[Food consumption patterns in the urban milieu of Bamako]. / Les enjeux de la consommation alimentaire en milieu urbain à Bamako.

Food consumption patterns in urban environments are changing and diversifying. This longitudinal study of individual food consumption took into account the coexistence of two types of food consumption: within the home and outside the home. This article presents a summary of qualitative and quantitative research carried out in Bamako, Mali in 1995 and 1996 among 74 families from different socio-economic groups. It provides a comprehensive analysis of their food strategies (at the family and individual level) and their nutritional intake. In the home, similarities are found: three meals a day, and a single dish with a "base" ingredient and sauce at each meal. Heterogeneity is expressed in the number of dishes prepared each day, the type of "base", and ingredients in the sauce. Almost all individuals, no matter what their age or socio-economic status, consume food outside the home. This does not substitute meals at home. Street food accounts for 19-27% of food expenses and provides 134-417 Kcal per day per person. It offers a market for local products not often consumed at home and provides a necessary nutritional supplement to people from families of intermediate or low socio-economic status, especially for children. For people from higher socio-economic levels, street food provides mainly gustative and symbolic satisfaction. Following the devaluation of the CFA franc, the most disadvantaged populations seem to have reached a limit in their capacity for adaptation, which includes not only the quality of consumed products but also quantities. In order to ensure food security in urban areas, food and nutritional policies must take into account all the factors that influence food consumption behaviours of different groups of individuals, in particular the behaviours inside and outside the home. The latter is too often overshadowed.

Low birthweight in infants born to African HIV-infected women: relationship with maternal body weight during pregnancy: Pregnancy and HIV Study Group (EGE).

The effect of maternal HIV infection on birthweight was estimated. In the prenatal clinic of the Centre Hospitalier de Kigali, HIV screening was proposed to women with a gestational age (GA) of less than 28 weeks. HIV-infected (HIV+) and uninfected (HIV-) women were recruited, when they consented. At inclusion, socioeconomic, obstetrical data, and body weight were collected, a clinical examination was performed, and tests for sexually transmitted diseases (STDs) and malaria were performed. Two prenatal visits were made, at 28-32 and 32-36 weeks, with clinical data and weight measurement. At delivery, birthweight, body length, and head circumference of the infant were documented. At inclusion and at the second follow-up visit, HIV+ women (N = 177) weighed less than HIV- women (N = 194) (p = 0.004). Mean birthweight in infants born to HIV+ women was 2947 g (SD = 429) and 3104 g (SD = 461) in infants born to HIV- women (p = 0.001). Frequencies of low birthweight (LBW, weight < 2500 g), prematurity (GA < 37 weeks, according to Finnström score at birth), and intrauterine growth retardation (defined by LBW and GA > or = 37 weeks) were higher in infants born to HIV+ women than to HIV- women (p = 0.009, 0.01, and 0.053, respectively). In multivariate logistic regression, the association between maternal HIV infection and LBW disappeared (p = 0.61), while low GA (p = 0.01) and low last prenatal weight (p = 0.01) were independant risk factors of LBW. LBW in infants born to HIV+ women could be partly attributable to impaired maternal weight. These results underline the need for nutritional surveillance and dietary counselling, hoping to improve the prognosis of pregnancy in HIV+ women, regardless of other therapeutic interventions.

[Home and outside home food complementarity in Bamako (Mali): nutritional and economic aspects. What is the rationality behind consumers' choices?]. / Complémentarité des alimentations à et hors domicile à Bamako (Mali): aspects nutritionnels et économiques. Quelle rationalité dans les choix des consommateurs?

BACKGROUND: Great modifications in social and family relationships and life style come from rapid urbanisation in developing countries. Various types of malnutrition coexist in these towns. Food consumption outside the home is more and more common. This in turn encourages rapid growth in the food informal economic sector which must be taken into account in food and nutrition policy and planning. The aim of this study was to analyse the characteristics and complementarities between home and outside the home food consumption of different kinds of individuals coming from different kinds of families in Bamako, in terms of expenditures and aspects of food and nutritional intakes. METHODS: 366 individuals from 74 families were interviewed. They were chosen according to defined criteria in three districts of Bamako of high, middle and poor socio-economic level. RESULTS: At home the daily food expenditure is 2.27 and 3.79 times greater per individual in rich than in middle income and poor families respectively. Animal proteins are respectively 41%, 19% and 9% of daily protein intake. Energy from lipids is 20 to 30% in rich and middle families. In poor ones it is only 15% which is the lower limit of nutritional recommendations. Moreover, contrary to proteins and carbohydrates, the cost of lipids seems, almost incompressible. Almost everybody eats out of home food, particularly children. Its cost, on an energy basis, is higher than home food. The expense is 19 to 27% of the family food budget. It appears necessary to the satisfaction of nutritional requirements in middle income and poor families. Despite various costs, whatever be the socio-economic level, energy intakes coming from that food are equivalent in absolute terms among various kinds of individuals: children, men and women. CONCLUSION: Families had to adapt their food strategies after the 1994 Franc CFA devaluation. Various hypotheses are presented, linked to intra-family relationships and, within poor families, to insertion in the street food economic sector, in order to understand, the logic of food choices. Such an analysis, where health, nutritional, economic, social and cultural aspects of food are taken into account, allows some concrete orientations for urban food and nutrition policy.

[Food habits outside the home by school children in Cotonou (Benin)]. / L'alimentation hors du domicile des écoliers de Cotonou (Bénin).

Urban growth leads to the consumption of food outside the home, with the demand for street food coming particularly from school children. A survey of 240 primary school children aged 8 to 13 was carried out, by means of personal interviews. More than 90% were regularly given pocket money by their parents, and this money was used mainly for buying food from vendors inside or near their schools. Less than 20% of children ate breakfast at home before going to school. Food purchases occurred mostly before the end of school morning break and an average of 38 CFA Francs were spent on each purchase (7.6 US cents). A wide variety of foods were bought, mostly including cereals. This buying of food seems to be part of a family food strategy to reduce the preparation of breakfast at home. The combination of this demand, and the supply of food in schools provides a useful means for campaigns aimed at improving the quality of children's diets in the short and long term.

Pregnancy, body weight and human immunodeficiency virus infection in African women: a prospective cohort study in Kigali (Rwanda), 1992-1994. Pregnancy and HIV Study Group (EGE).

OBJECTIVE: To study the relationship between human immunodeficiency virus (HIV) infection and body weight in African women during and after pregnancy. METHODS: A prospective cohort study was initiated at the Centre Hospitalier de Kigali in July 1992. Every woman seen at the antenatal clinic and with a gestational age of <28 weeks was offered HIV-1 antibody testing. Comparable numbers of HIV-infected (HIV+) and uninfected (HIV-) women were recruited. At inclusion, socio-demographic characteristics and self-reported pre-pregnancy weight were recorded; height and weight were measured. Each woman enrolled had a monthly follow-up until 9 months after delivery, with a clinical examination including weighing. Three anthropometric indices were used to answer the study objectives: weight, body mass index (BMI), and pregnancy balance. RESULTS: As of April 1994, 101 HIV+ and 106 HIV- women were followed until 5 months after delivery. Weight and BMI during pregnancy were lower in HIV+ women than in HIV- women. After delivery, weight and BMI gains were significantly lower in HIV+ women. Until 5 months after delivery, the mean weight variation was -2.2 kg (standard deviation [SD] = 5.9 kg) in HIV+ women and +0.2 kg (SD = 6.6 kg) in HIV- women (P = 0.007) in comparison to pre-pregnancy weight. Comparisons of the slopes of the weight curves did not show statistical differences throughout the pregnancy, but it did during the post-partum period (P = 0.02). CONCLUSIONS: Our study suggests that HIV infection could impair nutritional status in pregnant women, especially during the post-partum period. Family planning and maternal and child health services including HIV testing and counselling, should consider a nutritional assessment and intervention programme targeted to HIV+ pregnant women.

[Vitamin A deficiency: epidemiological aspects and control methods]. / Le déficit en vitamine A: aspects épidémiologiques et méthodes de contrôle.

Vitamin A deficiency is one of the most common nutrient deficiency syndromes in children from developing countries. It is also correlated with the increased severity and incidence of certain infections. Until recently, vitamin A research was focused on preventing xerophthalmia and blindness in Third World Countries and on the development of synthetic retinoid molecules, with lower toxicity than vitamin A, for the treatment of skin diseases. However, there has been a major shift of emphasis in the last five to ten years. There is a risk of death from xerophthalmia, primarily from complications with infectious diseases. Intermittent treatment with the very large doses of vitamin A prescribed to combat blindness was shown to be effective. This suggests that vitamin A may affect specific elements of the immune system. High-dose vitamin A supplements have been given, at widely-spaced time intervals, to preschool children in communities where vitamin A deficiency causes xerophthalmia and blindness, over the last 20 to 30 years. A strong correlation between mortality and xerophthalmia was identified. Death then became the principal outcome measured because it was easier to detect than xerophthalmia, particularly in large clinical trials in high risk regions where clinical expertise was minimal and vitamin A deficiency was a commoner cause of death than blindness. Other, food-based approaches to the treatment and prevention of vitamin A deficiency, involving foods naturally rich in retinol or carotenoid, or foods artificially fortified with these nutrients, should be developed.

[Devaluation of the African Financial Community franc and the dietary strategies of families in Bamako (Mali)]. / Dévaluation du franc CFA et stratégies alimentaires des familles à Bamako (Mali).

This survey, conducted in 1996, evaluated changes in the way families feed themselves caused by the effects of devaluation of the CFA franc. It involved semi-directed interviews with 64 subjects from various socio-economic backgrounds (affluent, middle-class, poor). The subjects spoke of the difficulties of daily life, lack of money and rapid, unpredictable rises in the prices of essential goods caused by the devaluation. They did not understand the reasons for the devaluation, which has caused rapid changes in the social conditions and nutrition of urban families and has exacerbated the inequality of access to foodstuffs. Affluent families have adopted strategies that increase the family food budget, compensating for price increases. The meals of poor and middle-class families have been directly affected in both structure and content. Poor families have been particularly badly affected. All the changes in strategy, and substitutions of one product for another described by middle-class families were already being used by the poor families before devaluation.

[Variability of home dietary habits of families living in Bamako (Mali) according to their socioeconomic status]. / Variabilité des pratiques alimentaires à domicile des familles vivant à Bamako (Mali) selon le niveau socio-économique.

We investigated the influence of standard of living on the dietary and eating habits of families in Bamako (Mali). Family meals eaten at home at any time of day were studied. Families were selected for the study according to two criteria: the place of residence and the domestic commodities and urban investments. Thus, 24 families were included from affluent and 24 from moderately affluent neighborhoods, and 26 families from poor neighborhoods. All families ate three meals a day, each including staples and sauce. However, the dishes selected for the different meals and their ingredients varied considerably with the family's status. Cereals were the main component of breakfast, but the type varied from one category of family to another. All poor families and 79% of the intermediate group and only 54% of the affluent group ate millet/sorghum. Seventy-five % of the affluent, 13% of the intermediate and none of the poor families drank coffee at breakfast. Fifty % of the affluent, 29% of the intermediate and 19% of the poor families ate rice with nadji sauce at lunch. The quality of the nadji sauce varied with economic status. Tigadeguena sauce was eaten with rice in 17% of the affluent families, 50% of the intermediate group and 12% of the poor families. Very little millet/sorghum was eaten by the affluent at lunch, whereas it was included in lunch by over half the poor and one fifth of the intermediate families. The diversity of dishes was larger at supper, but only in the affluent families which had 2 to 4 different dishes or produce. They included garden vegetable salads and stews, with or without bread. Dinner for the intermediate and poor families was similar to lunch, that is a cereal base and a sauce. Home eating habits also differed according to status. In the affluent families breakfast was eaten alone, whereas in the poor families it was a communal meal. The intermediate group displayed both patterns. Affluent families tried to alternate and diversify their food intake from one meal to another, whereas the diet of the poor was monotonous. Most intermediate families tried to alternate a small range of staples (rice and traditional cereals) although this necessitated reducing the quality of the sauce. Our study shows that eating habits are affected by both cultural factors and standard of living.

[An approach to food consumption in an urban environment. The case of west Africa]. / Approche de la consommation alimentaire en milieu urbain. Le cas de l'Afrique de l'Ouest.

West Africa has undergone rapid economic and political changes during the last 20 years. After the failure of economic policies implemented since independence, programs for structural adjustment have strongly influenced the economy. Food problems affect each country differently. The Sahel has experienced food shortages and starvation whereas in forested countries the food supply has remained stable. Nevertheless, food policies have not succeeded in contributing to urban and rural development. The rate of urbanization in west Africa is generally low but the rate of urban population growth is particularly high, much more than the growth rates of industry and infrastructure. Although metropolitan areas are affected by poverty, they offer more hope and opportunities than rural areas. Urban markets have expanded and diversified as social differences have also increased and contributed to changes in consumption structure. Urban growth has contributed to the increase of imported food: this is indicated by both the strong dependency and the change of food habits towards western food patterns. Recently however, west African urban dwellers are still preferring local items if they are affordable. When imported products are used, they are integrated within a stable meal plan consisting of a single dish with a base and a sauce, which is typical of African food preparation. Surveys of consumption-budgets are still only available on a national scale. These can provide accurate information about food consumption patterns of families, particularly for significant trends. However, they do not provide information about the dynamics of food consumption, neither for urban areas or the individual. Now a significant proportion of individual food consumption occurs outside of the home, mainly with food provided by street vendors. This new consumption habit is a response to the urban food crisis. Consumption of street-vendor-food comprises one component but this cannot be dissociated from in-home food consumption. Despite the growing importance of street-vendor food consumption, it has still not been adequately documented. Theoretically, food consumption is an evolving concept. Single disciplines, such as economics or nutrition, first studied food consumption. More recently, social sciences developed new approaches with various interpretations, which were sometimes contradictory. The evolution of urban food consumption and the numerous related problems support the approach proposed by some authors suggesting a mixed analysis integrating both economics and cultural factors. Operationally, a global and dynamic approach to food styles must consider urban heterogeneity and diversity of situations. For example, food consumption by people maintaining their in-home food habits shows the pertinence of studies focusing on individuals. Therefore, the food course concept may be a useful method for the study of food consumption.

PIP: The need to assure an adequate food supply has been a growing concern in West African countries for two decades. Food problems vary in different countries of the region. African countries have come to depend on food imports to satisfy the needs of their urban populations. There is evidence that food preferences are changing, but some research indicates that the imports do not necessarily signify imitation of western food habits. Instead, imported products are used in preparation of typical African meals consisting of a single dish with a base and a sauce. Studies of food consumption in urban West Africa are largely limited to consumption budgets, which provide fairly accurate information on family consumption and on trends but not on consumption by individual family members. In recent years, an increasing proportion of food consumption occurs outside the home and involves food purchased from street vendors. All studies of the consumption and composition of food from street vendors in Africa have demonstrated the importance of this new mode of consumption in urban areas. But little information exists on the contribution of food eaten outside the home to the daily diet in different socioeconomic groups. The great variety of foods for sale by vendors may contribute significantly to the provision of a varied diet, but the poor conditions of food handling entail health risks. Food consumption outside the home by the household's main wage earners could have deleterious effects if expenditures outside are made at the expense of the quality and quantity of food eaten at home. Analysis of food consumption by individuals in different cities and socioeconomic groups, taking into consideration both food consumed inside and outside the home and using a mixed approach integrating economic and cultural factors, offers the best promise for explaining evolving food consumption patterns in West Africa.

[Nutritional habits of adolescents in the Paris suburbs]. / Les styles alimentaires d'adolescents en banlieue parisienne.

BACKGROUND: Physical and psychological disorders in adolescence may lead to specific food behaviours. The aim of this work was to make a group of adolescents full actors of the conception and realization of a study on their food consumption and attitudes. POPULATION AND METHODS: Seventeen self-selected adolescents (age: 12 to 18 years) were enrolled in the study. They interviewed 186 peers (24% of the adolescents of the district) during March 1994. RESULTS: 5.9% of adolescents never had breakfast; only 57.7% had the three main meals every day during the last week, but 14% had these three main meals and three snacks the preceding day. During a week, 22% (12-14 years old) and 32% (15-18 years old) had had at least one lunch outside their home or school canteen. Fast-food attraction was very strong, mainly among the youngest, the boys and the foreign students. However, family meals were appreciated by 87% of them. CONCLUSION: Even though absence of representation of the sample gave doubts on the most marginal forms of food behavior, the interest manifested by adolescents for this research program and the results favor a food educational program that should be planned with them.

[A method to estimate the nutritional value of food sold by street vendors]. / Proposition d'une méthode d'estimation de l'apport nutritionnel des plats vendus dans la rue.

Food bought outside the house from woman vendors accounts for a significant part of the nutritional intake in urban areas in Africa regardless of age and socio-economic category of the inhabitants. Despite this fact outdoor food consumption is not adequately taken into account in relevant studies. The great variability in space and time of recipes used by vendors makes it very difficult to estimate the nutritional value of the food consumed. The purpose of the present study which was carried out on some female vendors in Bamako, Mali, was to evaluate a simplified assessment method. Assessment is based on information that vendors can easily provide: recipes including ingredients and quantities and sales figures. The results obtained were coherent and appeared to be fairly accurate. However they have to be confirmed by laboratory analyses. Compared to average per capita wages in Mali, the income of these female vendors appears to be high.

[Vitamin A deficiency and food consumption of children aged 6 to 84 months in a Mali rural area]. / Carence en vitamine A et consommation alimentaire chez les enfants de 6 à 84 mois en milieu rural malien.

A cross-sectional study was carried out during the dry season, within the framework of an extension of an existing sanitary program. In December 1991, a cluster sample of 2,631 children was selected in a rural district of Mali, in the district of Koutiala, with good agricultural conditions. A sub-sample of 262 mothers was selected for interviews concerning their knowledge and attitudes about vitamin A deficiency symptoms. Prevalence of clinical symptoms was 2% for night blindness, 0.3% for Bitot's spots and 0.2% for corneal scars. Night blindness was more common after 3 years. The study of weekly consumption of vitamin A rich foods, made on a sample of 519 children, revealed that only 3.3% ate vitamin A rich foods less than seven times a week and 2.7% never ate any. According to the recommended dietary allowances, vitamin A deficiency was not a public health problem in this region. However, these results do not agree with those of the clinical study. It should be noted also that protein energy malnutrition is scarce among the children. These results allowed an estimate of the prevalence of vitamin A deficiency, but were insufficient for the design of strategies to reduce this prevalence. Simple and relatively cheap epidemiological methods like case-control studies are not commonly used in developing countries. These methods could be used to obtain a better estimate of social, cultural and biological risk factors, and therefore, better targeting interventions.

[Bamako school age children and their diet from street vendors]. / Les écoliers de Bamako et l'alimentation de rue.

Eating outside the home is very common in African cities. Food is bought from street vendors and eaten on the street. A large proportion of these consumers are school children, but little is known about what they buy, and the reasons why they make the choices they do. We therefore surveyed 494 second and sixth year primary school children in 1993. They were all enrolled at schools or Muslim colleges in both affluent and underprivileged areas of Bamako (Mali). The language used for the survey was Bambara. Almost all the children had money, mostly given by either or both of their parents and in most cases supplemented by odd jobs. The richest group of children were those in the sixth year in the more privileged areas. However, within a district or a (school) class, there was no correlation between the family's socio-economic group (SEG) and money available to the child. The proportions of children in each area, SEG and class buying the following classes of food were nearly identical; drinks, ice cream, groundnuts, fruit, cooked meals, uncooked meals, and sweets. The amount of money available correlated with the purchase of cooked or uncooked meals and drinks. The amount spent on food correlated with the money available, and the relationship is particularly clear for cooked and uncooked meals. The independence of the children in buying food represents a large part of the total daily food budget of the family. Their true diet and its nutritional value should therefore be quantified. Strategies targeting these children to help improve their diet would have a favorable effect on nutrition, because of their autonomy. Any such strategy should involve the street vendors so as to improve the quality of their products.

[High altitude anemia: validity of definition criteria]. / Anémie en altitude: validité du critère de définition.

The effect of iron and folate supplementation on the hemoglobin response and iron status was studied in male and female equatorian medical students: 66 in Quito (2,800 m altitude) and 40 in Guayaquil (sea level). At the end of the supplementation, there was a nearly complete disappearance of biochemical evidence of iron deficiency in the two groups of students. In Quito, 30% of the men and 26% of the women increased their hemoglobin concentration by more than 1 g/dl after one month of supplementation and could be considered as true anemics, compared to 31% of the men and 29% of the women in Guayaquil. This study shows that at sea level, cut-off points defined by WHO for hemoglobin, taking as reference the impact of a supplementation trial, have a specificity of 100% but poor sensitivity (58%). For people living at high altitudes, cut-off limits adjusted for altitude seem unsuitable: the specificity is 98% but the sensitivity is 0%. Studies taking into account all the factors impacting on the hemoglobin level could be useful for defining cut-off points for high-altitude anemia better than those currently recommended.

[Adolescent pregnancy]. / La grossesse chez l'adolescente.

PIP: An unplanned adolescent pregnancy can have serious physical, psychological, and social consequences, especially in the youngest adolescent. Adolescents have not finished growing and their reserves are very low. Fetal growth and lactation increase the nutritional needs of the adolescent. Adolescent pregnancy-related risks carry over to the mother and the newborn. Adolescent growth in girls less than 16 years who have a child nearly stops, even if nutrition is good. Maternal mortality among adolescents is higher than it is among women aged 20-30. Maternal morbidity is also higher in girls aged 15-19. The main pregnancy complications are severe anemia, renal complications, eclampsia, pre-eclampsia, and labor complications (e.g., vesico-vaginal or recto-vaginal fistulas). They are most common in the youngest adolescents. Poor quality of prenatal care contributes greatly to poor pregnancy outcomes. Prematurity and low birth weight are also more common among adolescents than other age groups. The perinatal mortality rate of infants born to adolescent mothers is also greater: 104-120% greater in Sao Paulo, Brazil and 73% greater in India. The psychological and social consequences of adolescent pregnancy depend on the acceptance of the family and of society. In many cultures, the single pregnant adolescent carries feelings of shame and guilt and hides her condition from her family and society for as long as possible due to fear of a lack of understanding and of rejection. A pregnant adolescent in many countries is forced to quit school. Traditional societies in Africa and Latin America, however, consider a child a blessing and the family supports the adolescent during pregnancy and delivery. Urbanization, socioeconomic pressure, and female education have a tendency to dispel this traditional attitude. Interventions to reduce adolescent pregnancy and its consequences include accessible contraception and access to good quality prenatal care.^ieng

Nutrition education.

PIP: This paper presents an overview of the experience of an International Children's Center (ICC) team following many years of work in the field of education for nutrition in developing and industrialized countries. Nutrition education, a long term intervention in which individuals of all ages are active participants who acquire the knowledge, skills, and attitude pertaining to food and nutrition in the context of socioeconomic and cultural limitations. The discussion covers the concepts of attitude, behavior, and eating conduct. Attitude is defined as a way of viewing or internal disposition adopted by any person in a specific situation. Attitudes grow out of knowledge, beliefs, and values and personal predisposition. On the other hand, behavior denotes an observable act and results in a certain manner of acting in response to external stimuli. Eating conduct is expressed differently and in varying extents depending on living conditions and dietary resources. These concepts correspond to the different degrees of information, awareness, and participation achieved by individuals during the educational program. While examination of conduct and dietary resources are necessary for any education for nutrition programs, more attention and investigation should be given to the "negotiation" phase with the people. The community must be ready to take risks, made aware of the implications of the choices to be made to the professionals and to the general public. In this issue, the ICC team highlights important points concerning nutrition education programs.^ieng

Iron absorption from typical West African meals containing contaminating Fe.

Iron absorption from three typical West African meals was measured in fourteen subjects using the extrinsic-tag technique with 59Fe and 55Fe. All meals consisted of maize as the staple food. Meals were prepared in Benin under realistic conditions from locally grown foods. Of the non-haem-Fe in the meals 39-73% did not exchange with the added inorganic radio-Fe tracer, depending on the degree of Fe contamination of meals. Non-haem-Fe absorption was low in each maize meal, but was even lower for those eaten with a vegetable sauce than for those eaten with a fish sauce. When haem-Fe absorption was included, 70.0-160 micrograms Fe was absorbed. Expressed on an energy basis, the bioavailable nutrient density was 3.2-7.0 micrograms/100 kJ (13.4-29.5 micrograms/100 kcal). These findings suggest that total Fe available in the typical diets of West African countries does not meet the physiological requirements of large proportions of the population.