The nutrition transition and the double burden of malnutrition.

Chronic noncommunicable diseases are increasingly frequent in low- and medium-income countries, but problems of malnutrition, such as growth restriction in children or micronutrient deficiencies in both children and adults, persist in these same countries. This double burden of malnutrition and the emergence of chronic diseases such as type 2 diabetes strain healthcare systems and constitute a sometimes unbearable load for the countries concerned, for the government, but also for the individuals affected and their families. This double burden is often associated with the nutrition transition or the progression away from the local traditional diet towards a Westernized diet frequently high in fat, salt, and sugar, with low nutritional density. This transition is attributed to worldwide changes in dietary systems expressed by an increased availability of foodstuffs marketed across the planet, such as vegetable oils, sugars, and refined flours, but also the multiplication of points of sale of food that has been processed, even ultraprocessed. The efforts to battle this scourge must take into account the complexity of the phenomenon and the many factors associated with it. A systemic approach that considers the global forces governing the food systems must be promoted. Actions concerning nutrition must therefore emphasize simultaneously the problems of undernutrition and of overnutrition. WHO labels these interventions "double duty actions."

Deriving an optimal threshold of waist circumference for detecting cardiometabolic risk in sub-Saharan Africa.

BACKGROUND: Waist circumference (WC) thresholds derived from western populations continue to be used in sub-Saharan Africa (SSA) despite increasing evidence of ethnic variation in the association between adiposity and cardiometabolic disease and availability of data from African populations. We aimed to derive a SSA-specific optimal WC cut-point for identifying individuals at increased cardiometabolic risk. METHODS: We used individual level cross-sectional data on 24 181 participants aged ⩾15 years from 17 studies conducted between 1990 and 2014 in eight countries in SSA. Receiver operating characteristic curves were used to derive optimal WC cut-points for detecting the presence of at least two components of metabolic syndrome (MS), excluding WC. RESULTS: The optimal WC cut-point was 81.2 cm (95% CI 78.5-83.8 cm) and 81.0 cm (95% CI 79.2-82.8 cm) for men and women, respectively, with comparable accuracy in men and women. Sensitivity was higher in women (64%, 95% CI 63-65) than in men (53%, 95% CI 51-55), and increased with the prevalence of obesity. Having WC above the derived cut-point was associated with a twofold probability of having at least two components of MS (age-adjusted odds ratio 2.6, 95% CI 2.4-2.9, for men and 2.2, 95% CI 2.0-2.3, for women). CONCLUSION: The optimal WC cut-point for identifying men at increased cardiometabolic risk is lower (⩾81.2 cm) than current guidelines (⩾94.0 cm) recommend, and similar to that in women in SSA. Prospective studies are needed to confirm these cut-points based on cardiometabolic outcomes.International Journal of Obesity advance online publication, 31 October 2017; doi:10.1038/ijo.2017.240.

[Analysis of direct medical costs of type 2 diabetes in Mali]. / Analyse des coûts médicaux directs des soins du diabète de type 2 au Mali.

BACKGROUND: Type 2 Diabetes (T2D) is rapidly increasing in Africa, but it is still rather neglected. Demonstrating the medical costs for treating type 2 diabetes would be useful for improving awareness and proposing solutions. The purpose of this study was to compare the estimated medical costs for basic chronic treatment and the actual expenditures of diabetic patients, and to identify determinants of these expenditures. METHODS: The estimated medical costs were based on price data collected from three public hospitals and their pharmacies (one university and two district hospitals), as well as from three private clinics and three private pharmacies, in Bamako. A standard treatment protocol for diabetes care, with and without complications, was first established by a working group prior to pricing of consultations, medication, care devices and specialized tests and treatments. Costs were computed using an Excel® software program. We calculated actual expenditures for medical care and examined some determinants using the data from a cross-sectional survey on 500 adult diabetic subjects in Mali. Participants were randomly selected from registries of known diabetics. RESULTS: The estimated costs for basic medical care of uncomplicated diabetes ranged from 108 to 298 € per year in the public sector, and 325 to 756 € in the private sector. Median annual expenditures of survey subjects without complications for chronic care amounted to 178 € (range: 98-331) and were therefore in the estimated range in the public sector. Total median expenditures of all survey subjects, including 78% with complications, reached 241 € per year (142-386). Additional expenditures for the treatment of complications were lower than the estimated costs, except for retinopathy. Independent predictors of higher expenditures were insulin treatment, residence in Bamako, and the number of complications. The minimum estimated cost of medical treatment for uncomplicated diabetes in the public sector represented 29% of GNP per capita. Total medical expenditures as reported by survey respondents amounted to an average of 24% of their income. CONCLUSION: Treatment of T2D is expensive and beyond reach for many patients in Mali, particularly when there are complications. Prevention of diabetes is an urgent challenge in Africa, along with early screening in order to delay and reduce the occurrence of complications.

Dietary patterns of urban adults in Benin: relationship with overall diet quality and socio-demographic characteristics.

OBJECTIVES: To identify dietary patterns of urban Beninese adults and explore their links with overall diet quality and socio-demographics. SUBJECTS AND METHODS: A sample of 200 men and women aged 25-60 years was randomly selected in 10 neighbourhoods. Food intake was assessed through three non-consecutive 24 h food recalls. Dietary patterns were examined using cluster analysis. Diet quality was assessed based on diversity, a micronutrient adequacy score (MAS) and a healthfulness score (HS). Socio-demographics were documented using a questionnaire. RESULTS: Two distinct dietary patterns emerged: a 'traditional' type (66% of the subjects) and a 'transitional' type (34%). Subjects with a 'transitional diet' were predominantly from the upper socioeconomic status or born in the city. Compared with the traditional type, the 'transitional diet' had a significantly higher percentage of energy from fat (17.6 vs 15.5%), saturated fat (5.9 vs 5.2%) and sugar (6.3 vs 5.0%). It was also significantly higher in cholesterol and lower in fibre. The 'transitional diet' was more diversified, but it also showed a lower HS than the 'traditional diet'. Mean intake of fruit was low in both clusters (<16 g day(-1)). A higher intake of vegetables was associated with both a higher MAS (P<0.001) and a higher HS (P<0.001). CONCLUSIONS: The dietary transition is evidenced in this study, although both dietary patterns were still low in fat and sugar. Programmes focusing on the prevention of diet-related chronic diseases in this population should encourage the maintenance of the healthful elements of the diets, while emphasizing consumption of fruits and vegetables.

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 microg retinol activity equivalents (RAE) to 655+/-144 microg RAE in mothers (41 to 120% of safe intake level), and from 164+/-14 microg RAE to 514+/-77 microg RAE in children (36 to 97%). Rates of serum retinol <0.70 micromol l(-1) decreased 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.

[The overall nutritional quality of the diet is reflected in the growth of Nigerian children]. / La qualité nutritionnelle globale de l'alimentation d'enfants nigériens se reflète sur leur croissance.

Childhood malnutrition is widespread in the Sahel region of Africa. In Niger, the 1992 Population and Health Survey found that 32% of children under the age of five years had stunted growth and 16% had muscle wasting. Vitamin A deficiency and anemia are major health problems and it is thought that the rate of zinc deficiency is also high. However, very little is known about the dietary intakes of children. The aim of this study was to assess food consumption, energy and nutrient intake in weaned, preschool age children and to assess their risks of deficiency. Three surveys were conducted in periods of food shortage. Two of the surveys were carried out one year apart, in the rainy season (August to September). The third was conducted at the end of the subsequent dry season (July). Sixty children from rural areas (30 girls and 30 boys) aged 2 to 4 years of age at the start of the study (mean age 36.8 + 7.0 months) from the Ouallam district (western Niger) were studied in surveys 1 and 2, and thirty of these children were then studied in the third survey. Food intake was assessed using a modified weighed intake technique. All foods and beverages consumed by the child at each meal were recorded over three days. The raw ingredients of homemade family meals were weighed and the final cooked weight was also recorded. If the child ate from a shared bowl, the number of mouthfuls was counted and three mouthful samples were weighed. Total serving size was then calculated based on the number of mouthfuls and the mean mouthful weight. Snacks and meals eaten away from home were assessed by questioning the mother. Energy, protein, vitamin A, iron and zinc intakes were compared using the most relevant food composition data and the adequacy of the diet was determined from international recommendations for intake. Energy, iron and zinc requirements were adjusted for diets with a low level of digestibility. Protein requirements were adjusted according to the protein mix quality score (67%). The frequency of inadequate intake was calculated using the probability approach of Beaton (1985) or cutoff values roughly corresponding to the mean requirements for particular age/sex groups. Two overall diet scores were used: a nutritional quality score (NQS) and a diversity score (DS). The relationships between dietary intakes and scores, children's weights and heights were investigated. As expected, the children included in the study had monotonous diets, with few animal products, fats, fruits and vegetables other than green leaves (Figure 1). Cereals made up 80 to 90% of total energy, protein, iron and zinc intake. Green leaves supplied most of the vitamin A intake. Intakes were chronically inadequate, particularly during the rainy season, with only vitamin A intake being adequate (Table 1). Almost all the children were at high risk of zinc deficiency. Diet quality and diversity scores were correlated (Tables 2 and 3). About half the children had stunted growth (Table 4). Energy, protein and zinc intakes were highly and significantly correlated with the anthropometric status of the child one year later, particularly with height-for-weight Z scores, and with dietary NQS (Table 5). Both dietary scores were positively correlated with weight and height indices. However, only NQS was significantly associated with weight-for-height index, higher NQS scores being associated with higher growth indices. Diet quality also predicted the anthropometric status of the child one year later. Our findings suggest that both dietary scores are relevant but that the diversity of food eaten may be a better determinant of growth status if energy intake is close to meeting dietary requirements. Multiple dietary inadequacies are frequent among children from developing countries so scores of overall dietary quality may be more appropriate indicators than the intakes of specific nutrients. (ABSTRACT TRUNCATED)

Caregiver behaviors and resources influence child height-for-age in rural Chad.

The purpose of this study was to identify caregiver characteristics that influence child nutritional status in rural Chad, when controlling for socioeconomic factors. Variables were classified according to the categories of a UNICEF model of care: caregiving behaviors, household food security, food and economic resources and resources for care and health resources. Sixty-four households with 98 children from ages 12 to 71 mo were part of this study. Caregivers were interviewed to collect information on number of pregnancies, child feeding and health practices, influence on decisions regarding child health and feeding, overall satisfaction with life, social support, workload, income, use of income, and household food expenditures and consumption. Household heads were questioned about household food production and other economic resources. Caregiver and household variables were classified as two sets of variables, and separate regression models were run for each of the two sets. Significant predictors of height-for-age were then combined in the same regression model. Caregiver influence on child-feeding decisions, level of satisfaction with life, willingness to seek advice during child illnesses, and the number of individuals available to assist with domestic tasks were the caregiver factors associated with children's height-for-age. Socioeconomic factors associated with children's height-for-age were the amount of harvested cereals, the sources of household income and the household being monogamous. When the caregiver and household socioeconomic factors were combined in the same model, they explained 54% of the variance in children's height-for-age, and their regression coefficients did not change or only slightly increased, except for caregiver's propensity to seek advice during child illnesses, which was no longer significant. These results indicate that caregiver characteristics influence children's nutritional status, even while controlling for the socioeconomic status of the household.

Fortified foods contribute one half of recommended vitamin A intake in poor urban Guatemalan toddlers.

Vitamin A intake from food sources, not including breast milk, was determined from seven consecutive 24-h recalls for 55 children (mean age 20.8 mo, SD 8.9) from two poor communities of Guatemala City. Not including vitamin A derived from fortified sugar or breast milk, the median daily vitamin A intake was 194 retinol equivalents (RE). Including vitamin A derived from fortified sugar but not including that derived from breast milk, the median total vitamin A intake (25th and 75th percentiles) was 338 RE (146 and 617 RE) of which 78% was preformed retinol and 22% provitamin A. More than 90% of total vitamin A intake from non-breast milk food sources was derived from only 10 items; over half came from three fortified foods: fortified sugar, Incaparina and margarine. Sugar samples from 91 households in 1991 had a median of 3.3 RE/g (range, 0.0-29.9 RE/g), <25% of the target level (13-17 RE/g); nevertheless, fortified sugar provided 25% of these children's total vitamin A intake (81 RE/d) from non-breast milk food sources and their intake approached the level recommended by the FAO/WHO (400 RE/d). These results show that fortified foods make an important contribution towards vitamin A intake in this sample of poor urban Guatemalan toddlers.

PIP: Vitamin A intake from food sources was measured in 55 randomly selected toddlers 6-36 months of age (mean age, 20.8 months) from two poor communities in Guatemala City, Guatemala, in 1990. Seven consecutive 24-hour dietary recalls were obtained from mothers. Sugar, coffee, and tortilla accounted for one-third of the 7114 food items reported. Excluding vitamin A derived from breast milk or fortified sugar, the median daily vitamin A intake was 194 retinol equivalents (RE). Including vitamin A derived from fortified sugar but not from breast milk, median total vitamin A intake was 338 RE, of which 78% was preformed retinol and 22% was provitamin A. This figure was 162 RE in breast-fed children and 597 RE in weaned children. Only 10 food items contributed 91% of total vitamin A intake and 55% came from three fortified foods: fortified sugar, Incaparina, and margarine, contributing medians of 81, 94, and 61 RE/g, respectively). The mean retinyl palmitate concentration in sugar samples collected from 91 households in the study communities in 1991 was 3.3 RE/g (less than 25% the stipulated amount) and 24 of these samples did not have detectable vitamin A. Since collection of these sugar samples, the association of sugar manufacturers in Guatemala has strengthened quality control measures. Political will is required, however, to enhance and enforce sugar fortification efforts and protect this vital source of vitamin A.

The deterioration in children's nutritional status in rural Chad: the effect of mothers' influence on feeding.

OBJECTIVES: This study examined how maternal influence on child feeding modified the deterioration of child nutritional status in Chad. METHODS: The pattern of height with age was examined in 98 rural Chadian children aged 12 through 71 months from 64 households randomly chosen. RESULTS: Younger children were more stunted than older ones, probably reflecting secular deterioration in weanlings' nutritional status from 1982 to 1987. Children of mothers with influence over child feeding were taller than children of mothers with less influence, but this held only for the youngest children. CONCLUSIONS: Height-for-age can be a useful indicator of recent changes in social and environmental effects on child health. The mother's influence may have buffered the negative impact of socioeconomic conditions on child growth.

Effect of maternal diabetes on the pattern of selected insulin resistance syndrome parameters in normal glucose tolerant subjects of two Algonquin Indian communities in Quebec.

OBJECTIVE: To determine whether a maternal antecedent with diabetes has an effect on insulin resistance syndrome parameters. RESEARCH DESIGN AND METHODS: We studied 352 Algonquin Indians from Quebec aged at least 15 years who had no personal antecedents with diabetes. Data concerned clinical and biological parameters and the parental antecedents with diabetes. RESULTS: For subjects over > 30 years, fasting insulin and cholesterol levels were significantly higher in the group with a maternal history of diabetes than in the group with a paternal history. Significant differences were observed for serum triglyceride, BMI, and subscapular skinfold thickness when comparing subjects with a maternal history and those with no parental history of diabetes. Blood pressure and fasting glucose did not differ according to parental history. CONCLUSIONS: Subjects of maternal antecedents with diabetes have known risk factors for NIDDM. This study does not identify whether there is a genetic or maternal environmental reason for this association.

Chronic fatigue complaints in primary care: incidence and diagnostic patterns.

The complaint of chronic fatigue is ubiquitous in the primary care setting. Because of the nonspecific nature of chronic fatigue, practitioners do not focus on this complaint. Furthermore, most physicians use a problem-based approach. Such a prematurely narrowed focus could overlook the chronic fatigue complaint. Omissions in the data collection process would prove this oversight. Therefore, we postulated that a retrospective review of evaluations for chronic fatigue would demonstrate significant categorical deficiencies. These deficiencies would indicate a problem focus different than the chronic fatigue complaint itself. The authors reviewed the current literature to establish historical, physical, and laboratory findings pertinent to the evaluation of chronic fatigue. Six major categories and the associated data elements were identified for use in analyzing patient records. The patient records from the preceding 6 months were reviewed to find those containing a complaint of chronic fatigue. These records were analyzed to determine if a complete data set had been sought and if an associated diagnosis was made. A total of 425 consecutive charts from an academic family practice clinic were retrospectively reviewed; 9.9% (42) mentioned chronic fatigue. Physicians were lax in performing the mental status and physical examinations; taking the patient's psychiatric and sleep history, as well as the history of chief complaint; and ordering laboratory evaluations. The physician diagnoses included: depression (40.4%), nonspecific fatigue (35.7%), general medical disorders (16.6%), chronic fatigue syndrome (2.4%), fibromyalgia (2.4%), and sleep apnea (2.4%). From these data, the investigators conclude that the workup for chronic fatigue is often incomplete or lacks documentation. This oversight is likely due to a problem focus not directed at the chronic fatigue complaints. Also complicating the evaluation process are the multiple associated disorders, the prevalence of the complaint, and cost/benefit issues facing the primary care physician.

Prevalence estimates of diabetes and of other cardiovascular risk factors in the two largest Algonquin communities of Quebec.

OBJECTIVE: To compare the prevalence of non-insulin-dependent diabetes mellitus (NIDDM) in the two largest Algonquin communities of Quebec (Canada) with that of other native groups and to describe the different patterns of NIDDM and other cardiovascular risk markers in these communities (River Desert [RD] and Lac Simon [LS]). RESEARCH DESIGN AND METHODS: The population-based study targeted all residents aged 15 years and older. In the age-group considered here (30-64 years), there were 480 eligible subjects and 299 participants (50.8% in RD and 86.9% in LS). All except those with confirmed diabetes underwent an oral glucose tolerance test. Serum triglyceride and lipoprotein cholesterol levels, blood pressure, body mass index (BMI), and waist-to-hip ratio (WHR) were measured. RESULTS: The age-standardized (world population) prevalence of NIDDM in women was twice as high in LS as in RD (48.6% vs. 23.9%). In men, it was 23.9% in LS and 16.3% in RD. Upper-body obesity followed the same pattern. In contrast, high-risk serum low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol levels were significantly more prevalent in RD than in LS, particularly among men. The rate of high blood pressure was twice as high in men as in women, with little community differences. When we controlled for age, sex, diabetic, and obesity status, mean fasting serum glucose remained significantly higher triglycerides and LDL cholesterol lower in LS than in RD. There was also an independent community effect on WHR but no on BMI. CONCLUSIONS: The prevalence of NIDDM in LS women reaches the rate observed in Pima Indian women. The observed differences between two Algonquin communities suggest a highly heterogeneous pattern of NIDDM and cardiovascular disease risk factors in Amerindian populations, even within a given tribe and a limited geographic area.

Prevalence of non-insulin-dependent diabetes mellitus and impaired glucose tolerance in two Algonquin communities in Quebec.

OBJECTIVE: To assess and compare the prevalence of non-insulin-dependent diabetes mellitus (NIDDM) and impaired glucose tolerance (IGT) in two native Indian communities. DESIGN: Population-based study. SETTING: Two Algonquin communities in Quebec: River Desert and Lac Simon. PARTICIPANTS: All native Indian residents aged at least 15 years were eligible; 621 (59%) of them volunteered to enroll in the study. The participation rate was 49% in River Desert and 76% in Lac Simon. MAIN OUTCOME MEASURES: Fasting blood glucose level and serum glucose level 2 hours after 75-g oral glucose tolerance test, as described by the World Health Organization, in all subjects except those with confirmed diabetes. Other measures included body mass index (BMI), fat distribution and blood pressure. MAIN RESULTS: The age-sex standardized prevalence rate of NIDDM was 19% in Lac Simon (95% confidence interval [CI] 16% to 21%); this was more than twice the rate of 9% in River Desert (95% CI 7% to 11%). The IGT rates were comparable in the two communities (River Desert 5%, Lac Simon 6%). NIDDM and IGT were uncommon under the age of 35 years. Only in Lac Simon was the NIDDM prevalence rate significantly higher among the women than among the men (23% v. 14%); almost half of the women aged 35 years or more had diabetes. In Lac Simon the rate of marked obesity (BMI greater than 30) was significantly higher among the women than among the men (37% v. 19%; p < 0.001); this sex-related difference was not found in River Desert (rates 31% and 23% respectively). Previously undiagnosed NIDDM accounted for 25% of all the cases. NIDDM and IGT were significantly associated with high BMI, sum of skinfold thicknesses and waist:hip circumference ratio (p < 0.001). The subscapular:triceps skinfold ratio, however, did not display such an association, nor did the age-adjusted systolic blood pressure. CONCLUSIONS: The prevalence of NIDDM is high in Algonquin communities and may vary markedly between communities. Although widespread, particularly in women, obesity cannot entirely explain the much higher rate of NIDDM in Lac Simon. Family and lifestyle risk factors, in particular diet and activity patterns, are being analysed in the two communities.

Anthropometric status, serum prealbumin level and immune response to measles vaccination in Mali children.

Protein energy malnutrition (PEM) is known to depress cell-mediated immunity. Its effect on humoral immunity is less clear-cut. The purpose of the study was to assess seroconversion following measles vaccination according to child nutritional status as assessed by anthropometry and serum thyroxine-binding prealbumin (TBPA). Prior to vaccination, 200 Malian children aged 8-22 months (mode: 9 months) and free of infection were weighed and measured. A venous blood sample was drawn for determination of serum TBPA by radial immunodiffusion and of measles specific immunoglobulins (Ig) by Enzyme-linked Immuno-Sorbent Assay (ELISA). IgG and IgM were again assayed 6 weeks post-vaccination after excluding pre-immune subjects. Seroconversion took place in 91 per cent of the children (95 per cent confidence interval: 86-96 per cent). Based on the NCHS standards, 30 per cent of the children were wasted (weight-for-height less than -2.0 SD) and 18 per cent were stunted (height-for-age less than -2.0 SD). Low serum TBPA (less than 10 mg/dl) was found in 38 per cent of them. TBPA was significantly correlated with weight-for-height and weight-for-age (P less than 0.001), but not with height-for-age. Seroconversion was not significantly related to age, anthropometric indices or TBPA. This study using sensitive methods for the assessment of protein status and of the immune response confirms that children should be vaccinated against measles irrespective of their nutritional status, and PEM was not shown to impair their antibody response.