Refugee issues. Summary of WFP / UNHCR guidelines for estimating food and nutritional requirements

In line with recent recommendations by WHO and the Committee on International Nutrition, WFP and UNHCR will now use 2100 kcal/person/day as the initial energy requirement for designing food aid rations in emergencies. In an emergency situation, it is essential to establish such a value to allow for rapid planning and response to the food and nutrition requirements of an affected population. An in-depth assessment is often not possible in the early days of an emergency, and an estimated value is needed to make decisions about the immediate procurement and shipment of food. The initial level is applicable only in the early stages of an emergency. As soon as demographic, health, nutritional and food security information is available, the estimated per capita energy requirements should be adjusted accordingly. Food rations should complement any food that the affected population is able to obtain on its own through activities such as agricultural production, trade, labor, and small business. An understanding of the various mechanisms used by the population to gain access to food is essential to give an accurate estimate of food needs. Therefore, a prerequisite for the design of a longer-term ration is a thorough assessment of the degree of self-reliance and level of household food security. Frequent assessments are necessary to adequately determine food aid needs on an ongoing basis. The importance of ensuring a culturally acceptable, adequate basic ration for the affected population at the onset of an emergency is considered to be one of the basic principles in ration design. The quality of the ration provided, particularly in terms of micronutrients, is stressed in the guidelines, and levels provided will aim to conform with standards set by other technical agencies.

Differences in macronutrient selections in users and nonusers of an oral contraceptive

One of the problems inherent in using women in clinical research is the effect that oral contraceptive (OC) use might have on physical indexes. Although weight gain is frequently reported as a side effect of OC use, there is little empirical evidence that such weight gain actually occurs. The current study investigated differences in energy balance [ie, dietary intake, resting energy expenditure (REE), and physical activity] between groups of users and nonusers of OCs. Each group completed a protocol that covered one menstrual cycle and consisted of daily recording of dietary intake, measurement of REE once during each phase of the menstrual cycle, and reporting of physical activity over the entire cycle. Comparisons indicate that there was a marginal interaction (P = 0.06) of OC use with total energy intake, indicating a different pattern of intake for the two groups. There were qualitative between-group differences such that the OC group consumed a greater percentage of energy as fat (P = 0.02) and a lesser percentage of energy as carbohydrate (P = 0.008). No group differences were found in the percentage of energy consumed as protein, but both groups consumed significantly less protein during menses (P = 0.008). There were no significant differences in REE. Both groups of women reported marginally more activity (P = 0.09) during menses than during the luteal phase.

Energy and macronutrient intake of one-year-old South African urban children: the Birth to Ten (BTT) Study

With the changing situation in South Africa, new, reliable, longitudinal nutritional information on young children is needed. Part of the objective of the Birth to Ten (BTT) Study (1990-2000) in the Soweto-Johannesburg area, is to assess the nutrient intake of children. For each of the 2059 one-year-old children mean nutrient intake was determined using food frequency intakes, determined through interviewing parents or guardians. Urban 'coloured' children had the highest daily intake of all the macronutrients, energy being significantly higher than the other groups. Urban black children had the lowest macronutrient intake and energy was significantly lower than that of white children. All groups consumed a typical westernised diet, low in unrefined carbohydrate (47-49% of energy), but high in protein (200% of Recommended Dietary Allowances (RDA)) and fat (38-40% of energy). Among the 'black', 'coloured' and 'white' clinics a difference of approximately 300 kcal/day was noted between the highest and the lowest energy intakes, Pimville and Mofolo showing significantly higher differences among the 'black' clinics. Among the 'coloured' clinics Westbury had a significantly higher energy intake than Eldorado Park. Results have indicated that one-year-old 'coloured' and white children had adequate nutrient intakes, but black and Indian had inadequate energy intakes based on RDA and excluding the contribution of breast milk.

Control of fertility by metabolic cues

In female mammals, reproduction is extremely sensitive to the availability of oxidizable metabolic fuels. When food intake is limited or when an inordinate fraction of the available energy is diverted to other uses such as exercise or fattening, reproductive attempts are suspended in favor of processes necessary for individual survival. Both reproductive physiology and sexual behaviors are influenced by food availability. Nutritional effects on reproductive physiology are mediated by changes in the activity of gonadotropin-releasing hormone (GnRH) neurons in the forebrain, whereas the suppression of sexual behaviors appears to be due, at least in part, to decreases in estrogen receptor in the ventromedial hypothalamus. Work using pharmacological inhibitors of glucose and fatty acid oxidation indicates that reproductive physiology and behavior respond to short-term (minute-to-minute or hour-to-hour) changes in metabolic fuel oxidation, rather than to any aspect of body size or composition (e.g., body fat content or fat-to-lean ratio). These metabolic cues seem to be detected in the viscera (most likely in the liver) and in the caudal hindbrain (probably in the area postrema). This metabolic information is then transmitted to the GnRH-secreting or estradiol-binding effector neurons in the forebrain. There is no evidence to date for direct detection of metabolic cues by these forebrain effector neurons. This metabolic fuels hypothesis is consistent with a large body of evidence and seems to account for the infertility that is seen in a number of situations, including famine, eating disorders, excessive exercise, cold exposure, lactation, some types of obesity, and poorly controlled diabetes mellitus.

Nutrient intake and socio-economic status among children attending a health exhibition in Malaysian rural villages

A dietary survey was carried out in 216 children (109 males, 107 females) aged 1-7 years, living in rural villages in Selangor, Malaysia to assess their nutrient intake and to determine the association between nutrient consumption and socio-economic background. All the children studied had inadequate intakes of energy, iron and niacin according to Recommended Daily Intake (RDI). Children aged of 4-9 years showed inadequate intake of calcium, thiamine and riboflavin. However, the intake of protein, vitamin A and ascorbic acid were above the recommended value. The mean percentage requirements of protein, iron and niacin were significantly higher in children from small families compared with children from large families. However the employment status of mothers had a significantly effect on the mean percentage requirements of niacin. The results indicate that education level of the mothers, is strongly associated with the mean percentage nutrient requirements of children and we strongly feel that this is a strategy to be adopted for improvement in nutrition of children.

Child malnutrition in poor smallholder households in rural Kenya: an in-depth situation analysis

OBJECTIVE

To investigate the effect of seasonal changes on household food availability on the nutritional status of preschool children from rural households.

DESIGN

Households with preschool children were randomly selected from a sampling frame developed from a census list. Data were collected each month or at intervals for 14 months using pre-coded questionnaires.

SETTING

The study was carried out in Njoro division, Nakuru district, Kenya.

SUBJECTS

Subjects comprised 41 preschool children (22 girls and 19 boys) aged between 18 and 36 months. Households with preschool children were listed from a census conducted earlier. A random sample of 45 subjects was selected, out of which 41 completed the study.

INTERVENTION

Food consumption data were collected monthly using the 24-h recall method, and by the 3-day weighed record method during the peak of each season. Subjects were measured once each month, while length was measured at three intervals over the study period.

RESULTS

Significant differences in intake of calcium, vitamin A, thiamin and riboflavin were observed between the lean and the post-harvest months, but not with energy, protein, fat, iron, niacin and vitamin C. There were no significant seasonal differences in mean weight changes, which were at the rate of 182 g/month. Mean length increased at a faster rate during the lean season compared to the postharvest months. 51% of the children were stunted during the lean season compared to 28% in the post-harvest months.

CONCLUSION

The results indicate a seasonal influence on energy and nutrient intake among preschoolers from low income rural households in Kenya.

Improved energy intakes using amylase-digested weaning foods in Tanzanian children with acute diarrhea

Amylase from germinating cereal grains enables the preparation of porridge with a higher energy density than conventional weaning foods. This food can be combined with fermentation, which inhibits pathogen growth. These food technologies are inexpensive, can be implemented at the household level, and are therefore particularly appropriate for use in developing countries. In a controlled clinical trial, 75 children aged 6-25 months admitted to hospital with acute diarrhea were rehydrated and then randomly allocated to three corn porridge dietary groups: conventional, amylase-digested (AMD), and fermented and amylase-digested (FAD). The study diets were given ad libitum five times daily, and all intakes except breast milk were weighed. Mean daily energy intakes over 4 days in the conventional AMD, and FAD groups, respectively, were 32.4 (95% CI 28.7-36.6), 46.0 (CI 39.6-53.4), and 37.3 (CI 31.8-43.9) kcal/kg/day. The energy intake in the AMD group was 42% higher than the conventional group (p = 0.003). There were no significant differences between the groups for duration of diarrhea, frequency of stooling, or vomiting. Starch digestion using amylase from germination is an effective way of improving energy intake in children with acute diarrhea.

Differential response to early nutrition supplementation: long-term effects on height at adolescence

BACKGROUND

The classical risk approach to predicting who benefits from an intervention is unsound because it relies on the theoretical assumption that those at risk will necessarily benefit. A better approach to systematically test who benefits from nutrition supplementation is proposed using interactive models.

METHODS

Differential effects of nutrition supplementation during early childhood on stature at adolescence were studied in 245 males and 215 females to identify determinants of long-term benefit from food supplementation. Factors studied included family socioeconomic status (SES) and children's home diet and diarrhoea during the first 3 years of life. To determine whether a factor conferred benefit, the statistical significance of the interaction between this factor and the intervention was tested. Data from the INCAP supplementation trial in Guatemala and from the follow-up of the same subjects at adolescence were used.

RESULTS

Ordinary least squares (OLS) showed that high rates of diarrhoea in males and poor SES in females were significant determinants of benefit from supplementation at adolescence, and that the effects were mediated by length at 3 years old. Results of two-stage least squares (2SLS) analysis showed that length at 36 months, maturation and maternal height were significant determinants of height at adolescence but SES was not.

CONCLUSIONS

Nutrition supplementation in early childhood has long-lasting effects on body size and the larger benefits acquired by some groups of children remain throughout early adulthood. The relevance of these findings for screening and targeting of nutritional interventions is discussed.

Changes in energy expenditure, anthropometry, and energy intake during the course of pregnancy and lactation in well-nourished Indian women

Basal metabolic rate (BMR), thermic effect of a meal (TEM), anthropometry, and dietary intakes were measured in 18 control subjects; 18 pregnant women at 12, 24, and 34 wk gestation; and in 17 of these women at 12 and 24 wk postpartum, to uncover any metabolic economy associated with either pregnancy or lactation. Results indicated that the BMR and TEM were not associated with any energy saving either during pregnancy or lactation. Mean weight gain from 12 wk gestation to term was 11.4 +/- 3.7 kg; mean birth weight of the infants was 3.06 +/- 0.41 kg. Estimated gain in adipose tissue and fat mass were 3.1 +/- 3.6 and 2.5 +/- 2.9 kg, respectively. Energy cost of pregnancy was estimated to be 303 +/- 171 MJ. The cumulative increase in energy intake over the last two trimesters of pregnancy was 290 +/- 280 MJ, meeting a large part of the total estimated cost of pregnancy. Weight gained by infants who were exclusively breast-fed from birth to 12 wk of age was used as a proxy indicator of adequate lactational performance. The extra energy required during lactation appeared to have been met largely by increases in energy intake, rather than by any metabolic economy or increase in fat mobilization.

Validity and epidemiology of reported poor appetite among Peruvian infants from a low-income, periurban community

To assess the validity of maternal reports of poor infant appetite, these histories were compared with measured energy consumption on 1621 d of observation of 131 Peruvian infants in a low-income community. Mean (+/- SD) total energy intakes on days with reported anorexia were 338 +/- 88 kJ/kg body wt in infants 1-6 mo of age and 299 +/- 92 kJ/kg body wt in infants aged > 6 mo compared with 395 +/- 92 and 342 +/- 88 kJ/kg body wt in the respective age groups when appetites were reportedly normal (P < 0.001). Energy intake from non-breast-milk sources was more affected than energy from breast milk. The epidemiology of poor appetite was assessed in 153 infants who were monitored longitudinally during their first year of life. The prevalence of reported anorexia increased progressively from 22 to 317/1000 d of observation from < 1 to 11 mo of age. Infant age and the presence of fever, diarrhea, and respiratory illnesses were each associated negatively with the presence of reduced appetite. Poor appetite, rather than lack of food, may explain in part the low energy intakes by infants in this community.

Nutritional status of 3-6 year-old African children in the Cape Peninsula

A survey was conducted in the Cape Town metropolitan area in 1990 to determine the dietary intake and anthropometric status of 3-6 year-old African children (N = 163). Dietary data obtained from 24-hour recalls revealed that mean energy intake (5200 kJ) was low and that mean intakes of most nutrients fell considerably below the recommended dietary allowances (RDAs). The average diet included an adequate number of portions from the meat and cereal groups, but was inadequate with respect to the milk and fruit/vegetable groups when compared with the recommendations of the Department of Health Services and Welfare. The macronutrient energy distribution was within prudent dietary guidelines, with 28.1% of energy (E) being obtained from total fat, 63.7% from carbohydrate and 13.2% from protein. Anthropometric profiles expressed in terms of the National Centre for Health Statistics' (NCHS) standards, revealed evidence of growth retardation and wasting in this population, coexisting with emergent obesity. The development of a nutrition and health policy to address the problems of both deficit and excess represents a pressing challenge.

Diarrhoea and growth faltering in rural Zimbabwe

OBJECTIVE

To assess the evidence that diarrhoea is an important cause of growth faltering in young children in developing countries.

DESIGN

Prospective, longitudinal cohort study.

SETTING

Worker's compounds on commercial farms in Shamva, rural Zimbabwe.

SUBJECTS

204 children < 12 months old were enrolled, 73 from birth. The median age at enrolment was 4 months. Eleven children died and 39 were lost to follow-up.

INTERVENTIONS

Prospective weekly diarrhoea surveillance by farm health workers and monthly anthropometry.

RESULTS

Growth faltering was severe, but there was little difference in average rates of growth between children with frequent diarrhoea and infrequent diarrhoea. The results of an interval-based data analysis were consistent with there being only a transient effect of diarrhoea on weight gain. Estimation of weight faltering following episodes of diarrhoea and the rate of return to the trend in the 9-14 month age range, indicated that weight loss associated with each episode was small (approximately 2%) and return to the child's trend was 90% complete within a month. At older ages than this, weight loss appeared to be less, and estimates were not statistically significant.

CONCLUSIONS

These observations lend weight to the hypothesis that recurrent episodes of diarrhoea are not a potent cause of growth faltering in early childhood except in a small minority of largely catastrophic cases. Inadequate food intake is a more plausible explanation.

Within- and between-individual variation in energy intakes by low-income Peruvian infants

OBJECTIVES

(i) To examine the components of variation in infant energy intake. (ii) To calculate the precision of estimates of energy intake from different sources. (iii) To estimate the number of dietary studies required to estimate true energy intake with varying degrees of precision.

DESIGN

Energy intakes were determined from monthly 12-h observations with test-weighing of breastmilk and all foods consumed. Variance components were evaluated by pooling results of studies performed when infants were 1-4, 5-8 and 9-12 months old.

SETTING

Pueblo Joven Huáscar, a low-income, peri-urban community in Lima, Peru.

SUBJECTS

124 infants who were enrolled at birth and followed monthly.

RESULTS

Within-to-between infant variance ratios were > 1.0 for total energy and energy from solid foods, and < 1.0 for energy from breast- and non-human milks during the 4-month periods examined. Total energy and energy from breastmilk were estimated to within 13-24% of infants' true intake. Non-breastmilk energy was estimated to within 19-143% of true intake. Four dietary studies per age period are required to estimate total energy and breastmilk energy consumption with 20-30% precision. At least 16 studies are required to estimate infants' average energy intake from solid foods from 5-8 months with 30% precision.

CONCLUSIONS

The degree of precision achieved during assessment of infants' usual energy intake changes with age and composition of the diet. Thus, the number of dietary studies required to obtain a fixed level of precision differs according to these characteristics.

Nutrition and the variation in level and age patterns of mortality

We examine the associations between nutrition and mortality at the national level. Altogether four aspects of this association are explored: (1) total calories with expectation of life, (2) dietary composition with expectation of life, (3) total calories with the age patterns of mortality, and (4) dietary composition with the age patterns of mortality. The data consist of life tables and national food balance sheets for 341 populations from 96 countries. A preliminary principal components analysis conducted on the dietary composition data yields three dietary components: (1) the overall quality and quantity of the diet, (2) the relative contribution of carbohydrates versus fats, and (3) the relative contribution of fats versus proteins. The results indicate that expectation of life at birth increases with total calories, with overall quality and quantity of the diet, and with the ratio of fats to proteins. The ratio of carbohydrates to fats is negatively associated with level of mortality. However, evidence indicates that the main effect of the ratio of fats to proteins is reversed when diets are high in quality and that all the effects tend to saturate at high nutrient availability. Variation in nutrition is also strongly associated with the international variation in age patterns of mortality. For example, when expectation of life is held constant, populations with higher quality diets tend to have lower childhood mortality and higher adult mortality. The results indicate that nutritional patterns are highly correlated with much of the worldwide variation in mortality and may be a useful criterion for selecting or predicting the best suited model life table for use on a particular population.

Use of the multiple-day weighed record for Senegalese children during the weaning period: a case of the "instrument effect"

In West Africa, the multiple-day weighed record is the most widely used technique for measuring children's food intakes. The children's eating behavior might be disrupted by the frequent weighings and the presence of a field-worker in the home. We explored the possibility of such an "instrument effect" in a 7-d food survey of 70 Senegalese children aged 10-13 mo. Energy intakes decreased significantly during the food survey (P < 0.0001). The decrease affected both daytime breast milk intake (8%) and solid food intakes (15%). The children's weight gain also decreased from a presurvey value of 6.9 to 2.1 g.kg-1.wk-1, indicating that their intakes during the food survey were lower than their usual intakes. The food-survey methodology was responsible for this "instrument effect." Policy decision-makers should be aware that data collected with the multiple-day weighed record technique might not reflect African children's usual food intakes.

Changes in body composition of malnourished children after dietary supplementation as measured by bioelectrical impedance

Body composition was measured with bioelectrical impedance in 35 malnourished children aged 24-59 mo to investigate the effect of a 3-wk feeding supplementation. Twenty children received a high-protein diet with 15% of total energy as protein, whereas 15 children received an isoenergetic standard-protein diet with 7.5% of energy as protein. Bioelectrical impedance analysis and anthropometry were done before and after 21 d of dietary supplementation. The children fed the high-protein diet gained significantly more body weight than those receiving the standard-protein diet (1.33 +/- 0.54 vs 0.88 +/- 0.47 kg, P < 0.02). The total body water and fat-free mass determined by bioelectrical impedance analysis showed that the group fed the high-protein diet increased significantly more (0.92 vs 0.58 kg) than those on the standard-protein diet (P < 0.02). Results of this study suggest that feeding a high-protein diet accelerates catch-up growth and restores the reference body composition in children recovering from malnutrition.

Estimated vitamin intakes of toddlers: predicted prevalence of inadequacy in village populations in Egypt, Kenya, and Mexico

Vitamin intakes of 255 toddlers (aged 18-30 mo) were estimated from food consumption recorded during 1 y at sites in Egypt, Kenya, and Mexico. Mean intakes were compared with requirements standards by using a probability approach to estimate the prevalence of inadequate intakes. There were predicted inadequacies for vitamin A (32%) and riboflavin (20%) in Egypt, vitamins A (68%) and C (63%) and riboflavin (52%) in Mexico, and vitamin B-12 (44%) in Kenya. Vitamin E was inadequate in all diets, but in relation to polyunsaturated fatty acids only the intake in Mexico was low. No diet provided the recommended amount of vitamin D, but its dietary requirement is uncertain. Correlations among nutrient intakes suggest factors that may contribute to reported associations of consumption of animal products with improved growth or development among these children: provision of vitamin B-12 and available minerals, displacement of fiber and phytate-rich energy sources, and increased energy density.

The zinc nutriture of preschool children living in two African countries

The zinc nutrition of rural Malawian children (24 females, 33 males; age 62 +/- 10 mo) consuming cereal-based diets was compared with that of rural Ghanaian children (43 females, 33 males; age 59 +/- 10 mo) consuming cereals or starchy staples, using hair zinc concentrations, growth and body composition indices, and dietary intakes. Intakes of energy, protein, Ca, Zn, dietary fiber and phytate at two seasons of the year were estimated from 3-d weighed food records, using analyzed and literature food composition values. The mean annual intakes of energy (5419 +/- 1081 vs. 4698 +/- 885 kJ), protein (31.8 +/- 7.0 vs. 24.1 +/- 6.8 g), Zn (7.4 +/- 1.9 vs. 5.1 +/- 1.1 mg) and phytate (1899 +/- 590 vs. 604 +/- 151 mg), and the mean molar ratios of [phytate]/[Zn] and [Ca] x [phytate]/[Zn] mmol per MJ (25 +/- 4 vs. 12 +/- 2 and 44 +/- 13 vs 20 +/- 8 mmol/MJ), were higher for Malawian than for Ghanaian children. More Malawian than Ghanaian children had [phytate]/[Zn] > or = 15 (72% vs. 0%) and were severely stunted (57 vs. 28%). Ninety-four percent of children in Malawi and 83% in the Ghanaian village of Slepor had low hair Zn concentrations (< 1.68 mumol/g) compared with 39% in Gidantuba, Ghana. In Gidantuba, children with low hair Zn concentrations had low upper-arm-muscle-area-for-age and upper-arm-muscle-area-for-height Z-scores. The high intakes of phytic acid relative to zinc in Malawi suggest that these children were at greater risk for inadequate zinc nutriture than their Ghanaian counterparts.

Seasonality of reproductive function and weight loss in rural Nepali women

Menstrual and hormonal disturbances have been reported in thin, dieting and exercising Western women, and also recently in rural African women. A study of salivary progesterone profiles was undertaken in a Nepali population to examine whether seasonal increases in workload and changes in energy balance influenced ovarian function. Women's energy expenditure levels were moderately heavy in the winter and very heavy in the monsoon, and body mass fluctuated by -2.8 to +4.8 kg. Samples were collected from 24 normally menstruating women in two seasons, each individual serving as her own control. Progesterone levels were significantly depressed in the monsoon relative to winter for women who lost weight, but not for women who gained weight, indicating that energy imbalance is associated with a loss of fecundity. No differences in body mass index were found between women who lost or gained weight. Progesterone levels were age-dependent, and the degree of hormonal disturbance between age-groups was related to weight loss. The study demonstrates seasonal changes in the fecundity of hard-working Nepali women and a direct link between ovarian function and weight loss (negative energy balance), which is independent of current nutritional status.

Seasonality of energy expenditure during pregnancy and lactation for rural Nepali women

Total energy expenditure (TEE) was estimated for 19 nonpregnant, nonlactating (NPNL) and 24 pregnant (P) or lactating (L) women from 3601 h of minute-by-minute observation and 168 measurements of the energy cost of activities. NPNL women significantly increased subsistence activity and TEE from 9.9 MJ [1.89 x basal metabolic rate (BMR)] in the winter to 10.5 MJ (2.01 x BMR) in the monsoon season. There were differences between NPNL,P, and L women in the winter, but not in the spring or monsoon season when all individuals sustained very heavy physical activity. High TEE values resulted from spending very long hours in tasks that, although appearing physically demanding to the casual observer, were characterized by light or moderate energy cost. The study highlights the importance of seasonal constraints on women's work, which prevent P and L women from significantly curtailing physical activity during the monsoon season, and which effectively limit the scope of behavioral mechanisms for saving energy and reducing TEE.

The nutritional status of children of displaced families in Beirut

The nutritional status of children of displaced families in Greater Beirut was investigated in 1986 (a sample of 146 households) and in 1991 (137 households). Data on demographic variables, nutrient intake (calories, protein, and iron), and anthropometric measurements were collected. Iron intake was only 50-57% of the RDA for the 1-3 age group, and 35.6% and 32.0% of all children consumed < 60% of the RDA for iron in 1986 and 1991, respectively. Main sources of protein were dairy products, milk and eggs. The lower nutrient intake in 1991 compared to 1986 was negatively related to social class. Anthropometric measurements showed an increased past and recent undernutrition of the children in 1991 as compared to both the 1986 child sample and the NCHS standard child population. Severe inflation and marked increase in food prices were reflected in dietary intake and growth of the children. Food aid programmes, government subsidy of bread, and partial wage correction were possible stabilizing factors for the most destitute groups but not for the total population of displaced children.

Korean women's attitudes toward pregnancy and prenatal care

A convenience sample of 40 native-born pregnant Korean women receiving prenatal care at a U.S. military facility in a major metropolitan area in Korea completed a questionnaire about attitudes toward pregnancy and prenatal care. Responses revealed a family life characterized by positive maternal and paternal perceptions of the pregnancy and less preference for a male child than we had anticipated. Traditional beliefs in Tae Mong, a conception dream, and Tae Kyo, rituals for safe childbirth, were followed. Food taboos, including protein sources, were reported. Attitudes toward prenatal care services, care providers, and maternal health habits are described.

Biological determinants of pregnancy weight gain in a Filipino population

Patterns of pregnancy weight gain and predictors of first trimester and total weight gain were investigated in a sample of 1367 women from Cebu, Philippines, with pregnancy intervals of < 2 y. The mean total weight gain based on actual measurements of prepregnant weight was 8.4 kg. Controlling for gestational week when weight was measured, multivariate-regression models predicted higher first trimester weight gain with higher parity, lower prepregnant body mass index (BMI), and longer nonpregnant intervals. Higher total weight gain was associated with longer nonpregnant intervals, lower prepregnant BMI, taller maternal stature, and relatively high dietary energy intakes. Lactation into the third trimester of pregnancy and maternal age over 35 y had significant negative effects on total weight gain. Given the importance of maternal weight gain in predicting birth outcome, this study provides information on modifiable risk factors that should be considered when developing maternal-infant health policy and programs.

Influence of birth interval and child labour on family energy requirements and dependency ratios in two traditional subsistence economies in Africa

The consequences of different birth intervals on dietary energy requirements and dependency ratios at different stages of the family lifecycle are modelled for Gambian agriculturalists and !Kung hunter-gatherers. Energy requirements reach a peak at between 20 and 30 years after starting a family for the Gambians, and between 15 and 20 years for the !Kung. For the Gambians, shorter birth interval confers no economic advantage over the traditional birth interval of 30 months. For the !Kung, the lack of participation in subsistence activities by children gives an output:input ratio in excess of that reported in other studies, suggesting that they are in a state of chronic energy deficiency.

Prolonged lactation contributes to depletion of maternal energy reserves in Filipino women

This paper identifies determinants of women's postpartum weight and weight change in a large group of Filipino women followed for 24 mo. Longitudinal, multivariate models focused on the effects of lactation, while controlling for energy intake, energy expenditure, reproductive history and seasonality. Lactation was found to have a significant negative effect on weight of urban women. The negative effects of lactation increased with the intensity and duration of breast-feeding. Among rural women negative effects of lactation on weight were observed only after 10-14 mo. Models of net postpartum weight change (from 2 to 24 mo) among nonpregnant women confirmed an important role for lactation. The likelihood of weight loss was significantly increased by lactation of more than 12-mo duration, by greater maternal age and by low dietary energy intake. The effects of lactation on maternal energy reserves can be mitigated substantially be increasing maternal dietary energy intakes.

Reproduction and maternal nutrition in Madura, Indonesia

The prevalence and severity of chronic energy deficiency (CED) among women of reproductive age as well as its consequences on the newborn and the mother were assessed in a longitudinal study. More than 40% of the mothers had a Body Mass Index (BMI) less than 18.5 before pregnancy, a level below which CED is considered to exist. Weight gain during pregnancy was low, on average 6.6 kg. Taking the difference between 4 week postpartum weight and pre-pregnant weight as net weight gain during pregnancy, mothers with a BMI less than 18.5 before pregnancy gained weight while those with a higher BMI lost weight. This observation suggests that the partitioning of energy to the fetus and the mother depends on the energy reserves of the mother before pregnancy. The functional significance of BMI as an indicator of CED is illustrated by its relation with birth weight. Similarly, 4 week postpartum, weight and BMI were predictive for the weight changes in the mother in the first 12 months after delivery. The groups with the lowest values gained weight, while the heaviest mothers lost weight. In view of the negative effects of CED among women of reproductive age on the infant and the mother, maternal undernutrition should receive the same attention as malnutrition among preschool children.

Energetic and metabolic cost of growth in Gambian infants

The aim of the study was to measure the energy used for growth of healthy fullterm and breast-fed Gambian infants. The weight gain (WG) of 14 infants (mean age +/- SEM 17 +/- 1 d, weight 3.581 +/- 0.105 kg) was measured over a 2-week period; the energy intake (EI) from breast milk was assessed for 24 h in the middle of the study period by weighing the infant before and after each breast-feed. On the same day, sleeping energy expenditure (SEE) and respiratory quotient (RQ) were measured for 30 min on five occasions through the 24-h period. EI averaged 502 +/- 25 kJ/kg.d, and SEE 230 +/- 6 kJ/kg.d; thus, an average of 272 kJ/kg.d were available for physical activity and the energy stored for growth. The total energy spent by infants while sleeping and for periods of physical activity was calculated to be 1.7 x SEE. The mean RQ measured on five occasions averaged 0.879 +/- 0.009. SEE was correlated with WG (r = 0.747, P less than 0.005), with a slope of the regression line of 5.5 kJ/g; this value can be considered as an estimate of the energy spent for new tissue synthesis in the resting infant. The efficiency of weight gain was lower in this study (67%) than in studies conducted on fast-growing preterm infants or children recovering from malnutrition.

Lactation performance of rural Mesoamerindians

Anthropometry, body composition and dietary intake of 30 lactating Otomi Indians of Capulhuac, Mexico, were studied to identify maternal factors which potentially limit lactation and thereby infant growth. Human milk production, milk composition, and maternal dietary intake, body weight, skinfold thicknesses, and body composition were measured at 4 and 6 months postpartum. The 2H2O dose-to-mother method was used to estimate milk production and maternal total body water (TBW). Fat-free mass (FFM) was calculated as TBW/0.73. Body fat was computed as body weight minus FFM. Human milk samples were analyzed for energy, nitrogen, lactose and fat using standard analytical methods. Maternal diet was assessed by three 24-h intake recalls. Mean (SD) milk production was 885 (146) and 869 (150) g/d at 4 and 6 months, respectively. Milk concentrations of protein nitrogen (1.23 (0.17) mg/g) and lactose (66.6 (2.8) mg/g) were comparable to, but the concentrations of fat (22.2 (6.7) mg/g) and energy (0.54 (0.06) kcal/g) were lower than, values observed in economically privileged populations. Maternal height, weight, and BMI were 1.47 (0.06) m, 50.3 (6.0) kg, and 23.4 (3.1) kg/m2, respectively. Maternal TBW, FFM and body fat were 55.8 (4.6)%, 76.4 (6.3)%, and 23.6 (6.4)%, expressed as a percentage of body weight, respectively. Maternal energy and protein intakes averaged 1708 (338) kcal/d and 40 (10) g/d, respectively. Milk production was negatively correlated with maternal body fat (P = 0.006). Energy and fat concentrations in the milk of the Otomi women were positively related to their weight (P = 0.002), BMI (P = 0.05), and body fat (P = 0.004). Energy concentrations in milk were not related to rates of milk production (r = 0.24; P = 0.23). Nor was milk production or composition significantly associated with maternal dietary intake. Lactation performance of these Otomi women correlated significantly with maternal body size and composition, but not current dietary intake.

Is cow's milk suitable for the dietary supplementation of rural Gambian children? 1. Prevalence of lactose maldigestion

To define the age-related prevalence of lactose maldigestion (LM), 218 children aged 13-72 months from a rural Gambian village were studied using a lactose breath hydrogen test. There was a significant rise in LM from 21% to 76% between the 2nd and 3rd-5th years of life (p < 0.001). Only eight children had diarrhoea within 2 weeks before the test. Diarrhoea and abdominal discomfort followed in only seven children (3%). There was no difference in mean time of introduction of supplementary diet or cessation of breastfeeding between children aged 12-36 months with lactose digestion and LM. There was a greater proportion of children with normal lactose digestion than with LM in those still receiving breast milk (85% vs 15%), and a greater proportion of LM in the fully weaned group (63% vs 37%) (p < 0.001). There was no relation between weight-for-age or weight-for-height and the ability to digest lactose. The ability to digest lactose is lost in the majority of children during the 2nd year, coincident with the cessation of breastfeeding, but is not a major factor associated with growth failure thereafter.

Is cow's milk suitable for the dietary supplementation of rural Gambian children? 2. Patterns of cow's milk intake

Cow's milk has been advocated as a source of supplementary diet for children in many parts of the developing world. The frequency and forms of cow's milk intake and the factors regulating its availability and consumption by 507 children aged up to 6 years in three Gambian villages were measured. Nineteen per cent of mothers did not give cow's milk to their children. Of 413 children taking cow's milk, 41% consumed it only once a week, 32% two to four times a week, 19% once a day and 8% more than once a day. Eighty per cent of children took both fresh and sour milk. Forty-one per cent of infants up to 1 year old received cow's milk at some time. There was a decrease with age in the proportion of children taking fresh milk and a rise with age in the proportion taking sour milk alone (p < 0.001) and both forms of milk. Only 2% of children were reported to have an adverse reaction to fresh cow's milk. The main factors affecting intake were the availability of money and milk. The consumption of cow's milk in early life is common and free of adverse effects. When it is available, it should be used to supplement the diet of the weaned child.

Is human lactation a particularly efficient process?

The recommended dietary allowances of many expert committees (UK DHSS 1979, FAO/WHO/UNU 1985, USA NRC 1989) have set out the extra energy requirements necessary to support lactation on the basis of an efficiency of 80 per cent for human milk production. The metabolic efficiency of milk synthesis can be derived from the measurements of resting energy expenditure in lactating women and in a matched control group of non-pregnant non-lactating women. The results of the present study in Gambian women, as well as a review of human studies on energy expenditure during lactation performed in different countries, suggest an efficiency of human milk synthesis greater than the value currently used by expert committees. We propose that an average figure of 95 per cent would be more appropriate to calculate the energy cost of human lactation.

Assessment of knowledge and skills about growth monitoring amongst child development project officers

Knowledge and skills about growth monitoring (GM) amongst Child Development Project Officers (CDPOs) were assessed by interview technique. Majority (94%) of subjects had correct knowledge that GM helps in early detection of growth retardation while about 83% felt that a flattened growth curve indicates no weight gain. The percentages of CDPOs who were able to interpret and read correctly about what ascending descending and flattened growth curves indicate were 83, 71 and 50% respectively. There is thus a need of in-service training of CDPOs in GM activities.

Child nutrition in the pre-harvest season in Kenya

This study examines the food consumption and nutritional status of pre-school children during the period March-April, at the end of the dry season in the Kano Plain of Nyanza Province. The diet of pre-school children in this region of Kenya consists foremost of maize and milk. Food consumption was generally low with considerable deficits in energy intake and other nutrients among all age groups, although protein intake was generally at recommended levels. The heights of the children did not differ from the available national and regional figures, but the weights of the children were far below earlier figures which must be related to the prevailing lean seasons. The youngest group in the sample, aged 6-12 months, showed the largest deficit in weight status. This group appears to suffer most from the seasonal imbalance. Overall the findings indicate that the seasonal deficits in this part of Kenya are more severe than was assumed until now.

Nutrient intakes during pregnancy: observations on the influence of smoking and social class

The influence of smoking and social class on dietary intake in pregnancy was investigated in a random sample of smokers (greater than or equal to 15 cigarettes/d) and nonsmokers. A total of 206 subjects (94 smokers and 112 nonsmokers) completed a 7-d weighed dietary intake at 28 wk gestation and 178 completed a second assessment at 36 wk. Nonsmokers had higher intakes of almost all nutrients than did smokers and the nutrient density of their diet was greater. Energy intake was nonsignificantly higher in nonsmokers. Women in higher social classes had the highest nutrient intakes. Smokers were shorter than nonsmokers and tended to be of lower social class. After maternal height and social class were controlled for, smoking had a significant effect on intake of many micronutrients. Dietary intake was reduced in late pregnancy, particularly in smokers. These data suggest that smokers in all social classes have a poorer quality of diet.

Effect of protein rich diet during acute phase of dysentery

Ninety six children upto the age of five years suffering from uncomplicated acute dysentery of less than 3 days' duration were studied to find out the impact of feeding of extra-protein rich diet during their acute phase of illness. These children were randomly allocated to either control group (receiving only hospital diet) and study group (receiving hospital diet and extra milk which constituted 30% of ideal total calorie requirement of patients. Patients in the two groups were comparable on admission. Forty percent reduced food intake was observed among the children of both the groups due to severe anorexia which was reflected by no significant differences in clinical outcome, anthropometrical measurements and haematological parameters between the two groups on day 7 of hospitalisation and on day 15 after discharge.