Urban-rural contrasts in explanatory models and treatment-seeking behaviours for stroke in Tanzania.

Stroke is an emerging problem in sub-Saharan Africa, about which little is known since most research to date has been based on retrospective, hospital-based studies. This anthropological work, designed to complement a large community-based project on stroke incidence, focuses on local understandings and treatment-seeking behaviours in urban (Dar-es-Salaam) and rural (Hai) areas of Tanzania. Semi-structured interviews (n=80) were conducted with 20 stroke patients, 20 relatives of stroke patients, ten traditional healers, and 30 other local residents. In contrast to common expectations, and literature that finds witchcraft beliefs to be most common in rural areas, stroke in urban Dar was widely believed to emanate from supernatural causes (demons and witchcraft), while in rural Hai, explanations drew mostly on 'natural' causes (hypertension, fatty foods, stress). These different beliefs and explanatory models fed into treatment-seeking behaviours. The first option in Hai was hospital treatment, while in Dar-es-Salaam, where belief in demons led to hospital avoidance, it was traditional healers. In both sites, multiple treatment options (serially or simultaneously) were the norm. Analysis of patient and carer narratives suggested that causation beliefs outweighed other factors, such as cost and distance, in shaping effective treatment. Three policy implications are drawn. First, as other studies have also shown, it is important to engage with, rather than dismiss, local explanations and interpretations of stroke. Stroke awareness messages need to take into account the geographical and belief systems differences. Developing an understanding of explanatory models that recognizes that local beliefs arise from dynamic processes of social interaction will be critical to designing effective interventions. Second, there is a clear role for multiple healing systems with possibility of cross-reference in the case of a chronic, disabling condition like stroke, since biomedical treatment cannot offer a 'quick fix' while traditional healers can help people come to terms with their condition. Third, issues of communication between health services and their patients are particularly critical.

Immunostimulation and growth faltering in UK infants.

The purpose of the study was to determine whether chronic immunostimulation could explain growth faltering in disadvantaged children in the UK, as it does in developing countries such as The Gambia. In all, 216 infants, age 10-21 months, were recruited when blood samples were taken for the routine or clinical purposes of a longitudinal study tracking a larger cohort of children. Aliquots of blood were collected on Guthrie cards to determine blood concentrations of albumin (Alb), alpha(1)-antichymotrypsin (ACT), and immunoglobulin G (IgG). Haemoglobin concentrations were determined by routine hospital laboratory analysis. Heights and weights were measured and converted to z-scores; birth weights were used with recruitment weight to calculate a 'thrive index' for each child. Age-corrected plasma IgG concentration was negatively associated with both height- and weight-for-age z-scores (P = 0.042 and 0.038, respectively) but not with the thrive index or body mass index z-scores. Blood haemoglobin levels were positively related to height- and weight-for age z-scores, as well as to the thrive index (P = 0.026, 0.014, and 0.007, respectively). Although significant, these relationships could only account for a small part the observed growth variation. Although the relationships were weak, the results suggest that some of the observed variation in growth of these UK infants may be explained on the basis of persistent immunostimulation or poor iron status. In terms of markers of immunostimulation (Alb, ACT, ACT:Alb ratio, IgG), both absolute levels and relationships with height-for-age are substantially different than those previously observed in cohort studies of infants in The Gambia.

Do early infant feeding patterns relate to breast-feeding continuation and weight gain? Data from a longitudinal cohort study.

OBJECTIVES: To describe the first-week feeding patterns for breast- vs bottle-fed babies, and their association with sustained breast-feeding and infant weight gain at 6 weeks. DESIGN: A longitudinal cohort study. SETTING: Feeding diaries were completed by mothers in an urban UK community shortly after birth; follow-up weight and feeding data were collected at routine health checks. SUBJECTS: Mothers of 923 full-term infants born during the recruiting period agreed to join the study. In all, 502 usable diaries were returned from 54% of the cohort. RESULTS: Breast-fed infants were fed more frequently (2.71 h between feeds) than bottle-fed infants (3.25 h between feeds) and mixed-fed infants (3.14 h between feeds) (P<0.001) in the first week of life, while duration of feeds was similar. Only exclusive breast-feeding in the first week (P<0.001) and maternal education (P=0.004) were related to continued breast-feeding at 6 weeks. Greater first-week feeding frequency (as measured by feed-to-feed interval, h) was associated with higher weight gain at 6 weeks for breast-feeders, but no analysed factors were associated with higher weight gain for bottle-feeders. CONCLUSIONS: This large-scale study of first-week feeding patterns sheds light on the important and complicated issues of breast-feeding continuation and infant weight gain, with implications for the feeding advice given to mothers. Supplementary bottle feeds were clearly associated with discontinued breast-feeding at 6 weeks. Over that period, higher weight gain was associated with more frequent feeding for breast-fed infants only. SPONSORSHIP: Henry Smith Charity, SPARKS, Child Growth Foundation.

Elevated acute-phase protein in stunted Nepali children reporting low morbidity: different rural and urban profiles.

This study examined the associations between severity of stunting, plasma protein concentrations and morbidity of 104 Nepali boys, aged 10-14 years, living in contrasting environments. Boys from a remote village were compared with three similarly aged urban groups: poor squatters, homeless street children, and middle-class schoolchildren. All but the middle-class group were stunted, particularly village boys whose mean height-for-age z-score (-2.97, SD 0.82) indicates severe growth retardation. Stunting was significantly associated with increased plasma levels of the acute-phase protein alpha1-antichymotrypsin itself inversely related to plasma levels of albumin. Plasma ACT levels of village children (mean 1.52 g/l, SD 0.43) were three to four times higher than those of squatters and homeless street children, and five times higher than those of middle-class boys. Despite being the most severely stunted and having the most abnormal plasma protein values, village children reported the lowest burden of disease, a contradiction which may reflect exposure to sub-clinical infections or habituation to illness and low expectation of treatment. This study draws attention to the strikingly high levels of ACT and of stunting in the rural sample, and cautions on the use of uncorroborated morbidity reports across different epidemiological and socio-ecological environments. Possible mechanisms to explain the impact of illness and inflammation on growth faltering are discussed.

Seasonal growth patterns in rural Nepali children.

This paper reports on the prevalence of growth retardation, the impact of seasonality on height and weight gains, and significant relationships between growth velocity, nutritional status and morbidity, for a population living at subsistence level in rural Nepal. Monthly variation in growth pattern was examined for 71 boys and girls 0-49 months of age. At the height of the monsoon season, 71% of children were moderately stunted, but none was wasted (mean -2.61 SD height-for-age and -0.91 SD weight-for-height by reference to NCHS z-score values). Measures of stunting deteriorated from moderate to severe after 1 year of age. No differences by sex or ethnicity were detected. Environmental changes from the winter to the monsoon seasons were reflected in significant losses of weight and lower weight-for-height z-scores, especially for 0-35 month-olds, although height for 12-35-month-olds continued to be gained over this period. Growth velocity was significantly related to previous growth status (thinner and shorter children did not show catch-up in height or weight) and to morbidity reported over the period of observation. The prevalence of illnesses rose six-fold from the winter to the monsoon, and children with a high frequency of illnesses experienced a significant shortfall in weight and height increments. A poor diet and recurrent illnesses explain the slow and uneven growth of these children. Despite an increase in women's agricultural workloads in the monsoon season, childcare patterns per se do not seem to adversely affect small children. Small stature through later childhood and in adults is one consequence of the growth pattern seen at these young ages.

PIP: The monthly variation in growth pattern was examined for 71 boys and girls aged 0-49 months of age in rural Nepal. At the height of the monsoon season, 71% of children were moderately stunted, but none was wasted. Stunting worsened from moderate to severe after 1 year of age with no differences observed by sex or ethnicity. Overall measures of wasting significantly worsen over the winter to monsoon period, while measures of stunting improve. In particular, there was significant wasting especially among 0-35 month olds, while height for 12-35 month olds continued to be gained over the period. Growth velocity was significantly related to previous growth status and to morbidity reported over the period of observation. The prevalence of illnesses increased six-fold from the winter to monsoon season and children with a high incidence of illness experienced a significant shortfall in weight and height increments. Poor diet and recurrent illness explain the slow and uneven growth of these children. Increased women's workload during the monsoon season does not appear to adversely affect small children through poor child care.

Salivary testosterone levels among Tamang and Kami males of central Nepal.

Salivary testosterone levels are reported for 65 Nepalese males between the ages of 15 and 48 years who were drawn from 2 different ethnic populations (Tamang and Kami) from the central highlands of Nepal. Subjects collected morning and evening saliva samples on five consecutive days in two contrasting seasons, the winter dry season and the summer monsoon season. Anthropometric indexes of acute and chronic nutritional status were also measured. Morning and evening salivary testosterone levels in the winter averaged 233 +/- 14 (SE) pmol/L and 166 +/- 8 pmol/L, respectively, for the Tamang and 249 +/- 14 pmol/L and 163 +/- 13 pmol/L, respectively, for the Kami. In the summer the corresponding values were 219 +/- 12 pmol/L and 156 +/- 8 pmol/L for the Tamang and 249 +/- 19 pmol/L and 147 +/- 12 pmol/L for the Kami. These levels are significantly lower than those reported for Western populations and close to those reported for other non-Western populations. The magnitude of diurnal variation in salivary testosterone levels and the absence of significant age variation are also comparable with observations made on other populations. Weak relationships were observed between testosterone levels and indexes of acute and chronic nutritional status in the winter only. The absence of pronounced variation in salivary testosterone levels between populations and the absence of strong associations between salivary testosterone levels and indexes of acute and chronic nutritional status contrast with the prominent ecological and interpopulation variation reported for salivary progesterone levels in women. Male gonadal function seems less sensitive to moderate energetic stress than female gonadal function, probably reflecting the fact that energy availability is less crucial to male reproductive success than to female reproductive success. Variation in testosterone level associated with chronic energetic stress may be an adaptive somatic response to avoid the maintenance costs of a large active metabolic mass with little direct impact on male fecundity.

Growth status of homeless Nepali boys: do they differ from rural and urban controls?

The rapid increase in numbers of homeless children in cities of the developed and developing world is a matter of grave concern. A multi-disciplinary study was undertaken to examine the health and lifestyles of the homeless in Nepal in comparison to other local children. Few studies have quantified the health of street-children in the developing world using anthropometric indicators, and to our knowledge this is the first to systematically compare the homeless with appropriate controls from both rural and urban areas. Heights and weights were measured for 307 six to fourteen year-old boys (III homeless 62 squatter, 82 privileged school and 52 village boys). Height for age (HAz), weight for age (WAz) and weight for height (WHz) I-scores relative to reference data from the National Center for Health Statistics (NCHS) were used as indicators of growth status. Stunting characterized all but the school-boys, but wasting was not observed. the homeless were less stunted than either poor squatter or village boys. On arrival on the streets, they were taller than village boys, and duration of homelessness had no effect on their growth status. Thus in terms of physical growth, and despite frequent health complaints, homeless boys in Nepal fare relatively better than control groups of poor urban and rural boys. Comparative studies which reveal some successful aspects of street-life show that urban homelessness may represent an appropriate response to circumstances of poverty.

Seasonal and sex variation in physical activity levels among agro-pastoralists in Nepal.

Considerable attention has been devoted to variation in levels of energy expenditure between and within populations; these are commonly evaluated following international guidelines for grading light, moderate, and heavy physical activity levels (PAL). This study presents activity profiles by season and sex for subsistence agro-pastoralists in Nepal, comparing data for a sample of 20 men observed four times across the year with previously published data on women. Total energy expenditure (TEE) was estimated from direct minute-by-minute observation (totaling 1,679 h for men, 3,601 h for women) and measures of the energy cost of single tasks (117 for men, 168 for women). PAL were calculated and graded as multiples of predicted basal metabolic rate (BMR). Despite an explicitly egalitarian organization of labor, men achieved higher PAL than women (P <.0001), although according to international gradings, both men and women assume moderately heavy PAL in the winter and very heavy PAL in the monsoon. PAL were 1.88 and 2.22 x BMR for men in respective seasons (P <.005; TEE, 11.8 MJ/d and 13.9 MJ/d) and 1.77 and 2.0 x BMR for women (TEE, 9.1 MJ/d and 10.5 MJ/ d). High TEE values result from time-consuming work in subsistence tasks, most of which are of moderate energy cost. Results show that the international guideline (FAO/WHO/UNU [1985]) for grading levels of energy expenditure, which adopts discrepant sex-specific values to define thresholds for moderate or heavy PAL, can mask significant gender variation. Male/female ratios of PAL values are suggested instead for population-level comparisons.

Prolactin response to suckling and maintenance of postpartum amenorrhea among intensively breastfeeding Nepali women.

The aim of the study was to determine the association between PRL responses to suckling and maintenance of postpartum amenorrhea among breastfeeding mothers. Three blood spot samples (5, 30, and 50 min following a timed nursing bout) were collected from 71 intensively breastfeeding Nepali women for PRL determination. Maternal age, BMI (weight/height2), menstrual status, caste, infant age, nursing bout length, and duration of supplementation were recorded at time of sample collection. Independent and paired t tests, linear regression analyses, and general linear models were used to evaluate differences between cycling (n = 36) and amenorrheic (n = 35) women and associations among variables. Logistic regression analyses were used to relate PRL measures to the odds of maintaining lactational amenorrhea. Amenorrheic breastfeeding mothers had higher (P < .001) PRL levels at all 3 collection times than cycling breastfeeding mothers, and PRL levels declined with time since birth (P < 0.05). The odds (OR) of having ceased lactational amenorrhea was significantly higher (OR = 5.0, 95% Cl = 1.3-19.9) among mothers with lower PRL levels (< or = 10 ng/mL) at 50 min post-sucking, and PRL at 50 min showed a significant dose response relationship with menstrual status. The association between 50 min PRL levels and lactational amenorrhea appears to be independent of time postpartum, maternal age, BMI, nursing bout length, and duration of supplementation. Among intensively nursing women, maintenance of elevated PRL levels across the interbout interval increases the odds of maintaining lactational amenorrhea.

PIP: In August 1991, in Nepal, all women aged 19-45 from the Tamang caste (agro-pastoralists of Tibetan origin) and from the Kami caste (low-caste blacksmiths of Aryan origin) who were intensively breast feeding and lived in remote villages in the foothills of the Himalayas were included in a study aiming to examine the association between post-suckling prolactin (PRL) and menstrual status. The study also aimed to determine what PRL response time after suckling best predicts the odds of having resumed menses. There were 36 women whose menses had returned and 35 women who remained amenorrheic. 50-minute post-suckling PRL levels were more linked to menstrual status than 5-minute levels (odds ratio [OR] = 5 vs. 2.1). They (but not 5-minute post-suckling PRL levels) also had a significant dose relationship with menstrual status. During the first year postpartum, PRL levels were significantly higher at all three collection times (5, 30, or 50 minutes) in amenorrheic women than cycling women (p 0.001). PRL levels fell as infant age increased (16 ng/ml for 11 months or less, 13.7 ng/ml for 11-15 months, and 7.4 ng/ml for 15 months; p 0.05). At 50 minutes post-suckling, mothers with PRL levels at or below 10 ng/ml were much more likely to have returned to menses than those with higher levels (OR = 5; p = 0.041). The association between 50-minute PRL levels and lactational amenorrhea were independent of time postpartum, maternal age, body mass index, nursing bout length, and duration of supplementation. The maintenance of high PRL levels across the interbout interval increased the odds of maintaining lactational amenorrhea (p 0.05). In conclusion, intensively nursing women whose PRL levels remain high across the interbout interval are most likely to maintain lactational amenorrhea.

Comparative study of flex heart rate in three samples of Nepali boys.

Flex heart rate (HR, beats per minute) has assumed increasing importance in studies of energy expenditure and physical activity. Flex HR is defined as the mean of maximum rest and minimum exercise HR recorded during a standard test. This report examines methodological and substantive issues regarding the measurement and interpretation of population variation in flex HR values. Flex HR was determined for 80 Nepali 10-14-year-old boys living in contrasting physical and socioeconomic environments (31 village boys, 24 urban middle-class schoolboys, and 25 homeless street boys). The three populations exhibited significant differences in flex HR, with villagers averaging lower values than school or homeless boys (91, 100, and 103 bpm, respectively, P < 0.0001). They also differed in mean resting HR (P < 0.0002), but not in the percentage increase of flex over resting HR. To evaluate reliability, flex HR measurements were repeated on 14 school boys after a 3-month interval. Mean initial and repeat values were not significantly different, but discrepancies were large for individual subjects (-15 to +24 bpm). This suggests that flex HR is reliable at the population level, but not necessarily stable for individuals over time. The range of factors contributing to variation in flex HR between and within populations have implications for the use of HR monitoring to estimate levels of physical activity. © 1996 Wiley-Liss, Inc.

Heart rate monitoring of physical activity among village, school, and homeless Nepali boys.

Continuous HR monitoring, in conjunction with self-reports and direct observation of physical activity, was undertaken in three samples of 10-13-year-old Nepali boys living in different physical and socioeconomic environments. A total of 134 daytime HR profiles were recorded from 67 boys (76 from 31 villagers, 39 from 20 urban middle-class schoolboys, and 19 from 16 homeless street boys). Habitual levels of physical activity were compared using mean daytime HR (bpm) and the following indicators: percentage time during which boys are active (HR> flex, defined as an individual's average between resting and exercising HR), moderately active (HR> flex + 20%, also HR> 119 bpm), and vigorously active (HR> 139 bpm) over 10 hours of daylight. Mean daytime HR (102 bpm) and percentage time spent vigorously active (4%) did not differ between samples, despite obvious differences in lifestyles; thus better indicators are needed to characterize levels of physical activity. Percentage time spent active (HR> flex) was significantly higher (P < 0.0001) for villagers participating in subsistence activities, as a result of low flex HR values, indicating a higher level of physical fitness. Evaluation of moderate physical activity was sensitive to the choice of indicator, either an individual calibrated (above flex) or an absolute threshold of HR elevation. The former may be more appropriate than the latter to compare physical activity levels in populations with different lifestyles and levels of physical fitness. © 1996 Wiley-Liss, Inc.

Inter-individual and seasonal weight variation in rural Nepali women.

Changes in body weight were examined for non-pregnant women in rural Nepal, using 183 anthropometric measures between the early winter and monsoon seasons in 1982, 1982-83, 1990-91 and 1993. The women gained weight when work loads decreased after the monsoon, but despite substantial changes in total energy expenditure, which were out of phase with changes in food intake, seasonal changes were small, averaging only up to 2.6% of initial body weight. There were notable differences between individual women, changes in body weight ranging from -5.6 kg to 4.8 kg. Weight change was examined with respect to lactation status, age, body mass index, mid upper arm circumference and skinfolds as well as total energy expenditure and intake. Nonlactating women, very thin women and women aged under 25 years gained more weight than their counterparts, both before and after the monsoon. Data for a sub-sample in 1982-83 indicated that women who maintained high physical activity levels throughout the year were less prone to weight loss than women whose activity fluctuated between seasons. Initial energy reserves, age-related maturation factors, levels of physical activity and energy intake combine to produce the notable inter-individual variation in body weight changes observed in this population.

The ecological context of human ovarian function.

New methods for monitoring ovarian function have allowed an extension of research venue beyond typical clinical settings to studies of human populations in their natural settings. Such studies have confirmed that patterns of variation in ovarian function with age and energetic factors are general features of human reproductive biology. Age patterns of ovarian function are extremely robust across populations of distinct genetic, ecological and cultural backgrounds. Comparable ovarian responses to energetic stresses are likewise observable in different populations where they arise as correlates of local ecologies rather than as correlates of voluntary patterns of diet or exercise. Maternal age and energetic factors also appear to interact with lactation in the modulation of postpartum, ovarian function. Average levels of ovarian function, however, differ considerably between populations, perhaps correlated with chronic environmental conditions that affect growth, development, and the establishment of adult set-points. Western populations appear to represent an extreme of the spectrum of variation in ovarian function, a fact which may relate to the epidemiology of breast and ovarian cancer.

Seasonality of reproductive function and weight loss in rural Nepali women.

Menstrual and hormonal disturbances have been reported in thin, dieting and exercising Western women, and also recently in rural African women. A study of salivary progesterone profiles was undertaken in a Nepali population to examine whether seasonal increases in workload and changes in energy balance influenced ovarian function. Women's energy expenditure levels were moderately heavy in the winter and very heavy in the monsoon, and body mass fluctuated by -2.8 to +4.8 kg. Samples were collected from 24 normally menstruating women in two seasons, each individual serving as her own control. Progesterone levels were significantly depressed in the monsoon relative to winter for women who lost weight, but not for women who gained weight, indicating that energy imbalance is associated with a loss of fecundity. No differences in body mass index were found between women who lost or gained weight. Progesterone levels were age-dependent, and the degree of hormonal disturbance between age-groups was related to weight loss. The study demonstrates seasonal changes in the fecundity of hard-working Nepali women and a direct link between ovarian function and weight loss (negative energy balance), which is independent of current nutritional status.

PIP: In October-November 1990 and August-September 1991, anthropologists collected saliva samples from 24 17-46 year old nonpregnant, nonlactating, and normally menstruating Tamang women in a remote village in the foothills of the Himalayas in northwestern Nepal to measure progesterone levels (indicative of ovarian function). They used these levels to determine whether a very heavy workload during the monsoon season and changes in dietary intake affected ovarian function. Anthropometric measurements were also taken. The women served as their own controls. Seasonal changes in body mass ranged from -2.8 kg to 4.8 kg. Mean and mid-luteal progesterone levels fell 27% (104-76 pmol/l) and 38% (138-85 pmol/l), respectively, between the winter and monsoon (p .01). The levels of ovarian function were much lower than those of healthy, regularly menstruating Western women and of menstruating Lese women of the Ituri forest in Zaire (mean luteal phase progesterone levels, 104 pmol/l vs. 232 pmol/l for Boston women and 140 pmol/l for Lese women). Reduction in progesterone levels was most significant for 24-34 year old women. In fact, the reduction in mid-luteal progesterone levels was only significant in this age group (p .05). Body mass index did not influence progesterone levels, regardless of changes in weight or age. Reduced progesterone levels was only significant for women who lost weight between the winter and the monsoon seasons, suggesting that energy imbalance is linked to loss of fecundity. Younger women were more likely to gain weight than older women (.6 kg vs. -1.1 kg for middle aged women and -.2 for older women; p .05). The regression between changes in progesterone levels and degree of weight loss was also significant (p .01). Between the winter and the monsoon, the percentage of ovulatory cycles decreased from 71 to 38%. These findings showed seasonal changes in the fecundity of these women and a direct association between ovarian function and weight loss, regardless of current nutritional status.

Seasonality of energy expenditure during pregnancy and lactation for rural Nepali women.

Total energy expenditure (TEE) was estimated for 19 nonpregnant, nonlactating (NPNL) and 24 pregnant (P) or lactating (L) women from 3601 h of minute-by-minute observation and 168 measurements of the energy cost of activities. NPNL women significantly increased subsistence activity and TEE from 9.9 MJ [1.89 x basal metabolic rate (BMR)] in the winter to 10.5 MJ (2.01 x BMR) in the monsoon season. There were differences between NPNL,P, and L women in the winter, but not in the spring or monsoon season when all individuals sustained very heavy physical activity. High TEE values resulted from spending very long hours in tasks that, although appearing physically demanding to the casual observer, were characterized by light or moderate energy cost. The study highlights the importance of seasonal constraints on women's work, which prevent P and L women from significantly curtailing physical activity during the monsoon season, and which effectively limit the scope of behavioral mechanisms for saving energy and reducing TEE.

PIP: In Salme, Nepal, a remote rural village high in the Himalayas, an anthropologist directly observed 19 nonpregnant, nonlactating (NPNL) women and 24 pregnant or lactating women for 3601 hours on 297 single days (11 hours/day in the winter and 13 hours/day in the monsoon season). She also measured the energy cost of their activities. The women were subsistence farmers and of the Tamang ethnic group, the largest in Nepal. This study aimed to estimate these women's daily energy expenditure (EE) and to examine the effect of seasonality, pregnancy, and lactation on regular physical activity. Total EE (TEE) values increased significantly during the spring and monsoon season for all women. NPNL women also increased considerably TEE between the winter and monsoon seasons (9.9 MJ vs. 10.5 MJ, p .05). All of the women carried on very heavy physical activity during the spring and monsoon season, but NPNL women carried on the most very heavy physical activity during the winter. The high TEE levels were not a result of short bursts of intensive activity, but rather from many hours of doing activities of low to moderate energy cost. These activities included pounding grain, hoeing fields, cutting wood, walking, and carrying 10-55 kg loads. In July-September, the women worked 5 hours in agriculture, .5 hours in animal husbandry, traveled 1 hour, and rested 1.7 hours outdoors, equaling 8.2 hours/day of doing subsistence activities. These findings indicated that women faced seasonal constraints on their work, which prevented pregnant and lactating women from considerably cutting back on physical activity during the monsoon season. This limits their options for behavioral changes to save energy and reduce TEE.

Coping with an affected birth: genetic counseling in Saudi Arabia.

Saudi parents who have received genetic counseling following the birth of a child affected by a neurometabolic disorder were interviewed during their visits to a specialist hospital. As is common in the West, understanding of heredity was often incompletely assimilated, and this was related to parental education level. Coping behaviors, however, were substantially different from those in the West. The wide range of attitudes recorded toward consanguineous marriage and future births was a reflection of the position of Saudi families in a society undergoing rapid change.

The energy cost of common tasks in rural Nepal: levels of energy expenditure compatible with sustained physical activity.

Three hundred and six measurements of energy expenditure by indirect calorimetry of sitting at rest and self-paced activity were made on 41 men, 48 women and 6 adolescents in a mountain village of Nepal. Except for walking and carrying uphill, measured activities fell within the range of values for light to moderate effort, despite appearing physically demanding. Villagers tended to reduce travel speed when carrying heavy loads (54-102% of body mass on various inclines), averaging a moderate level of energy expenditure which could be sustained throughout the day. Such moderately demanding work was also assumed by pregnant, lactating women and young adolescents. Pregnant women worked more slowly at some tasks, but did not differentiate themselves from their non-pregnant, non-lactating counterparts for travel on the mountain side.