Nutritional predictors of chronic disease in a Central Australian Aboriginal cohort: A multi-mixture modelling analysis.

BACKGROUND AND AIMS: Chronic diseases (including diabetes, cardiovascular disease, hypertension and chronic kidney disease) are major contributors to the total burden of disease for Aboriginal people. Here we used novel epidemiological modelling to investigate nutritional profiles at a population level associated with chronic disease. METHODS AND RESULTS: Multi-mixture modelling, was used to group members of a Central Australian Aboriginal population (n = 444) based on their nutritional profile from a risk factor prevalence survey in 1995. Multi-mixture modelling assigned % membership to four classes; Class 1 (young, low adiposity and lipids, low dietary antioxidants; n = 171.7); Class 2 (older, greater adiposity and lipids; n = 22.6); Class 3 (predominantly female, greater adiposity and antioxidants, low smoking; n = 134.3) and Class 4 (predominantly male, greater lipids and adiposity, low antioxidants, high smoking prevalence; n = 115.4). For persons free of chronic disease (n = 285), incident chronic disease for classes 1, 3 and 4 was determined using follow up hospital, primary health care and death records collected in 2004/05. Fifty-four percent of Class 4 had incident chronic disease, an excess of 3355 events per 100,000 person years relative to Class 1. Incident CVD, hypertension, or CKD was highest for Class 4 and incident diabetes highest for Class 3. CONCLUSION: Multi-mixture modelling appears useful in identifying population subgroups of an Aboriginal population at risk of chronic conditions.

Effects of regular walking on cardiovascular risk factors and body composition in normoglycemic women and women with type 2 diabetes.

OBJECTIVE: To examine the impact of a 12-week walking program on body composition and risk factors for cardiovascular disease in women with type 2 diabetes and in normoglycemic women with first-degree diabetic relatives. RESEARCH DESIGN AND METHODS: There were 11 postmenopausal women with type 2 diabetes and 20 normoglycemic women of similar age and BMI who were asked to walk 1 h per day on 5 days each week for 12 weeks. Fitness (estimated VO2max) was assessed with a 1.6-km walking test; body composition was measured by dual-energy X-ray absorptiometry; and sex hormone, metabolic, and lipid concentrations were measured in serum. RESULTS: After 12 weeks, estimated VO2max improved in both groups (P < 0.005). In the diabetic women, BMI and fat content of the upper body and android waist region decreased (P < 0.05). Concentrations of fasting blood glucose (P < 0.05) HbAlc (P < 0.05), total cholesterol (P < 0.005), and LDL cholesterol (P < 0.05) decreased, while HDL cholesterol and sex hormones were unchanged. In contrast, normoglycemic women failed to lose body fat after 12 weeks of exercise in a walking program. However, their HbAlc, total cholesterol, LDL cholesterol, sex hormone-binding globulin, and total testosterone concentrations decreased (P < 0.05). On pooling the data and including diabetes as a categorical grouping variable, stepwise multiple regression analysis indicated that the change in centralized body fat, but not the change in VO2max, was related to change in fasting blood glucose. CONCLUSIONS: Twelve weeks of walking increased the fitness of diabetic and normoglycemic women. Improvement of fasting blood glucose was related to the loss of centralized body fat rather than to improved fitness.

Development of a single-frequency bioimpedance prediction equation for fat-free mass in an adult Indigenous Australian population.

BACKGROUND/OBJECTIVES: To describe the development of a single-frequency bioimpedance prediction equation for fat-free mass (FFM) suitable for adult Aboriginal and Torres Strait Islander peoples with and without diabetes or indicators of chronic kidney disease (CKD). SUBJECTS/METHODS: FFM was measured by whole-body dual-energy X-ray absorptiometry in 147 adult Indigenous Australians. Height, weight, body circumference and resistance were also measured. Adults with and without diabetes and indicators of CKD were examined. A random split sample with internal cross-validation approach was used to predict and subsequently validate FFM using resistance, height, weight, age and gender against measured FFM. RESULTS: Among 147 adults with a median body mass index of 31 kg/m(2), the final model of FFM was FFM (kg)=0.432 (height, cm(2)/resistance, ohm)-0.086 (age, years)+0.269 (weight, kg)-6.422 (if female)+16.429. Adjusted R(2) was 0.94 and the root mean square error was 3.33 kg. The concordance was high (rc=0.97) between measured and predicted FFM across a wide range of FFM (31-85 kg). CONCLUSIONS: In the context of the high burden of diabetes and CKD among adult Indigenous Australians, this new equation for FFM was both accurate and precise and based on easily acquired variables (height, weight, age, gender and resistance) among a heterogeneous adult cohort.

Body fat distribution and non-insulin-dependent diabetes: comparison of a fiber-rich, high-carbohydrate, low-fat (23%) diet and a 35% fat diet high in monounsaturated fat.

The effects of a fiber-rich, high-carbohydrate, low-fat (HCLF) diet and a modified-fat (MF) diet high in monounsaturated fat on body fat distribution were examined by dual-energy X-ray absorptiometry (DXA) in 16 subjects with non-insulin-dependent diabetes (NIDDM) during a randomized crossover study. Subjects lost similar amounts of body fat consuming the HCLF and MF diets (-0.83 +/- 0.37 and -0.87 +/- 0.40 kg, respectively) despite a marked difference in total fat consumption. With the MF diet, the ratio of upper- to lower-body fat (UF:LF) remained unchanged because fat was lost proportionately from the upper and lower body. In contrast, with the HCLF diet, a disproportionate loss of lower-body fat caused the UF:LF to increase. The effects of diet on regional body fat loss were significant (P < 0.05, two-factor repeated-measures ANOVA).

Changes in energy expenditure, anthropometry, and energy intake during the course of pregnancy and lactation in well-nourished Indian women.

Basal metabolic rate (BMR), thermic effect of a meal (TEM), anthropometry, and dietary intakes were measured in 18 control subjects; 18 pregnant women at 12, 24, and 34 wk gestation; and in 17 of these women at 12 and 24 wk postpartum, to uncover any metabolic economy associated with either pregnancy or lactation. Results indicated that the BMR and TEM were not associated with any energy saving either during pregnancy or lactation. Mean weight gain from 12 wk gestation to term was 11.4 +/- 3.7 kg; mean birth weight of the infants was 3.06 +/- 0.41 kg. Estimated gain in adipose tissue and fat mass were 3.1 +/- 3.6 and 2.5 +/- 2.9 kg, respectively. Energy cost of pregnancy was estimated to be 303 +/- 171 MJ. The cumulative increase in energy intake over the last two trimesters of pregnancy was 290 +/- 280 MJ, meeting a large part of the total estimated cost of pregnancy. Weight gained by infants who were exclusively breast-fed from birth to 12 wk of age was used as a proxy indicator of adequate lactational performance. The extra energy required during lactation appeared to have been met largely by increases in energy intake, rather than by any metabolic economy or increase in fat mobilization.

PIP: Researchers compared data on 18 nonpregnant, nonlactating staff and students (controls) with data on 18 pregnant women at 12, 24, and 34 weeks gestation and on 17 of these women at 12 and 24 weeks postpartum to determine any changes in maternal energy metabolism during pregnancy and lactation. All controls and cases were healthy and recruited at St. John's Medical College and Hospital in Bangalore, India. They had unlimited access to food. Mean birth weight stood at 3.06 kg. Pregnant women gained, on average, 11.4 kg between 12 weeks gestation and term. They also gained 3.1 kg of adipose tissue and 2.5 kg in fat mass during the same period. The total energy cost of pregnancy was 303 MJ. Pregnant women experienced a cumulative increase in energy intake over the last trimesters of pregnancy of 290 MJ, satisfying a considerable part of the total estimated cost of pregnancy. Neither the basal metabolic rate nor the thermic effect of a meal were related to any energy saving during pregnancy or lactation. Energy intake was significantly higher than that of controls at 24 and 34 weeks gestation (9.01 and 9.33 vs 7.58 MJ/d) and at 12 and 24 weeks postpartum (9.6 and 9.09 vs. 7.58 MJ/d) (p 0.05). The proxy indicator of adequate lactational performance was weight gain of infant between birth and 12 weeks. At 12 weeks, the body weights were similar to the 50th percentile of the NCHS weight-for-age. These findings suggest that increases in energy intake met the need for extra energy needed during lactation and that metabolic economy and increase in fat mobilization did not occur.

Resting metabolic rate and thermic effect of a meal in the follicular and luteal phases of the menstrual cycle in well-nourished Indian women.

The resting metabolic rate (RMR) and thermic effect of a standard test meal (TEM) were measured twice each during the follicular and luteal phases (confirmed by plasma concentrations of progesterone and estradiol) of a single menstrual cycle, and once during the follicular phase of the following menstrual cycle, by using indirect calorimetry, in 13 well-nourished Indian women. There was a significant increase in the TEM (P < 0.05) (6.72 +/- 1.57% vs 7.96 +/- 1.48% of the energy content of the test meal for follicular and luteal phases, respectively) of 18.5% during the luteal phase of the menstrual cycle but no significant difference in the RMR or postmeal total energy output (PMTEO). Dietary energy and macronutrient intakes in all subjects in both phases of the menstrual cycle were also similar. The RMR and the PMTEO were also similar when measured in the follicular phase of consecutive menstrual cycles.

Is there evidence for an age-related reduction in metabolic rate?

To determine whether the age-related reduction in basal metabolic rate (BMR) is explained by a quantitative and/or qualitative change in the components of lean tissue, we conducted a cross-sectional study in groups of young (n = 38, 18-35 yr) and older (n = 24, 50-77 yr) healthy individuals. BMR was measured by indirect calorimetry. Body composition was obtained by using dual-energy X-ray absorptiometry (DEXA), which permitted four compartments to be quantified [bone mineral mass, fat mass (FM), appendicular lean tissue mass (ALTM), and nonappendicular lean tissue mass (NALTM)]. Absolute BMR and ALTM were lower, whereas FM was significantly higher in the older, compared with young, subjects. BMR, adjusted for differences in FM, ALTM, and NALTM, was significantly lower in the older subjects by 644 kJ/day. In separate regression analyses of BMR on body compartments, older subjects had significantly lower regression coefficients for ALTM and NALTM, compared with young subjects. Hence, the age-related decline in BMR is partly explained by a reduction in the quantity, as well as the metabolic activity, of DEXA-derived lean tissue components.

Basal metabolic rates of Indian women.

Basal metabolic rates (BMRs) in 60 Indian women resident in Bangalore and aged 18-30 years were measured during the mid-follicular phase of the menstrual cycle. The data were used to obtain a predictive equation for BMR from body weight. The BMR measurements were comparable to BMRs of 52 Indian women reported more than 50 years ago, while they were 9.2% lower than Schofield's equation and 4.2% lower than that predicted by the equation of C.K.J. Henry & D.G. Rees (1991) Eur. J. Clin. Nutr. 45, 177-185. The equation obtained in this study predicts closely the BMRs of American women but underestimates BMRs of European women compared with figures recently reported in the literature.

Day-to-day variations in basal metabolic rates and energy intakes of human subjects.

Variations in BMR, body weight and energy intake were measured for 14 consecutive days in 6 young adults on ad libitum energy intakes, whose physical activity was uncontrolled. Energy intakes showed significant differences between days (P less than 0.025, CV = 6.7 per cent), between weeks (P less than 0.005, CV = 8.9 per cent) and between subjects (P less than 0.005, CV = 7.9 per cent). Energy intakes were 14 per cent higher (P less than 0.01) at weekends. Intra-individual variance contributed up to 86 per cent of the total variance in the energy intake. Replicate BMR measurements showed non-significant differences from day to day (CV less than 1.5 per cent), a training effect from week to week (P less than 0.05, CV = 1.5 per cent), and significant differences between subjects (P less than 0.001, CV = 12.4 per cent). Intra-individual variance contributed only 14 per cent to the total variance in BMR. There were no significant changes in body weight (CV = 0.7 per cent) or fat-free mass during the study. Auto-correlations of BMR, body weight and energy intake were non-significant at the different lag times studied. Cross-correlations between the above parameters were also non-significant for each subject. It is concluded that despite wide fluctuations in energy intake from day to day within an individual, the variations in BMR are small with a true CV of less than 1.5 per cent. Hence these variations are unlikely to be important while assessing energy requirements on the basis of the FAO/WHO/UNU (1985) BMR factorial method.

The effect of leprosy-induced deformity on the nutritional status of index cases and their household members in rural South India: a socio-economic perspective.

OBJECTIVES: To determine whether the socioeconomic and nutritional status of cured leprosy patients with residual deformity, and their household members, was lower than that of cured leprosy patients without deformity. DESIGN: Cross-sectional study. SUBJECTS: One hundred and fifty-five index cases with deformity, 100 without deformity. Also 616 household members comprising 48% of the total members enumerated. MEASUREMENTS: Nutritional status was evaluated using anthropometry. Disease characteristics, socio-economic parameters and household information were recorded using a questionnaire. RESULTS: Index cases with deformity had lower community acceptance (P<0.001), and employment (P<0.001) than those cases without deformity. Households of index cases with deformity had a lower income (P<0.01) and a lower expenditure on food (P<0.05). The presence of deformity (odds ratio (OR): 2.1-3.2, P<0.01), unemployment (OR: 2.3-4.3, P<0.01) and female gender (OR: 2.4, P<0. 01) significantly increased the risk of index cases being undernourished, as judged by body mass index (BMI) alone, or BMI and mid-upper arm circumference. A low BMI (<18.5) in the index case significantly increased the odds of other adults (OR 2.2), adolescents (OR 2.9-3.8) and children (OR 2.2) in the household being undernourished. CONCLUSIONS: Cured leprosy index cases with physical deformity are more undernourished than index cases without deformity. This is associated with a reduced expenditure on food, possibly brought on by increased unemployment, and a loss of income. Undernutrition in the index case increases the risk of undernutrition in other members of the family. European Journal of Clinical Nutrition (2000) 54, 643-649.

Relation of adiposity and body fat distribution to body mass index in Australians of Aboriginal and European ancestry.

OBJECTIVE: To compare the relations of adiposity and body fat distribution to body mass index (BMI) in Australians of Aboriginal and European ancestry. DESIGN: Cross-sectional volunteer samples. SETTING: Australian Aboriginal communities in remote central and northern Australia, urban European Australians resident in Melbourne, Australia. SUBJECTS: Healthy Aboriginal (130 women, 120 men) and European Australians (100 women, 47 men) with a BMI<30 kg/m(2), aged 18-35 y; all women were nonpregnant. INTERVENTIONS: Anthropometric variables and resistance-using a four-terminal impedance plethysmograph-were measured. RESULTS: Aboriginal women and men were significantly shorter and weighed less than European Australians (P<0.05). Aboriginal women had a significantly larger waist circumference and waist-to-hip ratio (WHR, P<0.0005) compared to European Australian women. The sum of four skinfold thicknesses (SFT) (S4) and trunk SFT was higher in Aboriginals as compared to European Australian women (P<0.0005); however, limb SFT tended to be lower (P=0.06). On the other hand, BMI was significantly lower in Aboriginals compared to European Australian men (P=0.011), as was hip circumference (P=0.001); however, WHR was significantly (P=0.007) higher. On regression analysis, Aboriginal women and men were significantly heavier than European Australians for the same height(2)/resistance (surrogate for fat-free mass) and S4 (surrogate for subcutaneous fat); and that Aboriginal men had a significantly higher BMI (by 1.2 kg/m(2); P<0.0005) for any given S4 and height(2)/resistance values, compared to European Australian men. CONCLUSION: Aboriginal and European Australians have a significantly different body fat distribution and fat mass for a given body weight or BMI. Use of the World Health Organization recommended BMI ranges to determine weight status may be inappropriate in Australian Aboriginal people.

The validity of predicting the basal metabolic rate of young Australian men and women.

OBJECTIVES: To assess the accuracy of the Schofield, Schofield & James (1985) equations and those of Hayter & Henry (1994) for the prediction of the basal metabolic rate (BMR), of young Australians. DESIGN: BMR was measured by indirect calorimetry, while fat free mass (FFM) and fat mass (FM) were measured by bioelectric impendence analysis (BIA) in 128 volunteers (39 men and 89 women), aged between 18 and 30 y. SETTING: Deakin Institute of Human Nutrition, Deakin University, Melbourne, Australia. RESULTS: The measured BMR of Australian men and women were significantly lower (P < or = 0.001) than the predicted BMR using the Schofield et al (1985) equation, with a mean (s.d.) bias (bias = measured - predicted BMR) of -406(513) kj/d in men and -124(348) kj/d in women. The measured BMR of Australian men and women were similar to the predicted BMR using the equations of Hayter & Henry (1994) and bias was unrelated to body weight. BMR adjusted for FFM and FM was significantly higher by three percent in women on oral contraceptive agents (OCA) as compared to those not on OCA. CONCLUSIONS: The Schofield et al (1985) equations are not valid for the prediction of BMR of young Australian men and women. The equations of Hayter & Henry (1994) for North Europeans and Americans, provide an accurate estimate of the BMR of Australian men and women at the group level. However, in young women not using OCA a correction factor of 0.97 applied to the predicted BMR provides a better estimate.

Use of the Bayer DCA 2000+ for the measurement of glycated haemoglobin in a remote Australian Aboriginal community.

BACKGROUND: Good glycaemic control in type 2 diabetes can reduce both morbidity and mortality, and monitoring of glycated haemoglobin A(1c) (HbA(1c)) is currently recommended for this purpose. METHODS: Haemoglobin A(1c) can be measured using the portable Bayer DCA 2000+. As part of a community-based screening project for chronic diseases, subjects with impaired fasting glucose concentrations or diabetes had their HbA(1c) concentration measured on the analyser. HbA(1c) measurements were also made in a laboratory using cation-exchange high-performance liquid chromatography. Results were then compared to those obtained in the field. HbA(1c) values were log(e) transformed to obtain a normal distribution. RESULTS: Mean (95% confidence interval) HbA(1c) measured on the DCA 2000+ (n = 39) was 6.3% (5.8, 6.9%), while that measured in the laboratory was 6.5% (6.0, 7.0%). The correlation coefficient (r) between the measurements was 0.96 (P < 0.01). Bland-Altman analysis revealed that the DCA 2000+ estimate of HbA(1c) could be used interchangeably with that from the laboratory (mean bias = 0.1%, limits of agreement - 1.1, 0.8%). The sensitivity, specificity and positive predictive value of the DCA 2000+ estimate of HbA(1c) using a cut-off value of <7% for adequate glycaemic control, were all 100%. CONCLUSIONS: The DCA 2000+ may be used to measure HbA(1c) in remote communities.

Is there a role for monounsaturated fat in the dietary management of obesity?

Animal and human studies indicate that high saturated fat (SFA) diets can be obesogenic. Monounsaturated fat (MUFA) has acute (meal related) effects that influence energy metabolism. These include increased postprandial fat oxidation and greater diet induced thermogenesis, factors that attenuate weight gain. Chronic (diet related) studies for 12 weeks or more, demonstrate that people following high MUFA diets do not gain excessive weight even when eating ad libitum. In fact, we have observed greater body weight and fat loss in men following an ad libitum MUFA diet, when compared to a SFA diet. High MUFA diets designed for weight loss should also incorporate a high vegetable intake according to traditional Mediterranean patterns. Such diets will promote the utilisation of fat and also have a low energy density. In our experience these diets are well accepted, and offer the prospect of greater long-term adherence to dietary advice.

Mechanistic roles for calcium and vitamin D in the regulation of body weight.

Low intakes of calcium and inadequate vitamin D status often cluster with higher prevalence rates of obesity. Consequently, there has been much interest in the mechanisms by which calcium and vitamin D could regulate body weight and adiposity. This review has focused on randomized controlled trials (RCTs) that have manipulated these nutrients and studied pathways of energy balance. Overall, there is consistent evidence that calcium and vitamin D increase whole body fat oxidation after single and multiple meals, and that calcium promotes a modest energy loss through increased faecal fat excretion. The evidence is equivocal for a greater diet-induced thermogenesis, increased lipolysis, suppression of key lipogenic enzymes, decreased hunger ratings or reduced energy/macronutrient intake. Emerging evidence suggests a potential improvement in insulin sensitivity following vitamin D that would impinge on food intake and substrate oxidation. However, the very few RCTs on supplemental vitamin D and energy balance have not explored postprandial avenues of the hormone's actions. Future efforts in this area need to define the threshold intake of these nutrients that would maximize metabolic and gastrointestinal outcomes. Such studies would provide a platform for endorsing the non-skeletal role of calcium and vitamin D in human pathophysiology.

Increased bone mineral density in Aboriginal and Torres Strait Islander Australians: impact of body composition differences.

Bone mineral density (BMD) has been reported to be both higher and lower in Indigenous women from different populations. Body composition data have been reported for Indigenous Australians, but there are few published BMD data in this population. We assessed BMD in 161 Indigenous Australians, identified as Aboriginal (n=70), Torres Strait Islander (n=68) or both (n=23). BMD measurements were made on Norland-XR46 (n=107) and Hologic (n=90) dual-energy X-ray absorptiometry (DXA) machines. Norland BMD and body composition measurements in these individuals, and also in 36 Caucasian Australians, were converted to equivalent Hologic BMD (BMD(H)) and body composition measurements for comparison. Femoral neck (FN) and lumbar spine Z-scores were high in Indigenous participants (mean FN Z-score: Indigenous men +0.98, p<0.0001 vs. mean zero; Indigenous women +0.82, p<0.0001 vs. mean zero). FN BMD(H) was higher in Aboriginal and/or Torres Strait Islander than Caucasian participants, after adjusting for age, gender, diabetes and height and remained higher in men after addition of lean mass to the model. We conclude that FN BMD is higher in Aboriginal and/or Torres Strait Islander Australians than Caucasian Australian reference ranges and these differences still remained significant in men after adjustment for lean mass. It remains to be seen whether these BMD differences translate to differences in fracture rates.

Australian Aboriginal people and Torres Strait Islanders have an atherogenic lipid profile that is characterised by low HDL-cholesterol level and small LDL particles.

AIM: To characterise lipid profiles for Australian Aboriginal people and Torres Strait Islanders. METHODS: Community-based, cross-sectional surveys in 1995-1997 including: 407 female and 322 male Australian Aboriginal people and 207 female and 186 male Torres Strait Islanders over 15 years old. A comparator of 78 female (44 with diabetes) and 148 male (73 with diabetes) non-indigenous participants recruited to clinical epidemiological studies was used. Lipids were determined by standard assays and LDL diameter by gradient gel electrophoresis. RESULTS: Diabetes prevalence was 14.8% and 22.6% among Aboriginal people and Torres Strait Islanders, respectively. LDL size (mean [95% CI (confidence interval)]) was smaller (P<0.05) in non-diabetic Aboriginal (26.02 [25.96-26.07] nm) and Torres Strait Islander women (26.01 [25.92-26.09] nm) than in non-diabetic non-indigenous women (26.29 [26.13-26.44] nm). LDL size correlated (P<0.0005) inversely with triglyceride, WHR, and fasting insulin and positively with HDL-cholesterol. HDL-cholesterol (mean [95% CI] mmol/L) was lower (P<0.0005) in indigenous Australians than in non-indigenous subjects, independent of age, sex, diabetes, WHR, insulin, triglyceride, and LDL size: Aboriginal (non-diabetic women, 0.86 [0.84-0.88]; diabetic women, 0.76 [0.72-0.80]; non-diabetic men, 0.79 [0.76-0.81]; diabetic men, 0.76 [0.71-0.82]); Torres Strait Islander (non-diabetic women, 1.00 [0.95-1.04]; diabetic women, 0.89 [0.83-0.96]; non-diabetic men, 1.00 [0.95-1.04]; diabetic men, 0.87 [0.79-0.96]); non-indigenous (non-diabetic women, 1.49 [1.33-1.67]; diabetic women, 1.12 [1.03-1.21]; non-diabetic men, 1.18 [1.11-1.25]; diabetic men, 1.05 [0.98-1.12]). CONCLUSIONS: Indigenous Australians have a dyslipidaemia which includes small LDL and very low HDL-cholesterol levels. The dyslipidaemia was equally severe in both genders. Strategies aimed at increasing HDL-cholesterol and LDL size may reduce high CVD risk for indigenous populations.

Measuring the impact of intimate partner violence on the health of women in Victoria, Australia.

OBJECTIVE: Using burden of disease methodology, estimate the health risks of intimate partner violence (IPV) among women in Victoria, Australia. METHODS: We calculated population attributable fractions (from survey data on the prevalence of IPV and the relative risks of associated health problems in Australia) and determined health outcomes by applying them to disability-adjusted life year estimates for the relevant disease and injury categories for Victoria, Australia for 2001. FINDINGS: For women of all ages IPV accounted for 2.9% (95% uncertainty interval 2.4-3.4%) of the total disease and injury burden. Among women 18-44 years of age, IPV was associated with 7.9% (95% uncertainty interval 6.4-9.5%) of the overall disease burden and was a larger risk to health than risk factors traditionally included in burden of disease studies, such as raised blood pressure, tobacco use and increased body weight. Poor mental health contributed 73% and substance abuse 22% to the disease burden attributed to IPV. CONCLUSION: Our findings suggest that IPV constitutes a significant risk to women's health. Mental health policy-makers and health workers treating common mental health problems need to be aware that IPV is an important risk factor. Future research should concentrate on evaluating effective interventions to prevent women being exposed to violence, and identifying the most appropriate mental health care for victims to reduce short- and long-term disability.

Thermic effect of a meal. 2. Role in chronic undernutrition.

The thermic effect of a standard liquid meal (TEM; energy 2.5 MJ; containing (g/kg) protein 100, fat 150, carbohydrate 750; volume 350 ml) was measured in a chronically undernourished (UN; n 9) group of human subjects and was compared with results from two control groups, one normal weight (NW)-for-height (BMI greater than 20; n 10) and the other underweight (UW)-for-height (BMI less than 18, n 10), using a ventilated-hood system over a period of 6 h after ingestion of the meal. Results indicated that the UN subjects had lower values for body-weight, height, percentage fat and fat-free mass (FFM) compared with those of either control group. Basal metabolic rates were lowest in the UN group in absolute terms; however, there were no significant differences among groups on an analysis of covariance (ANACOVA) with FFM as the covariate. TEM responses in the UN group were significantly higher when expressed either in absolute terms or as a percentage of the energy density of the meal. The post-meal total energy output was significantly lower (P less than 0.05) in the UW and UN groups as compared with the NW group in absolute terms; however, on adjusting for differences in FFM (by ANACOVA) there were no significant differences among groups. This would suggest that in the chronically undernourished thermogenic responses to a meal are unlikely to contribute towards any energy saving and may not constitute a part of any adaptive response to the undernourished state.