.

DESIGN

Cross-sectional study, stratified two-stage cluster sample. BMI (=weight/height2) ≥25·0 kg/m2 defined overweight and BMI≥30·0 kg/m2 obesity. Anaemia was defined as Hb <120 g/l for women, <130 g/l for men. Gender inequalities vis-à-vis the within-subject coexistence of excess adiposity and anaemia were assessed by women v. men relative prevalence ratios (RPR). Their variation with sociodemographic characteristics used models including gender × covariate interactions.

SETTING

Greater Tunis area in 2009-2010.

SUBJECTS

Adults aged 20-49 years (women, n 1689; men, n 930).

RESULTS

Gender inequalities in excess adiposity were high (e.g. overweight: women 64·9 % v. men 48·4 %; RPR=2·1; 95 % CI 1·6, 2·7) and much higher for anaemia (women 38·0 % v. men 7·2 %; RPR=8·2; 95 % CI 5·5, 12·4). They were striking for overweight and anaemia (women 24·1 % v. men 3·4 %; RPR=16·2; 95 % CI 10·3, 25·4). Gender inequalities in overweight adjusted for covariates increased with age but decreased with professional activity and household wealth score; gender inequality in anaemia or overweight and anaemia was more uniformly distributed.

CONCLUSIONS

Women were much more at risk than men, from both over- and undernutrition perspectives. Both the underlying gender-related and sex-linked biological determinants of this remarkable double burden of malnutrition inequality must be addressed to promote gender equity in health.

Socio-demographic association of non communicable diseases' risk factors in a representative population of school children: a cross-sectional study in Sousse (Tunisia)

INTRODUCTION

A better understanding of socio-demographic characteristics of subgroups, which have a high risk to develop chronic diseases, is essential to develop more efficient interventional programs especially for youth. This study aimed to determine the association between clusters of non communicable diseases (NCDs') risk factors and the socio-demographic characteristics among a sample of Tunisian school children.

MATERIALS AND METHODS

We conducted, in 2013/2014, a cross-sectional study among a proportional and stratified school children sample, selected in 17 elementary public schools in Sousse (Tunisia). A cluster analysis was used to identify different NCDs risk factors clusters, based on tobacco use, physical inactivity, unhealthy diet, and excess weight. Subsequent χ2-tests were used to identify differences between the NCDs risk factors clusters in regards to socio-demographic characteristics.

RESULTS

Four clusters of NCDs risk factors were found: 1) Cluster 1: physical inactivity behavior with normal weight, 2) Cluster 2: physical inactivity behavior associated to excess weight, 3) Cluster 3: unhealthy diet associated to excess weight and low practice of physical activity, and 4) Cluster 4: smoking behavior with physical activity behavior. The pattern of cluster membership differed across sex (<10-3), school level, and socioeconomic level (<10-3) but there was no significant difference between clusters for mother's education levels and household tenure.

CONCLUSION

This study can have important implications for health policy and practice. Indeed, it found that many subjects have simultaneous multiple NCDs risk factors which leads to identify groups at risk and implement integrated intervention program.

A Western dietary pattern is associated with higher blood pressure in Iranian adolescents

PURPOSE

The dietary determinants of adolescent blood pressure (BP) are not well understood. We determined the association between major dietary patterns and BP in a sample of Iranian adolescents.

METHODS

This cross-sectional study was conducted among a representative sample (n = 557) of Shirazi adolescents aged 12-19 years. Participants' systolic and diastolic BP was measured using a validated oscillometric BP monitor. Usual dietary intakes during the past 12 months were assessed using a valid and reproducible 168-item semiquantitative food frequency questionnaire through face-to-face interviews. Principal component factor analysis was used to identify major dietary patterns based on a set of 25 predefined food groups.

RESULTS

Overall, three major dietary patterns were identified, among which only the Western pattern (abundant in soft drinks, sweets and desserts, salt, mayonnaise, tea and coffee, salty snacks, high-fat dairy products, French fries, and red or processed meats) had a significant association with BP. After adjusting for potential confounders in the analysis of covariance models, multivariable adjusted means of the systolic and mean BP of subjects in the highest tertile of the Western pattern score were significantly higher than those in the lowest tertile (for systolic BP: mean difference 6.9 mmHg, P = 0.001; and for mean BP: mean difference 4.2 mmHg, P = 0.003). A similar but statistically insignificant difference was observed in terms of diastolic BP.

CONCLUSIONS

The findings suggest that a Western dietary pattern is associated with higher BP in Iranian adolescents. However, additional large-scale prospective studies with adequate methodological quality are required to confirm these findings.

A Western dietary pattern is associated with overweight and obesity in a national sample of Lebanese adolescents (13-19 years): a cross-sectional study

Adolescent obesity is associated with both immediate and longer-term health implications. This study aims to identify dietary patterns among a nationally representative sample of Lebanese adolescents aged between 13 and 19 years (n 446) and to assess the association of these patterns with overweight and obesity. Through face-to-face interviews, socio-demographic, lifestyle and anthropometric variables were collected. Dietary intake was assessed using a sixty-one-item FFQ. Dietary patterns were derived by factor analysis. The following two dietary patterns were identified: Western and traditional Lebanese. The Western pattern was characterised by high consumption of red meat, eggs and fast-food sandwiches. The traditional Lebanese pattern reflected high intakes of fruits and vegetables, legumes and fish. Female sex and a higher maternal education level were associated with a greater adherence to the traditional Lebanese pattern. As for the Western pattern, the scores were negatively associated with crowding index, physical activity and frequency of breakfast consumption. After adjustment, subjects belonging to the 3rd tertile of the Western pattern scores had significantly higher odds of overweight compared with those belonging to the 1st tertile (OR 2·3; 95 % CI 1·12, 4·73). In conclusion, two distinct dietary patterns were identified among adolescents in Lebanon: the traditional Lebanese and the Western, with the latter pattern being associated with an increased risk of overweight. The findings of this study may be used to guide the development of evidence-based preventive nutrition interventions to curb the obesity epidemic in this age group.

Dietary Patterns of Young Females and Their Association With Waist Circumference as a Health Index in Northwest of Iran, 2007

Background:

Despite the higher prevalence of overweight and obesity among young people in western countries, the 50th and 95th percentile ranks for waist circumference in the Iranian young Females are higher than those of the western ones.

Objectives:

Identifying major dietary patterns in Iranian young females, which associate with central obesity, can probably explain the difference between Iranian young females’ pattern and those of their western peers regarding obesity.

Patients and Methods:

In the current cross-sectional study, a total of 257 young females aged 11 - 15 years old from Talaat Intelligent Guidance School, Tabriz, Iran (2007) were selected for the study using non-probability simple sampling method. Then, usual dietary intakes of all subjects were evaluated by a food frequency questionnaire and anthropometric measurements such as weight, height, waist circumference, and Body Mass Index (BMI) using the standard protocols. Data were analyzed by inferential statistics (One-way ANOVA, Tukey test for Post-Hoc Analysis, Chi-square test, age-adjusted means, analysis of covariance with Bonferroni correction, correlation and partial correlation) by SPSS software.

Results:

In the current study, six major dietary patterns were extracted using factor analysis method. Before and after controlling the age, subjects in the upper tertile of the Iranian Central Obesity Making Dietary Pattern (rich in cruciferous vegetables, green leafy vegetables, soft drinks, tomatoes, other vegetables and vegetable oils) had larger waist circumference in comparison with the ones in the lower tertile (before controlling for age: 64.2 ± 9 vs. 61.6 ± 7 P = 0.03; after: 64.5 ± 0.8 vs. 61.5 ± 0.8, P = 0.009). However in lacto vegetarian dietary pattern (rich in legumes, potato, other vegetables, dough, high-fat dairy products and margarine), individuals in the upper tertile had significantly lower weight, waist circumference and body mass index (BMI) in comparison with the ones in the lower tertile (weight: 44.9 ± 9.3 vs. 51.4 ± 10.6, P < 0.01; WC: 59.9 ± 8 vs. 64 ± 7.9, P < 0.01; BMI: 18.6 ± 3.1 vs. 20.6 ± 3.5, P < 0.01).

Conclusions:

The current study findings suggest that the Iranian Central Obesity Making Dietary Pattern is directly associated with waist circumference (marker of central obesity), while lacto vegetarian dietary pattern is reversely associated with weight, waist circumference and BMI. Special obesity pattern in Iranian young females can be justified by Iranian Central Obesity Making Dietary Pattern”.

Mediterranean Diet: From a Healthy Diet to a Sustainable Dietary Pattern

The notion of the Mediterranean diet has undergone a progressive evolution over the past 60 years, from a healthy dietary pattern to a sustainable dietary pattern, in which nutrition, food, cultures, people, environment, and sustainability all interact into a new model of a sustainable diet. An overview of the historical antecedents and recent increased interest in the Mediterranean diet is presented and challenges related to how to improve the sustainability of the Mediterranean diet are identified. Despite its increasing popularity worldwide, adherence to the Mediterranean diet model is decreasing for multifactorial influences - life styles changes, food globalization, economic, and socio-cultural factors. These changes pose serious threats to the preservation and transmission of the Mediterranean diet heritage to present and future generations. Today's challenge is to reverse such trends. A greater focus on the Mediterranean diet's potential as a sustainable dietary pattern, instead than just on its well-documented healthy benefits, can contribute to its enhancement. More cross-disciplinary studies on environmental, economic and socio-cultural, and sustainability dimensions of the Mediterranean diet are foreseen as a critical need.