Underreporting of food intake by dietary recall is not universal: a comparison of data from egyptian and american women.

Underreporting of dietary intake has been observed consistently in food consumption surveys in affluent societies and in clinical studies in a variety of settings. Almost one third of quantitative 24-h recalls provided by adults in U.S. surveys appear to result in estimates that are biologically implausible. Underreporting has been linked to obesity in both the U.S. and Europe, with heavier individuals underreporting to a greater degree than lean persons. A relative dearth of data exists from developing countries and those in transition to address the question whether such underreporting is universal. We present the first data from a large survey of women in a rapidly urbanizing developing country to address this question. More than 4500 adult women in Egypt provided quantitative 24-h recalls of food intake on the previous day in 1993-1994, and weights and heights were measured. We compared the data, in terms of the ratio of reported energy intake to estimated basal metabolic rate, to data from 3010 women in the 1994-1996 U.S. Continuing Survey of Food Intake by Individuals, on whom quantitative 24-h recalls were also conducted. The Egyptian women reported food intakes consistent with FAO/WHO recommendations for energy intakes for women of comparable activity levels, whereas the data for U.S. women showed underreporting consistent with other U.S. surveys. Only 10% of Egyptian women reported energy intakes below accepted criteria for plausibility, compared with one third of American women. We discuss possible reasons for this difference, including cultural and food supply differences, and methodological differences between the two surveys.

Micronutrient deficiency conditions in the Middle East region: an overview.

The Middle East is perhaps the world's best laboratory for learning more about iron and zinc deficiencies, and their widespread prevalence contributes much to constraining the quality of life for a large share of the population. Always, in the context of endemic IDD, countries in the region need to make sure that the programs are in place to consign this still-serious problem to the history books. Research is not required so much in relation to IDD, but clearly applications need to be monitored. Vitamin A deficiency is probably widespread at mild to moderate levels, and should be addressed by a combination of appropriate case management for infectious disease, breastfeeding promotion, and dietary diversification/nutrition education. Iron deficiency is the most prevalent, and so far the most intractable, micronutrient problem. It probably will not yield to less than a multipronged strategy including fortification of the food supply with iron. Several other micronutrient deficiencies require our eventual attention as well, and looking forward to their solution should be part of the research agenda.

Dispersion Index: measuring trend assessment of geographical inequality in health--the example of under-five mortality in the Middle East/north African region, 1980-1994.

A Dispersion Index for the measurement of geographical inequality in the distribution of health status indicators across space and time is proposed. The Dispersion Index is computed independently of the mean and is robust to changes in distributional shape over time. Therefore, the Dispersion Index is shown to possess more desirable statistical properties as compared to the coefficient of variation for assessing trends in the geographical distribution of health status indicators. Application of the Dispersion Index to the 1994 under-five mortality data from the Middle East/North African region shows that regional inequality in the distribution of under-five mortality was reduced by 47% as compared to 1980. Curve-fitting illustrated that the trend in the Dispersion Index values was non-monotonic from 1980 through 1994. We suggest that apart from the World Summit for Children's under-five mortality target for the year 2000, intraregional targets to reduce geographical inequalities in under-five mortality should be specified. We also suggest that changes in the magnitude of the Dispersion Index be used for the assessment of progress made by a region or nation in achieving the specified numerical targets. From a policy perspective, the Dispersion Index has the potential to be useful in the evaluation of specific health strategies designed to reduce intraregional geographical inequality in the distribution of health status indicators within a specified period.

Persistent diarrhea as an emerging child health problem.

Persistent diarrhea (i.e. acute episodes lasting more than 14 days) has been recognized by the WHO as a major public health problem in developing countries and a research topic of high priority. Persistent diarrhea is often associated with malnutrition, growth faltering, and a substantial risk of mortality in children below 5 years of age. Reported incidence and case-fatality rates from persistent diarrhea vary substantially. Substantial disagreement exists regarding definition, incidence and various putative risk factors. Resolution of such measurement related problems will allow for an accurate estimate of the force of morbidity and mortality from presistent diarrhea, while the elucidation of its risk factors will simplify policy making and the tailoring of intervention programs.

Respiratory tract and diarrheal infections of breast-fed infants from birth to 6 months of age in household contexts of an Egyptian village.

OBJECTIVE: To investigate the pattern of respiratory tract infections (RTI) and diarrhea among brest-fed infants and the impact of birth weight, maternal diet during lactation, and household socioenvironmental conditions on these illnesses. DESIGN: A longitudinal household-based study of infant morbidity from birth to 6 months of age. SETTING: Kalama village, Egypt. SUBJECTS: Morbidity information was obtained for 119 infants; 80 had longitudinal records over the first 6 months of age. RESULTS: Birth weights were normally distributed and the mean was comparable to the National Center for Health Statistics reference median. Most infants experienced growth faltering and increased illness episodes during 3 to 6 months of age. Infants with RTI during the first 3-month period were at a significantly higher risk of developing subsequent RTI compared with infants without earlier infections (OR = 5.0, chi-square 10.4, P < (0.0001). Similar associations were not observed for diarrhea. Controlling for earlier RTI, lower maternal intakes of vitamin A or C and animal source energy, protein, riboflavin, zinc or calcium were associated with more days sick with RTI in infants during 3-6 months whereas lower birth weight was associated with a longer duration. Among the variables examined poor household sanitation was the only significant predictor of diarrheal illnesses in this population. CONCLUSIONS: Infants living in unsanitary households were the main victims of diarrhea. Duration of RTI was shorter for infants of higher birth weight and sick days were fewer for infants whose mothers consumed more animal source foods, vitamin A or vitamin C.

PIP: In a longitudinal household-based study of infant morbidity from birth to 6 months of age in the village of Kalama, Egypt, morbidity information was obtained for 119 singleton infants from 131 mothers; 80 had longitudinal records and more than 120 days of morbidity recall during the first 6 months of age. Birth weights were normally distributed and the mean was comparable to the National Center for Health Statistics reference median. Most infants experienced growth faltering and increased illness episodes during 3-6 months of age. Infants with respiratory tract infections (RTI) during the first 3-month period were at a significantly higher risk of developing subsequent RTI compared with infants without earlier infections (OR = 5.0, chi-square 10.4, p 0.0001). Similar associations were not observed for diarrhea. A combination of household and maternal variables were tested by multiple regression analysis in 2 samples of 74 and 65 infants, respectively. Poor household sanitation was the only significant predictor of diarrheal illnesses. Controlling for earlier RTI, lower maternal intakes of vitamin A or C and animal source energy, protein, riboflavin, zinc or calcium were associated with more days sick with RTI in infants during 3-6 months, whereas lower birth weight was associated with a longer duration. Among all the illness during the first 6 months of age the most frequent episodes of illness were RTI (39%) and diarrhea (31%), followed by eye infections (18%) and skin conditions (6%). Among the 80 infants 27 (34%) experienced diarrhea during 0-3 months of age and the mean percentage time of being sick was 9.2%; during the second 3 months, 40 infants (50%) were sick 121% of the time. Infants were sick more often with RTI than with diarrhea during both of these periods. RTI episodes were longer during the first 3 months than during the second 3 months.

Relation of maternal zinc nutriture to pregnancy outcome and infant development in an Egyptian village.

Zinc nutriture of women living in a periurban Egyptian village was examined over the last 6 mo of pregnancy and the first 6 mo of lactation as one of several potential determinants of pregnancy outcome and infant development. Estimated bioavailable zinc intake was approximately 2 mg/d from diets high in phytate and fiber. Among numerous variables analyzed by multiple regression, early pregnancy weight (3 mo) and plasma zinc concentrations in the second trimester formed the best predictor model of birth weight, accounting for 39% of the variance. Bioavailable zinc intake during pregnancy was part of a profile of micronutrient intakes related to neonatal habituation behavior, a measure of early information processing. Performance on the Bayley motor test at 6 mo of age was negatively related to maternal intakes of plant zinc, phytate, and fiber, suggesting that zinc bioavailability was involved. Maternal dietary intake explained most of the variance observed in infant motor performance; however, predictive variance was amplified by the psychosocial context.

Breastfeeding and weaning in a poor urban neighborhood in Cairo, Egypt: maternal beliefs and perceptions.

Maternal beliefs and perceptions about breastfeeding and weaning were investigated in a series of in-depth, open-ended interviews with 20 mothers of infants aged 2-12 months in a poor neighborhood of metropolitan Cairo during July-September 1990. The traditional pattern of breastfeeding well into or through the second year of life is changing rapidly, although essentially all mothers still wish to breastfeed and do so at least initially. Beliefs and behaviors reported varied somewhat by rural/urban origins of the mother herself, but exhibited consensus on many issues. The ability to breastfeed successfully is perceived to be a blessing, and to require maturity, patience and a sense of responsibility. The quantity and quality of breast milk are believed to be influenced by a wide variety of factors including the childs age and individual characteristics, the psychological and physical state of the mother, and her diet. Mothers reported a number of behaviors that are perceived to influence the quality of breast milk including changes in their diet when the infant was ill and behaviors designed to optimize the humoral qualities (hot/cold, light/heavy) of the milk. Supplementation with sugar water beings very early, and gradual introduction of other foods generally is begun soon after 40 days of age. Mixed formula and breastfeeding is commonly perceived to increase the nutritional quality of the childs diet. Weaning is ideally related to developmental milestones (walking, complete dentition) but often occurs early due to a variety of factors including maternal illness, desire for another pregnancy, and perceptions that breast milk may be inadequate. Weaning is perceived to be a difficult and dangerous transition.(ABSTRACT TRUNCATED AT 250 WORDS)

Diet during lactation associated with infant behavior and caregiver-infant interaction in a semirural Egyptian village.

Potential processes through which nutritional and non-nutritional factors can relate to infant state and behavior and mother-infant interactions were examined in 41 mother-infant pairs from semirural Egyptian households. All infants were breast-fed, and breast milk was the main source of their nutrient intake. Median birth weight was close to reference median; however, most infants showed growth faltering when they were 3-6 mo of age. Among the infant behavioral and state variables, only drowsiness (a proxy for activity and alertness) was significantly associated with the nutritional and non-nutritional factors examined. Among these factors, mothers' intakes of animal source foods and certain B vitamins were the strongest predictors of drowsiness. The nature of the association between maternal diet and drowsiness, examined by multiple regression analysis, showed clearly that inadequate diet of the mother was the major risk factor. Alertness of infants was further compromised when there were several children in the households. The small, less vocal and less alert infants received less vocalization from their mothers. In this environment, infants of undernourished mothers may not receive the extra care and stimulation needed and are at risk for subsequent developmental disabilities.

PIP: Each week physicians visited the households of 41 mother-infant pairs living in Kalama, Egypt, to examine infant behavior and caregiver-infant interactions from 3 to 6 months of age, as they relate to various factors, e.g., maternal nutrition and health and socioeconomic status. All the mothers breast fed their infants. Liquids which are inferior sources of energy and nutrients were the most customary food supplements during the first 6 months. Even though the median birth weight tended to equal that of the WHO international reference, most infants experienced faltering growth by 3 months. At 6 months, 75% were below the 25th percentile and 20% were in the 5th percentile. Growth faltering was linked with increased diarrhea (p .05). Even though the mothers' diets contained sufficient niacin, thiamin, folate, and vitamin C, the diets did not supply mothers enough riboflavin, vitamin B-6, vitamin A, calcium, and zinc. Breast milk did not have adequate amounts of vitamin B-6 and, perhaps, not even enough riboflavin and vitamin A. It did contain adequate amounts of calcium, however. Drowsiness was significantly related to maternal diet during lactation but not during pregnancy (especially energy intake from animal sources, p = .0001; energy intake from plant sources, p = .03); number of siblings (p = .009); crowding (p = .06); vocalization from mothers (p = .08); and low socioeconomic status (p = .07). Maternal diet was the best predictor of drowsiness followed by number of siblings. Without remediation in maternal nutrition, infants of undernourished mothers appeared not to receive appropriate care and stimulation, therefore placing them at risk of subsequent development disabilities. Intervention studies should be done to examine this main effect of maternal undernutrition and the importance of covarying environmental risk factors, e.g., crowding.

Determinants of pregnancy outcome and newborn behavior of a semirural Egyptian population.

Several potential determinants of birth weight and neonatal behavioral organization, ie, maternal anthropometry, food intake (energy, protein, and plant- and animal-source foods), morbidity, and household socioeconomic status, were followed systematically in a semirural Egyptian population during greater than or equal to 6 mo of pregnancy. In early pregnancy mothers were generally normal weight to moderately overweight. Their mean energy intake, largely from plant sources, was approximately 8.37 MJ/d (2000 kcal/d) during trimesters 2 and 3. Early (3 mo) pregnancy weight and weight gain during trimesters 2 and 3 were significantly positively related to birth weight Z scores. The best predictor model examined for birth weight included early pregnancy weight, weight gain, and length of gestation (R2 = 0.45). Early pregnancy weight and maternal intake of animal-source foods were significant positive predictors of the newborn's orientation and habituation behavior, respectively. Habituation and orientation measures assess the infant's early ability to process information.

Vitamin B-6 status of Egyptian mothers: relation to infant behavior and maternal-infant interactions.

Functional consequences of marginal maternal vitamin B-6 status for behavior of the neonate and for mother-infant interactions at age 3-6 mo were assessed by a double-blind procedure. In 27 of 70 Egyptian village women studied, vitamin B-6 concentration of their milk was considered indicative of poor maternal vitamin B-6 nutriture. Neonatal behavior, quantified by the Brazelton Neonatal Behavioral Assessment Scale, showed that consolability, appropriate build-up to a crying state, and response to aversive stimuli were significantly correlated with maternal vitamin B-6 nutriture. Naturalistic observational procedures, used twice monthly with infants aged 3-6 mo, indicated that mothers assessed as having marginal vitamin B-6 status were less responsive to their infants' vocalizations, showed less effective intervention to infant distress, and were more likely to use older siblings as care-givers than were mothers of better vitamin status. We conclude that vitamin B-6 was a factor influencing both the behavior of the mother and her infant.

Nutritional status and unfavourable pregnancy outcome in Egyptian women.

The nutritional status in 43 cases of repeated spontaneous (habitual and threatened) abortion with both favorable and unfavorable results was assessed by the 24-hour recall method, as compared to 19 normal terminating pregnancies, all of which were in women of low socioeconomic class and who were considered to be malnourished. All pregnant women were monitored at 2 points during gestation, namely 6-12 weeks and 12-16 weeks, by measuring human chorionic gonadotropin as the main hormonal marker in pregnancy and by total and fractional serum protein estimation as a biochemical probe to both the nutritional status and to the course and outcome of pregnancy. Chorionic gonadotropin was significantly decreased in cases of unfavorable outcome in both gestational periods. Apart from the usual physiological changes of pregnancy in total serum protein and its fractions, a significant increase of the beta globulin fraction in the earlier gestational period only was observed. This increase corresponded to and was inversely proportional to the decreased levels of hCG. The authors therefore suggest the introduction of serum protein electrophoresis as a simple routine procedure for screening high risk pregnancies and thus, the early prediction of unfavorable pregnancy outcome.

Development and evaluation of a colour-coded scale for birthweight surveillance in rural Egypt.

Birthweight surveillance is an important epidemiologic tool, yet it is largely unattainable in locales where most births occur at home attended by traditional midwives. A tempered-steel hand-held scale developed by Program for Appropriate Technology in Health (PATH, Seattle, USA) was adapted for use by Egyptian traditional midwives; it identified newborns weighing less than 2.5 kg by a colour code (yellow versus blue). The scale and reporting system were field tested in a rural Egyptian village. Traditional midwives reported 98% of 299 livebirths attended and 85% were reweighed by Salter scale within 48 hours. Sensitivity of the scale was 100%, specificity 94%. Field conditions are specified for incorporating this method into a surveillance system.

Etiology of rickets in Egyptian children.

Factors associated with the rickets found in children attending the Outpatients Department of Cairo Children's Hospital have been studied. All the children studied were small for their age with the rachitic children being significantly smaller than the controls. The clinical diagnosis of the disease was confirmed in 54 children by X-ray and plasma biochemistry. The best indicator of the disease was the enlarged epiphysis of the wrist and to a lesser extent that of the ankles. Some of the factors predisposing to rickets were assessed in the rachitic children and in age-matched controls. There was no difference in the nutrient intake of these two groups of children although intakes of energy, calcium and vitamin D, but not of protein, were lower than recommended dietary allowances. Although more of the rachitic children came from urban areas than the controls there were no significant differences in the environments to account for the occurrence of the disease. Factors contributing to the development of rickets are discussed with particular regard to aspects such as low body weight, low maternal vitamin D status and low calcium intakes which cause a high rate of utilization and metabolism of vitamin D.

Plasma albumin, parasitic infection and pubertal development in Egyptian boys.

Pubertal stage was assessed in 453 Egyptian boys aged from nine to 17 years. Weights and albumin concentrations were measured and parasites identified from stool samples. The mean age to reach each stage of puberty was significantly delayed in the presence of low albumin levels and parasites. The magnitude of the delay was greater for genital stage 2 than for later stages. Weight was also lower in children with reduced albumin concentration or parasites. Among children of the same age, weight and albumin were positively correlated (P less than 0.001), suggesting that albumin status is involved in the timing of puberty.

Sexual maturation and growth pattern in Egyptian boys.

The mean ages of attainment of successive stages of puberty were estimated in a cross-sectional sample of 453 Egyptian schoolboys from a semi-urban area of Cairo, ranging in age from 9 to 17 years. The stages of puberty were as defined by Tanner (1962). The mean age of onset of puberty (stage 2) was 11.1 years, assessed either by genitalia or by pubic hair. Stage 5 occurred at 16.2 years, again both for genitalia and pubic hair. The time interval between these ages, 5.1 years, was 2 years longer than for British or Chinese boys. There was a highly significant effect of social class on the mean ages of attainment, and the heights and weights of the boys were also related to social class, the class 1 boys being taller and heavier than Tanner's British boys.

Some aspects on liver enzymes in protein-energy malnutrition.

Liver enzymes alkaline phosphatase and transaminases (GPT & GOT) were studied in cases of protein-depleted rats. Alkaline phosphatase activities were determined with and without Mg addition to the incumedia, since it is the essential metal for this enzyme. The liver transaminases were also determined before and after pyridoxine injection, which is the coenzyme for this group. Both liver alkaline phosphatase and transaminases activities were increased on protein depletion. The study indicates that the increased activities of liver alkaline phosphatase in protein-depleted animals is suggestive of increased enzyme protein synthesis. On the contrary, high activities of liver transaminases are suggestive to be a result of some regulation mechanisms between the enzyme protein and its coenzyme.

Assessment for the value of serum lactic dehydrogenase in protein-energy malnutrition.

The present study was carried out in order to assess the value of serum LDH in cases suffering from PEM. In this respect, total serum LDH and its isoenzyme pattern in conjunction with serum GPT, GOT, CPK, and HBDH were assayed in cases suffering from PEM and compared with normal control group. The study revealed that increased activities of total serum LDH in PEM are neither of cardiac nor of hepatic origins. The activities and significance of other enzymes studied suggested that skeletal muscles are the main sources for these increased activities of serum LDH in PEM. The study offered a strong evidence for discrimination of liver cirrhosis in PEM.