In the present review, the association of out-of-home eating with anthropometric changes was examined. Peer-reviewed studies in eight databases were searched, and 15 prospective studies were included in the review. The quality of the data was assessed by considering risks of bias in sample selection, data collection methods, and the appropriateness of statistical tests. From this, seven studies, which used relatively large samples or had a follow-up period longer than 10 years, were retained for further analysis. It was concluded that eating out-of-home frequently, in the broad sense, is positively associated with the risk of becoming overweight or obese and weight change. With regard to specific out-of-home sources, the review shows that eating at fast-food outlets is associated with a greater increase in body weight and waist circumference over time than eating at restaurants and takeaway foods positively predict BMI change in women. More research is needed on out-of-home foods other than fast-foods and restaurant foods, such as street, canteen, and school foods.

Low iron and high phytic acid content make fonio based meals a poor source of bioavailable iron. Phytic acid degradation in fonio porridge using whole grain cereals as phytase source and effect on iron bioavailability when added to iron fortified fonio meals were investigated. Grains, nuts and seeds collected in Mali markets were screened for phytic acid and phytase activity. We performed an iron absorption study in Beninese women (n = 16), using non-dephytinised fonio porridge (FFP) and dephytinised fonio porridge (FWFP; 75% fonio-25% wheat), each fortified with Fe-57 or Fe-58 labeled FeSO4. Iron absorption was quantified by measuring the erythrocyte incorporation of stable iron isotopes. Phytic acid varied from 0.39 (bambara nut) to 4.26 g/100 g DM (pumpkin seed), with oilseeds values higher than grains and nuts. Phytase activity ranged from 0.17 +/- 1.61 (fonio) to 2.9 +/- 1.3 phytase unit (PU) per g (whole wheat). Phytic acid was almost completely degraded in FWFP after 60 min of incubation (pH approximate to 5.0, 50 degrees C). Phytate: iron molar ratios decreased from 23.7:1 in FFP to 2.7:1 in FWFP. Iron fortification further reduced phytate: iron molar ratio to 1.9:1 in FFP and 0.3:1 in FWFP, respectively. Geometric mean (95% CI) iron absorption significantly increased from 2.6% (0.8-7.8) in FFP to 8.3% (3.8-17.9) in FWFP (P<0.0001). Dephytinisation of fonio porridge with intrinsic wheat phytase increased fractional iron absorption 3.2 times, suggesting it could be a possible strategy to decrease PA in cereal-based porridges.

A food consumption survey on 420 children was conducted in four areas in Benin to identify the local vitamin A (VA)-rich foods most frequently eaten and assess their contribution to the coverage of VA requirements of young children. Mangoes, eggs, red palm oil, various leafy vegetable (LV) sauces and palm nut juice sauce appeared to be the main VA-rich foods consumed. The recipes of the most promising sauces were characterised. Sauces with red palm oil/palm nut juice showed high carotenoid contents ranging from 0.9±0.3 to 4.0±0.8mg Retinol Activity Equivalent/100g dry matter (DM). Lipid contents were also high (from 39.6 to 66.8g/100g DM). When consumed, and taking into account the mean quantity eaten per meal, LV sauces containing red palm oil or palm nut juice contributed to the meeting of more than 70% of the recommended VA intake of young children.

ObjectiveTo identify factors influencing intention to consume an indigenous nutritious grain, fonio (Digitaria exilis), among women in Mali.DesignA cross-sectional questionnaire survey based on the Theory of Planned Behavior and the Health Belief Model.Setting and ParticipantsOne hundred and eight women (31.5 ± 10.5 years), randomly selected by a 3-stage cluster sampling, Bamako, Mali.Main Outcome MeasuresModel constructs scores, intention to consume fonio, and fonio consumption.AnalysisCorrelation and multiple regression, Wilcoxon signed rank and Mann-Whitney tests for score comparison.ResultsAttitudes toward behavior (β = .32, P < .05) was the best predictor of intention to consume fonio, which was significantly correlated with fonio consumption (rho = .78, P < .001). Health value (β = .23, P < .05) was a significant predictor of health behavior identity, which was significantly correlated with attitudes toward behavior (rho = .67, P < 0.001) and perceived barriers (rho = .33, P < .001). The latter formed a significant interaction term between intention and behavior (β = -.72, P < .05).Conclusions and ImplicationsFonio consumption could be increased in Bamako through stimulation of positive attitudes, changing men's beliefs, influencing family and neighbors' opinions, and improving the processing and the skills of women who prepare fonio.

OBJECTIVE:To identify the determinants of fruit and vegetable consumption in urban Beninese adolescents and elements to develop a school-based fruit and vegetable program.DESIGN:Sixteen focus groups conducted with a key word guide.SETTING AND PARTICIPANTS:Two private and 2 public secondary schools in Cotonou, Benin. One hundred fifty-three students aged 13 to 19 years, 54% girls.ANALYSIS:The focus groups were audiotaped, transcribed, and analyzed. Three a priori categories from the Social Cognitive Theory were used for the coding: socioenvironmental, personal, and behavioral factors. Additionally, the data were checked to determine whether new categories should be created.RESULTS:Major determinants in the school were availability and accessibility of fruits and vegetables, nutrition education, and the competition of unhealthful foods. Food safety emerged as a strong barrier to the adolescents' fruit and vegetable consumption outside home and particularly at school.CONCLUSIONS AND IMPLICATIONS:Except for food safety, the determinants of fruit and vegetable intake in Beninese adolescents were similar to those in high-income countries. The food safety of fruits and vegetables outside home is a key issue to be studied in detail and integrated in any intervention in Benin and potentially other low- and middle-income countries.

The present study investigated the association between weight status and Fe deficiency (ID) among urban Malian women of reproductive age. Height, weight, serum ferritin (SF), soluble transferrin receptor (sTfR) and C-reactive protein (CRP) concentrations were measured in sixty apparently healthy women aged 15-49 years old in Bamako, Mali. Prevalences of overweight and obese were 19 and 9 %, respectively. SF was non-significantly different between overweight (84 μg/l) and normal-weight women (52 μg/l). The prevalence of ID (SF < 12 μg/l) was 9 % in the overweight group and no true ID (sTfR>8·3 mg/l) cases were recorded in the overweight and obese groups. The prevalence OR of ID (SF < 12 μg/l) in the overweight group was NS (OR = 0·3; P = 0·363). Conversely, the chronic energy deficiency group was at a significantly higher risk of ID than the normal-weight group, adjusting or not for CRP (OR = 7·7; 95 % CI 1·49, 39·96; P = 0·015). The lack of association between overweight and ID in the present study could be due to the fact that the excess of body fat of the women might not be critical to induce chronic inflammation related to reduced Fe absorption. Future research based on a larger convenience sample should be designed to further investigate associations between overweight, obesity and ID in developing countries.

The objective of the present study was to document the food, energy and macronutrient contribution of out-of-home prepared foods in school-going adolescents in Cotonou (Benin) and compare the food, energy and macronutrient intakes of low and high out-of-home consumers. We used a cross-sectional study with 24 h dietary recalls on two non-consecutive school days to collect food intake data. Low and high consumers were defined respectively as subjects whose percentage of daily energy intake from out-of-home foods was in the first and the third terciles of the sample distribution. The setting was twelve secondary schools in Cotonou with 656 adolescents aged 13-19 years. Out-of-home prepared foods contributed more than 40 % of the daily energy, fat, protein, carbohydrate and fibre intakes and of the daily weight of food in the adolescents. They were highly present at breakfast and as afternoon snacks in high consumers, providing respectively 94 and 82 % of the energy intake of high consumers at breakfast and as afternoon snacks. Low consumers ate more fruit and vegetables and cereal grain products than high consumers whereas high consumers consumed more sweet energy-dense foods. Both categories had a diet poor in fruit and vegetables (hardly one-fourth of the recommended 400 g) and high in fat. We concluded that out-of-home foods are important in the diet of urban school adolescents in Benin. Therefore, they should be investigated in depth and taken into account in the development of interventions to promote healthy diet and lifestyles in adolescents.

Food diversification is recognized as an approach to reduce nutrient deficiencies among the population. Samples of food commonly consumed by the children in two agro ecological zones (Coastal Savannah Zone in the South (CSZ) and Sudan Savannah Zone in the North (SSZ)) of Benin were collected for energy, protein, fat, iron, zinc and vitamin A contents determination. Energy content ranged from 76 to 82 kcal/100 g (wet basis) in the cereal paste collected in the CSZ and from 60 to 105 kcal/100 g in the SSZ. In the samples sauces from CSZ, energy ranged between 49 and 189 kcal/100 g; and protein from 1.9 to 5.6 g/100 g; Iron and zinc contents ranged between 1.8 - 5.0 and 0.2 - 1.1 mg/100 g respectively while vitamin A content from 428 to 6394 mg RE/100 g. Samples sauces gave 39.0 - 84.1 kcal/100 g of energy; 1.5 - 4.3 g of protein; 1.6 - 5.6 mg of iron; 0.08 - 0.8 mg of zinc and 44.8 - 3805 mg RE of vitamin A in the SSZ. The same zone showed high food variability with 12 types of foods versus 5 for CSZ. However, high prevalence of protein-energy malnutrition is observed among the children in the SSZ. Then, the food variability is not a sufficient factor to improve the nutritional status of the children. Key words: Agro-ecological zones, nutritional composition, energy content, protein content, iron content, zinc content.

The prevalence of micronutrient deficiency is high among women of reproductive age living in urban Mali. Despite this, there are little data on the dietary intake of micronutrients among women of reproductive age in Mali. This research tested the relationship between the quantity of intake of 21 possible food groups and estimated usual micronutrient (folate, vitamin B-12, calcium, riboflavin, niacin, vitamin A, iron, thiamin, vitamin B-6, vitamin C, and zinc) intakes and a composite measure of adequacy of 11 micronutrients [mean probability of adequacy (MPA)] based on the individual probability of adequacy (PA) for the 11 micronutrients. Food group and micronutrient intakes were calculated from 24-h recall data in an urban sample of Malian women. PA was lowest for folate, vitamin B-12, calcium, and riboflavin. The overall MPA for the composite measure of 11 micronutrients was 0.47 ± 0.18. Grams of intake from the nuts/seeds, milk/yogurt, vitamin A-rich dark green leafy vegetables (DGLV), and vitamin C-rich vegetables food groups were correlated (Spearman's rho = 0.20-0.36; P < 0.05) with MPA. Women in the highest consumption groups of nuts/seeds and DGLV had 5- and 6-fold greater odds of an MPA > 0.5, respectively. These findings can be used to further the development of indicators of dietary diversity and to improve micronutrient intakes of women of reproductive age.

The impact of a 4‐weeks nutrition education program combined with an increase in the content and bioavailability of dietary iron for 22 weeks was studied in 34 intervention boarding‐school girls who suffered from mild iron deficiency anemia. Thirty‐four anemic adolescent girls from another boarding‐school not exposed to the dietary program, served as control. There were no significant differences between the two groups for iron and vitamin C intakes at baseline. Within the intervention group, dietary iron increased from baseline (18.2 ± 5.0 mg) to mid (21.6 ± 5.4 mg) and post‐intervention (23.2 ± 4.5 mg) indicating a significant time effect interaction. In the control group, dietary iron intakes decreased from baseline (17.0 ± 3.6 mg) to mid‐intervention (15.6 ± 6.8mg) but increased at the end of the study (18.3 ± 5.9 mg), although the interaction time effect was not significant. A significant group‐by‐time interaction was observed between the two groups for dietary iron. Similar results were observed for all other nutrients including absorbable iron. A significant reduction in the prevalence of anemia (68%) and iron‐deficiency anemia (74%) was observed in the intervention group compared to the control group (15 and 44% respectively). A multi‐dietary strategy aiming to improve iron intakes and bioavailability without iron supplementation reduced iron deficiency anemia in these young Beninese adolescent girls.

BACKGROUND:Iron deficiency anemia (IDA) affects many young women in sub-Saharan Africa. Its etiology is multifactorial, but the major cause is low dietary iron bioavailability exacerbated by parasitic infections such as malaria.OBJECTIVE:We investigated whether asymptomatic Plasmodium falciparum parasitemia in Beninese women would impair absorption of dietary iron or utilization of circulating iron.DESIGN:Iron absorption and utilization from an iron-fortified sorghum-based meal were estimated by using oral and intravenous isotope labels in 23 afebrile women with a positive malaria smear (asexual P. falciparum parasitemia; > 500 parasites/μL blood). The women were studied while infected, treated, and then restudied 10 d after treatment. Iron status, hepcidin, and inflammation indexes were measured before and after treatment.RESULTS:Treatment reduced low-grade inflammation, as reflected by decreases in serum ferritin, C-reactive protein, interleukin-6, interleukin-8, and interleukin-10 (P < 0.05); this was accompanied by a reduction in median serum hepcidin of ≈ 50%, from 2.7 to 1.4 nmol/L (P < 0.005). Treatment decreased serum erythropoietin and growth differentiation factor 15 (P < 0.05). Clearance of parasitemia increased geometric mean dietary iron absorption (from 10.2% to 17.6%; P = 0.008) but did not affect systemic iron utilization (85.0% compared with 83.1%; NS).CONCLUSIONS:Dietary iron absorption is reduced by ≈ 40% in asymptomatic P. falciparum parasitemia, likely because of low-grade inflammation and its modulation of circulating hepcidin. Because asymptomatic parasitemia has a protracted course and is very common in malarial areas, this effect may contribute to IDA and blunt the efficacy of iron supplementation and fortification programs. This trial was registered at clinicaltrials.gov as NCT01108939.

Anemia affects many young women in sub-Saharan Africa. The aetiology of anemia in Africa is multifactorial, but the major cause is low dietary iron bioavailability from monotonous, cerealbased diets exacerbated by chronic parasitic infections such as malaria. Malaria causing chronic inflammation and therefore reducing iron bioavailability could be the reason for the blunted effect of iron fortification in fortification trials in sub-Saharan Africa. Many women in malaria endemic areas do not develop acute febrile malaria when infected with P. falciparum; rather, they exhibit asymptomatic parasitemia which has an unpredictable and often protracted course. Asymptomatic parasitemia potentially could reduce iron absorption and/or utilisation by causing subtle inflammatory changes. Therefore we measured the effect of asymptomatic parasitemia on host iron absorption and utilisation. The study site was Natitingou in northern Benin. Subjects were: 1) female; 2) age 18–30 y; 3) body weight < 65 kg; 4) not pregnant or lactating; 5) no chronic medical illnesses; 6) no medicinal iron at the time of entry into the study; 7) a positive malaria smear (asexual P. falciparum parasitemia > 500/μL blood without clinical symptoms; 8) no soil-transmitted helminthes infection. Iron absorption and utilisation was measured using stable isotope technique. Subjects were studied while infected, then they were treated, and then they were restudied. Clearance of parasitemia was associated with a reduction in low-grade inflammation, with a slight improvement in erythropoiesis and a significant 70 % increase in dietary iron absorption. No effect on systemic utilisation of iron was observed with clearance of parasitemia. Asymptomatic malaria may exacerbate nutritional iron deficiency by limiting iron absorption form diets that are already low in bioavailable iron. Thus the benefit of intermittent treatment of malaria on anemia rates is not only due to the suppression of acute malarial anemia, but also to the periodically clearance of asymptomatic parasitemia and thereby improving dietary iron bioavailability.

Background To our knowledge, the impact of a nutrition education program combined with an increase in bioavailable dietary iron to treat iron-deficiency anemia has never been studied in adolescent girls. Objective To evaluate the impact of an intensive dietary program for the treatment of iron-deficiency anemia in 34 intervention and 34 control boarding-school girls aged 12 to 17 years from Benin. Methods A quasi-experimental design consisting of 4 weeks of nutrition education combined with an increase in the content and bioavailability of dietary iron for 22 weeks was implemented in the intervention school, but not in the control school. Data were obtained from both groups from a nutrition knowledge questionnaire, 24-hour dietary recalls, anthropometric measurements, measurement of iron status indices, and screening for malarial and intestinal parasitic infections. Results Nutrition knowledge scores and mean intakes of nutrients, including dietary iron, absorbable iron, and vitamin C, were significantly higher in the intervention group ( p < .05) than in the control group after 26 weeks. Mean hemoglobin and serum ferritin values were also significantly higher in the intervention group than in the control group (122 vs. 112 g/L [p = .0002] and 32 vs. 19 μg/L [ p = .04], respectively), whereas the prevalence of anemia (32% vs. 85% [ p = .005] and iron-deficiency anemia (26% vs. 56% [ p = .04]) was significantly lower in the intervention group than in the control group. No significant differences between the groups were observed in intestinal parasitic infections or malaria status postintervention. Conclusions A multidietary strategy aiming to improve available dietary iron can reduce iron-deficiency anemia in adolescent girls.

UNLABELLED:To our knowledge, the impact of socioeconomic and health related factors on the iron status of adolescent girls has never been studied in Benin. OBJECTIVE:These factors were studied in 180 girls aged 12 to 17 years living in two boarding schools from South Benin. METHODS:Iron deficiency (ID) was defined as either serum ferritin (SF) < 20 microg/L or SF between 20-50 microg/L plus two abnormal values in the three following parameters: serum iron < 11 micromol/L, total iron binding capacity > 73 micromol/L or transferrin saturation < 20%. Socioeconomic and health related factors were obtained from each participant by mean of an interview using a standardized and pre-tested questionnaire. RESULTS:Almost half the participants reported some health problems in the last four months before the study, whereas more than 75% auto-medicated before going to the hospital. The majority of the girls believed themselves to be in good health, although only 16% could define the term 'anemia'. Multivariate regression analysis indicated that girls whose mother was a manual worker (P = .002), who came from a larger family (P = .0001), and who auto-medicated (P = .014), had a lower hemoglobin level, whereas girls who had started their menstruation (P = .008) had a lower SF level. In a logistic regression analysis, girls from a large family size and whose mother was a manual worker showed a higher risk of IDA (OR = 3.5; 95% CI = 1.1-2.5; P = .04; OR = 3.0; 95% CI = 1.2-2.2; P = .04 respectively). CONCLUSION:The findings indicate that iron deficiency is related to the occupation of the mother, family size, auto-medication, and menstruation.

A 26-week nutrition intervention, including 4 weeks of nutrition education, combined with an increase in the content and bioavailability of dietary iron for 22 weeks was carried out in 34 intervention and 34 control adolescent girls suffering from mild iron deficiency anemia (IDA). In post-intervention, hemoglobin and serum ferritin were significantly higher in the intervention group, whereas the incidence of IDA was significantly lower in the intervention group compared to the control group. Nutrition knowledge scores were significantly higher in intervention girls compared to control girls. Dietary changes to improve available dietary iron can reduce iron deficiency anemia.

The purpose of this study was to evaluate the impact of a multi‐dietary strategy to treat IDA in adolescent girls. A quasi‐experimental design involving 34 intervention and 34 control girls aged 12 to 17 years and suffering from mild IDA was carried out in two boarding schools from southern Benin. IDA was defined as haemoglobin (Hb) between 100–120 g/L and serum ferritin (SF) <20 μg/L or serum ferritin between 20–50 μg/L plus two of the following parameters: serum iron <11 μmol/L, total iron binding capacity >68 μmol/L or transferrin saturation <20%. A 26‐week intervention including 4 weeks of nutrition education combined with an increase in the content and bioavailability of dietary iron in the cafeteria menu for 22 weeks was implemented in the intervention school, but not in the control school. After controlling for baseline variables, Hb and SF were higher (122 vs. 113g/L; P=0.0002; 32 vs. 19μg/L; P=0.04), whereas incidence of anemia (32 vs. 85%; P=0.0003) and of IDA (26 vs. 56%; P=0.04) was lower in the intervention group compared to the control group. Also, nutrition knowledge scores were significantly higher in intervention girls compared to control girls at the end of the study. No significant differences were observed in IPI and malaria status of both groups post‐intervention. These findings indicate that dietary changes to improve available dietary iron can reduce iron deficiency anemia.

Intestinal parasitic infections (IPI), especially helminths, represent a major public health problem that increase iron deficiency anaemia in developing countries. This study investigated the prevalence, risk factors and nutritional consequences of IPIs in 180 adolescent girls aged 12-17 years living in two boarding schools in southern Benin. Data were collected using a structured questionnaire and laboratory analysis of blood and faecal samples. The relationships between socioeconomic indicators, IPIs and iron status were analysed using logistic regression analysis. Fifty percent of the subjects were infected with at least one IPI: 2% with helminths, 41% with protozoa and 7% with two or more intestinal parasites. Adolescent girls from a large family and those whose mothers were manual workers showed a higher risk of intestinal parasitism (odds ratio (OR) = 3.5, 95% CI 2.5-5.2 (P = 0.02) and OR = 2.4, 95% CI 2.0-3.0 (P = 0.03), respectively). Likewise, drinking untreated water was also a high risk factor for infection (OR = 2.3, 95% CI 1.5-2.4; P = 0.03). No significant association was observed between IPIs and iron deficiency or iron deficiency anaemia, which can be explained by the low wormload observed. These findings reinforce the need to involve mothers in health initiatives to control intestinal parasitism in Benin. (C) 2008 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.