Riboflavin, folate and vitamin C status of Gambian women during pregnancy: a comparison between urban and rural communities

Anthropometric, haematological and vitamin status indices were measured in a group of pregnant women living in the urban community of Bakau in The Gambia, West Africa. Their haematological and anthropometric indices were generally within normal limits. Vitamin C status was also acceptable and was similar to values observed in rural Gambian women sampled at the same time of year. Folate status was similar to that seen previously in rural Gambian communities, and there was a strong intrasubject correlation between plasma and red cell folate levels, together with a trend towards higher values as pregnancy progressed. This was consistent with probable compliance with local recommendations for folate supplementation during pregnancy. The urban Gambian women also resembled their rural counterparts in having very poor biochemical riboflavin status, which deteriorated as pregnancy progressed. In this respect they differed markedly from UK women, who had satisfactory riboflavin status even in late pregnancy. The existence of severe biochemical riboflavin deficiency, even in urban Gambian women, whose anthropometric indices are not compatible with severe general malnutrition, suggests that a deficiency of this vitamin may be widespread in Sahelian West Africa. Measures to improve maternal vitamin status during pregnancy would therefore be equally appropriate in both rural and urban communities.

Etiology of rickets in Egyptian children

Factors associated with the rickets found in children attending the Outpatients Department of Cairo Children's Hospital have been studied. All the children studied were small for their age with the rachitic children being significantly smaller than the controls. The clinical diagnosis of the disease was confirmed in 54 children by X-ray and plasma biochemistry. The best indicator of the disease was the enlarged epiphysis of the wrist and to a lesser extent that of the ankles. Some of the factors predisposing to rickets were assessed in the rachitic children and in age-matched controls. There was no difference in the nutrient intake of these two groups of children although intakes of energy, calcium and vitamin D, but not of protein, were lower than recommended dietary allowances. Although more of the rachitic children came from urban areas than the controls there were no significant differences in the environments to account for the occurrence of the disease. Factors contributing to the development of rickets are discussed with particular regard to aspects such as low body weight, low maternal vitamin D status and low calcium intakes which cause a high rate of utilization and metabolism of vitamin D.

McCance and Widdowson's 'The composition of foods': supplementary information and review of new compositional data

Publications are reviewed which give detailed nutritional analyses of a wide range of representative samples of UK foods that have been undertaken since the publication of the fourth edition of McCance and Widdowson's 'The composition of foods'. These include trace elements, vitamin A, immigrant foods, cereals, milk and milk products and potatoes. Typographical corrections to the fourth edition are also given as well as the weight loss on cooking the recipe dishes.

The nutrient intakes of pregnant and lactating mothers of good socio-economic status in Cambridge, UK: some implications for recommended daily allowances of minor nutrients

1. Forty-two mothers from social classes I, II and III non-manual and twenty-one from social classes III manual M), IV and V were studied longitudinally. The mean daily nutrient intakes in months 4-9 of pregnancy, months 2-4 of lactation and 3 and 6 months post-lactation are presented and are compared with the UK and the US recommended daily allowances (RDA). 2. The quality of the diets (nutrients per 4184 kJ (1000 kcal] was found to be better than that of other adult female populations studied in the UK, except for a group of dietitians. 3. The mean daily intakes of nutrients for which there are UK RDA were almost all greater than 100% of the RDA. The exceptions were iron, which in the manual group (social classes IIIM, IV and V) was 85% of the RDA in pregnancy and 75% post-lactation, and vitamin D. 4. Among the nutrients for which there are US, but not UK RDA, only phosphorus and vitamin B12 intakes were greater than 100% of the RDA in both groups at all stages of the study. Intakes of other nutrients were below the RDA: pantothenate 70-91, vitamin B6, zinc, vitamin E and copper 40-72, folate 21-44, and biotin less than 20% of the RDA. 5. The bases of the RDA for adult women were examined; for most nutrients the information is limited. It was concluded that the RDA for magnesium, vitamin E and pantothenate are probably higher than necessary and that deficiency is unlikely; that zinc, copper, vitamin B6 and folate are probably 'marginal' nutrients for 'at risk' groups; and that information on biotin is insufficient even roughly to assess the dietary requirement.

Weaning practices in the United Kingdom and variations in anthropometric development

The influence of different weaning practices on the dietary energy intake and growth of Cambridge infants has been investigated. Bottle fed children were in general given solid foods sooner, 10.6 weeks for boys and 13.9 weeks with girls: among breast-fed babies the average age was 14.9 weeks in the case of boys and 17.4 weeks for girls. All four groups of children exhibited different growth patterns from those of the NCHS and Tanner reference curves. Over the first three months both boys and girls exhibited a faster velocity of growth in weight, length and weight-for-length. After this time, however, growth velocity was slower than that of the reference children particularly among breast-fed boys who were not given solids until after 16 weeks. For most of infancy triceps and subscapular skinfold thicknesses remained around the 10th centile of the corresponding Tanner reference children, although again the babies weaned later had the lower values. Bottle-fed infants had growth patterns similar to those of the earlier weaned breast-fed babies for all parameters. It is concluded that babies grow differently now that infant feeding patterns have changed.

Family food purchases and home food consumption: comparison of nutrient contents

Estimates of nutrient intakes based on food purchasing records modelled on the National Food Survey (NFS) were compared with nutrient intakes calculated from food consumption records based on a semi-weighted method, a combination of weighing and household measurement techniques. Of eighty-two families in Cambridge who completed the study, thirty-two were volunteers and fifty were from a random sample in which the co-operation rate was 73%. The estimated energy and nutrient contents of the Cambridge food purchases were very similar to those reported by the NFS for families of similar composition and income. The energy intakes obtained by the semi-weighed method were compared with results from twenty-five studies of energy intake based on quantitative measurements of food consumption: there was no evidence to suggest that the semi-weighed method consistently under- or overestimated intakes in the Cambridge subjects. Purchases adjusted to allow for waste and consumption of food by visitors contained significantly more energy, protein, carbohydrate, calcium, iron and dietary fibre than measured home food consumption. There was no significant difference in the nutrient content of purchases and consumption per 4.184 MJ (1000 kcal), with the exception of Fe and ascorbic acid. Measured wastage of edible food in thirty-one families averaged 3.2% of purchases. Estimate of wastage in all eighty-two families was 3.8%, and consumption of food by visitors accounted for 3.0% of purchases. The excess of purchases over measured home food energy intake is probably accounted for by a net increase in larder stocks rather than wastage, consumption of food by visitors, or under-recording of intakes.

Footnotes to food tables: 1. Differences in nutrient intakes of dietitians as calculated from the DHSS food tables and the fourth edition of McCance and Widdowson's 'The composition of foods'

The differences in nutrient intakes as calculated by two British food composition tables (those compiled by the Department of Health and Social Security in 1963 [DHSS] and the 4th edition of McCance and Widdowson's 'The composition of Foods' [MW4] were examined. Intakes of 43 dietitians who kept weighed diet records every sixth day for 3 to 12 months with 11 to 75 (mean 40) days' records per subject were calculated from each food table and compared in a loge tranformation. Mean per cent differences between intakes (delta x 100) were vitamin A, +23.3; vitamin D, + 21.1; riboflavin, + 16.0;calcium, +6.3; thiamin +4.8; niacin, +3.2 (MW4 higher) and protein, -1.7; fat, -3.5; energy, -3.6; carbohydrate, -6.0; vitamin C, -6.1; iron, -11.3; vitamin B6, -14.4 (MW4 lower). Correlation coefficients were: nicotinic acid, 0.84; vitamin B6, 0.86; other nutrients 0.90 to 0.99; thus differences between the two food tables in classifying individuals as high or low consumers were small. Mean intakes compared by paired t-test were significantly different (P less than 0.001) for all nutrients except nicotinic acid, indicating consistent differences in the food tables when applied to foods eaten by different individuals (nicotinic acid excepted). Mean intakes compared by one-tailed t-test -- as if the data came from independent surveys -- were significantly different/only for riboflavin/and vitamin/B6 (P less than 0.01), vitamin A and iron (P less than 0.05). For these nutrients, significant differences in intakes could be found between two surveyed populations due solely to the use of different food tables and not to differences in foods eaten. For the other nutrients studied, differences between the food tables were of little practical importance. Differences were due primarily to new analytical values in MW4 for riboflavin in milk, retinol in liver, iron in meats, vitamin B6 in many foods, and the use of margarine fortified with vitamins A and D in recipes. Major differences in the (high) nicotinic acid content of beer, instant coffee and specific breakfast cereals resulted in unpredictable differences in intakes of individuals.

Breast-milk antimicrobial factors of rural Gambian mothers. I. Influence of stage of lactation and maternal plane of nutrition

The concentrations of IgA, IgG, IgM, C3, C4, lactoferrin, lysozyme and secretory component in the mature breast milk of 152 rural Gambian mothers were measured up to 26 months lactation. The concentrations and daily secretion of all the immunoproteins, except lysozyme, decreased during the first year of lactation, but were well maintained thereafter. The production of lysozyme increased progressively throughout lactation. Compared with 10 mothers in Cambridge, U.K., the daily secretion of IgG, IgM, C3 and C4 was higher in The Gambia, that of IgA and lactoferrin was similar in the two communities, and that of lysozyme and secretory component was lower in The Gambia. A dietary supplement given to 90 Gambian mothers, raised the mean daily energy intake from a maximum of 1650 kcal/day and a hungry-season minimum of 1 200 kcal/day to 2 300 kcal/day throughout the study. The supplement did not enhance the production of breast milk immunoproteins.

The impact of malnutrition on human lactation: observations from community studies

There is very little scope for the direct examination of relationships between nutrient intake and lactational performance in women. Experimental investigations are limited to the effects of dietary supplementation in pregnancy and/or lactation. To obtain comparisons between normal and undernourished women, studies have to be performed at a community level. Studies in Cambridge, The Gambia, and elsewhere indicate that the impact of variations in nutrient intake on lactational performance is limited: over the ranges normally found in developed and developing countries milk output does not vary in relation to energy intake, and effects of nutrient intake on milk quality are restricted to increases in vitamin content after appropriate supplementation.

Growth charts and the assessment of infant feeding practices in the western world and in developing countries

Changes during the past ten years in infant feeding practices are described and it is demonstrated that with the growing popularity of breast feeding, plus the later addition of solids, dietary energy intakes are substantially lower than they were. These dietary changes would appear to be associated with alterations in the detailed pattern of growth. When exclusively breast-fed, babies, if anything, grow more quickly than growth standard rates, but after 3-4 months a relative deceleration in growth velocity becomes apparent. The anthropometric and dietary findings are discussed in relation to the use of growth charts for the assessment of the adequacy of infant feeding practices in the western world and especially in the Third World. A reanalysis of data indicates that diet-related growth faltering probably does not occur in many developing country situations until later than would be suggested by growth standards currently in use.

Seasonal variations in plasma retinol and carotenoid levels in rural Gambian women

Plasma carotenoid levels exhibited a major seasonal variation in pregnant and lactating women in Keneba, a rural Gambian village. This is probably due mainly to the seasonally related contribution of mangoes, which are a major dietary component during May and June, but are essentially unavailable for the remainder of the year. Plasma retinol levels, on the other hand, exhibited much less seasonal variation, although a trend towards higher levels in May and June was just discernible. Plasma retinol levels were significantly lower than those observed in a group of pregnant and lactating women living in the UK.

The nutritive contribution of school dinners and other mid-day meals to the diets of schoolchildren

In a dietary study of 112 Cambridge families, 191 primary and secondary school children kept 7-day records of measured food consumption. Of 955 weekday lunches recorded, 533 (56 per cent) were school dinners. School dinners provided less than one quarter of the recommended daily amount (RDA) for energy, iron and riboflavin, and less than one third of the RDA for protein, calcium, thiamin and ascorbic acid. School dinners provided a smaller proportion of a day's nutrient intake than did other mid-day meals. Total energy intakes were lower on school-dinner days than on other week-days. Children from lower income families had larger school dinners and obtained a larger proportion of their daily nutrient intake from school dinners than did children from higher income families. School dinners played their most important nutritional role in the lower income families.

Analytical versus food table values for vitamin C in foods: the effect on calculated vitamin C intake of elderly subjects

During a longitudinal study of vitamin C nutrition in 23 healthy elderly people, samples of cooked vegetables and liver, canned meats, canned vegetables and fruit drinks were analysed for vitamin C content. The analytical data are presented here and the effect on calculated daily intake of vitamin C of using the analytical values in place of food table values is assessed. For cooked foods the analysed values were close to food table values; exceptions were spring cabbage, cauliflower and canned potatoes. Fortified fruit drinks contained 20-60 mg vitamin C per 100 ml and made an important contribution to intake. Canned meats contained 0.3-61.4 mg per 100 g (mean 14.9 mg), but their contribution to intake was considered small. The difference between daily intakes calculated using analytical and food table values was greater than 5 mg in 37 per cent of 1-day periods and in 17 per cent of 7-day periods. These differences were not sufficient to significantly alter the correlations between intake and biochemical indices found in the original study. Nevertheless, given the discrepancies between calculated and analysed vitamin C intakes reported in the literature, analytical work is probably essential in studies of vitamin C nutrition.

Dietary supplementation of lactating Gambian women. I. Effect on breast-milk volume and quality

In order to test whether lactational capacity can be improved by dietary interventions, a nutritionally balanced supplement was provided under carefully controlled conditions to 130 nursing mothers in Keneba, The Gambia over 12 months. Maternal mean energy intake (+/- s.e.) increased from 1568 +/- 15 kcal/d (6.56 +/- 0.06 MJ/d) to 2291 +/- 14 kcal/d (9.59 +/- 0.06 MJ/d). Protein intake was in excess of the WHO/FAO recommended intake after supplementation and serious deficits of riboflavin, vitamin A, vitamin C and calcium were rectified. The supplement had no effect on breast-milk volume, compared with retrospective controls, at any stage of lactation or in any season of the year. There was no selective effect on women with poor milk outputs. The average milk protein concentration was slightly improved over the entire period of lactation (+ 6.6 per cent, P less than 0.01), but the total energy content was unchanged since an increase in breast-milk fat concentration (+ 7.9 per cent, n.s.) was offset by a decrease in the milk lactose concentration (- 7.6 per cent, P less than 0.01). Breast milk vitamin content was improved for those vitamins for which the supplement provided a significant proportion of the recommended dietary intake.

How much breast milk do babies need?

A reassessment of the breast milk requirements of young babies at different ages has been made from a statistical analysis of energy intake data collected prospectively in Cambridge, U.K. and from data derived from a literature survey of cross-sectional food energy intakes of infants from Canada, Sweden, the U.K. and USA. In contrast to the slow progressive linear decline in energy requirements per kg body-weight that has previously been assumed, measured intakes have been shown to fall more rapidly in the first six months of life. Thereafter they then rise again as the baby becomes more active. These findings are of fundamental importance to a realistic assessment of the adequacy of breast milk as the sole source of food in the first six months of life. The data show that typical breast milk intakes found in the industrialized countries can satisfy infant energy needs for healthy growth for much longer than would be indicated by current international dietary recommendations. A discussion of the physiological interpretation of the results is included as is an appraisal of their practical significance both to breast and bottle feeding practices.

Seasonal changes in activity, birth weight and lactational performance in rural Gambian women

The activity of 81 pregnant, lactating and non-pregnant, non-lactating women in the rural subsistence farming village of Keneba, The Gambia, was measured for 12 months using a combination of 24-hour activity recall and activity diaries. During the course of pregnancy women became gradually less active and in the month before giving birth were 25% less active than non-pregnant, non-lactating women and lactating women when women in the month after birth were excluded. There were striking seasonal changes in activity. During the dry season, from January to April, lactating women were active 55% of the 15-hour working day. At the start of the farming season in June and July this figure increased to 92%. Similar changes were observed in the pregnant women whose activity increased from a mean 50% in April to 83% in June. The period of intense activity coincided with a general shortage of food and increased incidence of disease. The intense activity of pregnant women in the farming season coupled with the low food intakes are most probably the main factors responsible for the striking fall in birth weights observed at this time of the year. Reduced lactational performance was apparent in relation to high activity when it necessitated the mother regularly spending much of the day away from her child. FAO/WHO-recommended energy intakes during pregnancy and lactation are inappropriate for this community.

Seasonal variations in ascorbic acid status and breast milk ascorbic acid levels in rural Gambian women in relation to dietary intake

Vitamin C intakes from mangoes and oranges, and plasma and breast milk ascorbic acid concentrations were measured at regular intervals in a cohort of pregnant and lactating women in Keneba and Manduar, two neighbouring rural Gambian villages. Extremely wide seasonal variations in plasma ascorbic acid levels were observed, the peak during the mango season in May and June attaining mean levels of 1.4 mg/dl, while the lowest levels, averaging only 0.2 mg/dl, were observed during the rainy season, during September and October. Parallel, but less pronounced variations were observed in breast milk ascorbate levels. A vitamin-fortified milk and biscuit supplement, given first to the lactating, and later to the pregnant, mothers in Keneba, which provided about 35 mg ascorbic acid per day, failed to produce any major improvement in plasma ascorbic acid levels during the rainy season, although there was some evidence for an improvement in breast milk levels. It is therefore likely that considerably greater intakes are required to maintain satisfactory maternal circulating levels and biochemical status during this critical period.

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 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 Kundar; 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 biochemical 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.

Long-term energy balance in child-bearing Gambian women

The energy intake of 143 pregnant and lactating Gambian women was measured prospectively each week for a year. Anthropometric, birth weight, and breast milk output measurements were also obtained. The average energy intakes (+/- SE) during the dry and wet seasons respectively were: pregnancy, 1483 +/- 22 and 1417 +/- 41 kcal/day; lactation (1st trimester), 1773 +/- 31 and 1474 +/- 42 kcal/day; lactation (subsequent trimesters), 1662 +/- 16 and 1413 +/- 37 kcal/day. Pregnant women gained 1.4 kg body weight per month in the dry season, but only 0.4 kg in the wet season. Lactating women gained weight in the dry season and lost weight in the wet season. Maternal nutritional status did not deteriorate with increasing parity. Mean birth weights (+/- SE) were: 2.94 +/- 0.07 and 2.78 +/- 0.11 kg in dry and wet seasons, respectively. Breast milk output and quality and early infant growth were close to values from well-nourished communities during the dry season, but deteriorated markedly during the wet season. Wet season energy intakes were clearly inadequate, but these results indicate that, despite being low by international standards, the dry season intake was compatible with a good lactational performance. Except for a somewhat low birth weight, which is partly explained by small maternal stature, progress during pregnancy was also remarkably normal during the dry season.

A critical analysis of measured food energy intakes during infancy and early childhood in comparison with current international recommendations

An examination of published reports of measured energy intakes of infants and young children reveals that during the first year of life the pattern of change in food energy intake differs fundamentally from the WHO/FAO (1973) Recommendations. In contrast to the progressive linear decline in intake per kg body weight that has previously been assumed, measured intakes are not only substantially lower, but fall much more rapidly up to six months. In even greater contrast, they then rise again, to coincide with the recommendations, reaching a peak at around two years. These findings enable a more realistic assessment to be made of the adequacy of breast milk as the sole source of food in the early months of life.