Reproducibility and relative validity of a brief quantitative food frequency questionnaire for assessing fruit and vegetable intakes in North-African women

BACKGROUND

In the context of a rapidly increasing prevalence of noncommunicable diseases, fruit and vegetables could play a key preventive role. To date, there is no rapid assessment tool available for measuring the fruit and vegetable intakes of North-African women. The present study aimed to investigate the reproducibility and relative validity of an eight-item quantitative food frequency questionnaire that measures the fruit and vegetable intakes (FV-FFQ) of Moroccan women.

METHODS

During a 1-week period, 100 women, living in the city of Rabat, Morocco (aged 20-49 years) completed the short FV-FFQ twice: once at baseline (FV-FFQ1) and once at the end of the study (FV-FFQ2). In the mean time, participants completed three 24-h dietary recalls. All questionnaires were administered by interviewers. Reproducibility was assessed by computing Spearman's correlation coefficients, intraclass correlation (ICC) coefficients and kappa statistics. Relative validity was assessed by computing Wilcoxon signed-rank tests and Spearman's correlation coefficients, as well as by performing Bland-Altman plots.

RESULTS

In terms of reproducibility, Spearman's correlation coefficient was 0.56; ICC coefficient was 0.68; and weighted kappa was 0.35. In terms of relative validity, compared with the three 24-h recalls, the FV-FFQ slightly underestimated mean fruit and vegetable intakes (-10.9%; P = 0.006); Spearman's correlation coefficient was 0.69; at the individual level, intakes measured by the FV-FFQ were between 0.39 and 2.19 times those measured by the 24-h recalls.

CONCLUSIONS

The brief eight-item FV-FFQ is a reliable and relatively valid tool for measuring mean fruit and vegetable intakes at the population level, although this is not the case at the individual level.

The acceptability to stakeholders of mandatory nutritional labelling in France and the UK--findings from the PorGrow project

BACKGROUND

Implementing a European Union (EU)-wide mandatory nutrition labelling scheme has been advocated as part a multi-pronged strategy to tackle obesity. The type of scheme needs to be acceptable to all key stakeholders. This study explored stakeholders' viewpoints of labelling in two contrasting food cultures (France and the UK) to see whether attitudes were influenced by sectoral interests and/or national context.

METHODS

Using Multi Criteria Mapping, a decision analysis tool that assesses stakeholder viewpoints, quantitative and qualitative data were gathered during tape-recorded interviews. In France and the UK, 21 comparable stakeholders appraised nutritional labelling with criteria of their own choosing (i.e. feasibility, societal benefits, social acceptability, efficacy in addressing obesity, additional health benefits) and three criteria relating to cost (to industry; public sector; individuals). When scoring, interviewees provided both optimistic (best case) and pessimistic (worst case) judgements.

RESULTS

Overall, mandatory nutritional labelling was appraised least favourably in France. Labelling performed worse under optimistic (best case) scenarios in France, for five out of eight sets of criteria. French stakeholders viewed labelling as expensive, having fewer benefits to society and as being marginally less effective than UK stakeholders did. However, French interviewees thought implementing labelling was feasible and would provide additional health benefits. British and French stakeholders made similar quantitative judgements on how socially acceptable mandatory labelling would be.

CONCLUSIONS

There is agreement between some stakeholder groups in the two different countries, especially food chain operators. However, cultural differences emerged that could influence the impact of an EU-wide mandatory labelling scheme in both countries.

Health and behaviours of Tunisian school youth in an era of rapid epidemiological transition

To assess youth health behaviours and related quality of life in urban Tunisia, we conducted a cross-sectional survey of a representative sample of 699 secondary-school students. The overweight rate was 20.7%. Most of the sample had an insufficient level of physical activity and were unfamiliar with the recommended frequency of moderate physical activity. Norm-based scores of psychological state were about average, slightly better for boys than girls. Girls perceived themselves to be more stressed than boys. Of all students, 35% declared having smoked a cigarette and 14% having drunk alcohol at least once in their lives. The main sources of health education were mass media (59%) and medical staff (36%).

Prevalence of obesity and associated socioeconomic factors among Tunisian women from different living environments

Adult Tunisian women aged 20-59 (national random sample, n = 1849), were assessed with respect to environmental and socioeconomic factors associated with obesity (body mass index >or=30 kg m(-2)) and abdominal obesity (waist circumference >or=88 cm). At the national level, prevalence of obesity and abdominal obesity were, respectively, 22.6% and 29.2%, but varied markedly (both P < 0.0001) among living environments classified as big cities (30.2% and 36.6%), other cities (25.9% and 32.4%), rural clustered (19.4% and 24.8%) and rural dispersed (9.5% and 16.5%). Adjusted prevalences of both types of obesity increased with age, parity and economic level of the household, while educationally, the risk was greatest in women with intermediate schooling. Differences between the four environments were accounted for by socioeconomic factors, mostly household wealth, except for most rural environment; socio-cultural factors were possibly influential. Observed differences between rural areas confirmed that finer measures of urbanization are necessary for the drivers of obesity prevalence at the national level. Obesity was still more prevalent in wealthy than in poor women, but given the high prevalence in all the environments, actions are needed at the national level before highly prevalent obesity extends into those of lower socioeconomic status and thereby increases health inequities.

Are dietary diversity scores related to the socio-economic and anthropometric status of women living in an urban area in Burkina Faso?

OBJECTIVES

To study dietary diversity and its relationship with socio-economic and nutritional characteristics of women in an urban Sahelian context.

DESIGN

A qualitative dietary recall was performed over a 24-h period. Dietary diversity scores (DDS = number of food groups consumed) were calculated from a list of nine food groups (DDS-9) or from a list of 22 food groups (DDS-22) which detailed both micronutrient- and energy-dense foods more extensively. Body mass index (BMI), mid upper-arm circumference and body fat percentage were used to assess the nutritional status of the women.

SETTING AND SUBJECTS

Five hundred and fifty-seven women randomly selected in two districts of Ouagadougou, the capital of Burkina Faso.

RESULTS

The mean DDS-9 and DDS-22 were 4.9 +/- 1.0 and 6.5 +/- 1.8 food groups, respectively. In the high tertile of DDS-22, more women consumed fatty and sweetened foods, fresh fish, non-fatty meat and vitamin-A-rich fruits and vegetables. The DDS-9 was not associated with the women's socio-economic characteristics whereas the DDS-22 was higher when the women were younger, richer and had received at least a minimum education. Mean BMI of the women was 24.2 +/- 4.9 kg m-2 and 37% of them were overweight or obese (BMI > or = 25 kg m-2). Neither the DDS-9 nor the DDS-22 was associated with the women's anthropometric status, even though there was a trend towards fewer overweight women in the lowest tertile of DDS-22.

CONCLUSION

In this urban area, the qualitative measurement of dietary diversity is not sufficient to identify women at risk of under- or overweight.

Stakeholder views on policy options for responding to the growing challenge from obesity in France: findings from the PorGrow project

To explore the perspectives of key stakeholders towards a range of policy options to prevent obesity in France, a multi-criteria mapping method was used to gather quantitative and qualitative data from 21 types of stakeholder groups. During structured interviews, stakeholders appraised a set of pre-defined options by reference to criteria of their own choosing and provided relative weights to their criteria, and overall rankings of the policy options. Efficacy, feasibility and societal benefits were the groups of criteria given most importance by stakeholders. There was most consensus and preference for options related to health education, particularly in schools, compared with options that aimed at changing the environment to prevent obesity, i.e. options around physical activity; options that modified food supply and demand; and information-related options. There was little support for technological solutions or institutional reforms. While there was broad interest in a range of different options, those related to behaviour change through education were the most valued by stakeholders. Raising awareness among policymakers about the convincing scientific evidence for the effectiveness of environmental level policy options will be a crucial first step.

Red palm oil as a source of vitamin A for mothers and children: impact of a pilot project in Burkina Faso

Objective:

To demonstrate the effectiveness of the commercial introduction of red palm oil (RPO) as a source of vitamin A (VA) for mothers and children in a non-consuming area, as a dietary diversification strategy.

Design:

A pre–post intervention design (no control area) was used to assess changes in VA intake and status over a 24-month pilot project.

Setting and subjects:

The pilot project involved RPO promotion in 10 villages and an urban area in east-central Burkina Faso, targeting approximately 10?000 women and children aged < 5 years. A random sample of 210 mother–child (12–36-months-old) pairs was selected in seven out of the 11 pilot sites for the evaluation.

Results:

After 24 months, RPO was reportedly consumed by nearly 45% of mothers and children in the previous week. VA intake increased from 235 ± 23 μg retinol activity equivalents (RAE) to 655 ± 144 μg RAE in mothers (41 to 120% of safe intake level), and from 164 ± 14 μg RAE to 514 ± 77 μg RAE in children (36 to 97%). Rates of serum retinol < 0.70 μmoll−1decreased from 61.8 ± 8.0% to 28.2 ± 11.0% in mothers, and from 84.5 ± 6.4% to 66.9 ± 11.2% in children. Those with a lower initial concentration of serum retinol showed a higher serum retinol response adjusted for VA intake.

Conclusions:

Commercial distribution of RPO was effective in reducing VA deficiency in the pilot sites. While it is promising as part of a national strategy, additional public health and food-based measures are needed to control VA malnutrition, which remained high in the RPO project area

Measuring dietary diversity in rural Burkina Faso: comparison of a 1-day and a 3-day dietary recall

Objectives

To compare dietary diversity scores measured over a 1-day and a 3-day period, and to assess their relationships with socio-economic characteristics and the nutritional status of rural African women.

Design

A qualitative dietary recall allowed calculation of a dietary diversity score (DDS; number of food groups consumed out of a total of nine). Body mass index (BMI) and body fat percentage (BFP) were used to assess the nutritional status of women.

Setting and subjects

A representative sample of 550 mothers in north-east Burkina Faso.

Results

The DDS increased from 3.5 to 4.4 when calculated from a 1-day or a 3-day recall (P < 0.0001), although for the latter the DDS was affected by memory bias. The DDS calculated from a 1-day recall was higher when a market day occurred during the recall period. Both scores were linked to the sociodemographic and economic characteristics of the women. Women in the lowest DDS tertile calculated from the 1-day recall had a mean BMI of 20.5 kg m− 2 and 17.7% of them were underweight, versus 21.6 kg m− 2 and 3.5% for those in the highest tertile (P = 0.0003 and 0.0007, respectively). The DDS calculated from the 1-day recall was also linked to mean BFP; all these links remained significant after adjustment for confounders. For the 3-day period, no such relationships were found to be significant after adjustment.

Conclusion

The DDS calculated from a 1-day dietary recall was sufficient to predict the women's nutritional status. In such a context attention should be paid to market days.

Determinants of nutrition improvement in a large-scale urban project: a follow-up study of children participating in the Senegal Community Nutrition Project

OBJECTIVE

To study individual determinants of differential benefit from the Senegal Community Nutrition Project (CNP) by monitoring improvement in children's weight-for-age index (WA) or underweight status (WA < -2 Z-scores) during participation.

DESIGN

A follow-up study using the CNP child monitoring data. Linear general models compared variations in WA according to 14 factors describing the beneficiaries and CNP services.

SETTING

Poor neighbourhoods of Diourbel, a large city in Senegal, West Africa. Over a 6-month period, the CNP provided underweight or nutritionally at-risk 6-35-month-old children with monthly growth monitoring and promotion and weekly food supplementation, provided that mothers attended weekly nutrition education sessions.

SUBJECTS

All the children who participated in the first two years of the project (n=4084).

RESULTS

Mean WA varied from -2.13 (standard deviation (SD) 0.82) to -1.58 (SD 0.81) Z-scores between recruitment and the end of the follow-up. The lower the child's initial WA, the greater was their increase in WA but the lower was the probability of recovery from underweight. Only 61% of underweight children recovered. Six months of CNP services may not be sufficient for catch-up growth of severely underweight children. The number of food supplement rations received was not a direct indicator of the probability of recovery. After adjustment for services received and initial WA, probability of recovery was lower in girls, in younger children, in twins and when mothers belonged to a specific ethnic group.

CONCLUSIONS

Determinants of benefit from CNP differed from the risk factors for underweight. Identification of participants with a lower probability of recovery can help improve outcome. Moreover, an explanation for the lack of recovery could be that many underweight children are stunted but not necessarily wasted.

Use of variety/diversity scores for diet quality measurement: relation with nutritional status of women in a rural area in Burkina Faso

OBJECTIVES

To develop scores for food variety and diversity to assess the overall dietary quality in an African rural area; and to study their relationship with the nutritional status of women of childbearing age.

DESIGN

Cross-sectional.

SETTING

Sahelian rural area in the North-East Burkina Faso (West Africa).

SUBJECTS

A total of 691 mothers with children below the age of 5 y, selected at random in 30 villages.

METHODS

A qualitative recall of women's food consumption during the previous 24 h made it possible to calculate a food variety score (FVS = count of food items consumed) and a dietary diversity score (DDS = count of food groups, among 14 groups). These scores were then divided into terciles. Body mass index (BMI), mid-upper arm circumference (MUAC) and body fat percentage (BFP) were used to determine the women's nutritional status.

RESULTS

The overall dietary quality was poor: mean FVS (s.d.) = 8.3 (2.9) food items; mean DDS = 5.1 (1.7) food groups. A clear relationship was shown between both FVS and DDS (in terciles) and most nutritional indices. Women with a FVS in the lowest tercile had a mean BMI of 20.1, while those in the highest tercile had a BMI of 20.9 (P = 0.009). Those in the lowest tercile of DDS had a 22.8% prevalence of underweight vs 9.8% in the highest tercile (P < 0.0001). The latter relationship remained significant even when the subjects' sociodemographic and economic characteristics were accounted for.

CONCLUSION

Dietary scores measured at the individual level are good proxies for overall dietary quality of women living in a poor rural African area. These scores were also shown to be linked with the nutritional status of women.

FINANCING

IRD financed the study with the assistance of UNICEF for the purchase of anthropometric equipment. The first author received a research allowance from the French Ministry of Research through the doctoral school 393 of Pierre and Marie Curie University (Paris VI).

Perceptions of healthy and desirable body size in urban Senegalese women

OBJECTIVE

To examine the cultural ideals for body size held by urban Senegalese women; to determine the body size that women associate with health; and to estimate the change in prevalence of female obesity in an urban neighbourhood of Dakar.

DESIGN

Cross-sectional, population-based study in the subject's home, using a structured interviewer-administered questionnaire, conducted in the same Dakar neighbourhood as that of a previous survey conducted in 1996.

SUBJECTS

A total of 301 randomly selected women, aged 20-50 y, living in a specific Dakar neighbourhood, Senegal.

MEASUREMENTS

A total of 32 items concerning body satisfaction, social status, health and individual attributes to associate with one of six photographic silhouettes; body mass index (BMI), waist circumference, waist-to-hip ratio by anthropometry; and measures of economic status.

RESULTS

In all, 26.6% of women were overweight (BMI 25-29.9 kg/m2) and 18.6% were obese (BMI > or =30 kg/m2) compared with 22.4 and 8.0% respectively in 1996. Overweight was the most socially desirable body size, although obesity itself was seen as undesirable, associated with greediness and the development of diabetes and heart disease. Lay definitions of overweight and normal weight differed substantially from health definitions, as one-third of the sample saw the 'overweight' category as normal. Over a third of women with BMI > or =25 kg/m2 wanted to gain more weight.

CONCLUSION

There has been a sharp rise in the prevalence of obesity in Senegalese women living in a Dakar neighbourhood over the last 7 y. In general, overweight body sizes (but not obese) were seen in a positive light. The finding that the term 'overweight' made little sense to these Senegalese women could have important implications for developing public health policies.

Use of hand-to-hand impedancemetry to predict body composition of African women as measured by air displacement plethysmography

OBJECTIVES

To test the validity of a simple, rapid, field-adapted, portable hand-held impedancemeter (HHI) for the estimation of lean body mass (LBM) and percentage body fat (%BF) in African women, and to develop specific predictive equations.

DESIGN

Cross-sectional observational study.

SETTINGS

Dakar, the capital city of Senegal, West Africa.

SUBJECTS

A total sample of 146 women volunteered. Their mean age was of 31.0 y (s.d. 9.1), weight 60.9 kg (s.d. 13.1) and BMI 22.6 kg/m(2) (s.d. 4.5).

METHODS

Body composition values estimated by HHI were compared to those measured by whole body densitometry performed by air displacement plethysmography (ADP). The specific density of LBM in black subjects was taken into account for the calculation of %BF from body density.

RESULTS

: Estimations from HHI showed a large bias (mean difference) of 5.6 kg LBM (P<10(-4)) and -8.8 %BF (P<10(-4)) and errors (s.d. of the bias) of 2.6 kg LBM and 3.7 %BF. In order to correct for the bias, specific predictive equations were developed. With the HHI result as a single predictor, error values were of 1.9 kg LBM and 3.7 %BF in the prediction group (n=100), and of 2.2 kg LBM and 3.6 %BF in the cross-validation group (n=46). Addition of anthropometrical predictors was not necessary.

CONCLUSIONS

The HHI analyser significantly overestimated LBM and underestimated %BF in African women. After correction for the bias, the body compartments could easily be estimated in African women by using the HHI result in an appropriate prediction equation with a good precision. It remains to be seen whether a combination of arm and leg impedancemetry in order to take into account lower limbs would further improve the prediction of body composition in Africans.

Change in body water distribution index in infants who become stunted between 4 and 18 months of age

OBJECTIVE

To evaluate body composition changes using bioelectrical impedance analysis and skinfold thickness measurements in infants from tropical areas who become stunted between 4-18 months of age.

DESIGN AND MEASUREMENTS

Follow-up study. Extracellular water to total body water ratio index (length(2)/resistance at low to high frequency), peripheral fat (tricipital and subscapular skinfold thickness), and length-for-age index were studied at 4 and 18 months of age.

SETTINGS

Low-income areas in four tropical regions (Congo, Senegal, Bolivia and New Caledonia).

SUBJECTS

Infants were included in the analysis provided they were neither stunted nor wasted at 4 months. Two groups of infants were compared, those that were stunted at 18 months (n=61) or not (n=170).

RESULTS

The extracellular water to total body water ratio index and the sum of skinfold thickness measurements were similar in the two groups at 4 months, and only the extracellular water to total body water ratio index was significantly different at 18 months. When no stunting appeared between 4 and 18 months, the change in the extracellular water to total body water ratio index was not linked with variations in length-for-age, and presented the expected pattern of variation in body water compartments. When stunting occurred, variation in length-for-age was related to significant changes in the extracellular water to total body water ratio index, the biggest increase in the proportion of extracellular water being found in the most stunted infants. Variations in the sum of the two skinfold thickness measurements presented the expected pattern for the 4-18 months growth and did not differ between the two groups.

CONCLUSIONS

Multifrequency resistances suggested that stunting was associated with a lack of the expansion of the intracellular compartment that is expected during normal growth of cell mass, together with preserved fat mass.

SPONSORSHIPS

Supported by grant 92L0623 from the French Ministry of Research, and by Institut de Recherche pour le Développement (IRD).

Decreased attendance at routine health activities mediates deterioration in nutritional status of young African children under worsening socioeconomic conditions

BACKGROUND

Economic crisis and sociopolitical instability are generally associated with worsening health and nutrition in developing countries. This study examines the role played by the attendance rate of young children at routine health activities in the deterioration of their nutritional status under adverse social and economic conditions.

METHODS

Two nutritional cross-sectional surveys were carried out in two districts of Brazzaville, capital city of The Congo, in 1993 and 1996. They included respectively 2807 and 1695 randomly selected children 4--23 months old. The children's nutritional status was assessed by height-for-age in z-scores. Using embedded general linear regression models, explanatory variables (routine health activities index, socio-demographic context, household economic level, prenatal factors) were tested as potential mediators for the effect of the year of survey on child mean height-for-age.

RESULTS

The routine health activities index declined sharply from 1993 to 1996. Its introduction in the regression model including all other explanatory variables led to a sharp decrease in the effect of the year on children's nutritional status, showing the important mediating effect of routine health activities. This result was encountered across all economic categories of households. Other explanatory variables showed more limited mediating effect.

CONCLUSIONS

Attendance at preventive health activities should be fostered in African urban communities facing harsh socioeconomic situations to prevent further deterioration in the nutritional status of children.

Body composition unaltered for African women classified as 'normal but vulnerable' by body mass index and mid-upper-arm-circumference criteria

OBJECTIVE

To test the hypothesis that 'normal but vulnerable' adults, as defined by body mass index (BMI) in combination with mid-upper-arm-circumference (MUAC), are closer to normal than to malnourished ones. For that purpose body composition measurements were compared between normal and low BMI categories and according to MUAC value in an African context and for different age groups.

DESIGN

Reanalysis of data from a previous cross-sectional cluster sample nutrition survey.

SETTING

A rural area of the Republic of Congo, Central Africa.

SUBJECTS

A representative sample (n=544) of non-pregnant women.

MAIN OUTCOME MEASURES

Arm muscle area was calculated from measurements of triceps skinfold thickness and MUAC. Peripheral body fat was assessed by the sum of four skinfold thicknesses. The ratio of resistance at high and low frequencies was derived from whole body measurement of multifrequency bioelectrical impedance analysis and used as the extracellular to total body water ratio index.

RESULTS

The prevalence of thinness decreased from 18.7% as defined by BMI alone to 9.0% as defined by BMI and MUAC. This difference was due to the group of subjects classified as 'normal but vulnerable' (9.7%). Prevalence of thinness increased with age when assessed by BMI alone, but no longer when assessed by BMI and MUAC. Comparison with the BMI> or =18.5 kg/m(2) category showed that in 'normal but vulnerable' subjects lower BMI was accompanied by lower both fat and lean compartments, in absolute values, but the equilibrium of body water compartments was not altered. In BMI<18.5 women, low MUAC was associated with altered lean tissues, at peripheral and whole body level, whereas fat tissue did not differ.

CONCLUSIONS

'Normal but vulnerable' subjects appeared as 'thin but healthy' rather than malnourished, at all ages, even though their BMI was lower than 18.5 kg/m(2). The new classification of thinness based on BMI and MUAC provides a more specific index of nutritional status when restricting the thin category to more at-risk subjects.

[Nutrition, urbanization and poverty in subsaharan Africa]

Africa is currently the continent with the highest urbanization rate in the world. This demographic upheaval has sometimes been considered as an opportunity for modernization but as early as the 1980s experts called attention to its potential impact on nutrition. In recent decades, economic problems and structural reforms have had dire effects on urban populations. Today increasing poverty and the effects of globalization have revived concerns about urban nutrition. Retarded growth and emaciation are less common than in urban areas than in rural areas, but disparities between the rich and poor are much greater. However, in some cities, the incidence of emaciation progressed the more during the 1990s, and now equals that in rural areas. In cities the level of obesity in adult women is a sign of nutritional transition but emaciation has also increased. Despite the wide variety of urban conditions, analysis of the underlying factors reveals several constants. For most of these factors, the characteristic feature of the urban environment is a further increase of social inequality.

Dietary changes in African urban households in response to currency devaluation: foreseeable risks for health and nutrition

OBJECTIVE

To investigate the effects of currency devaluation on dietary change and nutritional vulnerability of poor households in two African capital cities.

DESIGN

A qualitative study based on 120 semistructured individual interviews and four focus group discussions in each city.

SETTING

Dakar, Senegal (western Africa) and Brazzaville, Congo (central Africa).

SUBJECTS

All of the subjects were randomly selected women from modest or poor households, who spoke the local common language and were responsible for household meal preparation. Only those likely to restrict the dynamic of focus group discussions (because of language, age or education) were excluded.

RESULTS

Changes were found in meal preparation characteristics (frequency, sharing pattern) and meal composition. There was frequent depletion of fat and vegetable contents in meals, frequent elimination of desserts and even the elimination of one daily meal. These changes specifically affected economically disadvantaged and socially isolated households, and those headed by women. Other changes were the reduction in the size of consumption units and the development of neighbourhood-specific street food - which has been a growing trend in Brazzaville since the outset of the economic crisis but is more recent in Dakar.

CONCLUSIONS

If lasting, these changes pose a dual health risk, i.e. reducing dietary diversity and altering the bacteriological quality of prepared meals. In addition, attempts to reduce the consumption units were found to upset community ties that bind these societies.

Deterioration in the nutritional status of young children and their mothers in Brazzaville, Congo, following the 1994 devaluation of the CFA franc

The effects of the January 1994 devaluation of the African Financial Community (CFA) franc on the nutritional situation of the populations concerned has been little documented. We report in this article on two nutritional cross-sectional surveys that were conducted before and after this devaluation (1993 and 1996) in two districts of Brazzaville, Congo. The surveys involved a representative sample of 4206 households with a child aged 4-23 months. Complementary feeding practices and the anthropometric indices of the children and their mothers were compared, adjusting for changes in household socioeconomic characteristics. The results show a decline in the quality of the first complementary foods offered to the infants, i.e. less frequent use of special transitional foods and imported complementary flours (of higher nutritional quality), and preparation of less nutritious local gruels. Overall, the nutritional situation had deteriorated, with greater levels of stunting and wasting among children, mothers with lower body mass index, and infants with reduced birth weights. Increased food prices would appear to be the direct cause of the decreased quality in complementary feeding, but factors other than the devaluation have also had an impact on household welfare. The influence of these factors on nutritional-status is discussed.

Economic crisis and malnutrition: socioeconomic determinants of anthropometric status of preschool children and their mothers in an African urban area

OBJECTIVE

To assess the relative importance of socioeconomic and maternal/prenatal determinants of the nutritional situation of children < 6 years old in an urban African area after several years of economic crisis.

DESIGN

Cross-sectional cluster sample survey.

SETTING

Brazzaville, capital city of the Congo.

SUBJECTS

Information on socioeconomic characteristics was gathered from a random sample of 1368 households by house visits and anthropometric measurements were performed using standardized procedures on preschool children (n = 2373) and their mothers (n = 1512).

RESULTS

The influence of socioeconomic factors on the nutritional status of children, taking into account adjustment variables such as mother's age and child's age and sex was assessed. For stunting, as well as for the mean height-for-age index among children, the main determinants were economic level of the household (P = 0.048 and P = 0.004, respectively), schooling of the mother (P = 0.004 and P < 10(-3)) and living in the peripheral district (P = 0.005 and P < 10(-3)). The influence of socioeconomic determinants on weight-for-age and wasting was less straightforward. When adjusting, in addition, for maternal and prenatal factors (mother's height and body mass index (BMI) and birth weight), most of the effects of the socioeconomic determinants on the nutritional status of children persisted somewhat, but the effect of the economic level on the stunting became not significant (P = 0.11). The mean BMI of mothers appeared to be related to the economic level of the household (P < 10(-4)), to the marital status (P = 0.01) and to the occupation of the mother (P < 10(-4)).

CONCLUSIONS

Among the socioeconomic determinants of malnutrition in children, some, such as economic level of the household or schooling of the mother, seem to act mainly through prenatal factors, whereas others, mainly dwelling district characteristics, seem to influence more directly the children's nutritional status.

[Logistic regression vs other generalized linear models to estimate prevalence rate ratios]

In cross-sectional studies, to quantify the association between a risk factor and a disease (possibly adjusted for confounders), in the framework of the multiplicative model, the more obvious effect measure is a prevalence rate ratio with an associated confidence interval. The validity of this confidence interval requires an unbiased estimator and an appropriate estimate of the variance. In numerous epidemiological studies however, routine use is made of odds ratios and logistic regression. As the odds ratio per se is difficult to understand, prevalence odds ratios are often interpreted as prevalence rate ratios. But this latter approximation is valid only under the rare disease assumption. Moreover, in the logistic regression model, the variance of the estimates is based on the assumption of binomial variability, which is not always supported by the data; in the frequent case of overdispersion, this leads to under-estimation of the type I error rate. Yet, within the generalized linear model, it is easy to choose a link function other than the logit. For example, the log link (log-binomial model) is appropriate to directly estimate adjusted prevalence rate ratios. In case of overdispersion, it is also possible to achieve a better fit of the model, either by choosing another distribution in the exponential family or by estimating a dispersion parameter for the binomial distribution. Thus, there are no valid reasons for the systematic choice of odds ratio and of the logistic regression model to estimate prevalence rate ratios, unless the type of study imperatively requires their use.

[Obesity and developing countries of the south]

An adult is considered as overweight if his body mass index is 25.0 kg/m2 or more and as obese if it is 30.0 kg/m2 or more. Since excess weight is a predisposing factor for many chronic diseases, e.g. diabetes, an increase in its incidence in the population is cause for concern. Until now, excess weight has been problem of epidemic proportions only in developed countries, but it has recently spread to the developing world. More than 30% of the population in Latin America, the Caribbean, the Middle East, and Northern Africa is overweight. Populations living on Pacific and Indian Ocean islands have the highest prevalence of obesity in the world. In Asia and Black Africa, the overall prevalence of overweight is still low but incidence is high in urban areas. In most of these countries, both underweight and overweight people can now be seen. In many countries, the increase in the number of overweight people has occurred within the last few years. Excess weight appears first among the affluent and then among low-income classes including young children and teenagers. The main causes are a nutrition transition to lipid-rich diets and, above all, reduced physical activity in city dwellers. Obesity and associated diseases could become major problems in the future since malnutrition during fetal development and early childhood are predisposing factors. Already overweight is creating an extra burden for countries where malnutrition and nutritional deficiencies are still observed in young children. Given the economic costs of management of obesity-related diseases, surveillance and prevention programs are needed to stem the growth of this problem.

Effect of early, short-term supplementation on weight and linear growth of 4-7-mo-old infants in developing countries: a four-country randomized trial

The effect of supplementation on growth was tested by means of four similar controlled randomized trials in the Congo (n = 120), Senegal (n = 110), Bolivia (n = 127), and New Caledonia (n = 90). Four-month-old infants were randomly allocated to supplement or control groups. A cereal-based precooked porridge was offered twice daily for 3 mo and consumption was monitored. Both groups were free to eat local food. At 7 mo of age, all infants were still breast-fed in the Congo, Senegal, and Bolivia compared with 47% in New Caledonia. Mean daily consumption of the supplement varied among countries (558-790 kJ/d). Mean length at 4 mo was lowest in Bolivia, higher in Senegal and the Congo, and near the National Center for Health Statistics reference in New Caledonia. The mean 4-7 mo length increment was 0.48 cm higher for supplemented than for control infants in Senegal (P < 0.05), whereas weight increments did not differ. No significant effect was found in the other countries.

[The "malnutrition-infection" complex, the most widespread public health problem in underprivileged populations.]

The synergistic association between malnutrition and infection remains today the most worrisome public health problem in the world. Although the high level of mortality among children in developing countries is mainly due to infectious and parasitic diseases, more than half of these children die in a state of overt undernourishment. Energy and nutrient deficiencies adversely affect various aspects of immunocompetence, thus malnourished people are particularly sensitive to many opportunistic infections. These, in turn, induce anorexia, various metabolic changes and malabsorption, which affect nutritional reserves, and lead to malnutrition if prolonged. In the absence of efficient measures to break this vicious cycle, malnutrition and morbidity lead to high levels of mortality. Experience from developing countries suggests that to improve the prevention and treatment of infectious diseases in such a context of poverty, one need to take into account simultaneously the basic environment of underprivileged groups and their dietary intake as well as their level of access to health care services.

[Complementary nutrition for the young child following the devaluation of the CFA franc (African Financial Community): 2 case studies in the Congo and Senegal urban environment]

Developing countries frequently see their currency depreciated to varying degrees. The consequences of such monetary disturbances on the nutrition of young children are not well known, though children are the most vulnerable in nutritional terms. One year after the 50% devaluation of the CFA Franc (communauté financière africaine, "African Financial Community"), which took place on 12 January 1994 simultaneously in fourteen countries, nine of which are on the UNDP list of least developed countries, we wanted to find out the long-term effects of the devaluation, and the strategies that families had adopted to cope with it. In Brazzaville, Congo, in December 1994, an epidemiological survey was conducted on a representative sample of 893 children between the ages of 4 and 12 months in two districts, and indicators of child nutrition were established. A comparable survey had been conducted in December 1993, before the devaluation. In Senegal, in the absence of a previous survey which could be used in comparison, a qualitative survey using RAP methodology, was conducted in January 1995 in two towns near the capital. In three districts in each of these towns, a cluster of ten plots was chosen at random and surveyed, with a combination of semi-structured individual interviews with mothers (n = 60) and group interviews with all the women together (n = 6). The information was put together with interviews of 25 local traders selling food. In the Congo, comparison of the two surveys shows that the practice of breast-feeding had hardly changed, nor had the age at which baby food was introduced (90% of children of 4-5 months take semi-solid and solid foods); on the other hand, more children are being given the ordinary family meal earlier, at 6-9 months. The proportion of baby foods based on commercially imported flour has fallen (from 32% in 1993 to 18% in 1994), and has been replaced with local products based on maize; this change is more marked among poorer families. The low nutritional value of such preparations is in part compensated by the addition of sugar, though less milk is added (28% in 1994 as opposed to 43% in 1993). In Senegal, mothers do not seem to have changed their breast-feeding practices either, the age at which baby foods are introduced, or the number of times they are provided daily. The most important change is the drop in quality of food given to children, and the poorer family food for the older children. The partial switch from imported products to local produce was an expected consequence of devaluation; it is clearly confirmed here for nutrition of young children, with the consequent loss of nutritional quality (a reduction in energy density and in nutrients). The first thing needed is, therefore, an improvement in local manufacture of food supplements of good nutritional quality, for young children. Mothers also complain of the increased difficulty in managing a family diet so as to take account of economic needs, cultural values and nutrition. They therefore criticize a number of nutritional education messages that are clearly no longer appropriate to the new economic context. Finally the fact that young children are getting poorer quality nutrition is worrying for the future: if it lasts, the nutritional status of children will deteriorate; whenever possible, monitoring must be established so that measures can be taken when necessary to forestall any dramatic deterioration that would endanger the health of the children.

Nutritional change and economic crisis in an urban Congolese community

BACKGROUND

In 1986, the government of Congo undertook a structural adjustment programme to cope with the economic crisis. We present the results of a study whose objectives were to assess the evolution of nutritional status of an urban community between 1986 and 1991 and to identify specific groups for which the nutritional status may have worsened.

METHODS

Two cross-sectional surveys were carried out on representative samples of Brazzaville children < 6 years old: 2295 children were surveyed in 1986 and 2373 in 1991. Anthropometric assessment of nutritional status was performed. For children, weight-for-height and height-for-age indices were used according to WHO recommendations. Wasting and stunting were respectively defined as indices under -2 z-scores. Body mass index of mothers was calculated and risk of chronic energy deficiency (CED) was defined as < 18.5 kg/m2. Socioeconomic data relative to the households were also collected. Multivariate statistical methods were used to obtain adjusted estimates of nutritional changes in the community.

RESULTS

Data analysis led to several converging results: increase in the percentage of low birthweight (10.2% in 1985 versus 18.7% in 1990), increase in the percentage of CED (from 7.9% to 10.5%), and increase in the prevalence of wasting (from 2.9% to 4.2%). By contrast, the overall prevalence of stunting decreased from 13.9% to 11.0%. After statistical adjustment, the factors found to influence the evolution of anthropometric status were: age of child, age of mother, schooling of mother and household characteristics such as number of preschool children, economic level and head of household's occupation.

CONCLUSIONS

The study enables the negative effects of the economic crisis to be quantified. Body mass index is shown to be sensitive to economic changes. It could be recommended as a possible indicator for monitoring the nutritional status at population level. The results also call for a new impetus in preventive health programmes and the implementation of nutritional surveillance activities.

Is body mass index sensitively related to socio-economic status and to economic adjustment? A case study from the Congo

Several nutritional surveys based on representative samples from various urban and rural situations show that the Congo presents a situation of nutritional transition. There is a large prevalence of low body mass index (BMI) in adults from rural zones and this increases with age. There is, however, a large prevalence of high BMI in urban populations despite the persistence of some degree of chronic energy deficiency (CED), particularly at younger ages. Correspondence analysis and logistic regression were used to construct a socio-economic index and measure adjusted risk factors for CED. In rural areas, the major risk factors were old age, sex (women) and the absence of schooling; low economic status, a commonly shared factor, did not differentiate between households for CED. In Brazzaville, CED was linked to a young age (< 30 years) and, clearly, to poverty. The change in the prevalence of CED in mothers from the capital city during a period of economic adjustment showed an increased incidence in young mothers, and also showed that the disparity between low and high economic levels regarding CED had grown. Finally, there was a high level of correspondence between the mean values for the weight-for-height of children and the BMI categories of the mothers. There is a parallel evolution during the period of economic adjustment between the increase of wasting in infants and the increase of CED in mothers. Therefore BMI appears to be a potential core indicator for use in nutritional surveillance in the Congo.

Bioelectrical impedance analysis in small- and appropriate-for-gestational-age newborn infants

OBJECTIVE

To determine the reliability of bioelectrical impedance analysis, and to compare and contrast the anthropometric and BIA status of newborns.

DESIGN

BIA and anthropometric parameters were compared in the few days after birth and at about 3 weeks of age.

SETTING

At the maternity hospital or in a paediatric care unit.

SUBJECTS

Small- or appropriate-for-gestational-age newborns, with birth weight below or above the 10th percentile of the reference value, respectively. Measurements were performed on 36 and 47 newborns at birth, and for a subgroup (21 and 11) again about 3 weeks later, respectively.

RESULTS

At birth, length2/resistance was 4.3 +/- 0.6 and 6.1 +/- 1.2 cm2/omega (P = 10(-7)), and at 3 weeks of age length2/resistance was 5.0 +/- 0.6 and 5.7 +/- 0.8 cm2/omega (P = 0.11), for small- and appropriate-for-gestational-age newborns, respectively. Percentage reliability was 2.2% and 2.6% for intra- and inter-observer measurements of resistance. Importance of a correct placement of the sensor electrode was demonstrated.

CONCLUSIONS

Ease of measurement and reliability of BIA in neonates were shown. Evolution of BIA values is in agreement with the known increase in total body water linked to regrowth of cell mass in small-for-gestational-age infants. Additional study is required before BIA should be used in usual clinical setting in newborns due to the lack of prediction equation.

The utility of infancy weight curves for the prediction of linear growth retardation in preschool children

Routine weight measurements, recorded on health cards of 95 Congolese infants, were collected during a cross-sectional survey as the children were aged 1 to 5 years. The subjects were divided into two groups according to height-for-age (more or less than -2 SD of NCHS reference) at the time of the survey. Adjustment of a mathematical function to the infancy weight curves allowed comparison of groups using the means of the function's parameters: The stunted children had been significantly lighter than the healthy group during infancy. Predictive values of estimated weights and quarterly weight gains were assessed by discriminant analysis and cut-off points were computed. The weight gain between 3 and 6 months of age predicted stunting just as well as weight at age 1 year did. Sensitivity and specificity were at 77% and 74%, respectively. These results suggest that good prediction of stunting is possible from first-year weight measurements.

[Nutrition survey in the Republic of the Congo: results from a national survey conducted in 1987]

The objective was to evaluate the nutritional status of preschool children in the rural areas in order to establish a baseline for the measurement of the impact of a Government Nutrition Education Project (NUTED) in forthcoming years. The household cross-sectional survey was carried out on a representative sample of the rural population. The sample was stratified in order to portray the nutritional status of the children in the northern regions (more thinly populated) and in the southern regions: one stratum for small towns (between 2000 and 30,000 inhabitants) and 4 strata for rural localities. The sampling method used was by clusters of 30 children, distributed randomly in 20 zones per stratum. The nutritional indices of 2429 children were calculated and analysed according to WHO recommendations. The prevalence of the different types of malnutrition was 27.5% (95% confidence interval (CI), 24.2-30.8) for stunting (height-for-age retardation) and 5.5% (CI = 4.2-6.8) for wasting (weight-for-height retardation). Both types coexisted among 1.9% of the children; 23% of children were underweight for their age (CI = 21.6-26.2), and 15.8% (CI = 14.7-16.9) aged greater than 12 months had a mid-arm circumference below 135 mm. No sex difference was observed in the results. Stunting seems to appear in the second trimester of life (3-5 months), and wasting appeared between 9 and 23 months (highest rate between 12 and 17 months: 14.0% (CI = 9.3-18.8], which presents a real public health problem. The stratification did not show any significant differences in nutritional status among the children living in rural zones and those living in the small towns. However, the prevalence of malnutrition in the rural zones was 2 or 3 times higher than that observed in 1986 in Brazzaville. The division of the country into five main ecological zones allows some useful comparisons, e.g., the prevalence of stunting ranges from 15.5% (CI = 12.8-18.2) in the northern inundated forest zone to 38.8% (CI = 32.9-44.7) in the southern forests of Mayombe and Chaillu. The diet also varied, the frequency of animal protein consumption on the preceding day ranging from 76.3% to 59.1% in the different zones. The Republic of the Congo differs from other African countries in having relatively lower rates of stunting but an astonishingly high prevalence of wasting.(ABSTRACT TRUNCATED AT 400 WORDS)

[Effect of the ingestion of dietary fiber on the digestibility of lipids in a sorghum-consuming African population]

Digestibility measurements were carried out on 12 men. Their habitual diet, deficient in animal products, is based on sorghum meals which supply between 2.4 and 4.2 g of crude fiber per 100 g of dry matter. Over three 11-day periods, the subjects received 3 successive diets (A, B and C) which supplied respectively 3.3, 4.8 and 5.4 g of crude fiber per 100 g of dry matter. Reduced lipids digestibility was noted, even for diet A which was the poorest in fiber content. No difference was observed between diet A and diet B (92.3 and 91.7% respectively). The apparent digestibility of lipids dropped to 86.1 with diet C. True digestibility of lipids is hidden by poorly digestible dietary lipids. Lipid losses increased more rapidly than nitrogen losses with increasing of fiber content in diets. On these regimens, there were no significant changes in concentrations of fecal fat. Concentration of fecal nitrogen decreases for diets B and C.

[Malnutrition and anemia in children hospitalized in Martinique]

In order to assess prevalences, characteristics and risk factors of malnutrition and anemia, a clinical and biological study was undertaken at Lamentin hospital in 100 hospitalized children aged 6 months to 6 years. Forty seven p. cent of children were underweight and 38 p. cent were anemic. Anemia and iron deficiency predominated in the under-24-month age group, whereas wasting was the dominate finding in older children. Under 2 years of age, risk factors for wasting and anemia were associated with method of breastfeeding. Over 2 years of age, low birthweight was the only risk factor of wasting identified. In Martinique, nutritional deficiency is common in children admitted to hospital and a high index of suspicion is indicated in the hospitalized population. Following the resolution of infections, supplemental iron therapy must be considered for a great number of children under 2 years of age.