Assessing Changing Food Consumption Patterns (1981) / Chapter Skim
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Appendix C: Background Papers for Workshop on Nutrition and Health Status Indicators
Appendix C: Background Papers for Workshop on Nutrition and Health Status Indicators
Pages 205-276
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APPENDIX Background Papers for C Workshop on Nutrition and Health Status Indicators
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In the early days of the ICNND'S country nutrition surveys, there was immediate recognition of the need for a procedural manual that would: 1. Establish uniformity in methods, techniques, procedures, and guidelines for conducting surveys in population groups in order to make meaningful comparisons of results within and between countries.
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Should we even waste time in doing it? COMPARISON OF DIETARY INTAKE METHODS Central America, INCAP-ICNND Survey Dietary surveys in the six Central American countries included a comparison of the following methodology: In the case of families, food consumption was estimated by a 3-day daily record, a 24-hour recall with two different approaches (interviews in the home and interviews at the clinic)
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Two methods of obtaining quantitative data on family food consumption were used: one by means of a 24-hour recall, using the
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At the end of the survey in each location, typical family diets were calculated and food composites were locally prepared for subsequent chemical analysis. Individual food intakes of preschool children were recorded by the 24-hour recall in most of the countries.
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Guate- El Sal- Hon- Nica- Costa Pana Foods malaa vador auras ragua Rica ma Milk productsb 84 190 194 243 193 73 Eggs 13 10 13 12 15 11 Meat, poultry, and fish 44 37 41 58 40 90 Beans end oily seeds 54 59 56 72 57 20 Vegetables 66 53 51 27 66 25 Fruits 14 17 40 41 7 50 Bananas and plantains 20 16 43 72 47 99 Starchy roots and tubers 14 13 22 33 46 82 Cereal products Rice 16 27 29 54 100 186 Corn tortillas, etch 359 352 224 139 41 32 Wheat bread 36 26 12 28 54 37 Wheat flour and pastes 4 0 8 7 12 10 Others 2 6 5 16 0 0 Sugar 52 41 39 58 89 51 Fats and oil 4 15 16 19 19 26 Number of families 203 293 331 355 456 361 aIn the report on Guatemala (INCAP v-25) , the figures for food consumption were those obtained by the 3-day-record method.
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Def icient FIGURE 1 Nutritional study in Central America and Panama: Urinary excretion of riboflavin in relation to the socioeconomic index of the families in the rural areas of Central America, 1965-1967, males 0-4 yr. Dietary studies revealed an even higher incidence of inadequate nutrient intakes than was evident from the biochemical and clinical studies.
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Ecuador ICNND Nutrition Survey The Ecuador nutrition survey conducted in 1959 employed three methods of obtaining food consumption data: 24-hour recall, 24-hour recipe food weighing, and food composite chemical analysis. Comparisons of the nutrients consumed in two major regions (coastal and sierra)
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Can Nutritional Status Be Determinedfrom Food Consumption?
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The food composite analysis method, which does require food intake data, provides the opportunity to obtain data on nutrient losses during cooking and on many nutrients for which food nutrient composition data were not available (vitamin B6, folic acid, zinc, sodium, potassium, etch. Chemical analyses of food composites in general include local water and
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On the positive side, one can interpret dietary intake data on population groups. An example of dietary intake correlating with biochemical assessment is illustrated by Figure 4.
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Manual for Nutrition Surveys, 2d ed.
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Third is the problem of how we relate our measures of food intake and other variables to the health status measures. The latter issue is the one that I would like to address.
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, and the third with environmental, attitude, and behavior, plus dietary intake (III)
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222 REFERENCES HOWARD G SCHUTZ Baird, P
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Iron transferrin saturation, % Dietary Intake (mean intake from food and supplements/day) (dependent variables, regressions I, IIa; independent variables, regression III)
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224 TABLE 1 Continued HOWARD G
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Measures of Nutritional Status TABLE 1 Continued 51. "Do (grow/hunt)
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231 C~ ~ ~ _ _ _ _ oo o ~ o ~ oo ~ _ _ _ o o o .
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232 1 1 of JO tl _, ~: c~ II c: o ._ c~ oo ct :: .
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233 Y~ Ct Pt o +1 V~ cr 11 ~: e~ a~ .
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236 o tl .
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Use of the four main quantitative methods of collecting dietary data are reviewed in relation to their use in cardiovascular disease, cancer, diabetes and obesity. It is concluded that in epidemiological studies of nutrition, reliance can be placed on a combination of estimated current record, 24-hour recall and diet history adapted in frequency and extent to meet the design needs of individual studies.
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GENERAL METHODS Literature purporting to describe the relationship between food intake patterns and chronic disease is as extensive as it is inconclusive, but describes a number of techniques common to the acquisition and use of dietary data. Dietary intakes of households and individuals have been measured since 1900, but studies designed to relate diet and nutrition to health and disease were uncommon until the 1930's.
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Like others, they fail to identify any single approach to assessing dietary intake but list the main methods in common use for epidemiological studies of ischemic heart disease. These again include direct measurement of food intake in which all food eaten by an individual or family is weighed or measured by a dietician in the home.
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Commenting on differences in Scottish food consumption compared with the average for Great Britain, the working party emphasized the need for analysis of the diets of randomly selected small groups of the Scottish population in areas of contrasting rates of ischemic heart disease mortality and socioeconomic opportunity.They regarded dietary analysis methodology as of critical importance and proposed utilizing
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evaluated three methods of estimating group and individual diet consumption in a case control study of diet in breast cancer. Their review of previous work in which nutritional
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In their evaluation, the authors compare the efficacy of 24-hour recall, detailed quantitative diet history directed towards the most recent 2-month period after diagnosis and the 2-month period 6 months before diagnosis, and a 4-day diet diary. They found in this case control study of diet and breast cancer a high degree of correlation between the estimates of food consumption for the controls using each of the three methods.
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examined the regional variation of breast cancer death rates in England and Wales and the higher rates in the South compared with the North of Wales using per capita food intakes from annual national food surveys and cancer mortality. He found positive associations between milk, butter, and cheese and negative associations between other fats such as margarine.
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consider antigens, estrogens, and prolactin. It is concluded that human breast cancer is multifactorial and that it seems highly probable that dietary factors are related to the disease in several ways.
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They describe total calorie intake, nutritional excess or deficit, exposure to carcinogens, and consumption of alcohol as contributory factors. Comparison of spouses of Japanese women with breast cancer was used to isolate environmental from dietary factors prospectively.
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When factors associated with obesity, like blood pressure, glucose intolerance or diabetes mellitus, physical activity, or raised plasma levels of triglycerides, cholesterol, and uric acid are held constant, the predictive value of obesity for ischemic heart disease is much reduced, suggesting that when obesity does increase morbidity or mortality it does so through these factors. Use of obesity as an index of dietary intake, nutritional health or disease, and disability status requires provision in analyses for hypertension, hyperlipidaemia, and glucose intolerance, as well as morbidity from ischemic heart disease.
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to random probability samples such as those developed for statewide telephone inquiry could provide baseline dietary data in a sample of 2,500, which could characterize a population of 10,000,000. Deficiencies could be reviewed by deployment of the resource represented by the First Health and Nutrition Examination Survey (19721.
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A report to the Chief Scientist by the Working Group on Ischaemic Heart Disease, Scottish Home and Health Department, Trinity Park House, Edinburgh, Scotland.
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1977. Role of nutrition in the etiology of breast cancer.
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1970. Breast cancer anomalies.
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On the one hand, there are those who focus upon dietary intake in evaluating nutritional status, while on the other, there are those who rely upon indicators of disease as evidence for disturbances in status. I will use nutritional status to refer to the extent to which the dietary intake has been sufficient to satisfy the nutrient needs.
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Likewise, the information provided by anthropometric data is valid within the constraints of the method, and, regardless of our wishes, we cannot push body measurements beyond those constraints, no matter how intently we wish or how elaborately we analyze our measurements. 253 ANTHROPOMETRY AS AN INDICATOR OF NUTRITIONAL STATUS The term nutritional anthropometry began first to appear after World War II, but seems to have had its first significant impact with the publication of Body Measurements and Human Nutrition, edited by Josef Brozek (1956)
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While it is true that one's present status is a function of past nutritional intake, nonetheless, anthropometry is not able to detect short-term, nutrient-specific disturbances in nutritional status. Second, while body morphology is indeed sensitive to nutritional disturbances, it is similarly altered by a variety of such disturbances; anthropometric indicators are not specific.
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The Rationale for Nutritional Anthropometry The initial step in establishing a rationale for nutritional anthropometry has been given above: Variations in the ratio between nutrient intake and nutrient requirement are recorded in the morphology of the body, perhaps permanently. The greater the disparity, the greater the morphological alterations, reaching the extremes of obesity and marasmus.
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the measurement of body composition. The Measurement of Growth Nutrient requirements, relative to body weight, are highest during the growing years, due to the additional nutrients needed to support body growth.
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Overnutrition is associated with increased deposition of adipose fat, accelerated rates of maturation, and possibly increased stature and lean body mass. Some researchers have suggested that decreased growth in stature and muscle mass is indicative of a deficiency of protein, while decreased fat stores reflect energy insufficiency.
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NUTRITIONAL ANTHROPOMETRY A MINIMUM LIST To suggest a minimum list of measurements to be used in assessing nutritional status is dangerous and possibly foolhardy. Different investigators will favor different measurements: Some will insist upon a lengthy list, while others will utilize but one or two.
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Finally, the muscle mass of the body may be estimated by deriving the estimated circumference of the muscle of the upper arm, upper arm muscle circumference. Since both the upper arm circumference and the triceps skinfold are to be taken at the same level, the middle of the upper arm, and since the triceps skinfold is an estimate of the double layer of fat at
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Reference Standards One of the problems of nutritional anthropometry is that it requires standards against which to evaluate the data collected. After several years of discussion and debate, the majority of investigators now agree that it is impossible to specify true "norms" as standards.
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Since antrhopometry is localized and noninvasive, estimates of body composition are necessarily indirect. Despite this, there does seem to be agreement that body measurements, given the proper analysis, can estimate underlying tissue masses.
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of Anthropometry and Body Composition (Densitometry) in 12-17-Year-Olds Males Females Sample size 1 19 24 Arm muscle circ./~sM 0.778 0.629 Triceps skinfold/fat 0.838 0.741 Subscapular skinfold/fat 0.832 0.766 Table 1 presents some yet-unpublished data from a recent study of ours, in which we correlated, among 12- to 17-year-olds, anthropometric dimensions with LBM and body fat, estimated by densitometry.
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The results are promising and suggest that body morphology is a sensitive indicator of malnutrition. Anthropometry cannot be employed haphazardly, uncritically, or without an understanding of the underlying theory relating body size and shape to body composition and growth and their alteration with malnutr~tion.
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1975. Body size in developing nations: Is bigger better?
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of the Food and Nutrition Board, National Research Council recommend that folic acid and iron supplements should be taken throughout pregnancy. The Committee on Dietary Allowances recommendation was that the recommended dietary allowance be doubled in 265
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Oral contraceptives reduce monthly blood loss, thereby reducing the frequency of iron deficiency. The question of whether the existing iron fortification of American flour should be increased (AMA Council on Foods and Nutrition, 1972: Wintrobe, 1973)
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These three anemias reflect an important nutritional problem affecting large population groups, particularly the poverty-stricken and those under metabolic stress. Iron deficiency and folate deficiency are more common in women because of two forms of metabolic stress peculiar to women: the monthly blood loss in premenopausal women and the drain on maternal nutrient stores imposed by pregnancy.
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Menstrual loss of iron is the main source of the iron losses in nonpregnant women in the fertile age-group (Rybo, 1970; Fairbanks et al., 19711. The average menstrual blood loss is about 40 ml/cycle (Fairbanks et al., 1971)
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during pregnancy. The physician should use his judgment in this regard, based on knowledge of the patient, the dietary habits, the fact that iron deficiency is frequent in pregnant women, and his evaluation of the blood and iron status of the particular patient (Herbert, 1975a)
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The physician must remember that the iron deficiency may have developed in association with menorrhagia; if that menorrhagia persists, iron therapy may have to persist as well so that the iron loss in blood does not again produce a negative iron balance. About 3 - percent of the iron in vegetable foods and 15-20 percent of the iron in animal foods is absorbed.
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These studies add to a growing body of evidence that nutritional deficiency of folic acid is prevalent among Americans of poor economic status. Based on findings up until 1970, Pritchard, writing for the Committee on Maternal Nutrition of the Food and Nutrition Board (1970)
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Until such fortification is practiced, administration of folic acid tablets, 200-400,ug/day, is appropriate for all pregnant women,
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That workshop included papers presenting the latest information on distribution of folates in food, food folate availability, results of several surveys to detect folate deficiency in certain American population groups, and reviews of the folic acid requirement in children, adults, and in situations of increased need. To briefly summarize the findings most pertinent to nutritional anemias: Measurement of serum and red-cell folate together constitute the best method for delineating the existence of folate deficiency; food folate availability is affected by various constituents present in different foodstuffs; pregnancy increases folate requirement.
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1968. Iron deficiency in the United States.
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1975. Folic acid deficiency in the United States: Folate assays in a prenatal clinic.
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Iron deficiency, Academic Press, London and New York. Smith, J
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