The double burden of malnutrition Case studies from six developing countries

Annexes

The NNI and FTRI/ARC surveys used different methods for analysing food intake data. In NNI surveys, data were converted into nutrient intakes using the Food Composition Table of Egypt, which is maintained by NNI and dates from 1996. To analyse the adequacy of nutrient intake, the NNI surveys used the RDAs from FAO/WHO/UNU (1985) for protein and energy, WHO (1989) for iron and FAO/WHO (1975) for vitamins A and C, except in the 2004 survey, for which FAO/WHO (2002) recommendations for vitamins and minerals were used.

The food intake data of ARC/FTRI surveys were converted into nutrient intakes using a modification of the USDA standard reference database (the Food Intake and Analysis System, Version 2.3, University of Texas), which was adjusted to remove the influence of enrichment/fortification and to include more than 1 000 Egypt-specific recipes (Khorshed et al., 1998). Nutrient intake adequacy was expressed using current versions of the United States RDAs (published by the National Academy Press from 1989 onwards).

Because of these important methodological differences between the surveys conducted by NNI and FTRI/ARC, each set is presented separately in these annexes. However, both used internally consistent methodology, so trends over time in the data are reliable.

ANNEX 1: FOOD INTAKE AND NUTRITIONAL STATUS

Survey name	Year	Sample size	Age range	Representation	Method of analysis	Institution	Source
National Food	1981	6 300 households	2-6 years	National	Dietary¹	NNI	Aly et al., 1981
Consumption			10-19 years		Anthropometry²
Survey			Adults = 20 years
Effect of increasing food cost on families’ behaviour regarding feeding their members	1989	2 022	Individuals	Regional (Cairo	Dietary¹	NNI	Hussein, et al., 1989
		363	Households	- Assuit, El-Behera)
Household food budget survey	1990/1991	1 500	Households	National	Questionnaire	CAPMAS
		82 109	Individuals
Assessment of IDD status among schoolchildren	1992	9 538	6-11 years	National (22 governorates)	Total goitre rate	NNI	Hussein et al., 1992
		11 466	12-14 years		Lab³
		9 854	15-18 years		- urinary iodine
Assessment of vitamin A status in Egypt	1995	1 628	0.5-5.99 years	National (five governorates representing different regions of urban and rural Egypt)	Dietary¹
		855 M			Anthropometry²
		775 F			Lab³
		1 629 F			- haemoglobin	NNI	Moussa, El-Nehry and Abdel Galil, 1995
					- plasma retinol

Survey name	Year	Sample size	Age range	Representation	Method of analysis	Institution	Source
EDHS	1995	9 766 M/F	0-5 years	National (26 governorates)	Anthropometry²	National	EDHS, 1995
		265 F	15-19 years			Population
		6 314 F	15-49 years			Council
Development of food consumption monitoring system	1995	3 186 households	2-6 years Mothers	National (five governorates representing urban and rural areas: Cairo, Ismalia, Dhakahlia, Aswan, New Valley)	Anthropometry²	Food Technology Research Institute	Khorshed, Ibrahim and Galal, 1995
					Dietary¹
Household food budget survey	1995/1996	14 805	Households	National	Questionnaire	CAPMAS
		73 939	Individuals
Child well-being in Egypt	1997	814 M		National (six governorates: Alexandria, Assuit, Aswan, Great Cairo, Quena, Sohag)	Anthropometry²	American University in Cairo, Social Research Center	El-Tawela, 1997
		815 F	0-5 years

Survey name	Year	Sample size	Age range	Representation	Method of analysis	Institution	Source
EDHS	1997	3 328	6-60 months	National (26 governorates)	Anthropometry²	National Population Council	EDHS, 1997
Assessment of protein energy malnutrition, iron deficiency anaemia and vitamin A deficiency in Menia, Assuit and Sohag governorates	1997	2 700	Mothers	Regional (Menia Sohag, Assuit)	Anthropometry²	High Institute of Public Health Alexandria	El-Sayed, 2002
		2 700	Children 6-71 months		Dietary¹
					Laboratory³
					- haemoglobin
					- plasma retinol
					- stool analysis

Survey name	Year	Sample size	Age range	Representation	Method of analysis	Institution	Source
Nutritional deficiencies among primary schoolchildren	1998	3 000	6-12 years	Regional (three governorates: Cairo, Quena, Sherkia)	Anthropometry²	NNI	Hassan et al., 1998
o					Dietary¹
					Laboratory³
					- haemoglobin
					- serum ferritin
					- serum zinc
					- serum retinol
					- serum selenium
					- urinary iodine
					- stool analysis
Transition to adulthood: national survey of Egyptian adolescents	1999	9 128	10-19 years	National (21 governorates)	Anthropometry²	Agriculture Research Centre	ARC, 2001/2002
		13 271	Households		Dietary¹
					Laboratory³
					- haemoglobin
Household food budget survey	1999/2000	47 949	Households	National	Questionnaire	CAPMAS
		226 107	Individuals
Egyptian adolescent anaemia prevention programme	1992/2000	700	Schoolchildren	Regional (Aswan)	Questionnaire	Ministry of Health, health insurance organization

Survey name	Year	Sample size	Age range	Representation	Method of analysis	Institution	Source
Intra-household food distribution among Egyptian families	2000	720	2-6 years	Subnational: Cairo, Kalyobia and Beheira	Dietary¹	NNI	Shaheen and Tawfik, 2000
		885	6-12 years		Anthropometry²
		532 M	12-19 years
		554 F
		1 270 M	20-65 years
		1 470 F	20-48 years
Food consumption pattern and nutrition intake among different population groups	2000	9 134 M/F	< 24 years	National (six governorates representing urban and rural areas: Cairo, Alexandria, Sharkia, Beheria, Fayoum, Sohag)	Anthropometric measurement²	NNI	Hassanyn, 2000
		384 M/F	2-6 years		Dietary assessment¹
		1 151 M/F	6-10 years
		942 M/F	10-18 years
		3 047 M/F	³ 18 years
		4 562 M/F
EDHS	2000	15 573 M/F	0-5 years	National (26 governorates)	Anthropometry²	National Population Council	EDHS, 2000
			5-10 years		Laboratory³
			10-20 years		- haemoglobin
			20-65 years
			³ 65 years

Survey name	Year	Sample size	Age range	Representation	Method of analysis	Institution	Source
Iron supplement distribution system: A trial for primary schoolchildren	2000	1 950 girls	11-14 years	Regional (Giza)	Laboratory³	NNI/MOHP	Shaheen et al., 2000
		1 250 boys			-haemoglobin
					Focus group discussions
School-based delivery system for iron supplement programme in Egyptian primary schools	2000	7 256	Schoolchildren (11-14 years)	Regional (Sharkia, Kafr El sheikh)	Focus group	NNI/MOHP	Shaheen et al., 2000
					Laboratory³
					- haemoglobin
Health and nutritional status of the elderly	2001	4 876	³ 65 years	National (six governorates representing urban and rural areas: Cairo, Alexandria, Port Said, Garbia, Fayoum, Aswan)	Anthropometry²	NNI	Hassan et al., 2001
					Dietary¹
					Laboratory³
					- haemoglobin
					- fasting blood sugar
					- serum retinol
					- total cholesterol
					- liver enzymes
					- renal function
					Tests
					- plasma oestrogen
					- urinary calcium

Survey name	Year	Sample size	Age range	Representation	Method of analysis	Institution	Source
Survey to assess current status of anaemia and vitamin A deficiency	2002	3 000	F adults	National (Alexandria, Beheria, Garbia, Assuit)	Anthropometry²	High Institute of Public Health/MOHP/Health Care Department/UNICEF	El Sayed et al., 2002
		3 000	2-6 years		Laboratory³
					- haemoglobin
					- plasma retinol
EDHS	2003	5 761	< 5 years	National (26 governorates)	Anthropometry²	National Population Council	EDHS, 2003
		3 014 M	15-49 years		Laboratory³
		2 748 F			- haemoglobin
		8 078 F
Social marketing campaign for iodized salt	2003/2004	1 208	Market	Regional (Quena)	Focus group discussion	NNI	Hassan, Abdel Galil and Moussa, 2004
		3 114	Household

Survey name	Year	Sample size	Age range	Representation	Method of analysis	Institution	Source
Prevalence of obesity in Egypt	2004	31 798	Individual	National (eight governorates representing urban and rural areas: Cairo, Gharbia, Quena, Beniswef, Marsa Matrouh, El wadi El Gadid, Beheria, Swey)	Anthropometric measurement²	NNI	Shaheen, Hathout and Tawfik, 2004
		4 154	2-6 years
		2 433	6-12 years
		6 190	12-19 years
		19 021	³ 20 years
Determination of bone mass density among adolescents and adults in Egypt	2004	2 520	Households 20-60 years	National (Cairo, Red Sea, Sohag, Sharkia)	Dietary¹	NNI	Hassan, Abdel Galil and Moussa, 2004
		2 446	F adults 20-60 years		Anthropometry²
		2 028	M adults 20-60 years		- BMD (DXA densitometry)
		2 039	M adolescents 10-19 years		Laboratory³
		2 021	F adolescents 10-19 years		- haemoglobin
					- calcium
					- phosphorus
					- alkaline phosphates
					- osteocalcin
					- oestrogen
					- testosterone
					- cholesterol
					- retinol
					- vitamin D
					- zinc/selenium
					- TSH

¹ Method used for dietary analysis was 24-hour recall, comparing the raw composition of the diet in the analysis with the NNI food composition tables.

² Anthropometry analysis was according to age: for two to 12 years - weight, height z-score (weight-for-age, weight-for-height, height-for-age); for 12 to 19 years - BMI for age, height for age; = 20 years - BMI.

³ The laboratory method used was selected according to the objectives of the study.

ANNEX 2: DIETARY ASSESSMENT

The methods used to measure the food consumption of the families surveyed can be classified into two major categories: dietary pattern methods, for example, those that use food frequency questionnaires; and quantitative daily consumption methods, which are based on recall or records of the quantities of foods and beverages consumed over a one-day period - the 24-hour recall method.

Dietary pattern: food frequency questionnaire

This method obtained qualitative descriptive information about the usual frequency of food and beverage consumption for the whole family per day or per week; food items were categorized according to whether they were consumed - for example - fewer than three times a week, or at least three times a week.

The food groups included in this questionnaire were:

cereals and starchy roots;
legumes and pulses;
oils and fats;
meat, fish and poultry;
milk and dairy products;
vegetables and fruits;
sugar.

24-hour recall method

In this method, every surveyed person was asked to recall his or her exact food and beverage intake for the previous 24-hour period. Quantities of foods and beverages consumed were estimated in household measures and grams.

The information obtained covered all eating events, in sequence, beginning with the first of the day; each event was classified as major or minor and all the food items consumed were recorded.

Each food and beverage consumed was described in detail, including cooking methods and the amounts of each ingredient used. Household measures were converted into grams by referring to a list of weights of commonly used household measures in Egypt, which was developed by NNI. NNI’s food composition tables were used to determine the energy and nutrient intakes of each individual.

Adequacy of the diet consumed was assessed by comparing the energy and nutrient intakes of each person with his or her RDAs (FAO/WHO/UNU, 1985; WHO, 1989).

A food coding system was used, in which the first two digits denoted the food group, the second two digits denoted the food item, and the third two digits denoted the preparation method.

Weights of foods and beverages were converted into energy and nutrient intakes by a computer program developed from an energy and nutrient database.

Analysis was based on:

energy and nutrients as percentages of RDAs (< 50 percent, 50 to 75 percent, 75 to 100 percent, and ³ 100 percent);
iron bioavailability was assessed according to the daily quantity of haem iron sources consumed - meat, poultry and fish - in grams, or of ascorbic acid in milligrams:

- low bioavailability: < 30 g of haem iron sources, or < 25 mg of ascorbic acid;
- intermediate bioavailability: 30 to 90 g of haem iron sources, or 25 to 75 mg of ascorbic acid;
- high bioavailability: ³ 90 g of haem iron sources, or > 75 mg of ascorbic acid;
the vitamin A content of the diet was based on the retinol activity equivalent, which is equivalent to 1 µg of all trans retinol, to 6 µg of all trans betacarotene, and to 12 µg of other provitamin A carotenes.

ANNEX 3: DIET-RELATED CHRONIC DISEASES, DATA SETS

Survey name and source	Year	Sample size	Age range	Representation	Method of analysis used
Health Profile of Egypt-Health Examination Survey (HPE-HES) Said, 1987	1987	14 151	> 6 years	National	Measurement of blood pressure
		48.0% F		33.7% urban areas	Questionnaire, self-reported treatment with antihypertensive medication
		52.0% M		66.3% rural areas
National Hypertension Project (NHP) Ibrahim et al., 1995	1991	6 733	25-95 years	National (six governorates: Cairo, Bani Sweif, Aswan, Sharkia, Port Said, El Wadi El Gedid)	Measurements of blood pressure (average of four)
					Hypertension defined as average systolic blood pressure ³ 140 mmHg, and/or diastolic ³ 90 mmHg, and/or self-reported treatment with antihypertensive medication
Prevalence of Hypertension in Adolescents Abdel Fattah, Abd-Alla and Al-Saeid, 2000	2000	5 133	14-20 years	Regional (Qalyubia governorate)	Measurements of blood pressure (average of three)
		2 660 M			Blood pressure classified according to Fifth Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNCV) (1993) for the young age group, as a percentile correlated with height
		2 473 F
		Most primary and secondary schools
Diet, Nutrition and Prevention of Chronic Non-Communicable Diseases Ismail, 2005	2003/2004	6 000	12-18 years	National, urban and rural areas (seven governorates: Giza, Kalyubia, Kafr al Shekh, Al Sharkia, Aswan, Suhag, Al Menia)	Full medical history
					Dietary history
					Anthropometric measurement (weight and height) for BMI
					Blood pressure measurement
					Blood pressure classified according to Fifth Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNCV) (1993) for the young age group, as a percentile correlated with height
					Blood sugar: fasting and post-prandial
					Serum lipids: cholesterol, LDL-ch, HDL-ch and triglycerides

Survey name and source	Year	Sample size	Age range	Representation	Method of analysis used
Diabetes Mellitus in Egypt	1991-1994	4 620	³ 20 years	Regional (Cairo, Giza, Kaliubia)	Height, weight, WHR
Hermann et al., 1995					Random capillary glucose
					For individuals at risk:
					- fasting blood glucose
					- glucose 2 hours after 75 g glucose load
					- diabetes and impaired glucose tolerance (IGT) classified according to WHO (1993) criteria
Focusing on the Health Requirements and Style of Living to Improve the Health of Elderly People in Different Cultural Sectors in Egypt	2001	4 876	³ 65 yrs	National, rural and urban areas (six governorates: Cairo, Alexandria, Port- Said, El Garbia, El Fayoum, Aswan)	Full medical history
Hassan et al., 2001					BMD measured by DXA densitometer acting peripherally on calcaneous site
					Assessment of BMD status based on WHO (1994) diagnostic categories
					Anthropometric measurements (weight and height) for BMI
					Dietary history (24-hour recall)
					Laboratory measurement: liver function, kidney function and heartbeat
National Survey for the Determination of Bone Mass Density (BMD) among Adolescents and Adults in Egypt.	2004	2 520 families	10-19 years	National, rural and urban (six governorates: Cairo, Sohag, Red Sea, Sharkia, Dhakahlia, Beheira)	Full medical history
Hassan, Abdel Galil and Moussa, 2004			20-60 years		BMD measured by DXA densitometer acting peripherally on calcaneous site
					Anthropometric measurements (weight and height) for BMI
					Dietary history (24-hour recall)
					Laboratory measurement of haemoglobin, calcium, phosphorus, alkaline phosphates, osteocalcin, oestrogen, testosterone, cholesterol, retinol, vitamin D, zinc, TSH, and selenium
					Assessment of BMD status based on WHO (1994) diagnostic categories