Hidden hunger in adolescent Mozambican girls : dietary assessment, micronutrient status, and associations between dietary diversity and selected biomarkers

Poor micronutrient intake and status (also called hidden hunger ) may compromise the health and work capacity of adolescent girls. In Mozambique, a low-income country with a high rate of adolescent pregnancies, girls poor micronutrient status is also an important risk factor for maternal and child mortality, adverse birth outcomes such as low birth weight, and impaired cognitive performance of the child. The main aims of this thesis were to examine the diet and micronutrient status of adolescent girls in Central Mozambique and to study whether dietary diversity is associated with biomarkers of micronutrient status. The thesis also includes a methodological study assessing the validity of using food photographs in portion size estimation in adolescent Mozambican girls. The validity study on food photographs was conducted in 2009. Two local staple foods and three sauces were selected as test foods and photographs of three different portion sizes were produced for each of them. The participants (99 Mozambican girls aged 13-18 years) were served weighted food portions, and after eating their meal, they were interviewed and asked to estimate the size of their portions with the help of the food photographs. The findings of this study indicated a tendency towards under-estimation of portion sizes. On the group level, the results were acceptable, but large variation in the accuracy of individuals estimates was found. The ZANE Study was conducted in 2010. It was a population-based cross-sectional study on the diet and nutritional status of 14- to 19-year-old girls in Zambézia Province. The study regions included one urban area and two rural districts. Two separate samples of girls were recruited: the first in January-February ( hunger season , n=283) and the second in May-June (harvest season, n=268). A 24-hour dietary recall interview and a seven-day food frequency questionnaire interview were conducted for each participant. Blood and urine samples were collected and blood haemoglobin, serum ferritin, serum zinc, serum selenium, urinary iodine, plasma retinol and serum folate concentrations were analysed. The ZANE Study revealed a low median energy intake calculated from the 24-hour recalls [5.2 MJ/day, interquartile range: 3.6, 7.4 (calculated using sampling weights); n=543]. This is in line with the findings of the validity study and is at least partly explained by under-reporting. Low intakes of several micronutrients and relatively high phytate:zinc molar ratios, typical for diets in low-income settings, were found. Marked seasonal variation was noted for vitamin A intake. According to the World Health Organization definitions, anaemia was a severe public health problem and vitamin A deficiency a moderate public health problem. The serum ferritin concentrations indicated that iron depletion was prevalent in the population. The population was also found to have a risk of zinc deficiency. Folate status was considered to be generally adequate, but an exception to this was the low serum folate concentrations in the urban area in May-June. Mild to moderate iodine deficiency was found in the rural districts, whereas the iodine status of urban girls was adequate. Selenium status was considered adequate. In the last part of the thesis, associations between dietary diversity and low concentrations of haemoglobin and serum/plasma ferritin, zinc, retinol, and folate in non-pregnant girls (n=227 in January-February and n=223 in May-June) were examined in logistic regression models using three different dietary diversity scores. First, the Women s Dietary Diversity Score (WDDS), consisting of nine food groups was calculated from the 24-hour recalls according to instructions by the Food and Agriculture Organization of the United Nations. The second score employed a minimum portion size limit of 15 g (WDDS15g), and the third was based on the seven-day food frequency questionnaires (7dWDDS). The most consistent findings of this work were the associations observed for zinc. In January-February, after adjusting for confounders, a low (≤3) WDDS and a low (≤5) 7dWDDS were each associated with higher odds of having lowserum zinc (≤25th percentile of the season-specific distribution) compared with having a higher score. These associations were not present in May-June. In conclusion, using food photographs in portion size estimation in adolescent Mozambican girls showed an acceptable level of validity. There was, however, a tendency towards under-reporting. In the future, producing and testing more comprehensive sets of locally relevant food photographs will be useful for dietary studies in Sub-Saharan African settings. Hidden hunger was found to be a public health problem among adolescent girls in Central Mozambique. Actions are needed to prevent and control hidden hunger, especially with regard to low iron, zinc, iodine, and vitamin A status. Programmes may need to be tailored according to urban-rural differences in diet and micronutrient status. Some associations between dietary diversity and micronutrient status may exist, especially in the case of zinc. However, the associations seem to be season-specific, which may limit the practical application of dietary diversity scores as tools to identify populations at risk of low micronutrient status.Uma ingestão pobre em micronutrientes (também chamado de "fome oculta"), pode comprometer a saúde e a capacidade de trabalho das meninas adolescentes. Em Moçambique, um país de baixa renda com uma elevada taxa de gravidez na adolescência, a deficiência em micronutrientes nas meninas é também um importante factor de risco para mortalidade materna e infantil, assim como para outros resultados adversos, como o baixo peso ao nascer, e deficiente desempenho cognitivo da criança. Os principais objectivos desta tese foram examinar a qualidade da dieta e os níveis de micronutrientes nas raparigas adolescentes no centro de Moçambique e verificar se a diversidade da dieta está associada aos bio-indicadores de micronutrientes. A tese também incluiu um estudo metodológico com o objectivo de avaliar a validade do uso de fotografias de alimentos (em porções estimadas) em raparigas adolescentes moçambicanas. O estudo de validação das fotografias de alimentos foi realizado em 2009. Dois alimentos básicos locais e três molhos (caril) foram seleccionados como teste e fotografias com três diferentes porções foram elaboradas, para cada porção. Foram servidas refeições pesadas as participantes (99 meninas de 13 a 18 anos de idade) e depois destas comerem a refeição, foram entrevistadas e pedidas a estimarem o tamanho das suas refeições com a ajuda das fotografias das diferentes porções de alimentos. Os resultados deste estudo indicaram uma tendência de subestimação do tamanho das porções. Ao nível do grupo, os resultados foram aceitáveis, mas foi encontrada uma grande variação na precisão das estimativas dos indivíduos. O estudo ZANE foi realizado em 2010. Foi um estudo transversal de base populacional sobre a dieta e o estado nutricional de raparigas, de 14 a 19 anos de idade, na Província da Zambézia. As regiões abrangidas no estudo incluíram uma área urbana e dois distritos rurais. Duas amostras diferentes de raparigas foram selecionadas: a primeira em Janeiro-Fevereiro ("período de fome", n=283) e a segunda em Maio-Junho (época de colheita, n=268). Uma entrevista sobre o consumo alimentar das últimas 24 horas e outra sobre a frequência alimentar dos últimos sete dias foram realizadas a cada participante. Amostras de sangue e de urina foram recolhidas, feitas análise sobre os níveis de hemoglobina no sangue e concentrações de ferritina sérica, zinco sérico, selénio no soro, iodo urinário, retinol no plasma e folato no soro. No estudo ZANE verificou-se que a mediana da ingestão energética, calculada a partir do consumo alimentar das últimas 24 horas, foi baixa [5.2 MJ / dia, intervalo entre os quartis: 3,6-7,4 (calculadas utilizando o peso da amostra); n=543]. Isto está de acordo com as conclusões do estudo de validade e é, pelo menos parcialmente explicado pelo facto das raparigas subestimarem a porção consumida com base nas fotos com as porções de alimentos. A baixa ingestão de vários micronutrientes e relativo altos níveis de relação molar fitato/zinco, típico em dietas em grupos populacionais de baixa renda, foram encontrados. Foi também registada uma variação sazonal na ingestão de vitamina A. Segundo as definições da Organização Mundial de Saúde, a anemia foi identificada como um problema de saúde pública grave enquanto que a deficiência de vitamina A foi consideradas como um problema de saúde pública moderado. As concentrações de ferritina sérica indicaram que a deficiência de ferro é prevalente na população. Também se identificou que a população tem o risco de deficiência de zinco. O estado de folato foram considerados adequado de um modo geral, mas uma excepção foram os baixos níveis de concentrações de folato sérico baixos registados na área urbana no período de Maio-Junho. Deficiência de iodo ligeira a moderada foi encontrada nos distritos rurais, enquanto os níveis de iodo das meninas urbanas era adequada. O estado de selénio foram considerados adequados. Na última parte da tese, as associações entre a diversidade alimentar e baixas concentrações de hemoglobina, ferritina no soro, zinco no soro, retinol no plasma e folato no soro nas raparigas não grávidas (n=227 em Janeiro-Fevereiro e n=223 em Maio-Junho) foram examinados em modelos de regressão logística usando três diferentes pontuações da diversidade alimentar. Na primeira pontuação, a pontuação da diversidade da dieta da mulher (WDDS) consistiu em nove grupos de alimentos calculadas a partir do consumo alimentar das ultimas 24 horas de acordo com as instruções da Organização para Alimentação e Agricultura das Nações Unidas (FAO). A segunda pontuação utilizou um limite mínimo de porção de 15 g (WDDS15g), e o terceira pontuação foi baseada nos questionários de frequência alimentar dos últimos sete dias (7dWDDS). Os resultados mais consistentes deste estudo foram as associações observadas para o zinco. Em Janeiro-Fevereiro, depois do ajuste dos factores de confusão (confunding factors), uma baixa (≤3) WDDS e uma baixa (≤5) 7dWDDS foram, cada um associado com maior chance de ter baixo níveis de zinco sérico (percentil ≤25 da distribuição sazonal específica) em comparação as altas pontuações. Essas associações não se registaram em Maio-Junho. Em conclusão, o uso de fotografias de porção de alimentos em adolescentes Moçambicanas mostrou um nível aceitável de validade. Entretanto, registou-se uma tendência das raparigas subestimarem as porções consumidas. No futuro, a produção e testagem conjuntos mais abrangentes de fotografias relevantes de alimentos locais será útil para estudos sobre dietas em países da África Subsahariana. A fome oculta foi registada como um problema de saúde pública entre as adolescentes no centro de Moçambique. Acções são necessárias para prevenir e controlar a fome oculta, especialmente no que diz respeito aos baixo níveis de ferro, zinco, iodo e de vitamina A. Os programas precisam de ser adaptados respondendo as diferenças urbano-rurais em termos de dieta e níveis de micronutrientes. Alguma relação entre a diversidade da dieta e os níveis de micronutrientes podem existir, especialmente no caso do zinco. Entretanto, esta associação parece ser específicas a estação do ano, o que pode limitar a aplicação prática do instrumento da pontuação da diversidade da dietética para a identificar populações em risco de ter baixos níveis de micronutrientes

Urban and rural dietary patterns are associated with anthropometric and biochemical indicators of nutritional status of adolescent Mozambican girls

Objective: The objective of the present study was to explore whether dietary patterns (DP) are associated with nutritional status indicators among adolescent Mozambican girls. Design/Setting/Subjects: In this population-based cross-sectional study we used the FFQ data of 547 girls aged 14-19 years from Central Mozambique to derive dietary patterns by means of principal component analysis. We used two-level linear regression models to examine the associations between the DP and anthropometric and biochemical indicators of nutritional status. Results: We identified three DP: 'Urban bread and fats', 'Rural meat and vegetables' and 'Rural cassava and coconut'. The 'Urban bread and fats' DP was positively associated with BMI-for-age Z-score (BMIZ), mid-upper arm circumference (MUAC), triceps skinfold (P for all <0.001) and blood Hb (P = 0.025). A negative association was observed between the 'Urban bread and fats' DP and serum folate (P <0.001). The 'Rural meat and vegetables' DP and the 'Rural cassava and coconut' DP were associated negatively with BMIZ, MUAC and triceps skinfold (P for all <0.05), but the 'Rural meat and vegetables' DP was associated positively with serum ferritin (P = 0.007). Conclusions: Urban and rural DP were associated with nutritional status indicators. In a low-resource setting, urban diets may promote body fat storage and blood Hb concentrations but compromise serum folate concentration. It is important to continue valuing the traditional, rural foods that are high in folate.Peer reviewe

Incorporation of novel foods in European diets can reduce global warming potential, water use and land use by over 80%

Global food systems face the challenge of providing healthy and adequate nutrition through sustainable means, which is exacerbated by climate change and increasing protein demand by the world's growing population. Recent advances in novel food production technologies demonstrate potential solutions for improving the sustainability of food systems. Yet, diet-level comparisons are lacking and are needed to fully understand the environmental impacts of incorporating novel foods in diets. Here we estimate the possible reductions in global warming potential, water use and land use by replacing animal-source foods with novel or plant-based foods in European diets. Using a linear programming model, we optimized omnivore, vegan and novel food diets for minimum environmental impacts with nutrition and feasible consumption constraints. Replacing animal-source foods in current diets with novel foods reduced all environmental impacts by over 80% and still met nutrition and feasible consumption constraints. The environmental impacts of more sustainable diets vary across regions. Using linear optimization, this study compares the reductions of global warming potential, water use and land use associated with the replacement of animal-sourced foods with novel or plant-based foods in European diets. Three diet types were considered to meet nutritional adequacy and consumption constraints.Peer reviewe

Fruit, Vegetable, and Fibre Intake among Finnish Preschoolers in Relation to Preschool-Level Facilitators and Barriers to Healthy Nutrition

Preschool is a major factor affecting food consumption among young children in Finland, given that most preschoolers eat three meals a day in that setting. Thus, it is important to recognise the determinants of dietary intake at preschool. The aim of this study was to examine food-related factors at the preschool and manager level, and their association with the dietary intake of children in childcare. The study was a part of the cross-sectional DAGIS survey conducted in 2015 to 2016 in Finland. The managers of 58 preschools filled in a questionnaire related to food and nutrition at their preschools. Preschool personnel kept food records for the children (n = 585) on two preschool days. Multilevel linear and logistic regression analyses were conducted with age, gender, and municipality as covariates, preschool-level factors as independent variables, and children’s vegetable (g/day) and fruit (yes vs. no) consumption and fibre intake (g/MJ) as outcome variables. Having many written food policies in the preschool was associated with a higher intake of vegetables (p = 0.01) and fibre (p = 0.03) among the children. Having at least two out of three cooperation-related challenges with the catering service was associated with a higher intake of fibre (p = 0.03) and lower odds of eating fruit (p = 0.01). Factors that are relatively distal from meal situations may have an effect, and should be taken into account in the promotion of healthy eating at preschool, but more studies are needed

Replacing dietary animal-source proteins with plant-source proteins changes dietary intake and status of vitamins and minerals in healthy adults : a 12-week randomized controlled trial

Purpose A shift towards more plant-based diets promotes both health and sustainability. However, controlled trials addressing the nutritional effects of replacing animal proteins with plant proteins are lacking. We examined the effects of partly replacing animal proteins with plant proteins on critical vitamin and mineral intake and statuses in healthy adults using a whole-diet approach. Methods Volunteers aged 20-69 years (107 female, 29 male) were randomly allocated into one of three 12-week intervention groups with different dietary protein compositions: ANIMAL: 70% animal-source protein/30% plant-source protein; 50/50: 50% animal/50% plant; PLANT: 30% animal/70% plant; all with designed protein intake of 17 E%. We analysed vitamin B-12, iodine, iron, folate, and zinc intakes from 4-day food records, haemoglobin, ferritin, transferrin receptor, folate, and holotranscobalamin II from fasting blood samples, and iodine from 24-h urine. Results At the end point, vitamin B-12 intake and status were lower in PLANT than in 50/50 or ANIMAL groups (PPeer reviewe

A cross-sectional study of children's temperament, food consumption and the role of food-related parenting practices

Although evidence exists of the association between children's temperament and weight, only few studies have examined how temperament is associated with actual food consumption among preschoolers. We examined concurrent associations between children's temperament and the consumption of different foods, and investigated whether the association between children's temperament and vegetable consumption is mediated by vegetable-related parenting practices. We utilized the data from the cross-sectional DAGIS study of 864 preschool children aged between three to six and their families, conducted between 2015 and 2016 in Finland. The parents reported their children's temperament, food consumption, and their vegetable-related parenting practices. Adjusted logistic regression analyses found positive associations between surgency and vegetable consumption as well as between effortful control and vegetable consumption. Both associations were mediated by one examined vegetable-related parenting practice: enhanced availability and autonomy support. No associations were found between children's negative affectivity and food consumption or vegetable-related parenting practices. In conclusion, children's temperament may be an important factor behind food-related parenting practices and children's diet. However, further longitudinal research and research covering different food-related parenting practices and home environment factors is necessary to better understand the complex associations between temperament and food consumption among young children.Peer reviewe

The Contribution of Preschool Meals to the Diet of Finnish Preschoolers

Preschool meals may influence the formation of children’s dietary habits and health. We assessed the contribution of preschool meals to the diet of Finnish children. We used food record data from the cross-sectional DAGIS survey and selected recording days which included all three meals (breakfast, lunch, afternoon snack) at preschool. We analyzed the diet of three- to four-year-olds (n = 324) and five- to six-year-olds (n = 233). Preschool meals accounted for 54% of the weekday’s energy intake in both age groups, and provided ≥60% of total fiber, polyunsaturated fatty acids, and vitamins D and E. More than 60% of fish dishes but only one third of total daily fresh fruit were consumed at preschool. The mean (SD) percentages of energy from protein and fat at preschool were 17% (3%) and 30% (7%) in the younger and 17% (3%) and 31% (6%) in the older age group, respectively. The mean proportions of energy from added sugar at preschool were below 5% in both age groups. On average, salt intake exceeded recommendations and 60% of salt came from preschool food. Tackling high salt intake should be a future goal of guidance for early childhood education and care food services

Associations of dietary diversity scores and micronutrient status in adolescent Mozambican girls

Purpose In low-income settings, dietary diversity scores (DDSs) often predict the micronutrient adequacy of diets, but little is known about whether they predict levels of biochemical indicators of micronutrient status. Methods In 2010, we studied two samples of non-pregnant 14-to 19-year-old girls in central Mozambique, the first in January-February ('hunger season'; n = 227) and the second in May-June (harvest season; n = 223). In this paper, we examined whether a low Women's Dietary Diversity Score (WDDS) predicts a low concentration of haemoglobin, serum ferritin, zinc, and folate, and plasma retinol in adolescent Mozambican girls. We constructed three scores: WDDS based on 24-h recalls, WDDS15g based on 24-h recall and employing a 15 g limit, and 7dWDDS based on 7-day food frequency questionnaires. Logistic regression models, stratified by season, were used to estimate the odds of having a low concentration of a status indicator ( Results In January-February, after adjusting for confounders, a low ( Conclusions Our data from Mozambique suggest that dietary diversity is associated with serum zinc, but this association seems to be limited to the hunger season.Peer reviewe