Survival and costs of colorectal cancer treatment and effects of changing treatment strategies: a model approach

New and emerging advances in colorectal cancer (CRC) treatment combined with limited healthcare resources highlight the need for detailed decision-analytic models to evaluate costs, survival and quality-adjusted life years. The objectives of this article were to estimate the expected lifetime treatment cost of CRC for an average 70-year-old patient and to test the applicability and flexibility of a model in predicting survival and costs of changing treatment scenarios. The analyses were based on a validated semi-Markov model using data from a Norwegian observational study (2049 CRC patients) to estimate transition probabilities and the proportion resected. In addition, inputs from the Norwegian Patient Registry, guidelines, literature, and expert opinions were used to estimate resource use. We found that the expected lifetime treatment cost for a 70-year-old CRC patient was €47,300 (CRC stage I €26,630, II €38,130, III €56,800, and IV €69,890). Altered use of palliative chemotherapy would increase the costs by up to 29%. A 5% point reduction in recurrence rate for stages I-III would reduce the costs by 5.3% and increase overall survival by 8.2 months. Given the Norwegian willingness to pay threshold per QALY gained, society's willingness to pay for interventions that could result in such a reduction was on average €28,540 per CRC patient. The life years gained by CRC treatment were 6.05 years. The overall CRC treatment costs appear to be low compared to the health gain, and the use of palliative chemotherapy can have a major impact on cost. The model was found to be flexible and applicable for estimating the cost and survival of several CRC treatment scenarios.

Modeling and validating the cost and clinical pathway of colorectal cancer

BACKGROUND

Cancer is a major cause of morbidity and mortality, and colorectal cancer (CRC) is the third most common cancer in the world. The estimated costs of CRC treatment vary considerably, and if CRC costs in a model are based on empirically estimated total costs of stage I, II, III, or IV treatments, then they lack some flexibility to capture future changes in CRC treatment. The purpose was 1) to describe how to model CRC costs and survival and 2) to validate the model in a transparent and reproducible way.

METHODS

We applied a semi-Markov model with 70 health states and tracked age and time since specific health states (using tunnels and 3-dimensional data matrix). The model parameters are based on an observational study at Oslo University Hospital (2049 CRC patients), the National Patient Register, literature, and expert opinion. The target population was patients diagnosed with CRC. The model followed the patients diagnosed with CRC from the age of 70 until death or 100 years. The study focused on the perspective of health care payers.

RESULTS

The model was validated for face validity, internal and external validity, and cross-validity. The validation showed a satisfactory match with other models and empirical estimates for both cost and survival time, without any preceding calibration of the model.

CONCLUSIONS

The model can be used to 1) address a range of CRC-related themes (general model) like survival and evaluation of the cost of treatment and prevention measures; 2) make predictions from intermediate to final outcomes; 3) estimate changes in resource use and costs due to changing guidelines; and 4) adjust for future changes in treatment and trends over time. The model is adaptable to other populations.

Humans seem to produce arsenobetaine and dimethylarsinate after a bolus dose of seafood

Seafood is the predominant food source of several organoarsenic compounds. Some seafood species, like crustaceans and seaweed, also contain inorganic arsenic (iAs), a well-known toxicant. It is unclear whether human biotransformation of ingested organoarsenicals from seafood result in formation of arsenicals of health concern. The present controlled dietary study examined the urinary excretion of arsenic compounds (total arsenic (tAs), iAs, AB (arsenobetaine), dimethylarsinate (DMA) and methylarsonate (MA)) following ingestion of a single test meal of seafood (cod, 780 μg tAs, farmed salmon, 290 μg tAs or blue mussel, 690 μg tAs or potato (control, 110 μg tAs)) in 38 volunteers. The amount of ingested tAs excreted via the urine within 0-72 h varied significantly among the groups: Cod, 74% (52-92%), salmon 56% (46-82%), blue mussel 49% (37-78%), control 45% (30-60%). The estimated total urinary excretion of AB was higher than the amount of ingested AB in the blue mussel group (112%) and also ingestion of cod seemed to result in more AB, indicating possible endogenous formation of AB from other organoarsenicals. Excretion of iAs was lower than ingested (13-22% of the ingested iAs was excreted in the different groups). Although the ingested amount of iAs+DMA+MA was low for all seafood groups (1.2-4.5% of tAs ingested), the urinary DMA excretion was high in the blue mussel and salmon groups, counting for 25% and 11% of the excreted tAs respectively. In conclusion our data indicate a possible formation of AB as a result of biotransformation of other organic arsenicals. The considerable amount of DMA excreted is probably not only due to methylation of ingested iAs, but due to biotransformation of organoarsenicals making it an inappropriate biomarker of iAs exposure in populations with a high seafood intake.

Capacity development in food composition database management and nutritional research and education in Central and Eastern European, Middle Eastern and North African countries

BACKGROUND/OBJECTIVES

Capacity development (CD) in food and nutrition is much more than formal training and includes human resource development, and organisational, institutional and legal framework development with the aim of enhancing nutrition-relevant knowledge and skills to support infrastructural development. The goal of the European Food Information Resource (EuroFIR) Network of Excellence has been to develop and integrate food composition data throughout Europe. EuroFIR joined forces in CD with the United Nations (UN) University and UN System Standing Committee on Nutrition, the Network for Capacity Development in Nutrition in Central and Eastern Europe, the Central and Eastern European Countries Food Data Systems network and with the Middle East and North African Capacity Building Initiative. The aim of this paper is to discuss an inventory of the status of food composition databases (FCDBs) and the training needs of compilers in non-EuroFIR countries in Central and Eastern Europe (CEE) and in the Middle East and North Africa (MENA), and to present the CD achieved through EuroFIR and other network collaborations.

SUBJECTS/METHODS

Two online questionnaires were created addressing the FCDB status and specific training needs in countries of the targeted regions. Data were collected during 2006-2008 and then analysed. Subsequently, CD activities were organised.

RESULTS

Contacts were established in 19 CEE and 7 MENA countries, of which several had national food composition tables, but no electronic versions. Education, training, workshops, networking and the sharing of experiences were uniformly requested. Subsequently, CD activities in EuroFIR were organised focussing on food composition courses, exchange visits, workshops and individual training for PhD students, junior scientists and other staff categories, as well as conferences linked to food composition research and food information. To facilitate CD activities, EuroFIR has signed a Memorandum of Understanding with the Czech Republic, Hungary, Slovenia, Croatia and Estonia.

CONCLUSIONS

EuroFIR has created training activities that complement national activities. Collaboration with other networks has provided an overview of FCDB status and training needs, providing directions for CD activities in those countries. This provides a platform for new funding and further development and networking for CD, which would be conducive to European Commission objectives and public health strategies for CD.

Data quality and practical challenges of thyroid volume assessment by ultrasound under field conditions - observer errors may affect prevalence estimates of goitre

Background

The ultrasonographic estimation of thyroid size has been advocated as being more precise than palpation to diagnose goitre. However, ultrasound also requires technical proficiency. This study was conducted among Saharawi refugees, where goitre is highly prevalent. The objectives were to assess the overall data quality of ultrasound measurements of thyroid volume (Tvol), including the intra- and inter-observer agreement, under field conditions, and to describe some of the practical challenges encountered.

Methods

In 2007 a cross-sectional study of 419 children (6-14 years old) and 405 women (15-45 years old) was performed on a population of Saharawi refugees with prevalent goitre, who reside in the Algerian desert. Tvol was measured by two trained fieldworkers using portable ultrasound equipment (examiner 1 measured 406 individuals, and examiner 2, 418 individuals). Intra- and inter-observer agreement was estimated in 12 children selected from the study population but not part of the main study. In the main study, an observer error was found in one examiner whose ultrasound images were corrected by linear regression after printing and remeasuring a sample of 272 images.

Results

The intra-observer agreement in Tvol was higher in examiner 1, with an intraclass correlation coefficient (ICC) of 0.97 (95% CI: 0.91, 0.99) compared to 0.86 (95% CI: 0.60, 0.96) in examiner 2. The ICC for inter-observer agreement in Tvol was 0.38 (95% CI: -0.20, 0.77). Linear regression coefficients indicated a significant scaling bias in the original measurements of the AP and ML diameter and a systematic underestimation of Tvol (a product of AP, ML, CC and a constant). The agreement between re-measured and original Tvol measured by ICC (95% CI) was 0.76 (0.71, 0.81). The agreement between re-measured and corrected Tvol measured by ICC (95% CI) was 0.97 (0.96, 0.97).

Conclusions

An important challenge when using ultrasound to assess thyroid volume under field conditions is to recruit and train qualified personnel to perform the measurements. Methodological studies are important to assess data quality and can facilitate statistical corrections and improved estimates.

Women's iodine status and its determinants in an iodine-deficient area in the Kayes region, Mali

Objective

To assess iodine status and its determinants in women of childbearing age in a rural area in the Kayes region, Mali, West Africa.

Design

Cross-sectional study where women's iodine status was indicated by urinary iodine concentration (UIC) and level of goitre based on palpation. Salt iodine was assessed semi-quantitatively at household level. Individual characteristics were collected using questionnaires.

Setting

Fifteen villages in a rural area in the Kayes region of Mali.

Subjects

Women aged 15–45 years (n = 423).

Results

Median UIC was 2.7 μg dl−1, and only 6% of the women had adequate iodine status of UIC > 10 μg dl−1. Most women (60%) had visible goitre, and only 9% were classified as without goitre. Only 39% of the households were using salt with any iodine, and level of knowledge about salt iodisation was low. Main determinants of UIC were breast-feeding and level of salt iodisation; currently breast-feeding women had lower UIC, and UIC increased with increasing level of iodine in household salt. Prevalence of goitre was lower in older women with higher body mass index.

Conclusion

The study indicates severe iodine deficiency in the study area. Urgent action is needed to improve the situation through enforcing salt iodisation legislation and increasing the level of knowledge about the importance of iodised salt in the population.

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.

CONCLUSION

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.

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

Spearman's 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.

CONCLUSION

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.

Validation of the second version of a quantitative food-frequency questionnaire for use in Western Mali

OBJECTIVE

To assess the relative validity of the second version of a quantitative food-frequency questionnaire (QFFQ), designed to measure the habitual food and nutrient intake in one season in rural populations in Western Mali, West Africa.

DESIGN

The dietary intake during the previous week was assessed with the 164-item QFFQ administered by interview. This was compared with the intake from a 2-day weighed record (WR) with weighed recipes.

SETTING

The village of Ouassala in the Kayes region, Western Mali.

SUBJECTS

Thirty-four women and 36 men aged 15-45 years, from 29 households.

RESULTS

The QFFQ gave a lower intake of lunch and dinner and a higher intake of snacks than the WR. The discrepancies were larger for women than for men. The median proportion of subjects classified in the same quartile of intake was 29% for food groups and 36% for energy and nutrients. For classification into extreme opposite quartiles, the median proportion was 6% for food groups and 7% for energy and nutrients. Spearman's rank correlation for energy and nutrients ranged from 0.16 (% energy from protein) to 0.62 (retinol equivalents).

CONCLUSIONS

The second version of the QFFQ tends to underestimate total food weight. The methods used for estimating food portion size should therefore be applied with caution. The changes made from the first version had little effect. The ability to rank subjects according to dietary intake is similar with both versions. The improved layout of the new QFFQ makes it a more user-friendly tool for comparing dietary intake between population groups and for measuring changes over time.

Validation of a quantitative food-frequency questionnaire for use in Western Mali

OBJECTIVE

The purpose of this study was to validate a quantitative food-frequency questionnaire (QFFQ) created for assessing the usual intake of foods and nutrients in the prevailing season in Western Mali.

DESIGN

Intake of foods and nutrients over the week preceding the interview was measured with a 69-item QFFQ. Intakes were compared with intakes as measured with 2-day combined weighed and recalled diet records.

SETTING

A rural village in Western Mali, West Africa.

SUBJECTS

Twenty-seven men and 48 women (15-59 years of age) representing 18 households.

RESULTS

Spearman rank correlations between intake of food groups from the QFFQ and the diet record ranged from 0.09 (meat/fish) to 0.58 (tea/coffee). Median coefficient was 0.37. Median Spearman correlation coefficient for nutrient intake was 0.40. Men had higher median correlation coefficients than did women. The proportion of subjects being classified into the same quartile of food intake was on median 33%, while a median of 7% was misclassified into extreme quartiles. Correct classification into the same quartile for intake of nutrients was on median 34% while a median of 4% was grossly misclassified. Intakes of most food groups and nutrients as measured by the QFFQ were higher than those measured by the diet records. However, while men had higher estimated intakes for foods eaten in-between meals, women in general had higher intake of foods eaten in the main meals.

CONCLUSION

This QFFQ can be used for comparing the intake of foods and nutrients between groups within this study population. It therefore represents a useful tool in the surveillance of food intake in the population, both in identifying vulnerable groups and for tracking food intake over time. The differences between men and women in overestimating food intake need to be taken into account when using the method.

Food variety, socioeconomic status and nutritional status in urban and rural areas in Koutiala (Mali)

OBJECTIVE

The purpose of this study was to analyse the associations between the food variety score (FVS), dietary diversity score (DDS) and nutritional status of children, and to assess the associations between FVS, DDS and socioeconomic status (SES) on a household level. The study also assessed urban and rural differences in FVS and DDS.

DESIGN

Cross-sectional studies in 1994/95, including a simplified food frequency questionnaire on food items used in the household the previous day. A socioeconomic score was generated, based on possessions in the households. Weight and height were measured for all children aged 6-59 months in the households, and anthropometric indices were generated.

SUBJECTS AND SETTING

Three hundred and twenty-nine urban and 488 rural households with 526 urban and 1789 rural children aged 6-59 months in Koutiala County, Sikasso Region, Mali.

RESULTS

Children from urban households with a low FVS or DDS had a doubled risk (OR>2) for being stunted and underweight. Those relations were not found in the rural area. There was an association between SES and both FVS and DDS on the household level in both areas. The FVS and DDS in urban households with the lowest SES were higher than the FVS and DDS among the rural households with the highest SES.

CONCLUSIONS

Food variety and dietary diversity seem to be associated with nutritional status (weight/age and height/age) of children in heterogeneous communities, as our data from urban areas showed. In rural areas, however, this association could not be shown. Socioeconomic factors seem to be important determinants for FVS and DDS both in urban and rural areas. FVS and DDS are useful variables in assessing the nutritional situation of households, particular in urban areas.

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.

Diet, an independent determinant for plasma total homocysteine. A cross sectional study of Norwegian workers on platforms in the North Sea

OBJECTIVE

To examine whether diet is an independent determinant for total homocysteine (tHcy) levels.

DESIGN

Data on background variables was collected by questionnaire interviews, food intake by one 24 h recall and tHcy levels in a blood sample in 310 healthy men (mean age, 38 y).

SETTING

Two oil producing platforms in the Norwegian sector in the north sea.

RESULTS

The arithmetic mean (s.d.) and median tHcy levels were 10.4 (2.9) mumol/L and 9.9 mumol/L, respectively. In a covariance analysis, mean adjusted plasma tHcy decreased by 7-21% from no intake to highest category of intake of bread, vegetables, and skimmed milk, and increased by 8-9% from less than 30% to above 35% energy from fat, and from no intake to one liter or more for coffee. Smokers had a lower intake of cereals, bread vegetables and fruits, but ate more fat and meat. Thus, smoking may have an indirect effect on the tHcy level through its effect on diet. In a multiple regression model, bread and vegetables were negatively associated with tHcy, while fat was positively associated.

CONCLUSIONS

The results suggest that changes in diet may be an important means to lower the tHcy level in the overall population, and that dietary advice should be considered in subjects diagnosed with elevated tHcy levels.

Human milk: an invisible food resource

Human milk is an invaluable food resource for infants and young children in Sub-Saharan Africa. Statistics on production of human milk at local and national levels are lacking. In this article, estimates of the quantity of human milk production in Mali, Senegal, Nigeria, and Zimbabwe were calculated. Annual production in the urban and rural areas in Mali was 13 and 17 kg per capita, respectively. National annual median production ranged from 93,000 (Zimbabwe) to 1.3 million metric tons (Nigeria), and from 9 (Zimbabwe) to 15 kg per capita (Mali). Given a value of (US)$1 per liter, inclusion of human milk in calculations of the gross national product (GNP) for these countries would increase this value by more than 5% for Mali, and nearly 2% for Senegal. Human milk is a significant food source to children in this region and should be included in national food statistics due to its nutritional and economic importance.

Nutrient composition and nutritional importance of green leaves and wild food resources in an agricultural district, Koutiala, in southern Mali

This paper discusses the nutrient composition and the nutritional importance of green leaves and wild gathered foods in an area with surplus food production in Mali. In this West African country, there is little information about the nutrient composition and the nutritional quality of foods in general, and of wild gathered foods in particular. Food frequency was collected in two cross-sectional surveys. Focus group discussions with women in the area were used to collect information about seasonality, availability and preparation of various foods. Selected food samples were collected for chemical analysis of nutrient composition. The food samples of green leaves (Adansonia digitata, Amaranthus viridis, Tamarindus indica, Allium cepa), seeds and flour (Parkia biglobosa) and fruits (Tamarindus indica) were analysed for water, energy, fat, protein, minerals, amino acids and carotenoids. Availability and use of the foods varied with seasons. In the rainy season, wild gathered foods (e.g. A. digitata) were used as much as fresh cultivated foods (e.g., A. viridis and A. cepa). The wild food resources were more frequently used in rural than in urban areas, with A. digitata as the dominating green leaves. Green leaves were rich in energy, protein and minerals (calcium, iron). Leaves of A. viridis were, in particular, rich in beta-carotene (3290 micrograms/100 g). Chemical score in dried green leaves varied from 47 (A. cepa) to 81 (A. digitata), with lysine as the first limiting amino acid. P. biglobosa fermented seeds, with 35% fat and 37% protein were a complementary source of lysine in the diet. Based on the seasonality, the frequency of use and the nutrient contents of selected green leaves and wild gathered foods in Koutiala district, it is concluded that these traditional and locally produced foods are valuable and important nutrient contributors in the diet both in rural and urban areas, but most important in rural areas.

Nutrition promotion and dietary change at off-shore oil installations in the Norwegian sector of the North Sea

OBJECTIVE

This paper examines whether diet had changed at platforms in the Norwegian sector of the North Sea between 1985 and 1993 and if this was caused by nutrition promotive activities, including the use of a health handbook (HHB).

DESIGN

The report is based on two cross-sectional surveys, one in 1985 and one in 1993, with special reference to cardiovascular risk. Standardised questionnaires, structured and open interviews were used, incorporating information on food intake and availability, and socioeconomic variables.

SUBJECTS AND SETTING

The study population was 194 healthy men in 1985 and 336 in 1993. The mean age was 35 years in 1985 (range 18-57) and 38 (range 21-59) in 1993.

RESULTS

From 1985 to 1993 the mean intake of foods and nutrients changed in the same direction as recommended by the Norwegian National Nutrition Council and according to the HHB. The mean energy percentage from fat was 12% lower in 1993 than in 1985. Overall 56% of the workers said they had changed diet since 1985. Those who had changed, consumed more cereals, fruits, more low fat milk, and more fruit juice, and had lower energy percentage from fat, lower intake of dietary cholesterol, more intake of vitamin C and dietary fibre in 1993 than those who had not changed. About 70% of those who had received the HHB had changed their diet, against 50% of those who had not. The use of the HHB was inversely related to intake of energy, energy from fat, and dietary cholesterol, and positively related to vitamin C and dietary fibre.

CONCLUSION

It is concluded that the dietary changes are likely to be caused by the interventions, including the HHB.

Use of anthropometric measurements in assessing risk for coronary heart disease: a useful tool in worksite health screening?

The study examined the association between the anthropometric measurements body mass index (BMI), waist/hip ratio (WHR), and waist/thigh ratio (WTR) and cardiovascular risk factors, and assessed whether a combination of BMI and WHR could be used in routine screening of risk for cardiovascular arteriosclerotic disease at worksites. The data were obtained from a cross-sectional survey designed to assess the nutritional situation, with special reference to cardiovascular risk factors. The study population comprised 372 healthy men working on platforms in the North Sea. Serum cholesterol, triglyceride, fibrinogen, and blood pressure were positively related to the anthropometric variables, while high-density lipoprotein (HDL) was inversely related with them. The relations remained after adjusting for possible confounders, such as age, smoking, physical activity, and an indicator of dietary fat intake. In stepwise multiple linear regression models, BMI, WHR, and WTR were positively related to serum cholesterol, triglycerides, fibrinogen, diastolic blood pressure, and systolic blood pressure, and inversely related to HDL. When controlling for the anthropometric variables WHR and WTR, BMI was not independently related to fibrinogen and risk score. WHR and WTR were not independently related to systolic and diastolic blood pressure, and WTR was in addition not related to triglycerides when controlling for BMI. Overall, the anthropometric variables BMI and WHR were considered the best predictors for CAD risk when taking several risk factors into consideration. A joint variable between BMI and WHR, called "body score", constituted the four categories lean, lean android, overweight gynoid, and overweight ovoid. This body score was positively associated with levels of serum lipids, fibrinogen, and blood pressure, and inversely associated with HDL. In stepwise multiple linear regression models, controlling for possible confounding variables, body score was positively related to CAD risk. Dividing the risk score into tertiles, about 51% of the lean were in the first, while 46% of the overweight ovoid were in the third tertile. Those classified as lean android or overweight gynoid had about the same distribution, namely between 31% and 39% in each tertile if the two categories were combined. These data support the hypothesis that BMI, WHR, and WTR are independent predictors for risk factors for CAD among oil workers, and that combinations of BMI and WHR are strong enough predictors to be useful in routine screening for CAD risk at worksites. Based on these findings, supported by data from the literature, a matrix aimed at screening for follow-up at worksites is proposed.

Associations between serum ferritin and cardiovascular risk factors in healthy young men. A cross sectional study

OBJECTIVE

This study examines the association between serum ferritin levels and cardiovascular risk factors.

DESIGN

The data were obtained from a cross-sectional survey designed to assess the nutrition situation, with special reference to cardiovascular risk factors.

SUBJECTS AND SETTING

The study population was 337 healthy men, median age 38 years (range 21-59), working at oil platforms in the North Sea.

RESULTS

The associations between serum ferritin, risk factor levels and anthropometric measurements were analysed by age-adjusted partial correlations, step-wise multiple regression, and one-way ANOVA analysis. Body mass index and waist-to-thigh ratio were the strongest predictors for serum ferritin when controlling for age (P < 0.001). In multiple regression analysis, when anthropometric measurements were excluded, fibrinogen, high density lipoprotein (HDL)-cholesterol and diastolic blood pressure were significant predictors for serum ferritin levels when controlling for age (P < 0.001). There was a significant difference in triglyceride concentration between those with low stores of iron and those with high stores (P = 0.006). There were consistently higher levels of total cholesterol, triglycerides, fibrinogen, diastolic and systolic blood pressure, except for HDL where it was reversed, in the highest quartile of serum ferritin levels compared to the lowest. For all the variables the differences between the quartiles of serum ferritin were significant.

CONCLUSION

These findings support the hypothesis that the associations between cardiovascular arteriosclerotic disease and serum ferritin are at least partially caused by confounding.

SPONSORSHIP

The project was supported by the Norwegian State Oil Company (STATOIL), Amoco Norway Oil Company and Ross Offshore AS.

Problems and pitfalls in the use of estimated age in anthropometric measurements of children from 6 to 60 months of age: a case from Mali

Estimates of the age of children are often used uncritically in anthropometric measures. This study shows that even with construction of calendars for use of determination of age, substantial training, a careful follow-up in the field by research assistants, and control of all questionnaires immediately after the interviews of the caretakers and weighing of the children, errors remain in estimating the age of children. Such errors may affect the results substantially, leading to errors in the estimation of age-based measures of nutritional status. In the case of Northern Mali, the effect was most likely an underestimation of malnutrition by perhaps as much as 10 to 30 percentage points. The biases in age estimation in many cases are not constant across subgroups of a population. Therefore age estimation problems may lead to wrong decisions regarding policy formulation, planning of development programs and activities, identification of target groups, and, in particular, evaluation of programs and activities. In situations where age has to be estimated, anthropometric measurements that are less influenced by errors in age estimation are recommended.

[Nutrition on the world map. The UN International Conference on Nutrition]

The first International Conference on Nutrition ever organized by the United Nations took place in Rome in December 1992. The conference was attended by representatives of 159 countries and of various non-governmental organizations and the food industry. Preparations for the conference included preparation of a number of background documents, including an analysis of the nutritional situation in the different countries (country papers), twelve in-depth studies, eight theme papers and an assessment of the global nutrition situation. This article describes the process leading up to the conference, some of the problems and conflicts that appeared, controversial issues that were discussed and the final outcome of the conference (The world declaration and Plan of action for nutrition). The countries that participated in the conference pledged to make every effort to eliminate, before the end on this decade, famine and famine-related deaths, starvation and nutritional deficiencies related to natural and man-made disasters, and deficiencies of iodine and vitamin A.

Diet among oil-workers on off-shore oil installations in the Norwegian sector of the North Sea

Dietary studies based on 24 h recalls were carried out on four oil installations in the Norwegian sector of the North Sea. Two hundred and three persons were interviewed about what they had eaten the previous 24 h. Food purchased for the installations in the previous 5 months was recorded. Results based on 24 h recalls showed that average daily intake of energy was 12.2 MJ of which 17% came from protein, 44% from fat and 39% from carbohydrate, including 8% from sugar. Meat, vegetables, fresh fruits, seafood (shellfish), french fries, eggs, cream and ice-cream were important components of the diet, while bread, fish and cereals played a minor role. Average daily intake (mg) of nutrients were: calcium 1244, iron 15, vitamin A 1049 micrograms, vitamin D 4.1 micrograms, thiamin 1.6, riboflavin 2.2, nicotinic acid 22, ascorbic acid 143. Dietary fibre intake, estimated as unavailable carbohydrate, was on average 19 g, and the average daily intake of cholesterol was 755 mg. Intakes were compared with the Norwegian recommended dietary allowance. Most of the employees chose a diet which when eaten over a longer period of time may contribute to the development of coronary heart diseases (CHD) and thereby increase the morbidity and mortality from CHD in the oil industry.