Liv Elin Torheim

Food variety -- a good indicator of nutritional adequacy of the diet? A case study from an urban area in Mali West Africa.

Objective: This study assesses whether a simple count of food items and food groups can predict the nutritional adequacy of the diet in an economically poor country.Design: A three-day weighed record of children.Setting: Koutiala town, in Southeastern Mali.Subjects: Seventy-seven children, 13–58 months of age. One child was excluded owing to an extraordinarily low food variety.Intervention: The study was conducted in April–August 1995. Data from this study were used to create two different indices: Food Variety Score (FVS), a simple count of food items, and Dietary Diversity Score (DDS), a count of food groups. Mean Adequacy Ratio (MAR) was calculated as an indicator for nutrient adequacy, and used to validate FVS and DDS.Results: Mean (s.d.) FVS was 20.5 (3.8) and mean (s.d.) DDS was 5.8 (1.1). A positive correlation was found both between FVS and MAR (Pearson 0.33, P<0.001) and DDS and MAR (Pearson 0.39, P<0.001). With cut-off points for FVS at 23 and for DDS at 6, the indices have high ability to identify those with a nutritionally inadequate diet. MAR increased with increasing FVS and DDS. FVS needs to be at least 15 or DDS at least 5 to give a satisfactory MAR.Conclusion: Although a simple count of food items or food groups cannot give a full picture of the adequacy of the nutrient intake, the results from this study show that the food scores can give a fairly good assessment of the nutritional adequacy of the diet, particularly if combined. Such indicators are important for identification of vulnerable groups in areas where people normally eat from a shared bowl, which makes detailed dietary intake studies difficult, time consuming and expensive.Sponsorship: The Norwegian Universities’ Committee for Development Research (NUFU), the Norwegian Research Council and the Nordic Africa Institute funded the project.

Nutrient adequacy and dietary diversity in rural Mali: association and determinants

Objective: To examine the association between nutrient adequacy and dietary diversity, and to assess and compare the determinants for the two constructs in an adult population in rural Mali.Design: Cross-sectional study assessing food intake by a validated 7-day quantitative food frequency questionnaire. Two different dietary diversity indexes were created: food variety score (FVS), a simple count of food items, and diet diversity score (DDS) a count of food groups. Mean adequacy ratio, the mean ratio of intake to recommended intake (each truncated at one) of energy and nine nutrients, was calculated as an indicator of nutrient adequacy. Information on household and individual characteristics, including demography, socioeconomic conditions and food production strategies was obtained using precoded questionnaires.Setting: Bafoulabé district, Kayes region, Western Mali.Subjects: In total, 502 subjects (55% women) aged 15–45 y from 319 different households.Results: Both FVS and DDS had a positive correlation with mean adequacy ratio (MAR). Multivariate analysis (linear regression) showed that the most important factors explaining MAR was the number of milk products, vegetables and green leaves consumed, as well as sex and the number of crops produced in the household. Dietary diversity was associated with socioeconomic status, residence and age.Conclusions: Dietary diversity is useful as an indicator of nutrient adequacy. It is important to examine how various food groups contribute to the nutrient adequacy of the diet in an area.Sponsorship: The Norwegian Research Council and The Strømme Foundation funded the project.

Simple Food Group Diversity Indicators Predict Micronutrient Adequacy of Women’s Diets in 5 Diverse, Resource-Poor Settings

Women of reproductive age living in resource-poor settings are at high risk of inadequate micronutrient intakes when diets lack diversity and are dominated by staple foods. Yet comparative information on diet quality is scarce and quantitative data on nutrient intakes is expensive and difficult to gather. We assessed the potential of simple indicators of dietary diversity, such as could be generated from large household surveys, to serve as proxy indicators of micronutrient adequacy for population-level assessment. We used 5 existing data sets (from Burkina Faso, Mali, Mozambique, Bangladesh, and the Philippines) with repeat 24-h recalls to construct 8 candidate food group diversity indicators (FGI) and to calculate the mean probability of adequacy (MPA) for 11 micronutrients. FGI varied in food group disaggregation and in minimum consumption required for a food group to count. There were large gaps between intakes and requirements across a range of micronutrients in each site. All 8 FGI were correlated with MPA in all sites; regression analysis confirmed that associations remained when controlling for energy intake. Assessment of dichotomous indicators through receiver-operating characteristic analysis showed moderate predictive strength for the best choice indicators, which varied by site. Simple FGI hold promise as proxy indicators of micronutrient adequacy.

Women in Resource-Poor Settings Are at Risk of Inadequate Intakes of Multiple Micronutrients

A systematic review was conducted to identify all studies that were published between 1988 and 2008 reporting micronutrient intakes of women in resource-poor settings. Inclusion criteria were study location (resource-poor), dietary assessment method (24-h recall, estimated/weighed record, or locally validated FFQ), energy and 1 or more micronutrient intakes reported (vitamin A, vitamin B-6, vitamin B-12, vitamin C, thiamin, riboflavin, niacin, folate, iron, or zinc), age range (15-50 y), sample size (≥30), and sex (female). Of the 1560 papers identified, 52 papers were included. Results showed that, except for vitamin A (29%), vitamin C (34%), and niacin (34%), the reported mean/median intakes in over 50% of studies were below the Estimated Average Requirement (EAR). Folate intake was most often below EAR (91% of studies). Regional differences were apparent for intakes of vitamins A, C, and B-6 and riboflavin; mean/median intakes in Latin America exceeded the EAR, whereas in Asia, reported mean/median intakes of vitamin C, vitamin A, and riboflavin were below the EAR in 47, 50, and 77% of the studies, respectively, as was the case for vitamin B-6 in 75% of the studies in Africa. These results suggest that inadequate intakes of multiple micronutrients are common among women living in resource-poor settings and emphasize the need for increased attention to the quality of womens diets. There is a need for more high-quality studies of womens micronutrient intakes.

Validation of food variety as an indicator of diet quality assessed with a food frequency questionnaire for Western Mali

Objective: To assess the validity of two diet quality indexes—food variety score (FVS) and diet diversity score (DDS) in Western Mali.Design: In two separate studies (A and B), FVS and DDS were derived from a food frequency questionnaire (FFQ) and were compared with the same scores and with measures of nutrient adequacy derived from 2-day weighed records (WR).Setting: Two rural, adjacent villages in Mali, West Africa.Subjects: In study A (1996), 48 women and 27 men (15–59 y) participated. Study B (1999) included 34 women and 36 men (15–45 y).Results: Spearmans correlation coefficients between FVS from the FFQ and WR for men were 0.5 in study A and 0.4 in study B. The corresponding correlations for DDS were 0.2 and 0.4, respectively. Correlations for women were lower, especially in study B. Classification into quartiles was also best for men. Correlations for the two diet variety scores from the FFQ with nutrient adequacy from the WR in study A were about 0.3 for men, but lower for women. In study B, these correlations were around 0.5 for men, whereas for women there was no association.Conclusions: FVS and DDS can be assessed by our FFQ. The two diet variety scores reflect diet quality and are simple tools that can be used for monitoring. The validation study gave better results for men than for women, which has implications for further use of these instruments.Sponsorship: The Norwegian Research Council and The Stromme Foundation funded the project.

Endemic goitre and excessive iodine in urine and drinking water among Saharawi refugee children

OBJECTIVE To assess the prevalence of enlarged thyroid volume (Tvol) in Saharawi refugee children, and their urinary iodine concentration (UIC), and to identify possible sources of excess iodine intake. DESIGN A cross-sectional survey was performed during January-February 2007. Tvol was measured by ultrasound and iodine concentration was analysed in casual urine samples, in household drinking water and in milk samples from household livestock. SETTING The study was undertaken in four refugee camps in the Algerian desert. SUBJECTS The subjects were 421 Saharawi children, 6-14 years old. RESULTS Enlarged Tvol was found in 56 % (Tvol-for-age) and 86 % (Tvol-for-body-surface-area) of the children. The median (25th percentile-75th percentile, P25-P75) UIC was 565 (357-887) microg/l. The median (P25-P75) iodine concentration in household drinking water was 108 (77-297) microg/l. None of the children had UIC below 100 microg/l, 16 % had UIC between 100 and 299 microg/l, and 84 % had UIC above 300 microg/l. There was a positive association between Tvol and whether the household possessed livestock. CONCLUSIONS The children are suffering from endemic goitre and high UIC caused probably by an excessive intake of iodine. The excessive iodine intakes probably originate from drinking water and milk.

Suboptimal Maternal Iodine Intake Is Associated with Impaired Child Neurodevelopment at 3 Years of Age in the Norwegian Mother and Child Cohort Study

Background: Severe iodine deficiency in pregnancy has major effects on child neurodevelopment, but less is known about the potential consequences of mild-to-moderate deficiency and iodine supplement use.Objective: We explored the associations between maternal iodine intake and child neurodevelopment at 3 y of age and the potential impact of maternal intake of iodine from supplements on the same outcomes.Methods: This population-based prospective observational study included 48,297 mother-child pairs recruited during pregnancy from 2002 to 2008. Maternal iodine intake was calculated based on a validated food-frequency questionnaire answered during midpregnancy that covered mean intake since the beginning of pregnancy. Associations between iodine intake and maternal-reported child language and motor development and behavior problems were explored by multivariable regression analyses.Results: In 33,047 mother-child pairs, excluding iodine supplement users, maternal iodine intake was associated with child language delay (P = 0.024), externalizing and internalizing behavior problems (both P < 0.001), and fine motor skills (P = 0.002) but not gross motor skills or the risk of not walking unaided at 17 mo of age. In 74% of the participants who had an iodine intake <160 μg/d (Estimated Average Requirement), suboptimal iodine intake was estimated to account for ∼5% (95% CI: -5%, 14%) of the cases of language delay, 16% (95% CI: 0%, 21%) of the cases of externalizing behavior problems >1.5 SD, and 16% (95% CI: 10%, 21%) of the cases of internalizing behavior problems >1.5 SD. In 48,297 mother-child pairs, including iodine supplement users, we found no protective effects of supplemental iodine during pregnancy on neurodevelopment.Conclusions: Maternal iodine intake below the Estimated Average Requirement during pregnancy was associated with symptoms of child language delay, behavior problems, and reduced fine motor skills at 3 y of age. The results showed no evidence of a protective effect of iodine supplementation during pregnancy.

Low dietary diversity and micronutrient adequacy among lactating women in a peri-urban area of Nepal

OBJECTIVE The main objectives were to assess the adequacy of the micronutrient intakes of lactating women in a peri-urban area in Nepal and to describe the relationships between micronutrient intake adequacy, dietary diversity and sociodemographic variables. DESIGN A cross-sectional survey was performed during 2008-2009. We used 24 h dietary recall to assess dietary intake on three non-consecutive days and calculated the probability of adequacy (PA) of the usual intake of eleven micronutrients and the overall mean probability of adequacy (MPA). A mean dietary diversity score (MDDS) was calculated of eight food groups averaged over 3 d. Multiple linear regression was used to identify the determinants of the MPA. SETTING Bhaktapur municipality, Nepal. SUBJECTS Lactating women (n 500), 17-44 years old, randomly selected. RESULTS The mean usual energy intake was 8464 (sd 1305) kJ/d (2023 (sd 312) kcal/d), while the percentage of energy from protein, fat and carbohydrates was 11 %, 13 % and 76 %, respectively. The mean usual micronutrient intakes were below the estimated average requirements for all micronutrients, with the exception of vitamin C and Zn. The MPA across eleven micronutrients was 0·19 (sd 0·16). The diet was found to be monotonous (MDDS was 3·9 (sd 1·0)) and rice contributed to about 60 % of the energy intake. The multiple regression analyses showed that MPA was positively associated with energy intake, dietary diversity, womens educational level and socio-economic status, and was higher in the winter. CONCLUSIONS The low micronutrient intakes are probably explained by low dietary diversity and a low intake of micronutrient-rich foods.

The Trouble in Mali—corruption, collusion, resistance

Abstract The combined force of the 2012 coup in Bamako and the rebellion in the north entailed an unmasking of Mali. What had been presented as a showcase of democracy, good governance, and peace and reconciliation proved to be a facade for institutional weakness and mismanagement. The collusion between regional and national ‘big man’ interests that the crisis revealed showed little if any respect for human security and development. This article will analyse the causes of the crisis and the strategies of key actors, including the Islamist rebels. The consequences of and responses to the conflict will also be addressed before the article ends with some tentative conclusions concerning the future stability of Mali and the Sahel region. The article is based on the authors’ long engagement with Mali, spanning more than a decade, but the most recent material presented is based on a series of in-depth interviews conducted there in February and March 2013.

Iodine-induced goitre and high prevalence of anaemia among Saharawi refugee women

OBJECTIVE The main objective was to assess iodine status (thyroid volume (Tvol) and urinary iodine concentration (UIC)) and their determinants in Saharawi refugee women. DESIGN A cross-sectional survey was performed during January-February 2007. Tvol was measured by ultrasound and iodine concentration was analysed in spot urine samples and in household drinking water. Anthropometry and Hb concentration were measured and background variables were collected using pre-coded questionnaires. SETTING The survey was undertaken in four long-term refugee camps in the Algerian desert. SUBJECTS Non-pregnant women (n 394), 15-45 years old, randomly selected. RESULTS Median (25th percentile-75th percentile (P25-P75)) UIC was 466 (294-725) μg/l. Seventy-four per cent had UIC above 300 μg/l and 46 % above 500 μg/l. Median (P25-P75) Tvol was 9·4 (7·4-12·0) ml and the goitre prevalence was 22 %. UIC was positively associated with iodine in drinking water and negatively associated with breast-feeding, and these two variables explained 28 % of the variation in UIC. The mean (sd) Hb level was 11·8 (2·4) g/dl. In total 46 % were anaemic with 14 %, 25 % and 7 %, classified with respectively mild, moderate and severe anaemia. CONCLUSIONS The Saharawi women had high UIC, high levels of iodine in drinking water and increased Tvol and probably suffered from iodine-induced goitre. The high prevalence of anaemia is considered to be a severe public health concern. To what extent the excessive iodine intake and the anaemia have affected thyroid function is unknown and should be addressed in future studies.