Menstrual disorders are common in young women, and heavy menstrual blood losses (MBL) are an important cause of anaemia. Menstrual morbidity normally goes untreated in developing countries where cultural barriers also serve to mask the problems. We investigated the prevalence of menstrual morbidity, and measured MBL and its relationship to iron deficiency in a rural adolescent population. The rationale was to assess whether or not reducing heavy MBL could be part of a strategy to reduce iron deficiency anaemia.

Rural village in south-east Nigeria.

Cross-sectional survey.

The study included all non-pregnant, unmarried nulliparous girls (< 20 years) who had menstruated, and who lived in K'Dere village.

A field worker allocated to each girl completed a questionnaire, and supervised recovery and collection of soiled pads and ensured blood sampling. MBL was measured using the standard alkaline haematin method. Haemoglobin (Hb), serum iron, transferrin saturation and protoporphyrin levels (ZPP) were also measured.

307 girls completed MBL measurements; 11.9% refused to participate. 12.1% had menorrhagia (> 80 ml); median MBL was 33.1 ml. Menorrhagia was more frequent in girls who had menstruated for > 2 years (P = 0.048), and had longer duration of menses (P < 0.001). Iron status as measured by haematocrit, serum iron, transferrin saturation and ZPP values was inversely related to MBL. Neither height nor body mass index for age was associated with current iron status.

The level of menorrhagia detected (12%) may be an ‘expected’ level for a condition which often has no underlying pathology. Heavy MBL is one of the most important factors contributing to iron deficiency anaemia. Measures are needed to alleviate menstrual disorders, and improve iron status. Oral contraceptives can be part of a strategy to reduce anaemia, particularly for adolescents at high risk of unwanted pregnancies.

To describe food consumption during the school day of rural Jamaican children and participation in two government school feeding programmes. To determine factors which were related to these.

Cross sectional.

16 primary schools in rural Jamaica.

415 children in grades 2 and 5 (ages 7 and 10 years).

Consumption of sweets, sweet drinks and snacks was high. Mean intakes at lunch were: energy 1537 kJ (SD 756), protein 10.4 g (SD 7.6) and iron 1.5 mg (SD 1.2). The mean energy intake was 17–20% of the daily requirement for this age group. Two types of school feeding programmes were available in the schools, one provided a cooked meal and the other a bun and milk. Median availability of school meals (as a percentage of children enrolled in the schools) over three terms was 24.6% (range 0–85.4%). Twenty per cent of the children participated in one or other programme. Poorer children were more likely to participate in the bun and milk programme (odds ratio 2.1, 95% C1 1.3–3.5) but children with more money to purchase food participated in the more costly cooked meal programme (odds ratio 2.4, 95% CI 1.3–4.6).

Energy intakes at lunch in Jamaican children were somewhat below optimal levels and the reliance on sweets and snacks is an area of concern. Programme characteristics such as meal cost, may affect access to school feeding by poor children.

To estimate the incidence of Wernicke's encephalopathy (WE) and Korsakoffs psychosis (KP) before and after the introduction of thiamin enrichment of bread in Australia.

Inpatient records were examined in 17 major public general hospitals in greater Sydney for the 4 years 1993–96 (inclusive) with the International Classification of Diseases (ICD) 9 diagnoses 265.1 (WE), 291.1 and 294.0 (KP). Relevant clinical data were recorded on a specially designed form so that cases could be classified as confirmed or probable WE, confirmed or probable KP, confirmed or probable Wernicke–Korsakoff syndrome (WE + KP) or not WE or KP. The average number of cases of WE + KP was 38 acute (new) cases and 69 total (acute+chronic) cases per annum for all the hospitals combined.

This study used the same methods as our earlier retrospective examination of Wernicke–Korsakoff cases in essentially the same hospitals for 1978–93. Records for 1993 were thus pulled twice and, while individual cases (using hospital index number) did not always coincide, the total numbers for 1993 were 69 and 70.

For the 5 years after 1991 the number of acute cases of WE and KP in Sydney hospitals was 61% of the number for the 5 years before 1991 (P<0.01). There is, however, no continuing downward trend.

These results are consistent with a 40% reduction of the incidence of acute WE and KP since bread has been enriched with thiamin. The disease complex has, however, not been eliminated. To achieve this, further public health action would be needed, such as addition of thiamin to beer.

Qualitative case study and mathematical model.

Belgium.

To evaluate the correlation between the polyamine mean concentration of the milk drunk during the first postnatal month and the appearance of allergy in children who drank this milk.

A model that describes the dependence of the allergy appearance with the spermine mean concentration of milk drunk during the first postnatal month was established.

This model shows that 5.02 nmol ml−1 of spermine is a critical value to prevent the appearance of allergy.

To assess the nutritional status of older people in an unstable situation.

Anthropometric and socioeconomic data were collected cross-sectionally. Body mass index (BMI), arm muscle area (AMA) and arm fat area (AFA) were calculated to evaluate nutritional status. For 41 subjects with kyphosis, height was estimated from arm span using sex-specific regression equations from the non-kyphotic group.

The study was carried out in the post-emergency phase in a Rwandan refugee camp in Karagwe district, north-west Tanzania.

Measurements were obtained from 413 men and 415 women aged 50–92 years.

The prevalence of undernutrition (BMI < 18.5) was 19.5% in men and 13.1% in women and was higher above age 60 years in both sexes: in men the prevalences were 23.2% and 15.0% (P < 0.05) and in women 15.1% and 10.9% for the older and younger age groups respectively. AMA, which is important in relation to the ability to remain active and independent, was also significantly lower in older age groups. No difference was found in AFA. The proportion with low BMI was much higher in the group with kyphosis.

Even in this population of older Rwandans who managed to reach the camp and survive in exile for more than a year, undernutrition does occur and is more prevalent at an advanced age. The higher prevalence of undernutrition in kyphotic people illustrates the importance of including this group in nutritional status assessments.

To develop and test a food frequency questionnaire (FFQ) for use in rural areas of Kerala, India.

Based on food use and market surveys of the study area, a quantitative 81-item interviewer-administered FFQ was developed. A validation study was conducted consisting of 24-h diet recalls (24HR) administered on 8 days randomly selected over an entire year and two administrations of the FFQ, one at the beginning of the l-year period and the other at the end. FFQ and 24HR-derived nutrient scores were compared using correlation and regression analyses and by examining differences in the nutrient scores.

Rural villages in Ernakulum district, Kerala, South India.

In each of 30 households, the male head of household and female food preparer were enrolled.

Pearson (parametric) correlation coefficients (rp) averaged about 0.50 in comparing nutrient scores derived from the 24HR with those from the first FFQ and about 0.55 in comparing the second FFQ. On average, Spearman correlation coefficients (rs) were slightly lower than the rp in comparing the scores derived from the first FFQ, but virtually identical for the second FFQ. Regression analyses indicated better agreement in the comparison of the 24HR-derived scores with the first FFQ than the second FFQ. Difference scores, however, tended to be larger in comparing the first FFQ scores with the 24HR.

This FFQ produces results broadly comparable to those used in Europe and North America, indicating its suitability for comparing exposures within a study population in reference to health-related endpoints.

Dietary surveys are a valuable tool in nutrition surveillance programmes to monitor the nutritional status of a group or population of a country. The objective of this study was to assess the food consumption pattern in the adult population of the Basque Country (Spain).

A cross-sectional nutritional survey was carried out in 1990. Dietary habits were assessed by means of ‘24-h recall’ during 3 non-consecutive days and a food frequency questionnaire.

Population survey in the Basque Country (Spain).

Random sample of the adult population (25–60 years) in the Basque Country (n=2348).

Results draw a food pattern characterized by a high consumption of meat, 163±3.04 g day−1 (mean±SEM), supplied mainly by poultry, butchery products, veal and fish (88±2.68 g day−1). The average consumption of milk and dairy products was 359±5.19 g day−1, although 39% of the sample did consume less than 2 portions from this group of foods daily. Olive oil was the most widely used fat for cooking (4i%), followed by sunflower seed oil (30%). Cereals supplied 21.5% of the average energy intake and the consumption of vegetables and garden products was 159±3.13 g day−1. Only 29% of the group usually had 2 or more portions of vegetables per day. Women consumed higher amounts of chocolate, cookies, sweets and coffee (P < 0.01) than men. Younger adults consumed more meat (P < 0.01), while the older community consumed more fish, vegetables and fruit (P < 0.01). More highly educated people consumed more dairy products, vegetables and butter (P < 0.01). Conversely, less educated people consumed higher amounts of olive oil, pulses and bread (P < 0.01).

The dietary pattern observed in the Basque Country, although in keeping with its traditions, is in harmony with the actual dietary trends in Mediterranean countries. In order to satisfy the dietary guidelines suggested by the Spanish Society of Community Nutrition, it would be desirable to gradually increase the consumption of vegetables, fresh garden produce, fruit and cereals. At the same time, it would be advisable to decrease the consumption of animal products (whole fat dairy products, meat, added fats) so the proportion of energy intake from fat can be reduced by 5% (3% from saturated fatty acids).

The objective of this paper is to examine the impact of the Health Service Research Project of the Pakistan Medical Research Council (PMRC) on mothers and infants in Budhni village, North West Frontier Province (NWFP), Pakistan.

Information from the PMRC records on the socioeconomic and demographic situation over the last 10 years and anthropometric measurements made on all infants from 1986–96 were collected and analysed.

The demographic data showed a number of changes, namely a reduction in birth rate and improvements in perinatal, neonatal, infant and child mortality rates. Literacy in the village was poor (27 and 39% literate in 1986 and 1996, respectively) and female literacy showed no improvement (14%). Improvements in sanitation and in the water supply introduced by the PMRC had limited success, as clean water was subsequently contaminated by unclean hands and utensils, and 50% of the population continued to use open fields for sanitation. In 1986 only 27% of children 0–5 years were vaccinated, but by 1996, 96% of children had completed polio, diphtheria/pertussis/tetanus (DPT) and bacille Calmette-Guérin (BCG) vaccination programmes and 95% of women of child-bearing age were vaccinated against tetanus. Protection against tetanus reduced neonatal deaths and from 1333 onwards there have been no further cases.

Anthropometric data for the period 1986–96 for infants (0–24 months) showed that at birth the majority of infants were close to the 50th National Centre for Health Statistics (NCHS) centile for weight and length, and only 5% of birth-weights were less than 2.5 kg. Growth charts showed faltering in length and weight and by 24-months length in both boys and girls was below the 3rd NCHS centile and weights were just above.

Reductions in child mortality have occurred over the period 1986–96. However, the slow progress in adopting hygienic practices, despite health education, and the low literacy rates, particularly in women, may hamper continued improvement.

To assess attitudes, predictors of intention, and identify perceived barriers to increasing fruit and vegetable (F&V) intakes.

UK nationwide postal survey utilizing the theory of planned behaviour.

Stratified (by social class and region) random sample of 2020 UK adults providing a modest response rate of 37% (n = 741).

Belief measures (e.g. health, cost, taste, etc.) were strongly associated with overall attitudes which were reported as being largely favourable towards fruit, vegetables and, to a lesser extent, vegetable dishes, and were strongly associated with reported intention to increase consumption. Subjects reported they could increase their consumption, but this was only weakly associated with intention to do so. Approximately 50% of respondents reported an intention to increase intakes. Social pressure was strongly associated with reported intention to increase; however, scores indicated low perceived social pressure to change. Evidence of unrealistic optimism concerning perceived intakes and the perceived high cost of fruit may also act as barriers.

Results from this study suggest a lack of perceived social pressure to increase F&V intakes and suggests that public health efforts require stronger and broader health messages that incorporate consumer awareness of low present consumption.

To review and categorize the problems associated with undertaking physical activity validation studies and to construct a checklist against which any study could be compared.

The studies reviewed demonstrated problems in defining the dimension of physical activity that is of interest and in the selection of an appropriate comparison technique. Ideally this should be closely related to the true exposure of interest and assess that exposure objectively and without correlated error from the study instrument in question. In many studies inappropriate comparison methods have been chosen which do not measure the true underlying exposure and which are likely to have correlated error. The choice of study populations, the frame of reference of the exposure measurement and the use of appropriate statistical methods are also problematic areas.

There is no ideal measurement instrument or validation study design that is suitable for all situations. However, the checklist in this paper provides a means whereby the appropriateness of studies already undertaken or at the planning stage can be assessed.

This study explores the factors that influence eating patterns in a nationally representative sample of the English population.

Subjects were interviewed in 1993; questions covered basic demographic details, attitudes about nutrition, and they completed a short food frequency questionnaire that had previously been validated. Cluster analysis was used to summarize dietary intake into more or less healthy clusters.

A random sample ofthe English population.

A cross-sectional survey of 5553 men and women (response rate 70%) aged between 16 and 74 years.

As defined from the cluster analysis about half the sample were currently reporting a more healthy diet; respondents in the better educated middle-aged demographic cluster were more likely to report eating a more healthy diet than respondents in the younger lower-income family cluster. About three-quarters of all respondents believed that they either already ate a healthy diet or had changed to a healthy diet in the last 3 years. For those respondents who said they were eating a healthy diet about half of them were eating a more healthy diet. Respondents who had not changed their diet were more likely than those who had to believe that healthy foods were just another fashion (men 34% v. 13%; women 30% v. 12%). or expensive (men 50% v. 35%; women 53% v. 40%); they were less likely to care about what they ate (men 45% v. 13%; women 27% v. 7%). Nearly three-quarters of all respondents agreed that experts never agree about what foods are good for you. Younger, low-income families, and those who smoked, were the group least likely to be eating a more healthy diet.

The results of this study suggest that about half of the population has reported a change to a healthier diet over the last 3 years and that overall about half of the population report eating a healthy diet. Those who had not made any change and were currently reporting a less healthy diet were more likely to smoke and come from the 'worse off' group in the survey; they were also more likely to hold negative attitudes about healthy eating. A more focused and integrated approach to promoting Dietary change healthy lifestyle in general is required, while at the same time ensuring that there is healthy eating continued support for the majority of the population who have made healthy dietary Cluster analysis changes.

To investigate the frequency and the determinants of under-reporting in a semi-quantitative food frequency questionnaire used in the Greek segment of the European Prospective Study on Nutrition, Cancer and Health (EPIC study).

A food frequency questionnaire was completed by 9262 adult men and women. The questions included in this questionnaire covered the average intake of approximately 150 food items and beverages over 1 year. Evaluation of under-reporting was conducted on an individual basis taking into account the expected daily variation of nutritional intakes during the time period of recording. Individuals whose energy intake was lower than 1.14*BMR (basal metabolic rate) were defined as under-reporters.

Urban and rural population of Greece.

The data indicated underestimation of energy intake by 11.8% of individuals enrolled. Results from a logistic regression model indicated that body mass index (BMI), gender, age and educational level were significant predictors of under-reporting. The proportion of overweight participants (BMI>30) who tend to under-report energy intake was more than twice that of normal-weight individuals. Men were significantly more prone to under-reporting compared to women, while low education individuals under-report more often than others. Exclusion of under-reporters generated, as expected, mean nutrient values that were significantly higher (by about 6%) than those derived from the total number of participants. When the nutrient values were energy-adjusted, however, or were expressed as percentages of energy intake for macronutrients or as nutrient densities for micronutrients, the emerging differences were minimal and generally statistically not significant.

Under-reporting does exist and it is more extensive among men, those with low education levels and the overweight participants. Adjustment for energy intake minimizes the bias generated by under-reporting with respect to particular nutrients and their association with various disease outcomes in the cohort.

To evaluate the effect of a dietary treatment programme on blood cholesterol concentration in hypercholesterolaemic patients in general practice and to analyse subjectively experienced side-effects.

A 1-year parallel trial comparing a new treatment programme with conventional treatment.

General practitioners in Roskilde county, Denmark.

355 men and women, aged 20–60 years, with a persistent blood cholesterol concentration above age- and gender-specific cut-off points (265 in an intervention group and 90 in a control group).

A treatment strategy based on collaboration between doctor and dietitian using individual dietary advice and feedback from measured biological parameters.

Serum lipids, body weight, blood pressure, dietary behaviour, health parameters, quality of life parameters and acceptance by patients and general practitioners.

Total blood cholesterol concentration decreased by 14% (1.07 mmol l−1, P < 0.0001) in 159 patients in the intervention group, not having any lipid altering drug during treatment, in addition to 3% from screening to start of treatment. In 65 patients in the control group, without any lipid altering drug, the reduction of cholesterol concentration was 4% (0.27 mmol l−1, P < 0.01; intervention vs. control P < 0.001). In the intervention group overweight subjects (body mass index > 30) reduced body weight by 6% (P < 0.0001). Systolic blood pressure was reduced by 11% (P < 0.0001) and diastolic blood pressure by 10% (P < 0.0001) and 19% (P < 0.003) for intervals 90–110 mmHg and > 110 mmHg, respectively. Risk score decreased and self-assessed health, physical and psychological well-being improved.

The treatment strategy tested proved to be efficient, without side-effects and well accepted by patients and general practitioners. The results strongly suggest that hypercholesterolaemia can efficiently be treated non-pharmacologically in general practice.

To validate a dietary assessment method, a 4-day food record together with a duplicate portion technique, with biological markers for food intake.

Four days of duplicate portions were collected in parallel with food recording. A 24-h urine sample and the faeces corresponding to the food intake (using a coloured marker) were collected. Completeness of urine and faeces collections was assessed using para-aminobenzoic acid (PABA) in urine and cadmium in faeces, respectively. Biomarkers of food intake (energy, protein, fibre, sodium, potassium, calcium) were measured in urine and faeces.

Swedish west coast.

Non-smoking Swedish women, 20–50 years of age, consuming a mixed diet (n=34), a mixed diet rich in shellfish (n=17) or a vegetarian/high-fibre diet (n=23).

The average ratio (food intake according to the dietary assessment methods/biological marker) for protein, sodium, potassium and calcium was 0.86. This indicates an underestimation of the food intake by approximately 15%. The ratio of stated fibre intake to biological marker was 1.20 for the mixed diet and the vegetarian diet group, indicating an overestimation by approximately 20%.

The underestimation of the intake of protein, sodium, potassium and calcium by all three groups and the overestimation of the fibre intake by two groups indicate that underreporting is selective to certain nutrients and foods and to various groups of people. The two dependent dietary assessment methods were equally good in measuring protein intake, which indicates that the women recorded what they actually duplicated.

To describe how the Nutrition Society developed public health nutrition as a profession between 1992 and 1997, and to analyse the influences propelling on this professionalization.

Qualitative case study.

Britain.

The Nutrition Society of Britain consulted with various stakeholders (such as dietitians, researchers, professionals and practitioners and educators from the UK, and latterly from mainland Europe) to build a consensus about the definition, roles and functions of public health nutritionists and the need for, and scope of, this new profession. Building on this consensus, the Society developed a curriculum in line with British national nutrition policy. Analysis shows that the design and philosophy of the curriculum is explicitly international and European in orientation, in keeping with the tradition of the discipline and the Society. The curriculum is designed in terms of specialist competencies in public health nutrition, defining competency so that registered public health nutritionists are advanced practitioners or leaders: this is in keeping with contemporary trends in professional education generally and as expressed by the UNU/IUNS and at Bellagio, in nutrition in particular.

Despite a unique relationship with British state and policy, this case of professionalization contributes to contemporary international inter- and intraprofessional debates about the nature of public health nutrition and is consistent with professional educational theory.

In the vast majority of surveys and research in humans, dietary data are obtained from self-reports: recalls; records; or historical methods, usually food frequency questionnaires (FFQ). This study provides a rare opportunity to compare data derived from all three methods.

A crossover study of dietary fat in which data were collected using an average of 11.4 food records and 11.7 24-h diet recalls. Using simple subtraction and correlation, energy and nutrient intakes derived from the three methods were compared to each other and with those derived from a single FFQ. Analysis of variance was used to evaluate sources of variability in nutrient intakes estimated from the individual days of records and recalls.

An independent, free-standing medical research institute.

13 men who were compliant with study procedures.

FFQ-derived estimates of energy and nutrient intake were highest (e.g. 1967 kcal versus 1858 kcal and 1936 kcal for the records and recalls, respectively). Mean differences in energy and nutrient intakes and their variances were lowest and correlation coefficients highest in comparing the records and recalls (e.g. for fat the mean difference was 5.0 g, and r=0.85). Analysis of variance of individual days of record- and recall-derived datd (n=300) revealed that there was no effect due to either method (record or recall) or the sequence of administration.

Results of this study indicate that the FFQ overestimated dietary intake. Energy and nutrient results obtained from the records and recalls were interchangeable. However, based on smaller SDs around the means, it appears that the recalls may perform slightly better in estimating dietary intake in groups such as these well-educated, highly compliant men.