Changes in women's dietary diversity before and during pregnancy in Southern Benin.

Dietary diversity before and during pregnancy is crucial to ensure optimal foetal health and development. We carried out a cohort study of women of reproductive age living in the Sô-Ava and Abomey-Calavi districts (Southern Benin) to investigate women's changes in dietary diversity and identify their determinants both before and during pregnancy. Nonpregnant women were enrolled (n = 1214) and followed up monthly until they became pregnant (n = 316), then every 3 months during pregnancy. One 24-hr dietary recall was administered before conception and during each trimester of pregnancy. Women's dietary diversity scores (WDDS) were computed, defined as the number of food groups out of a list of 10 consumed by the women during the past 24 hr. The analysis included 234 women who had complete data. Mixed-effects linear regression models were used to examine changes in the WDDS over the entire follow-up, while controlling for the season, subdistrict, socio-demographic, and economic factors. At preconception, the mean WDDS was low (4.3 ± 1.1 food groups), and the diet was mainly composed of cereals, oils, vegetables, and fish. The mean WDDS did not change during pregnancy and was equally low at all trimesters. Parity and household wealth index were positively associated with the WDDS before and during pregnancy in the multivariate analysis. Additional research is needed to better understand perceptions of food consumption among populations, and more importantly, efforts must be made to encourage women and communities in Benin to improve the diversity of their diets before and during pregnancy.

Effects of Malaria in the First Trimester of Pregnancy on Poor Maternal and Birth Outcomes in Benin.

BACKGROUND: In sub-Saharan Africa, malaria in the first half of pregnancy is harmful for both the mother and her fetus. However, malaria in the first trimester of pregnancy, when women are usually not protected against malaria, has been little investigated. For the first time, we assessed the effects of malaria in the first trimester on maternal and birth outcomes using a preconceptional study design. METHODS: From June 2014 to March 2017, 1214 women of reproductive age were recruited and followed monthly until 411 became pregnant. The pregnant women were then followed from 5-6 weeks of gestation until delivery. Path analysis was used to assess the direct effect (ie, not mediated by malaria in the second or third trimester) of malaria in the first trimester on maternal anemia and poor birth outcomes. The cumulative effect of infections during pregnancy on the same outcomes was also evaluated. RESULTS: The prevalence of malaria infections in the first trimester was 21.8%. Malaria in the first trimester was significantly associated with maternal anemia in the third trimester (adjusted odds ratio 2.25, 95% confidence interval 1.11-4.55). While we did not find evidence of any direct effect of first trimester malaria infections on birth outcomes, their association with infections later in pregnancy tended to increase the risk of low birth weights. CONCLUSIONS: Malaria infections in the first trimester were highly prevalent and have deleterious effects on maternal anemia. They highlight the need for additional preventive measures, starting in early pregnancy or even before conception.

Intra-household double burden of malnutrition in a North African nutrition transition context: magnitude and associated factors of child anaemia with mother excess adiposity.

OBJECTIVE: In the Middle East and North Africa region, the nutrition transition has resulted in drastic increases in excess adiposity, particularly among women, while some types of undernutrition remain prevalent, especially among pre-school children. We assessed the magnitude, nature and associated factors of the within-household co-occurrence of anaemia in children and excess adiposity in mothers. DESIGN: Cross-sectional survey using stratified two-stage random cluster sampling to survey households with women aged 20-49 years. BMI≥25·0 kg/m2 defined overweight and BMI≥30·0 kg/m2 obesity, while anaemia for children was defined as Hb<110 g/l. The associations between child anaemia and mother excess adiposity, and sociodemographic and lifestyle factors were estimated by multinomial regression. SETTING: Greater Tunis area, Tunisia, in 2009-2010. SUBJECTS: Children aged 6-59 months living with their 20-49-year-old mothers (437 child-mother pairs). RESULTS: The most prevalent double burden of malnutrition in child-mother pairs by far was the anaemic child and overweight mother (24·4 %; 95 % CI 20·1, 29·3 %). A significant proportion of pairs were anaemic child and obese mother (14·4 %; 95 % CI 11·0, 18·5 %). The co-occurrence of anaemia in child and excess adiposity in mother was neither synergetic nor antagonistic (P=0·59 and 0·40 for anaemia-overweight and anaemia-obesity, respectively). This double burden was more frequent among child-mother pairs with younger children, with mothers of higher parity and higher energy intakes. CONCLUSIONS: The high prevalence of anaemic child and overweight or obese mother requires special attention e.g. through interventions which simultaneously target both types of malnutrition within the same household.

Gender inequalities in excess adiposity and anaemia combine in a large double burden of malnutrition gap detrimental to women in an urban area in North Africa.

OBJECTIVE: The nutrition transition has exacerbated the gender gap in health in the Middle East and North Africa region as the increase in excess adiposity has been much higher among women than men. This is not exclusive of the persistence of anaemia, generally also more prevalent among women. We assessed the magnitude and sociodemographic factors associated with gender inequality vis-à-vis the double burden of excess adiposity and anaemia. DESIGN: Cross-sectional study, stratified two-stage cluster sample. BMI (=weight/height2) ≥25·0 kg/m2 defined overweight and BMI≥30·0 kg/m2 obesity. Anaemia was defined as Hb <120 g/l for women, <130 g/l for men. Gender inequalities vis-à-vis the within-subject coexistence of excess adiposity and anaemia were assessed by women v. men relative prevalence ratios (RPR). Their variation with sociodemographic characteristics used models including gender × covariate interactions. SETTING: Greater Tunis area in 2009-2010. SUBJECTS: Adults aged 20-49 years (women, n 1689; men, n 930). RESULTS: Gender inequalities in excess adiposity were high (e.g. overweight: women 64·9 % v. men 48·4 %; RPR=2·1; 95 % CI 1·6, 2·7) and much higher for anaemia (women 38·0 % v. men 7·2 %; RPR=8·2; 95 % CI 5·5, 12·4). They were striking for overweight and anaemia (women 24·1 % v. men 3·4 %; RPR=16·2; 95 % CI 10·3, 25·4). Gender inequalities in overweight adjusted for covariates increased with age but decreased with professional activity and household wealth score; gender inequality in anaemia or overweight and anaemia was more uniformly distributed. CONCLUSIONS: Women were much more at risk than men, from both over- and undernutrition perspectives. Both the underlying gender-related and sex-linked biological determinants of this remarkable double burden of malnutrition inequality must be addressed to promote gender equity in health.

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

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

Socio-economic and behavioural determinants of fruit and vegetable intake in Moroccan women.

OBJECTIVE: To estimate daily fruit and vegetable intakes and to investigate socio-economic and behavioural differences in fruit and vegetable consumption among urban Moroccan women. DESIGN: A cross-sectional survey. Fruit and vegetable intake was measured with a single 24 h recall. SETTINGS: A representative population-based survey conducted in the area of Rabat-Salé. SUBJECTS: Women (n 894) of child-bearing age (20-49 years). RESULTS: Mean fruit and vegetable intake was 331 g/d (155 g/d for fruit and 176 g/d for vegetables). Only one-third (32.1 %) of women consumed ≥ 400 g/d and half the sample (50.6 %) were considered as low consumers, i.e. <280 g/d. Women of higher economic status ate significantly more fruit (P<0.05) and more fruit and vegetables combined (P<0.05). Women ate significantly less vegetables if they ate out of home more often or skipped at least one main meal (breakfast, lunch or dinner) or ate more processed foods (P<0.05, P<0.01 and P<0.001, respectively). Fruit and vegetable diversity was not associated with any of the factors investigated. CONCLUSIONS: In this population, fruit and vegetable intakes are driven by different determinants. Indeed, while vegetable consumption was related only to behavioural determinants, fruit consumption was influenced only by economic status. Therefore, programmes promoting fruit and vegetable intake would be more effective if they account for these specific determinants in their design.

A double burden of overall or central adiposity and anemia or iron deficiency is prevalent but with little socioeconomic patterning among Moroccan and Tunisian urban women.

In North Africa, overnutrition has dramatically increased with the nutrition transition while micronutrient deficiencies persist, resulting in clustering of opposite types of malnutrition that can present a unique difficulty for public health interventions. We assessed the magnitude of the double burden of malnutrition among urban Moroccan and Tunisian women, as defined by the coexistence of overall or central adiposity and anemia or iron deficiency (ID), and explored the sociodemographic patterning of individual double burden. In cross-sectional surveys representative of the region around the capital city, we randomly selected 811 and 1689 nonpregnant women aged 20-49 y in Morocco and Tunisia, respectively. Four double burdens were analyzed: overweight (body mass index ≥25 kg/m(2)) or increased risk abdominal obesity (waist circumference ≥80 cm) and anemia (blood hemoglobin <120 g/L) or ID (C-reactive protein-corrected serum ferritin <15 µg/L). Adjusted associations with 9 sociodemographic factors were estimated by logistic regression. The prevalence of overweight and ID was 67.0% and 45.2% in Morocco, respectively, and 69.5% and 27.0% in Tunisia, respectively, illustrating the population-level double burden. The coexistence of overall or central adiposity with ID was found in 29.8% and 30.1% of women in Morocco, respectively, and in 18.2% and 18.3% of women in Tunisia, respectively, quite evenly distributed across age, economic, or education groups. Generally, the rare, associated sociodemographic factors varied across the 4 subject-level double burdens and the 2 countries and differed from those usually associated with adiposity, anemia, or ID. Any double burden combining adiposity and anemia or ID should therefore be taken into consideration in all women. This trial was registered at clinicaltrials.gov as NCT01844349.

A frequency questionnaire to estimate free-living physical activity among Tunisian preadolescent and adolescent children.

OBJECTIVE: To develop a child- and adolescent-appropriate physical activity frequency questionnaire (PAFQ) in Tunisia, North Africa. DESIGN: A PAFQ was developed from a physical activity (PA) inventory that comprised major activity components (at home, preparing meals, school time, transport, non-sport leisure, sports, prayer and sleeping time). Then, type and duration of each activity undertaken during the past week were estimated. Total energy expenditure (TEE) estimated by the PAFQ was compared with data derived from two criterion methods: heart-rate monitoring (HRM) and a 24 h PA recall (24h-R), both collected during a 3 d period including one weekday and two weekend days. SETTING: Two elementary schools and two high schools of the most developed and urbanized area, Greater Tunis. SUBJECTS: One hundred and forty-two volunteer children and adolescents aged 10-19 years. RESULTS: The PAFQ strongly was correlated with both HRM (r = 0·70; 95% CI 0·62, 0·76) and 24h-R (r = 0·81; 95% CI 0·77, 0·84). It featured acceptable agreement with both criterion measures, slightly underestimating TEE compared with 24h-R (-2·8%, mean of individual differences -272·7 kJ/d; 95% CI -490·6, -57·4 kJ/d) and moderately overestimating it compared with HRM (+11·3%, mean of individual differences +1106·2 kJ/d; 95% CI 845·8, 1366·6 kJ/d). Reliability ranged from moderate to good (weighted kappa coefficients from 0·47 to 0·78 and intra-class correlation coefficients between 0·79 and 0·86 for energy expenditure by PA categories), indicating strong agreement between the two assessments. CONCLUSIONS: This PAFQ could be useful in the description and surveillance of PA patterns or for the evaluation of population-based interventions directed at promoting PA in Tunisian children and adolescents.

Poor maternal anthropometric status before conception is associated with a deleterious infant growth during the first year of life: a longitudinal preconceptional cohort.

BACKGROUND: According to the Developmental Origins of Health and Diseases concept, exposures in the preconception period may be critical. For the first time, we evaluated the effect of preconception poor anthropometric status on infant's growth in sub-Saharan Africa. METHODS: A mother-child cohort was followed prospectively from preconception to 1 year old in Benin. Maternal anthropometric status was assessed by prepregnancy body mass index (BMI), approximated by BMI at the first antenatal visit before 7 weeks' gestation, and gestational weight gain (GWG). BMI was categorized as underweight, normal, overweight, and obesity according to World Health Organization standards. GWG was categorized as low (<7 kg), mild (7-12 kg), and high (>12 kg). In infant, stunting and wasting were defined as length-for-age and weight-for-length z scores less than -2 SD, respectively. We evaluated the association between BMI/GWG and infant's weight and length at birth and during the first year of life, as well as with stunting and wasting at 12 months using mixed linear and logistic regression models. RESULTS: In multivariate, preconceptional underweight was associated with a lower infant's weight at birth and during the first year (-164 g; 95% CI, -307 to -22; and -342 g; 95% CI, -624 to -61, respectively) and with a higher risk of stunting at 12 months (adjusted odds ratio [aOR] = 3.98; 95% CI, 1.01-15.85). Furthermore, preconceptional obesity and a high GWG were associated with a higher weight and length at birth and during the first year. CONCLUSION: Underweight and obesity before conception as well as GWG were associated with infant's growth. These results argue for preventive interventions starting as early as the preconception period to support child long-term health.

Validity of impedance-based predictions of total body water as measured by 2H dilution in African HIV/AIDS outpatients.

Measurements of body composition are crucial in identifying HIV-infected patients at risk of malnutrition. No information is available on the validity of indirect body composition methods in African HIV-infected outpatients. Our first aim was to test the validity of fifteen published equations, developed in whites, African-Americans and/or Africans who were or not HIV-infected, for predicting total body water (TBW) from bioelectrical impedance analysis (BIA) in HIV-infected patients. The second aim was to develop specific predictive equations. Thirty-four HIV-infected patients without antiretroviral treatment and oedema at the beginning of the study (age 39 (SD 7) years, BMI 18.7 (SD3.7) kg/m2, TBW 30.4 (SD7.2) kg) were measured at inclusion then 3 and 6 months later. In the resulting eighty-eight measurements, we compared TBW values predicted from BIA to those measured by 2H dilution. Range of bias values was 0.1-4.3 kg, and errors showed acceptable values (2.2-3.4 kg) for fourteen equations and a high value (10.4) for one equation. Two equations developed in non-HIV-infected subjects showed non-significant bias and could be used in African HIV-infected patients. In the other cases, poor agreement indicated a lack of validity. Specific equations developed from our sample showed a higher precision of TBW prediction when using resistance at 1000 kHz (1.7 kg) than at 50 kHz (2.3 kg), this latter precision being similar to that of the valid published equations (2.3 and 2.8 kg). The valid published or developed predictive equations should be cross-validated in large independent samples of African HIV-infected patients.

Cohort profile: effect of malaria in early pregnancy on fetal growth in Benin (RECIPAL preconceptional cohort).

PURPOSE: REtard de Croissance Intra-uterin et PALudisme (RECIPAL) is an original preconceptional cohort designed to assess the consequences of malaria during the first trimester of pregnancy, which is a poorly investigated period in Africa and during which malaria may be detrimental to the fetus. PARTICIPANTS: For this purpose, a total of 1214 women of reproductive age living in Sô-Ava and Akassato districts (south Benin) were followed up monthly from June 2014 to December 2016 until 411 of them became pregnant. A large range of health determinants was collected both before and during pregnancy from the first weeks of gestation to delivery. Five Doppler ultrasound scans were performed for early dating of the pregnancy and longitudinal fetal growth assessment. FINDINGS TO DATE: Pregnant women were identified at a mean of 6.9 weeks of gestation (wg). Preliminary results confirmed the high prevalence of malaria in the first trimester of pregnancy, with more than 25.4% of women presenting at least one microscopic malarial infection during this period. Most infections occurred before six wg. The prevalence of low birth weight, small birth weight for gestational age (according to INTERGROWTH-21st charts) and preterm birth was 9.3%, 18.3% and 12.6%, respectively. FUTURE PLANS: REtard de Croissance Intra-uterin et PALudisme (RECIPAL) represents at this time a unique resource that will provide information on multiple infectious (including malaria), biological, nutritional and environmental determinants in relation to health outcomes in women of reproductive age, pregnant women and their newborns. It will contribute to better define future recommendations for the prevention of malaria in early pregnancy and maternal malnutrition in Africa. It confirms that it is possible to constitute a preconceptional pregnancy cohort in Africa and provides valuable information for researchers starting cohorts in the future.

Has the first implementation phase of the Community Nutrition Project in urban Senegal had an impact?

OBJECTIVE: We evaluated the impact of the Community Nutrition Project (CNP) of Senegal, West Africa on the population. In poor urban districts, the CNP provided underweight 6- to 35-mo-old children with growth monitoring/promotion and food supplementation, and education for mothers for a period of 6 mo. METHODS: A before/after intervention and intervention zone (IZ)/control zone (CZ) design was used to assess whether CNP had an impact 18 mo after it began in Diourbel. Exhaustive samples included children 6-35 mo old in the CZ (n = 895 before and 917 after) and IZ (n = 912 and 759). The impact was assessed by the differential effect of the zone on changes in underweight, wasting, and stunting defined by the threshold of -2 or -3 z scores. RESULTS: The decrease in wasting was higher in the CZ (from 13.7% to 8.6% versus 11.3% to 10.8%, P = 0.042). Changes in stunting did not differ between zones (18.8% to 14.5% versus 15.1% to 14.7%, P = 0.21). However, in the IZ, severe wasting, stunting, and underweight disappeared in children 6-11 mo of age. In the CZ, the socioeconomic data and some outcomes in children reflected a favorable context independent of the CNP. CONCLUSION: Despite a globally satisfactory decrease in malnutrition in the IZ, no impact was demonstrated because the same or an even larger decrease was observed in the CZ, highlighting the importance of relying on a quasi-experimental design. This may be explained in part by weaknesses in the process, which probably interfered with a potential impact, and by the high degree of population mobility, which could have interfered with efficiency assessed on a geographic scale.

Determinants of persistent underweight among children, aged 6-35 months, after huge economic development and improvements in health services in Oman.

Over the last decades, health indicators have witnessed major improvements in the Sultanate of Oman. This study was aimed at factors associated with underweight among children in four regions of Oman, as, in 1998, underweight was prevalent among 17.9% of children aged less than five years. A case-control study was conducted in 2002: 190 cases were 6-35-month old children with weight-for-age < -2 z-scores. Controls were individually matched by village of residence, sex, and age. The questionnaire included anthropometry of children, child-feeding practices, morbidity, anthropometry of mothers, parity, birth-spacing, and socioeconomic characteristics. Conditional logistic regression was used for analyses. Birth-weight of < 2,500 g was strongly associated with underweight and also were height of mother, low level of education of mother, bad quality of water in households, diarrhoea of children in the last two weeks, and regular use of infant formula. Factors, such as birth-weight, height of mother, supply of safe water in household, and care for mothers and children were the determinants of persistent underweight after huge economic development and improvements in health services. Further research is also needed to investigate further specific determinants of low birth-weight in the Omani context and try to disentangle emaciation and determinants of linear growth retardation.

Validity of impedance-based equations for the prediction of total body water as measured by deuterium dilution in African women.

BACKGROUND: Little information is available on the validity of simple and indirect body-composition methods in non-Western populations. Equations for predicting body composition are population-specific, and body composition differs between blacks and whites. OBJECTIVE: We tested the hypothesis that the validity of equations for predicting total body water (TBW) from bioelectrical impedance analysis measurements is likely to depend on the racial background of the group from which the equations were derived. DESIGN: The hypothesis was tested by comparing, in 36 African women, TBW values measured by deuterium dilution with those predicted by 23 equations developed in white, African American, or African subjects. These cross-validations in our African sample were also compared, whenever possible, with results from other studies in black subjects. RESULTS: Errors in predicting TBW showed acceptable values (1.3-1.9 kg) in all cases, whereas a large range of bias (0.2-6.1 kg) was observed independently of the ethnic origin of the sample from which the equations were derived. Three equations (2 from whites and 1 from blacks) showed nonsignificant bias and could be used in Africans. In all other cases, we observed either an overestimation or underestimation of TBW with variable bias values, regardless of racial background, yielding no clear trend for validity as a function of ethnic origin. CONCLUSIONS: The findings of this cross-validation study emphasize the need for further fundamental research to explore the causes of the poor validity of TBW prediction equations across populations rather than the need to develop new prediction equations for use in Africa.

Sensitivity and specificity of the body mass index to assess low percent body fat in African women.

The objective of this study was to evaluate the ability of the body mass index (BMI, kg/m(2)) to reflect low percent body fat (%BF) in a population with a rather mild but widespread prevalence of low BMI. A sample of 586 women was studied in the Plateau Koukouya, a rural area of the Republic of Congo, Central Africa. Percent BF was estimated from bioelectrical impedance (BIA). BIA parameters were assumed to reflect lean body mass. The correlation between %BF and BMI was high (r = 0.84; P < 0.001). Low %BF or low BIA parameters were defined as the first quartile of the distribution. Sensitivity, specificity, positive and negative predictive value of BMI <18.5, an accepted international cutoff for thinness, in relation to %BF was 58.5%, 93.6%, 75.4%, and 87.1%, respectively. A continuous sensitivity/specificity analysis (receiver operator characteristic [ROC] curves) for characterizing low %BF or low BIA parameters was done for a large range of BMI values. ROC curve analysis for %BF suggested that an acceptable trade-off between sensitivity (89.8%) and specificity (77.9%) occurred at a BMI of 19.7 kg/m(2). However, the positive predictive value was low (57.6%). For the prediction of low BIA parameters, results were similar, showing moderate sensitivity and high specificity for BMI <18.5, a cutoff point of BMI = 19.6, and low positive predictive values (<48%). The data suggest that BMI was not a good predictor of low %BF. This is consistent with the assumption of a decrease in both fat and fat free body mass in cases of low BMI. Am. J. Hum. Biol. 12:25-31, 2000. Copyright 2000 Wiley-Liss, Inc.

[Nutritional transition and non-communicable diet-related chronic diseases in developing countries]. / Transition nutrionnelle et maladies chronique non transmissibles liées à l'alimentation dans les pays en développement.

It is increasingly recognized that developing countries are undergoing an epidemiologic transition similar to that which occurred in industrialized countries in previous centuries. While infectious diseases are still the main cause of morbidity and mortality, there is a marked increase in chronic non-communicable diseases, particularly in the most advanced developing countries, and these diseases are expected to take the lead in a decade or two. Most of these diseases, above all coronary heart diseases, stroke and diabetes, are related to diet and lifestyles, for example tobacco and alcohol consumption. As a matter of fact, these societies are also facing a growing epidemic of overweight and obesity, due to the frequent energetic imbalance between energy-dense food consumption and reduced daily physical expenditure. This health transition, favoured by demographic changes towards aging populations, is occurring at an increased pace in urban societies widely exposed to the modernization of lifestyle, sedentary occupation, and to lipid- and sugar-rich food, often poor in fibre and micronutrients. Increased world access to cheaper vegetable oil is thought to have triggered off this accelerated and generalized trend, though animal food, rich in saturated fat, and imported or locally-made industrialized food also play a role. While increased national and household incomes facilitate the initial change, as the transition advances poor people progressively become the main victims, as has been observed in the more advanced developing countries. Metabolic imprinting due to intra-uterine and infant malnutrition, which are still common in these societies, is also thought to play a significant role in the increase in the expression of insulin resistance, obesity and chronic diseases when these children are exposed to abundant food and modern lifestyle, later in life. Treatment and secondary prevention of nutrition-related chronic diseases and associated disabilities have an ever rising cost in industrialized countries, which is far beyond the means of the still fragile economies of developing countries. This double burden of infectious diseases and undernutrition that still exist, and of non-communicable diseases and overnutrition represents a threat to the frequently unprepared health care services in developing countries. There is a clear need to focus health policies on the prevention of chronic diseases through primary health care services, the use of mass media for communication and education about healthy nutrition and lifestyle, and the adaptation of public policies. Nutritionists must also adapt to this changing nutritional situation which may result in apparently contradictory nutritional status findings within societies if not even within households.

Assessment of iron deficiency in the context of the obesity epidemic: importance of correcting serum ferritin concentrations for inflammation.

BACKGROUND: The correction of serum ferritin (SF) concentrations for inflammation because of infectious or parasitic diseases was recently proposed, especially in developing countries, but in many countries, adiposity has become the main cause of inflammation. OBJECTIVE: We assessed, overall and by adiposity status, the bias in the estimation of iron deficiency (ID) on the basis of uncorrected SF. DESIGN: A cross-sectional survey in 2010 in Rabat-Salé, Morocco, used a random sample of 811 women aged 20-49 y. Adiposity was assessed by body mass index (BMI) (in kg/m²) (normal: BMI <25; overweight: BMI ≥25 to <30; obese: BMI ≥30), waist circumference, and body fat. Inflammation was indicated by a C-reactive protein (CRP) concentration >2 mg/L. ID was indicated by an SF concentration <15 µg/L. The correction factor of SF for inflammation was derived from our sample. Differential effects of SF correction on ID status on the basis of adiposity were assessed by models that included adiposity × correction interactions and accounted for the within-subject correlation. RESULTS: The prevalence of overweight was 33.0% and of obesity was 34.0%. Inflammation (42.3%) was strongly linked with adiposity (20.1%, 37.6%, and 68.4% in normal, overweight, and obese subjects, respectively; P < 0.0001). SF increased from a CRP concentration >2 mg/L. The correction factor of SF was 0.65. The prevalence of ID (37.2% compared with 45.2%; difference -8.0%, P < 0.0001) was underestimated by not correcting SF, and the difference increased with adiposity (-2.9%, -8.5%, and -12.4% in normal, overweight, and obese subjects, respectively; P-interaction < 0.0001). Analogous results were observed for other adiposity measures. CONCLUSION: In developing countries where ID remains prevalent but rates of obesity are already high, corrected SF should be used when assessing ID status, even if infectious or parasitic diseases are no longer widespread. This trial was registered at clinicaltrials.gov as NCT01844349.

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

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