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1.  Dietary factors associated with obesity indicators and level of sports participation in Flemish adults: a cross-sectional study 
Nutrition Journal  2007;6:26.
Background
Obesity develops when energy intake continuously exceeds energy expenditure, causing a fundamental chronic energy imbalance. Societal and behavioural changes over the last decades are held responsible for the considerable increase in sedentary lifestyles and inappropriate dietary patterns. The role of dietary fat and other dietary factors in the aetiology and maintenance of excess weight is controversial. The purposes of the present study were to investigate the dietary factors associated with body mass index (BMI) and waist circumference (WC), and to analyse whether dietary intake varies between subjects with different levels of sports participation.
Methods
Data for this cross-sectional study, including anthropometric measurements, 3-day diet diary and physical activity questionnaire, were collected by the Flemish Policy Research Centre Sport, Physical Activity and Health (SPAH) between October 2002 and April 2004. Results of 485 adult men and 362 women with plausible dietary records were analysed. Analyses of covariance were performed to determine the differences in dietary intake between normal weight, overweight and obese subjects, and between subjects with different levels of sports participation.
Results
Total energy intake, protein and fat intake (kcal/day) were significantly higher in obese subjects compared to their lean counterparts in both genders. Percentage of energy intake from fat was significantly higher in obese men compared to men with normal weight or WC. Energy percentages from carbohydrates and fibres were negatively related to BMI and WC in men, whereas in women a higher carbohydrate and fibre intake was positively associated with obesity. Alcohol intake was positively associated with WC in men. Subjects participating in health related sports reported higher intake of carbohydrates, but lower intake of fat compared to subjects not participating in sports.
Conclusion
This study supports the evidence that carbohydrate, fat, protein and fibre intake are closely related to BMI and WC. The sex differences for dietary intake between obese men and women might reflect the generally higher health consciousness of women. Alcohol intake was only associated with WC, emphasizing the importance of WC as an additional indicator in epidemiological studies. Besides enhancing sports and physical activity, it is necessary to improve the knowledge about nutrition and to promote the well-balanced consumption of wholesome food.
doi:10.1186/1475-2891-6-26
PMCID: PMC2094711  PMID: 17883880
2.  Feeding practices, nutritional status and associated factors of lactating women in Samre Woreda, South Eastern Zone of Tigray, Ethiopia 
Nutrition Journal  2013;12:28.
Background
Lactating mothers from low-income settings are considered as a nutritionally vulnerable group. Due to the nursing process, mothers are subjected to nutritional stresses. Frequent pregnancies followed by lactation increase the health risk of mothers resulting in a high maternal mortality.
Objective
To assess the feeding practices, nutritional status and associated factors of lactating women from Samre Woreda, South Eastern Tigray, Ethiopia.
Design
Community based cross-sectional survey
Setting
Four kebeles of Samre Woreda (2 urban & 2 rural kebeles)
Methods
Four hundred lactating mothers were recruited from 400 randomly selected households. Data on socio-demographic characteristics, maternal characteristics, feeding practices, frequency of foods eaten and dietary diversity was collected using a pre-tested and structured questionnaire. Anthropometric measurements were taken from each mother using calibrated equipments and standardized techniques. A one-day weighed food record was also collected from randomly selected sub sample (n=60) of mothers. The nutrient and energy content of foods consumed by the mothers was calculated by using ESHA Food Processor and the Ethiopian Food Composition Tables. To investigate the socio-economic and demographic factors affecting the nutritional status of the women, logistic regression was used. ANOVA and t-test were also used to see if there was a mean difference in nutritional status among the lactating mothers.
Results
Majority (71.2%) of the participants did not take additional meals during lactation. The median dietary diversity score of the study participants was 5 out of 14 food groups. The prevalence of underweight, chronic energy deficiency and stunting were 31%, 25% and 2.2% respectively. Using logistic regression model, factors significantly associated with the nutritional status of the study participants (as determined by BMI and MUAC) were size of farm land, length of years of marriage, maize cultivation, frequency of antenatal care visit and age of breastfeeding child.
Conclusions
The feeding practices, dietary intakes and nutritional status of the lactating women were short of the national and international recommendations. Therefore, sustained health and nutrition education is recommended to the women and their families and communities on increased food intake, proper dietary practices and dietary diversification during lactation in order to improve health and nutrition outcomes of lactating women.
doi:10.1186/1475-2891-12-28
PMCID: PMC3599359  PMID: 23452646
South Eastern Tigray; Lactating mothers; Weighed food record; Feeding practices
3.  Dietary intake practices associated with cardiovascular risk in urban and rural Ecuadorian adolescents: a cross-sectional study 
BMC Public Health  2014;14(1):939.
Background
Cardiovascular diseases (CVD) are amongst the leading causes of death worldwide. Risk factors of CVD develop during childhood and adolescence, and dietary quality has been linked to the development of CVD itself. This study examines the association between dietary patterns and cardiovascular risk in a group of urban and rural Ecuadorian adolescents from different socioeconomic backgrounds.
Methods
A cross-sectional study was conducted from January 2008 to April 2009 among 606 adolescents from the 8th, 9th and 10th grade in an urban area (Cuenca), and 173 adolescents from a rural area (Nabón) in Ecuador. Data collection involved measuring anthropometric data (weight, height and waist circumference), blood pressure, dietary intake (2-day 24 h recall) and socio-demographic characteristics. Fasting blood lipids and glucose were measured in a subsample of 334 adolescents. Factor analysis was used to identify dietary patterns and linear regression models were used to (i) identify differences in food intake practices according to socioeconomic status and place of residence and (ii) establish relationships between dietary patterns and cardiovascular risk factors.
Results
Median energy intake was 1851 kcal/day. Overall, fiber, fish and fruit and vegetables were scarcely consumed, while added sugar, refined cereals and processed food were important constituents of the diet. Two dietary patterns emerged, one labelled as “rice-rich non-animal fat pattern” and the other one as “wheat-dense animal-fat pattern”. The first pattern was correlated with a moderate increase in glucose in urban participants, while the second pattern was associated with higher LDL and cholesterol blood levels in rural participants.
Conclusions
This group of adolescents presented various dietary practices conducive to CVD development. Effective strategies are needed to prevent CVD in the Ecuadorian population by encouraging a balanced diet, which contains less refined cereals, added sugar, and processed food, but has more fruits, vegetables and whole grain cereals.
doi:10.1186/1471-2458-14-939
PMCID: PMC4171553  PMID: 25205169
Diet; Adolescents; Cardiovascular risk; Socioeconomic status
4.  Nutritional Consequences of Adhering to a Low Phenylalanine Diet for Late-Treated Adults with PKU 
JIMD Reports  2012;7:109-116.
Background: The main treatment for phenylketonuria (PKU) is a low phenylalanine (Phe) diet, phenylalanine-free protein substitute and low-protein special foods. This study describes dietary composition and nutritional status in late-diagnosed adult patients adhering to a PKU diet.
Methods: Nineteen patients, followed at Oslo University Hospital in Norway, participated; median age was 48 years (range 26–66). Subjects were mild to severely mentally retarded. Food intake, clinical data and blood analyses relevant for nutritional status were assessed.
Results: Median energy intake was 2,091 kcal/day (range 1,537–3,277 kcal/day). Carbohydrates constituted 59% (range 53–70%) of the total energy, including 15% from added sugar; 26% was from fat. The total protein intake was 1.02 g/kg/day (range 0.32–1.36 g/kg/day), including 0.74 g/kg/day (range 0.13–1.07 g/kg/day) from protein substitutes. Median dietary Phe intake was 746 mg/day (range 370–1,370 mg/day). Median serum Phe was 542 μmol/L (range 146–1,310 mg/day). Fortified protein substitutes supplied the main source of micronutrients. Iron intake was 39.5 mg/day (range 24.6–57 mg/day), exceeding the upper safe intake level. Intake of folate and folic acid, calculated as dietary folate equivalents, was 1,370 μg/day (range 347–1744 μg/day), and resulted in high blood folate concentrations. Median intake of vitamin B12 was 7.0 μg/day (range 0.9–15.1 μg/day).
Conclusions: The diet supplied adequate protein and energy. Fortification of the protein substitutes resulted in excess intake of micronutrients. The protein substitutes may require adjustment to meet nutritional recommendations for adults with PKU.
doi:10.1007/8904_2012_157
PMCID: PMC3575047  PMID: 23430504
5.  P25 - Growing Strong and Healthy with Mister Bone: An Educational Programme to Ensure Strong Bones Later in Life 
Bone mass increases steadily until the age of 20–30 years and most bone mass is acquired during the first two decades of life. Nutrition plays a critical role in the achievement of one’s optimal genetically programmed peak bone mass (PBM), reducing the risk of osteoporosis later in life. PBM is the amount of bony tissue present in the skeleton at the end of skeletal maturation. Even though 90% of PBM is acquired by the end of second decade of life, skeletal mass continues to increase for up to 10–15 years after that, through the process of bone consolidation, with maximal PBM occurring at around 30 years of age. As a 10% increase in PBM corresponds to a gain of one standard deviation in bone mineral density in adulthood, osteoporotic fracture risk may be reduced by up to 50% by interventions aimed at maximising PBM in a sustainable manner in childhood and adolescence. Although genetic factors are the strongest predictors of bone mass, accounting for 50–80% of its variance, nutritional and lifestyle factors can explain an additional 20–30% of bone mass variance.
Bone is living tissue like any other, and its cells have the same kinds of nutrient needs as those of the rest of the body; it does not require only an energy supply, but also protein and micronutrients, calcium and vitamin D in primis. In a balanced western-style diet, about 60% of dietary calcium should come from milk and dairy products, 20% from fresh vegetables and dried fruits, and the rest from drinking water or other discrete sources.
Current research indicates that calcium intake in school-age children is below the recommended adequate level.The recommended adequate intake of calcium for children between the ages of 9 and 11 years is about 1100–1200 mg.
In response to this critical health issue it is essential to monitor children’s intake of dairy products and nutrients important for bone health, such as calcium and vitamin D, in order to ensure that their nutritional needs are met and that they are receiving the nutritional intakes needed to safeguard their health later in life. The aim of our study was to monitor and promote the intake of dairy products, calcium and vitamin D in children, in order to help them achieve their optimal PBM and to safeguard their bone health later in life. Modifications in schoolchildren’s nutritional behaviour were evaluated through a nutritional programme designed to increase calcium intake. The project was conducted with the support of novel instruments specifically created for this educational programme.
Our study sample comprised 180 children (48% males and 52% females) aged 9–11 years from a primary school in Florence. We evaluated the children’s eating habits through a questionnaire designed to assess intake of calcium, dairy products, and total caloric energy intake at baseline and at follow up. Data were processed using nutrition software (Win-Food 2.7-MediMatica) and analysed using Student’s paired T-test to determine pre- versus post-intervention differences. The results showed that total caloric intakes rose from 1690±290 before the educational intervention to 1700±330 kcal/day after the educational intervention in boys and from 1620±256 to 1640±260 kcal/day in girls. Statistical analysis of the data did not show any significant variation in pre- versus post-educational assessments (p<0.05), although the protein percentage increased by two points, from 14.5 to 16.5%, while both carbohydrate and lipid intake decreased by one percentage point. Student’s T-test analysis of dietary intakes evaluated, through the questionnaire, before and after the educational intervention revealed a significant increase (p<0.05) in calcium intake, which rose from 860±190 to 1060±200 mg/day in the girls and from 890±200 to 1100±210 mg/day in the boys, and in vitamin D intake, which rose from 3.6±1.53 μg/day to 4.1±2 μg/day, without significant differences emerging between the boys and girls. Although sub-optimal, the calcium intake obtained after the educational programme was sufficient to attain the target RDI of 1100–1200 mg/day. During the educational programme the percentage of children who drank milk rose from 92 to 96%. A change in the quantity of milk intake was also detected: the results showed a significant increase from 200±35 to about 270±65 ml/day in boys and girls (p<0.05). The observations on hard cheese intake revealed an increase in cheese consumers, from 84% to 91% at the end of the educational period. Similarly, a positive change was recorded in the percentage of children eating fresh vegetables: an increase from 89% to 96%.
Our educational programme appears to be significantly effective in modifying calcium intake in children. Analysis of the questionnaire data, which showed significantly increased consumption of dairy products and vegetables, without significant changes in total caloric intakes, revealed an important change in these children’s dietary habits. These behavioural modifications are the result of progressive nutritional education imparted through lessons, brochures, calendars, games, and crosswords. These findings may prompt school policy-makers to introduce educational strategies to promote students’ skeletal health.
PMCID: PMC3213834
6.  The association of meat intake and the risk of type 2 diabetes may be modified by body weight 
Aim: To investigate the association between meat intake and incidence of type 2 diabetes (type 2 DM) in a large cohort of middle-aged women.
Design, subjects and methods: Incident cases of type 2 DM were identified during an average of 4.6 years of follow-up in a prospective cohort study of 74,493 middle-aged, Chinese women (mean age ± SD =51.7± 8.97 years). Participants completed in-person interviews that collected information on type 2 DM risk factors such as dietary factors and physical activity in adulthood. Anthropometric indices were measured. Dietary intake was assessed using a validated food frequency questionnaire (FFQ). We included in the current analysis 70,609 women who had no prior history of type 2 DM at study recruitment and who had valid dietary data. The association of type 2 DM with unprocessed meat intake (g/day) and the frequency of consumption of processed meat was evaluated using the Cox model with adjustment for age, kcals/day, body mass index (BMI), waist to hip ratio (WHR), vegetable intake, smoking, alcohol consumption, physical activity, income level, education level, occupation status, and history of hypertension and chronic disease at baseline.
Principal results: We identified 1972 incident cases of type 2 DM during a total of 326,581 person-years of follow up. Intake of unprocessed meat, particularly poultry, was associated with a decrease in the risk of type 2 DM in this cohort. The fully adjusted relative risks (RRs) for quintiles of total unprocessed meat intake were 1.00, 0.78, 0.83, 0.74, and 0.83 (P for trend: <0.01). When the joint effect between meat intake and BMI categories was evaluated, high intake of total unprocessed meat appeared to be associated with an increased risk of type 2 DM among obese women but a reduced risk among lean women (P value for the interaction tests = 0.05). Processed meat consumption was positively associated with the risk of type 2 DM. The adjusted RR was 1.15 (95% 1.01-1.32) in women consuming processed meats compared to those who did not consume processed meats (P=0.04).
Conclusions: Processed meat intake was positively associated with the risk of type 2 DM. There was an indication that the effect of unprocessed meat intake on type 2 DM may be modified by BMI.
PMCID: PMC1633824  PMID: 17088942
type 2 diabetes; meat intake; middle-aged women
7.  Regional comparison of dietary intakes and health related behaviors among residents in Asan 
Nutrition Research and Practice  2007;1(2):143-149.
Inadequate dietary intakes and poor health behaviors are of concern among rural residents in Korea. This study is conducted to compare dietary intakes, dietary diversity score (DDS), mean nutrient adequacy ratio (MAR) and health related behaviors by rural, factory and urban areas in Asan. A total of 930 adults (351 men and 579 women) were interviewed to assess social economic status (SES), health related behaviors and food intakes by a 24-hour recall method. Mean age was 61.5 years with men being older (64.8 years) than women (59.3 years, p<0.001). Men in the factory area were older than rural or urban men while urban women were the youngest. Education and income of urban residents were higher than other area residents. There were more current drinkers in urban area while smoking status was not different by regions. Physical activity was significantly higher in rural or factory areas, whilst urban residents exercised more often (p<0.05). Rural or factory area residents considered themselves less healthy than others while perceived stress was lower than urban residents. Energy intakes were higher in urban residents or in men, however, after SES was controlled, energy intake did not show any differences. Energy-adjusted nutrient intakes were significantly higher in the urban area (p<0.05) for most nutrients except for carbohydrate, niacin, folic acid, vitamin B6, iron and fiber. Sodium intake was higher in factory area than in other areas after SES was controlled. DDS of rural men and MAR of both men and women in the rural area were significantly lower when SES was controlled. In conclusion, dietary intakes, diversity, adequacy and perceived health were poor in the rural area, although other health behaviors such as drinking and perceived stress were better than in the urban area. In order to improve perceived health of rural residents, good nutrition and exercise education programs are recommended.
doi:10.4162/nrp.2007.1.2.143
PMCID: PMC2882589  PMID: 20535400
Dietary intake; health behavior; regional comparison; rural area
8.  Nutritional practices and their relationship to clinical outcomes in critically ill children—An international multicenter cohort study* 
Critical care medicine  2012;40(7):2204-2211.
Objectives
To examine factors influencing the adequacy of energy and protein intake in the pediatric intensive care unit and to describe their relationship to clinical outcomes in mechanically ventilated children.
Design, Setting, Patients
We conducted an international prospective cohort study of consecutive children (ages 1 month to 18 yrs) requiring mechanical ventilation longer than 48 hrs in the pediatric intensive care unit. Nutritional practices were recorded during the pediatric intensive care unit stay for a maximum of 10 days, and patients were followed up for 60 days or until hospital discharge. Multivariate analysis, accounting for pediatric intensive care unit clustering and important confounding variables, was used to examine the impact of nutritional variables and pediatric intensive care unit characteristics on 60-day mortality and the prevalence of acquired infections.
Main Results
31 pediatric intensive care units in academic hospitals in eight countries participated in this study. Five hundred patients with mean (sd) age 4.5 (5.1) yrs were enrolled and included in the analysis. Mortality at 60 days was 8.4%, and 107 of 500 (22%) patients acquired at least one infection during their pediatric intensive care unit stay. Over 30% of patients had severe malnutrition on admission, with body mass index z-score >2 (13.2%) or <−2 (17.1%) on admission. Mean prescribed goals for daily energy and protein intake were 64 kcals/kg and 1.7 g/kg respectively. Enteral nutrition was used in 67% of the patients and was initiated within 48 hrs of admission in the majority of patients. Enteral nutrition was subsequently interrupted on average for at least 2 days in 357 of 500 (71%) patients. Mean (sd) percentage daily nutritional intake (enteral nutrition) compared to prescribed goals was 38% (34) for energy and 43% (44) for protein. A higher percentage of goal energy intake via enteral nutrition route was significantly associated with lower 60-day mortality (Odds ratio for increasing energy intake from 33.3% to 66.6% is 0.27 [0.11, 0.67], p = .002). Mortality was higher in patients who received parenteral nutrition (odds ratio 2.61 [1.3, 5.3], p = .008). Patients admitted to units that utilized a feeding protocol had a lower prevalence of acquired infections (odds ratio 0.18 [0.05, 0.64], p = .008), and this association was independent of the amount of energy or protein intake.
Conclusions
Nutrition delivery is generally inadequate in mechanically ventilated children across the world. Intake of a higher percentage of prescribed dietary energy goal via enteral route was associated with improved 60-day survival; conversely, parenteral nutrition use was associated with higher mortality. Pediatric intensive care units that utilized protocols for the initiation and advancement of enteral nutrient intake had a lower prevalence of acquired infections. Optimizing nutrition therapy is a potential avenue for improving clinical outcomes in critically ill children.
doi:10.1097/CCM.0b013e31824e18a8
PMCID: PMC3704225  PMID: 22564954
adequacy; critical care; enteral; infections; mortality; nutrition; parenteral; pediatric; pediatric intensive care unit
9.  Nutrient Profiles of Vegetarian and Non Vegetarian Dietary Patterns 
Background
Differences in nutrient profiles between vegetarian and non vegetarian dietary patterns reflect nutritional differences that may contribute to the development of disease.
Objective
To compare nutrient intakes between dietary patterns characterized by consumption or exclusion of meat and dairy products.
Design
Cross-sectional study of 71751 subjects (mean age 59 years) from the Adventist-Health-Study-2. Data was collected between 2002 and 2007. Participants completed a 204-item validated semi-quantitative food frequency questionnaire. Dietary patterns compared were: non vegetarian, semi vegetarian, pesco vegetarian, lacto-ovo vegetarian and strict vegetarian. ANCOVA was used to analyze differences in nutrient intakes by dietary patterns and were adjusted for age, and sex and race. BMI and other relevant demographic data were reported and compared by dietary pattern using chi-square tests and ANOVA.
Results
Many nutrient intakes varied significantly between dietary patterns. Non vegetarians had the lowest intakes of plant proteins, fiber, β-Carotene, and Mg than those following vegetarian dietary patterns and the highest intakes of saturated, trans, arachidonic, and docosahexaenoic fatty acids. The lower tails of some nutrient distributions in strict vegetarians suggested inadequate intakes by a portion of the subjects. Energy intake was similar among dietary patterns at close to 2000 kcal/d with the exception of semi vegetarians that had an intake of 1713 kcal/d. Mean BMI was highest in non-vegetarians (mean; standard deviation [SD]) (28.7; [6.4]) and lowest in strict vegetarians (24.0; [4.8]).
Conclusions
Nutrient profiles varied markedly between dietary patterns that were defined by meat and dairy intakes. These differences can be of interest in the etiology of obesity and chronic diseases.
doi:10.1016/j.jand.2013.06.349
PMCID: PMC4081456  PMID: 23988511
Dietary Pattern; Nutrient Profile; Vitamins; Minerals; Vegetarian
10.  Nutritional status in relation to lifestyle in patients with compensated viral cirrhosis 
AIM: To assess the nourishment status and lifestyle of non-hospitalized patients with compensated cirrhosis by using noninvasive methods.
METHODS: The subjects for this study consisted of 27 healthy volunteers, 59 patients with chronic viral hepatitis, and 74 patients with viral cirrhosis, from urban areas. We assessed the biochemical blood tests, anthropometric parameters, diet, lifestyle and physical activity of the patients. A homeostasis model assessment-insulin resistance (HOMA-IR) value of ≥ 2.5 was considered to indicate insulin resistance. We measured height, weight, waist circumference, arm circumference, triceps skin-fold thickness, and handgrip strength, and calculated body mass index, arm muscle circumference (AMC), and arm muscle area (AMA). We interviewed the subjects about their dietary habits and lifestyle using health assessment computer software. We surveyed daily physical activity using a pedometer. Univariate and multivariate logistic regression modeling were used to identify the relevant factors for insulin resistance.
RESULTS: The rate of patients with HOMA-IR ≥ 2.5 (which was considered to indicate insulin resistance) was 14 (35.9%) in the chronic hepatitis and 17 (37.8%) in the cirrhotic patients. AMC (%) (control vs chronic hepatitis, 111.9% ± 10.5% vs 104.9% ± 10.7%, P = 0.021; control vs cirrhosis, 111.9% ± 10.5% vs 102.7% ± 10.8%, P = 0.001) and AMA (%) (control vs chronic hepatitis, 128.2% ± 25.1% vs 112.2% ± 22.9%, P = 0.013; control vs cirrhosis, 128.2% ± 25.1% vs 107.5% ± 22.5%, P = 0.001) in patients with chronic hepatitis and liver cirrhosis were significantly lower than in the control subjects. Handgrip strength (%) in the cirrhosis group was significantly lower than in the controls (control vs cirrhosis, 92.1% ± 16.2% vs 66.9% ± 17.6%, P < 0.001). The results might reflect a decrease in muscle mass. The total nutrition intake and amounts of carbohydrates, protein and fat were not significantly different amongst the groups. Physical activity levels (kcal/d) (control vs cirrhosis, 210 ± 113 kcal/d vs 125 ± 74 kcal/d, P = 0.001), number of steps (step/d) (control vs cirrhosis, 8070 ± 3027 step/d vs 5789 ± 3368 step/d, P = 0.011), and exercise (Ex) (Ex/wk) (control vs cirrhosis, 12.4 ± 9.3 Ex/wk vs 7.0 ± 7.7 Ex/wk, P = 0.013) in the cirrhosis group was significantly lower than the control group. The results indicate that the physical activity level of the chronic hepatitis and cirrhosis groups were low. Univariate and multivariate logistic regression modeling suggested that Ex was associated with insulin resistance (odds ratio, 6.809; 95% CI, 1.288-36.001; P = 0.024). The results seem to point towards decreased physical activity being a relevant factor for insulin resistance.
CONCLUSION: Non-hospitalized cirrhotic patients may need to maintain an adequate dietary intake and receive lifestyle guidance to increase their physical activity levels.
doi:10.3748/wjg.v18.i40.5759
PMCID: PMC3484346  PMID: 23155318
Hepatitis C virus; Insulin resistance; Liver cirrhosis; Nutrition assessment; Obesity; Lifestyle; Exercise
11.  Body Composition and Dietary Intake of Elite Cross-country Skiers Members of the Greek National Team 
Asian Journal of Sports Medicine  2012;3(4):257-266.
Purpose
To assess the anthropometric characteristics and dietary intake of the Greek national cross-country skiing team.
Methods
Thirty-three athletes (10 females aged 20 ± 5 years; 23 males aged 20 ± 6 years old) participated in the study. All athletes were members of the Greek national ski team, and they had been selected to take part in the Winter Olympics, World Ski Championships, European Ski Championships or other international events, according to their performance. Body composition was estimated by bioelectrical impedance (BIA) and skinfold thickness. The athletes recorded their physical activity and dietary intake for 3 training days, and on a competition day.
Results
The female skiers had 14.2±1.9% body fat, the men 11.0±1.5% body fat. Female athletes consumed a diet of 1988±319 Kcal during training days and 2011±330 Kcal during competition days. Male athletes consumed 2255±790 Kcal and 2125±639 Kcal respectively. These values are below those recommended for highly active people. During the training period, carbohydrate, fat and protein contributed to 44.5±7.1%, 39.2±5.3% and 16.1±3.7% of the total energy intake (EI) respectively for the males, and to 52.8±5.6%, 33.0±3.7% and 14.3±2.5% of the EI of the women. Between training and competition days, men demonstrated an increased carbohydrate and reduced fat consumption when competing (P<0.001 for both). Women, on the other hand, consumed more carbohydrate and less protein during competition days (P<0.05 for both). Protein intake was within the recommended range for both males and females, but fat exceeded the recommended values and was consumed at the expense of carbohydrate. Vitamins B12, D, E and K, biotin, folate, Ca, Mg, K, I were inadequately consumed (below the RDA) by both women and men, while the women also exhibited inadequate intakes of iron and the men of manganese.
Conclusions
The inadequate energy and nutrient intake in the Greek national cross-country ski team could put the athletes at risk of nutritional deficiencies, and possibly compromise their athletic performance.
PMCID: PMC3525822  PMID: 23342224
Athletes; Body Fat; Cross-country Skiing; Nutrients; Diet
12.  Effect of fruit restriction on glycemic control in patients with type 2 diabetes – a randomized trial 
Nutrition Journal  2013;12:29.
Background
Medical nutrition therapy is recognized as an important treatment option in type 2 diabetes. Most guidelines recommend eating a diet with a high intake of fiber-rich food including fruit. This is based on the many positive effects of fruit on human health. However some health professionals have concerns that fruit intake has a negative impact on glycemic control and therefore recommend restricting the fruit intake. We found no studies addressing this important clinical question. The objective was to investigate whether an advice to reduce the intake of fruit to patients with type 2 diabetes affects HbA1c, bodyweight, waist circumference and fruit intake.
Methods
This was an open randomized controlled trial with two parallel groups. The primary outcome was a change in HbA1c during 12 weeks of intervention. Participants were randomized to one of two interventions; medical nutrition therapy + advice to consume at least two pieces of fruit a day (high-fruit) or medical nutrition therapy + advice to consume no more than two pieces of fruit a day (low-fruit). All participants had two consultations with a registered dietitian. Fruit intake was self-reported using 3-day fruit records and dietary recalls. All assessments were made by the “intention to treat” principle.
Results
The study population consisted of 63 men and women with newly diagnosed type 2 diabetes. All patients completed the trial. The high-fruit group increased fruit intake with 125 grams (CI 95%; 78 to 172) and the low-fruit group reduced intake with 51 grams (CI 95%; -18 to −83). HbA1c decreased in both groups with no difference between the groups (diff.: 0.19%, CI 95%; -0.23 to 0.62). Both groups reduced body weight and waist circumference, however there was no difference between the groups.
Conclusions
A recommendation to reduce fruit intake as part of standard medical nutrition therapy in overweight patients with newly diagnosed type 2 diabetes resulted in eating less fruit. It had however no effect on HbA1c, weight loss or waist circumference. We recommend that the intake of fruit should not be restricted in patients with type 2 diabetes.
Trial registration
http://www.clinicaltrials.gov; Identifier: NCT01010594.
doi:10.1186/1475-2891-12-29
PMCID: PMC3599615  PMID: 23497350
Glycemic control; Nutrition counseling; Weight loss; Fruit; Medical nutrition therapy; Type 2 diabetes
13.  Gaps between calcium recommendations to prevent pre-eclampsia and current intakes in one hospital in Argentina 
BMC Research Notes  2014;7(1):920.
Background
Hypertensive disorders are a major cause of maternal mortality. In Latin America and the Caribbean, pre-eclampsia accounts for approximately one in every four maternal deaths. The World Health Organization recommends calcium supplementation during pregnancy for the prevention and treatment of pre-eclampsia and eclampsia in locations where dietary calcium intake is low. Calcium intake in Argentina is reported to be below WHO recommended levels; however, calcium intake from supplements and water has not been fully evaluated. The objective of this study was to evaluate calcium intake from supplements and water in a group of pregnant women.
Methods
This cross-sectional study was conducted at a maternity hospital in the city of Buenos Aires, Argentina. Questionnaires were verbally administered to women attending a routine antenatal care visit. Participants were 18 years of age or older and in their third trimester of pregnancy. Participants were first interviewed to evaluate nutritional supplement consumption and a subgroup was invited to undergo a 24-hour dietary recall.
Results
137 women meeting inclusion criteria consented to participate. The average participant age was 27 years (SD ± 5.9), and all resided in an urban setting. None of the subjects took calcium supplements specifically, although 24 (17%) recalled taking supplements or antacids which contributed to their calcium intake. Mean calcium intake was 663mg SD ±389 for those women completing the 24-hour dietary recall,. This value increased to 706 mg SD ±387 upon considering water intake and measuring chemical composition of water from the areas where women lived at the time of the interview and was further increased to 719 mg (SD ±392) when calcium from supplements was taken into consideration.
Conclusions
None of the subjects were consuming calcium supplements. Taking into account the low calcium intake in this population, diverse strategies would be required to comply with recommendations.
doi:10.1186/1756-0500-7-920
PMCID: PMC4302104  PMID: 25515116
Perinatal; Prenatal; Healthcare; Pre-eclampsia; Argentina; Calcium intake; Maternal nutrition
14.  Association between Dietary Patterns and Body Composition in a Group or Puerto Rican Obese Adults: a Pilot Study 
Objective
Obesity is a public health problem in Puerto Rico. Dietary patterns that include high intakes of energy and sweetened drinks and low consumption of fruits, vegetables and fiber are associated with obesity. The aim of this study is to relate dietary patterns with body composition in obese subjects.
Methods
Dietary patterns were evaluated using 3-day food records. Body composition was assessed by body weight, hip and waist circumferences and % body fat, and then used to classify subjects by obesity stages using BMI and by low or high risk using WHR or % body fat. The resulting comparison groups were associated with energy, macronutrients, fruits, vegetables, fiber, and sweetened drinks intake and with meal energy density and meal frequency intake. Kruskal Wallis and Mann Whitney tests were used to compare groups and Spearman correlations were used for continuous variables.
Results
Thirty subjects completed the study. By BMI, 30% were obese type I, 33% type II and 37% type III; by WHR, 43% were low risk and 57% high risk; by % body fat, all were high risk. Dietary patterns were similar between groups. WHR was positively correlated with fiber consumption (r=0.42; p<0.05) and CHO intake (r=0.35; p=0.057).
Conclusion
In this pilot study, dietary patterns appeared similar between groups and sound with nutritional recommendations; however, we observed a poor quality of the diet due to very low intakes of fruits, vegetables and fiber and high intakes of sweetened drinks.
PMCID: PMC3449311  PMID: 21449494
Body composition; Obesity; Waist to hip ratia; Dietary patterns
15.  Plain water intake of Korean adults according to life style, anthropometric and dietary characteristic: the Korea National Health and Nutrition Examination Surveys 2008-2010 
Nutrition Research and Practice  2014;8(5):580-588.
BACKGROUND/OBJECTIVES
The objective of the study was to provide useful insights into plain water intake of Korean adults according to life style, anthropometric, and dietary characteristics.
SUBJECTS/METHODS
The data from the 2008-2010 Korea National Health and Nutrition Examination Survey were used. The subjects were 14,428 aged 20-64 years. Water intake was estimated by asking the question "How much water do you usually consume per day?". Dietary intake was estimated by 24-hour dietary recall. A qualitative food frequency questionnaire including 63 food items was also administered.
RESULTS
The mean plain water intake for men and women were 6.3 cup/day and 4.6 cup/day, respectively. Plain water intake increased as lean body mass, waist circumference, and body mass index levels increased, except for percentage of body fat. As energy and alcohol intakes increased, plain water intake increased. As total weight of food intake and total volume of food intake increased, plain water intake increased. Plain water intake increased as consumption of vegetables increased. Plain water intake increased as frequencies of green tea, alcoholic drink, and all beverages were increased in men. Plain water intake increased with increased frequencies of green tea, milk, soy milk, and alcoholic drink and decreased frequencies of coffee and soda in women.
CONCLUSIONS
Our results suggest that persons who had a higher waist circumference or lean body mass and women with higher BMI consumed more plain water. The persons eating high quality diet, or the persons who had more vegetables, green tea, milk, soy milk, or alcoholic drink consumed more plain water.
doi:10.4162/nrp.2014.8.5.580
PMCID: PMC4198973  PMID: 25324940
Plain water intake; dietary intake; adults; KNHANES; life style
16.  Anthropometric and Nutritional Profile of People Living with HIV and AIDS in India: an Assessment 
Background:
Importance of nutrition in human immunodeficiency virus (HIV) is well-established; however, the information regarding the diet quality of people living with HIV (PLHIV) especially in India is lacking.
Objectives:
The objective of this study is to assess the anthropometric and nutritional profile of Indian PLHIV.
Material and Methods:
The study was performed on 400 adult PLHIV registered at the Antiretroviral Center (ART) center in New Delhi, India. Anthropometric data including height, weight, waist, hip, mid arm, and calf circumferences, were collected; 1-day 24-h dietary recall was done to gather nutrient intake from which nutrient adequacy ratios were computed. Mini Nutritional Assessment (MNA) was also conducted.
Results:
The mean body mass index (BMI) of the sample was 19.73 ± 3.55 kg/m2 with around 40% having BMI <18.5 kg/m2 . All anthropometric measurements were found to correlate positively and significantly with CD4 count (P < 0.05). The sample consumed poor quality of diet as they could not meet even the 2/3rd of the Indian Council of Medical Research (2010) requirements for energy, protein, calcium, iron, riboflavin, niacin, folic acid, B12, copper, and zinc. Classification of subjects according to MNA indicated that more than 50% of the sample was at-risk of malnutrition and 34% were malnourished. With 40% of sample having BMI less than normal, 50% at risk of malnutrition together with poor nutrient intakes over a long period of time could contribute to further worsening of the nutritional status.
Conclusion:
There is a need to develop a database on nutritional profile of PLHIV in India which reinforces the need for development of effective strategies to improve their nutritional status.
doi:10.4103/0970-0218.137153
PMCID: PMC4134532  PMID: 25136157
Anthropometry; diet record; HIV/acquired immunodeficiency syndrome; MNA; nutrition
17.  Food consumption patterns and associated factors among Vietnamese women of reproductive age 
Nutrition Journal  2013;12:126.
Background and objectives
Adequate nutrient intakes among women of reproductive age (WRA) are important determinants of maternal, neonatal and child health outcomes. However, data on dietary intake for WRA in Vietnam are lacking. This paper aimed to examine the adequacy and determinants of energy and macronutrient intakes among WRA enrolled in a study of preconceptual micronutrient supplementation (PRECONCEPT) being conducted in 20 rural communes in Thai Nguyen province, Vietnam.
Methods
Dietary intakes were determined for 4983 WRA who participated in the baseline survey using a previously validated 107-item (semi-quantitative) food-frequency questionnaire that was administered by trained field workers. Multivariate linear and logistic regression analyses were used to examine factors associated with energy and macronutrient intakes.
Results
A disproportionate number of energy came from starches, primarily rice. Carbohydrate, fat and protein constituted 65.6%, 19.5% and 14.8% of total energy, respectively. Fat intake was below recommended levels in 56.5% of respondents, but carbohydrate intakes were above recommended level in 54.6%. Only 0.1% and 5.2% of WRA achieved adequate intake of n-3 and n-6 long-chain polyunsaturated fatty acids, respectively. Multivariate linear regression revealed that low education, low socioeconomic status, and food insecurity were significant predictors of reduced total energy intake, reduced energy from protein and fat, and greater energy from carbohydrates. Logistic regression confirmed that inadequate macronutrient intake was more common among the poor, food insecure, and less educated.
Conclusions
Imbalanced dietary intakes among underprivileged women reflect lack of dietary diversity. Nutrition programs should be linked with social development, poverty reduction, education programs and behavior change counseling in order to improve the nutritional status of WRA in Vietnam.
doi:10.1186/1475-2891-12-126
PMCID: PMC3847174  PMID: 24028650
Food frequency questionnaire; Food consumption; Macronutrient intakes; Thai Nguyen; Vietnam; Women of reproductive age
18.  Prognostic Indices of Poor Nutritional Status and Their Impact on Prolonged Hospital Stay in a Greek University Hospital 
BioMed Research International  2014;2014:924270.
Background. To ascertain the potential contributors to nutritional risk manifestation and to disclose the factors exerting a negative impact on hospital length of stay (LOS), by means of poor nutritional status, in a nonselected hospitalized population. Materials and Methods. NutritionDay project questionnaires were applied to 295 adult patients. Study parameters included anthropometric data, demographics, medical history, dietary-related factors, and self-perception of health status. Body Mass Index (BMI) and Malnutrition Universal Screening Tool (MUST) were calculated for each participant. MUST score was applied for malnutrition assessment, while hospital LOS constituted the outcome of interest. Results. Of the total cohort, 42.3% were at nutritional risk and 21.4% malnourished. Age, gender, BMI, MUST score, autonomy, health quality, appetite, quantity of food intake, weight loss, arm or calf perimeter (P < 0.001, for all), and dietary type (P < 0.01) affected nutritional status. Poor nutrition status (P = 0.000), deteriorated appetite (P = 0.000) or food intake (P = 0.025), limited autonomy (P = 0.013), artificial nutrition (P = 0.012), weight loss (P = 0.010), and arm circumference <21 cm (P = 0.007) were the most powerful predictors of hospital LOS >7 days. Conclusion. Nutritional status and nutrition-related parameters such as weight loss, quantity of food intake, appetite, arm circumference, dietary type, and extent of dependence confer considerable prognostic value regarding hospital LOS in acute care setting.
doi:10.1155/2014/924270
PMCID: PMC3981013  PMID: 24779021
19.  Prevalence of Malnutrition in Orally and Tube-Fed Elderly Nursing Home Residents in Germany and Its Relation to Health Complaints and Dietary Intake 
Objective. To investigate the prevalence of malnutrition in orally and tube-fed nursing home (NH) residents in Germany and its relation to common health complaints and dietary intake. Methods. In 350 NH residents, subjects' characteristics, Mini Nutritional Assessment (MNA), and several health problems were inquired with the nursing staff using standardised interviews. In a subset of 122 residents, dietary intake was assessed by 3-day weighing records. Results. 7.7% of the participants were tube fed. 24.1% of orally nourished and 57.7% of tube-fed residents were malnourished (MNA < 17 p.). Malnutrition was significantly related to nausea/vomiting, constipation, pressure ulcers, dehydration, infections, antibiotic use, and hospitalisation. Mean daily energy intake was 1535 ± 413 kcal and mean protein intake was 54.2 ± 0.9 g/d irrespective of the nutritional state. Conclusion. In Germany, malnutrition is widespread among NH residents and is related to common health problems. The MNA rather reflects health condition than currently reduced dietary intake.
doi:10.1155/2011/247315
PMCID: PMC3112531  PMID: 21687611
20.  Nutritional intake of Korean population before and after adjusting for within-individual variations: 2001 Korean National Health and Nutrition Survey Data 
Nutrition Research and Practice  2011;5(3):266-274.
Accurate assessment of nutrient adequacy of a population should be based on usual intake distribution of that population. This study was conducted to adjust usual nutrient intake distributions of a single 24-hour recall in 2001 Korean National Health and Nutrition Surveys (KNHNS) in order to determine the magnitude of limitations inherent to a single 24-hour recall in assessing nutrient intakes of a population. Of 9,960 individuals who provided one 24-hour recall in 2001 KNHNS, 3,976 subjects provided an additional one-day 24-hour recall in 2002 Korean National Nutrition Survey by Season (KNNSS). To adjust for usual intake distribution, we estimated within-individual variations derived from 2001 KNHNS and 2002 KNNSS using the Iowa State University method. Nutritionally at risk population was assessed in reference to the Dietary Reference Intakes for Koreans (KDRIs). The Korean Estimated Average Requirement (Korean EAR) cut-point was applied to estimate the prevalence of inadequate nutrient intakes except for iron intakes, which were assessed using the probability approach. The estimated proportions below Korean EAR for calcium, riboflavin, and iron were 73%, 41%, and 24% from usual intake distribution and 70%, 51%, and 39% from one-day intake distribution, respectively. The estimated proportion of sodium intakes over the Intake Goal of 2,000 mg/day was 100% of the population after adjustment. The energy proportion from protein was within Korean Acceptable Macronutrient Distribution Ranges (Korean AMDR), whereas that of carbohydrate was higher than the upper limit and that of fat was below the lower limit in the subjects aged 30 years or older. According to these results, the prevalence of nutritional inadequacy and excess intake is over-estimated in Korea unless usual intake distributions are adjusted for one-day intakes of most nutrients.
doi:10.4162/nrp.2011.5.3.266
PMCID: PMC3133761  PMID: 21779532
Dietary assessment; DRIs (Dietary Reference Intakes); usual intake; within-individual variation
21.  In-Depth Assessment of the Nutritional Status of Korean American Elderly 
While studies of immigrants have generally indicated significant dietary changes upon immigration that mirror a Western diet, previous data are limited to the dietary patterns and intakes of younger and middle-aged adults. Using a relatively large sample of Korean American elderly (KAE) immigrants, this paper offers an in-depth assessment of the nutritional status of KAE, one of the most rapidly increasing minority populations in the United States. A total of 202 KAE in a metropolitan city on the East coast participated in a comprehensive nutritional survey using 24-hour dietary recall. Despite their spending about 16 years in the U.S., the KAE consumed more than two regular meals in a day which qualified under a Korean food pattern. When compared with the National Health and Nutrition Examination Survey III, the average consumption of nutrients reported was generally lower than Americans, with the exception of carbohydrates, vegetable protein, and sodium intakes. Inadequate intakes of calcium, dietary fiber, and folate were notable when examined in comparison to the Dietary Reference Intakes. The findings can help healthcare providers and researchers to design appropriate nutritional education programs to facilitate the adoption of healthier dietary practices in this immigrant population. In particular, future interventions should consider ways to lower sodium intake and increase fruit and vegetable consumption among KAE, while encouraging them to maintain their healthy dietary pattern.
doi:10.1016/j.gerinurse.2009.02.001
PMCID: PMC2791536  PMID: 19818265
22.  Health aspects, nutrition and physical characteristics in matched samples of institutionalized vegetarian and non-vegetarian elderly (> 65yrs) 
Background
Epidemiological studies indicate that a well balanced vegetarian diet offers several health benefits including a lower prevalence of prosperity diseases in vegetarians compared to omnivores. It was the purpose of the present study to compare nutritional and physical characteristics in matched samples of institutionalized vegetarian (V) and non-vegetarian (NV) elderly.
Methods
Twenty-two female and 7 male V (females: 84.1 ± 5.1yrs, males: 80.5 ± 7.5yrs) and 23 female and 7 male NV (females: 84.3 ± 5.0yrs, males: 80.6 ± 7.3yrs) participated. All subjects were over 65 years of age, and free of major disease or physical handicap. Dietary intake, blood profile, anthropometrics, and handgrip strength were determined.
Results
Mean daily energy intake was 6.8 ± 2.0MJ in V females, and 8.0 ± 1.4MJ in the NV females, only the V did not reach the recommended value of 7.8 MJ. Male V and NV had a mean daily energy intake of 8.7 ± 1.6MJ and 8.7 ± 1.2MJ respectively (RDI: 8.8 MJ). Mean carbohydrate intake was significantly below the RDI in NV only (female V: 47.8 ± 7.5E%, female NV: 43.3 ± 4.6E%, male V: 48.1 ± 6.4E%, male NV: 42.3 ± 3.6E%), while protein (female V: 17.3 ± 3.4E%, female NV: 19.5 ± 3.5E%, male V: 17.8 ± 3.4E%, male NV: 21.0 ± 2.0E%), and saturated fat intake (female V: 25.4 ± 8.2 g/day, female NV: 32.2 ± 6.9 g/day, male V: 31.4 ± 12.9 g/day, male NV: 33.4 ± 4.7 g/day) were too high in both V and NV. Mean micronutrient intakes met the RDI's in all 4 groups. Mean blood concentrations for vitamin B12, folic acid, iron, and calcium were normal in all 4 groups. Mean zinc blood serum was below the reference value in all groups, whereas estimated zinc intake was in agreement with the RDI. The mean blood cholesterol concentration was above the 200 mg/dl upper limit in the V group (213 ± 40 mg/dl) and below that limit in the NV (188 ± 33 mg/dl) group. Mean BMI was 26.1 ± 4.7 kg/m2 in the female V, 26.8 ± 3.7 kg/m2 in the female NV, 23.5 ± 3.7 kg/m2 in the male V, and 25.2 ± 4.2 kg/m2 in the male NV. V and NV scored below the reference values for the handgrip strength test.
Conclusions
Generally, our results show a similar profile for V and NV concerning dietary intake, blood values, and physical characteristics. Attention should be paid to the intake of mono- and disaccharides and saturated fats in the diet of both V and NV. This study indicates that a vegetarian lifestyle has no negative impact on the health status at older age.
doi:10.1186/1743-7075-8-37
PMCID: PMC3135511  PMID: 21672249
23.  Association between the dietary factors and metabolic syndrome with chronic kidney disease in Chinese adults 
Objective: The aim of study was to examine the relationship between the dietary nutrition and the prevalence and risk of renal damage in patients with metabolic syndrome. Methods: 260 patients with metabolic syndrome and chronic renal disease meeting criterion were recruited in this cross-sectional study. Metabolic syndrome was defined according to NCEP-ATPIII guidelines. Food-frequency questionnaire was performed to collect the information on dietary nutrition. Anthropometric measurements, including body weight, height and waist circumference were collected. Blood pressure, triglyceride, cholesterol, high density lipoprotein-cholesterol and fasting plasma glucose, renal function and 24-hour urine protein were measured. The correlations between GFR and actual nutrient intakes of participants were examined. Results: The actual intakes of energy, carbohydrates, protein, fat and cholesterol in participate were all significantly higher than recommended nutrient intakes/adequate intakes of Chinese Dietary Reference Intakes. GFR was significantly inversely correlated with energy, protein intake, cholesterol intake, carbohydrates intake, sodium intake, calcium intake and actual protein/energy ratio. Logistic regression analyses showed that actual protein intakes/recommended protein intakes (APIs/RPIs) were significant independent predictors of GFR < 60 ml/min•1.73 m2. Conclusions: Dietary nutrition is closely correlated with kidney damage in patients with metabolic syndrome. High protein intakes may be one of the risk factors of renal damage.
PMCID: PMC4276225  PMID: 25550967
Metabolic syndrome; chronic kidney disease; dietary
24.  The Double Burden of Obesity and Malnutrition in a Protracted Emergency Setting: A Cross-Sectional Study of Western Sahara Refugees 
PLoS Medicine  2012;9(10):e1001320.
Surveying women and children from refugee camps in Algeria, Carlos Grijalva-Eternod and colleagues find high rates of obesity among women as well as many undernourished children, and that almost a quarter of households are affected by both undernutrition and obesity.
Background
Households from vulnerable groups experiencing epidemiological transitions are known to be affected concomitantly by under-nutrition and obesity. Yet, it is unknown to what extent this double burden affects refugee populations dependent on food assistance. We assessed the double burden of malnutrition among Western Sahara refugees living in a protracted emergency.
Methods and Findings
We implemented a stratified nutrition survey in October–November 2010 in the four Western Sahara refugee camps in Algeria. We sampled 2,005 households, collecting anthropometric measurements (weight, height, and waist circumference) in 1,608 children (6–59 mo) and 1,781 women (15–49 y). We estimated the prevalence of global acute malnutrition (GAM), stunting, underweight, and overweight in children; and stunting, underweight, overweight, and central obesity in women. To assess the burden of malnutrition within households, households were first classified according to the presence of each type of malnutrition. Households were then classified as undernourished, overweight, or affected by the double burden if they presented members with under-nutrition, overweight, or both, respectively.
The prevalence of GAM in children was 9.1%, 29.1% were stunted, 18.6% were underweight, and 2.4% were overweight; among the women, 14.8% were stunted, 53.7% were overweight or obese, and 71.4% had central obesity. Central obesity (47.2%) and overweight (38.8%) in women affected a higher proportion of households than did GAM (7.0%), stunting (19.5%), or underweight (13.3%) in children. Overall, households classified as overweight (31.5%) were most common, followed by undernourished (25.8%), and then double burden–affected (24.7%).
Conclusions
The double burden of obesity and under-nutrition is highly prevalent in households among Western Sahara refugees. The results highlight the need to focus more attention on non-communicable diseases in this population and balance obesity prevention and management with interventions to tackle under-nutrition.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Good nutrition is essential for human health and survival. Insufficient food intake causes under-nutrition, which increases susceptibility to infections; intake of too much or inappropriate food, in particular in interaction with sedentary behaviour, can lead to obesity, which increases the risk of non-communicable diseases such as diabetes. During the past 30 years, the prevalence (the proportion of a population affected by a condition) of obesity has greatly increased, initially among adults in industrialized countries, but more recently among children and in less-affluent populations. Now, worldwide, overweight people outnumber under-nourished people. Furthermore, some populations are affected by both under-nutrition and obesity, forms of malnutrition that occur when the diet is suboptimal for health. So, for example, a child can be both stunted (short for his or her age, an indicator of long-term under-nutrition) and overweight (too heavy for his or her age). The emergence of this double burden of malnutrition has been attributed to the nutrition transition—the rapid move because of migration or urbanization to a lifestyle characterized by low levels of physical activity and high consumption of refined, energy-dense foods—without complete elimination of under-nutrition.
Why Was This Study Done?
Refugees are one group of people in whom under-nutrition and obesity sometimes coexist. Worldwide, in 2010, 15.4 million refugees were dependent on host governments and international humanitarian agencies for their food security and well-being. It is essential that these governments and organizations provide appropriate food assistance programs to refugees—policies that are appropriate during acute emergencies may not be appropriate in protracted emergencies and may contribute to the emergence of the double burden of malnutrition among refugees. Unfortunately, the extent to which the double burden of malnutrition affects refugees in protracted emergencies is unknown. In this cross-sectional study (an investigation that looks at the characteristics of a population at a single time), the researchers assessed the double burden of malnutrition among people from Western Sahara who have been living in four refugee camps near Tindouf city, Algeria, since 1975.
What Did the Researchers Do and Find?
The researchers used data from a 2010 survey that measured the height and weight of children and the height, weight, and waist circumference of women living in 2,005 households in the Algerian refugee camps. For the children, they estimated the prevalence of global acute malnutrition (which includes thin, “wasted” children, as indicated by a low weight for height based on the World Health Organization growth standards, and those with nutritional oedema), stunting, and underweight and overweight (low and high weight for age and gender, respectively). For the women, they estimated the prevalence of stunting, underweight (body mass index less than 18.5 kg/m2), overweight (body mass index greater than 25 kg/m2), and central obesity (a waist circumference of more than 80 cm). Among the children, 9.1% had global acute malnutrition, 29.1% were stunted, 8.6% were underweight, and 2.4% were overweight. Among the women, 14.8% were stunted, 53.7% were overweight, and 71.4% had central obesity. Notably, central obesity and overweight in women affected more households than global acute malnutrition, stunting, and underweight in children. Finally, based on whether a household included members with under-nutrition or overweight, alone or in combination, the researchers classified a third of households as overweight, a quarter as undernourished, and a quarter as affected by the double burden of malnutrition.
What Do These Findings Mean?
These findings indicate that there is a high prevalence of the double burden of malnutrition among households in Western Saharan refugee camps in Algeria. Although this study provides no information on men and does not investigate whether the obesity seen in these camps leads to an increased risk of diabetes and other non-communicable diseases, these findings have several important implications for the provision of food assistance and care for protracted humanitarian emergencies. For example, they highlight the need to promote long-term food security and to improve nutrition adequacy and food diversity in protracted emergencies. In addition, they suggest that current food assistance programs that are suitable for acute emergencies may not be suitable for extended emergencies. They also highlight the need to focus more attention on non-communicable diseases in refugee camps and to develop innovative ways to provide obesity prevention and management in these settings. However, as the researchers stress, careful policy and advocacy work is essential to ensure that efforts to deal with the threat of obesity among refugees do not jeopardize support for life-saving food assistance programs for refugees.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001320.
Wikipedia provides background information about the Western Sahara refugee camps near Tindouf, Algeria (note that Wikipedia is a free online encyclopedia that anyone can edit)
The World Health Organization provides information on all aspects of nutrition and obesity (in several languages)
The United Nations World Food Programme is the world's largest humanitarian agency fighting hunger worldwide; its website provides detailed information about hunger and information about its work in the Western Sahara refugee camps in Algeria, including personal stories and photographs of food distribution
The United Nations High Commissioner for Refugees is the United Nations body mandated to lead and coordinate international action to protect refugees and resolve refugee problems worldwide; its website provides detailed information about its work in the Western Sahara refugee camps in Algeria
Oxfam also provides detailed information about its work in the Algerian refugee camps, a description of the camps, and personal stories from people living in the camps
An article published by the Food and Agriculture Organization of the United Nations explains the double burden of malnutrition
doi:10.1371/journal.pmed.1001320
PMCID: PMC3462761  PMID: 23055833
25.  Nutritional Practices of National Female Soccer Players: Analysis and Recommendations 
The aim of the study was to establish the nutritional practices and activity patterns of elite female soccer players. The nutritional intake of 16 female England Soccer players was self-reported over a seven-day period. Participants were provided with written and verbal guidelines for the completion of the diaries. Training details were also recorded, and used in combination with BMR predictions to calculate daily energy expenditure. Energy, macronutrient and micronutrient intakes were determined using DietMaster 4.0 software. Results suggest that energy intake was low (1904 ± 366.3 kcal) in relation to previous recommendations for soccer players. Energy expenditure (2153.5 ± 596.2 kcal) was not significantly different (p > 0.05) from intake, suggesting energy balance was achieved. Carbohydrate (53.8 ± 6.8%), protein (16.8 ± 2.1%) and fat (28.8 ± 6.6%) intakes were in line with recommendations. Fluid intake (2466 ± 1350.5ml·day-1) was sufficient to meet baseline recommendations, but would need to be higher to meet the additional requirement of training and competition. With the exception of vitamin A and iron, all micronutrient intakes were higher than the DRI. In conclusion, recommendations for female soccer players are to encourage consumption of carbohydrate-electrolyte beverages to enhance carbohydrate intake and increase fluid intake, and ensure sufficient iron rich foods are included in the diet to meet the DRI.
Key pointsFemale soccer players demonstrate a low energy intake in relation to predicted requirements, but were in energy balance in this study.Increased carbohydrate intake may be beneficial to both training and competition performance of elite female soccer playersFluid requirements should be addressed on an individual basis and matched to player requirements.The iron status of female soccer players may be compromised due to insufficient dietary intake to meet the DRV.
PMCID: PMC3818665  PMID: 24198690
Energy; intake; expenditure; carbohydrate; fluid; micronutrient

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