Ten-year changes in the obesity, abdominal adiposity, and serum lipoprotein cholesterol measures of Western Samoan men.

Previously reported associations between abdominal adiposity and coronary heart disease (CHD) may be mediated through serum lipids. In the present longitudinal study, 43 Western Samoan men who participated in a 1982 study were recontacted for a second determination of anthropometric and serum lipoprotein cholesterol levels. The men showed dramatic increases in weight (mean change +/- SD: 10.5 +/- 8.8 kg), abdominal circumference (10.0 +/- 7.6 cm), total cholesterol (49.5 +/- 26.4 mg/dl), and non-HDL cholesterol (53.1 +/- 26.6 mg/dl). A new indicator was used to estimate changes in abdominal adiposity: the residual from the regression of change in the abdominal circumference on change in body weight (the AR). The AR was significantly correlated with changes in total (r = 0.38) and non-HDL cholesterol (r = 0.39). Changes in HDL cholesterol were correlated with changes in weight only (r = -0.37). These bivariate relations remained significant in multiple linear regression analyses. These longitudinal results are the first to suggest changes in abdominal adiposity are related to changes in total and non-HDL cholesterol levels.

The food-first bias and nutrition policy: lessons from Ethiopia.

PIP: This paper presents results of the 1992 National Rural Nutrition Survey in Ethiopia that challenge the appropriateness of the centrality of food security as a dominant element of nutrition policy and planning. While the focus of this work is on protein-energy malnutrition in Ethiopia, the implications extend to other countries, and some of the same principles apply to micronutrient deficiencies. After a description of the design of the Ethiopian national nutrition surveillance system, results are presented for rural Ethiopia in terms of 1) the prevalence of stunting, wasting, and underweight by age; 2) changes in prevalence of stunting and underweight between February 1983 and March 1992; 3) prevalence of stunting and wasting by region; 4) distribution of stunted children by economic group and size of cultivated land; 5) prevalence of stunting and wasting in selected household economic groups by age group; 6) prevalence of stunting and wasting among children 24-59 months of age by size of cultivated area among cereal growers; 7) height-for-age z-scores across regions and cultivated areas; 8) weight-for-age z-scores; and 9) prevalence of stunting and medial age of introducing complementary foods. The most relevant findings of the study are that 1) stunting is far more common than wasting; 2) chronic malnutrition occurs at high rates among infants aged 6-11 months despite a typical rate of low birth rate, and the presence of stunting does not increase markedly after 24 months; 3) high rates of chronic malnutrition are ubiquitous, with some of the highest in food surplus areas; 4) the prevalence of chronic malnutrition has increased since 1983; 5) household food security is not uniformly associated with child nutritional status; and 6) cultivated area and child nutritional status are not significantly associated among children 6-23 months old.^ieng

The effects of malnutrition on child mortality in developing countries.

Conventional methods of classifying causes of death suggest that about 70% of the deaths of children (aged 0-4 years) worldwide are due to diarrhoeal illness, acute respiratory infection, malaria, and immunizable diseases. The role of malnutrition in child mortality is not revealed by these conventional methods, despite the long-standing recognition of the synergism between malnutrition and infectious diseases. This paper describes a recently-developed epidemiological method to estimate the percentage of child deaths (aged 6-59 months) which could be attributed to the potentiating effects of malnutrition in infectious disease. The results from 53 developing countries with nationally representative data on child weight-for-age indicate that 56% of child deaths were attributable to malnutrition's potentiating effects, and 83% of these were attributable to mild-to-moderate as opposed to severe malnutrition. For individual countries, malnutrition's total potentiating effects on mortality ranged from 13% to 66%, with at least three-quarters of this arising from mild-to-moderate malnutrition in each case. These results show that malnutrition has a far more powerful impact on child mortality than is generally appreciated, and suggest that strategies involving only the screening and treatment of the severely malnourished will do little to address this impact. The methodology provided in this paper makes it possible to estimate the effects of malnutrition on child mortality in any population for which prevalence data exist.

PIP: Conventional methods of classifying causes of death suggest that about 70% of the deaths of children 0-4 years old worldwide are due to diarrheal illness, acute respiratory infection, malaria, and immunizable diseases. The role of malnutrition in child mortality is not revealed by these conventional methods, despite the long-standing recognition of the synergism between malnutrition and infectious diseases. This paper describes a recently-developed epidemiological method to estimate the percentage of child deaths (ages 6-59 months) which could be attributed to the potentiating effects of malnutrition in infectious disease. The methodology is based on the results of 8 community-based, prospective studies of the relationship between anthropometry and child mortality from the rural areas of Bangladesh, India, Indonesia, Malawi, Papua New Guinea, and Tanzania. These studies suggest that the risk of mortality increases at a compounded rate of 5.9% for each percentage point decline in weight-for-age below the reference point of 90% weight-for-age. Using the relative risk estimates, the standard epidemiological statistic of population-attributable risk (PAR) was used to estimate the percentage of child deaths attributable to malnutrition's potentiating impact on infectious disease. The results from 53 developing countries with nationally representative data on child weight-for-age indicated that 56% of child deaths were attributable to malnutrition's potentiating effects. 83% of these were attributable to mild-to-moderate as opposed to severe malnutrition, with a range of 73-74% in Bangladesh and India to a high of 100% in countries with very low malnutrition prevalences. For individual countries, malnutrition's total potentiating effects on mortality ranged from 13% in Paraguay to 67% in India, with at least 3/4 of this arising from mild-to-moderate malnutrition in each case. The powerful impact of malnutrition on child mortality suggests that strategies involving only the screening and treatment of the severely malnourished are not sufficient.

The potentiating effects of malnutrition on child mortality: epidemiologic evidence and policy implications.

The physiologic synergism between malnutrition and infection has been recognized for some time, but its implications have not been addressed in current child survival policies and programs. This paper summarizes the conclusions from a recent analysis of 28 epidemiologic studies of the malnutrition-mortality relationship. It concludes that the relationship is consistent across diverse world populations, that there is a significant effect of both mild-to-moderate malnutrition and severe malnutrition, and that the effect is not simply due to confounding by socioeconomic factors or intercurrent illness. In addition, evidence is provided supporting the hypothesis that malnutrition and infection have multiplicative effects on child mortality, rather than the additive effects implicitly assumed, and the policy implications of these findings are described.

The relationship between child anthropometry and mortality in developing countries: implications for policy, programs and future research.

The prevention of child mortality is a commonly stated health goal in developing countries and the target of much international assistance in the health sector. Over the past decade the primary strategy for accelerating the reduction in child mortality has been the dissemination of simple, low-cost technologies, such as immunization, oral rehydration therapy and antibiotics, that target specific diseases (Huffmann and Steel 1994). This is done despite the knowledge that malnutrition and disease have a synergistic relationship (Scrimshaw et al. 1968) and that the optimal strategy may involve a combination of health and nutrition interventions. In the 1970s, for instance, it was estimated that malnutrition (notably protein-energy malnutrition--PEM) was the underlying or contributing cause of death for roughly half of all deaths to children aged 1-4 years in several Latin American countries (Puffer and Serrano 1973). Apart from this early study, however, there has been little effort to quantify the contribution of malnutrition to child mortality in other regions of the world in ways which are meaningful to policy. This paper reviews the results of 28 community-based, prospective studies, in 12 Asian and Sub-Saharan African countries, which examined the relationship between anthropometric indicators of malnutrition and child mortality. One purpose is to estimate the contribution of malnutrition to child mortality--distinguishing the effects of severe malnutrition from mild-to-moderate malnutrition--and to examine a number of related issues relevant to policy, programs and research in this area. The accumulated results are consistent in showing that the risk of mortality is inversely related to anthropometric indicators of nutritional status and that there is elevated risk even in the mild-to-moderate range of malnutrition. This latter result contradicts the findings from an earlier, landmark study which suggested that mild-to-moderate malnutrition was not associated with an increased risk of mortality (Chen et al. 1980). The present results indicate that somewhere between 20% and 75% of child deaths are statistically attributable to anthropometric deficits, with most estimates falling in the range 25-50%. When taking account of the relative proportions of severe versus mild-to-moderate malnutrition in the population, the results show further than 16-80% of all nutrition-related deaths are associated with mild-to-moderate malnutrition rather than severe malnutrition. In most studies 46-80% of all nutrition-related deaths are in the mild-to-moderate category.(ABSTRACT TRUNCATED AT 400 WORDS)

Child anthropometry and mortality in Malawi: testing for effect modification by age and length of follow-up and confounding by socioeconomic factors.

As shown in a review of 28 studies, anthropometric measurements of preschool-aged children are consistently related to the risk of subsequent mortality in community-based studies from Asia and Africa (Pelletier 1994). Although the results are consistent at this general level, a number of important questions remain concerning the relationship. The purpose of this study is to address two of these questions using data from a similar study conducted in rural northern Malawi: 1) In relation to screening, are the anthropometry-mortality relationships affected by the child's age and the interval between measurement and death ("length of follow-up") and 2) In relation to policy implications, is the anthropometry-mortality relationship due to confounding by socioeconomic factors, especially when considering mild-to-moderate malnutrition. The results reveal that mortality prediction is significantly affected by child's age and length of follow-up, but the strength and direction of this effect modification varies across the four commonly used anthropometric indicators [weight-for-age (WA), height-for-age (HA), weight-for-height (WH) and arm circumference-for-age (ACA)]. An important result for public health practice is that there are no statistically significant differences in prediction across these four indicators when applied to young children (6-23 mo) and employing a 1-y follow-up period. As regards confounding, the results indicate that the anthropometry-mortality relationship is not due to confounding by socioeconomic factors when all grades of malnutrition are considered. When only mild-to-moderate malnutrition is considered, statistically controlling for confounders reduces most of the anthropometric predictors to nonsignificance (probability values to > 0.20), but the strength of the association (odds ratio) remains of the same order of magnitude. However, when effect modification by child's age and length of follow-up is taken into account, the effect of mild-to-moderate malnutrition (WA and WH) remains statistically significant for young children dying with 1 y of follow-up.

PIP: The author has previously shown in a review of 28 studies that anthropometric measurements of preschool-aged children are consistently related to the risk of subsequent mortality in community-based studies from Asia and Africa. A number of questions, however, remain about the relationship. This study was therefore conducted to address two of the questions using data from a similar study in rural northern Malawi. First, in relation to screening, are the anthropometry-mortality relationships affected by child's age and the interval between measurement and death, and second, in relation to policy, is the anthropometry-mortality relationship due to confounding by socioeconomic factors, especially when considering mild to moderate malnutrition? The authors find that mortality prediction is significantly affected by child's age and length of follow-up, but the strength and direction of the effect modification varies across the four commonly used anthropometric indicators of weight-for-age, height-for-age, weight-for-height, and arm circumference-for-age. There are no statistically significant differences in prediction across the four indicators when applied to children aged 6-23 months and employing a one-year follow-up period. As for confounding, the study found the anthropometry-mortality relationship to not be due to socioeconomic factors when all grades of malnutrition are considered.

A methodology for estimating the contribution of malnutrition to child mortality in developing countries.

According to conventional methods of classifying cause of death, approximately 70% of child deaths (0-4 y) worldwide are due to a small number of priority infectious diseases which, in turn, receive the vast majority of donor and national resources in the health sector. Despite the long-recognized synergism between malnutrition and infection in the causation of child mortality, malnutrition does not appear as a major cause of death in health statistics from developing countries. Part of the reason for this has been the difficulty of estimating the percent of deaths due to malnutrition, because the conventional methods of classifying cause of death do not recognize the potentiating effect of malnutrition on the disease. The purpose of this paper is to develop and test a simple methodology to estimate the percent of child deaths in a given country or community that is due to malnutrition's potentiating effects on prevailing infectious diseases. The cornerstone of the methodology is knowledge of the strength of the association between malnutrition and mortality in developing countries, as measured in eight prospective studies. These studies reveal remarkable consistency in relative risk across different grades of malnutrition. The mean and SE of relative risk for severe malnutrition is 8.4 +/- 2.1, for moderate malnutrition it is 4.6 +/- 0.9, and for mild malnutrition it is 2.5 +/- 0.3. When applied to survey data from Ethiopia, Malawi, Guatemala and India for illustrative purposes, this methodology indicates that 42-57% of all child deaths in these samples (6-59 mo) are due to malnutrition's potentiating effects on infectious disease, of which 76-89% is attributable to mild-to-moderate malnutrition. This methodology is recommended for use in a variety of policy and planning applications.

Continuing needs for food consumption data for public health policy.

There are five broad categories of food-related public health problems in the U.S. for which survey data on food consumption are needed. These relate to reproduction, growth and development, chronic disease, food safety, food insecurity and problems specific to the elderly. The collection and analysis of food consumption data has become increasingly difficult for three major reasons. First, broad societal trends (e.g., ethnicity and use of food away from home) and changes in the food production, processing and marketing sectors have complicated the task. Second, the traditional concerns of monitoring (tracking population means and prevalences) are no longer the only objectives; there is a growing demand for data on habitual intake of individuals and variability in habitual intakes (e.g., to estimate the frequency of acute exposures). Third, data are required at several levels of aggregation (e.g., nutrients, food categories, commodities and name-brand foods) and a high frequency of non-consumption at lower levels of aggregation places high demands on sample size. It is suggested that the current large national surveys be supplemented with special purpose surveys that meet individual agency needs, and that principles and methods of state and local monitoring be further developed and implemented.

The role of information in the planning, management and evaluation of community nutrition programmes.

Protein-energy malnutrition has many diverse location-specific causes which make if difficult to solve through uniform interventions implemented through vertical programmes. This paper investigates the role of information in the planning, management and evaluation of several community nutrition programmes judged to be successful. The programmes come from Tanzania (Iringa), India (Tamil Nadu), Dominican Republic and Colombia. The review finds that the initial conceptualization and design of these programmes benefited from the results of earlier surveys and experience with similar programmes in the same or other countries. Strong capacity for operations research is important to assist with a myriad of small but important programme design details and larger mid-term re-orientations. The impact of this information depends upon the flexibility of the programme and receptivity of its management towards a learning-by-doing approach. Information for on-going programme management differs widely and conforms to the overall character of the individual programme. Thus, Iringa employs a simple system based on community growth monitoring, primarily to catalyze intervention planning and action at household and community levels. Tamil Nadu's system is far more complex and is primarily intended to assist in the delivery of centrally planned interventions. Programme evaluation benefited from information generated within the programme, but more rigorous impact evaluation requires stronger designs and more in-depth analysis than is usually provided. Overall, the review suggests that characteristics like community participation, empowerment and growth monitoring are less important in the short/medium term than strong management, a learning-by-doing approach, and the existence of some method for informing programme design and management about community needs and responses to the programme. The former characteristics may well be important for the longer-term sustainability of programmes.

Epidemiologic evidence for a potentiating effect of malnutrition on child mortality.

OBJECTIVES: Despite broad agreement that severe malnutrition contributes to child mortality in developing countries and that malnutrition has a physiologically synergistic relationship with morbidity, evidence of an epidemiologic synergism has been lacking. Also, the literature provides conflicting evidence concerning the existence of elevated mortality among children with mild to moderate malnutrition. A review of published population-based studies of anthropometry-mortality relationships was undertaken to clarify these relationships. METHODS: Six studies with the relevant data were reanalyzed to test for synergism and elevated mortality in mild to moderate malnutrition. RESULTS: The results demonstrate that mortality increases exponentially with declining weight for age. This effect is consistent across studies and there is no apparent threshold effect on mortality. The primary difference across studies is in baseline levels of mortality, which determine the quantitative impact of malnutrition on mortality in a population. CONCLUSIONS: These results indicate that mild to moderate malnutrition is associated with elevated mortality and that there is an epidemiologic synergism between malnutrition and morbidity. This previously undemonstrated finding has significant implications for child survival policies and research.

Comparison of two growth charts in Lesotho: health workers' ability to understand and use them for action.

BACKGROUND: Two growth monitoring charts widely used for growth monitoring in Africa (the Road-to-Health (RTH) and the Growth Surveillance (GS] were compared in order to assist the Government of Lesotho to decide on an appropriate national growth chart. METHODS: Thirty-four health workers were taught and tested on the RTH during a first week of training and on the GS during a second week (the RTH-GS group), while the order was reversed for another 25 trainees (the GS-RTH group). The health workers were trained and tested on their ability not only to use and interpret the two charts, but also to make the right decisions about specific actions to be taken when growth faltering occurs. RESULTS: There was no difference between scores to the RTH and GS charts after one week of training. After the second week of training, the scores to the RTH chart improved and became better than those to the GS chart. The scores to the GS test did not increase with previous knowledge of the RTH chart. CONCLUSIONS: For this reason and others discussed in the paper, the RTH chart was recommended for nationwide use in Lesotho. The adoption of this recommendation was facilitated by the close involvement in this research of public and private agencies responsible for growth monitoring in Lesotho.

The use of national sample surveys for nutritional surveillance: lessons from Malawi's National Sample Survey of Agriculture.

National sample surveys, containing measurements of the weights and heights of children along with other socioeconomic modules, represent one of the important sources of information for nutritional surveillance. The potential uses of such information are political sensitization, targeting by geographic area, targeting by socioeconomic group, and identifying the most promising intervention options according to the presumed causes of malnutrition. The latter two applications depend upon the ability to detect stable associations between nutritional status and socioeconomic factors. This paper examines the extent to which these planning applications are affected by variation in the ecology of malnutrition across different segments of society, using Malawi's National Sample Survey of Agriculture (NSSA). The NSSA is nationally representative of Malawi's smallholder sector and contains information on anthropometrics of underfives and various socioeconomic characteristics of their households. This analysis is based upon 3000 households containing at least one underfive, with one child per household being selected for analysis. Height-for-age Z-scores (HAZ) are calculated using WHO standards, and analyzed using analysis of variance (ANOVA). Variation in nutritional ecology is investigated by examining statistical interactions among socioeconomic variables as they relate to HAZ and by comparing ANOVA models constructed within several sample strata. These strata are defined according to geographic region, size of cultivated area, child's sex, child's age and, for a subsample, ethnic/religious identification. The results demonstrate that significant two-way interactions exist between region, cultivated area, household labor availability and age of the child. For the total sample HAZ declines with increasing cultivated area among young children (less than 24 months) but improves with increasing cultivated area among older children (greater than or equal to 24 months). The overall trend for young children is region-specific, however, such that no generalizations can be made concerning the effects of region and cultivated area without taking the other factor and child's age into account. Similarly, cultivated area interacts with household labor availability among young children, such that more labor is associated with lower HAZ on plots less than 0.7 ha, but more labor is associated with higher HAZ on plots above 1.5 ha. The existence of variation in nutritional ecology is further borne out by the observed variation in multivariable ANOVA models constructed within various sample strata. It is concluded that significant variation in nutritional ecology does exist between various segments of society. This limits the usefulness of national sample surveys for selecting intervention options and for targeting interventions according to socioeconomic characteristics.

The importance of context in choosing nutritional indicators.

Nutritional indicators are used to screen, diagnose, and evaluate interventions in individuals. They are also used in populations to ascertain and place under surveillance the magnitude of nutritional problems, their location and causes, and to evaluate the impact of programs and policies. Nutritional indicators are also used for research to make inferences about biological and social mechanisms affecting or being affected by nutrition. All these activities include measurements of nutritional indicators, but the choice of indicators, their measurements, analyses, and the need for other data can be very different for inferences from research, for patient management, for making public policy, or for planning or evaluating programs. There is no best indicator, best measure of an indicator, or best analysis of an indicator in a generic sense. The definition of "best" depends ultimately on what is most appropriate for the decision that must be made. This paper gives examples.

Comparison of mothers' understanding of two child growth charts in Lesotho.

Reported are the results of a study that compared mothers' understanding of two growth monitoring charts in Lesotho, which was carried out to assist the government in selecting a national growth chart. The study was conducted over 4 months in nine primary health care (PHC) clinics, where 1221 mothers were enrolled. Mothers were assigned to one of the following chart groups: "road-to-health" (RTH), "growth surveillance" (GS), or no chart (controls). Mothers in the first two groups received instruction on their respective chart during monthly growth monitoring sessions and were tested on their knowledge of this chart before and after the follow-up period. The mothers in the control group were tested on the RTH and GS charts at the beginning and at the end of the study. The results indicated that mothers who received training on either chart markedly improved their understanding compared with the control group and that the RTH group understood their chart better than the GS group did theirs.

PIP: In Lesotho the Ministry of Health uses the World Health Organization (WHO) version of the road-to-health (RTH) growth chart, while the Catholic Relief Services, which administer approximately 2/3 of the primary health care (PHC) clinics in the country, use the growth surveillance (GS) system. Maternal knowledge of the charts before and after 3 months' participation in a growth monitoring program was compared. A total of 1221 mothers from 9 PHC clinics situated in the lowland and foothills of Mafeteng and Mohale's Hoek districts of Lesotho were enrolled in the study from December 1985 to April 1986. With the exception of one clinic that used the RTH chart, all the others employed the GS chart. Mothers were selected if they had a child under 2 years old and if their level of exposure to clinic activities was low. In each participating clinic, mothers were assigned sequentially to the GS group (367 mothers who received a GS chart); the RTH group (389 mothers who received an RTH chart); and the control group (465 mothers who received no growth monitoring chart). A total of 335 (27.4%) of the 1221 mothers did not complete 4 visits to the clinics. Of these drop-outs, 82 were visited at home and were administered the final questionnaire. Improvements in scores were 1.72 points for the GS group and 1.77 for the RTH group, and were significantly higher than that of the control group. Analysis of covariance indicated that there was a significantly greater improvement for the group of mothers who received instruction on the RTH chart (2.28) compared with those who were instructed on the GS chart (1.54). Relative to the results for the control mothers, the mean adjusted improvement score was several times higher for mothers who had been given instruction on the charts, while that for the controls was similar to the unadjusted improvement score.

Comparison of mothers' understanding of two child growth charts in Lesotho

Reported are the results of a study that compared mothers' understanding of two growth monitoring charts in Lesotho, which was carried out to assist the government in selecting a national growth chart. The study was conducted over 4 months in nine primary health care (PHC) clinics, where 1221 mothers were enrolled. Mothers were assinged to one of the following chart groups: "road-to-health (RTH), "growth surveillance" (GS), or no chart (controls. Mothers in the first two grups received instruction on their respective chart during monthly growth monitoring sessions and were tested on their knowledge of this chart before and after the follow-up period. The mothers in the control group were tested on the RTH and GS charts at the beginning and at the end of the study. The results indicated that mothers who received training on either chart markedly improved their understanding compared with the control group and that the RTH group understood their chart better than the GS group did theirs

Physical activity and plasma total- and HDL-cholesterol levels in Western Samoan men.

This study examines effects of physical activity on plasma total- and high-density lipoprotein (HDL) cholesterol and derived variables in Western Samoan men who differ in rural/urban residence and occupation. Rural agriculturalists have significantly higher HDL cholesterol and HDL:total ratio than men employed in either physically active or physically sedentary occupations in an urban setting. Total cholesterol levels do not vary significantly, but when the differences in HDL cholesterol are accounted for, the means for agriculturalists and active workers are significantly lower than those for sedentary workers who do not play sports. These differences in HDL- and non-HDL-cholesterol levels are consistent with measures of physical activity among the groups. Variation in physical activity due to residence and occupation in Western Samoan men is related to lipoprotein cholesterol levels, but not to total cholesterol levels, and some effects may be secondary to differences in body composition.