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Applied nutritional investigation
Dietary intakes of essential nutrients among Arab and Berber ethnicgroups on rural Tunisian island
Thouraya Baroudi, Ph.D.
a ,
,Hafaoua Kammoun Abid, Ph.D., M.D.
,and Leila Trabelsi Alouane, Ph.D.
a
Laboratory of Genetics, Immunology and Human Pathologies, Faculty of Sciences of Tunis, El Manar II University, Tunis, Tunisia
b
Hospital Charles Nicolle, Internal Medicine A, Tunis, Tunisia
c
High School of the Sciences and Techniques of the Health of Tunis, University of Tunis II, Bab Suika BP 176, Tunis, Tunisia
Manuscript received February 16, 2008; accepted May 18, 2009.
Abstract Objective:
The dietary intake was investigated and food sources were identified among Tunisianethnic groups from Jerba Island in the south of Tunisia.
Methods:
Ninety-four subjects of moderate socioeconomic status (47 Berbers and 47 Arabs) aged 32to64ycompleteda1-moqualitativefood-frequencyquestionnaireandasingle24-hdietaryrecall,anddietary intakes and demographic status were observed from 2006 to 2007.
Results:
The prevalence of overweight and obesity was not significantly associated with Arab mencompared with Berber men. Therefore, obesity was significantly associated with Berber women(
P
<
0.001). Height was significantly different between Arab and Berber women (
P
<
0.001). Therewere no significant differences in energy intake between men and women. Protein intake was not significantly different between ethnic groups. Milk and dairy products in the Berber group weresignificantly different from the Arab group. Intakes of calcium, zinc, iron, and folate were belowrecommended nutrient intakes in men and women in the two ethnic groups. Vitamin E intake wasgreater in Berbers than in Arabs (
P
<
0.01).
Conclusion:
Ethnicity was significantly associated with dietary intakes in the two ethnic groups of Jerba Island.
Ó
2010 Published by Elsevier Inc.
Keywords:
Ethnicity; Dietary intake; Arabs; Berbers; Jerba Island
Introduction
Ethnicity is a complex construct of biology, culture,language, religion, and distinct health beliefs and behaviorsencompassing a range of biological and environmental expo-sures[1]. The Tunisian population is characterized by itsdiversity. In Tunisia, there still exists, despite civilizationsmixing, areas where ethnic separation remains clear. Amongthese areas Jerba Island (in the southeast) shelters two differ-ent populations in their culture and their lifestyle. The first consists of Berbers, original citizens of the island, whosehistory extends to the end of the Paleolithic period. Thesecond community consists of Arabs installed in the islandat the time of the Islamic conquest during the 7th century.Although the two ethnic groups are Muslim, they differ bytheir doctrines. Religious and cultural differences have repre-sented an obstacle to their intermixing and marriages usuallyoccur between members from the same extended family inthe same ethnic group.The influence of lifestyle patterns on health status hasbeen evaluated in numerous ecologic and analytic studies.Avoiding cigarette smoking[2], maintaining a normal bodymass index (BMI)[3], and adding physical activity to dailyactivities are well studied[4]. Lifestyle habits are stronglyassociated with decreased rates of mortality. There isgrowing awareness that variations in dietary practices amongethnic groups may help to explain interethnic differencesin morbidity and mortality. These differences have beenidentified among many ethnic groups[5–7].To our knowledge, the assessment of ethnic differences infood intake or physical activity patterns between Berbers and
*Correspondingauthor.Tel.:
þ
216-71-60-65-15;fax:
þ
216-71-82-17-0.
E-mail address:
Ó
2010 Published by Elsevier Inc.doi:10.1016/j.nut.2009.05.020Nutrition 26 (2010) 75–81www.nutritionjrnl.com
Arabs has not yet been performed. The aims of this studywere to describe the dietary patterns in two ethnic groupson Jerba Island and to relate these patterns to anthropometricmeasurements.
Methods
Study population
The data for this study were collected from July 2006 toJuly 2007 in two Arab villages, Midoun and Houmet Essouk,and two Berber villages, Guellala and Sedwikch. Theseethnic groups live far from each other on Jerba Island. Thesample for our analyses included 47 Berber and 47 Arabsubjects aged 32–64 y. The recruitment of the populationwas done among the patients who came to medical centerson the island and those who accompanied them. Each partic-ipant agreed to take part in our investigation by signing aninformed consent before entering the study; the appropriatelocal ethical committee approved this research and it wasperformed in accordance with the Declaration of Helsinki.Each individual was examined by medical personnel andsurveyed with a comprehensive questionnaire that theycompleted at home (including information on their pheno-typic measurements about age, smoking habits, medicalhistory and current use of medications, lifestyle, diet, andsocioeconomic status).The inclusion criteria in this study were to be an adult anda life-long full-time resident of the island who never left or lived elsewhere; the spouse had to originate from the islandand have the same ethnicity. These criteria seemed important to us to avoid any modification of the food culture.Because it is recognized that social inequalities play animportant role in health and disease outcomes in manyregions of the world[8–10], we recruited in the study onlysubjects of moderate socioeconomic status. Participantswere also invited to provide information on their educationlevel (as number of years spent in the education system).
Physical activity assessment
For physical activity assessment, subjects completeda physical activity–recall questionnaire. They were asked torecord whether they were sleeping, sitting, standing, or watching television during each hour of the day. Subjectsnoted thetime of day they started each new activity, body po-sitionduringtheactivity(reclining,sitting,standing,orwalk-ing), and effort (light, moderate, or vigorous). They wereasked about leisure and occupational physical activities per-formed during the previous week. For the previous week, theaverage number of hours per week of each activity was cal-culated. The total hours of each activity was multiplied bytheestimatedmetaboliccostoftheactivityandthenthephys-ical activity level (PAL) was computed as the total energyexpended over 24 h divided by 24[11]. Gender, age, height,and body weight are the main determinants of basal meta-bolic rate (BMR). To estimate the BMR we used predictiveequations based on these factors[12]. Multiplying the PALby the BMR produced the total energy expenditure.The same investigator instructed the subjects in the use of these physical activity records and inspected the completedforms.
Measurement of diet
Usual dietary intake was assessed with the use of a 168-item semiquantitative food-frequency questionnaire.All questionnaires were administered by trained dieticians.The food-frequency questionnaire consisted of a list of foodswithastandardserving size.Participants wereaskedtoreport their frequency of consumption of each food item during thepreviousmonthonadaily(e.g.,bread)orweekly(e.g.,riceor meatorfish)basis.Portionsizesofconsumedfoodswerecon-verted from household measurements to grams. Each foodandbeveragewasthencodedaccordingtotheprescribedpro-tocol and analyzed for content of energy and other nutrientsusing Bilnut software (SCDA Nutrisoft, Cerelles, France),which was designed for Tunisian foods. We used a 24-hdietary recall to obtain detailed information about foodsincluding brand names, preparation methods, and ingredientsused in the preparation. Three-dimensional food models,measurement aids, and food-specific units were used toestimate amounts consumed. We determined total calories,total and percentage of calories from protein, carbohydrateand fat, and the nutrients cholesterol, fiber, folates, vitaminC, vitamin E, calcium, zinc, iron, and magnesium.We calculated the nutrient density (amount of nutrient per 100 kcal) for fiber, sucrose, and iron.An appropriate intake of energy with energy distributionsof carbohydrate, protein, and fat was determined within therecommended nutrient intakes (RNIs) established by theU.S. National Academy of Sciences. No subject had lactoseintolerance during his/her lifetime.
Anthropometric determination
Measurements of height by using a stadiometer andweight on a digital scale while wearing lightweight clothingwithout shoes was used to calculate BMI; BMI was definedas weight in kilograms divided by height squared in meters.Non-obese subjects had a BMI
<
25 kg/m
2
, overweight subjects had a BMI 25–30 kg/m
2
, and obese subjects hada BMI
>
30 kg/m
2
. Obesity was defined as a BMI
!
30 kg/m
2
according to recommendations of the WorldHealth Organization[13].Waist and hip circumferenceswere measured at the level of the umbilicus and the widest area around the buttocks, respectively, and the waist-to-hipratio was also calculated[14].To avoid the influence of height, the ratio of waist circum-ference (WC) to body height (BH) was computed. The WC/ BH ratio has been reported to have closer values betweenmen and women than BMI or WC; therefore, the same
T. Baroudi et al. / Nutrition 26 (2010) 75–81
76
boundary value may be applied to men and women[15].Meanwhile, a WC/BH ratio equal to 0.5 may be a simpleand effective index to identify not only almost overweight people but also normal-weight people with higher metabolicrisks[15,16].To avoid data variability from measurement techniques,all measurements were undertaken by the same individual.
Statistical analysis
Analysis was performed with SPSS 10.0 (SPSS Inc.,Chicago, IL, USA). Subgroups were analyzed by gender,age, and ethnic group. All results were presented as relativeand absolute data means. Dietary intakes were calculatedfrom the food-frequency questionnaires using Bilnut 4.0,which was adapted for Tunisian foods. Group means werecompared by least significant difference at
P
<
0.05.
Results
Anthropometric characteristics of studied samples
Table1listsmeans
6
standarddeviations(SDs)forageandanthropometric measurements (BMI, WC, and WC/BH) for men and women by ethnicgroup. The studied populationcon-sistedof38men(22Arabsand16Berbers)and56women(25Arabsand31Berbers).AmongtheArabs12men(54.5%)wereoverweight and four (18.2%) were obese. Among the Berberseight men (50%) were overweight and two (12.5%) wereobese. Among the Arabs nine women (36%) were overweight and eight (32%) were obese. Among the Berbers five women(16%) were overweight and 24 (77%) were obese.The prevalence of overweight and obesity was not significantly greater for Arab men compared with Berber men. However, the prevalence of obesity was significantlygreater for Berber women (
P
<
0.001). Arab women showedasignificantlylowerBMIthanBerbers. Arabmenshowednodifference in BMI from Berbers. BMI did not show a signifi-cant difference between ethnic groups (
P
¼
0.66). WC waslarger in women than in men and there was no differencebetweenethnicgroups.Berberwomenshowedasignificantlyshorter height than Arab women (
P
<
0.001). WC/BH ratiomeasurements were significantly different between sexes(
P
<
0.001) and ethnicities (
P
<
0.01).
Physical activity
The evaluation of physical activity of the two groups didnot show a significant difference according to ethnicity. Theonly difference was found according to sex; the men weremore active than the women (
P
<
0.00). The men were ontheir feet for most of the day as part of their job but did not take regular physical exercise. The two ethnic groups canbe considered as sedentary because the PAL was
<
Energy intakes
Table 2lists mean
6
SD daily dietary intake by ethnicgroup and by sex. Mean
6
SD energy intakes in Arab menwere 1846
6
262 kcal. Energy intakes in Berber men were2039
6
316 kcal. Energy intakes were 1833
6
254 kcal inArab women and 1858
6
239 kcal in Berber women.Mean
6
SD energy intakes were 1839
6
256 kcal in Arabsubjects and 1927
6
283 kcal in the Berber population.There were no significant differences in energy intake inmen and women by ethnicity.We compared energy intake with calculated expenditureenergy (PAL multiplied by BMR produced total energyexpenditure).Overtheentirestudiedpopulation,men’sneedswere covered (81
6
16) was significantly less than those of women (102
6
16,
P
<
0.001). Among men, 14 Arabs and5 Berbers covered
<
80% of their needs. Among women,
Table 1Anthropometric characteristics in ethnic groups*Arab group Berber groupMen(
n
¼
22)Women(
n
¼
25)Total(
n
¼
47)Men(
n
¼
16)Women(
n
¼
31)Total(
n
¼
47)Age (y) 49
6
7 50
6
10 50
6
9 54
6
10 49
6
11 50
6
11Education level
y
(%)Illiterate 4.5 40 23.4 31.3 74.2 59.6Low 36.4 32 34.0 37.5 25.8 29.8Moderate 31.8 16 23.1 25 0 8.5High 27.3 12 19.1 6.3 0 2.1Height (m) 1.68
6
0.08 1.57
6
0.06 1.62
6
0.09 1.66
6
0.09 1.52
6
0.08 1.57
6
0.1Weight (kg) 78
6
13 71
6
15 74
6
14 68
6
12 78
6
14 74
6
14BMI (kg/m
2
)
z
27
6
5 29
6
6 28
6
6 25
6
5 33
6
5 90
6
6WC (m)
z
83.1
6
9.7 85.9
6
11.3 84.6
6
10.5 78.1
6
8.9 94.4
6
8.8 88.9
6
11.7WC/BH
yz
0.50
6
0.07 0.55
6
0.08 0.52
6
0.08 0.47
6
0.07 0.62
6
0.06 0.57
6
0.09BH, body height; BMI, body mass index; WC, waist circumference* Values are means
6
SDs or percentages of subjects.
y
P
<
0.001 between Arab and Berber groups.
z
P
<
0.001 between men and women.
T. Baroudi et al. / Nutrition 26 (2010) 75–81
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