Are prevention of mother-to-child HIV transmission service providers acquainted with national guideline recommendations? A cross-sectional study of primary health care centers in Lagos, Nigeria.

BACKGROUND: Implementation of interventions for the prevention of mother-to-child transmission (PMTCT) of HIV in low- and middle-income countries, faces several barriers including health systems challenges such as health providers' knowledge and use of recommended guidelines. This study assessed PMTCT providers' knowledge of national PMTCT guideline recommendations in Lagos, Nigeria. METHODS: This was a cross-sectional survey of a purposive sample of twenty-three primary health care (PHC) centers in the five districts of Lagos, Nigeria. Participants completed a self-administered 16-item knowledge assessment tool created from the 2016 Nigeria PMTCT guidelines. Research Electronic Data Capture (REDCap) was used for data entry and R statistical software used for data analysis. The Chi square test with a threshold of P < 0.05 considered as significant was used to test the hypothesis that at least 20% of service providers will have good knowledge of the PMTCT guidelines. RESULTS: One hundred and thirteen (113) respondents participated in the survey. Most respondents knew that HIV screening at the first prenatal clinic was an entry point to PMTCT services (97%) and that posttest counselling of HIV-negative women was necessary (82%). Similarly, most respondents (89%) knew that early infant diagnosis (EID) of HIV should occur at 6-8 weeks of life (89%). However, only four (3.5%) respondents knew the group counselling and opt-out screening recommendation of the guidelines; 63% did not know that haematocrit check should be at every antenatal clinic visit. Forty-eight (42.5%) service providers had good knowledge scores, making the hypothesis accepted. Knowledge score was not influenced by health worker cadre (p = 0.436), training(P = 0.537) and professional qualification of ≤5 years (P = 0.43). CONCLUSION: Service providers' knowledge of the PMTCT guidelines recommendations varied. The knowledge of group counselling and opt-out screening recommendations was poor despite the good knowledge of infant nevirapine prophylaxis. The findings highlight the need for training of service providers.

Validation of the Arizona Activity Frequency Questionnaire using doubly labeled water.

PURPOSE: Physical activity questionnaires (PAQs) are considered the most cost-efficient method to estimate total energy expenditure (TEE) in epidemiological studies. However, relatively few PAQs have been validated using doubly labeled water (DLW) in women or in samples with diverse ethnic backgrounds. This study was conducted to validate the Arizona Activity Frequency Questionnaire (AAFQ) for estimation of TEE and physical activity energy expenditure (PAEE) over 1 month using DLW as a reference method. METHODS: Thirty-five relatively sedentary women completed the AAFQ before participating in an 8-d DLW protocol to measure TEE. TEE and PAEE were estimated from the AAFQ by calculating resting metabolic rate (RMR) using the equation of Mifflin et al. (AAFQmif), by measuring RMR using indirect calorimetry (AAFQic), and using MET conversion (AAFQmet). A predictive equation for TEE was generated. RESULTS: The mean +/- SD for TEE and PAEE from DLW were 9847 +/- 2555 kJ x d(-1) and 5578 +/- 2084 kJ x d(-1), respectively. Formulas using RMR to calculate the TEE and PAEE from the AAFQ tended to underestimate TEE and PAEE, whereas those that included only weight tended to overestimate TEE and PAEE. On the basis of the Mifflin et al. equation, the AAFQ tends to underestimate PAEE by 13%. This underestimation may be explained by the low lean body mass of the sample population and by effectiveness of the METs/RMR ratio in the obese. The following predictive equation was calculated: TEE (kJ x d(-1)) = (86.0 * average total daily METs) + (2.23 * RMRmif) - 6726. When the predictive equation is used, TEE calculated from the AAFQ is highly correlated with DLW TEE (adjusted r(2) = 0.70, P < 0.001). CONCLUSION: The AAFQ is an effective tool for the prediction of TEE and PAEE in epidemiological studies.

Effect of an integrated nutrition curriculum on medical education, student clinical performance, and student perception of medical-nutrition training.

BACKGROUND: Ninety-eight percent of medical schools report nutrition as a component of medical education. However, most schools do not have an identifiable nutrition curriculum. Medical schools that do include nutrition have not evaluated its effect on clinical skills. OBJECTIVE: The objective was to determine the efficacy of an integrated undergraduate medical curriculum to increase the quantity of nutrition instruction and to advance nutrition clinical skills demonstrated by medical students. DESIGN: A quasiexperimental design was constructed to determine whether an integrated nutrition curriculum increased the performance on nutrition-oriented clinical examinations of medical school classes that received 1, 2, or 3 y of the curriculum. The evaluation of the curriculum focused on 3 areas: 1) hours of nutrition instruction, 2) the application of nutrition within a clinical setting, and 3) perceptions about the nutrition curriculum. The Objective Structured Clinical Examination (OSCE) nutrition score was compared between graduating classes by use of analysis of variance. Data from the American Association of Medical Colleges were analyzed to determine the change in the proportion of students who reported that the amount of time devoted to nutrition was adequate. RESULTS: The implementation of the integrated nutrition curriculum resulted in a doubling of the total hours of required instruction in the medical curriculum (35 compared with 75 h). The mean (+/-1 SEM) OSCE nutrition score significantly improved after the implementation of the curriculum (41.7 +/- 0.9% compared with 50.6 +/- 1.1%) and the percentage of students who reported that the amount of nutrition taught during medical school was inadequate decreased (68.4% compared with 11.5%). CONCLUSION: Medical students improved their clinical nutrition practice skills through participation in an integrated nutrition curriculum.

Red palm oil in the maternal diet increases provitamin A carotenoids in breastmilk and serum of the mother-infant dyad.

BACKGROUND: Despite vitamin A supplementation programs, vitamin A deficiency in children remains a public health concern in Honduras. AIM OF THE STUDY: We investigated the effectiveness of short-term dietary supplementation of mothers with red palm oil as a strategy for improving the vitamin A status of the mother-infant dyad. METHODS: Lactating mothers in Colonia Los Pinos, a barrio of Tegucigalpa, Honduras, consumed a total of 90-mg beta-carotene as red palm oil (n = 32) supplements (n = 36) or placebo (n = 18) in six equal doses over 10 days. Carotenoids and retinol in maternal and infant serum, and breastmilk carotenoids and retinol were measured before and after supplementation. Maternal diet was evaluated by 24-hour recall. RESULTS: Maternal serum alpha-carotene and beta-carotene concentrations were increased 2 fold by palm oil compared with 1.2 fold by beta-carotene supplements. Changes were significantly different in infant serum alpha-carotene but not beta-carotene among the three experimental groups. Increases in breastmilk beta-carotene were greater for the palm oil group (2.5 fold) than for the beta-carotene supplement group (1.6 fold) and increases in milk alpha-carotene concentrations (3.2 fold) were slightly greater than those of beta-carotene. There were also small but significant changes among groups in breastmilk lutein and lycopene. Breastmilk retinol was not significantly different among the groups over the treatment period. CONCLUSIONS: Red palm oil in the maternal diet increases provitamin A carotenoids in breastmilk and serum of the mother-infant dyad. The use of dietary red palm oil to improve the vitamin A status of this population should be further investigated.

Efficacy of transdermal nicotine in reducing post-cessation weight gain in a Hispanic sample.

This study examined nicotine replacement effects and pre-quit smoking characteristics with respect to post-cessation weight gain in a primarily Mexican-American sample of Hispanic smokers. Hispanic smokers (108) were randomly assigned to receive either nicotine transdermal patch or placebo patch for 10 weeks, during which time smoking status and weight change were measured. The overall weight gain experienced by the successful quitters was greater than that experienced by non-quitters. Differences between quitters and non-quitters were significant for both females (2.0 vs. 0.86 kg; p < 0.05) and for males (2.3 vs. 1.2 kg; p < 0.05) at 6 weeks post-randomization. At the end of the 10-week treatment, only the females showed a significant difference in weight gain between the quitters and non-quitters (2.8 vs. 1.1; p < 0.01). Results of the random effects regression models for quitters indicated that the active group gained weight at a significantly lower rate than the placebo group (p = 0.047) for females, but not for males (p = 0.87). Years of smoking (p = 0.001) but not baseline cigarettes (p = 0.13) were significant predictors of weight for females, but not for males (p = 0.24 and 0.72, respectively). The use of nicotine patch treatment for smoking cessation effectively attenuated weight gain for successful female quitters compared with placebo-treated quitters. Identification of pre-quit smoking characteristics may prove useful in predicting who is most likely to gain weight when quitting smoking.

A qualitative study of participants' experiences with dietary assessment.

OBJECTIVE: This article reports on the use of focus groups and an experimental participatory activity to investigate factors influencing participants' decisions about what to eat and what to report on food records and food frequency questionnaires. DESIGN: Four focus groups examined participants' experience with diet records and 3 focus groups explored the topic of food portions using a group consensus activity. Twenty-two women participated in the diet record focus groups, and 15 participated in portion estimation groups. SUBJECTS: Focus group participants were equally distributed by age and body mass index values. Each woman completed a 10-day doubly labeled water protocol to measure total energy expenditure, 7 days of diet records (before and during total energy expenditure), and a food frequency questionnaire after the total energy expenditure. ANALYSIS: Transcripts of the focus groups were coded to index categories of responses and to identify themes within and across those responses. Themes discussed in this article are those that were discussed most often and at greatest length by all groups. RESULTS: The diet record focus groups revealed that 2 major factors influenced reporting on diet records: honesty vs social acceptability, and simplifying food intake. The portion estimation focus groups revealed 5 factors that influenced perceptions of portion size: the role of food in the meal, the type of food, personal preferences, product serving sizes, and comparison of personal servings with those of others. APPLICATIONS: The validity and reliability of self-reported food consumption is greatly influenced by the ways people interpret and respond to dietary assessment instruments. These findings indicate that dietetics professionals need to take extra steps to address issues of accurately recording "bad" foods when training patients to complete diet records. Extra probing is needed when dietary records do not include snacks and include simple meals and a large amount of prepared and packaged food because this may indicate that changes in normal dietary patterns were made in order to more easily complete a dietary record.

An integrated nutrition curriculum in medical education.

R25 grant support from the NIH/NCI enabled the University of Arizona to assess nutrition education, develop and evaluate specific course content, and move toward comprehensive prevention-based nutrition education in 1991-1997. Hours of nutrition education increased to 115% over baseline, and students indicated greater satisfaction with the amount of nutrition instruction they received. Especially valuable was a course in prenatal and infant nutrition that paired each student with a pregnant patient. After the grant support ended, nutrition began to be crowded out of the curriculum by other, more traditional, topics, but a 57% gain over baseline was sustained. External support for nutrition education is urgently needed.

Dieting, essential fatty acid intake, and depression.

Studies have both supported and contested the proposition that lowering plasma cholesterol by diet and medications contributes to depression. Evidence suggests that an imbalance in the ratio of the essential fatty acids (EFAs), namely the n-6 and n-3 fatty acids, and/or a deficiency in n-3 fatty acids, may be responsible for the heightened depressive symptoms associated with low plasma cholesterol. These relationships may explain the inconsistent findings in trials of cholesterol-lowering interventions and depression. Dieting behaviors have similarly been associated with alterations in mood state. This review discusses studies of EFAs and depression and explores the involvement of dieting-related psychological factors as potential confounders.

Implementing a 5-a-day peer health educator program for public sector labor and trades employees.

Peer education in the Arizona 5-a-Day project achieved lasting improvements in fruit and vegetable intake among multicultural employees. Measures monitored implementation of peer education from peer educators' logs, the program's reach from employee surveys, and employees' use in terms of employees' dietary change. Peer educators logged 9,182 coworker contacts. Contacts averaged 10.9 minutes, according to coworkers. Coworkers read an average of 4.7 booklets and 2.23 newsletters. Many employees talked with peer educators (59%) and read materials (54%) after the program finished. Employee reports of peer educator contact were positively associated with fruit and vegetable intake. Peereducation was implemented as intended and reached many coworkers. It continued after program completion, reached into coworkers' families, and was used by employees to improve intake. This method can be used with employees who rely on informal sources and whose work presents barriers to wellness activities.

A new, simple, inexpensive means of testing functional vitamin A status: the night vision threshold test (NVTT). A preliminary field-test report.

Vitamin A deficiency is the leading cause of preventable childhood blindness in developing countries. Each year, an estimated 13.5 million children world-wide are unable to adapt to the dark and half a million children progress to complete blindness annually from lack of vitamin A. Most of the currently available methods for assessing vitamin A status are expensive, require sophisticated instrumentation and are not efficacious in field conditions. A simple, inexpensive method was developed to identify children with defective dark-adaptability, thereby providing a reflection of marginal vitamin A stores. The purpose of this preliminary study was to test the field-efficacy of the Night Vision Threshold Tester (NVTT). Thirty-nine middle-school children with a mean age of 13.5 +/- 1.37 years were initially tested for their ability to adapt to the dark using the

Communication strategies for dietary change in a worksite peer educator intervention.

At the heart of peer health education programs is the assumption that tapping social networks increases adoption of behavior change, yet the communication strategies used by peer educators have not been previously documented to assess the use of social networks in promotion of health messages. Our program in public worksites trained peer health educators to utilize their social networks along with individual persuasive strategies to promote the 5 a Day for Better Health message (i.e. eat five or more servings of fruits and vegetables every day). Communication strategies utilized by the peer health educators were tracked via monthly focus groups over a 9 month intervention in 40 social networks of labor and trades employees. Audiotapes were transcribed and content analyzed to identify 10 communication strategies used by peer educators. Strategies were rated as enacted in an individual or a group (collective) context. Peer health educators were more likely to implement 'creating context' and 'role modeling' as group context change strategies, and 'encouragement' and 'responding to employee needs' as individual change strategies. Strategies used most frequently by males were 'mock competition', 'giving materials' and 'encouragement', while females used 'creating context' and 'keeping 5 a Day visible' most frequently. Hispanic peer health educators were more likely to use individual change strategies than their non-Hispanic counterparts. Documentation of the creative approaches utilized by lay educators among their peers can inform public health professionals on (1) how to better train outreach workers within various cultural, gender and social contexts, and (2) how to maximize social network effects.

Chocolate: food or drug?

Although addictive behavior is generally associated with drug and alcohol abuse or compulsive sexual activity, chocolate may evoke similar psychopharmacologic and behavioral reactions in susceptible persons. A review of the literature on chocolate cravings indicates that the hedonic appeal of chocolate (fat, sugar, texture, and aroma) is likely to be a predominant factor in such cravings. Other characteristics of chocolate, however, may be equally as important contributors to the phenomena of chocolate cravings. Chocolate may be used by some as a form of self-medication for dietary deficiencies (eg, magnesium) or to balance low levels of neurotransmitters involved in the regulation of mood, food intake, and compulsive behaviors (eg, serotonin and dopamine). Chocolate cravings are often episodic and fluctuate with hormonal changes just before and during the menses, which suggests a hormonal link and confirms the assumed gender-specific nature of chocolate cravings. Chocolate contains several biologically active constituents (methylxanthines, biogenic amines, and cannabinoid-like fatty acids), all of which potentially cause abnormal behaviors and psychological sensations that parallel those of other addictive substances. Most likely, a combination of chocolate's sensory characteristics, nutrient composition, and psychoactive ingredients, compounded with monthly hormonal fluctuations and mood swings among women, will ultimately form the model of chocolate cravings. Dietetics professionals must be aware that chocolate cravings are real. The psychopharmacologic and chemosensory effects of chocolate must be considered when formulating recommendations for overall healthful eating and for treatment of nutritionally related health issues.

Randomized trial testing the effect of peer education at increasing fruit and vegetable intake.

BACKGROUND: The National Cancer Institute recommends that Americans eat at least five daily servings of fruits and vegetables. National strategies to increase consumption may not reach minority and lower socioeconomic populations. In a randomized trial, peer education was tested for effectiveness at increasing fruit and vegetable intake among lower socioeconomic, multicultural labor and trades employees. METHODS: Employees (n = 2091) completed a baseline survey and received an 18-month intervention program through standard communication channels (e.g., workplace mail, cafeteria promotions, and speakers). Ninety-three social networks (cliques) of employees were identified, which were pair matched on intake. At an interim survey (during months 8 and 9), 11 cliques no longer existed and 41 matched pairs of cliques containing 905 employees remained, with one clique per pair being randomly assigned to the peer education intervention. Employees who were central in the communication flow of the peer intervention cliques served as peer educators during the last 9 months of the intervention program. Fruit and vegetable intake was measured with 24-hour intake recall and with food-frequency questions in baseline, outcome (i.e., at 18 months), and 6-month follow-up surveys. All P values are two-sided. RESULTS: By use of multiple regression, statistically significant overall effects of the peer education program were seen in the intake recall (increase of 0.77 total daily servings; P<.0001) and the food-frequency (increase of 0.46 total daily servings; P =.002) questions at the outcome survey. The effect on the total number of servings persisted at the 6-month follow-up survey when measured by the intake recall (increase of 0.41 total daily servings; P =.034) but not the food-frequency (decrease of 0.04 total daily servings; P =.743) questions. CONCLUSIONS: Peer education appears to be an effective means of achieving an increase in fruit and vegetable intake among lower socioeconomic, multicultural adult employees.

The association of energy intake bias with psychological scores of women.

OBJECTIVE: Assess the association between reporting bias of dietary energy intake and the behavioral and psychological profiles in women. DESIGN: At baseline a series of questionnaires were administered to 37 women, (the Marlowe-Crowne Social Desirability Scale, Weinberger Adjustment Inventory (WAI), the Eating Disorder Inventory (EDI), the Restraint Scale and Sorensen-Stunkard's silhouettes). Subjects received training on how to record dietary records. Subjects recorded three days of dietary records to measure energy intake (EI) during a study to determine total energy expenditure (TEE) using doubly labeled water. Reporting accuracy (RA = EI/TEE x 100) was determined for each subject. Statistical analysis of the data used a mixed effects model accounting for within subject variability to determine if the psychological scores were associated with reporting accuracy. SETTING AND SUBJECT: Women were recruited with local advertisements in Tucson, Arizona. The women had a mean ( +/- 1 s.d.) age of 43.6 +/- 9.3 yrs, body mass index (BMI) of 28.7 +/- 8.5 kg/m2 and total body fat (%TBF) of 31.9 +/- 7.3%. RESULTS: Age and %TBF were significantly and inversely associated with RA. Furthermore, Social Desirability was negatively associated with RA. Body dissatisfaction and associating a smaller body size than one's own as being more healthy were also associated with a lower RA. CONCLUSIONS: These results suggest that Social Desirability and self image of body shape are associated with RA. Modifications in subject training may reduce the effect of these factors on RA.

Short-term beta-carotene supplementation of lactating mothers consuming diets low in vitamin A.

We have previously shown that beta-carotene supplementation of the diets of healthy U.S. mothers increases serum and milk beta-carotene concentrations. Building on these results, we investigated the possibility that beta-carotene supplementation could enhance the vitamin A status of mothers and their nursing infants. Three 30-mg doses of beta-carotene were administered on 3 consecutive days to 44 lactating mothers who had vitamin-A-poor diets. Concentrations of maternal serum and milk carotenoids and retinol were evaluated at baseline and after 2 and 3 days of supplementation. Infant serum carotenoids and retinol were measured at baseline and 2 days following maternal supplementation. beta-Carotene supplementation markedly elevated maternal serum and milk beta-carotene concentrations (nine- and sevenfold, respectively) and resulted in smaller, transient increases of alpha-carotene, lycopene, and beta-cryptoxanthin concentrations in maternal serum. Maternal serum and milk retinol were unchanged in response to the treatment. In contrast, maternal beta-carotene supplementation significantly increased infant serum retinol (P

Prevalence of intestinal encephalitozoonosis in Mexico.

Infections with Encephalitozoon (phylum Microspora) protozoa in immunodeficient patients have emerged worldwide. The prevalence of infections due to Encephalitozoon species in nonclinical populations remains unclear. We conducted a cross-sectional survey of two rural highland villages in Mexico by using monoclonal antibody 3B6 to Encephalitozoon in immunofluorescence to assess the prevalence of Encephalitozoon spores in human stools. We found that 20 (7.84%) of the 255 subjects were positive and that 15 (21.4%) of the 70 households had at least one member who was positive. These results suggest that Encephalitozoon species, most likely Encephalitozoon intestinalis, may be commonly present in community settings.

Use of a food frequency questionnaire to screen for dietary eligibility in a randomized cancer prevention phase III trial.

Cancer prevention clinical trials use food frequency questionnaires (FFQs) to assist in eligibility screening. FFQ reliability and validity studies are available, but these studies do not evaluate FFQs as screening tools. The Wheat Bran Fiber Trial of the University of Arizona used a FFQ as an eligibility screen with the goal of screening out subjects whose true daily calcium intake was less than 500 mg per day (for safety) and whose true dietary fiber intake was greater than 30 g per day (for safety and trial efficiency). Subjects ineligible by FFQ were interviewed for final dietary eligibility determinations. A study was undertaken within the Wheat Bran Fiber Trial to evaluate the sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of the FFQ used in this context. Four-day food records were collected on 183 potential participants before entry into the study. Using the 4-day averages as the "true" value, sensitivity, specificity, positive predictive value, and NPV were calculated for men and women separately under two screening conditions: using the target calcium and dietary fiber values and using "revised" values identified in interim analysis within the study. NPV was acceptable in all analyses. Sensitivity for low calcium intake was inadequate under the original criteria (0.33 for men and 0.09 for women) but acceptable under the revised criteria (0.80 for men and 0.81 for women). With the revised criteria, specificity declined, resulting in heavy screening burdens deemed worthwhile for the safety considerations. Dietary fiber eligibility screening worked well at target values. These differences were not predicted by reliability/validity studies.

Pneumatic retinopexy failures. Cause, prevention, timing, and management.

BACKGROUND: Pneumatic retinopexy is a procedure for reattaching the retina by injecting an expanding gas bubble and using either laser or cryopexy. The procedure is controversial because there may be a lower initial success rate, and intraocular gas may increase the risk of proliferative vitreoretinopathy. METHODS: The authors performed a retrospective review of 107 unpublished consecutive cases of pneumatic retinopexy together with a literature review of 25 statistical series with primary attention to failures. Univariate and multivariate analyses were carried out on the data set, and adjusted odds ratios for risk factors associated with failure were calculated using logistic regression. RESULTS: Initially, 74 (69%) of 107 patients had successful results, and with re-operations the success rate increased to 98%. Failure of the procedure to achieve retinal reattachment occurred soon after the initial procedure, with 86% of recorded failures occurring within the first month. The initial cause of failure was new or missed breaks in 14.9%, reopened initial breaks in 11.2%, and breaks never closed in 4.6%. Risk factors that showed a correlation with failure were patients being male (adjusted odds ratio = 2.65), eyes with preoperative visual acuity worse than 20/50 (adjusted odds ratio = 1.21), eyes with four quadrants of retinal detachment or total detachment (adjusted odds ratio = 2.03), aphakic or pseudophakic eyes (adjusted odds ratio = 1.91), and eyes with additional pathologic findings (adjusted odds ratio = 3.14). Poor visual outcome was associated with initial visual acuity less than 20/50 (adjusted odds ratio = 15.7) and eyes with four quadrants of retinal detachment or total detachment (adjusted odds ratio = 5.01). CONCLUSIONS: Failures of pneumatic retinopexy occur early in the postoperative course. Factors known to be associated with failure of retinal reattachment using scleral buckling also were associated with failure in pneumatic retinopexy. A higher success rate in females was noted, suggesting that educational efforts may need to be greater in males. Poorer visual results occurred in patients with poor initial vision and in eyes with four quadrants of retinal detachment or total detachments.

Cryptosporidium parvum in children with diarrhea in Mexico.

Using an anti-oocyst wall monoclonal antibody-based immunofluorescence assay, the presence of Cryptosporidium parvum was evaluated in children with diarrhea from rural areas (selected from a door-to-door community survey) and from urban areas (patients attending hospitals) in the State of Puebla, Mexico. Prevalences of 9.4% in a rural population (n = 85) and 29.6% in a hospital-based urban population (n = 81). There was no consistent correlation between water source and other environmental data and the presence of C. parvum in stools. It is concluded that C. parvum may be an important pathogen associated with diarrhea in this Mexican state.