Abdominal vs. overall obesity among women in a nutrition transition context: geographic and socio-economic patterns of abdominal-only obesity in Tunisia.

BACKGROUND: Most assessments of the burden of obesity in nutrition transition contexts rely on body mass index (BMI) only, even though abdominal adiposity might be specifically predictive of adverse health outcomes. In Tunisia, a typical country of the Middle East and North Africa (MENA) region, where the burden of obesity is especially high among women, we compared female abdominal vs. overall obesity and its geographic and socio-economic cofactors, both at population and within-subject levels. METHODS: The cross-sectional study used a stratified, three-level, clustered sample of 35- to 70-year-old women (n = 2,964). Overall obesity was BMI = weight/height(2) ≥ 30 kg/m(2) and abdominal obesity waist circumference ≥ 88 cm. We quantified the burden of obesity for overall and abdominal obesity separately and their association with place of residence (urban/rural, the seven regions that compose Tunisia), plus physiological and socio-economic cofactors by logistic regression. We studied the within-subject concordance of the two obesities and estimated the prevalence of subject-level "abdominal-only" obesity (AO) and "overall-only" obesity (OO) and assessed relationships with the cofactors by multinomial logistic regression. RESULTS: Abdominal obesity was much more prevalent (60.4% [57.7-63.0]) than overall obesity (37.0% [34.5-39.6]), due to a high proportion of AO status (25.0% [22.8-27.1]), while the proportion of OO was small (1.6% [1.1-2.2]). We found mostly similar associations between abdominal and overall obesity and all the cofactors except that the regional variability of abdominal obesity was much larger than that of overall obesity. There were no adjusted associations of AO status with urban/rural area of residence (P = 0.21), education (P = 0.97) or household welfare level (P = 0.94) and only non-menopausal women (P = 0.093), lower parity women (P = 0.061) or worker/employees (P = 0.038) were somewhat less likely to be AO. However, there was a large residual adjusted regional variability of AO status (from 16.6% to 34.1%, adjusted P < 0.0001), possibly of genetic, epigenetic, or developmental origins. CONCLUSION: Measures of abdominal adiposity need to be included in population-level appraisals of the burden of obesity, especially among women in the MENA region. The causes of the highly prevalent abdominal-only obesity status among women require further investigation.

Obesity and association with area of residence, gender and socio-economic factors in Algerian and Tunisian adults.

INTRODUCTION: The epidemiological transition has resulted in a major increase in the prevalence of obesity in North Africa. This study investigated differences in obesity and its association with area of residence, gender and socio-economic position among adults in Algeria and Tunisia, two countries with socio-economic and socio-cultural similarities. METHODS: Cross-sectional studies used stratified, three-level, clustered samples of 35-70 year old adults in Algeria, (women n = 2741, men n = 2004) and Tunisia (women n = 2964, men n = 2379). Thinness was defined as Body Mass Index (BMI) = weight/height <18.5 kg/m(2), obesity as BMI ≥30, and abdominal obesity as waist circumference/height ≥0.6. Associations with area of residence, gender, age, education, profession and household welfare were assessed. RESULTS: Prevalence of thinness was very low except among men in Algeria (7.3% C.I.[5.9-8.7]). Prevalence of obesity among women was high in Algeria (30.1% C.I.[27.8-32.4]) and Tunisia (37.0% C.I.[34.4-39.6]). It was less so among men (9.1% C.I.[7.1-11.0] and 13.3% C.I.[11.2-15.4]).The results were similar for abdominal obesity. In both countries women were much more obesity-prone than men: the women versus men obesity Odds-Ratio was 4.3 C.I.[3.4-5.5] in Algeria and 3.8 C.I.[3.1-4.7] in Tunisia. Obesity was more prevalent in urban versus rural areas in Tunisia, but not in Algeria (e.g. for women, urban versus rural Odds-Ratio was 2.4 C.I.[1.9-3.1] in Tunisia and only 1.2 C.I.[1.0-5.5] in Algeria). Obesity increased with household welfare, but more markedly in Tunisia, especially among women. Nevertheless, in both countries, even in the lowest quintile of welfare, a fifth of the women were obese. CONCLUSION: The prevention of obesity, especially in women, is a public health issue in both countries, but there were differences in the patterning of obesity according to area of residence and socio-economic position. These specificities must be taken into account in the management of obesity inequalities.

Gender obesity inequities are huge but differ greatly according to environment and socio-economics in a North African setting: a national cross-sectional study in Tunisia.

INTRODUCTION: Southern Mediterranean countries have experienced a marked increase in the prevalence of obesity whose consequences for gender related health inequities have been little studied. We assessed gender obesity inequalities and their environmental and socio-economic modifiers among Tunisian adults. METHODS: Cross-sectional survey in 2005; national, 3 level random cluster sample of 35-70 years Tunisians (women: n = 2964, men: n = 2379). Overall adiposity was assessed by BMI = weight(kg)/height(m)(2) and obesity was BMI≥30, WHtR = waist circumference to height ratio defined abdominal obesity as WHtR≥0.6. Gender obesity inequality measure was women versus men Prevalence Proportion Odds-Ratio (OR); models featuring gender x covariate interaction assessed variation of gender obesity inequalities with area (urban versus rural), age, marital status or socio-economic position (profession, education, household income proxy). RESULTS: BMI was much higher among women (28.4(0.2)) versus men (25.3(0.1)), P<0.0001) as was obesity (37.0% versus 13.3%, OR = 3.8[3.1-7.4], P<0.0001) and abdominal obesity (42.6% versus 15.6%, 4.0[3.3-4.8], P<0.0001). Gender obesity inequalities (women versus men adjusted OR) were higher in urban (OR = 3.3[1.3-8.7]) than rural (OR = 2.0[0.7-5.5]) areas. These gender obesity inequalities were lower for subjects with secondary education or more (OR = 3.3[1.3-8.6]), than among those with no schooling (OR = 6.9[2.0-23.3]). They were also lower for those with upper/intermediate profession (OR = 1.4[0.5-4.3]) or even employees/workers OR = 2.3[1.0-5.4] than those not professionaly active at all (OR = 3.3[1.3-8.6]). Similar results were observed for addominal obesity. CONCLUSION: The huge overall gender obesity inequities (women much more corpulent than men) were higher in urban settings, but lower among subjects of higher education and professional activity. Reasons for gender inequalities in obesity and their variation with socio-economic position should be sought so that appropriate policies to reduce these inequalities can be implemented in Tunisia and similar settings.

Nutrition transition among adolescents of a south-Mediterranean country: dietary patterns, association with socio-economic factors, overweight and blood pressure. A cross-sectional study in Tunisia.

BACKGROUND: The increase in the burden of chronic diseases linked to the nutrition transition and associated dietary and lifestyle changes is of growing concern in south and east Mediterranean countries and adolescents are at the forefront of these changes. This study assessed dietary intake and association with socio-economic factors and health outcomes among adolescents in Tunisia. METHODS: Cross-sectional survey (year 2005); 1019 subjects 15-19 y. from a clustered random sample. Dietary intake was assessed by a validated semi-quantitative frequency questionnaire (134 items) as was physical activity; the Diet Quality Index International measured diet quality; dietary patterns were derived by multiple correspondence analysis from intakes of 43 food groups. Body Mass Index (BMI) ≥ 85th and 95th percentile defined overweight and obesity. Waist Circumference (WC) assessed abdominal fat. High blood pressure was systolic (SBP) or diastolic blood pressure (DBP) ≥ 90th of the international reference for 15-17 y., and SBP/DBP ≥ 120/80 mm Hg for 18-19 y. RESULTS: Energy intake levels were quite high, especially for females. The macro-nutrient structure was close to recommendations but only 38% had a satisfactory diet quality. A main traditional to modern dietary gradient, linked to urbanisation and increased economic level, featured an increasing consumption of white bread, dairy products, sugars, added fats and fruits and decreasing consumption of oils, grains, legumes and vegetables; regarding nutrients this modern diet score featured a decreasing relationship with total fat and an increase of calcium intake, but with an increase of energy, sugars and saturated fat, while vitamin C, potassium and fibre decreased. Adjusted for age, energy and physical activity, this modern pattern was associated with increased overweight in males (2nd vs. 1st tertile: Prevalence Odds-Ratio (POR) = 4.0[1.7-9.3], 3rd vs. 1st: POR = 3.3[1.3-8.7]) and a higher WC. Adjusting also for BMI and WC, among females, it was associated with decreased prevalence of high blood pressure (2nd vs. 1st tertile: POR = 0.5[0.3-0.8], 3rd vs. 1st tertile: POR = 0.4[0.2-0.8]). CONCLUSION: The dietary intake contrasts among Tunisian adolescents, linked to socio-economic differentials are characteristic of a nutrition transition situation. The observed gradient of modernisation of dietary intake features associations with several nutrients involving a higher risk of chronic diseases but might have not only negative characteristics regarding health outcomes.

Food shopping transition: socio-economic characteristics and motivations associated with use of supermarkets in a North African urban environment.

OBJECTIVE: In the context of the nutrition transition and associated changes in the food retail sector, to examine the socio-economic characteristics and motivations of shoppers using different retail formats (large supermarkets (LSM), medium-sized supermarkets (MSM) or traditional outlets) in Tunisia. DESIGN: Cross-sectional survey (2006). Socio-economic status, type of food retailer and motivations data were collected during house visits. Associations between socio-economic factors and type of retailer were assessed by multinomial regression; correspondence analysis was used to analyse declared motivations. SETTING: Peri-urban area around Tunis, Tunisia, North Africa. SUBJECTS: Clustered random sample of 724 households. RESULTS: One-third of the households used LSM, two-thirds used either type of supermarket, but less than 5 % used supermarkets only. Those who shopped for food at supermarkets were of higher socio-economic status; those who used LSM were much wealthier, more often had a steady income or owned a credit card, while MSM users were more urban and had a higher level of education. Most households still frequently used traditional outlets, mostly their neighbourhood grocer. Reasons given for shopping at the different retailers were most markedly leisure for LSM, while for the neighbourhood grocer the reasons were fidelity, proximity and availability of credit (the latter even more for lower-income customers). CONCLUSIONS: The results pertain to the transition in food shopping practices in a south Mediterranean country; they should be considered in the context of growing inequalities in health linked to the nutritional transition, as they differentiate use and motivations for the choice of supermarkets v. traditional food retailers according to socio-economic status.

Trends in food intake in French children from 1999 to 2007: results from the INCA (étude Individuelle Nationale des Consommations Alimentaires) dietary surveys.

The objectives of the present study were to assess the intake of different food groups in French children aged 3-17 years (n 1455), and to analyse trends since a dietary survey undertaken 8 years ago. Dietary intake was evaluated using data from the 2006-7 cross-sectional INCA2 national dietary survey (étude Individuelle Nationale sur les Consommations Alimentaires), based on a 7 d food record. Dietary intake (percentage of subjects consuming the food group and amount eaten) was assessed for thirty-nine food categories. We observed variations in food consumption by age, sex, North-South regional gradient, seasonal period and educational level of the responding parent. Trends in dietary intake between 1999 and 2007 were determined by comparing the INCA1 (n 1126) and the INCA2 surveys. Both surveys had been carried out using the same methodology. The findings showed a decrease in energy intake in children aged 3-14 years, due to a reduction in the consumption of foods of animal origin and sweetened products. In adolescents aged 15-17 years, energy intake remained rather stable; during this 8-year period, the consumption of meat decreased, whereas the consumption of savoury snacks such as sandwiches and hamburgers significantly increased. These trends occurred during a time of growing concern about overweight and the associated co-morbidities in France. A number of public health measures were implemented over this period to improve dietary habits and physical activity patterns in children and adults. The periodic monitoring of dietary patterns through the INCA surveys is an essential part of the surveillance network in France.

Are eating occasions and their energy content related to child overweight and socioeconomic status?

The objectives of this study were: (i) to assess the relationships between childhood overweight (OW) and four eating behaviors: daily eating frequency, and the relative contribution of breakfast, main meals (lunch and dinner), and snacks to total daily energy intake (EI); (ii) to explore whether these eating behaviors are involved in the negative association between socioeconomic status (SES) and OW. A representative sample of French children aged 3-11 years (n = 748) was taken from the 1998-1999 cross-sectional French INCA1 (Enquête Individuelle et Nationale sur les Consommations Alimentaires) food consumption survey. Food intake was reported in a 7-day food record, and SES, physical activity, sedentary behavior (SED), weight, and height were reported by answering face-to-face questionnaires. After adjusting for EI, physical activity, and SED, OW was positively associated with the contribution of the main meals to EI (P = 0.03), not significantly associated with the contribution of breakfast to EI, and inversely correlated to the number of eating episodes (P = 0.009) and to the contribution of snacking episodes to EI (P = 0.007). Our data suggest that a combination of more frequent intake occasions and lower contribution of the main meals to total daily EI is associated with a smaller risk of OW in children. However, eating frequency was the only eating behavior that played a slight mediation role (contributing approximately 8%) in the inverse relationship between SES and OW.

Nutritional status of Tunisian adolescents: associated gender, environmental and socio-economic factors.

OBJECTIVE: To assess the nutritional status of Tunisian adolescents and associated factors. DESIGN: A cross-sectional study based on a national stratified random cluster sample. SUBJECTS AND METHODS: In all, 1,295 boys and 1,577 girls aged 15-19 years, of whom 28.4 % had already left school. Socio-economic characteristics of the parents, anthropometric measurements, food behaviours and physical activity of the adolescents were recorded during home visits. RESULTS: Prevalence of underweight, overweight and obesity (WHO/National Center for Health Statistics reference) were, respectively, 8.1 %, 17.4 % and 4.1 % among boys and 1.3 %, 20.7 % and 4.4 % among girls; abdominal obesity was highly prevalent among both sexes. Prevalence of overweight differed by region (from 11.5 % to 22.2 %) and was higher in urban v. rural areas for males (21.7 % v. 10.4 %) but not for females (21.7 % v. 19.2 %). These differences were partially mediated by socio-economic and lifestyle factors for males. For females, influence of cultural factors is hypothesised. In rural areas, overweight was more prevalent among boys of higher economic level households, having a working mother or a sedentary lifestyle; for girls, prevalence increased with the level of education of the mother. In urban areas, prevalence of overweight was related to eating habits: it was higher for boys with irregular snacking habits and for girls skipping daily meals. Urban girls having left school were also more overweight. CONCLUSION: Overweight and abdominal obesity in late adolescence have become a true public health problem in Tunisia with the combined effects of cultural tradition for girls in rural areas, and of rapid economic development for boys and girls in cities.

Assessment of child feeding practices using a summary index: stability over time and association with child growth in urban Madagascar.

BACKGROUND: Previous studies investigating the association between an infant and child feeding index (ICFI) and length-for-age were based on a cross-sectional design and on the assumption that data collected with brief recalls could provide information about more enduring processes. OBJECTIVES: The objectives were to test the stability of the individual ICFI values over time and to investigate how they relate to length-for-age z score (LAZ) and weight-for-length z score (WLZ) at the end of the study. DESIGN: This prospective cohort study included 363 children aged 6-17 mo who were visited 3 times over 6 mo. A cross-sectional ICFI (CS-ICFI) was constructed for each visit by using data on feeding practices and data from quantitative 24-h recalls. A longitudinal ICFI (L-ICFI) was constructed with use of the 3 CS-ICFIs. The stability of the CS-ICFI was assessed by using the variance of the repeatability coefficient (s(2)r). RESULTS: Stability of the CS-ICFI was shown by the value of 0.704 (95% CI: 0.625, 0.805) of the s(2)r, which differed significantly from 1 (P < 0.0001). There was no significant association between the CS-ICFIs and LAZ or WLZ at visit 3. In contrast, when moving from low to high L-ICFI, there was a highly significant 0.5 z score difference in mean LAZ at visit 3 (P = 0.0008). The L-ICFI was not associated with WLZ. CONCLUSIONS: The ICFI constructed by using data collected with brief recalls can provide information about feeding in the long term. However, the absence of association with LAZ suggests a lack of precision that can be reduced by using an ICFI based on repeated measurements.

Regular users of supermarkets in Greater Tunis have a slightly improved diet quality.

Despite the recent and rapid expansion of supermarkets in developing countries, their association with diet quality has been hardly studied. The study took place in Tunisia, where incidences of obesity and nutrition-related diseases are rising. The target population was households of the Greater Tunis area where supermarkets are mostly located. Households (n = 724) were selected by a 2-stage clustered random sampling. A purposely developed quantitative questionnaire assessed food retail habits. Socioeconomic data were collected at individual and household levels. The diet quality index-international (DQI-I) derived from a FFQ specific for Tunisia measured diet quality. Data analysis by regression or logistic regression models adjusted for energy intake and socioeconomic confounders when relevant. Overall, 60% of the households used supermarkets. Most households still used the nearby grocer; only 26% shopped at the market. Characteristics associated with supermarket use were urban milieu, small-sized households, greater educational attainment, higher economic level, steady income, or easy access. Associations between these variables and using supermarkets as a first shopping place (20% of households) were even stronger. After adjustment for energy intake and socioeconomic and access data, using supermarkets chosen as first food shopping place vs. other retail resulted in a slightly higher DQI-I (63.2 vs. 59.6; P = 0.0004). Despite the long-standing presence of supermarkets in Tunis, shopping at supermarkets has not yet spread to the whole population. Supermarkets do not yet markedly modify food consumption in the Greater Tunis. However, a slight improvement of diet quality can be observed among those people who use supermarkets regularly.

Influence of socio-economic and lifestyle factors on overweight and nutrition-related diseases among Tunisian migrants versus non-migrant Tunisians and French.

BACKGROUND: Migrant studies in France revealed that Mediterranean migrant men have lower mortality and morbidity than local-born populations for non-communicable diseases (NCDs). We studied overweight and NCDs among Tunisian migrants compared to the population of the host country and to the population of their country of origin. We also studied the potential influence of socio-economic and lifestyle factors on differential health status. METHODS: A retrospective cohort study was conducted to compare Tunisian migrant men with two non-migrant male groups: local-born French and Tunisians living in Tunisia, using frequency matching. We performed quota sampling (n = 147) based on age and place of residence. We used embedded logistic regression models to test socio-economic and lifestyle factors as potential mediators for the effect of migration on overweight, hypertension and reported morbidity (hypercholesterolemia, type-2 diabetes, cardiovascular diseases (CVD)). RESULTS: Migrants were less overweight than French (OR = 0.53 [0.33-0.84]) and had less diabetes and CVD than Tunisians (0.18 [0.06-0.54] and 0.25 [0.07-0.88]). Prevalence of hypertension (grade-1 and -2) and prevalence of hypercholesterolemia were significantly lower among migrants than among French (respectively 0.06 [0.03-0.14]; 0.04 [0.01-0.15]; 0.11 [0.04-0.34]) and Tunisians (respectively OR = 0.07 [0.03-0.18]; OR = 0.06 [0.02-0.20]; OR = 0.23 [0.08-0.63]). The effect of migration on overweight was mediated by alcohol consumption. Healthcare utilisation, smoking and physical activity were mediators for the effect of migration on diabetes. The effect of migration on CVD was mediated by healthcare utilisation and energy intake. No obvious mediating effect was found for hypertension and hypercholesterolemia. CONCLUSION: Our study clearly shows that lifestyle (smoking) and cultural background (alcohol) are involved in the observed protective effect of migration.

Process evaluation of the Senegal-Community Nutrition Project: an adequacy assessment of a large scale urban project.

OBJECTIVE: Although essential for understanding the reasons for success or failure of large scale nutritional interventions, process evaluation results are rarely reported. Our objective was to assess whether the process output objectives of the Community Nutrition Project (CNP) in Senegal, West Africa, were adequately met. METHODS: An adequacy assessment study based on monitoring data for individuals collected during the CNP was used to assess 'fidelity', 'extent' and 'reach' of participants recruitment and of the services provided. The CNP provided underweight or nutritionally at risk 6- to 35-month-old children in poor districts with monthly growth monitoring and promotion and a weekly food supplementation for 6 month periods, provided that mothers attended weekly nutrition education sessions. An exhaustive sample of the participating children (n = 4084) in Diourbel was used for evaluation over the first 2 years. RESULTS: At recruitment, only 66% of children were underweight (vs. 90% expected) varying with the CNP center and cohort, and the child's sex and age. Attendance at growth monitoring reached expected levels (93%vs. 90%) whereas numbers of food supplements distributed and education sessions attended were lower than expected (45%vs. 90% and 62%vs. 80%, respectively). At the end of follow-up, 61% of underweight children recovered vs. 80% expected. CONCLUSIONS: Because of CNP design for underweight diagnosis and bias in the targeting process, respect for selection criteria was low and consequently under coverage and leakage occurred. Besides a globally satisfactory process, wide discrepancies were observed between CNP centres concerning the utilization and effectiveness of services. This formative evaluation helped diagnose weaknesses; ongoing feedback enabled the CNP to improve targeting and supply of supplements. It also informed a larger impact evaluation. Some generalizable lessons for similar programmes have been highlighted.

Bringing together viewpoints of mothers and health workers to enhance monitoring and promotion of growth and development of children: a case study from the Republic of Congo.

In 1996, the Government of the Republic of Congo launched a pilot project to improve the child growth and development component of primary healthcare. The present study was carried out (i) to explore perceptions and practices of mothers and health workers regarding child growth, health, and development, and (ii) to design culturally-appropriate tools to enhance their monitoring and promotion. The study was carried out in two randomly-selected health centres in Brazzaville. Qualitative data collected included 16 focus-group discussions with 174 mothers, two focus-group discussions with 18 health workers, and 20 individual interviews with paediatricians or psychologists. The health workers reported that the main indicator of child growth was weight, while the mothers used broader concepts for evaluating growth and development of their toddlers. A strategy encompassing anthropometrics, developmental milestones, and acquisition of social skills was elaborated to enhance communication between health workers and mothers. A new growth chart was designed, and a new calendar of systematic visits, including key tasks and messages, was established. However, these new tools derived from the formative research still need to be carefully tested.