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Family-level evaluation of the effect of nutrition activities in programmes of primary health care
The United Nations University and the United Nations Children's Fund (UNICEF) have developed a programme for the support of research designed to analyse the extent to which the nutritional and health practices of families are affected by programmes of primary health care that include nutrition activities.
The methodology proposed is one of in-depth interviews by professional social anthropologists or others utilizing an anthropological approach The objective is to analyse the extent to which various programmes of primary health care in countries that are making an effort to incorporate nutritional goals are actually affecting the nutritional and health practices of individual families in selected communities. Projects are not to be process evaluations, nor are they impact evaluation studies of a nutritional type, since no nutritional measurements will be made. Rather, the studies should focus on the impact of nutrition-related activities in programmes of nutrition and primary health care as judged by awareness, perception, and contact of individual families with the programmer and their effects on nutritional and health practices. Nutrition-related activities are interpreted to include not only weighing of children and nutrition education, but also oral rehydration, immunization, environmental sanitation, prenatal care and family planning. The projects should:
1. Select communities that are within the area of responsibility of local primary health care programmes being conducted with strong government support that includes commitment to nutrition activities and goals.
2. Conduct in-depth, relatively unstructured, interviews of a range of families in each community selected. Interviewers will be professional social scientists and several visits with each family will be required.
3. Identify and describe the design of the primary health programme and its local financing and staffing only as background information.
Interviews are not to be done using formal questionnaires or pare-professional interviewers.
All projects must be completed in time for a workshop or conference in 1984 that will provide WHO with an input into a major follow-up to the Alma-Ata Conference that established health for all by the year 2000 as a goal and primary care as the methodology. Hence, the time span of the individual projects will need to be relatively short, i.e., from a few months to a maximum of one year, but seasonal factors should be taken into account.
The principle to be followed is one of viewing the system through the eyes of the individual families it is supposed to serve. No purpose will be served by studying systems that do not have a nutrition component, or families that do not have potential access to health services. The programmes selected for study should be those that have a nutrition component either integrated with, or parallel to, the primary health care service.
Samples need not be large, but must provide a fair judgment of the range and balance of family experiences in the communities selected for study. The costs of individual projects are likely to vary widely because of the individual circumstances of the investigators, but they must be relatively modest in scope, cost, and duration. Individuals interested in submitting a proposal should write, telex, or cable for more information from:
Dr. Nevin S. Scrimshaw
Director, Hunger, Health and Society Sub-programme
The United Nations University
Massachusetts Institute of Technology 20-A-201
Cambridge, Mass. 02139, USA
Telex: 92-1473 MITCAM
Cable: MITCAM Cambridge
Nutrition Policy Implementation: Issues and Experience, edited by Nevin S. Scrimshaw and Mitchel B. Wallerstein (PIenum, New York, 1982) is another new book based on a conference co-sponsored by the Rockefeller Foundation, the Ford Foundation, and The United Nations University. It addresses the problems encountered in nutrition planning and policy-making in the fields of food fortification; supplementary feeding and formulated foods; village-level interventions; small-farm agricultural systems; food conservation and post-harvest losses; food price controls and consumer subsidies. It opens with three chapters devoted to the rationale for investment in nutrition and then deals with the many facets of implementing policy to alleviate malnutrition. Successes and failures alike are discussed. After each of the eight subject divisions there are comments and discussions that provide additional experiences of the commentors with the topics covered in the preceding chapters. The book ends with Concluding Afterthoughts of six participants, reflecting on the themes covered in the conference, and pointing out the direction future nutrition policy implementation should take, with emphasis on learning how and why successful programmes have worked.
Excerpts from Tropical Products Institute Report on "Farm Level Storage Losses in Eastern Nepal" by R.A. Boxall and R. Gillet, May 1982
"A study of farm level storage losses was undertaken in the Eastern Hills of Nepal between May 1979 and June 1980. The project was a collaborative one involving the Gurkha Reintegration Scheme and the Kosi Hill Area Rural Development Programme, both of which are supported by the UK Overseas Development Administration. Technical support and advice to the project was provided by the Tropical Products Institute during three consultancy visits.
"The assessment of post-harvest losses in Nepal is exceptionally difficult because of the severity of the terrain, which poses serious problems of access and communication in many parts of the country, particularly in the hill areas. This, in turn, introduces complexities into the post-harvest system.
"The project began with a study of the minor wheat crop, which provided the opportunity for field staff to gain essential experience and to develop a methodology for assessing storage losses
"The main study of maize losses was undertaken between July 1979 and June 1980, and a limited study of losses occurring during the storage of paddy was conducted between November 1979 and June 1980.
"The results of the survey demonstrated that farm level storage losses were lower Approximately 5 per cent) than previously reported (10 to 30 per cent), and in consequence tentative proposals for a programme to reduce losses by introducing new storage structures and pesticides, even if practical to implement, were shown to be unjustifiable. "
The full report may be obtained from:
Tropical Products Institute
56/62 Gray's Inn Road
London WC1 X 8LU, UK
for £ 3.10, postage included. Ask for Document G157.
Seed Banks Serving People
Recently, ecologists, biologists, and social scientists have become alarmed about the seriousness of genetic loss of seed varieties. The genetic diversity of traditional agro-ecosystems is vital for sustained world food production. The United Nations has established germ-plasm banks in centres concerned with preserving diversity in the Philippines, Mexico, Peru, and Australia. The United States Department of Agriculture maintains its own seed bank in tort Collins, Colorado.
Proceedings are now available from a two-day workshop, "Seed Banks Serving People", held in October 1981 in Tucson, Arizona, sponsored by Meals for Millions/Freedom from Hunger Foundation and the National Sharecroppers Fund. The 66-page book contains highlights from talks and demonstrations related to all aspects of seed conservation, including identification of seed stocks, field collections, storage methods and distribution.
Seed Banks Serving People may be obtained for US$3.50 from:
Patti Butzer-Larson
Meals for Millions
P.O. Drawer 680
Santa Monica, Calif. 90406, USA
Iron Deficiency: Brain Biochemistry and Behavior
Of interest to biochemists, neurochemists, behavioural scientists, and nutritionists is a new book on Iron Deficiency: Brain Biochemistry and Behavior, edited by Ernesto Pollitt and Rudolf Leibel (Raven Press, New York, 1982), based on a conference sponsored by the Ford Foundation and the World Hunger Programme of The United Nations University, held at the University of Texas in Houston.
The book contains the most recent basic and clinical findings on the effect of mild iron deficiency on brain function. There are three major sections in this 214-page volume; one is on the role of metals, especially iron, in nervous system metabolism. Chapters deal with iron involvement in central nervous system oxidative metabolism, catecholamine, dopamine receptor function, and body temperature regulation. Another deals with clinical assessment of iron deficiency and measurement of central nervous system neurotransmitter metabolites. Final chapters describe animal and human studies on functional effects of iron deficiency. The special aim of this book is to provide a model for studies of the complex, developing field of nutrient/behaviour interactions.
Food Carbohydrates
The Fifth Basic Symposium of the Institute of Food Technologists, held 5-6 June 1981, focused on food carbohydrates. The proceedings, edited by David Lineback and George Inglett, represent the most recent developments in research on this subject. Included are uses and potential implications to health of simple carbohydrates such as fructose, polyols, sucrose, and lactose, as well as more complicated carbohydrate-binding proteins in plant seed lectins. Analysis of polysaccharide and protein interactions, the metabolism of Maillard reaction products, and their mutagenic activity are presented.
Nutritionists, research dietitians, and food technologists in universities and the food industry will find Food Carbohydrates a useful book. This 494-page volume may be purchased from booksellers or directly from:
AVI Publishing Company, Inc.,
250 Post Road East, P. O. Box 831,
Westport, Conn. 06881, USA
for US$ 45.00 in the United States and $49.50 elsewhere.
SELECTED FOOD AND NUTRITION ABSTRACTS
Health Planning
A. Wretlind, "Standards for Nutritional Adequacy of the Diet: European and WHO/FAO Viewpoints"
The dietary recommendations of FAO/WHO and of the various European nations differ in several ways. There are two types of dietary recomendations or standards. The first is related to the recommended daily intake of nutrient and the second refers to the nutrient content of the diet expressed either as percentage of total energy (energy % or cal 9-0) derived from protein, fat, and carbohydrate or as the amounts of nutrients in relation to units of energy, the so-called nutrient concentration or nutrient density (vveight per 1000 kcal, per 1 MJ or per 10 MJ). The numbers of recommended nutrients vary between eight and 28. The recommendations are given for individuals of different age, sex, and physiological status. The highest number of subgrouping is 41 and the lovvest 11. The ranges of recommended values are sometimes very wide. There are many good reasons for this situation, such as cultural background, food tradition, food production, and availability.
Am. J. Clin. Nutr. 36: 366 (1982).
J.H. Hulse, "Food Science and Nutrition: The Gulf betvveen
Rich and Poor"
The people of economically developed countries benefit greatly from modern food science. They are protected from food contamination, have access to a great variety of food, and need spend little time preparing it. The poor in developing countries enjoy few of the benefits of food science. Their diets are often nutritionally deficient and they spend many hours each day processing their food and searching for wood with which to cook it. In most tropical countries food losses between harvest or slaughter and eventual consumption are inestimable. Efforts to improve post-harvest food systems in developing countries require the attention and ingenuity of many scientific disciplines and the support of all development agencies.
Science 216: 1291 (dun 18, 1982).
P. Lunven and Z.l Sabry, "Nutrition and Rural Development"
This paper summarizes the conceptual and methodological work carried out by a team of FAO staff and consultants in a continuing effort to introduce nutritional considerations into the planning and execution of agricultural programmes and projects. Guidelines were prepared on the basis of experience acquired to various case studies and are currently being applied in field projects.
Food Nutr. (Rome) 7: 13; 1981).
Nutritional Status Assessment
J.C. Wolgemuth, M.C. Latham, A. Hall, A. Chesher, and D.W. Crompton, "Worker Productivity and the Nutritional Status of Kenyan Road Construction Laborers"
The effects of energy supplementation (group I received 200 kcal/day and group 11 received 1000 kcal/day) were examined on road workers in Kenya. Anthropometric, dietary, worker productivity, clinical hematology, and parasitology data were collected from 224 worked of both sexes or sub-samples of these workers at base-line, midpoint, and final measurement periods. Sixty-seven per cent of the work force was less than 85 per cent of weight for height. Females tended to be better nourished than males. Multiple regression analysis showed that increases in arm circumference and Hb levels were associated with significant productivity gains of about 4 per cent. At the midpoint, group 11 males gained 1.10 kg (p less than 0.0003), while group I males showed no change. Weight loss during the latter part of the study resulted in no significant final weight change for males. "Successful" supplementation was weakly associated with a productivity increase for group 11 workers of 12.5 per cent (p less than 0.10).
Am. J. Clin. Nutr. 36: 68 (1982).
Malnutrition Complications
A. Sommer and J. Tarwotjo, "Protein Deficiency and Treatment of Xerophthalmia"
In a controlled trial of massive-dose vitamin A therapy for xerophthalmia, holo-retinol-binding protein (holo-RBP) response was related to baseline protein status. Corneal healing was more commonly delayed or transient in children with protein-energy malnutrition (PEM), despite the Vast majority achieving holo-RBP levels incompatible with severe corneal destruction. Correction of PEM is essential to ensuring a sustained clinical coupe, and repeated massive vitamin A therapy is advisable until that occurs.
Arch. Ophthalmol. 100: 785 (1982).
A. Sommer, "Nutritional Factors in Corneal Xerophthalmia and Keratomalacia"
Six measures of nutritional status were studied in 162 consecutive cases of presumed nutritional keratopathy ranging from mild xerosis through full-thickness necrosis (keratomalacia) and in a variety of control subjects. The severity of corneal involvement WE related to the severity of wasting prevalence of edema and serum levels of albumin, transferrin, and vitamin A. Even the most severe corneal alterations were compatible with normal indices of protein and anthropometric status, but not with normal serum vitamin A levels. Analysis suggests that interaction between vitamin A and protein status determines cellular adequacy of vitamin A metabolism, which virtually co lapses in keratomalacia. Serum levels of holoretinolbinding protein were severely and uniformly depressed in all degrees of corneal involvement. Arch. Ophthalmol. 100: 399 (1982).
I. Tarwotjo, A. Sommer, T. Soegiharto, D. Susanto, and Muhilal, "Dietary Practices and Xerophthalmia among Indonesian Children" The stated frequency with which 30 Indonesian children with corneal xerophthalmia and age/sex/neighborhood matched contra s ordinarily consumed vitamin-and pro-vitamin A-rich foods was compared. Controls were more frequent consumers of eggs (p less than 0.05), fish (p less than 0.05), dark green leafy vegetables (p less than 0.05), carrots (p less than 0.01), and carotene-containing fruits up less than 0.01). Similar data were colected on 358 children in a countryside survey. Breast-feeding was more common among normals than among cases (p less than 0.001). Normals were also more frequent consumers of mango and papaya during the 2nd and 3rd year of life (p less than 0.05); and of dark green leafy vegetables and eggs during the third through sixth year of life (p less than 0.01). In two separate studies, differences in carotene consumption by normals and abnormals were confirmed by differences in their serum carotene levels. Approximately 80 per cent of Indonesian families, with and without xerophthalmia children, consumed dark green leafy vegetables at least once a day, and 99 per cent at least once a week. Diet therefore appears to be an important factor in the genesis of xerophthalmia in Indonesia despite the availability of suitable provitamin A-rich foods.
Am. J. Clin. Nutr. 35: 574 (1982)
L.G. Macdougall, G. Moodley, C. Eyberg, and M. Quirk, "Mechanisms of Anemia in Protein-Energy Malnutrition in Johannesburg" Studies of red cell metabolism, erythropoietin concentration, iron and folate status were made in 48 children with protein-energy malnutrition in Johannesburg (altitude 1800 m). Biochemical evidence of iron deficiency was presented in 26 per cent of cases on admission and developed in 90 per cent during recovery. Biochemical evidence of folate deficiency was present in 14 per cent of cases on admission and resolved on dietary therapy alone. Serum erythropoietin was increased on admission and remained elevated during recovery. There was no relationship between serum erythropoietin and Hb concentrations. Key enzymes in the red cell glycolytic and hexose monophosphate pathways and red cell membrane showed increased activity. Red cell adenosine triphosphate concentration was increased and unstable. Red cell potassium was decreased and, in the fatal cases, red cell sodium was increased. The possible significance and practical implications of these findings are discussed.
Am. J. Clin Nutr 35: 229 (1982).
R.H. Meakins, P.S. Harland, and F. Carsell, "A Preliminary Survey of Malnutrition and Helminthiasis among Schoolchildren in One Mountain and One Lowland Ujama Village in Northern Tanzania"
The nutritional status, parasite prevalence and immediate skin hypersensitivity to Ascaris and Schistosoma antlgEns were determined for 185 schoolchildren living in two Ujama villages in Northern Tanzania. In the lowland village of Kwamsisi the parasite ova found were Schistosoma haematobium (53.8 per cent), Ascaris (26 per cent) and hookworm (24.7 per cent); 57.5 per cent of the children examined were regarded as malnourished, being less than 80 per cent of their expected weight for age. In the mountain village of Ubiri the parasite prevalence rates were 15.2 per cent for Schistosoma haematobium, 1.6 per cent for S. mansoni, 65.2 per cent Ascaris, and 24.1 per cent hookworm. Malnutrition was found in 81.9 per cent of the boys and in 41.2 per cent of the girls. This sex difference is considered to be due to the physiological effects of living in a hilly environment. Correlation between malnutrition and multiple infections of Ascaris, hookworm, and Schistosoma gave a chi-square value of 5.972 (p = 0.02). All other statistical comparisons between parasite prevalence and nutritional status were insignificant. Immediate skin hypersensitivity tests proved unreliable, with 23.3 per cent false negatives (negative skin test with parasite ova found). The serum lgE levels were extremely high, with a mean of 3174 units per ml, suggesting that the immune mechanisms were not retarded by undernutrition.
Trans Roy. Sow Trop Med Hyg 75: 731 (1981).
C.L. Jenkins, "Patterns of Growth and Malnutrition among Preschoolers in Belize"
An anthropometric survey of 750 preschoolers was conducted in 1979 in Belize to assess nutritional status in two districts, one coastal and the other inland. Mothers were interviewed concerning reproductive history, child's health and dietary history, and associated factors, Analysis included the recognition of low arm circumference, weight-for-age, stature-for-age, and weight-for-stature. Survey results indicate that about 25 per cent of the children, birth to 5 years old, show evidence of stunting, while 2.5 per cent show evidence of wasting. Comparisons of rates of malnutrition by ethnic group reveal the Maya and Garifuna (Black Carib) children are significantly more commonIy malnourished than others. Applying a discriminant function to groups of children designated as "poor" and "better--than-average" growth classes reveals several factors that may be contributory to the etiology of preschool malnutrition in Belize. The frequency of diarrhea and age at introduction of solid foods are significantly related to growth retardation among preschoolers. Analysis of 24-hour-diet recalls corroborates the patterning of malnutrition among the ethnic groups.
Am. J. Phys. Anthropol. 56: 169 (1981).
L.A. Mora, M. Navarrete, R. Jiménez, J.M. Carrillo, E. Jiménez, and M. Ramón, "Hematologic Features of Nutritional Anemias in Children" [in Spanish] In 89 anemic children aged from 6 months to 13 years, the etiology of their anemia was studied: 67 (75 per cent) of the cases presented iron deficiency, 18 (20 per cent) iron and folate deficiency, and 4 megaloblastic anemia (2 folate and 2 vitamin B12 deficiency ). Patients with vitamin B12 deficiency showed severe pancytopenia and megaloblastic changes in bone marrow, but no morphological difference, either in circulating blood or bone marrow, was found in patients with iron deficiency compared to iron plus folate deficiency. The serum measurements of iron, folate and B12 were essential in order to establish the etiology of nutritional anemias. The majority of the children were accepted to the hospital for other causes than anemia, such as diarrhea (58 per cent) and respiratory diseases (18 per cent). Clinical features and the high incidence of anemia in children under two years of age are also discussed.
Boll Med. Hosp. infant Mex. 38: 923 (1981).
A.E. Masawe, "Nutritional Anaemias. Part 1: Tropical at rice"
A review of anaemia in Africa is presented . . . It has been noted that nutritional anaemia, including iron-deficiency anaemia, megaloblastic anaemia due to folate deficiency or vitamin B12 deficiency, or both, and protein deficiency anaemia, is widespread throughout Africa. It is particularly common in growing children, women of child-bearing age, pregnant women and lactating mothers. The anaemia is also especially common during the second half of the dry season and the first half of the wet season, when food supplies are limited. In all cases the anaemia is caused either by limited dietary intake, excessive loss of nutrients or excessive utilization. The anaemia is associated with a number of sequelae, including both structural changes, like mitochondrial swelling and mucosal atrophy, and functional abnormalities, such as cardiac failure, decreased work output, increased pregnancy risks and increased susceptibility to infections.
Clin. Haematol 10: 815 (1981).
Public Health
M.A. Reyes, N.G. Saravia, R.R, Watson, and D.N. Mc Murray, "Effect of Moderate Malnutrition on Immediate Hypersensitivity and Immunoglobulin E Levels in Asthmatic Children"
Dermal reactions and lgE levels were compared in 51 asthmatic Colombian children identified on the basis of anthropometric measurements as nutritionally normal (25) or mildly (16) or moderately (10) undernourished. Twenty-five nonatopic children served as controls. Total serum lgE concentrations were significantly elevated in the asthmatic group as a whole. Moderately malnourished (grade II) asthmatic children had more than twice as much serum lgE as normal or mildly malnourished (grade 1) asthmatic subjects and seven times more than nonatopic children. Intestinal parasitism did not appear to contribute to these differences in lgE levels. Serum levels of lgA and lgD were similarly elevated in grade 11 asthmatics. Concentrations of serum lgG, lgM, and C3 and C4 complement were unaffected by nutritional or allergic status. Eosinophilia in nasal mucus was significantly reduced in grade I and grade II malnourished asthmatic children. Among asthmatics, the most frequent dermal reactions were to mite antlgEns (96 per cent), house dust (67 per cent), and grass pollens (35 per cent). Significant levels of specific lgE were detected by the RAST to two species of mites in nearly all atopic children. There was no apparent influence of nutritional status on the distribution of reactivity or specific lgE assay. The clinical significance of hyperimmunoglobulin E in atopic, moderately malnourished children reamins to be elucidated.
J. Allergy Clin. Immunol. 70: 94 (1982).
Food Processing
B. Torún, M. l. Cabrera-Santiago, and F.E . Viteri, "Protein Requirements of Preschool Children: Obligatory Nitrogen Losses and Nitrogen Balance Measurements Using Cow's Milk"
Obligatory N losses through feces (FN) and urine (UN) were measured in five children and N balance was measured in them and in five others (23±4 months old) using four levels of cow's milk intake. FN, UN and FN + UN were 19.5±6.9, 34.0±5.3, and 53.7±8.1 mg N/kg/ day, respectively. The ratios of FN, UN and total obligatory losses (FN + UN + sweat and integumental N) to basal energy expenditure were 0.38, 0.64, and 1.11 mg N/ basal kcal, respectively. The two latter values are 32 and 45 per cent lower than the 1971 FAO/WHO estimates. Mean N requirement determined by factorial calculations using a correction factor of 1.3 and by N balance techniques was 98 mg N or 0.61 9 milk protein/kg/day, which is 33 per cent lower than the FAO/WHO estimates. Depending on the allowances made for inter-individual variability, safe levels of protein intake ranged from 0.79 to 0.94 g/kg/day, 33 to 21 per cent lower than FAO/WHO recommendations. Apparent and "true" milk protein digestibilities were 80±4 per cent and 94±4 per cent, respectively.
Arch Latinoamer. Nutr. 31: 571 (1981).
D.L. Plucknett and N.J. Smith, "Agricultural Research and Third World Food Production"
By the close of this century the world may have to feed as many as 2 billion additional people. Most of them will be born in developing countries, especially in marginal lands ill-suited for food production. This article focuses on efforts by the international Agricultural Research Centers to increase food production in the Third World and addresses the social and ecological issues raised by the introduction of high-yielding varieties into fertile Third World lands and describes how varieties are being tailored for introduction into marginal areas.
Science 217:215 (Jul 16 1982).
P.C. Huanq and C.P. Lin, "Protein Requirements of Young Chinese Male Adults on Ordinary Chinese Mixed Diet and Egg Diet at Ordinary Levels of Energy
Intake"
With a total of 28 normal, healthy male adults, N balance studies with both Chinese mixed diet and egg diet were conducted at four protein levels with the former (0.45, 0.-5, 0.65, and 0.75 g/kg/day-1) and at three protein levels with the latter (0.35, 0.45, and 0.55 g/kg. day-1) at ordinary levels of energy intake. By regression analysis, the mean maintenance N requirement (PRm) of the mixed Chinese diet calculated was 127.0 mg . kg-1 . day-1 (0.79 9 protein, kg-1 . day-1). Estimate allowance for individual variation to cover the 97.5 per cent population (PRO.975) was 188.1 mg . kg-1 . day-1 (1.18 9 protein . kg-1 . day-1). As for the egg diet series, PRm and PRO.975 were 98.2 mg N . kgpl . day-1 (0.61 9 protein . kg-1 . day-1), respectively. Net protein utilization (NPU) of egg diet protein was significantly higher than that of the Chinese mixed diet protein Up less than 0.01 ), with mean values of 56 versus 43. True dlgEstibility of the mixed diet and egg diet proteins was 96.5 and 98 per cent, respectively. The efficiency of utilization of the Chinese mixed diet protein was 73-77 per cent of the egg protein, based on relative N requirements.
Nutr. 1 12: 897 ( 1982J.
S. Mobharan, G. Maiani, E. Zanacchi, A.M. Ferrini, C. Scaccini, S. Sette, and A. Ferro-Luzzi, "Riboflavin Status among Rural Children in Southern Italy"
A sample of 107 boys aged 7-10 in a rural area of Southern Italy was studied for riboflavin deficiency and its association with milk consumption. The boys represented 74 per cent of the total male population of that age group in the study area. The nutritional status was assessed by means of anthropometric indicators, dietary intakes by a 24-hr recall methods and the riboflavin status was evaluated by the assay of erythrocyte glutathione reductase activity. The nutritional status was found to be generally satisfactory with about one-tenth of the children presenting stunting, wasting, of obesity. This picture is comparable to that recorded at the national level. The overall incidence of biochemical riboflavin deficiency was 13 per cent. No clinical sign of riboflavin deficiency was observed. None of the anthropometric indicators of malnutrition appeared to be related to biochemical evidence of riboflavin malnutrition. Dietary data showed that the children consumed a relatively small amount of milk and dairy products (mean 224 109 g/d). Thirteen out of 14 children with biochemical evidence of riboflavin deficiency belonged to the group who consumed less than 300 g/day of milk. However, only 15 per cent of the children consuming less than 300 g/d of milk and dairy products had biochemical evidence of riboflavin deficiency. It appears that the dietary pattern in rural areas with tradionally low milk consumption is compatible with a relatively satisfactory riboflavin nutriture. This finding suggests that milk and dairy products may occupy, under different dietary practices, a role less critical than usually attributed.
Hum. Nutr. Clin. Nutr. 36C: 71 (1982).
J. Ek and E. Magnus, "Plasma and Red Cell Folate Values and Folate Requirements in Formula-Fed Term Infants"
Plasma and red cell folate concentrations (L. cased activity) and other pertinent blood values have been studied during the first year of life in 64 term infants. After weaning and until 6 months of age, 33 infants were given milk formula I (88 nmole ( 39 micrograms ) folate per liter) and 31 infants MF II (178 nmole ( 78 micrograms ) folate per liter). These infants were compared with 35 breast-fed term infants, considered to have an optimal folate status. The mean folate concentration in the human milk consumed at 3 months of age was 124 nmole (59 micrograms) per liter. The infants fed MF I had low plasma and red cell folate concentrations during the first months of life. The infants fed MF II had folate values almost comparable to those of the breast-fed infants. The weight gain in the infants fed MF II was significantly higher than observed in the infants fed MF I during the first 6 months of life. No significant differences realted to folate deficiency were observed between hemoglobin, RBC, and VPRC values in the formula-fed infants and those recorded in the breast-fed infants. It is estimated that the optimal folate
intake during the first months of life in formula-fed infants is about 170 nmole (75 micrograms) per day. This amount is higher than previously recommended. Infants from all groups had foliate intake similar to, or above, the minimal daily requirement needed for erythropoeisis.
J. Pediat. 100: 738 (1982).
P.E. Soysa, "Priorities for Research in Maternal Nutrition in the Developing World"
Two aspects of maternal nutrition are highlighted - an adequate weight at birth and successful lactation - as the outcome of satisfactory maternal nutrition. The following priorities for research are considered: 1. Pre-pregnancy weights and heights related to birth weight, height, skull circumference and placental weight. 2. Practical implementation of national supplementary feeding of pregnant mothers. 3. Support networks in pregnancy and lactation through the health care system. 4. Study of hypogalactia. 5. Assessment of lactation performance. 6. Lactational amenorrhea. 7. Training of primary health care workers to improve maternal nutrition.
Frog. Clin. Biol. Res 77: 671 (1981).
C.A. Geissler, T.A. Brun, I. Mirbagher, A. Soheli, A. Naghibi, and H. Hedayat, "The Energy Expenditure of Female Carpet Weavers and Rural Women in Iran"
The energy cost of individual activities and the daily energy expenditure of female carpet weavers and villagers were measured in Iranian villages and in the town of Isfahan as part of a series of studies to assess the validity for the population of past and present FAO recommended energy allowances. The energy cost of typical activities was measured by indirect calorimetry using Max-Planck respirometers. Daily energy expenditure was assessed using these figures combined with a 24-hr activity diary. The results of standard activity values are compared with other published values for Europeans and populations of countries with hot climates. The mean daily energy expenditure for both groups was in the order of 2000 kcal/day, below but close to the FAO recommendations, which appear valid for rural women in a large part of the country but are probably an underestimate for areas where the participation of women in agriculture is greater.
Am. J. Clin. Nutr. 34:2776 (1981).
M. Schoepfer, R. Gamier, P. Ropero, M. Traore, and C. Gateff, "Anthropometric Nutritional Indices and Food Intake of a Child Population of South Ivory Coast" (in French)
The present study was carried out in order to determine new biochemical or immunological parameters which would be used to make an early diagnosis of protein-calorie malnutrition. For the first phase of the research, based on anthropometrics (circumference of the arm, head, weight) and on the quantitative evaluation of daily nutritional food intake, three groups of children between the ages of 1 and 3 were selected according to the following criteria: -properly nourished children, -malnourished children without physical signs of malnutrition, -malnourished children with malnutrition signs. The description of these three groups using the forementioned indicators is reported. This work performed on 652 infants shows the following results: Whatever the age, mid-arm circumference and weight are significantly reduced in confirmed cases of malnutrition, but are not useful in detecting malnutrition at an early stage. Whatever the age, head circumference does not change with nutritional status, but it is reduced when the nalnutrition has set in. Whatever the age, the caloric ration (25 per cent deficit) and the protein ration (35 per cent deficit) of a malnourished child without signs of malnutrition and those of a well nourished child are different.
Med. Trop. (Marseille) 41:393 (1981).
J.E. Keith, "The Economics of Nutrition Planning"
Economic theory suggests that consumers act to maximize their utility subject to constraints on their income and time. An individual's actions in the market (demand) generally reflect preferences based on his or her perception of utility, or welfare. Economic research has indicated that consumers purchase food, not nutrients, and that public programs and decisions concerning nutrition which have ignored consumer preferences have often been ineffective and heavily criticized. Approaches which integrate consumer demand and nutrition planning may be more successful in achieving national and institutional goals.
J. Am. Dietet Assoc. 79:649 (1981).
Pregnancy/Child/Aged
T.J. French, M. Colbeck, D. Burman, B.D. Spiedel, and R.A. Hendey, "A Modified Cow's Milk Formula Suittable for Low Birthweight Infants"
Low birthweight babies fed standard modified cow's milk formula are at risk from the high fluid intake needed for adequate nutrition, and very preterm babies often develop late hyponatremia if the sodium intake fails to match large renal losses. A new cow's milk formula (Cow and Gate Prematalac) provides 120 kcal, 3.6 9 protein, 7.5 9 fat, and 4 mmol sodium in 150 ml. Then low birthweight babies were fed the new formula at 150 ml/kg a day and compared with 12 similar babies fed a standard modified cow's milk formula (Wyeth SMA Gold Cap) at 180 ml/kg/ day. All the babies grew at intrauterine rates and there was no difference in clinical course. None fed the new formula developed hypernatremia, oedema, or dehydration and none fed the standard formula developed hyponatremia. The Prematalac group safely excreted the increased osmotic load and had a higher urinary sodium concentration which should protect less mature preterm infants from late hyponatremia.
Arch. Dis. Child. 57:507 (1982).
C.J. Bates, A.M. Prentice, A.A. Paul, A. Prentice, B.A. Sutcliffe, and R.G. Whitehead, "Riboflavin Status in Infants Born in Rural Gambia, and the Effect of a Weaning Food Supplement"
Riboflavin status was measured in infants between birth and two years of age, by the erythrocyte glutathione reductase (NAD(P)H2: glutathione and oxidoreductase, EC 1.6.4.2) Test on finger-prick blood samples. The infants were living in three rural Gambian villages: Keneba, Manduar, and Kanton Kunder; those in Keneba were receiving a weaning food supplement between three and 12 months, which provided 0.15 to 0.20 mg riboflavin per day, in addition to their normal intake from breast-milk and locally available weaning foods, which provided 0.13 to 0.21 mg/day over the same age range. On the basis of currently accepted criteria of biochemical normality, the unsupplemented infants were born deficient and, in the absence of a supplement, remained so throughout their first two years of life, with only a minor, short lived improvement during the first few months. In the supplemented group, however, riboflavin status fell within normal limits for the duration of the supplement, but rapidly deteriorated again once the supplement was withdrawn. It is concluded that infants born to deficient mothers are usually deficient at birth, and remain so throughout suckling and weaning on to locally available foods. The daily requirement to achieve satisfactory bio chemical status is thus greater than 0.13 to 0.21 mg/day, and probably approaches 0.4 mg/day, for most individuals up to the age of one year.
Trans Roy. Son Trop. Med. Hyg. 76: 253 (1982).
H.L. Delgado, R. Martorell, and R.E. Klein, "Nutrition, Lactation, and Birth Interval Components in Rural Guatemala"
The effects of maternal nutritional status and food supplementation ingested by the infant on the duration of postpartum amenorrhea and on the duration of the menstruating interval was examined. A significant negative association was found between the nutritional status of the mother during the 3rd trimester of pregnancy and infant supplementation, on the one hand, and the length of postpartum amenorrhea on the other. These associations remained significant after controlling for each other and for potentially confounding factors for which data were collected. These results support the hypothesis that maternal nutritional status, by determining the amount of breast-milk available, hence the frequency, duration, and intensity of suckling, is indirectly negatively associated with the length of postpartum amenorrhea. Furthermore, no association between maternal nutritional status and the length of the menstruating interval was found.
Am. J. Clin. Nutr. 35: 1468 (1982).
E.C. Henley and S. Bahl, "Nutrition Across the Woman's Life Cycle. Special Emphasis on Pregnancy"
Nutrition plays a crucial role in the maintenance of health of a woman throughout life, but assumes an even more important role during growth, pregnancy, lactation, and menopause. The nutrient reserves accumulated during other, non-stressful periods of life are of vital importance during these phases of physiological stress. Requirements for various nutrients, such as protein, carbohydrate, fat, minerals, and vitamins, throughout life are qualitatively similar; however, they change quantitatively with the rate and intensity of physiological processes taking place within the body. Pregnant and lactating women require more energy, protein, iron, calcium, and vitamins to meet their increased needs. Rapid growth during infancy, childhood, and adolescence also increases the requirements for essential nutrients. In the elderly female, it is important to decrease energy consumption as the basal metabolic rate declines. However, minerals and vitamins, particularly calcium, thiamine, and pyridoxine continue to be as essential in the elderly populations as in adult women.
Nurs. Clin. North Amer. 17: 99 ( 1982).
A. Ashworth, "International Differences in Infant Mortality and the Impact of Malnutrition: A Review"
In the industrialized countries infant mortality continues to decline even though mortality is already at a low level. The greatest number of infant deaths occur in the neonatal period, especially during the first day of life, and the main determinants of infant death are perinatal causes and congenital anomalies. In less developed countries infant mortality remains high, particularly in Africa, the Indian subcontinent and South-east Asia. Observed rates of decline during the last 20 years have been no faster than in the industrialized countries and may indeed have been slower. Although a greater proportion of infant deaths occur postneonatally compared with industrialized countries, the majority nevertheless occur within the first three months of life. The main causes of infant mortality are low birth-weight and diarrhoeal disease The implications in terms of health and nutrtion policies are discussed.
Hum. Nutr. Clin. Nutr. 36C: 7 (1982).
K.H. Brown, R.E. Black, A.D. Robertson, N.A. Akhtar, G. Ahmed, and S. Becker, "Clinical and Field Studies of Human Lactation: Methodological Considerations"
A variety of studies has been completed to assess selected methods that are currently being used or might potentially be used to evaluate lactation performance. During the 64 test-weighings of infants before and after the consumption of a known amount of milk, the mean +/SD "recovery" of milk ingestion was 94.9 +/- 13.2 per cent. The weight of milk extracted by a mechanical pump was approximately 7 per cent greater than the amount measured during test-weighings of infants of the same women within periods of 1 week. To evaluate the possibility of performing abbreviated studies in field settings, the proportion of 24-hr milk comsumption received during 12 daytime hours was measured by test-weighings. Daytime consumption ranged from 46 to 58 per cent of 24-hr consumption (mean +/- SD = 52 +/- 3 per cent). Attempts to predict the amount of milk consumption during 341 daytime studies from the age of infants and their frequency and duration of feedings met with limited success. Although each independent variable was significantly correlated with the amount consumed (multiple r = 0.69, p less than 0.001), the SE of the estimate (Sy.x) was relatively large. The effects of time of day and side of extraction on the volume and composition of extracted milk were determined during 24-hr studies of seven women. There were significant changes in the concentration of fat (p less than 0.001) and nitrogen Up = 0.003) during the day and significant differences in the concentrations of fat (p = 0.04) and lactose (p = 0.04) and in the volume (p less than 0.001) of milk produced by each breast. The importance of these findings for the planning and interpretation of studies of human lactation is discussed.
Am. J. C/in. Nutr. 35: 745 (1982).
B. Bogin and R.B. MacVean, ''Body Composition and Nutritional Status of Urban Guatemalan Children of High and Low Socioeconomic Class"
The effects of socioeconomic differences on the nutritional status of two groups of urban-living children are considered via an anthropometric assessment of body composition. The sample consists of 981 Guatemala City children seven to 13+ years old, of high and low socioeconomic status (SES). High SES children have larger median values for triceps skinfold, subscapular skinfold, arm circumference, and estimated mid-arm muscle and fat areas than low SES children Compared with children of a US reference sample, the high SES children have smaller values. However, the differences between the low SES children and the children of the other two samples are greater for arm fat area than for arm muscle area. The analysis suggests that low SES Guatemalan children suffer to a greater extent from chronic energy, rather than protein, undernutrition. A similar pattern of energy malnutrition has been observed for rural Guatemalan children. These combined data suggest that estimates of fat reserves of the arm provide a useful indication of nutritional status for Third World Children. Results from rural Costa Rican and Honduran studies have been taken to mean that muscle reserves are better than fat reserves as indicators of nutritional status in developing countries. But, those studies did not estimate cross-sectional muscle and fat areas and only considered the extremes of the population distribution for muscle and fat.
Am. J. Phys. Anthropol. 55: 543 (1981).
M Gueri, P Jutsum, and B. Sorhaindo, "Anthropometric Assessment of Nutritional Status in Pregnant Women: A Reference Table of Weight-for-Height by Week of Pregnancy" A reference table of weight-for-height by week of pregnancy has been devised on theoretical grounds, based on the premises that the average increment of weight during pregnancy is 20 per cent of the pre-pregnant weight and that almost all the increment takes place linearly during the second and third trimesters of pregnancy. The table was tested with retrospective clinic and hospital data. The results show a good correlation between the weight-for-height at different stages of pregnancy as a percentage of the reference table and the birth weight of the offspring. This reference table can be a useful tool to assess the nutritional status of pregnant women and, within limits, to "predict" the changes of delivering a low birth-weight infant.
Am. .1. C/in. Nutr. 35: 609 (1982).
E.D. Ojofeitimi and l.A. Elegbe, "The Effect of Early Initiation of Colostrum Feeding on Proliferation of Intestinal Bacteria in Neonates" One-hundred-eighty normal neonates with an average weight above 2.50 kg and having no feeding difficulties were divided into two groups and randomly assigned to either colostrum or to glucose-water feeding regimens during the 3-day stay at the maternity ward. The effects of the feeding regimens on intestinal colonization were studied by examining the stools of the neonates. All bacteria recovered were identified quantitatively and biochemically. Of the 180 mothers, 105 complied with the instructions on feeding regimens. The majority of the neonates receiving colostrum had significantly lower bacterial counts than those on glucose-water (p less than 0.001). The results of the preliminary study indicated that early initiation of colostrum feeding to neonates where potable water is not readily available will suppress the proliferation of bacteria in neonates.
Clin. Pediat (Philadelphia) 21:39 (1982).
S.J. Gross, hi. Geller, and R.M. Tomarelli,"Composition of Breast Milk from Mothers of Preterm Infants"
The influence of daily mechanical expression of breast milk on nutritional composition wet examined by comparing expressed milk from 12 mothers who delivered preterm with milk from two groups of mothers delivering at term: nine who mechanically expressed all milk and five mothers who nursed their infants at the breast. Collections were obtained at four-hour intervals over a period of 24 hours so that variability of constituents in milk of different mothers, as well as variability in the same mother over a 24-hour period, could be assessed. Preterm milk contain significantly higher concentrations of protein, sodium, and chloride, and lower concentrations of lactose than the milk from either group of mother delivering at term. The mean concentrations of protein, sodium, chloride, and potassium in early preterm milk were adequate to meet the estimated requirements for the preterm infant. However, there was large variability in nutritional composition of milk among mothers and among samples from the same mother.
Pediatrics 68: 490 (1981).
B. Luke, C. Dickinson, and R.H. Petrie, "Intrauterine Growth: Correlation of Maternal Nutritional Status and Rate of Gestational Weight Gain"
The influence of increasing pregravid weight and gestational rate of gain on birthweight, length, head circumfeence and complications was investigated. Each gravida was categorized by height and pregravid weight as underweight, normal, or obese. Birthweights, lengths, and head circumferences were evaluated as well as maternal and infant complications. Within each pregravid category and each rate gain group there was an increase in mean birthweight, length, and head circumference with advancing gain and pregravid weight. The incidence of small for gestational age (SGA) infants decreased and large for gestational age (LGA) infants increased with higher gain and pregravid weight. The incidence of antepartum anemia decreased with higher pregravid weight and gain (p less than 0.02). Higher pregravid weight and rate of gestational gain may help insure optimal intrauterine growth.
Eur.J. Obstet Gynaecol. Reprod. Biol. 12: 113 /(1981).
K.S. Moghissi, "Risks and Benefits of Nutritional Supplements during Pregnancy"
This review emphasizes the role of minerals and vitamins in pregnancy. Of the trace elements, iron, copper, zinc, and iodine have a fundamental role in human nutrition; Supplementation of iron, zinc, and iodine in the diet of all pregnant women, when dietary deficiencies exist, seems justified. The average diet in developed countries contains sufficient amounts of the various vitamins, with the exception of folic acid, which may require supplementation. However, in developing nations and among poor populations in which the diet is inadequate, additional supplies of micronutrients are advisable.
Obstet Gynecol 58: (5 Suppl.) 68S (1981).