Plasma metabolite biomarkers of boiled and filtered coffee intake and their association with type 2 diabetes risk.

BACKGROUND: Habitual coffee intake has been associated with a lower risk of developing type 2 diabetes (T2D), but few studies used biomarkers to reflect intake and investigated different coffee brews, that is boiled and filtered, separately. OBJECTIVES: To identify plasma metabolites associated with boiled or filtered coffee intake and to examine their association with T2D risk in Swedish adults. METHODS: In a case-control study nested within the Västerbotten Intervention Programme, baseline plasma samples from 421 case-control pairs and samples from a subset of 149 pairs at a 10-year follow-up were analysed using untargeted LC-MS metabolomics. We identified metabolites associated with food frequency questionnaires (FFQ)-estimated coffee intake and assessed odds ratios of T2D. RESULTS: In total, 24 and 32 metabolites were associated with boiled or filtered coffee intake. We determined robust metabolite panels for highly specific prediction of boiled or filtered coffee. We observed an inverse association between the metabolite panel of filtered coffee and T2D risk. No association with T2D was observed for the panel of boiled coffee intake. Similar results were observed for FFQ-estimated coffee intake. CONCLUSIONS: We identified plasma metabolites specifically associated with boiled or filtered coffee intake, which might be used as selective biomarkers. Our study supports a protective role of habitual intake of filtered coffee on T2D development. The lack of association for boiled coffee intake might be due to the lack of a protective effect of boiled coffee or due to the limited number of boiled coffee consumers in this population, but it warrants further investigation.

Meal patterns across ten European countries - results from the European Prospective Investigation into Cancer and Nutrition (EPIC) calibration study.

OBJECTIVE: To characterize meal patterns across ten European countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) calibration study. DESIGN: Cross-sectional study utilizing dietary data collected through a standardized 24 h diet recall during 1995-2000. Eleven predefined intake occasions across a 24 h period were assessed during the interview. In the present descriptive report, meal patterns were analysed in terms of daily number of intake occasions, the proportion reporting each intake occasion and the energy contributions from each intake occasion. SETTING: Twenty-seven centres across ten European countries. SUBJECTS: Women (64 %) and men (36 %) aged 35-74 years (n 36 020). RESULTS: Pronounced differences in meal patterns emerged both across centres within the same country and across different countries, with a trend for fewer intake occasions per day in Mediterranean countries compared with central and northern Europe. Differences were also found for daily energy intake provided by lunch, with 38-43 % for women and 41-45 % for men within Mediterranean countries compared with 16-27 % for women and 20-26 % for men in central and northern European countries. Likewise, a south-north gradient was found for daily energy intake from snacks, with 13-20 % (women) and 10-17 % (men) in Mediterranean countries compared with 24-34 % (women) and 23-35 % (men) in central/northern Europe. CONCLUSIONS: We found distinct differences in meal patterns with marked diversity for intake frequency and lunch and snack consumption between Mediterranean and central/northern European countries. Monitoring of meal patterns across various cultures and populations could provide critical context to the research efforts to characterize relationships between dietary intake and health.

Dietary assessment among women with overweight and obesity in early postpartum.

BACKGROUND: The present study aimed to assess dietary intake and evaluate the degree of agreement of group-level dietary intake as measured by 24-h recall against a 4-day diet record among postpartum women with overweight and obesity. METHODS: A cross-sectional study was conducted of 110 Swedish women with a body mass index of ≥27 kg m(-2) at 6-15 weeks postpartum who were recruited to a weight loss trial and randomised to diet intervention or control. One 24-h recall was conducted among all women prior to randomisation. In addition, women subsequently randomised to diet intervention also conducted a 4-day diet record before receiving dietary treatment (n = 54). Paired tests were used to evaluate agreement of group-level dietary intake as measured by 24-h recall against 4-day diet record among women randomised to diet intervention. RESULTS: Women reported a median (25th and 75th percentiles) energy intake of 9.1 (6.9, 11.7) MJ day(-1) and an intake of fibre, vitamin D, folate and iron below the recommended intake as assessed by 24-h recall prior to randomisation (n = 110). Group-level median intakes of energy (9.9 versus 10.0 MJ day(-1) ), fibre (21.9 versus 21.3 g day(-1) ), vitamin D (4.8 versus 6.5 µg day(-1) ), folate (296 versus 287 µg day(-1) ), iron (11.0 versus 11.3 mg day(-1) ) and calcium (915 versus 968 mg day(-1) ) did not differ significantly between the methods; however, the record captured a higher energy-adjusted intake of fat, saturated fat and alcohol, as well as a lower intake of carbohydrates, compared to the recall (n = 54). CONCLUSIONS: We found no difference in group-level estimates of energy or micronutrients between the recall and the record; however, there were some differences for macronutrients.

Effect of the New Nordic Diet compared with usual care on glucose control in gestational diabetes mellitus: Study protocol for the randomized controlled trial intervention with new Nordic DIet in women with GestatiOnal diabetes mellitus (iNDIGO).

BACKGROUND: Gestational diabetes mellitus (GDM) is a pregnancy complication associated with short- and long-term health consequences for mother and child. First line treatment is diet and exercise but there is a recognized knowledge gap as to what diet treatment is optimal. A healthy Nordic diet has been associated with improved health but no studies in women with GDM exist. The New Nordic Diet (NND) is an initiative with the purpose to develop a healthy Nordic diet including foods with the potential to grow in Nordic countries; including fruit, berries, vegetables, whole-grain cereal products, nuts, fish, and rapeseed oil. The purpose of the intervention with new Nordic DIet in women with GestatiOnal diabetes mellitus (iNDIGO) is to test if the NND compared with usual care improves glucose control in women with GDM. METHODS: The iNDIGO study is a randomized parallel controlled trial where 50 women with GDM will be randomized to either an NND or usual care for 14 days (30-32 weeks of gestation). Participants in the NND group will receive menus and food bags containing foods to be consumed. Primary outcome is glycemic control (time in target) measured using continuous glucose monitoring. Compliance to the dietary intervention will be tested using dietary biomarkers and adherence questionnaires. CONCLUSION: Diet treatment represents first line treatment in GDM but it remains unclear what type of diets are effective. iNDIGO is an efficacy study and will provide evidence as to whether a healthy Nordic diet can improve glucose control in women with GDM. TRIAL REGISTRATION: ClinicalTrials.gov registration Number: NCT04169243. Registered 19 November 2019, https://clinicaltrials.gov/ct2/show/NCT04169243.

Fish consumption and school grades in Swedish adolescents: a study of the large general population.

AIM: To study the associations between fish intake and academic achievement as cognitive parameter among Swedish adolescents. METHODS: In 2000, a questionnaire including respiratory items, socioeconomic conditions and dietary information was mailed to all schoolchildren (n = 18 158), aged 15 and living in Västra Götaland region of Sweden. The questionnaire was returned by 10 837 subjects. One year later, the total school grades for each subject who had completed the questionnaire and who included their full personal identification number were obtained from the national registers. Multiple linear regression models were applied to evaluate the association between fish intake and academic grades among 9448 schoolchildren, while adjusting for potential confounders, e.g. parents' education. RESULTS: Grades were higher in subjects with fish consumption once a week compared with subjects with fish consumption of less than once a week (reference group) [increment in estimate 14.5, 95% confidence interval (CI) 11.8-17.1]. Grades were even higher in subjects with fish consumption of more than once a week compared with the reference group (increment in estimate 19.9, 95% CI 16.5-23.3). In the model stratified for parents' education, there were still higher grades among subjects with frequent fish intake in all educational strata (p < 0.01). CONCLUSION: Frequent fish intake among schoolchildren may provide benefits in terms of academic achievement.

Plasma folate and total homocysteine levels are associated with the risk of myocardial infarction, independently of each other and of renal function.

OBJECTIVES: To investigate the relationship between plasma folate, vitamin B12 and total homocysteine concentrations, dietary intake of folate and vitamins B12, B6 and B2, and the risk of first acute myocardial infarction (MI). DESIGN: Nested case-referent study with up to 13 years of follow-up. SETTING: The population-based Northern Sweden Health and Disease Study, with 73 879 participants at the time of case ascertainment. SUBJECTS: A total of 571 MI cases (406 men) and 1569 matched referents. Of the cases, 530 had plasma samples available, and 247 had dietary B-vitamin intake data. RESULTS: Plasma concentrations of folate were inversely associated, and total homocysteine positively associated, with the risk of MI, independently of each other and of a number of established and novel cardiovascular risk factors, including renal function [multivariate odds ratio for highest vs. lowest quintile of folate 0.52 (95% CI 0.31-0.84), P for trend = 0.036, and homocysteine 1.92 (95% CI 1.20-3.09), P for trend = 0.006]. For plasma vitamin B12 concentrations, and vitamin B12, B6 and B2 intake, no clear risk relationship was apparent. Though not statistically significant, the results for folate intake were consistent with those for plasma concentrations. CONCLUSIONS: In this large prospective study of a population without mandatory folic acid fortification, both folate and homocysteine were strongly associated with the risk of myocardial infarction, independently of each other and of renal function. Although randomized trials of folic acid supplementation are needed to determine causality, our findings highlight the potential importance of folate, or sources of folate, in incident cardiovascular disease.

Neither self-reported atopy nor IgE-mediated allergy are linked to gastrointestinal symptoms in patients with irritable bowel syndrome.

BACKGROUND: Among patients with irritable bowel syndrome (IBS), atopic disease has been proposed as a common comorbidity increasing the IBS symptom burden. We therefore assessed the prevalence of self-reported atopy among patients with IBS as compared to non-IBS controls, and whether atopy and higher serum IgE levels were associated with increased IBS symptom severity. METHODS: Levels of total and specific IgE in serum were measured and questionnaires assessing the presence of atopic disease (ie, eczema, asthma, rhinoconjunctivitis, and pollen allergy), gastrointestinal symptom burden, food intolerance, somatic, and psychological symptoms were completed. KEY RESULTS: In total, 223 patients with IBS and 47 controls participated. Presence of atopic disease was reported in 55% of patients with IBS compared to 40% of controls (P = .07). IBS patients with atopic manifestations (N = 123) had higher total serum IgE levels (median 31 vs 16 kUA /L, P < .001) and higher prevalence of self-reported food intolerance (28% vs 9%, P = .002) than non-atopic IBS patients (N = 100), respectively, but no major difference in gastrointestinal or psychological symptom burden was noted. However, severe somatic symptoms were more common among atopic than non-atopic patients with IBS (38% vs 27%, P = .028). We found no associations between self-reported atopy and IBS symptom severity using linear regression models. CONCLUSIONS & INFERENCES: Atopic disease is common in patients with IBS, but that is also true for subjects without IBS. The presence of atopic disease in IBS is associated with self-reported food intolerance and somatic symptom severity, but unrelated to IBS symptom severity.

Low folate levels may protect against colorectal cancer.

BACKGROUND AND AIMS: Dietary folate is believed to protect against colorectal cancer (CRC). However, few studies have addressed the role of circulating levels of folate. The aim of this study was to relate prediagnostic plasma folate and homocysteine concentrations and the methylenetetrahydrofolate reductase (MTHFR) 677C>T and 1298A>C polymorphisms to the risk of developing CRC. SUBJECTS: Subjects were 226 cases and 437 matched referents from the population based Northern Sweden Health and Disease Cohort. RESULTS: We observed a bell-shaped association between plasma folate concentrations and CRC risk; multivariate odds ratio for middle versus lowest quintile 2.00 (95% confidence interval (CI) 1.13-3.56). In subjects with follow up times greater than the median of 4.2 years however, plasma folate concentrations were strongly positively related to CRC risk; multivariate odds ratio for highest versus lowest quintile 3.87 (95% CI 1.52-9.87; p trend = 0.007). Homocysteine was not associated with CRC risk. Multivariate odds ratios for the MTHFR polymorphisms were, for 677 TT versus CC, 0.41 (95% CI 0.19-0.85; p trend = 0.062), and for 1298 CC versus AA, 1.62 (95% CI 0.94-2.81; p trend = 0.028). Interaction analysis suggested that the result for 1298A>C may have been largely due to linkage disequilibrium with 677C>T. The reduced CRC risk in 677 TT homozygotes was independent of plasma folate status. CONCLUSIONS: Our findings suggest a decreased CRC risk in subjects with low folate status. This possibility of a detrimental component to the role of folate in carcinogenesis could have implications in the ongoing debate in Europe concerning mandatory folate fortification of foods.

Does diet intervention in line with nutrition recommendations affect dietary carbon footprint? Results from a weight loss trial among lactating women.

BACKGROUND/OBJECTIVES: Results from studies evaluating the sustainability of diets combining environmental and nutritional aspects have been diverse; thus, greenhouse gas emissions (that is, carbon footprint (CF)) of diets in line with dietary recommendations in free-living individuals warrants further examination. Here, changes in dietary CF related to changes in food choice during a weight loss trial among lactating women who received a 12-week diet intervention based on the Nordic Nutrition Recommendations (NNR) 2004 were analyzed. The objective of this study was to examine if a diet intervention based on NNR 2004 results in reduced dietary CF. SUBJECTS/METHODS: Changes in dietary CF were analyzed among 61 lactating women participating in a weight loss trial. Food intake data from 4-day weighed diet records and results from life cycle analyses were used to examine changes in dietary CF across eight food groups during the intervention, specified in the unit carbon dioxide equivalent (CO2eq/day). Differences in changes in dietary CF between women receiving diet treatment (D-group) and women not receiving it (ND-group) were compared. RESULTS: There was no difference in change in dietary CF of the overall diet between D- and ND-group (P>0.05). As for the eight food groups, D-group increased their dietary CF from fruit and vegetables (+0.06±0.13 kg CO2eq/day) compared with a decrease in ND-group (-0.01±0.01 kg CO2eq/day) during the intervention, P=0.01. CONCLUSIONS: A diet intervention in line with NNR 2004 produced clinically relevant weight loss, but did not reduce dietary CF among lactating women with overweight and obesity. Dietary interventions especially designed to decrease dietary CF and their coherence with dietary recommendations need further exploration.

Body composition in overweight and obese women postpartum: bioimpedance methods validated by dual energy X-ray absorptiometry and doubly labeled water.

BACKGROUND/OBJECTIVES: Obesity, pregnancy and lactation all affect body composition. Simple methods to estimate body composition are useful in clinical practice and to evaluate interventions. In overweight and obese lactating women, such methods are not fully validated. The objective of this study was to validate the accuracy and precision of bioimpedance spectroscopy (BIS) by Xitron 4200 and 8-electrode multifrequency impedance (multifrequency bioimpedance analysis, MFBIA) by Tanita MC180MA with the reference methods dual energy X-ray absorptiometry (DXA) and doubly labeled water (DLW) for the assessment of body composition in 70 overweight and obese women postpartum. SUBJECTS/METHODS: The LEVA-study (Lifestyle for Effective Weight loss during lactation) consisted of an intervention and follow-up with three assessments at 3, 6 and 15 months postpartum, which made possible the validation of both accuracy and precision. Mean differences between methods were tested by a paired t-test and Bland-Altman plots for systematic bias. RESULTS: At baseline, BIS and MFBIA underestimated fat mass (FM) by 2.6±2.8 and 8.0±4.2 kg compared with DXA (P<0.001) but without systematic bias. BIS and MFBIA overestimated total body water (TBW) by 2.4±2.2 and 4.4±3.2 kg (P<0.001) compared with DLW, with slight systematic bias by BIS. BIS correctly estimated muscle mass without systematic bias (P>0.05). BIS overestimated changes in TBW (P=0.01) without systematic bias, whereas MFBIA varied greatly and with systematic bias. CONCLUSIONS: BIS underestimates mean FM compared with DXA but can detect mean changes in body composition, although with large limits of agreement. BIS both accurately and precisely estimates muscle mass in overweight and obese women postpartum. MFBIA underestimates FM and overestimates TBW by proprietary equations compared with DXA and DLW.

Changes in cortical volumetric bone mineral density and thickness, and trabecular thickness in lactating women postpartum.

CONTEXT: Lactation is associated with decreased areal bone mineral density (aBMD). Replenishment occurs especially after ceased lactation. Changes in volumetric bone mineral density (vBMD), microstructure, and dimensional parameters are unknown and may clarify the role of lactation for skeletal health. OBJECTIVE AND MAIN OUTCOMES: The objective of the study was to test the hypothesis that lactation is associated with changes in aBMD, vBMD, microstructure, and dimensional parameters. DESIGN: At baseline (0.5 mo after delivery) and 4, 12, and 18 months thereafter, bone was assessed using dual-energy x-ray absorptiometry and high-resolution peripheral quantitative computed tomography. PARTICIPANTS AND SETTING: Eighty-one fair-skinned postpartum women and 21 controls aged 25-40 years were recruited. The completion ratio was 73%. Postpartum women were categorized depending on duration of lactation: 0-3.9, 4-8.9, and 9 months or longer. RESULTS: During the first 4 months, aBMD decreased at several sites (geometric mean ± SE; -0.73% ± 0.21% to -3.98% ± 0.76%) in women lactating at least 4 months. During the same time, cortical vBMD at the ultradistal tibia decreased in women lactating 4-8.9 months (-0.26% ± 0.08%) and 9 months or longer (-0.49% ± 0.10%). At 12 months postpartum, cortical thickness (≥ 9 mo, -2.48% ± 0.41%) and trabecular thickness (4-8.9 mo, -2.14% ± 0.92%; ≥ 9 mo, -2.56% ± 1.21%) also were lower than baseline. No decreases were found in women lactating less than 4 months or in controls in these parameters. At 18 months postpartum, both cortical vBMD (≥ 9 mo, -0.77% ± 0.17%) and trabecular thickness (4-8.9 mo, -2.25% ± 1.25%; ≥ 9 mo, -3.21% ± 1.41%) were lower in women with long lactation. CONCLUSIONS: Decreases in cortical vBMD, thickness, and trabecular thickness at the ultradistal tibia were found in women lactating 4 months or longer. Longer follow-up is needed to confirm whether women with extended lactation recover fully or whether the changes could potentially lead to an increased risk of fracture in later life.

High AIDS awareness may cause tuberculosis patient delay: results from an HIV epidemic area, Thailand.

OBJECTIVE: To elicit community perceptions about tuberculosis (TB) and the behaviour of TB patients in an area where significant public health attention has been focused on AIDS. SETTING: Chiang Rai, Thailand, the epicentre of HIV/AIDS in this country. DESIGN: Eleven focus group sessions with a cross-section of the population. PARTICIPANTS: Health centre staff, community members, persons having HIV, TB patients (with and without HIV infection), and male injecting drug users; five female groups and six male groups. RESULT: People had good knowledge of AIDS but they knew little about TB. Only a few female patients, whose husbands had died of TB and AIDS, recognized their symptoms as TB and immediately sought care. People defined persons losing weight, having fever and cough as AIDS rather than TB. This resulted in delay in seeking care and non-adherence to TB treatment in some patients who suspected they had AIDS, and feared AIDS detection. Most HIV-negative TB patients were also suspected by their relatives and neighbours of having AIDS. Most participants, except HIV-positive females, believed TB to be curable. Although less than AIDS, the community stigmatized TB patients because of it being contagious and easily transmitted through exhalations, foods and drinks and closeness to TB patients. CONCLUSION: In HIV/AIDS high endemic situation, increased awareness and stigmatization of AIDS and inadequate knowledge of TB can result in delay in seeking TB care and in treatment non-adherence.

Linking maternal and infant benefits of a nutritional supplement during pregnancy and lactation.

To evaluate the effect of a nutritional supplement on change in women's weight during a reproductive cycle and on the difference in birth weight between one infant and the previous one, we analyzed data on 176 complete reproductive cycles from an experiment that was conducted in rural Guatemala. Women with an initial weight <50 kg were classified as marginally nourished or malnourished. Women whose intake of the supplement was in the top 2 tertiles were distinguished from those whose intake was in the lowest tertile. Linear regression modeling was used to estimate the effect of supplementation on these outcomes and to control for confounding factors. Malnourished women gained weight during the reproductive cycle, but their second (study) infant tended to weigh less at birth than their prior-born infant. Higher intakes of supplement were associated with a less negative difference in birth weight. Marginally nourished women lost weight during the reproductive cycle and their second (study) infant tended to weigh more at birth than their prior-born infant. Higher intakes of supplement were associated with a less negative weight [corrected] trend for the women themselves. Well-nourished women and their infants did not show any of these benefits from supplementation. These findings help explain past contradictory findings on maternal depletion as well as on the benefits of nutritional supplementation for mothers and their infants.

Familial patterns in birth characteristics: impact on individual and population risks.

BACKGROUND: Familial patterns in reproductive outcome have been suggested previously, but few studies have comprehensively evaluated both length of gestation and types of growth retardation. METHODS: Information on intrauterine period and birth characteristics for a cohort of Swedish women born 1955-1972 was linked with information on these women's own reproductive experiences during 1973-1990. Familial trends in preterm deliveries, small-for-gestational age (SGA) births and two types of growth retardation were evaluated for mothers relative to their own birth characteristics (n = 4746), relative to their older sisters' deliveries (n = 2931) and among consecutive deliveries of the mothers (n = 14,209). Adjusted relative risks (RR) were calculated from logistic regression analyses. RESULTS: Mothers who had themselves been preterm at birth were not at increased risk of any of the outcomes studied. Mothers who had themselves been SGA at birth had an almost 50% higher risk (NS) of giving birth to either a preterm or an SGA infant than had mothers who had not been SGA at birth. Mothers tended to repeat the same patterns in subsequent deliveries: RR was 3.7 for a second preterm delivery given a previous one and 7.8 for a second SGA delivery given a previous one. Among SGA siblings, chronic growth retardation was more often repeated than was acute growth retardation. Mothers with an older sister who had given birth to a preterm infant had an 80% higher risk of giving birth to a preterm infant. CONCLUSIONS: Familial trends in gestational age and body proportions at birth were demonstrated; however, the relatively small population attributable risk per cents in Sweden are discussed.

Health seeking behaviour and diagnosis for pulmonary tuberculosis in an HIV-epidemic mountainous area of Thailand.

SETTING: Chiang Rai Hospital, Chiang Rai Province, the epicentre of the human immunodeficiency virus (HIV) in Thailand. OBJECTIVE: To describe the health seeking behaviour among tuberculosis (TB) patients, to measure patient and provider delays and to analyse factors determining these delays. DESIGN: All patients aged over 15 years with new smear-positive pulmonary TB detected in Chiang Rai Hospital (n = 557) were interviewed using a structured questionnaire. RESULTS: The median patient delays for HlV-positive and HIV-negative patients and those whose HIV status was unknown were 10, 15 and 15 days respectively, while provider delays were respectively 7, 7.5 and 10 days. HIV-positive patients suffered more symptoms and had a shorter patient's delay. Risk factors of long patient delay (>21 days) included being HIV-negative, having no health insurance, hill tribe ethnicity, no previous visits to the hospital, and borrowing money for hospital visits. Multivariate logistic analysis suggested that being married or widowed and being HIV-positive led to the shortest patient delay. Provider delay was significantly longer in female patients than male patients. CONCLUSION: Although patient and provider delays were favourably short, certain specific groups require further attention. Hill tribe people should be targeted to improve accessibility to TB treatment. Active case-finding services for people known to be HIV-positive should be encouraged. The reasons for the longer provider delay in female patients require further investigation.

Feasibility of home-based and health centre-based DOT: perspectives of TB care providers and clients in an HIV-endemic area of Thailand.

Focus groups were conducted in a high human immunodeficiency virus (HIV) prevalence area of Thailand to elicit perspectives of health staff and clients regarding the feasibility of directly observed therapy (DOT) for tuberculosis. Most participants perceived health centre-based DOT to be impractical for clients due to severe illness, travel inconvenience, and interference with employment. Most providers perceived home-based DOT to be difficult because of the inconvenience of travel, staff shortages and the high tuberculosis caseload. Most clients except HIV-negative tuberculous females considered home visits to be undesirable due to stigma. The preparedness of providers for home-based DOT might be improved through awareness building among staff about multidrug-resistant tuberculosis.

Attitudes to compliance with tuberculosis treatment among women and men in Vietnam.

SETTING: A study carried out in 1996 in four districts representing south and north as well as urban and rural areas of Vietnam. OBJECTIVE: To explore gender differences in knowledge, beliefs and attitudes towards tuberculosis and its treatment, and how these factors influence patients' compliance with treatment. DESIGN: Sixteen focus group discussions were performed by a multi-disciplinary research team from Vietnam and Sweden. Analysis was performed using modified Grounded Theory technique, specifically evaluating gender differences. RESULTS: Women were believed to be more compliant than men. Insufficient knowledge and individual cost during treatment were reported as main obstacles to compliance among men (poor patient compliance), while sensitivity to interaction with health staff and stigma in society (poor health staff and system compliance) were reported as the main obstacles among women. CONCLUSIONS: It is time to adopt a more comprehensive and gender-sensitive approach to compliance, which incorporates patient compliance, doctor compliance and system compliance, in order to fully support individual patients in their efforts to comply with treatment.

Longer delays in tuberculosis diagnosis among women in Vietnam.

SETTING: Study conducted in 23 randomly selected districts in four provinces of Vietnam. OBJECTIVE: To describe and compare health seeking behaviour between men and women and to measure delays in tuberculosis (TB) diagnosis. DESIGN: All patients (n = 1027) aged 15-49 years with new smear-positive pulmonary TB detected in the selected districts during 1996 were interviewed using a structured questionnaire. RESULTS: Mean total delay to TB diagnosis was 13.3 weeks (95% confidence interval [CI] 11.5, 15.1) for women and 11.4 weeks (95% CI 10.6, 12.2) for men, including a patient's delay of 7.9 weeks (95% CI 6.5, 9.3) and 7.6 weeks (95% CI 6.9, 8.3) respectively. Doctor's delay was significantly longer among women (5.4 weeks, 95% CI 4.2, 6.6) than among men (3.8 weeks, 95% CI 3.3, 4.3). Women did not start seeking care later than men, nor did they have a different health seeking pattern. Women visited more health care providers than men (1.7 and 1.5 providers, respectively, P = 0.02). CONCLUSION: Patient's delay is unacceptably long for both men and women. Women do not receive a diagnosis of TB by doctors or other health care providers as quickly as men once they seek health care. The reasons for this gender difference warrant further investigations.

Women's strategic responses to violence in Nicaragua.

STUDY OBJECTIVE: To describe the responses of women in León, Nicaragua to partner abuse and identify contextual factors associated with the use of certain coping mechanisms and the likelihood of permanent separation. DESIGN: Cross sectional population-based survey. SETTING: León, Nicaragua. PARTICIPANTS: 188 women 15-49 years of age who had experienced physical partner abuse, out of 488 women interviewed. MAIN RESULTS: 66% of women defended themselves effectively from abuse either physically or verbally. Forty one per cent of women had left home temporarily because of violence and 20% had sought help outside the home. Women experiencing severe abuse were more likely to leave or seek help, whereas women with less severe abuse were more able to defend themselves effectively. Seventy per cent of women eventually left abusive relationships. Help seeking and temporary separations increased the likelihood of a permanent separation, whereas women who defended themselves and were able to stop the violence, at least temporarily, were more likely to remain in abusive relationships. CONCLUSIONS: Women in Nicaragua use a variety of methods in order to overcome physical partner abuse. Temporary leaving and help seeking are critical steps in the process of leaving a violent relationship. However, many women indicated that they did not receive support for their situation. More interventions are needed to help women recognise and deal with violence, as well as strengthening the community support networks available to abused women.

Images of health and health care options among low income women in Punjab, Pakistan.

We studied women's beliefs and experiences of health and health care among 42 women in an urban slum area in Lahore and a village 40 km outside of Lahore. Data were collected through repeated, in-depth interviews in Urdu or Punjabi totalling 200 hours. For triangulation purposes, four focus group discussions with additional women were performed, as well as in-depth interviews with eight mothers-in-law, three traditional practitioners and three medical practitioners. The women's images of health reflected expectations on the women in society. Women from the village and women from the lowest socioeconomic stratum (SES) spoke of health in terms of physical strength; women from the city and women from low SES spoke of health in terms of mental strength; and women from medium SES discussed it in terms of cultural competence. Overall, health had a very low priority in these women's lives. Two health problems were reported by all women: mental tension leading to headache and white vaginal discharge leading to body pains and fatigue. These health problems were seen as part of womanhood; if treatment was sought, it was often from traditional healers. Village women had a flexible, pragmatic attitude toward health care resources and used all types until treated. Their relation to the doctor was specific; they were mostly concerned with the medical treatment. In contrast, city women chose health care providers depending on type of illness, and being met with respect was for them of equal concern. Childbearing experiences influenced the perceptions of health and health care. Mothers of daughters were seen to both need and deserve less food, health care and attention. These mothers were less vocal about health complaints. Women without children spoke of health in terms of physical strength. These women may have less access to health care because children cannot be used as an "excuse", and because they are not worth spending resources on.