Nutrition Surveillance System Research Articles

Mortality and Morbidity in Refugee Camps in Eastern Sudan: 1985–90

Civil war has disrupted life in Ethiopia since the 1960s and many people have sought refuge in Eastern Sudan, particularly during the famine emergency of 1984-85. UNHCR has provided the main financial support for the refugee programme, but began scaling down operations in 1990. Nearly 300,000 refugees still live in camps and benefit from food and health programmes. Health services are co-ordinated by the Sudanese Refugee Health Unit which operates a centralised health and nutrition surveillance system with the co-operation of the NGOs responsible for health care in the camps. A revision of the monthly reporting system and the establishment of a computer database in 1990 provided an opportunity to review the situation in the camps over the five years since the emergency. Child death rates for example, appear to have been reduced to levels below those expected in rural Africa. Patterns of mortality, morbidity, and nutritional status are outlined here and point to the general effectiveness of the health care programme. The surveillance system can, however, be used to identify those camps which have persistent problems, while monthly comparisons with the situation in previous years can provide early warning of deteriorating conditions.

On the Utility of Growth Curves

In this issue ofThe JOURNAL, Yip et al 1 describe the changes that have taken place in a decade (1980 through 1989) in the birth weight and early childhood growth of children of low-income immigrant families from Southeast Asia. While Asian See also p 937. immigrant infants and young children showed a marked shift in growth status toward the reference standards of the National Center for Health Statistics (NCHS), 2 during this same period the status of black, white, and Hispanic subjects from the same low-income population remained essentially unchanged. Data were collected through the Centers for Disease Control Pediatric Nutrition Surveillance System, which monitors the status of children who are receiving services through certain public health and nutrition programs (in major part through the Special Supplemental Food Program for Women, Infants, and Children). The data show a fall in incidence of low birth weight (less than 2500 g)

Improving Growth Status of Asian Refugee Children in the United States

To analyze the trend and pattern of the nutrition status of Southeast Asian refugee children and other low-income children in the United States. Descriptive analysis of the growth data from the Pediatric Nutrition Surveillance System of the Centers for Disease Control, Atlanta, Ga, from 1980 through 1989. Children under 5 years of age from low-income families enrolled in public health clinics in 12 selected states. Asian refugee children experienced a progressive and significant decline in the prevalence of low birth weight, low height-for-age, and low weight-for-age, while these nutritional indexes remained stable for low-income white, black, and Hispanic children. By 1989, the growth status of Asian children was near that of other ethnic groups. The marked improvement of growth status among Asian refugee children over a short period suggests that the poor growth status often observed among recently immigrated Asian children is primarily related to nutritional and health factors, rather than genetic factors. In assessing the growth of Asian or immigrant children, it would be helpful to take their family and early childhood background into account.

Nutritional status and food consumption in 10-11 year old Dutch boys (Dutch Nutrition Surveillance System).

As part of the Dutch Nutrition Surveillance System, cardiovascular risk factors and food consumption (24 h recall) as well as haematological, Fe and vitamin status (A, B6, C) were assessed in 126 Dutch boys aged 10-11 years (response 71%). Body mass index (BMI) and the sum of four skinfolds were strongly associated (r 0.85, P less than 0.01) and 8% of the boys were overweight (BMI greater than 20.1 kg/m2). Elevated serum total cholesterol levels (greater than 4.4 mmol/l) were observed in 38%; total cholesterol and low-density-lipoprotein-cholesterol levels were strongly associated (r 0.88, P less than 0.001). Intake of fat was high (38% of energy) and too much fat was saturated (polyunsaturated: saturated 0.44, guideline: 0.5-1.0), whereas intake of carbohydrate (49% of energy) and dietary fibre was low. About 12% of the boys had insufficient Fe stores (plasma ferritin less than 12.0 micrograms/l) and the mean Fe intake (9.0 mg/d) was below recommended daily allowance (10.0 mg/d). Plasma ferritin was, however, not associated with haematological indices and no frank anaemias were observed. No marginal values were observed for vitamins A, B6 and C status. In conclusion, the main nutritional risks in boys aged 10-11 years are cardiovascular risk factors and Fe nutrition.

The Dutch National Food Consumption Survey: design, methods and first results

The first Dutch National Food Consumption Survey (DNFCS) was conducted in 1987–1988. This report describes the design and methods of the Dutch nutrition surveillance system. The rationale for the use of an existing panel and a two-day record is given, and some potential pitfalls are discussed. The DNFCS data are compared with data from the Dutch national food balance sheets. Data from both individual and household levels are presented and discussed. An example regarding risk group identification is given.

Nutrition and blood pressure among elderly men and women (Dutch Nutrition Surveillance System).

Associations between blood pressure and nutrition-related variables (body mass index, dietary intake, and 24-hr excretion of sodium, potassium, magnesium, and calcium in the urine) were investigated in men (n = 138) and women (n = 117) 65-79 years old not using drugs known to affect blood pressure and not on a diet. Among men, body mass index was positively and creatinine clearance was inversely associated with systolic blood pressure, whereas body mass index and urinary sodium:potassium ratio were positively associated with diastolic blood pressure. Among women, both age and urinary calcium:creatinine ratio were positively associated with systolic as well as diastolic blood pressure. Coffee consumption was positively correlated with blood pressure and urinary calcium:creatinine ratio among the women. From the results it appears that, besides "normal" weight, increased potassium intake and urinary excretion may exert a protective effect among elderly men against hypertension when sodium exposure is relatively high. The positive association between urinary calcium:creatinine ratio and blood pressure among the women may be partly due to coffee consumption.

Food Patterns and Health Problems: Central Europe

Central Europe comprises a heterogeneous group of some 120 million persons from 11 countries which differ greatly in food availability and preferences. The region has undergone dramatic changes in food consumption patterns and in the patterns of nutritionally related diseases. The changes in the political situation in central Europe have provided a unique natural experiment which allows the study of the effects of different eating behaviors on health within a genetically homogeneous population and an analysis of the time frame in which effects can be seen at the national level. This is in particular the case for the FRG and the GDR. Epidemics of nutritionally related disease have arisen, including cardiovascular disease, cancers of the colon and breast and obesity. These occur at very different rates in neighboring countries. Furthermore, unknown factors, probably including food-hygienic factors and methods of storage and preparation, have resulted in drastic reductions in the rates of stomach cancers in all countries. These have only recently been detected, as no systematic nutritional surveillance systems are currently in effect in Europe. Due to the chronic nature of the diseases in question, we are noticing too little, too late. Food patterns provide a realistic and sensitive predictor of disease incidence. They are timely enough to detect changes before they are reflected in a diminished health status of the population or specific risk groups. Details on the patterns of intake and secular trends, as far as they are available for individual countries, reveal that eating behavior is quite labile and subject to dramatic changes within decades. The current information status does not allow a closer examination of specific population groups, such as the behavior of children or the elderly, the intakes of pregnant or breast-feeding women, or the eating behavior of men at high risk of heart disease. The foundations of a European nutrition surveillance system need to be laid, to make possible the timely detection of high-risk-related changes in food consumption, unfavorable trends and early signs of nutritionally related epidemics. The regular, standardized assessment of eating patterns will be an important building stone in such a system.

Father's unemployment and height of primary school children in Britain

In a nutritional surveillance system of 5-11-year-old children the association between father's employment status and his child's height, weight-for-height and their rates of change over 2 years were assessed. The study was carried out in three samples: quasi-representative English sample 1984-86; quasi-representative Scottish samples 1983/84-1985/86; and a sample of English inner city areas 1983-85. For the cross-sectional analysis the sample sizes were 6527 for the English representative sample, 4285 for the Scottish representative sample and 6709 for the English inner city areas sample. In an analysis of height gain in 2 years the samples comprised 3814, 2676 and 3682 children respectively. In the analysis the following data were used: father's employment status and social class; number of children in the family; parents' reported height and child's reported birth weight; and child's height and weight measurements and a classification of ethnic origin obtained during fieldwork. Children with an unemployed father were shorter, especially if the father was unemployed for more than a year, than children with a currently employed father. After adjustment for parents' height, child's birth weight, father's social class and family size the difference persisted but reduced, to approximately 1.2 cm. Height gain in a 2-year period was not associated with father's employment status. If father's unemployment is causally linked to child's height a child is most vulnerable at pre-school age.

Nutrition and Serum Cholesterol Levels Among Elderly Men and Women (Dutch Nutrition Surveillance System)

Associations of serum cholesterol with relevant dietary intake variables (assessed with the dietary history method) and body mass index were investigated in elderly men (n = 199) and women (n = 180) 65-79 years old. All subjects were apparently healthy, nondiabetic, and not on a dietary regimen. The associations were studied separately for men and women using linear regression analysis and all possible subsets regression analysis. Among men, body mass index (kg/m2) and intake of monounsaturated fat and of alcohol were positively and consistently associated with serum total cholesterol. Among women, intake of alcohol and of saturated fat were positively associated, and intake of polysaccharides was inversely associated with serum total cholesterol. The intake of monounsaturated fatty acids was highly (r greater than .60) positively correlated with the intake of total fat and saturated fatty acids, and inversely with carbohydrates. HDL-cholesterol was positively associated with alcohol intake (significant for men only), and inversely with body mass index (women). The results indicate that the effect of dietary factors on serum cholesterol levels is probably not age-limited. Elderly people may potentially benefit from weight reduction or control, moderate alcohol consumption, and avoidance of too much dietary fat. These suggestions are in fair accordance with general population-based guidelines for a healthy diet. However, as our study was cross-sectional, causation as well as the public health impact remains to be proven.

Long-term effects of a vegetarian diet on the nutritional status of elderly people (Dutch Nutrition Surveillance System).

The health and nutritional status (anthropometry, and blood and urine biochemistry) of 44 Dutch apparently healthy vegetarians, aged 65-97 years, refraining from meat, fish, and poultry consumption, was assessed for insight into long-term consequences of ovo-lacto- or lacto-vegetarianism. The results indicate that in comparison to omnivorous elderly the vegetarian elderly (especially men) have aged successfully with respect to cardiovascular risk factors. In contrast, vegetarian elderly are at a higher risk for a marginal iron, zinc, and vitamin B12 status. Although several vegetarian elderly showed low levels of 25-hydroxyvitamin D in plasma and many had low values of 24-hr urine volume (per kg body weight), these values are not likely the result of a vegetarian diet per se. It is concluded that, although some nutrition-related risks are prevalent among vegetarian elderly, these risks can probably be prevented by lifestyle changes.

Methodological Issues in Nutrition Surveillance: The CDC Experience

Nutrition surveillance systems serve to provide state- and locality-specific data that are useful for the management of public health nutrition programs. Current systems, such as the Pediatric and Pregnancy Nutrition Surveillance Systems coordinated by the Centers for Disease Control (CDC), collect program-based data focused on nutrition problems in infants, children, and pregnant women. These systems provide highly useful information, but also present significant methodological challenges relating to representativeness, quality control, and indicator sensitivity/specificity. As the importance of nutritional risk factors for chronic disease is increasingly recognized, the concept of nutrition surveillance must be expanded beyond maternal and child nutrition to include nutrition-related behaviors and risk factors in adolescents and adults. The Behavioral Risk Factor Surveillance System (BRFSS), coordinated by CDC, collects telephone survey data that include information on nutrition-related issues such as overweight, weight-loss practices, and cholesterol screening. In addition, a school-based surveillance system is being established by CDC in coordination with state education agencies to assess adolescent health behaviors, including nutrition. The operation of these nutrition surveillance systems presents significant methodological issues that must be considered in interpreting and using the data for public health purposes.

Dependence of Vitamin B-6 Status Assessment on Alcohol Intake Among Elderly Men and Women (Dutch Nutrition Surveillance System)

To obtain more insight into the effect of moderate alcohol intake on vitamin B-6 status indicators, we studied the associations of alcohol intake (unadjusted and adjusted for intake of vitamin B-6 and protein) with the erythrocyte aspartate aminotransferase activation coefficient (EAST-AC) and plasma pyridoxal 5'-phosphate (PLP) level. Data obtained from men (n = 224) and women (n = 217) aged 65-79 (nationwide sample in the Netherlands) were used for this purpose. Although alcohol intake (a maximum of 21% of the energy came from alcohol) tended to be positively associated with PLP, this association never reached statistical significance (p greater than or equal to 0.05). EAST-AC was inversely associated with alcohol intake, whether or not it was adjusted for vitamin B-6 and protein intake. Similar results were found for the total EAST activity (after adding PLP) or apoenzyme activity; the basal EAST activity (before adding PLP) or holoenzyme activity was not associated with the alcohol intake. These results indicate that caution is needed in the interpretation of the specificity of EAST-AC (i.e., the degree to which EAST-AC is unaffected by other factors) as an indicator of vitamin B-6 intake.

Adequacy of a vegetarian diet at old age (Dutch Nutrition Surveillance System).

To assess the adequacy of a vegetarian diet at old age, the dietary intake (assessed through dietary history with cross-check) of 44 apparently healthy lacto-(ovo-)vegetarians, aged 65-97 years, was evaluated. Adequacy was assessed by a comparison of nutrient intake with (Dutch) recommendations and by evaluating data on nutritional status. The results were also compared with data of elderly omnivores. In contrast to elderly omnivores, percentages of energy from protein (13%), fat (37%), and carbohydrates (50%) as well as P/S ratio (0.63) were close to or within the range of Dutch guidelines regarding a healthy diet (percentages of energy from protein, fat, and carbohydrates 10-15, 30-35, and 55%, respectively: P/S ratio 0.5-1.0). For most of the micronutrients studied intake was adequate, and nutrient density of the vegetarian diet was higher than of the omnivorous diet. However, the supply of zinc (average daily intake 8.5 and 7.6 mg for men and women, respectively), iron (because of lower bioavailability of nonheme iron), vitamin B12 (women only: intake 2.3 micrograms/day), and water (daily intake less than 1600 ml for 30% of the vegetarians) need special attention, considering the relatively high prevalence of a marginal status of these nutrients. In conclusion, a lacto-(ovo-)vegetarian diet can be adequate at old age, provided that it is carefully planned, especially with respect to the supply of iron, zinc, and vitamin B12.

Effect of dietary fiber on the vitamin B6 status among vegetarian and nonvegetarian elderly (Dutch nutrition surveillance system).

To obtain more insight into the effect of dietary fiber on vitamin B6 status among elderly people, we studied dietary interrelationships as well as associations between dietary intake and plasma pyridoxal-5'-phosphate (PLP) and cofactor stimulation of aspartate aminotransferase in erythrocytes (EAST-AC) among 441 nonvegetarian (aged 65-79) and 32 vegetarian elderly (aged 65-94). EAST-AC was found to be inversely related with intake of vitamin B6 and dietary fiber in bivariate regression analyses. After adjustment for age, intake of energy, protein, and fiber, the intake of vitamin B6 was still inversely related with EAST-AC. The association between EAST-AC and dietary fiber disappeared in the multivariate analysis, whereas total protein intake proved to be positively related with EAST-AC in the multivariate analysis only. The differences between bi- and multivariate analyses are most likely due to the observed interrelationships between intake of vitamin B6, fiber, and protein. It is concluded that dietary fiber does not have a significant impact on the vitamin B6 status among Dutch elderly people, since only protein (positively) and vitamin B6 (inversely) intake appeared to be related with EAST-AC in the multivariate analysis.

The relationships between selected anthropometric and socio-economic data in schoolchildren from different social strata in Rio de Janeiro, Brazil

The nutritional status according to anthropometric data was assessed in 756 schoolchildren from 5 low-income state schools and in one private school in the same part of Rio de Janeiro, Brazil. The prevalence of stunting and wasting (cut-off point: less than 90% ht/age and less than 80% wt/ht) ranged in the public schools from 6.2 to 15.2% and 3.3 to 24.0%, respectively, whereas the figures for the private school were 2.3 and 3.5%, respectively. Much more obesity was found in the private school (18.0%) than in the state schools (0.8-6.2%). Nutritional problems seem to develop more severely in accordance with the increasing age of the children. Therefore it appears advisable to assess schoolchildren within the context of nutritional surveillance system.

Nutrition and aging: nutritional status of “apparently healthy” elderly (Dutch nutrition surveillance system).

In a nationwide survey the nutritional status was assessed of 539 apparently healthy, independently living elderly aged 65-79 years. Anthropometric data showed no energy deficits. The prevalence of anemia was 4 and 1% among men and women, respectively. Many elderly showed a low level of 25-hydroxyvitamin D in plasma (less than 31 nmol/L: men 35%; women 43%), indicating a marginal status. Although the prevalence of low blood levels of folate, pyridoxal-5'-phosphate, and total carotenoids was higher among the elderly than among younger adults, clear (clinical) signs of nutritional deficiencies were not observed. Prevalence of obesity (13%), hypercholesterolemia (38%), and hypertension (63%) was found to be high, the percentages being higher for women than for men. Several indicators of the nutritional status appeared to differ among age groups. It is concluded that few differences can be considered as being due to physiological aging, which finding should be reflected in reference values for elderly people.

Serum uric acid correlates in elderly men and women with special reference to body composition and dietary intake (Dutch nutrition surveillance system)

In 460 apparently healthy Dutch elderly, aged 65–79 years, serum uric acid correlates were studied by linear regression analyses, for men and women separately. Diuretic therapy, total serum cholesterol (women only) and creatinine clearance (in bivariate analysis only) were significantly associated with serum uric acid level. Positive associations of serum uric acid with body weight, body mass index, body fatness (men) and lean body mass (men) were observed, with and without adjustment for diuretic therapy, creatinine clearance and age. Serum uric acid levels, whether adjusted or not for these variables and for body mass index, were positively associated with alcohol intake (men) and consumption of meat and fish (women), and inversely with consumption of bread, margarine and milk products (women). These results indicate that limited medication with diuretics, weight control and restriction of alcohol use may help to prevent hyperuricemia in the elderly.

Nutrition and aging: dietary intake of "apparently healthy" elderly (Dutch Nutrition Surveillance System).

The dietary intake (assessed through dietary history) of 539 apparently healthy, independently living elderly aged 65-79 years, was evaluated in a nationwide random sample. Except for pyridoxine, the intake of vitamins, minerals, and water was adequate according to the Dutch recommended dietary allowances. Fat intake (40 energy%) as well as P/S ratio (0.41) was assessed as being unfavorable, whereas the intake of vitamin B6 was marginal. The prevalence of obesity was higher among the women, while food selection was healthier as reflected in the higher nutrient density than among the men. Food consumption of elderly men (26%) and women (33%) on a dietary regimen was more prudent and nutrient density higher than among the elderly not on a diet. Our results are in accordance with previous food consumption studies among elderly in The Netherlands, but differ substantially from dietary intake figures for American elderly. Although the intake of energy and nutrients was lower among elderly men than among younger men, we conclude that age per se is not an important determinant of dietary intake among Dutch apparently healthy elderly aged 65-79 years.

Dose-response relationships regarding vitamin B-6 in elderly people: a nationwide nutritional survey (Dutch Nutritional Surveillance System)

The dietary intake and biochemical status of vitamin B-6 in 476 apparently healthy Dutch elderly people (aged 65-79 y), who were not using drugs known to affect vitamin B-6 metabolism, were evaluated. Intake of vitamin B-6 per gram protein was related to biochemical data, namely plasma pyridoxal 5'-phosphate (PLP) and cofactor stimulation of aspartate aminotransferase in erythrocytes (AST-AC). Based on a cutoff point of 2.02 for AST-AC, approximately 9% of the elderly people not using vitamin B-6 supplements had a marginal vitamin B-6 status. About 7% were using vitamin B-6 supplements. Dietary intake of vitamin B-6 per gram protein was negatively related to AST-AC. Vitamin B-6 intakes per gram protein higher than 0.020 mg were necessary to ensure an AST-AC value less than 2.02. At high PLP values AST-AC hardly varied. The results seem to indicate a higher requirement of vitamin B-6 in elderly people than in younger adults.

The Food and Nutrition Surveillance Systems of Chad and Mali: The “SAP” After Two Years

The "Systèmes d'Alerte Précoce" - the SAPs - of Chad and Mali have been in operation since April 1986. Their purpose is to forecast (or more realistically, detect as early as possible) food shortages in the drought-prone areas of each country. They are based on a multidisciplinary strategy, taking into account all relevant phenomena, from meteorology to nutritional status, and are implemented through the governmental networks. The present experience shows that, compared with the devastations due to famine and the cost of emergency food aid, they are not that expensive and they seem sustainable over the long term. "Faultless" prediction is not yet the rule, but several procedures permit progressive improvement in the ability of the systems to analyse and interpret. This paper explains the functioning process of the SAPs and presents several operational results. Additionally, it covers innovative concepts that have proved to be successful, such as the "participative information network".