Development of the Diet Quality Questionnaire for Measurement of Dietary Diversity and Other Diet Quality Indicators.

Background: To monitor trends toward healthy and sustainable diets, there is a need for feasible survey tools, with cross-cultural validity, low-cost, and low-expertise requirements. Objectives: The objective of this research was to develop a method to gather data suitable for monitoring diet quality in the general population (women and men of all ages) that is feasible within multitopic surveys, low burden for both enumerators and respondents, valid at population level, and that captures the information necessary for understanding diet quality at global and local levels. Methods: A literature review was conducted to identify constructs of diet quality with existing consensus, indicators with existing global demand, and methods that may be feasible and valid. Results were presented to a technical advisory group for debate, resulting in consensus on a set of constructs to be measured, desired indicators, viable data collection platforms, and an approach for testing and piloting. Results: Food group-based indicators and 24-h recall period were selected as the most feasible and valid approach for population-level monitoring. A 29-item Diet Quality Questionnaire (DQQ) was developed, where each yes/no question asks about the consumption of a distinct food group on the previous day or night. The food groups were selected for the purpose of deriving indicators to capture the constructs for which there was consensus: nutrient adequacy, and protection against noncommunicable diseases, including both positive and negative risk factors. Conclusions: The DQQ is low cost and feasible to administer in existing large-scale surveys, overcoming barriers to diet data collection that have precluded the routine monitoring of diet quality in the past. This novel approach has now been used across >85 countries in the Gallup World Poll and other surveys, generating the first nationally representative available datasets on Minimum Dietary Diversity for Women and complementary diet quality indicators.

Does social support modify the relationship between food insecurity and poor mental health? Evidence from thirty-nine sub-Saharan African countries.

OBJECTIVE: The present study aimed to determine the relationship among food insecurity, social support and mental well-being in sub-Saharan Africa, a region presenting the highest prevalence of severe food insecurity and a critical scarcity of mental health care. DESIGN: Food insecurity was measured using the Food Insecurity Experience Scale (FIES). Social support was assessed using dichotomous indicators of perceived, foreign perceived, received, given, integrative and emotional support. The Negative and Positive Experience Indices (NEI and PEI) were used as indicators of mental well-being. Multilevel mixed-effect linear models were applied to examine the associations between mental well-being and food security status, social support and their interaction, respectively, accounting for random effects at country level and covariates.ParticipantsNationally representative adults surveyed through Gallup World Poll between 2014 and 2016 in thirty-nine sub-Saharan African countries (n 102 235). RESULTS: The prevalence of severe food insecurity was 39 %. The prevalence of social support ranged from 30 to 72 % by type. In the pooled analysis using the adjusted model, food insecurity was dose-responsively associated with increased NEI and decreased PEI. Perceived, integrative and emotional support were associated with lower NEI and higher PEI. The differences in NEI and PEI between people with and without social support were the greatest among the most severely food insecure. CONCLUSIONS: Both food insecurity and lack of social support constitute sources of vulnerability to poor mental well-being. Social support appears to modify the relationship between food security and mental well-being among those most affected by food insecurity in sub-Saharan Africa.

Measuring the Food Access Dimension of Food Security: A Critical Review and Mapping of Indicators.

BACKGROUND: With food security now a top priority for many governments and for the global development community, there is heightened awareness of the need to improve our understanding and measurement of food security. OBJECTIVE: To bring clarity in the assessment of the food access dimension of food security at the household and individual level. METHODS: For the most commonly used indicators, we reviewed their original purpose and construction, at what levels (household or individual) they were designed to be used, what components (quality, quantity, safety, and cultural acceptability) they were intended to reflect, and whether or not they have been tested for validity and comparability across contexts. RESULTS: We identified nine indicators and grouped them in three broad categories: experience-based, coping strategies, and dietary diversity. The indicators only capture the quantity and quality components of food access; none of the indicators capture information on safety or cultural acceptability of food access. Household Dietary Diversity (HDDS) and Food Consumption Score (FCS) are often considered indicators of both quantity and quality, but they have not been validated for the latter. CONCLUSIONS: We recommend the use of experience-based indicators, HDDS, or FCS to assess household access to energy; experience-based indicators to assess household access to diet quality (defined qualitatively as not having to adopt practices that favor acquiring cheaper, less appealing, and less micronutrient-dense foods); and individual dietary diversity scores for women or children to assess individual access to diet quality, defined as micronutrient adequacy.

Validity and reliability of food security measures.

This paper reviews some of the existing food security indicators, discussing the validity of the underlying concept and the expected reliability of measures under reasonably feasible conditions. The main objective of the paper is to raise awareness on existing trade-offs between different qualities of possible food security measurement tools that must be taken into account when such tools are proposed for practical application, especially for use within an international monitoring framework. The hope is to provide a timely, useful contribution to the process leading to the definition of a food security goal and the associated monitoring framework within the post-2015 Development Agenda.

Proxy measures of household food consumption for food security assessment and surveillance: comparison of the household dietary diversity and food consumption scores.

OBJECTIVE: To provide an overview of the household dietary diversity score and the food consumption score, two indicators used for food security assessment and surveillance, and compare their performance in food security assessments in three countries. DESIGN: Cross-sectional cluster sampling design using an interview-administered structured questionnaire on household food security, including household-level food group consumption measured over 1 d and 7 d. SETTING: Survey data are from Burkina Faso, Lao People's Democratic Republic (Lao PDR) and northern Uganda. SUBJECTS: Households in Burkina Faso (n 3640), Lao PDR (n 3913) and northern Uganda (n 1956). RESULTS: Spearman's correlation coefficients between the scores were 0·73 in Burkina Faso, 0·65 in Lao PDR and 0·53 in northern Uganda. Prevalence-adjusted kappa coefficients showed substantial strength of agreement in two countries. The proportion of agreement between the two scores ranged from 85 % in Lao PDR to 65 % in northern Uganda. Dietary profiles based on food group consumption using score tertiles were comparable. Rankings of the most food-insecure areas within a country corresponded well in northern Uganda and Burkina Faso but not in Lao PDR. Both indicators showed moderate correlations with other proxy measures of food security. CONCLUSIONS: The comparative study highlights the similarities and differences between the food consumption and household dietary diversity scores. Similar classification of the most food-insecure areas within sub-national levels was obtained. The choice of indicator for food security assessment and surveillance will vary depending on user needs.

Persistent environmental contaminants in human milk: concentrations and time trends in Italy.

Breast milk monitoring studies of persistent and toxic environmental contaminants are of primary importance for carrying out an adequate risk assessment at the actual levels of human exposure and represent a major source of information on infant perinatal exposure. Milk specimens from mothers of the general population of the Venice and Rome areas were collected over the 1998-2001 period, pooled, and analyzed for selected persistent organic pollutants such as polychlorodibenzodioxins (PCDDs), polychlorodibenzofurans (PCDFs), polychlorobiphenyls (PCBs), organochlorinated pesticides (p,p'-DDE, p,p'-DDT, hexachlorobenzene), and polybromodiphenyl ethers (PBDEs), and the heavy metals Cd, Co, Cu, Hg, Mn, Pb, Sn, and Zn. The goal was to verify whether mother milk from the Venice area, whose lagoon is partly under direct industrial impact, had a contaminant load greater than that from the Rome area, primarily urban. For mothers from the Venice area, the correlation between fish and fishery product consumption and contaminant concentrations in milk was also explored, with however inconclusive results. The concentrations of PCDDs, PCDFs, dioxin-like PCBs, and organochlorinated pesticides determined in this study were compared with those available from a previous analytical work carried out on 1987 human milk pools of domestic origin: the declining trend of the aforesaid contaminants in milk is confirmed to be in agreement with what was observed in other European countries. The breast milk content of (137)Cs and (40)K radionuclides was also determined and compared with data obtained in other research programmes carried out in Italy: the health risk for breastfed infants was deemed to be not significant.

Polychlorinated biphenyls (PCBs) and polybrominated diphenyl ethers (PBDEs) in milk from Italian women living in Rome and Venice.

The levels of selected polychlorinated biphenyls (PCBs) and polybrominated diphenyl ethers (PBDEs) were measured in human milk samples from the areas of Venice and Rome, primarily in order to characterize the current levels of infant exposure to PCBs and PBDEs due to breast feeding in Italy. Sixteen non-dioxin-like PCBs, including the traditional indicator congeners, and 11 PBDEs, comprising the relevant PBDE-47, PBDE-99, and PBDE-153, were determined. Congeners were selected for analysis according to their relative abundance in human tissues, toxicological relevance, and diffusion in the environment. Dietary habits of the milk donors were recorded by questionnaires; mothers of the Venice area were classified into three groups according to their consumption of local fish, molluscs, and other fishery products. Sigma(16)(PCBs) and Sigma(11)(PBDEs) (ng g(-1) fat) for the areas of Venice and Rome were respectively, 250-390 and 240, and 1.6-2.8 and 4.1. An increase of fish and fishery product consumption could not be associated with an increase of PCB and PBDE levels in milk.

Reproductive disorders and pregnancy outcomes among female flight attendants.

BACKGROUND: Occupational exposures in female aircrew may cause adverse pregnancy outcomes and menstrual disturbances. We studied reproductive health among female flight attendants. METHODS: We conducted a cross-sectional health survey among an occupational cohort of current and former flight attendants using a postal questionnaire including items on pregnancy outcome, menstrual characteristics, and infertility. We investigated these factors by occupational status (in service or not). RESULTS: The questionnaire was sent to 3036 women with a response rate of 64% (74% for current and 48% for former flight attendants). Spontaneous abortion rates were similar for pregnancies of women in service and not (12.6 vs. 11.4%; p = 0.58). Induced abortion rates were lower for in-service pregnancies (7.9%) compared with pregnancies of women not in service (21.1%) (p < 0.001). Menstrual irregularities in the year preceding the survey for women under 40 yr were more frequent among current than former flight attendants (20.6% vs. 10.4%, p = 0.02). Fertility problems were reported by 20.6% of respondents. An association between infertility and irregular menstrual cycles was found: odds ratio 1.6; 95% confidence limits 1.1, 2.4. CONCLUSIONS: Active flight attendants had a lower rate of induced abortions than former flight attendants, but the spontaneous abortion rate was similar between the two groups. Active flight attendants reported more menstrual irregularities, which are a risk factor for infertility. Lack of comparison with working women in other occupations precludes a conclusion that flight attendants are at greater occupational risk of reproductive disorders. Future studies of reproductive health in flight attendants should address personal and work-related risk factors in more detail and include comparison occupational groups.

Occupational risks for uveal melanoma results from a case-control study in nine European countries.

OBJECTIVE: Uveal melanoma is a rare disease with poor prognosis and largely unknown etiology. We studied potential occupational risk factors. METHODS: A population based case-control study was undertaken during 1995-1997 in nine European countries using population and colon cancer controls with personal interviews. Occupational exposure to sunlight and artificial UV radiation was assessed with a job exposure matrix. In total, 320 uveal melanoma cases were eligible at pathology review, and 292 cases were interviewed, participation 91%. Out of 3357 population controls, 2062 were interviewed, 61%, and out of 1272 cancer controls 1094 were interviewed, 86%. RESULTS: Using population controls, occupational exposure to sunlight was not associated with an increased risk (RR=1.24, 95% CI=0.88-1.74), while an excess risk found with use of colon cancer controls was attributed to confounding factors. An excess risk in welders was restricted to the French part of the data. Cooks, RR=2.40; cleaners, RR 2.15; and laundry workers, RR=3.14, were at increased risk of uveal melanoma. CONCLUSION: Our study does overall not support an association between occupational sunlight exposure and risk of uveal melanoma. The finding of an excess risk of eye melanoma in cooks in several European countries is intriguing.

Mortality from cancer and other causes among male airline cockpit crew in Europe.

Airline pilots and flight engineers are exposed to ionizing radiation of cosmic origin and other occupational and life-style factors that may influence their health status and mortality. In a cohort study in 9 European countries we studied the mortality of this occupational group. Cockpit crew cohorts were identified and followed-up in Denmark, Finland, Germany, Great Britain, Greece, Iceland, Italy, Norway and Sweden, including a total of 28,000 persons. Observed and expected deaths for the period 1960-97 were compared based on national mortality rates. The influence of period and duration of employment was analyzed in stratified and Poisson regression analyses. The study comprised 547,564 person-years at risk, and 2,244 deaths were recorded in male cockpit crew (standardized mortality ratio [SMR] = 0.64, 95% confidence interval [CI] = 0.61-0.67). Overall cancer mortality was decreased (SMR = 0.68; 95% CI = 0.63-0.74). We found an increased mortality from malignant melanoma (SMR = 1.78, 95% CI = 1.15-2.67) and a reduced mortality from lung cancer (SMR = 0.53, 95% CI = 0.44-0.62). No consistent association between employment period or duration and cancer mortality was observed. A low cardiovascular mortality and an increased mortality caused by aviation accidents were noted. Our study shows that cockpit crew have a low overall mortality. The results are consistent with previous reports of an increased risk of malignant melanoma in airline pilots. Occupational risk factors apart from aircraft accidents seem to be of limited influence with regard to the mortality of cockpit crew in Europe.

Mortality from cancer and other causes among airline cabin attendants in Europe: a collaborative cohort study in eight countries.

There is concern about the health effects of exposure to cosmic radiation during air travel. To study the potential health effects of this and occupational exposures, the authors investigated mortality patterns among more than 44,000 airline cabin crew members in Europe. A cohort study was performed in eight European countries, yielding approximately 655,000 person-years of follow-up. Observed numbers of deaths were compared with expected numbers based on national mortality rates. Among female cabin crew, overall mortality (standardized mortality ratio (SMR) = 0.80, 95% confidence interval (CI): 0.73, 0.88) and all-cancer mortality (SMR = 0.78, 95% CI: 0.66, 0.95) were slightly reduced, while breast cancer mortality was slightly but nonsignificantly increased (SMR = 1.11, 95% CI: 0.82, 1.48). In contrast, overall mortality (SMR = 1.09, 95% CI: 1.00, 1.18) and mortality from skin cancer (for malignant melanoma, SMR = 1.93, 95% CI: 0.70, 4.44) among male cabin crew were somewhat increased. The authors noted excess mortality from aircraft accidents and from acquired immunodeficiency syndrome in males. Among airline cabin crew in Europe, there was no increase in mortality that could be attributed to cosmic radiation or other occupational exposures to any substantial extent. The risk of skin cancer among male crew members requires further attention.

Occupational risk factors for small bowel carcinoid tumor: a European population-based case-control study.

Small bowel carcinoid tumor (SBC) is a rare disease of unknown etiology but with an age-, sex-, and place-specific occurrence that may indicate an occupational origin. A European multicenter population-based case-control study was conducted from 1995 through 1997. Incident SBC cases between 35 and 69 years of age (n = 101) were identified, together with 3335 controls sampled from the catchment area of the cases. Histological review performed by a reference pathologist left 99 cases for study; 84 cases and 2070 population controls were interviewed. The industries most closely associated (a twofold or more odds ratio [OR]) with SBC, taking into account a 10-year time lag after exposure were, among women, employment in wholesale industry of food and beverages (OR, 8.2; 95% confidence interval [CI], 1.9 to 34.9]) and among men, manufacture of motor vehicle bodies (OR, 5.2; 95% CI, 1.2 to 22.4), footwear (OR, 3.9; 95% CI, 0.9 to 16.1), and metal structures (OR, 3.3; 95% CI, 1.0 to 10.4). The identified high-risk occupations with an OR above 2 were shoemakers, structural metal preparers, construction painters and other construction workers, bookkeepers, machine fitters, and welders (men). The OR for regular occupational use of organic solvents for at least half a year was 2.0 (95% CI, 1.0 to 4.2). Exposure to rust-preventive paint containing lead was suggested as another potential occupational exposure (OR, 9.1; 95% CI, 0.8 to 107). This explorative study suggests an association between certain occupational exposures and SBC, but some of these associations could be attributable to chance. All findings should be regarded as tentative.

A retrospective cohort mortality study of Italian commercial airline cockpit crew and cabin attendants, 1965-96.

A retrospective cohort mortality study was conducted among Italian commercial flight personnel for the period 1965-1996. The cohort was composed of 3,022 male cockpit crew members and 3,418 male and 3,428 female cabin attendants. Cause-specific standardized mortality ratios (SMRs) and exact 95% confidence intervals (CIs) were calculated as estimates of the relative risk. Mortality from all cancers was less than expected for all categories (SMRs of 0.58 for male cockpit crew, 0.67 for male cabin attendants, and 0.90 for female cabin attendants). Among male flight personnel, the SMR for leukemia was somewhat elevated (SMR 1.73; 95% CI: 0.75-3.41) based on eight deaths, with a positive trend by length of employment (p = 0.046). Additionally, an excess of death by suicide was seen among female cabin attendants (SMR 3.38; 95% CI: 1.24-7.35). Other Italian studies of flight personnel are under way, including a detailed assessment of cosmic radiation exposure and investigations of non-radiation occupational risk factors and prevalence of nonfatal outcomes.