FRANK W. LOWENSTEIN AND DANIEL E. O'CONNELL
Health and Nutritional Status of Village Boys 6-11 Years Old in Southern Tunisia* bv FRANK W. LOWENSTEIN, M.D. and DANIEL E. O'CONNELL National Centerfor Health Statistics, Division of Health Examination Statistics, U.S. Public Health Service, 5600 Fishers Lane, Rockville, Maryland 20852 In the summer of 1970, a total of 146 boys between the ages of 6 and 11 in three villages in Southern Tunisia were examined as part of a nutrition project concerned with the effect of wheat products fortified with lysine and certain B-vitamins on growth and nutritional status. These boys constituted part of a larger sample that had a number of anthropometric measurements done; results of these measurements have been published in a previous paper.1 This paper deals with the findings from the clinical examinations and the laboratory tests of boys from the villages of Mansoura, Menchia and Negga, located in the Kebili delegation (district) in Southeastern Tunisia, east of the Chot el Djerid, a big salt lake on the northern edge of the Sahara. The climate is arid and differences in temperature are considerable between day and night, particularly in the winter. Each village is-attached to a large oasis. The oases are the centers of life in this desert country. Here a variety of crops are produced, both for cash and subsistence. The main cash crop is dates, a large part of which is for export. The major food crops are wheat, barley, olives and various fruits and vegetables. The production of food crops, however, is not sufficient to meet nutritional requirements. Most of the wheat, the main staple food, is brought in from the north of Tunisia. Animal husbandry is on a rather small scale, comprising mainly sheep and goats. Information has become available from a qualitative and several quantitative food consumption surveys on a household basis in the whole area of the nutrition project mentioned in the first paragraph between 1970 and 1974.5 According to this information, cereals (principally wheat) provided 60 percent of the dietary (calories) energy and 85 percent of the dietary protein. Animal protein, primarily from meat, constituted only 6 percent of the total protein consumption with legumes, vegetables and potatoes providing 8 percent. Sixty-six percent of the population in this area consumed less than the mean requirement of 2.631 K •Supported by the Agency for International Development (AID) and the Department of Nutrition, Harvard University School of Public Health. The authors gratefully acknowledge the assistance of Mr. M. Turki, with the clinical examinations, and of Dr. Sam Gamble, Chief of the Laboratory, Harvard-AID project in 1970. 66
calories per adult male equivalent (Tunisian male, aged 20-40, moderately active, as modified from the FAO/WHO energy requirements).6 Seasonal variations in food consumption also play a role as was shown by Tesi and co-workers.3 Consumption of wheat products is lowest in the summer resulting in a reduction of 9g in protein intake as compared-to the winter months. The survey of the boys took place in the summer of 1970 (June-July). Another important factor is food cost and expenditure. With the limited economic resources of most families, food was the greatest expense. Cereals accounted for 51 percent of all food expenses with a relatively low cost per energy and protein unit. Oil and sugar accounted for 12 percent of the total while legumes, potatoes and fresh vegetables constituted 16 percent of the total food cost. Meat, however, was so expensive at $2.70 per kilogram, that it was a rare luxury, but it still constituted 19 percent of total food expenses. Information on family income in the sample showed Menchia ahead with 71 Tunisian Dinars per capita per year income, Mansoura and Negga had per capita yearly incomes of 37 and 49 Dinars respectively. These incomes were much lower than those for the whole project area in 19713 due to great losses in cash income from dates in the 1969-70 season. Heavy rains with floods in the fall of 1969 had damaged the date crop in these villages so severely that per capita income was greatly reduced as compared to good years. The information mentioned earlier on food consumption in the area shows that the majority of the people have diets deficient in both calories and protein.. Sample The boys in the sample were randomly selected from the school in each village. The number and percentage this represents of the total in the age groups are shown in Table I. A few boys examined were either below age 6 or above age 11; however, they have been eliminated form the analysis because there were too few by years of age to make the analysis meaningful. In Negga and Mansoura, over 90 percent of the boys are in school during ages 6-11. In Menchia, the attendance was between 82 and 90 percent. Methodology Each boy received the following.examinations: 1) a clinical examination by the first author with particular Environmental Child Health, April 1977
_J
FRANK W. LOWENSTEIN AND DANIEL E. O'CONNELL
Table I
Table III
Size of population and sample, and the percent of the population in the sample
% Prevalence of Clinical Signs by Village Boys 6-11 Years
Estimated number Number in Percent of of boys 6-11 sample 6-11 Population years in the population years in sample
Mansoura
214 160 118
Menchia Negga
36 65
-41 146
1. 2. 3. 4. 5. 6. 7.
16.8 40.6 38.1
attention to signs of possible nutritional deficiencies (see table III); 2) a urine test for albumen, blood and a microscopic examination of the sediment for schistosoma eggs and parasites; 3) a microscopic stool examination for worm eggs and parasites; 4) in approximately 50 percent of the boys examined, blood was taken from a finger prick at a later date (two weeks after the first examination) and examined for hemoglobin by the cyanmethemoglobin method2 and micro hematocrit by the Wintrobe method.3 Results 1) Clinical signs: The percentage of boys showing one or more clinical signs suggestive of nutrition deficiencies was 88.9 percent in Mansoura, 95.4 percent in Menchia and 93.3 percent in Negga (Table II). Forall three villages there was a tendency for the: average number of signs to increase with age. This was more pronounced in Menchia than in the other two villages. Boys in Negga had the highest average number of signs: 3.0 versus 2.0 and 2.7 percent in Mansoura and Menchia respectively. Mansoura boys had the lowest percentage with multiple signs while Negga and Menchia boys had the highest. In all three villages, at least 88 percent of the boys had one or more signs. In Table III, some of the signs are shown where prevalences were greater then 5 percent. From this it appears that bowed legs, suggestive of past rickets were more prevalent in Mansoura and Menchia than
Head Bossing Bowed legs Angular Scars — Lips Cheilosis — Lips Discoloration of enamel Bleeding Gums Thyroid Visibly Enlarged
Mansoura 9.7 9.7 — 25.0 27.8
Menchia —
9.2 6.9 23.6 24.6
Negga 9.0 6.7 10.4 18.6 17.9 6.7 6.7
Other signs found in the villages included the following: (prevalence less than 5 percent). Diffuse depigmentation Eyes — pale conjuctivae Angular Blepharitis Circumcorneal injection Angular lesions of the lips Atrophic papillae of tongue White spots of enamel of teeth Ridging of enamel of teeth Bleeding gums (for Mansoura and Menchia) Follicular hyperkeratosis
in Negga. Signs possibly indicating riboflavin deficiency were more frequent in Negga and Menchia than in Mansoura. Only boys in Negga showed any signs suggesting a possible deficiency of iodine (enlarged thyroid). 2) Laboratory findings: Urine: In Table IV, a summary of the findings is presented from the microscopic examination of the sediment. The greatest prevalence of urines with blood, albumen and eggs of schistosoma hematobium was found in Negga (73.3 percent) and in Mansoura (65.7 percent) while boys in Menchia had a much lower prevalence (19.1 percent). Prevalence in Negga and Mansoura increased slightly with age. The severity of the infection was also much less among the Menchia boys where 50 percent of those infected showed albumen only in their urine. In Negga and Mansoura, 68.9 and 51.4 percent respectively showed all three, blood, albumen and schistosoma eggs in the urine.
Table II Number and Percent of Boys 6-11 Years with Multiple Physical Signs by Village MANSOURA No. of Signs
0 1 2
No. of Boys 4 10 22
or more TOTAL
36
Percent Cumulative of Boys - Percent 11.1 11.1 27.8 38.9 61.1 100.0 100.0
Environmental Child Health, April 1977
NEGGA No. of No. of Boys Signs 0 3 1 3 2 39 or more 45
Percent Cumulative No. of Percent Signs of Boys 0 6.1 6.7 13.4 1 6.7 86.6 100.0 2 or more 100.0
MENCHIA
Percent Cumulative of Boys Percent 4.6 4.6 12.3 16.9 83.1 100.0
No. of Boys
3 8 54 65
-.
,
100.0
67
FRANK W. LOWENSTEIN AND DANIEL E. O'CONNELL
Table IV Urine Analysis: Prevalence of Schistosome eggs, Albumin and Blood in Boys 6-11 Years. Mansoura, Menchia and Negga Number and Prevalence With Specific Positive Specimens
Total Boys
Number and % Negative
a1
b
c
ab 2
ac
be
abc2
Total Positive
Mansoura Total Percent
35
12 34.3
0 0
2 5.7
0 0
2 5.7
1 2.9
0 0
18 51.4
23 65.7
Menchia Total Percent
63
51 80.9
0
6 9.5
2 3.2
0
1 1.6
1 1.6
2 3.2
12 19.1
Negga Total Percent
45
12 26.7
2 4.4
0
0
0
0
0
31 68.9
33 73.3
'a — Schistosoma eggs b — Albumin c — Blood 'Combinations found of a, b, and c. first two parasites listed (ankylostoma and/or E. Histolytica) which may have more serious effects on health. Blood Blood for hemoglobin and hematocrit was taken at a later date (two weeks after the clinical examination) in approximately 50 percent of the total sample that was randomly selected. Negga had the highest percentage of low values for both hemoglobin (71.4 percent) and hematocrit (25.0 percent) while Mansoura had the lowest percentage, 43.8 percent for hemoglobin and 5.6 percent for hematocrit (Table VI). Menchia boys aged 7 and 8 had relatively higher proportions of low values compared to the older boys.
Stool
Menchia showed the highest prevalence for parasites among the three, villages. 80.0% of the boys had ascaris lumbricoides and approximately one in 4 had two or more of the parasites (Table V). Mansoura also had high levels (48.7%) of ascaris lumbricoides and approximately one in five of the boys had two or more of the parasites. In Negga few (4.4%) of the boys had two or more parasites, but over one-half (51.1%) had strongyloides stercoralis. Other prevalences that need mention include in Negga, ascaris lumbricoides (17.8%) and giarda Iamblia (15.6%). Mansoura and Menchia had 11.1% and 15.4% respectively of trichuris trichuris. Few boys were found to have the
Table V Number and Percent of Parasites Found in the Stool of Boys 6-11 Years in Three Tunisian Villages Boys with Particular Parasite1 No Parasites Village
No.
Mansoura Menchia
5 4 3
Negga
' 1. 2. 3. 4. 5. 6. 7. 68
2
1
%
No.
13.9 6.2: 6.7
3 0 0
% No. 8.3 0.01 0.0
0 3 1
3 % No.
4 % No.
0.0 19 48.7' 4.6 52 80.0 2.2 8 17.8
5 % No.
6 % No.
Boys with two or more parasites
7 % No.
1 2.8 1 2.8 4 11.1 4 6.2 1 1.5 10 15.4 7 15.6 23 51.1 0 0.0
0 2 2
% 0.0 3.1 4.4
No.
%
7 19.4 16 24.6 2 4.4
•
Ankylostoma (Eggs) Entamoeba Histolytica (Cysts) Ascaris Lumbricoides (Eggs) Giardia Lamblia (Parasites) Strongyloides Stercoralis (Eggs) Trichuris Trichuris (Eggs) Enterobius Vemcularis (Eggs) Environmental Child Health, April 1977
FRANK W. LOWENSTEIN AND DANIEL E. O'CONNELL
Table VI Mean, Standard Deviation, Number and Percent of Boys Low for Hematocrit and Hemoglobin Measures in Three Villages of Tunisia Negga
Menchia
Mansoura No. % Low Low
X
Health and Nutritional Status of Village Boys 6-11 Years Old in Southern Tunisia* bv FRANK W. LOWENSTEIN, M.D. and DANIEL E. O'CONNELL National Centerfor Health Statistics, Division of Health Examination Statistics, U.S. Public Health Service, 5600 Fishers Lane, Rockville, Maryland 20852 In the summer of 1970, a total of 146 boys between the ages of 6 and 11 in three villages in Southern Tunisia were examined as part of a nutrition project concerned with the effect of wheat products fortified with lysine and certain B-vitamins on growth and nutritional status. These boys constituted part of a larger sample that had a number of anthropometric measurements done; results of these measurements have been published in a previous paper.1 This paper deals with the findings from the clinical examinations and the laboratory tests of boys from the villages of Mansoura, Menchia and Negga, located in the Kebili delegation (district) in Southeastern Tunisia, east of the Chot el Djerid, a big salt lake on the northern edge of the Sahara. The climate is arid and differences in temperature are considerable between day and night, particularly in the winter. Each village is-attached to a large oasis. The oases are the centers of life in this desert country. Here a variety of crops are produced, both for cash and subsistence. The main cash crop is dates, a large part of which is for export. The major food crops are wheat, barley, olives and various fruits and vegetables. The production of food crops, however, is not sufficient to meet nutritional requirements. Most of the wheat, the main staple food, is brought in from the north of Tunisia. Animal husbandry is on a rather small scale, comprising mainly sheep and goats. Information has become available from a qualitative and several quantitative food consumption surveys on a household basis in the whole area of the nutrition project mentioned in the first paragraph between 1970 and 1974.5 According to this information, cereals (principally wheat) provided 60 percent of the dietary (calories) energy and 85 percent of the dietary protein. Animal protein, primarily from meat, constituted only 6 percent of the total protein consumption with legumes, vegetables and potatoes providing 8 percent. Sixty-six percent of the population in this area consumed less than the mean requirement of 2.631 K •Supported by the Agency for International Development (AID) and the Department of Nutrition, Harvard University School of Public Health. The authors gratefully acknowledge the assistance of Mr. M. Turki, with the clinical examinations, and of Dr. Sam Gamble, Chief of the Laboratory, Harvard-AID project in 1970. 66
calories per adult male equivalent (Tunisian male, aged 20-40, moderately active, as modified from the FAO/WHO energy requirements).6 Seasonal variations in food consumption also play a role as was shown by Tesi and co-workers.3 Consumption of wheat products is lowest in the summer resulting in a reduction of 9g in protein intake as compared-to the winter months. The survey of the boys took place in the summer of 1970 (June-July). Another important factor is food cost and expenditure. With the limited economic resources of most families, food was the greatest expense. Cereals accounted for 51 percent of all food expenses with a relatively low cost per energy and protein unit. Oil and sugar accounted for 12 percent of the total while legumes, potatoes and fresh vegetables constituted 16 percent of the total food cost. Meat, however, was so expensive at $2.70 per kilogram, that it was a rare luxury, but it still constituted 19 percent of total food expenses. Information on family income in the sample showed Menchia ahead with 71 Tunisian Dinars per capita per year income, Mansoura and Negga had per capita yearly incomes of 37 and 49 Dinars respectively. These incomes were much lower than those for the whole project area in 19713 due to great losses in cash income from dates in the 1969-70 season. Heavy rains with floods in the fall of 1969 had damaged the date crop in these villages so severely that per capita income was greatly reduced as compared to good years. The information mentioned earlier on food consumption in the area shows that the majority of the people have diets deficient in both calories and protein.. Sample The boys in the sample were randomly selected from the school in each village. The number and percentage this represents of the total in the age groups are shown in Table I. A few boys examined were either below age 6 or above age 11; however, they have been eliminated form the analysis because there were too few by years of age to make the analysis meaningful. In Negga and Mansoura, over 90 percent of the boys are in school during ages 6-11. In Menchia, the attendance was between 82 and 90 percent. Methodology Each boy received the following.examinations: 1) a clinical examination by the first author with particular Environmental Child Health, April 1977
_J
FRANK W. LOWENSTEIN AND DANIEL E. O'CONNELL
Table I
Table III
Size of population and sample, and the percent of the population in the sample
% Prevalence of Clinical Signs by Village Boys 6-11 Years
Estimated number Number in Percent of of boys 6-11 sample 6-11 Population years in the population years in sample
Mansoura
214 160 118
Menchia Negga
36 65
-41 146
1. 2. 3. 4. 5. 6. 7.
16.8 40.6 38.1
attention to signs of possible nutritional deficiencies (see table III); 2) a urine test for albumen, blood and a microscopic examination of the sediment for schistosoma eggs and parasites; 3) a microscopic stool examination for worm eggs and parasites; 4) in approximately 50 percent of the boys examined, blood was taken from a finger prick at a later date (two weeks after the first examination) and examined for hemoglobin by the cyanmethemoglobin method2 and micro hematocrit by the Wintrobe method.3 Results 1) Clinical signs: The percentage of boys showing one or more clinical signs suggestive of nutrition deficiencies was 88.9 percent in Mansoura, 95.4 percent in Menchia and 93.3 percent in Negga (Table II). Forall three villages there was a tendency for the: average number of signs to increase with age. This was more pronounced in Menchia than in the other two villages. Boys in Negga had the highest average number of signs: 3.0 versus 2.0 and 2.7 percent in Mansoura and Menchia respectively. Mansoura boys had the lowest percentage with multiple signs while Negga and Menchia boys had the highest. In all three villages, at least 88 percent of the boys had one or more signs. In Table III, some of the signs are shown where prevalences were greater then 5 percent. From this it appears that bowed legs, suggestive of past rickets were more prevalent in Mansoura and Menchia than
Head Bossing Bowed legs Angular Scars — Lips Cheilosis — Lips Discoloration of enamel Bleeding Gums Thyroid Visibly Enlarged
Mansoura 9.7 9.7 — 25.0 27.8
Menchia —
9.2 6.9 23.6 24.6
Negga 9.0 6.7 10.4 18.6 17.9 6.7 6.7
Other signs found in the villages included the following: (prevalence less than 5 percent). Diffuse depigmentation Eyes — pale conjuctivae Angular Blepharitis Circumcorneal injection Angular lesions of the lips Atrophic papillae of tongue White spots of enamel of teeth Ridging of enamel of teeth Bleeding gums (for Mansoura and Menchia) Follicular hyperkeratosis
in Negga. Signs possibly indicating riboflavin deficiency were more frequent in Negga and Menchia than in Mansoura. Only boys in Negga showed any signs suggesting a possible deficiency of iodine (enlarged thyroid). 2) Laboratory findings: Urine: In Table IV, a summary of the findings is presented from the microscopic examination of the sediment. The greatest prevalence of urines with blood, albumen and eggs of schistosoma hematobium was found in Negga (73.3 percent) and in Mansoura (65.7 percent) while boys in Menchia had a much lower prevalence (19.1 percent). Prevalence in Negga and Mansoura increased slightly with age. The severity of the infection was also much less among the Menchia boys where 50 percent of those infected showed albumen only in their urine. In Negga and Mansoura, 68.9 and 51.4 percent respectively showed all three, blood, albumen and schistosoma eggs in the urine.
Table II Number and Percent of Boys 6-11 Years with Multiple Physical Signs by Village MANSOURA No. of Signs
0 1 2
No. of Boys 4 10 22
or more TOTAL
36
Percent Cumulative of Boys - Percent 11.1 11.1 27.8 38.9 61.1 100.0 100.0
Environmental Child Health, April 1977
NEGGA No. of No. of Boys Signs 0 3 1 3 2 39 or more 45
Percent Cumulative No. of Percent Signs of Boys 0 6.1 6.7 13.4 1 6.7 86.6 100.0 2 or more 100.0
MENCHIA
Percent Cumulative of Boys Percent 4.6 4.6 12.3 16.9 83.1 100.0
No. of Boys
3 8 54 65
-.
,
100.0
67
FRANK W. LOWENSTEIN AND DANIEL E. O'CONNELL
Table IV Urine Analysis: Prevalence of Schistosome eggs, Albumin and Blood in Boys 6-11 Years. Mansoura, Menchia and Negga Number and Prevalence With Specific Positive Specimens
Total Boys
Number and % Negative
a1
b
c
ab 2
ac
be
abc2
Total Positive
Mansoura Total Percent
35
12 34.3
0 0
2 5.7
0 0
2 5.7
1 2.9
0 0
18 51.4
23 65.7
Menchia Total Percent
63
51 80.9
0
6 9.5
2 3.2
0
1 1.6
1 1.6
2 3.2
12 19.1
Negga Total Percent
45
12 26.7
2 4.4
0
0
0
0
0
31 68.9
33 73.3
'a — Schistosoma eggs b — Albumin c — Blood 'Combinations found of a, b, and c. first two parasites listed (ankylostoma and/or E. Histolytica) which may have more serious effects on health. Blood Blood for hemoglobin and hematocrit was taken at a later date (two weeks after the clinical examination) in approximately 50 percent of the total sample that was randomly selected. Negga had the highest percentage of low values for both hemoglobin (71.4 percent) and hematocrit (25.0 percent) while Mansoura had the lowest percentage, 43.8 percent for hemoglobin and 5.6 percent for hematocrit (Table VI). Menchia boys aged 7 and 8 had relatively higher proportions of low values compared to the older boys.
Stool
Menchia showed the highest prevalence for parasites among the three, villages. 80.0% of the boys had ascaris lumbricoides and approximately one in 4 had two or more of the parasites (Table V). Mansoura also had high levels (48.7%) of ascaris lumbricoides and approximately one in five of the boys had two or more of the parasites. In Negga few (4.4%) of the boys had two or more parasites, but over one-half (51.1%) had strongyloides stercoralis. Other prevalences that need mention include in Negga, ascaris lumbricoides (17.8%) and giarda Iamblia (15.6%). Mansoura and Menchia had 11.1% and 15.4% respectively of trichuris trichuris. Few boys were found to have the
Table V Number and Percent of Parasites Found in the Stool of Boys 6-11 Years in Three Tunisian Villages Boys with Particular Parasite1 No Parasites Village
No.
Mansoura Menchia
5 4 3
Negga
' 1. 2. 3. 4. 5. 6. 7. 68
2
1
%
No.
13.9 6.2: 6.7
3 0 0
% No. 8.3 0.01 0.0
0 3 1
3 % No.
4 % No.
0.0 19 48.7' 4.6 52 80.0 2.2 8 17.8
5 % No.
6 % No.
Boys with two or more parasites
7 % No.
1 2.8 1 2.8 4 11.1 4 6.2 1 1.5 10 15.4 7 15.6 23 51.1 0 0.0
0 2 2
% 0.0 3.1 4.4
No.
%
7 19.4 16 24.6 2 4.4
•
Ankylostoma (Eggs) Entamoeba Histolytica (Cysts) Ascaris Lumbricoides (Eggs) Giardia Lamblia (Parasites) Strongyloides Stercoralis (Eggs) Trichuris Trichuris (Eggs) Enterobius Vemcularis (Eggs) Environmental Child Health, April 1977
FRANK W. LOWENSTEIN AND DANIEL E. O'CONNELL
Table VI Mean, Standard Deviation, Number and Percent of Boys Low for Hematocrit and Hemoglobin Measures in Three Villages of Tunisia Negga
Menchia
Mansoura No. % Low Low
X
