Impact of the Nutrition-Friendly School Initiative: analysis of anthropometric and biochemical data among school-aged children in Ouagadougou.

The Nutrition-Friendly School Initiative was developed in 2006 to counter the double burden of malnutrition and implemented on a pilot basis in primary schools in Ouagadougou (Burkina Faso) in 2009. A baseline study was conducted in intervention and control schools and repeated in 2014 to assess the impact. This paper reports on anthropometric and biochemical data in the final and baseline surveys. Both studies were conducted in the fifth grade classes of the same primary schools in Ouagadougou. Six intervention schools had been selected and matched at baseline with six control schools. The total sample consisted of 699 and 651 pupils in 2009 and 2014, respectively. Anthropometric and hemoglobin measurements were performed on all children, whereas serum retinol was measured in a random subsample to assess Vitamin A Deficiency (VAD). Independent t-tests and chi-squared tests were used for comparison of means and proportions, respectively, and multiple logistic regressions were conducted to examine associations between nutritional parameters and school characteristics. Final rates of anaemia and VAD were 32.6% and 26.1%, respectively, down from 40.4% and 38.7% at baseline. The final prevalence rate of stunting was 8.1%, thinness was 8.7% and overweight/obesity was 4.4%. Thinness declined significantly in 2014 compared to 2009, but there was no change in the rate of stunting even though the rate of overweight/obesity showed an upward trend. When comparing intervention with control schoolchildren, the only significant differences found in the final survey were less thinness and less anaemia in the intervention children. However, the prevalence of anaemia was also significantly lower in the intervention group at baseline. Our results point to a significant improvement in the nutritional status of schoolchildren in Ouagadougou and suggest a positive, although modest, role for the Nutrition-Friendly School Initiative in reducing thinness, but not overweight.

Chronic disease and malnutrition biomarkers among unemployed immigrants and Canadian born adults.

BACKGROUND: Immigration status and unemployment may intersect on the health outcomes of men and women. This study aimed to identify intersections between unemployment and immigration in inflammatory, metabolic and nutritional blood markers and assess gender differences. METHODS: We used Canadian Health Measures Survey data on 2493 participants aged 18 to 65. Outcomes were chronic inflammation (high-sensitivity C-reactive protein (hsCRP) and fibrinogen), nutritional (albumin and hemoglobin), and metabolic blood markers (glycosylated hemoglobin, blood glucose, total and high density lipoprotein (HDL) cholesterol). Multivariate linear regressions were used to assess the associations between each biomarker, unemployment and immigrant status, controlling for age, education, province, smoking, physical inactivity and body mass index and testing for multiplicative interactions between unemployment, immigrant status and gender. RESULTS: Unemployment was associated with higher inflammation (hsCRP and fibrinogen) in Canadian born men; Canadian born employed women showed higher hsCRP values compared with corresponding employed men. Unemployed immigrant women presented the highest values of hsCRP while employed immigrant women had the lowest hsCRP. Unemployment was associated with higher glucose; immigrant status was associated with higher glucose and glycosylated hemoglobin. Unemployed immigrants had significantly lower levels of hemoglobin and albumin than employed immigrants, and Canadian-born citizens regardless of their employment status. Some of these associations were attenuated after adjustment by body mass index, physical inactivity and smoking. CONCLUSION: Blood biomarkers unveil intersections among unemployment, immigration and gender. This study provides evidence on biological pathways of unemployment on the likelihood of common chronic diseases, inflammation and potential malnutrition with some increased vulnerabilities in unemployed immigrants, and particularly in unemployed immigrant women.

Structured peer-led diabetes self-management and support in a low-income country: The ST2EP randomised controlled trial in Mali.

OBJECTIVES: Our objective was to evaluate the effectiveness of peer-led self-management education in improving glycaemic control in patients with type 2 diabetes in a low-income country (Mali). METHODS: We conducted an open-label randomised controlled trial. A total of 151 adults (76% women, mean age 52.5) with type 2 diabetes (HbA1c≥8%), treated in the diabetes consultation units of two secondary health centres in Bamako, were allocated to peer-led structured patient education (n = 76) or conventional care alone (n = 75). The intervention group received 1 year of culturally tailored structured patient education (3 courses of 4 sessions) delivered in the community by five trained peer educators. Both groups underwent conventional diabetes monitoring and follow-up. Primary outcome was the mean absolute change in HbA1c from baseline to 12 months. RESULTS: 177 education sessions were delivered to the intervention group. Patient attrition was 8%. From baseline to 12 months, the decrease in HbA1c levels was 1.05% (SD = 2.0; CI95%: 1.54;-0.56) in the intervention group compared with 0.15% (SD = 1.7; CI95%: -0.56; 0.26) in the control group, p = 0.006. Mean BMI change was -1.65 kg/m2 (SD = 2.5; CI95%: -2.25; -1.06) in the intervention group and +0.05 kg/m2 (SD = 3.2; CI95%: -0.71; 0.81) in the control group, p = 0.0005. Mean waist circumference decreased by 3.34 cm (SD = 9.3; CI95%: -5.56;-1.13) in the intervention group and increased by 2.65 cm (SD = 10.3; CI95%: 0.20; 5.09) in the control group, p = 0.0003. CONCLUSIONS: Peer-led structured patient education delivered over 1 year to patients with poorly controlled type 2 diabetes in Mali yielded substantial improvements in glycaemic control and anthropometric parameters. This is of importance for the scaling up of efficient interventions in low-resource settings in the future. TRIAL REGISTRATION: ClinicalTrials.gov NCT01485913.

Inventory on the dietary assessment tools available and needed in africa: a prerequisite for setting up a common methodological research infrastructure for nutritional surveillance, research, and prevention of diet-related non-communicable diseases.

OBJECTIVE: To carry out an inventory on the availability, challenges, and needs of dietary assessment (DA) methods in Africa as a pre-requisite to provide evidence, and set directions (strategies) for implementing common dietary methods and support web-research infrastructure across countries. METHODS: The inventory was performed within the framework of the "Africa's Study on Physical Activity and Dietary Assessment Methods" (AS-PADAM) project. It involves international institutional and African networks. An inventory questionnaire was developed and disseminated through the networks. Eighteen countries responded to the dietary inventory questionnaire. RESULTS: Various DA tools were reported in Africa; 24-Hour Dietary Recall and Food Frequency Questionnaire were the most commonly used tools. Few tools were validated and tested for reliability. Face-to-face interview was the common method of administration. No computerized software or other new (web) technologies were reported. No tools were standardized across countries. CONCLUSIONS: The lack of comparable DA methods across represented countries is a major obstacle to implement comprehensive and joint nutrition-related programmes for surveillance, programme evaluation, research, and prevention. There is a need to develop new or adapt existing DA methods across countries by employing related research infrastructure that has been validated and standardized in other settings, with the view to standardizing methods for wider use.

[Educational practices and diabetes study of health professionals in Burkina Faso and Mali]. / Pratiques éducatives et diabète : étude auprès des professionnels de santé au Burkina Faso et au Mali.

OBJECTIVE: To examine educational practices in type 2 diabetes among health professionals. METHODS: A cross-sectional study took place from June to September 2012 in Bamako and Ouagadougou. The study population consisted of all health professionals responsible for diabetes care in secondary and tertiary public health facilities. RESULTS: A total of 78 participants were interviewed. Doctors and nurses accounted for 77% and 23% respectively. The median number of patients seen in consultation was 10 per week (range 1-100). The median age of experience in diabetes care for health professionals was 5 years (range: 1-25 years). Sixteen participants reported giving advice for cooking. Of the 62 that did not, the reasons given were mainly: non-competence to give such advice (60/62); lack of time (35/62) and useless counseling (5/62). For out-of-home meals, recommendations included: taking a meal to work (60/77); avoiding meals outside the home (30/77); avoid alcohol and oils at parties (10/77). CONCLUSION: The recommendations made to patients come down to information and advice. As a result, the data collected lacks an educational strategy that aims to render the patient more independent by facilitating his adherence to counseling and improving his quality of life.

The Human Resources for Health Program in Rwanda - Reflections on Achievements and Challenges Comment on "Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda".

This commentary is a further discussion of a paper published in this journal on the health professional training initiative led by the Government of Rwanda since 2012 and presented as a case study. According to the authors, the partnership program with international academic institutions may serve as model for other countries to address the shortage of health professionals and to strengthen institutional capacity, based on the competencybased and innovative training programs, the numbers of graduates, the improved quality of health services and institution strengthening. However, the conditions may not be as optimal elsewhere. A supportive government policy, massive funding and an academic consortium comprised of 19 United States academic institutions have contributed to the success of the program. We also noted that the trained professionals were clinicians almost exclusively, at the expense of public health specialists and other health professionals who can better address emerging issues such as non-communicable diseases (NCDs) particularly for their prevention, which is now compelling. Among others, the training of more nutritionists as members of the health team is needed.

Evaluation of the international standardized 24-h dietary recall methodology (GloboDiet) for potential application in research and surveillance within African settings.

BACKGROUND: Collection of reliable and comparable individual food consumption data is of primary importance to better understand, control and monitor malnutrition and its related comorbidities in low- and middle-income countries (LMICs), including in Africa. The lack of standardised dietary tools and their related research support infrastructure remains a major obstacle to implement concerted and region-specific research and action plans worldwide. Citing the magnitude and importance of this challenge, the International Agency for Research on Cancer (IARC/WHO) launched the "Global Nutrition Surveillance initiative" to pilot test the use of a standardized 24-h dietary recall research tool (GloboDiet), validated in Europe, in other regions. In this regard, the development of the GloboDiet-Africa can be optimised by better understanding of the local specific methodological needs, barriers and opportunities. The study aimed to evaluate the standardized 24-h dietary recall research tool (GloboDiet) as a possible common methodology for research and surveillance across Africa. METHODS: A consultative panel of African and international experts in dietary assessment participated in six e-workshop sessions. They completed an in-depth e-questionnaire to evaluate the GloboDiet dietary methodology before and after participating in the e-workshop. RESULTS: The 29 experts expressed their satisfaction on the potential of the software to address local specific needs when evaluating the main structure of the software, the stepwise approach for data collection and standardisation concept. Nevertheless, additional information to better describe local foods and recipes, as well as particular culinary patterns (e.g. mortar pounding), were proposed. Furthermore, food quantification in shared-plates and -bowls eating situations and interviewing of populations with low literacy skills, especially in rural settings, were acknowledged as requiring further specific considerations and appropriate solutions. CONCLUSIONS: An overall positive evaluation of the GloboDiet methodology by both African and international experts, supports the flexibility and potential applicability of this tool in diverse African settings and sets a positive platform for improved dietary monitoring and surveillance. Following this evaluation, prerequisite for future implementation and/or adaptation of GloboDiet in Africa, rigorous and robust capacity building as well as knowledge transfer will be required to roadmap a stepwise approach to implement this methodology across pilot African countries/regions.

Public health nutrition capacity: assuring the quality of workforce preparation for scaling up nutrition programmes.

OBJECTIVE: To describe why and how capacity-building systems for scaling up nutrition programmes should be constructed in low- and middle-income countries (LMIC). DESIGN: Position paper with task force recommendations based on literature review and joint experience of global nutrition programmes, public health nutrition (PHN) workforce size, organization, and pre-service and in-service training. SETTING: The review is global but the recommendations are made for LMIC scaling up multisectoral nutrition programmes. SUBJECTS: The multitude of PHN workers, be they in the health, agriculture, education, social welfare, or water and sanitation sector, as well as the community workers who ensure outreach and coverage of nutrition-specific and -sensitive interventions. RESULTS: Overnutrition and undernutrition problems affect at least half of the global population, especially those in LMIC. Programme guidance exists for undernutrition and overnutrition, and priority for scaling up multisectoral programmes for tackling undernutrition in LMIC is growing. Guidance on how to organize and scale up such programmes is scarce however, and estimates of existing PHN workforce numbers - although poor - suggest they are also inadequate. Pre-service nutrition training for a PHN workforce is mostly clinical and/or food science oriented and in-service nutrition training is largely restricted to infant and young child nutrition. CONCLUSIONS: Unless increased priority and funding is given to building capacity for scaling up nutrition programmes in LMIC, maternal and child undernutrition rates are likely to remain high and nutrition-related non-communicable diseases to escalate. A hybrid distance learning model for PHN workforce managers' in-service training is urgently needed in LMIC.

Lifestyle Interventions to Prevent Type 2 Diabetes: A Systematic Review of Economic Evaluation Studies.

Objective. To summarize key findings of economic evaluations of lifestyle interventions for the primary prevention of type 2 diabetes (T2D) in high-risk subjects. Methods. We conducted a systematic review of peer-reviewed original studies published since January 2009 in English, French, and Spanish. Eligible studies were identified through relevant databases including PubMed, Medline, National Health Services Economic Evaluation, CINHAL, EconLit, Web of sciences, EMBASE, and the Latin American and Caribbean Health Sciences Literature. Studies targeting obesity were also included. Data were extracted using a standardized method. The BMJ checklist was used to assess study quality. The heterogeneity of lifestyle interventions precluded a meta-analysis. Results. Overall, 20 studies were retained, including six focusing on obesity control. Seven were conducted within trials and 13 using modeling techniques. T2D prevention by physical activity or diet or both proved cost-effective according to accepted thresholds, except for five inconclusive studies, three on diabetes prevention and two on obesity control. Most studies exhibited limitations in reporting results, primarily with regard to generalizability and justification of selected sensitivity parameters. Conclusion. This confirms that lifestyle interventions for the primary prevention of diabetes are cost-effective. Such interventions should be further promoted as sound investment in the fight against diabetes.

[Abdominal obesity and other cardiometabolic risk biomarkers: influence of socioeconomic status and lifestyle on two African-origin population groups, Cotonou (Benin) and Port-au-Prince (Haiti)]. / Obésité abdominale et autres biomarqueurs de risque cardiométabolique: influence du niveau socioéconomique et du mode de vie dans deux populations noires apparentées, Cotonou (Bénin) et Port-au-Prince (Haïti).

INTRODUCTION: Increased cardio metabolic risk (CMR) in low- and middle-income countries is largely due to rapid nutrition transition. We conducted a study of two African-origin populations groups living, however, in widely different settings. It aimed to assess the relationship between lifestyle and CMR biomarkers as well as between abdominal obesity (AO) and other biomarkers. METHODS: The study included 200 Benineses from Cotonou and 252 Haitians from Port-with-Prince (PAP) aged between 25 to 60 years and apparently in good health. AO was specifically defined as waist circumference ≥ 88cm (men) and ≥ 95 cm (women). Other most common biomarkers were: high total cholesterol/HDL cholesterol ratio, high blood pressure and insulin resistance by HOMA (Homeostasis Model Assessement). Socioeconomic status, diet, alcohol and tobacco were documented by questionnaire. Two dietary patterns emerged from cluster analysis, one traditional and the other "transitional" with increasing frequency of western foods. RESULTS: Socioeconomic status, consumption of alcohol and nicotinism were associated with CMR, but not the food diagram. AO was associated with other CMR markers, with no marked effect of socioeconomic status and lifestyle variables. CONCLUSION: Specific TT threshold values are confirmed as socioeconomic status and lifestyle have an impact on CMR, but not the relationship between AO and other CMR biomarkers.

Simple calculator to estimate the medical cost of diabetes in sub-Saharan Africa.

AIM: To design a medical cost calculator and show that diabetes care is beyond reach of the majority particularly patients with complications. METHODS: Out-of-pocket expenditures of patients for medical treatment of type-2 diabetes were estimated based on price data collected in Benin, Burkina Faso, Guinea and Mali. A detailed protocol for realistic medical care of diabetes and its complications in the African context was defined. Care components were based on existing guidelines, published data and clinical experience. Prices were obtained in public and private health facilities. The cost calculator used Excel. The cost for basic management of uncomplicated diabetes was calculated per person and per year. Incremental costs were also computed per annum for chronic complications and per episode for acute complications. RESULTS: Wide variations of estimated care costs were observed among countries and between the public and private healthcare system. The minimum estimated cost for the treatment of uncomplicated diabetes (in the public sector) would amount to 21%-34% of the country's gross national income per capita, 26%-47% in the presence of retinopathy, and above 70% for nephropathy, the most expensive complication. CONCLUSION: The study provided objective evidence for the exorbitant medical cost of diabetes considering that no medical insurance is available in the study countries. Although the calculator only estimates the cost of inaction, it is innovative and of interest for several stakeholders.

Specific cut-off points for waist circumference and waist-to-height ratio as predictors of cardiometabolic risk in Black subjects: a cross-sectional study in Benin and Haiti.

PURPOSE: Waist circumference (WC) and waist-to-height ratio (WHtR) are widely used as indicators of abdominal adiposity and the cut-off values have been validated primarily in Caucasians. In this study we identified the WC and WHtR cut-off points that best predicted cardiometabolic risk (CMR) in groups of African (Benin) and African ancestry (Haiti) Black subjects. METHODS: This cross-sectional study included 452 apparently healthy subjects from Cotonou (Benin) and Port-au-Prince (Haiti), 217 women and 235 men from 25 to 60 years. CMR biomarkers were the metabolic syndrome components. Additional CMR biomarkers were a high atherogenicity index (total serum cholesterol/high density lipoprotein cholesterol ≥4 in women and ≥5 in men); insulin resistance set at the 75th percentile of the calculated Homeostasis Model Assessment index (HOMA-IR); and inflammation defined as high-sensitivity C-reactive protein (hsCRP) concentrations between 3 and 10 mg/L. WC and WHtR were tested as predictors of two out of the three most prevalent CMR biomarkers. Receiver operating characteristic (ROC) curves, Youden's index, and likelihood ratios were used to assess the performance of specific WC and WHtR cut-offs. RESULTS: High atherogenicity index (59.5%), high blood pressure (23.2%), and insulin resistance (25% by definition) were the most prevalent CMR biomarkers in the study groups. WC and WHtR were equally valid as predictors of CMR. Optimal WC cut-offs were 80 cm and 94 cm in men and women, respectively, which is exactly the reverse of the generic cut-offs. The standard 0.50 cut-off of WHtR appeared valid for men, but it had to be increased to 0.59 in women. CONCLUSION: CMR was widespread in these population groups. The present study suggests that in order to identify Africans with high CMR, WC thresholds will have to be increased in women and lowered in men. Data on larger samples are needed.

University-level nutrition training in West Africa: cost and financing issues.

BACKGROUND: There is a serious shortage of skilled nutrition professionals in West Africa. Investing in nutrition training is one of the strategies for strengthening the human resource base in nutrition. However, little is known about how nutrition training in the region is financed and the levels of tuition fees charged. The purpose of this study was to provide a comprehensive assessment about the levels of tuition fees charged for nutrition training in the West Africa region and to determine to what extent this is of reach to the average student. METHODOLOGY: The data for this study were obtained from 74 nutrition degree programs operating in nine West African countries in 2013 through semi-structured interviews during on-site visits or through self-administered questionnaires. They included the age of the programs, school ownership, tuition fees, financial assistance, and main sources of funding. Tuition fees (in 2013 US$) were expressed per program to enable uniformity and comparability. Simple descriptive and bivariate analyses were performed. RESULTS: Results from 74 nutrition training programs in nine countries showed a wide variation in tuition fees within and between countries. The tuition fees for bachelor's, master's, and doctoral programs, respectively, ranged from 372 to 4,325 (mean: 2,353); 162 to 7,678 (mean: 2,232); and 369 to 5,600 (mean: 2,208). The tuition fees were significantly higher (p<0.05) in private institutions than in public institutions (mean: US$3,079 vs. US$2,029 for bachelor's programs; US$5,118 vs. US$1,820 for master's programs; and US$3,076 vs. US$1,815 for doctoral programs). The difference in the tuition fees between Francophone and Anglophone countries was not statistically significant (mean: US$2,570 vs. US$2,216 for bachelor's programs; US$2,417 vs. US$2,147 for master's programs; US$3,285 vs. US$2,055 for doctoral programs). In most countries, the tuition fees appeared to be out of reach of the average student. Recent master's programs appeared to charge higher fees than older ones. We found a significant negative correlation between tuition fees and the age of the program, after controlling for school ownership (r=-0.33, p<0.001). CONCLUSIONS: Our findings underscore the urgent need for national governments in the region to establish benchmarks and regulate nutrition training costs. In a region where the average annual gross national income (GNI) per capita is barely 890$, the rising cost of tuition fees is likely to hinder access of students from poor background to nutrition training. Governments should institute financing mechanisms such as scholarships, public-private partnerships, credit facilities, and donor funding to facilitate access to tertiary-level nutrition training in the region.

Contribution to the development of a food guide in Benin: linear programming for the optimization of local diets.

OBJECTIVE: Food guides are important tools for nutrition education. While developing a food guide in Benin, the objective was to determine the daily number of servings per food group and the portion sizes of common foods to be recommended. DESIGN: Linear programming (LP) was used to determine, for each predefined food group, the optimal number and size of servings of commonly consumed foods. Two types of constraints were introduced into the LP models: (i) WHO/FAO Recommended Nutrient Intakes and dietary guidelines for the prevention of chronic diseases; and (ii) dietary patterns based on local food consumption data recently collected in southern Benin in 541 adults. Dietary intakes of the upper tertile of participants for diet quality based on prevention and micronutrient adequacy scores were used in the LP algorithms. SETTING: Southern area of the Republic of Benin. SUBJECTS: Local key-players in nutrition (n 30) from the government, academic institutions, international organizations and civil society were partners in the development of the food guide directed at the population. RESULTS: The number of servings per food group and the portion size for eight age-sex groups were determined. For four limiting micronutrients (Fe, Ca, folate and Zn), local diets could be optimized to meet only 70 % of the Recommended Nutrient Intakes, not 100 %. CONCLUSIONS: It was possible to determine the daily number of servings and the portion sizes of common foods that can be recommended in Benin with the help of LP to optimize local diets, although Recommended Nutrient Intakes were not fully met for a few critical micronutrients.

High serum organochlorine pesticide concentrations in diabetics of a cotton producing area of the Benin Republic (West Africa).

The Borgou region of northern Benin is a major cotton producing area and consistently uses higher amounts of pesticides than other areas of the country. Organochlorine pesticides (OCPs), poorly handled, have been widely used and are still illegally present. We therefore hypothesized that serum OCP levels would be high in Borgou. As part of a case-control study on diabetes status and pesticide exposure, we measured the distribution of serum concentrations of 14 OCPs by gas chromatography with mass spectrometry. A sample of 118 diabetic subjects was selected using a four-stage cluster sampling with 54.2% of men and 45.8% of women; 43% lived in urban areas, 14.4% were obese and 39.8% had high economic status. The four detected OCPs were p,p'-DDT, p,p'-DDE, ß-HCH and trans-nonachlor with respective geometric means (geometric standard deviation) of 497.1 (4.5), 20.6 (7.9), 2.9 (3.4), and 2.0 (2.3) ng/g of total serum lipids. OCP levels were significantly higher in obese, wealthier and more educated subjects and in those living in urban areas as compared to the other groups, particularly for p,p'-DDE, p,p'-DDT and ß-HCH. Levels of DDT and DDE were higher than reported in other countries where DDT is no longer permitted. The low DDT/DDE ratio of 0.05 suggests past human exposure through food contamination. There is thus a need to reinforce governmental regulations for a more responsible use of pesticides in the country, in order to reduce health risks associated with persistent organic pollutants.