Excluding infants under 6 months of age from surveys: impact on prevalence of pre-school undernutrition.

OBJECTIVE: Infants aged 0-5 months are not systematically included in assessments of child nutritional status and are generally excluded from surveys conducted in emergencies. We estimated the impact of excluding 0-5-month-old infants on the prevalence of stunting, wasting and underweight among children under 5 years (U5) and under 3 years (U3) of age. DESIGN: Comparison of the prevalence of stunting, wasting and underweight in U5 and U3 with or without inclusion of the age group 0-5 months. SETTING: Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 76 developing countries and countries in transition. SUBJECTS: Children under 3 or under 5 years of age included in the surveys. Results Excluding 0-5-month-old infants resulted in an overestimation of the prevalence of stunting, wasting and underweight in U5 of 3.0, 0.3 and 2.6 percentage points, respectively, and of 4.8, 1.0 and 5.2 percentage points, respectively, in U3. The overestimation for wasting was negligible. The regions showing the highest overestimations for stunting and underweight were Asia and sub-Saharan Africa. Overall, countries with high prevalences of stunting and underweight showed especially large overestimations. The prevalence of underweight in infants aged 0-5 months was correlated with the prevalence of low maternal body mass index. CONCLUSION: All surveys, even in situations of nutrition emergency, should include 0-5-month-old infants. Strictly comparable age ranges are essential in nutrition surveys for monitoring trends and evaluating programme impact. Greater awareness of prenatal and early child undernutrition is needed among policy-makers.

Lipid content and essential fatty acid (EFA) composition of mature Congolese breast milk are influenced by mothers' nutritional status: impact on infants' EFA supply.

OBJECTIVE: To measure the lipid content and the fatty acid (FA) composition of breast milk as part of a nutritional survey of the essential fatty acid (EFA) status of 5 months old Congolese infants. DESIGN: Cross sectional nutrition survey. SETTING: A suburban district of Brazzaville (capital of the Congo). SUBJECTS: A random sample of nursing mothers and their 5 months old infants (n = 102). Data collection procedures: The mothers were questioned on their socio-economic status, dietary habits, and their body mass index (BMI) was measured. Breast milk samples were collected from each mother. Milk lipid content and fatty acid composition were determined. RESULTS: Compared with milk from various countries, Congolese women's mature breast milk was low in lipid (28.70+/-11.33 g/L) but rich in 8:0-14:0 FAs (25.97+/-8.17% of total FAs) and in polyunsaturated FAs (PUFAs), particularly n-3 PUFAs (2.39+/-0.68% of total FAs, mainly 18:3 and 22:6). This was associated with the frequent consumption of high-carbohydrate foods (processed cassava roots, wheat bread, doughnuts) known to enhance 8:0-14:0 FA biosynthesis, and with that of foods providing n-6 and n-3 EFAs such as freshwater and saltwater fish, vegetable oil, green leafy vegetables, and high-fat fruit (peanuts, avocado, bushbutter). These foods were traditionally and locally produced. Milk lipid content was negatively related with mothers' BMI (P < 0.01) and varied with the frequency of consumption of certain foods corresponding to distinct dietary patterns. CONCLUSIONS: Lipid content and FA composition of Congolese breast milk were dependent on mother's nutritional status. However, despite an adequate EFA composition of breast milk, partially breast-fed 5 months old Congolese infants probably did not get enough n-6 and n-3 EFAs from breast milk to meet their EFA requirements.

PIP: Optimum infant growth and development, especially neurodevelopment and visual acuity, require sufficient n-6 and n-3 essential fatty acid supplies from the placenta or breast milk. The lipid content and fatty acid composition of mature breast milk were measured in samples from 102 randomly selected Congolese mothers of 5-month-old infants, residing in a suburban district of Brazzaville. Mean body mass index (BMI) was 22.3; 14% of mothers were energy-deficient and 22% were overweight. Breast milk samples from these mothers were low in lipids (mean, 28.70 g/l), and 75% had a lipid content below reference values. Adequate lipid content was associated with a maternal diet high in carbohydrates and low in fats. Breast milk was rich in 8:0-14:0 fatty acids (25.97% of total fatty acids) and in polyunsaturated fatty acids, especially n-3. These findings appear related to Congolese mothers' frequent consumption of high-carbohydrate foods such as processed cassava roots, wheat bread, and doughnuts known to enhance 8:0-14:0 fatty acid biosynthesis, as well as locally produced foods such as fish, vegetable oil, leafy green vegetables, and high-fat fruit that provide n-6 and n-3 essential fatty acids. Milk lipid content was inversely associated with the maternal BMI, but was unrelated to maternal age or socioeconomic status. Since the essential fatty acid content of traditional complementary foods is lower than that present in breast milk, Congolese mothers should be encouraged to postpone the introduction of such foods until their infant is 4-6 months old.

Tobacco, alcohol, and colorectal tumors: a multistep process.

A case-control study in the Côte d'Or area of France used the multistep concept of colorectal carcinogenesis to compare lifetime tobacco consumption and present alcohol consumption in patients with small adenomas (less than 1 cm, n = 154) or large adenomas (n = 208) and in polyp-free controls (n = 427). Cancer patients (n = 171) were compared with population controls (n = 309). In men, smoking was associated with the risk of adenomas (odds ratio = 3.6 over 20 pack-years vs. nonsmokers, p < 0.001). Alcohol was a risk factor for large adenomas only, with relative risks of 4.2 (p < 0.01), 3.0 (p < 0.05), and 4.4 (p < 0.01) for consumptions of 20-39, 40-59, and 60 g/day compared with less than 10 g/day. When patients with large adenomas were compared with polyp-free controls, both alcohol and tobacco were independently related to the risk of tumor. There was no association between tobacco or alcohol intakes and cancer risk. In women, consumption was much lower in all groups, and no significant association with either risk factor was observed. These data suggest for the first time that there is an independent effect of alcohol and tobacco in men at different early steps of the adenoma-carcinoma sequence. They demonstrate the usefulness of such a model for etiologic studies on cancer.

The 24-hour recall for Senegalese weanlings: a validation exercise.

OBJECTIVE: In Africa, where growth retardation is highly prevalent, the use of expensive and time-consuming diet assessment techniques is a major obstacle to the collection of dietary data on large samples of children. The 24-h recall could be a valuable alternative. Its validity and reproducibility were assessed by comparison with the precise weighing technique. DESIGN & SUBJECTS: Intakes of complementary foods of 45 Senegalese weanlings, aged 11-18 months, were estimated with both techniques on the same days. RESULTS: There was neither a level-dependent nor a systematic bias with the 24-h recall for energy and macronutrient intakes. Mean differences between techniques were < 11% of mean intakes. Rank order correlations (r) ranged from 0.60 to 0.81 for energy and macronutrients. However, the analysis by food group showed that the 24-h recall was less precise than the reference, especially for foods from the household common pot (r ranged from 0.31 to 0.61 for rice, oil and fish). In particular, measuring rice intake as a number of 'handfuls' was not satisfactory. The technique needs further improvement for these foods. CONCLUSION: Since it provides unbiased estimates of weanlings' intakes, the 24-h recall can be used for diet surveys of groups of children. Its lack of precision, which could cause attenuation in epidemiological studies, can be compensated by increasing the number of days of survey. This study suggests that a precision equivalent to that of a 1-day weighed survey could be obtained with two 24-h recalls, at a considerably lower cost.

PIP: Growth retardation is highly prevalent in Africa. Given the limited available financial resources across most of the continent for the collection of dietary data on large samples of children, alternatives to expensive and time-consuming diet assessment techniques are called for. 24-hour recall may be one such alternative. The authors report their findings from an exploration of the validity and reproducibility of this approach compared to the precise weighing technique. The intakes of complementary foods were estimated for 45 Senegalese weanlings aged 11-18 months with both techniques on the same days. For each child, the study lasted four days spread over one day of qualitative observation, two days of precise weighing, and three days of 24-hour interviews. The study found the 24-hour recall approach to have neither a level-dependent nor systematic bias with regard to energy and macronutrient intakes. Mean differences between techniques were 11% of mean intakes. Analysis by food group found recall to be less precise than the reference, especially for food from the household common pot such as rice, oil, and fish. The authors conclude that the recall approach's ability to provide unbiased estimates of weanling's intakes makes it a viable assessment tool in diet surveys of groups of children. Its lack of precision can be compensated by increasing the number of days of the survey. Findings suggest that the precision of a one-day weighed survey could be obtained with two 24-hour recalls at considerably lower cost.

Use of the multiple-day weighed record for Senegalese children during the weaning period: a case of the "instrument effect".

In West Africa, the multiple-day weighed record is the most widely used technique for measuring children's food intakes. The children's eating behavior might be disrupted by the frequent weighings and the presence of a field-worker in the home. We explored the possibility of such an "instrument effect" in a 7-d food survey of 70 Senegalese children aged 10-13 mo. Energy intakes decreased significantly during the food survey (P < 0.0001). The decrease affected both daytime breast milk intake (8%) and solid food intakes (15%). The children's weight gain also decreased from a presurvey value of 6.9 to 2.1 g.kg-1.wk-1, indicating that their intakes during the food survey were lower than their usual intakes. The food-survey methodology was responsible for this "instrument effect." Policy decision-makers should be aware that data collected with the multiple-day weighed record technique might not reflect African children's usual food intakes.

PIP: The multiple-day weighed record derived from Food and Agriculture Organization methodology is the most widely used technique in West Africa for measuring children's food intakes. Children's eating behavior may, however, be disrupted by the frequency of weighings and the presence of a field-worker in the home. The authors therefore explored the possibility of this instrument effect in a 7-consecutive-day food survey of 39 Senegalese boys and 31 Senegalese girls aged 10-13 months residing in Pikine, a suburb of Dakar. Analysis of variance with a repeated-measures design was used to test day-of-the-week, day-of-the-food survey, and week-of-study effects, while contrast analysis was used to compare particular days or weeks. The study found that energy intakes decreased significantly during the food survey. The overall decreases were 8% in the amount of daytime breast milk intake and 15% of solid food intake. Children's weight gain also decreased from a presurvey value of 6.9 to 2.1 grams per kilogram per week. The food survey methodology was responsible for the decrease relative to usual food intake. Policy decision makers should thus be aware of the potential of this effect when reviewing and employing data derived from the methodology.

[Anemia at delivery in Lome (Togo): prevalence, risk factors and consequences in newborn infants]. / L'anémie à l'accouchement à Lomé (Togo): prévalence, facteurs de risque et répercussions chez le nouveau-né.

A prevalence study was carried out on 125 mothers and their newborns in Lome (Togo): at delivery 48% of the mothers and 30% of the newborns were anaemic according to WHO criteria. Iron deficiency was the major determinant of anaemia in the mothers, as three out of four showed at least one biochemical indicator of iron deficiency. Folate deficiency was detected in 68% of the mothers but did not influence their haematological parameters. Severe iron deficiency in the mothers (serum iron < 7 mumol/l) was associated with a decrease in serum iron in the newborns, thus demonstrating an impaired iron transfer to the fetus. Folate supplementation of the mothers during pregnancy improved their newborn's folate status. A systematic ferro-folic supplementation is needed during pregnancy and would be beneficial to both mothers and newborns. Supplements could be given to women at prenatal care clinics. Attendance in these centers by 98% of pregnant women in Lomé allows us to anticipate a good coverage for such an intervention.

Dietary determinants of the iron status in menstruating women.

Serum ferritin, haemoglobin, serum iron and total iron binding capacity were determined in 203 healthy menstruating women (32.9 +/- 0.6 years). Demographic and medical data were collected in the whole sample. Dietary intakes were evaluated by the dietary history method in a randomized subsample of 127 women. One fifth of the women had exhausted iron stores, as defined by a serum ferritin of 12 micrograms/l or less. The duration of menses influenced the serum ferritin concentration but contraception did not. Most of women had daily iron intake below the recommended dietary allowances for menstruating women. Serum ferritin was not correlated with daily total iron intake. But a relationship was found between serum ferritin and dietary intakes; intakes of meat, dairy products and coffee had a significant effect of serum ferritin concentration.

Factors affecting iron stores in French female students.

Serum ferritin and haematological variables were determined in 476 healthy French students (21.3 +/- 0.2 years). Information was collected on the duration of menses and contraceptive uses. Dietary intakes were assessed by the dietary history method in a randomized subsample of 157 women. The proportion of anaemic subjects was low, but 16 per cent of women had exhausted iron stores (serum ferritin less than or equal to 12 micrograms/l). Duration of menses was negatively correlated with serum ferritin concentration. The mean iron intake was 10.92 +/- 0.02 mg/d. Only fewer than 5 per cent of the students had daily iron intakes corresponding to the recommended dietary allowances for menstruating women (greater than or equal to 16 mg/d). There was a positive correlation between energy consumption and iron intake (r = 0.79, P less than 10(-9) ). Tea and dairy products intakes appeared to have a significant negative correlation with serum ferritin. The positive correlation between serum ferritin and haemoglobin suggests that decreased or depleted iron stores are associated with suboptimal haemoglobin values. This raises the problem of the definition of normal serum ferritin and haemoglobin values in menstruating women.

Effects of iron supplementation on serum ferritin and other hematological indices of iron status in menstruating women.

Serum ferritin, hemoglobin, serum iron and transferrin iron-binding capacity were evaluated in 107 healthy female students. 21 women had a serum ferritin of 12 micrograms/l or less, corresponding to an exhaustion of body iron stores. After 1 month of iron supplementation, significant increase of hemoglobin concentration and decrease of total iron-binding capacity were observed. Mean serum ferritin had increased from 24 to 41 micrograms/l, and all women had a serum ferritin above 12 micrograms/l. 1 month after the end of the trial, serum ferritin fell significantly. This study points out the problem of serum ferritin reference values and the definition of normal iron stores in menstruating women.