Nutrition and Health, 1992, Vol. 8, pp. 195-206 0260-1060/92 $10 © 1992 A B Academic Publishers, Printed in Great Britain
195
NUTRIENT INTAKE AND WEIGHT/HEIGHT OF SAUDI PATIENTS AT KING FAISAL SPECIALIST HOSPITAL IN RIYADH, SAUDI ARABIA ABDULAZIZ I. AL-OTHAIMEEN,* MICHAEL KIPPS,** JAMES THOMSON** and BENILDA P. VILLANUEVA* Keywords: Weight/Height, Nutrient Intake, Dietary Practice, Saudi Arabia
INTRODUCTION
Saudi Arabia is one of those countries that experienced many developmental changes that affected not only its economy but also its people's health. The major transition from economic dependency to one of stability was a dramatic event that had a sudden impact on the people's lives. This descriptive survey was conducted to find out if there were concomitant changes in socioeconomic status, traditional food consumption patterns, nutritional status, dietary adequacy and disease states of Saudi hospitalized patients. This paper will deal in particular with the nutritional status through anthropometric measurements and dietary intakes. The early years of the economic upheaval saw some reported cases of malnutrition among infants and preschool children. One major reason offered was the decline in breast-feeding practice which was dictated by urban sophistication that came with oil discovery (Chowdhury, 1989, Elias, 1985, Al-Frayh, 1988). Earlier investigators in the Kingdom attributed malnutrition to lack of knowledge about infant-feeding techniques and inadequate supplementation (Abdulla, 1981; Lawson, 1981; Sebai, 1981). Nutrition surveys of population groups in the other Gulf countries (Musaiger, 1987), showed substantially lower than Recommended Daily Allowance (RDA) intakes of energy, vitamins, and minerals among schoolchildren aged between 6 and 17 years. Kamel, et al., (1984)found that For correspondence, address to: Abdulaziz I. Al-Othaimeen, MPH, t"nD or Michael Kipps *Food and Nutrition Services, King Faisal Specialist Hospital and Research Centre, P.O. Box 3354, Riyadh 11211, Kingdom of Saudi Arabia. **Department of Management Studies for Tourism and Hotel Industries, University of Surrey, Guildford, Surrey, GU2 5XH, England. Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
196
vitamin A and thiamin were inadequate in both men and women, and calcium and iron were low in women. The Gulf countries' evolution of changes in food consumption patterns and food habits due to progress because of oil are similar to the Saudi Arabian experience. Three longitudinal studies by Persson in 1989 in Sweden of children aged 7-15 years from 1930-1980 showed the same chain of events from economic dependence to affluence that went with increased incomes. The studies showed the transformation in the people's socioeconomic conditions and the children's general states of health from the early years up to the eighties. While the 1930's dietary patterns were characterized by a lack of variation and insufficient intake of vitamins and iron, and prevalence of undernutrition, the 1980's showed a big improvement in the food consumption where there was an increased protein intake, less of fat but increasing carbohydrate intakes, mostly from sweet snacks. The problem of undernutrition was replaced by overnutrition with children's weight exceeding standards by 20%. The new times saw the emergence of food habits that were more harmful than beneficial to the population. This research is part of a bigger survey of Saudis that studied food habits, socioeconomic levels, nutritional status, dietary intake and disease patterns in Saudi Arabia. This report will deal with the anthropometric measurements and dietary intake of patients. A unique feature of this study is the inclusion of the adolescent and adult group, a major area that has not been tapped yet and for which literature in the Kingdom is lacking. METHODOLOGY
Sampling. The general design of the survey is a sample of 1,005 male and female participants ranging in age from birth to 96 years. Participants were picked from the accessible population of newly admitted patients and the sitters that attended them at the King Faisal Specialist Hospital and Research Centre (KFSH) in Riyadh, Saudi Arabia. This is a referral and tertiary care hospital that caters to Saudi patients. Out of the total sample, 714 patients were sub-sampled and became the subject of this report. Method of Analysis The survey questionnaire recorded some personal data information from patients that included height, weight, age and sex and these were the data used in grouping patients by age and sex. Groupings were done in accordance with the US NCHS standard. Mean height and weight were taken for each age and sex group and compared with the
standard (NCHS, 1989) using t-tests. Mean dietary intakes of energy, protein, vitamins C, B1, B2, niacin, and minerals sodium, potassium, calcium, and iron were estimated from the diet history form. Household measures of portions consumed were converted to actual amounts eaten and were computed through the use of food composition tables (Pennington, et Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
197
al., 1984; Composition of Foods, 1963; Food Composition Table for Use in East Asia, 1972; Musaiger, et al., 1988). Food items that could not be found in the food composition tables, especially those that are characteristically Saudi or middle eastern were analyzed from standardized recipes of the main hospital kitchen. Two other nutrient data using the 24-hour recall and diet record were done but were not included in this report. The nutrient data were compared with the US RDA (1989) using t-tests. Statistical analysis was conducted using the BMDP statistical software package (1980) where a program supplied the descriptive analysis (mean, standard deviation, etc.). RBASE applications were used to summarize the raw nutrient intake data. As part of the methodology, and to control for quality, a FORTRAN program was designed to compare all the data which were entered twice by two data entry technicians. RBASE data were exported to FORTRAN to check for mismatches between the two entries. The mismatches were then corrected and transferred to BMDP for analyses. Contingency table and regression analyses were employed to analyze data relationships.
RESULTS Anthropometries
A total of714 patients were surveyed. There were more females (64.4%) than males (35.6%) (Figure 1). Almost 50% belong to the GT 24-LE 50 (greater than 24 to less than or equal to 50) age group (Figure 2). Anthropometric measurements of weight for height and height for age as compared with the standard are found in Table 1. For all age groups between birth to 14 years, weight for height was not significantly different from the standard (except for the GT 10-LE 14 years, female). The same was true of ages GT 14-LE 18 years, male, and GT 18-GT 50 female groups. For the adolescent women from GT 10-LE 18, and for the adult males from GT 18 up to GT 50, significantly low weight for height were obtained. Height for age from birth up to LE 1-LE 10, males, did not differ significantly from the NCHS standard. All the heights from age 10 up to more than 50 years old for both males and females, were significantly lower than the standard.
Nutrient Intake
Table 2 shows percentages of the RDA of nutrients of 714 patients by age and sex. Most of the nutrient intake for each age and sex groups were adequate in amounts. Statistically significant inadequate amounts were noted for energy for the adult males, from GT 18-GT 50 years old; and for iron for the LE 1 age group. Lower the RDA energy intakes were also Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
198
/
~/// /
Figure I.
Sample distribution of 714 patients by sex.
reported for the males, GT 10-LE 18 years old but they were not statistically significant. Iron intake lower than RDA was also found for the females, GT 14-LE 18 age group but it was not statistically significant. All other nutrients for other age and sex groups were higher than the standard. DISCUSSION The oil discovery in 1938 did not result in instant change. The intervening world war set the drilling backward and it was only during the 1950's that the production of oil from crude got underway and the golden years in Saudi Arabia started then. Revenues came pouring in and development projects started that made a difference in the Saudi economic and social life (Development Plans, 1987). With the money came the technocrats, goods and services, food and agriculture, education and social services. There was an overall improvement in the quality of life of the people. The question of whether or not these changes had an effect on the nutritional status of the population has always been a topic of interest to Saudi nutrition investigators. Several investigators in the Kingdom noted some mild and moderate degrees of malnutrition in preschool children in studies done on those 10 to 15 years of age (Abdulla, 1982; Al-Othaimeen, 1988; Sebai, 1981). This survey of Saudi patients has shed some new light on the potential of a population Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
-MALE 13 -FEMALE 11 -MALE 12 24
GT10-LE14 GT14-LE18
-FEMALE
-FEMALE -MALE 84 60
-MALE 76 257
.6610
.0000 .3379
.0000 .0113
.0000 .2805
.2220 .0002
.7099 .0034
SLS*** NSLS**
SLS*** SHS***
SLS*** NSHS*
NSLS** SLS***
NSLS** SLS***
NSLS**
NSHS*
NSHS*
Statistical significance
*NSHS- NOT SIGNIFICANT LY HIGHER STATISTICALL Y **NSLS- NOT SIGNIFICANT LY LOWER STATISTICALL Y ***SLS- SIGNIFICANT LY LOWER STATISTICALL Y ****SHS- SIGNIFICANT LY HIGHER STATISTICALL Y
GT50
GT24-LE50
-FEMALE
-MALE 29 57
28
GT6-LE10
GT18-LE24
51
-FEMALE
.0642
11
LE 1 GT1-LE6 .4760
P-value
Weight for height Number
Age (yrs) & sex groups
84 60
76 255
29 57
12 24
13 11
28
51
11
Number
.0000 .0000
.0000 .0000
.0000 .0000
.0120 .0000
.7921 .0023
.1380
.4450
.0640
P-value
Height for age
Comparison of patients' anthropometric measurements with NCHS standards and statistical significance (N = 714)
TABLE 1
SLS*** SLS***
SLS*** SLS***
SLS*** SLS***
SLS*** SLS***
NSLS** SLS**
NSLS**
NSHS*
NSHS*
Statistical significance
\0 \0
Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
45.2 335
s
48 149 NS 0.7 200 1.4 309
s
6.7 122 NS 1458 911 1769 295
PROTEIN - g/day %RDA t-TEST VIT C- mg/day %RDA t-TEST VIT 81 - mg/day %RDA t-TEST VIT 82- mg/day %RDA t-TEST NIACIN - mg/day %RDA t-TEST SODIUM- mg/day %RDA t-TEST POTASSIUM- mg/day %RDA t-TEST
s
s
s
1025 137 NS
LE 1 ENERGY - kcal/day %RDA t-TEST
Nutrients (Diet history)
s
2061 159
s
s
2062 787
15.2 145
s
2.2 229
s
1.5 188
s
92 216
s
63.7 319
1556 100 NS
GT 1LE 6
s
2375 132
s
2521 630
s
20.3 162
s
2.6 228
s
2.1 220
s
97 216
s
82.0 315
1866 98 NS
2394 120 NS
s
2862 572
s
21.5 143
5.1 379 NS
s
2.5 217
84 177 NS
s
88.7 243
2049 91 NS
s
s
2775 139
s
3269 654
s
22.8 163
s
2.8 224
s
2.5 241
131 276 NS
97.6 264
2343 112 NS
s
2854 143 NS
s
2551 510
s
26.2 142
4.2 255 NS
s
2.6 188
151 275 NS
103 198
2340 85 NS
s
2734 137
s
3229 646
s
24.2 161
s
2.6 200
s
2.4 221
s
s
103 187
94.8 211
2168 99 NS
s
2542 127
s
3500 700
s
29.1 149
s
3.4 195
s
2.4 158
89 148 NS
s
104.7 179
s
2208 75
s
2864 143
s
3411 682
s
24.5 163
s
3.2 246
s
2.4 218
s
s
103 171
97.9 218
2244 102 NS
s
3050 153
s
3309 662
s
26.3 138
s
3.5 206
s
2.6 173
s
97 162
s
106.5 176
s
2212 76
s
2952 148
s
3407 681
s
23.2 155
s
3.7 284
s
2.6 235
s
s
100 166
99 206
2183 99 NS
GT 6- GT 10 - LE 14 GT 14- LE 18 GT 18 - LE 24 GT 24- LE 50 LE 10 M F M M F F M F
Age and sex groups (years)
Mean intake and percentages of RDA of nutrients of 714 patients by age & sex and t-test
TABLE 2
s
2609 130
s
2862 572
s
23.1 136
s
2.8 181
s
2.4 161
s
76 127
s
85 135
s
F
s
2854 143
s
s
2947 589
21.6 154
s
2.6 205
s
2.8 280
s
89 149
s
91.5 183
1969 104 NS
GT 50 1891 82
M
N
0 0
Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
S- STATISTICALLY SIGNIFICANT NS- NOT STATISTICALLY SIGNIFICANT
s
5.1 64
IRON- mg/day %RDA t-TEST
s
863 173
CALCIUM- mg/day %RDA t-TEST
NS
10.5 105
NS
907 113
s
13.5 135
s
1070 134
NS
16.1 146
NS
1119 112
NS
13.1 101
s
1366 137
NS
16.0 133
NS
1249 104
NS
13.9 93
NS
1121 93
s
18.5 168
NS
1150 96
NS
16.3 109
s
1244 124
s
15.4 154
NS
1408 141
NS
15.0 100
s
1353 169
s
12.4 124
s
1185 148
Ill NS
11.1
s
1366 171
N
0
Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
300 -·
0
50
100 -··
150-
200-·
Figure 2.
z
:::a
:::!! 250
IX)
a: w
350--
400
450
8(1.1%)
GT1-LE6
24(3.3%)
GT10-LE14
GT14-L.E18
AGE GROUPS (VAS)
GT6-LE10
10(1.4%)
Age and sex distribution of 714 patients.
LE1
3(04%)
-·-·------
~FEMALES
. . MALES
------·-----· ---·r
GT18-LE24
GT24-L.E50
GT50
:.fr;t:
I
~~~(8.4%)
84(11.7%)
1-"-'-....__ _1:1·:~_;.,..-
2'..iO(J6.1 %)
I
000·-r-----------------------------------------------------------------------------~
0
N
N
203
group for growth and development once given the opportunity. This is assuming that factors other than nutritional are responsible for the distortion of the balance between food intake and nutrient requirements. Although some discretion needs to be practiced in making hasty conclusions, the findings of this research showed some promise of improvement in the nutritional status of the new breed of Saudi Arabian children. In both of the growth parameters of weight for height and height for age up to 14 years (except the girls of the age group GT 10-LE 14), the Saudi Arabian children can now compare with the NCHS standard, the accepted international yardstick for good growth performance (Whitehead and Paul, 1981 ). A number of early studies cited the unrealistic use of the NCHS as a standard for comparison because of the differences in the genetic and environmental backgrounds. Genetics may still be at play here, but the effect of the environment has a stronger influence on the outcome of this particular study. There may have been isolated cases of malnutrition and disease in the rural areas that could not be reached by the general upward trend in the improvement of health. Then there are those children who are potential obese adults with their associated risk of having hypertension or cardiovascular disorders, diabetes and cancer. This is a new problem that is emerging from the recent economic order of affluence, and for which government and public efforts are being drawn because of the great risks involved. The trend for the decreased weight for height of adolescent girls from age GT 10 up to LE 18 follows the normal physiological change occurring in females during this stage-the girls becoming more conscious of their form and shape and so the tendency to eat less (Williams, 1973). Later on, from age 18 upwards (weight for height above normal), marriageable girls and their mothers follow the acccepted norms of their culture of being on the plump side. Add to this the fact that their activity is confined mostly to light housework (surveyed but not shown here) with some help from the maid or other female members of the household. The adult males from age 18, on the other hand, had lower than standard weight for height values. Whether this was affected by the disease process or not has not been investigated. Height for age of all Saudis surveyed from age 14 upwards (except GT 10-LE 14, females) had statistically lower than NCHS values. As Waterlow ( 1977) noted, height for age is a measure of past nutriture and in this survey especially could be a reflection of poor nutritional status of the past years of children surveyed before the economic boom. Gopalan (1987) has recently suggested that height measurements could be an index of socioeconomic development in societies where populations have not yet been able to express their full genetic potential. The low energy intakes for the adult Saudi male patients could be explained in terms of higher body weight used in establishing the new RDA's which was the standard used in determining adequacy of nutrient intake. The reference population that was used (NHANES II) in establishing the 1989 RDA standards was based on actual body weights for the 19 years and Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
204
older group. The higher body weights resulted in higher recommendations for energy, protein, thiamin, riboflavin, and niacin (Monsen, 1989). The Saudi intakes of protein, vitamin C, thiamin, riboflavin, niacin, calcium and iron for all age and sex groups (except iron for the LE 1 age group) were just high enough to be comparable to the new RDA's. Excessively high intakes of sodium and potassium were reported. The typical Saudi diet is well known for its salty taste. The high potassium intake could be partly explained by the increasing use of fruits and vegetables because of their availability. Sodium and potassium were also high because the new RDA's allowed only for estimated minimum requirements (EMRs) as there was no dietary need for higher intakes. Another thing to remember when using the new RDA's is that the EMR's did not allow for prolonged heat losses. In hot climates like in Saudi Arabia, this could be a major problem. In this study as it was in earlier ones, infants up to one year of age had low intake of iron that was statistically significant. There were even reports of iron-deficiency anaemia in those earlier studies. Although this study did not find biochemical support for the low iron intake, it is interesting to find the same deficiency despite the obvious change in the food consumption pattern of the population. It is possible that the practice of prolonged infant milk feeding with minimum or late supplementation, if there is at all, still persists. The low iron content of milk is well-known and infants that depend on milk alone for food, as in the Saudi culture will inevitably have a deficiency of this nutrient. It would seem that traditional feeding practices are deeply ingrained and it would probably take more time to notice the changes in the population's nutritional status. Diseases of affluence are sometimes caused by a lack of or oversupply of dietary components and nutrition surveys such as this one may show groups of individuals with extraordinarily low intakes of nutrients, but apart from the impact of disease, it is not expected to find deficiencies severe enough to yield clinical signs. It seems necessary to pay attention to an adequate intake of nutrients even in the midst of plenty.
SUMMARY AND CONCLUSIONS
Nutrition surveys in the past showed some mild and moderate degrees of malnutrition in young children below 10 years of age. Deficiency diseases like anaemia were also reported. This survey is part of a large study of 1005 patients and sitters to see the relationship of diet and disease. Seven hundred and fourteen patients were subsampled and became the subject of this report to find out if the nutritional status of the children surveyed 10 to 15 years ago had any major change. It also presented some new information about nutritional status of older groups up to 96 years of age. It was found that weight for height and height for age of children up 14 years (except the girls GT 10-LE 14 years) could now compare with the US Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
205
NCHS standard. The adolescent girls' (up to age 18) weight for height were statistically lower than the standard. Later in life, with some influences from· the other female members of the household, and because of their limited activity, the women's weights were even higher than the standard. The adolescent males' weights were within standard, but the adult males' from age 18 were statistically lower than NCHS. Height for age from age 14 years for all were statistically lower than standard and was attributed to poor nutritional states in the past. Energy intakes of the adult males and iron intakes of the infants below one year of age were significantly lower than standard. Low energy intakes of the adult males confirm low weight for height performance. The same problem with iron of milk-fed infants of 10 to 15 years ago was still encountered. This shows that some traditional practice of infant feeding still persists despite the improvement in the quality oflife and standard ofliving of the Saudis due to the economic upheaval created by oil. This survey emphasizes the importance of follow-up reports to see the changes in the people's state of health after a period of transition from economic dependence to affluence.
REFERENCES 1. Abdullah, A.A., Sebai, Z.A. and Swailem, A.R., 1982. Health and nutritional status of preschool children. Saud Med J Monograph, 1-18. 2. Al-Frayh, A., Wong, S.S. and Haque, K.N., 1986. Infant-feeding practices in Riyadh, Saudi Arabia. Ann Saudi Med 8(3): 194-197. 3. Al-Othaimeen, A.l., Sawaya, W.N., Tannous, R.I. and Villanueva, B.P., 1988. A nutrition survey of infants and preschool children in Saudi Arabia. Saudi Med J9(IO): 40-48. 4. Al-Othaimeen, A.l. and Villaneuva, B.P., 1988. The effects of prolonged breast-feeding on the nutritional status of Saudi Arabian children. Ann Saudi Med 8: 97-102. 5. Azad Chowdhury, M.A.K., 1989. Infant-feeding practices and immunization in the Khamis Mushayt area. Ann Saudi Med 9: 19-22. 6. Composition of Foods, 1963, Agricultural Handbook No. 8, Agricultural Research Service, US Department of Agriculture. 7. Dixon, W.J., ed., 1983. BMDP Statistical Software. Los Angeles: University of California Press. 8. Elias, J.B.T., 1985. A survey of place of delivery, modes of milk feeding and immunization in a primary health care center in Saudi Arabia. Saudi Med J 6(2): 169-176. 9. Food Composition Table for Use in East Asia, 1972. US Department of Health, Education and Welfare, and Food and Agriculture Organization of the United Nations. 10. Gopalan, C., 1987. Height of populations-an index of their nutrition and socioeconomic development. Bulletin of the Nutrition Foundation of India 8(3). 11. Kamel, B.S. and Martinez, O.B., 1984. Food habits and nutrient intakes of Kuwaiti males and females. Ecol Food Nutr 15: 261-272. 12. Lawson, M., 1981. Infant feeding habits in Riyadh. Saudi Med J 2: 26-29. 13. Jelliffe, D.B. and Jelliffe, E.F.P., 1978. The volume and composition of human milk in poorly nourished communities. Am J Clin Nutr 31: 492-514. 14. Ministry of Planning, Kingdom of Saudi Arabia, 1985. Achievements of the Development Plans, 1970-1985. Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
206 15. Monsen, E.R., 1989. The lOth edition of the recommended dietary allowances: What's new in the RDA's? JAm Diet Assoc 89(12): 1748-52. 16. Musaiger, A.O., 1987. The state of food and nutrition in the Arabian Gulf countries. World Rev Nutr Diet 54: 105-73. 17. Musaiger, A.O. and Abdullah, Z.S., 1985. Food Composition for Use in Bahrain. Bahrain: Ministry of Health. 18. National Center for Health Statistics, 1977. NCHS Growth Curvesfor Children, Birth-18 years. Rockville, Md: US Department of Health, Education and Welfare (publication no. 12 (PHS). 19. National Health and Nutrition Examination Survey (NHANES II), 1980. National Center for Health Statistics. Overweight Adults 20-74 Years of Age: United States, 19711978. Vital and Health Statistics, Advance Data No. 51. Hyattsville, Public Health Service, DHEW. 20. Pennington, J.A.T. and Church, H.N., 1984. Bowes and Church's Food Values of Portions Commonly Used. Philadelphia: J.B. Lippincott Company. 21. Recommended Daily Dietary Allowances, revised 1980, US National Academy of Sciences, Washington, DC. 22. Recommended Dietary Allowances, 1989. Estimated Minimum requirements (EMR's) for sodium, chloride, and potassium for healthy persons. NAS. 23. Sebai, Z.A., 1981. Anthropometric measurements among preschool children in Wadi Turaba, Saudi Arabia. J Trap Paed 27: 150-154. 24. Waterlow, J.C., Buzina, R., Keller, W., Lane, J.M., McNickman, M.Z. and Tanner, J.M., 1977. The presentation and use of height and weight data for comparing the nutritional status of groups of children under the age of ten. Bull WHO 55: 489-98. 25. Whitehead, R.G. and Paul, A.A., 1981. Infant growth and human milk requirements. Lancet 2: 161-163. 26. Williams, S.R., 1978. Essentials of Nutrition and Diet Therapy. Saint Louis: The C.V. Mosby Company. (Received 13 December 1991; infinalform 1 Apri/1992)
Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
195
NUTRIENT INTAKE AND WEIGHT/HEIGHT OF SAUDI PATIENTS AT KING FAISAL SPECIALIST HOSPITAL IN RIYADH, SAUDI ARABIA ABDULAZIZ I. AL-OTHAIMEEN,* MICHAEL KIPPS,** JAMES THOMSON** and BENILDA P. VILLANUEVA* Keywords: Weight/Height, Nutrient Intake, Dietary Practice, Saudi Arabia
INTRODUCTION
Saudi Arabia is one of those countries that experienced many developmental changes that affected not only its economy but also its people's health. The major transition from economic dependency to one of stability was a dramatic event that had a sudden impact on the people's lives. This descriptive survey was conducted to find out if there were concomitant changes in socioeconomic status, traditional food consumption patterns, nutritional status, dietary adequacy and disease states of Saudi hospitalized patients. This paper will deal in particular with the nutritional status through anthropometric measurements and dietary intakes. The early years of the economic upheaval saw some reported cases of malnutrition among infants and preschool children. One major reason offered was the decline in breast-feeding practice which was dictated by urban sophistication that came with oil discovery (Chowdhury, 1989, Elias, 1985, Al-Frayh, 1988). Earlier investigators in the Kingdom attributed malnutrition to lack of knowledge about infant-feeding techniques and inadequate supplementation (Abdulla, 1981; Lawson, 1981; Sebai, 1981). Nutrition surveys of population groups in the other Gulf countries (Musaiger, 1987), showed substantially lower than Recommended Daily Allowance (RDA) intakes of energy, vitamins, and minerals among schoolchildren aged between 6 and 17 years. Kamel, et al., (1984)found that For correspondence, address to: Abdulaziz I. Al-Othaimeen, MPH, t"nD or Michael Kipps *Food and Nutrition Services, King Faisal Specialist Hospital and Research Centre, P.O. Box 3354, Riyadh 11211, Kingdom of Saudi Arabia. **Department of Management Studies for Tourism and Hotel Industries, University of Surrey, Guildford, Surrey, GU2 5XH, England. Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
196
vitamin A and thiamin were inadequate in both men and women, and calcium and iron were low in women. The Gulf countries' evolution of changes in food consumption patterns and food habits due to progress because of oil are similar to the Saudi Arabian experience. Three longitudinal studies by Persson in 1989 in Sweden of children aged 7-15 years from 1930-1980 showed the same chain of events from economic dependence to affluence that went with increased incomes. The studies showed the transformation in the people's socioeconomic conditions and the children's general states of health from the early years up to the eighties. While the 1930's dietary patterns were characterized by a lack of variation and insufficient intake of vitamins and iron, and prevalence of undernutrition, the 1980's showed a big improvement in the food consumption where there was an increased protein intake, less of fat but increasing carbohydrate intakes, mostly from sweet snacks. The problem of undernutrition was replaced by overnutrition with children's weight exceeding standards by 20%. The new times saw the emergence of food habits that were more harmful than beneficial to the population. This research is part of a bigger survey of Saudis that studied food habits, socioeconomic levels, nutritional status, dietary intake and disease patterns in Saudi Arabia. This report will deal with the anthropometric measurements and dietary intake of patients. A unique feature of this study is the inclusion of the adolescent and adult group, a major area that has not been tapped yet and for which literature in the Kingdom is lacking. METHODOLOGY
Sampling. The general design of the survey is a sample of 1,005 male and female participants ranging in age from birth to 96 years. Participants were picked from the accessible population of newly admitted patients and the sitters that attended them at the King Faisal Specialist Hospital and Research Centre (KFSH) in Riyadh, Saudi Arabia. This is a referral and tertiary care hospital that caters to Saudi patients. Out of the total sample, 714 patients were sub-sampled and became the subject of this report. Method of Analysis The survey questionnaire recorded some personal data information from patients that included height, weight, age and sex and these were the data used in grouping patients by age and sex. Groupings were done in accordance with the US NCHS standard. Mean height and weight were taken for each age and sex group and compared with the
standard (NCHS, 1989) using t-tests. Mean dietary intakes of energy, protein, vitamins C, B1, B2, niacin, and minerals sodium, potassium, calcium, and iron were estimated from the diet history form. Household measures of portions consumed were converted to actual amounts eaten and were computed through the use of food composition tables (Pennington, et Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
197
al., 1984; Composition of Foods, 1963; Food Composition Table for Use in East Asia, 1972; Musaiger, et al., 1988). Food items that could not be found in the food composition tables, especially those that are characteristically Saudi or middle eastern were analyzed from standardized recipes of the main hospital kitchen. Two other nutrient data using the 24-hour recall and diet record were done but were not included in this report. The nutrient data were compared with the US RDA (1989) using t-tests. Statistical analysis was conducted using the BMDP statistical software package (1980) where a program supplied the descriptive analysis (mean, standard deviation, etc.). RBASE applications were used to summarize the raw nutrient intake data. As part of the methodology, and to control for quality, a FORTRAN program was designed to compare all the data which were entered twice by two data entry technicians. RBASE data were exported to FORTRAN to check for mismatches between the two entries. The mismatches were then corrected and transferred to BMDP for analyses. Contingency table and regression analyses were employed to analyze data relationships.
RESULTS Anthropometries
A total of714 patients were surveyed. There were more females (64.4%) than males (35.6%) (Figure 1). Almost 50% belong to the GT 24-LE 50 (greater than 24 to less than or equal to 50) age group (Figure 2). Anthropometric measurements of weight for height and height for age as compared with the standard are found in Table 1. For all age groups between birth to 14 years, weight for height was not significantly different from the standard (except for the GT 10-LE 14 years, female). The same was true of ages GT 14-LE 18 years, male, and GT 18-GT 50 female groups. For the adolescent women from GT 10-LE 18, and for the adult males from GT 18 up to GT 50, significantly low weight for height were obtained. Height for age from birth up to LE 1-LE 10, males, did not differ significantly from the NCHS standard. All the heights from age 10 up to more than 50 years old for both males and females, were significantly lower than the standard.
Nutrient Intake
Table 2 shows percentages of the RDA of nutrients of 714 patients by age and sex. Most of the nutrient intake for each age and sex groups were adequate in amounts. Statistically significant inadequate amounts were noted for energy for the adult males, from GT 18-GT 50 years old; and for iron for the LE 1 age group. Lower the RDA energy intakes were also Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
198
/
~/// /
Figure I.
Sample distribution of 714 patients by sex.
reported for the males, GT 10-LE 18 years old but they were not statistically significant. Iron intake lower than RDA was also found for the females, GT 14-LE 18 age group but it was not statistically significant. All other nutrients for other age and sex groups were higher than the standard. DISCUSSION The oil discovery in 1938 did not result in instant change. The intervening world war set the drilling backward and it was only during the 1950's that the production of oil from crude got underway and the golden years in Saudi Arabia started then. Revenues came pouring in and development projects started that made a difference in the Saudi economic and social life (Development Plans, 1987). With the money came the technocrats, goods and services, food and agriculture, education and social services. There was an overall improvement in the quality of life of the people. The question of whether or not these changes had an effect on the nutritional status of the population has always been a topic of interest to Saudi nutrition investigators. Several investigators in the Kingdom noted some mild and moderate degrees of malnutrition in preschool children in studies done on those 10 to 15 years of age (Abdulla, 1982; Al-Othaimeen, 1988; Sebai, 1981). This survey of Saudi patients has shed some new light on the potential of a population Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
-MALE 13 -FEMALE 11 -MALE 12 24
GT10-LE14 GT14-LE18
-FEMALE
-FEMALE -MALE 84 60
-MALE 76 257
.6610
.0000 .3379
.0000 .0113
.0000 .2805
.2220 .0002
.7099 .0034
SLS*** NSLS**
SLS*** SHS***
SLS*** NSHS*
NSLS** SLS***
NSLS** SLS***
NSLS**
NSHS*
NSHS*
Statistical significance
*NSHS- NOT SIGNIFICANT LY HIGHER STATISTICALL Y **NSLS- NOT SIGNIFICANT LY LOWER STATISTICALL Y ***SLS- SIGNIFICANT LY LOWER STATISTICALL Y ****SHS- SIGNIFICANT LY HIGHER STATISTICALL Y
GT50
GT24-LE50
-FEMALE
-MALE 29 57
28
GT6-LE10
GT18-LE24
51
-FEMALE
.0642
11
LE 1 GT1-LE6 .4760
P-value
Weight for height Number
Age (yrs) & sex groups
84 60
76 255
29 57
12 24
13 11
28
51
11
Number
.0000 .0000
.0000 .0000
.0000 .0000
.0120 .0000
.7921 .0023
.1380
.4450
.0640
P-value
Height for age
Comparison of patients' anthropometric measurements with NCHS standards and statistical significance (N = 714)
TABLE 1
SLS*** SLS***
SLS*** SLS***
SLS*** SLS***
SLS*** SLS***
NSLS** SLS**
NSLS**
NSHS*
NSHS*
Statistical significance
\0 \0
Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
45.2 335
s
48 149 NS 0.7 200 1.4 309
s
6.7 122 NS 1458 911 1769 295
PROTEIN - g/day %RDA t-TEST VIT C- mg/day %RDA t-TEST VIT 81 - mg/day %RDA t-TEST VIT 82- mg/day %RDA t-TEST NIACIN - mg/day %RDA t-TEST SODIUM- mg/day %RDA t-TEST POTASSIUM- mg/day %RDA t-TEST
s
s
s
1025 137 NS
LE 1 ENERGY - kcal/day %RDA t-TEST
Nutrients (Diet history)
s
2061 159
s
s
2062 787
15.2 145
s
2.2 229
s
1.5 188
s
92 216
s
63.7 319
1556 100 NS
GT 1LE 6
s
2375 132
s
2521 630
s
20.3 162
s
2.6 228
s
2.1 220
s
97 216
s
82.0 315
1866 98 NS
2394 120 NS
s
2862 572
s
21.5 143
5.1 379 NS
s
2.5 217
84 177 NS
s
88.7 243
2049 91 NS
s
s
2775 139
s
3269 654
s
22.8 163
s
2.8 224
s
2.5 241
131 276 NS
97.6 264
2343 112 NS
s
2854 143 NS
s
2551 510
s
26.2 142
4.2 255 NS
s
2.6 188
151 275 NS
103 198
2340 85 NS
s
2734 137
s
3229 646
s
24.2 161
s
2.6 200
s
2.4 221
s
s
103 187
94.8 211
2168 99 NS
s
2542 127
s
3500 700
s
29.1 149
s
3.4 195
s
2.4 158
89 148 NS
s
104.7 179
s
2208 75
s
2864 143
s
3411 682
s
24.5 163
s
3.2 246
s
2.4 218
s
s
103 171
97.9 218
2244 102 NS
s
3050 153
s
3309 662
s
26.3 138
s
3.5 206
s
2.6 173
s
97 162
s
106.5 176
s
2212 76
s
2952 148
s
3407 681
s
23.2 155
s
3.7 284
s
2.6 235
s
s
100 166
99 206
2183 99 NS
GT 6- GT 10 - LE 14 GT 14- LE 18 GT 18 - LE 24 GT 24- LE 50 LE 10 M F M M F F M F
Age and sex groups (years)
Mean intake and percentages of RDA of nutrients of 714 patients by age & sex and t-test
TABLE 2
s
2609 130
s
2862 572
s
23.1 136
s
2.8 181
s
2.4 161
s
76 127
s
85 135
s
F
s
2854 143
s
s
2947 589
21.6 154
s
2.6 205
s
2.8 280
s
89 149
s
91.5 183
1969 104 NS
GT 50 1891 82
M
N
0 0
Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
S- STATISTICALLY SIGNIFICANT NS- NOT STATISTICALLY SIGNIFICANT
s
5.1 64
IRON- mg/day %RDA t-TEST
s
863 173
CALCIUM- mg/day %RDA t-TEST
NS
10.5 105
NS
907 113
s
13.5 135
s
1070 134
NS
16.1 146
NS
1119 112
NS
13.1 101
s
1366 137
NS
16.0 133
NS
1249 104
NS
13.9 93
NS
1121 93
s
18.5 168
NS
1150 96
NS
16.3 109
s
1244 124
s
15.4 154
NS
1408 141
NS
15.0 100
s
1353 169
s
12.4 124
s
1185 148
Ill NS
11.1
s
1366 171
N
0
Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
300 -·
0
50
100 -··
150-
200-·
Figure 2.
z
:::a
:::!! 250
IX)
a: w
350--
400
450
8(1.1%)
GT1-LE6
24(3.3%)
GT10-LE14
GT14-L.E18
AGE GROUPS (VAS)
GT6-LE10
10(1.4%)
Age and sex distribution of 714 patients.
LE1
3(04%)
-·-·------
~FEMALES
. . MALES
------·-----· ---·r
GT18-LE24
GT24-L.E50
GT50
:.fr;t:
I
~~~(8.4%)
84(11.7%)
1-"-'-....__ _1:1·:~_;.,..-
2'..iO(J6.1 %)
I
000·-r-----------------------------------------------------------------------------~
0
N
N
203
group for growth and development once given the opportunity. This is assuming that factors other than nutritional are responsible for the distortion of the balance between food intake and nutrient requirements. Although some discretion needs to be practiced in making hasty conclusions, the findings of this research showed some promise of improvement in the nutritional status of the new breed of Saudi Arabian children. In both of the growth parameters of weight for height and height for age up to 14 years (except the girls of the age group GT 10-LE 14), the Saudi Arabian children can now compare with the NCHS standard, the accepted international yardstick for good growth performance (Whitehead and Paul, 1981 ). A number of early studies cited the unrealistic use of the NCHS as a standard for comparison because of the differences in the genetic and environmental backgrounds. Genetics may still be at play here, but the effect of the environment has a stronger influence on the outcome of this particular study. There may have been isolated cases of malnutrition and disease in the rural areas that could not be reached by the general upward trend in the improvement of health. Then there are those children who are potential obese adults with their associated risk of having hypertension or cardiovascular disorders, diabetes and cancer. This is a new problem that is emerging from the recent economic order of affluence, and for which government and public efforts are being drawn because of the great risks involved. The trend for the decreased weight for height of adolescent girls from age GT 10 up to LE 18 follows the normal physiological change occurring in females during this stage-the girls becoming more conscious of their form and shape and so the tendency to eat less (Williams, 1973). Later on, from age 18 upwards (weight for height above normal), marriageable girls and their mothers follow the acccepted norms of their culture of being on the plump side. Add to this the fact that their activity is confined mostly to light housework (surveyed but not shown here) with some help from the maid or other female members of the household. The adult males from age 18, on the other hand, had lower than standard weight for height values. Whether this was affected by the disease process or not has not been investigated. Height for age of all Saudis surveyed from age 14 upwards (except GT 10-LE 14, females) had statistically lower than NCHS values. As Waterlow ( 1977) noted, height for age is a measure of past nutriture and in this survey especially could be a reflection of poor nutritional status of the past years of children surveyed before the economic boom. Gopalan (1987) has recently suggested that height measurements could be an index of socioeconomic development in societies where populations have not yet been able to express their full genetic potential. The low energy intakes for the adult Saudi male patients could be explained in terms of higher body weight used in establishing the new RDA's which was the standard used in determining adequacy of nutrient intake. The reference population that was used (NHANES II) in establishing the 1989 RDA standards was based on actual body weights for the 19 years and Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
204
older group. The higher body weights resulted in higher recommendations for energy, protein, thiamin, riboflavin, and niacin (Monsen, 1989). The Saudi intakes of protein, vitamin C, thiamin, riboflavin, niacin, calcium and iron for all age and sex groups (except iron for the LE 1 age group) were just high enough to be comparable to the new RDA's. Excessively high intakes of sodium and potassium were reported. The typical Saudi diet is well known for its salty taste. The high potassium intake could be partly explained by the increasing use of fruits and vegetables because of their availability. Sodium and potassium were also high because the new RDA's allowed only for estimated minimum requirements (EMRs) as there was no dietary need for higher intakes. Another thing to remember when using the new RDA's is that the EMR's did not allow for prolonged heat losses. In hot climates like in Saudi Arabia, this could be a major problem. In this study as it was in earlier ones, infants up to one year of age had low intake of iron that was statistically significant. There were even reports of iron-deficiency anaemia in those earlier studies. Although this study did not find biochemical support for the low iron intake, it is interesting to find the same deficiency despite the obvious change in the food consumption pattern of the population. It is possible that the practice of prolonged infant milk feeding with minimum or late supplementation, if there is at all, still persists. The low iron content of milk is well-known and infants that depend on milk alone for food, as in the Saudi culture will inevitably have a deficiency of this nutrient. It would seem that traditional feeding practices are deeply ingrained and it would probably take more time to notice the changes in the population's nutritional status. Diseases of affluence are sometimes caused by a lack of or oversupply of dietary components and nutrition surveys such as this one may show groups of individuals with extraordinarily low intakes of nutrients, but apart from the impact of disease, it is not expected to find deficiencies severe enough to yield clinical signs. It seems necessary to pay attention to an adequate intake of nutrients even in the midst of plenty.
SUMMARY AND CONCLUSIONS
Nutrition surveys in the past showed some mild and moderate degrees of malnutrition in young children below 10 years of age. Deficiency diseases like anaemia were also reported. This survey is part of a large study of 1005 patients and sitters to see the relationship of diet and disease. Seven hundred and fourteen patients were subsampled and became the subject of this report to find out if the nutritional status of the children surveyed 10 to 15 years ago had any major change. It also presented some new information about nutritional status of older groups up to 96 years of age. It was found that weight for height and height for age of children up 14 years (except the girls GT 10-LE 14 years) could now compare with the US Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
205
NCHS standard. The adolescent girls' (up to age 18) weight for height were statistically lower than the standard. Later in life, with some influences from· the other female members of the household, and because of their limited activity, the women's weights were even higher than the standard. The adolescent males' weights were within standard, but the adult males' from age 18 were statistically lower than NCHS. Height for age from age 14 years for all were statistically lower than standard and was attributed to poor nutritional states in the past. Energy intakes of the adult males and iron intakes of the infants below one year of age were significantly lower than standard. Low energy intakes of the adult males confirm low weight for height performance. The same problem with iron of milk-fed infants of 10 to 15 years ago was still encountered. This shows that some traditional practice of infant feeding still persists despite the improvement in the quality oflife and standard ofliving of the Saudis due to the economic upheaval created by oil. This survey emphasizes the importance of follow-up reports to see the changes in the people's state of health after a period of transition from economic dependence to affluence.
REFERENCES 1. Abdullah, A.A., Sebai, Z.A. and Swailem, A.R., 1982. Health and nutritional status of preschool children. Saud Med J Monograph, 1-18. 2. Al-Frayh, A., Wong, S.S. and Haque, K.N., 1986. Infant-feeding practices in Riyadh, Saudi Arabia. Ann Saudi Med 8(3): 194-197. 3. Al-Othaimeen, A.l., Sawaya, W.N., Tannous, R.I. and Villanueva, B.P., 1988. A nutrition survey of infants and preschool children in Saudi Arabia. Saudi Med J9(IO): 40-48. 4. Al-Othaimeen, A.l. and Villaneuva, B.P., 1988. The effects of prolonged breast-feeding on the nutritional status of Saudi Arabian children. Ann Saudi Med 8: 97-102. 5. Azad Chowdhury, M.A.K., 1989. Infant-feeding practices and immunization in the Khamis Mushayt area. Ann Saudi Med 9: 19-22. 6. Composition of Foods, 1963, Agricultural Handbook No. 8, Agricultural Research Service, US Department of Agriculture. 7. Dixon, W.J., ed., 1983. BMDP Statistical Software. Los Angeles: University of California Press. 8. Elias, J.B.T., 1985. A survey of place of delivery, modes of milk feeding and immunization in a primary health care center in Saudi Arabia. Saudi Med J 6(2): 169-176. 9. Food Composition Table for Use in East Asia, 1972. US Department of Health, Education and Welfare, and Food and Agriculture Organization of the United Nations. 10. Gopalan, C., 1987. Height of populations-an index of their nutrition and socioeconomic development. Bulletin of the Nutrition Foundation of India 8(3). 11. Kamel, B.S. and Martinez, O.B., 1984. Food habits and nutrient intakes of Kuwaiti males and females. Ecol Food Nutr 15: 261-272. 12. Lawson, M., 1981. Infant feeding habits in Riyadh. Saudi Med J 2: 26-29. 13. Jelliffe, D.B. and Jelliffe, E.F.P., 1978. The volume and composition of human milk in poorly nourished communities. Am J Clin Nutr 31: 492-514. 14. Ministry of Planning, Kingdom of Saudi Arabia, 1985. Achievements of the Development Plans, 1970-1985. Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
206 15. Monsen, E.R., 1989. The lOth edition of the recommended dietary allowances: What's new in the RDA's? JAm Diet Assoc 89(12): 1748-52. 16. Musaiger, A.O., 1987. The state of food and nutrition in the Arabian Gulf countries. World Rev Nutr Diet 54: 105-73. 17. Musaiger, A.O. and Abdullah, Z.S., 1985. Food Composition for Use in Bahrain. Bahrain: Ministry of Health. 18. National Center for Health Statistics, 1977. NCHS Growth Curvesfor Children, Birth-18 years. Rockville, Md: US Department of Health, Education and Welfare (publication no. 12 (PHS). 19. National Health and Nutrition Examination Survey (NHANES II), 1980. National Center for Health Statistics. Overweight Adults 20-74 Years of Age: United States, 19711978. Vital and Health Statistics, Advance Data No. 51. Hyattsville, Public Health Service, DHEW. 20. Pennington, J.A.T. and Church, H.N., 1984. Bowes and Church's Food Values of Portions Commonly Used. Philadelphia: J.B. Lippincott Company. 21. Recommended Daily Dietary Allowances, revised 1980, US National Academy of Sciences, Washington, DC. 22. Recommended Dietary Allowances, 1989. Estimated Minimum requirements (EMR's) for sodium, chloride, and potassium for healthy persons. NAS. 23. Sebai, Z.A., 1981. Anthropometric measurements among preschool children in Wadi Turaba, Saudi Arabia. J Trap Paed 27: 150-154. 24. Waterlow, J.C., Buzina, R., Keller, W., Lane, J.M., McNickman, M.Z. and Tanner, J.M., 1977. The presentation and use of height and weight data for comparing the nutritional status of groups of children under the age of ten. Bull WHO 55: 489-98. 25. Whitehead, R.G. and Paul, A.A., 1981. Infant growth and human milk requirements. Lancet 2: 161-163. 26. Williams, S.R., 1978. Essentials of Nutrition and Diet Therapy. Saint Louis: The C.V. Mosby Company. (Received 13 December 1991; infinalform 1 Apri/1992)
Downloaded from nah.sagepub.com at NANYANG TECH UNIV LIBRARY on May 22, 2015
