editor.
RobertB.
BradfieId,Ph.D
international
nutrition
Mehari
Gebre-Medhin,2
M.D.,
and
and
10 privileged
ABSTRACT
The
nonpnivileged inventory that
survey.
was deficient
FAO/WHO
except
lower
Am.J.
C/in.
Gobezie,3
dietary
intake
the exception
in all nutrients,
The
for calcium
and
mean
birth
Nutr.
28: 1322-1329,
weight
ofC/inical
and
privileged
when
Nutrition
third
compared
of
was
protein
pregnancy
studied
the nonpnivileged
daily
Infants
trimester
Ababa
thiamin, group
riboflavin.
-
Journal
the in Addis
an average
group
and energy
below
was
found
born
to the nonpnivileged
women
infants
privileged
with
the
born
20
weighing
consumed
intake
to meet
among
in a 2 day
a diet
60%
of the
the recommendations to the
for
had signifiwomen.
1975.
-
The American
during
of iron with
In the past decade dietary surveys carried out in different communities in Ethiopia have all shown the existence of major dietary deficiencies, especially in infants and children (I 4). There are, however, no published data focusing specifically on dietary intake during the last trimester of pregnancy, a time characterized by nutritional stress. A high fetal wastage, increased stillbirth rate and low mean birth weight rate have been reported from various parts of the country (5-9). Furthermore, there is good evidence to suggest that infants born to low income mothers with an estimated deficient nutrient intake have significantly lower mean birth weight and length when compared to infants from high income groups (10). Despite extensive investigations elsewhere the role of nutrition as a factor in the clinical course and outcome of pregnancy remains a debated subject ( I 1 16). The present study, one of a series on the interaction of pregnancy and nutrition in Ethiopia, was designed to collect information on dietary intake from a group of Ethiopian primigravidae during the third trimester of pregnancy. 1322
M.Sc.
pnimignavidae
Recommendations.
all nutrients cantly
With
Abeba
Material Clinical
and methods material
The study was conducted on Ethiopian women Selected from two institutions in Addis Ababa: a municipal antenatal clinic for the indigent and an antenatal clinic for paying patients in the Department of Obstetrics and Gynaecology, Haile Selassie I University. The basic
criteria
for the selection
of the subjects
were socioeco-
nomic. Patients selected from the municipal clinic all had a family income of less than Ethiopian $100 pen month and are subsequently described as the nonpnivileged. Patients selected from the university clinic all had an income of more than $650 pen month and are subsequently described as privileged. A monthly family in-
come
not exceeding Ethiopian $100 (US $49) is thought to be inadequate for the purchase of a balanced family diet (unpublished observations). An income above Ethiopian $650 pen month corresponds roughly to the starting salary ofa recent university graduate (17). There was no difference between the two groups with respect to family size. The study was carried out in Addis Ababa during the 4-month period April July 1970. Healthy young third trimester pnimignavidae without glucose or protein in the t
From
the
Ethiopian
Children’s Nutrition Ababa, Ethiopia. 2
Director,
Nutritionist,
28: NOVEMBER
Nutrition Unit)
Ethiopian
Ethiopian
1975,
P.
Institute 0.
Nutrition
Nutrition
pp.
Box
(formerly 5654,
Institute.
Addis
Chief
Institute.
1322-1329.
Printed
in U.S.A.
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/11/1322/4732877 by Boston University user on 11 January 2019
Dietary intake in the third trimester of pregnancy and birth weight of offspring among nonprivileged and privileged women1
DIETARY
INTAKE
Examination
methods
The length of gestation was determined by interviewing the women with the help of a specially constructed local calendar. Anthropometnic measurements were performed at the beginning of the 7th month of gestation according to standard methods. The dietary intake of the women in the third trimester was studied by a record technique. Experienced Ethiopian nutritionists paid home visits during 2 consecutive weekdays in order to measure the amount of food actually consumed by the individual woman. Raw food ingredients and prepared foods were weighed in each instance. The nutrient content of the various items was calculated Ethiopia analyzed laboratory laboratory vitamins
from the Food Composition Table for use in (19). Items not included in the food table were for nutrient contents at the food analytical of the Ethiopian Nutrition Institute, the same which did the analyses for the food table. For the values are based on raw food items. For
evaluation FAO/WHO nutrients
of adequacy the Recommendations (20-25).
results
were compared concerning energy
with and
Results “he among “wot.” type of grostis
most commonly encountered dishes both study groups were “injera” and “Injera” is a large, circular pancake leavened bread made from teff (Eraabyssinica Schrad), sorghum, wheat
TABLE I Age, anthropometnic
data
and
socioeconomic
status
Nonprivileged
20 10
Privileged Mean
No
and
observed
years
.
I 323
or barley and consumed throughout highland Ethiopia. Teff is the cereal most frequently used for making “injera.” It is a good source of minerals, particularly iron (20). Its amino acid pattern is more favorable than that of other cereals, although lysine seems to be the principal limiting amino acid (1). “Wot” is a spiced sauce which may be prepared from any one or a mixture of the following: meat, leguminous seeds, green vegetables, onions, peppers and fat. It is usually eaten with “teff injera,” occasionally with other bread. Pea flour was the most common food item in the sauce of the nonprivileged group. Due to shortage of fuel the “wot” was boiled only once a day or often the pea flour was just mixed with salt and water and eaten with “injera” usually bought from the nearest market. Onions and pppers were added occasionally. No animal protein was seen and butter added to the “wot” on one occasion in one case only. Most of the women in the nonprivileged group lIved under very simple conditions and often ate only one meal a day in the evening. Breakfast and lunch were usually very light and consisted of roasted grain su#{231}j’j as wheat, chickpeas or corn. The diet was strikingly monotonous. In the privileged group the meals also consisted basically of “injera” and “wot.” However, in addition to onions and peppers, meat, butter, eggs and other animal products were used abundantly in the “wot” which was, very often, eaten three times a day together with “injera.” Vegetables were added quite liberally. Occasionally food items such as noodles, spaghetti and rice were also consumed. With the exception of iron and thiamin the nonprivileged consumed a diet that was, on the average, inadequate in all nutrients (Table 2). The average daily protein and energy intake in the group was below 60% of the
and
observed
Weight, kg
Age,
Grou p
Mean
PREGNANCY
range
Height. cm
I ncome, Eth. Se/month
Mean
Range
Mean
Range
Mean
Range
18.3 23.4
16-27 20-30
58.0 58.8
47-66 48-67
157.7 157.3
152-162 150-164
range.
Eth,$
100
=
US
$ 49.
Mean
42 1160
% Literacy
Range
4-100 650-2,500
5.0 100.0
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/11/1322/4732877 by Boston University user on 11 January 2019
urine, with normal blood pressure and with no clinical signs of acute on chronic disease were selected consecutively. Twenty nonpnivileged and ten privileged women were studied. Age, anthropometnic and socioeconomic data of the subjects are presented in Table I. All but one in the nonpnivileged group were illiterate and had.never attended any school, fourteen in this group were housewives, two were housemaids, three were ban girls, and one woman did not specify occupation. Half of the subjects in the privileged group were college graduates and the rest had completed at least secondary school. Eight were professionals (four nurses and four secretanies) and two were housewives. The socioeconomic status of the privileged group could be considered representative of a relatively small elite whereas that of the nonpnivileged group reflects the condtion of a sizable proportion of Ethiopian women (18). Both groups studied consisted of the four main ethnic groups of highland Ethiopia. They were all interviewed around the beginning of the third trimester and had no regular antenatal cane.
IN
GEBRE-MEDHIN
I324
5’
E
r1
Cs --
5’
sC r-
r-
1
r
oc
H
z
C
4)
ri r=c sC
‘C
ri
oor s
r
-H
r
c
cc
-d-cc
.H
H
C
ri Os
3005
, 1’
o
00
r -OO
.H
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Os
rsC C
c
.
.H
41
. 5) 5)
.
C C
C 0
-
5)
.
E
-r
C
r.i:sc.:
C
r
r
L)
r
-H
C
41
.C C 0. >5
C r .s’ C
-
C
r-
,.
C
-
C
41
C U
41
5,3 >
C
c
c
C 0
5)
sO,
C 5)
Cs 5)
_41
-
sO C r-
0 sO
Os
c
a
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30
5,3
z
(-.141
5,3
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5)
5)
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5),.,
s
5)
C
.,
.
.
5) >
C 5,3
C
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C
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5) 811
5,3
. ..-
‘O 5) Oil 0
0
z
C 5,3
Discussion
5)
.
l-
FAO/WHO Recommendations (Fig. I). The privileged group on the other hand, displayed a considerably higher mean intake for all nutrients and with the exception of calcium and riboflavin was found to meet the recommendations. With the exception of iron and thiamin between 17 and 19 of the 20 women in the nonprivileged group were found to have a level of intake that was below 80% of the FAO/WHO Recommendations (Fig. 2). For energy, protein, riboflavin, niacin and ascoric acid, about 10 scored below 40% of the recommendations. Except for calcium and riboflavin only I or 2 privileged women displayed a level of intake below 80% of the recommendations for any given nutrient. For vitamin A 6 were found to have a level of intake below 80% and 7 below 40% of the recommendation. Nearly 97% of the protein and over 80% of the energy in the diet of the nonprivileged subjects were of plant origin (Tables 3 and 4). Almost no protein of animal origin was consumed by this group and only 10% of the energy was derived from fat. In the privileged group 45% of the protein was obtained from animal sources and nearly 25% of the energy was derived from fat. In both groups starch dominated clearly with glucose and sucrose as negligible sources of carbohydrates (Table 5). Vegetable oil, of which 78% was derived from safflower accounted for all the fat consumed by the nonprivileged group. In contrast to this, 37% of the total fat in the diet of the privileged group consisted of vegetable fat and 14% of this was derived from safflower oil. Despite the supposed dietary deficiencies of the nonprivileged group no clinical signs of nutritional deficiency were observed. Half of the nonprivileged and all ten of the privileged women were delivered in a hospital or maternity center after an uneventful pregnancy. One infant in the privileged group was stillborn. The birth weights of the newborns from both groups are presented in Fig. 3.
5,3
0
811
GOBEZIE
e
The question tion of findings
of validity of the is a well-known
interpretaproblem
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/11/1322/4732877 by Boston University user on 11 January 2019
rC
o
-
.H
AND
DIETARY
120 110 1 c:
INTAKE
IN
I 325
PREGNANCY
p
1,
p
p
‘I
80 70
60 50 30 20 I0 0 .
bL.1111i1uii niacin
0 FIG.
equivaLent
R
nonprivit.eged I. Percentage
of adequacy
not
of tryptophan
of energy
and
nutrients
inherent in surveys designed to compare nutrient intake of different population groups. In this study the choice of well-defined socioeconomic groups of apparently healthy, young primigravidae in the third trimester of pregnancy may be expected to produce valid results. Dietary information was obtained from a weighing-inventory survey conducted during 2 consecutive days. This method was adopted as a result of the study of published experiences from elsewhere which indicate that, in areas where dietary patterns are monotonous, the first 2-4 days provide practically all the information of a 7-day survey (26, 27) and that the diet of the individual primigravida remains very similar in two widely separated weeks (28). Recent analysis of data from several surveys at the Ethiopian Nutrition Institute seems to confirm these observations (unpublished observations). In both the groups studied the main meal consisted of the typical highland Ethiopian items “injera” and “wot.” “Injera” prepared from the cereal teff, has proved to be a unique source of dietary iron (29, 30). the exceedingly high iron intake of the Ethiopian highh&.nd population, discussed at length by Hofvander (29), contributes to the striking rarity of nutritional anemia among highland Ethi-
I
considered
privi’eged compared
with
FAO/WHO
recommendations.
opians, including pregnant women (31, 32). Teff has a higher iron content than any other cereal. In addition, a considerable amount of iron-containing particles adhere to the teff seeds during the traditional process of threshing but the availability ofthe iron is low (29). The difference between the two groups resides in the ingredients added to the “wot.” In the privileged group this abounds in animal protein, fat and vegetables with riboflavin and calcium the only nutrients below the recommendations. The nonprivileged group, however, add almost no animal protein or fresh vegetables and over 80% of all energy was derived from carbohydrates. The calcium intake in both groups was very low because of the scarcity of milk and its products. Satisfactory adaption to lower 1evels of calcium intake has been convincingly demonstrated in man (33). A habitually low intake of this mineral does not appear to be deleterious to man, neither does an increase result in clinically detectable benefits (34). The deficiency in vitamins and minerals would have been greater had allowances for losses during food preparation and cooking been made. In both groups starch was the main source of energy and even in the privileged refined sugars were consumed in very limited quan-
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/11/1322/4732877 by Boston University user on 11 January 2019
90
GEBRE-MEDHIN
I 326
3of
n
AND
GOBEZIE
%of n
Vitamin
Energy
100
80 60 40
4O4O
1%
rLrIrI
., adequacy
80%etodequacy
RibofLavin
Calcium ‘3’
‘3, 40 20’ ‘0
#{163}0.10 >80’.
at adequacy
80%
40-80
Ascorbic
ot adequacy
80%
of tryptophan
of adequacy not
80 ‘3
40 20
LI
80%
of subjects Three classes
0
nonprivileged
U
priviLeged
at adequacy
consuming of adequacy:
different 80.
and
nutrients
compared
with
3
Percentage
of energy Group
Nonpnivileged Privileged
derived Cereals 65.5 41.2
from
different Legumes 16.1 4.1
food
sources Fats
Fruits and vegetables
10.7 24.7
l.I 4.2
tities generally confined to the addition of sugar (sucrose) to tea or coffee. Although generous quantities of meat and butter were contained in the diet of the privileged group,
Sugar
Roots
Others
1.1 1.2
1.2 2.5
4.3 22.0
Total 100.0 100.0
only 25% of their energy was derived from fat. This may be due to the fact that Ethiopian meat has a mean fat content of about 1.3% (19), whereas the United States stan-
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/11/1322/4732877 by Boston University user on 11 January 2019
iii
IL
20
A
DIETARY TABLE
distribution
of protein
Group
from
animal
Animal
protein
Nonpnivileged
PREGNANCY
and
plant
I 327
Plant
roots,
TABLE S Percentage distribution
of carbohydrate Glucose
Nonpnivileged Privileged
legumes
58.2
33.8
cereals
legumes
35.8
9.0
SS.2
Lactose
Starch
Fructose
S 7
Sucrose I 2
2
3800
.1:
3Z0 S
#{149}1#{149}
280C
nonprivileged n=10, Meon=3110 SD ±245
S
*
privileged
n=9
240C 3. Distribution
of birth
others
8.0
00.0 100.0
others 100.0
sources
4
FIG.
cereals
54.3
4400
2X
100.0
etc.
Group
360C
Total
weights
Mean=3580 S D ± 305 of hospital
born
infants.
dard grade meat contains 21% and prime grade meat 41% fat (35). In the face of such widely divergent levels of nutrient intake one would have expected marked differences in body weight or other anthropometric data between the two groups, but this was not the case. It is conceivable that both groups of women had similar nutritional experiences during early childhood resulting in permanent stunting of growth. It is more difficult to find an explanation for the similarity in the mean weights. Possibly the nonprivileged group had just a marginal energy supply before conception
2
94 87
Total 100.0 100.0
which could still cover basic needs at the beginning of the third trimester whereas the privileged group easily responded to increasing demand, maybe even with excess intake. From this point of view it would have been interesting to have access to dietary as well as anthropometric data for the two groups both in pre- or early pregnancy period and at the very end of the gestation period. One wonders also whether the possibility of increased water retention should be considered, especially in view of the low protein content of the diet of the nonprivileged group which, in addition, might have been used in part for energy needs. Judging from the birth weights alone, it would seem that in the nonprivileged group the fetus has suffered from the effect of undernutrition during gestation. The newborns in this group would seem to be characterized by intrauterine growth retardation (Fig. 3). Further investigation is needed to throw more light on this important public health issue in Ethiopia. Summary The dietary intake during the third trimester of pregnancy among 20 nonprivileged and 10 privileged primigravidae in Addis Ababa was studied in a 2 day weighing-inventory survey. With the exception of iron and thiamm, the nonprivileged group consumed a
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/11/1322/4732877 by Boston University user on 11 January 2019
fruits,
protein
97.3
45.7
Vegetables,
34X
sources
2.7
Privileged
i
IN
4
Percentage
a
INTAKE
GEBRE-MEDHIN
1328
AND
diet that was deficient in all nutrients, with an average daily protein and energy intake below 60% of the FAO/WHO Recommendations.
The privileged
group
was found
Kebkabe in interviewing the mothers and in the dietary calculations. The collaboration of the staff at the Ethiopian Nutrition Institute and the Lideta Maternal and Child Health Demonstration and Training Centre is gratefully acknowledged.
References Committee
on
Nutrition
National Defense. Ethiopia-Nutrition Washington, D. C.: U.S. Govt. Printing 1959. 2. SLl.1NLs, R., A. GoBIzli:, K. E. KNL’TSSON VAHLQLIST.
3.
4.
S.
6.
7.
8.
9.
10.
I I.
Dietary
studies
in
Ethiopia:
for survey. Office, AM)
B.
intake and
K.,
1962. A. K. pregnancy
ANt)
during offspring.
Bost. Effect on obstetrical
of low nutrient performance
J. Clin. Nutr. Il: 586, 1962. M. N. SLSSER. Low birth weight and prenatal nutrition: an interpretative review. Pediatrics 46: 946, 1970. IS. Committee on Maternal Nutrition/Food and Nutnition Board, National Research Council-National Academy of Sciences. Maternal nutrition and the course of pregnancy: summary report. U.S. Dept. of Health, Education and Welfare, Rockville, Md., 1970. 16. LEcIITIG, A., i-P. HABICIIT, E. LEoN AND G. 14.
Am.
BERGNER,
L.,
GUZMAN.
Influencia
ANI)
de Ia nutnicion
materna
sobre
el
crecimento fetal en poblaciones rurales de Guatemala. II. Supplementacion Alimentania. Arch. Latinoamer. Nutn. 22:1 17, 1972. 17. Statistical Abstract. Imp. Ethiopian Govt. Centr. Stat. Off., Addis Ababa, 1971, p. 140. 18. Statistical Abstract. Imp. Ethiopian Govt. Centr. Stat. Off., Addis Ababa, 1971, p. 120. 19. AGREN, G., ANI) R. GIBsoN. Food Composition Table for Use in Ethiopia. Swedish Intern. Develop. Authority, 1968. 20. Food and Agriculture Organization. Food Composition Table for Use in Africa. Washington, D. C.: U.S. Dept. Health, Education Welfare, 1968. 21.
dietary
pattern among the Rift Valley Ansi Galla. Am. J. Clin. Nutr. 24: 365, 1971. StI.1NLS, R., G. AwAI.o1 ANt) A. GoaizlF. Dietary studies in Ethiopia. II. Dietary pattern in two rural communities in N. Ethiopia. A study with special attention to the situation in young children. Acta Soc. Med. Upsal. 76: 17. 197l. Sut.1NLs, R., A. GoBEzii ANI) B. VA1H.QLIST. Dietany studies in Ethiopia. III. Dietary pattern among the Sidamo ethnic group. A study of villagers in the enset monoculture area in S. Ethiopia with special attention to the situation in young children. Acta Soc. Med. Upsalien. 76:158, 1971. CATiPoic A. Address presented at the Eighth Annual Conference of the Ethiopian Medical Association. Addis Ababa, 1972. HoFv,\NlR, Y. A survey of 3000 children examined at the “ Mobile Child Health Centre” in Addis Ababa in 1962. Ethiopian Med. J. 1:156, 1963. Y0UN(,, P. N. Birth weights of hospital-delivered infants in Addis Ababa and Gondar. Ethiopian Med. J. 6:15, 1968. LARSSON, U. Mimeographed Ann. Report. Lidetta Mother and Child Health Demonstration and Training Centre, Addis Ababa. 1969. GEBRI-MEliiiN, M., S. GuRovsk\ Al) L. BoNuisTAM. Association of maternal age and parity with birth weight, sex ratio, stillbirths and multiple births in an Ethiopian sample. To be published. GEBR-MEuiii’, M. Body weight at birth of viable infants from non-privileged and privileged women in Addis Ababa, Ethiopia. To be published. GoPAI..;N, C. Effect of nutrition on pregnancy and lactation. Bull. World Health Organ. 26: 203. 1962.
26:193,
BACCHI,
status Health
22.
23.
24.
Report of a joint FAO/WHO Ad Hoc Expert Committee: Energy and protein requirements. World Health Organ. Tech. Rept. Sen. no. 522, Rome, I973. Report ofjoint FAO/WHO Expert Group: Calcium Requirements. World Health Organ. Tech. Dept. Sen. no. 230, Geneva, 1962. Report of a joint FAO/WHO Expert Group: Requinements of vitamin A, thiamine, riboflavin and niacin. World Health Organ. Tech. Rept. Sen. no. 362, Geneva, 1967. Report of a joint FAO/WHO Expert Group: Vita-
mm and mineral
requirements.
Food
Agni.
Organ.
U.N. Nutn. Newsletter 7:3, 1969. 25. Amino acid content of foods and biological data on proteins. Food Agni. Organ. U.N., Rome, 1968. 26. CELLI1R, K. M., ANI) M. E. HANKIN. Studies on nutrition in pregnancy. I. Some considerations in collecting dietary information. Am. J. Clin. Nutn. 13: 55, 1963. 27. LECIITIG, A., i-P. HABIcIIT, E. LEoN, G. GLZMAN AND M. FLORES. Influencia de Ia nutnicion materna sobre el cnecimiento fetal en poblaciones nunales de Guatemala. I. Aspectos Dieteticos. Arch. Latinoam. Nutr. 22: 101, 1972. 28. THoisoN, A. M. Diet in pregnancy: I. Dietary survey technique and the nutritive value of diets taken
29.
30.
31.
by pnimignavidae. Bnit. J. Nutn. 12: 446, 1958. Y. Hematological investigations in Ethiopia with special reference to high iron intake. Acta Med. Scand. Suppl. 494, 1968. ALMGARD, G. High content of iron in tef, Enagnostis abyssinica link, and some other crop species from Ethiopia - a result of contamination. Ann. Agni. Coil. Sweden 29: 215, 1963. GEBR-MEIIiIN, M., ANt) B. VAIIL.QLIST. Serum HOFVANL)ER,
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/11/1322/4732877 by Boston University user on 11 January 2019
We wish to express our sincere thanks to Professor Bo Vahlquist for valuable guidance and encouragement through all the stages of the study and to Professor Goran Stenky for his advice during preparation of the manuscript. We are indebted to Dr. Sam Ross for allowing us to interview his patients and to Woizenit
its effect
Organ. 13.
P. S. Maternal nutritional on the newborn. Bull. World
VENKATACI-JALAM,
and
to meet the
recommendations for all nutrients except for calcium and riboflavin. Infants born to the nonprivileged women had significantly lower mean birth weight when compared with the infants born to the privileged women.
I . Interdepartmental
12.
GOBEZIE
DIETARY iron,
32.
binding
capacity,
folate
and vitamin
IN
B,2 in
pregnancy: a study of non-privileged women in Addis Ababa, Ethiopia. To be published. Ross, S. M. Haemoglobin and haematocnit values in pregnant women on high iron intake and living at a high altitude. J. Obstet. Gynaecol. Bnit. Commonwealth 79:1103, 1972. MALM. 0. 5. Calcium requirement and adaptation in adult men. Scand. J. Clin. Lab. Invest. 10: Suppl. 36,
PREGNANCY
1329
1958.
34.
A. R. P. The human requirement should low intakes be supplemented? Nutn. 25:518, 1972. 35. WATT, B. K., AND A. L. MERRIE.. Composition Foods-Raw, Processed, Prepared. Agr. Res. Handbook No. 8, U.S. Dept. Agn. Washington, C.: U.S. Govt. Printing Office, 1963. WALKER,
calcium: J. Clin.
of Am. of Serv. D.
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/11/1322/4732877 by Boston University user on 11 January 2019
33.
iron
INTAKE
RobertB.
BradfieId,Ph.D
international
nutrition
Mehari
Gebre-Medhin,2
M.D.,
and
and
10 privileged
ABSTRACT
The
nonpnivileged inventory that
survey.
was deficient
FAO/WHO
except
lower
Am.J.
C/in.
Gobezie,3
dietary
intake
the exception
in all nutrients,
The
for calcium
and
mean
birth
Nutr.
28: 1322-1329,
weight
ofC/inical
and
privileged
when
Nutrition
third
compared
of
was
protein
pregnancy
studied
the nonpnivileged
daily
Infants
trimester
Ababa
thiamin, group
riboflavin.
-
Journal
the in Addis
an average
group
and energy
below
was
found
born
to the nonpnivileged
women
infants
privileged
with
the
born
20
weighing
consumed
intake
to meet
among
in a 2 day
a diet
60%
of the
the recommendations to the
for
had signifiwomen.
1975.
-
The American
during
of iron with
In the past decade dietary surveys carried out in different communities in Ethiopia have all shown the existence of major dietary deficiencies, especially in infants and children (I 4). There are, however, no published data focusing specifically on dietary intake during the last trimester of pregnancy, a time characterized by nutritional stress. A high fetal wastage, increased stillbirth rate and low mean birth weight rate have been reported from various parts of the country (5-9). Furthermore, there is good evidence to suggest that infants born to low income mothers with an estimated deficient nutrient intake have significantly lower mean birth weight and length when compared to infants from high income groups (10). Despite extensive investigations elsewhere the role of nutrition as a factor in the clinical course and outcome of pregnancy remains a debated subject ( I 1 16). The present study, one of a series on the interaction of pregnancy and nutrition in Ethiopia, was designed to collect information on dietary intake from a group of Ethiopian primigravidae during the third trimester of pregnancy. 1322
M.Sc.
pnimignavidae
Recommendations.
all nutrients cantly
With
Abeba
Material Clinical
and methods material
The study was conducted on Ethiopian women Selected from two institutions in Addis Ababa: a municipal antenatal clinic for the indigent and an antenatal clinic for paying patients in the Department of Obstetrics and Gynaecology, Haile Selassie I University. The basic
criteria
for the selection
of the subjects
were socioeco-
nomic. Patients selected from the municipal clinic all had a family income of less than Ethiopian $100 pen month and are subsequently described as the nonpnivileged. Patients selected from the university clinic all had an income of more than $650 pen month and are subsequently described as privileged. A monthly family in-
come
not exceeding Ethiopian $100 (US $49) is thought to be inadequate for the purchase of a balanced family diet (unpublished observations). An income above Ethiopian $650 pen month corresponds roughly to the starting salary ofa recent university graduate (17). There was no difference between the two groups with respect to family size. The study was carried out in Addis Ababa during the 4-month period April July 1970. Healthy young third trimester pnimignavidae without glucose or protein in the t
From
the
Ethiopian
Children’s Nutrition Ababa, Ethiopia. 2
Director,
Nutritionist,
28: NOVEMBER
Nutrition Unit)
Ethiopian
Ethiopian
1975,
P.
Institute 0.
Nutrition
Nutrition
pp.
Box
(formerly 5654,
Institute.
Addis
Chief
Institute.
1322-1329.
Printed
in U.S.A.
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Dietary intake in the third trimester of pregnancy and birth weight of offspring among nonprivileged and privileged women1
DIETARY
INTAKE
Examination
methods
The length of gestation was determined by interviewing the women with the help of a specially constructed local calendar. Anthropometnic measurements were performed at the beginning of the 7th month of gestation according to standard methods. The dietary intake of the women in the third trimester was studied by a record technique. Experienced Ethiopian nutritionists paid home visits during 2 consecutive weekdays in order to measure the amount of food actually consumed by the individual woman. Raw food ingredients and prepared foods were weighed in each instance. The nutrient content of the various items was calculated Ethiopia analyzed laboratory laboratory vitamins
from the Food Composition Table for use in (19). Items not included in the food table were for nutrient contents at the food analytical of the Ethiopian Nutrition Institute, the same which did the analyses for the food table. For the values are based on raw food items. For
evaluation FAO/WHO nutrients
of adequacy the Recommendations (20-25).
results
were compared concerning energy
with and
Results “he among “wot.” type of grostis
most commonly encountered dishes both study groups were “injera” and “Injera” is a large, circular pancake leavened bread made from teff (Eraabyssinica Schrad), sorghum, wheat
TABLE I Age, anthropometnic
data
and
socioeconomic
status
Nonprivileged
20 10
Privileged Mean
No
and
observed
years
.
I 323
or barley and consumed throughout highland Ethiopia. Teff is the cereal most frequently used for making “injera.” It is a good source of minerals, particularly iron (20). Its amino acid pattern is more favorable than that of other cereals, although lysine seems to be the principal limiting amino acid (1). “Wot” is a spiced sauce which may be prepared from any one or a mixture of the following: meat, leguminous seeds, green vegetables, onions, peppers and fat. It is usually eaten with “teff injera,” occasionally with other bread. Pea flour was the most common food item in the sauce of the nonprivileged group. Due to shortage of fuel the “wot” was boiled only once a day or often the pea flour was just mixed with salt and water and eaten with “injera” usually bought from the nearest market. Onions and pppers were added occasionally. No animal protein was seen and butter added to the “wot” on one occasion in one case only. Most of the women in the nonprivileged group lIved under very simple conditions and often ate only one meal a day in the evening. Breakfast and lunch were usually very light and consisted of roasted grain su#{231}j’j as wheat, chickpeas or corn. The diet was strikingly monotonous. In the privileged group the meals also consisted basically of “injera” and “wot.” However, in addition to onions and peppers, meat, butter, eggs and other animal products were used abundantly in the “wot” which was, very often, eaten three times a day together with “injera.” Vegetables were added quite liberally. Occasionally food items such as noodles, spaghetti and rice were also consumed. With the exception of iron and thiamin the nonprivileged consumed a diet that was, on the average, inadequate in all nutrients (Table 2). The average daily protein and energy intake in the group was below 60% of the
and
observed
Weight, kg
Age,
Grou p
Mean
PREGNANCY
range
Height. cm
I ncome, Eth. Se/month
Mean
Range
Mean
Range
Mean
Range
18.3 23.4
16-27 20-30
58.0 58.8
47-66 48-67
157.7 157.3
152-162 150-164
range.
Eth,$
100
=
US
$ 49.
Mean
42 1160
% Literacy
Range
4-100 650-2,500
5.0 100.0
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urine, with normal blood pressure and with no clinical signs of acute on chronic disease were selected consecutively. Twenty nonpnivileged and ten privileged women were studied. Age, anthropometnic and socioeconomic data of the subjects are presented in Table I. All but one in the nonpnivileged group were illiterate and had.never attended any school, fourteen in this group were housewives, two were housemaids, three were ban girls, and one woman did not specify occupation. Half of the subjects in the privileged group were college graduates and the rest had completed at least secondary school. Eight were professionals (four nurses and four secretanies) and two were housewives. The socioeconomic status of the privileged group could be considered representative of a relatively small elite whereas that of the nonpnivileged group reflects the condtion of a sizable proportion of Ethiopian women (18). Both groups studied consisted of the four main ethnic groups of highland Ethiopia. They were all interviewed around the beginning of the third trimester and had no regular antenatal cane.
IN
GEBRE-MEDHIN
I324
5’
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Discussion
5)
.
l-
FAO/WHO Recommendations (Fig. I). The privileged group on the other hand, displayed a considerably higher mean intake for all nutrients and with the exception of calcium and riboflavin was found to meet the recommendations. With the exception of iron and thiamin between 17 and 19 of the 20 women in the nonprivileged group were found to have a level of intake that was below 80% of the FAO/WHO Recommendations (Fig. 2). For energy, protein, riboflavin, niacin and ascoric acid, about 10 scored below 40% of the recommendations. Except for calcium and riboflavin only I or 2 privileged women displayed a level of intake below 80% of the recommendations for any given nutrient. For vitamin A 6 were found to have a level of intake below 80% and 7 below 40% of the recommendation. Nearly 97% of the protein and over 80% of the energy in the diet of the nonprivileged subjects were of plant origin (Tables 3 and 4). Almost no protein of animal origin was consumed by this group and only 10% of the energy was derived from fat. In the privileged group 45% of the protein was obtained from animal sources and nearly 25% of the energy was derived from fat. In both groups starch dominated clearly with glucose and sucrose as negligible sources of carbohydrates (Table 5). Vegetable oil, of which 78% was derived from safflower accounted for all the fat consumed by the nonprivileged group. In contrast to this, 37% of the total fat in the diet of the privileged group consisted of vegetable fat and 14% of this was derived from safflower oil. Despite the supposed dietary deficiencies of the nonprivileged group no clinical signs of nutritional deficiency were observed. Half of the nonprivileged and all ten of the privileged women were delivered in a hospital or maternity center after an uneventful pregnancy. One infant in the privileged group was stillborn. The birth weights of the newborns from both groups are presented in Fig. 3.
5,3
0
811
GOBEZIE
e
The question tion of findings
of validity of the is a well-known
interpretaproblem
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/11/1322/4732877 by Boston University user on 11 January 2019
rC
o
-
.H
AND
DIETARY
120 110 1 c:
INTAKE
IN
I 325
PREGNANCY
p
1,
p
p
‘I
80 70
60 50 30 20 I0 0 .
bL.1111i1uii niacin
0 FIG.
equivaLent
R
nonprivit.eged I. Percentage
of adequacy
not
of tryptophan
of energy
and
nutrients
inherent in surveys designed to compare nutrient intake of different population groups. In this study the choice of well-defined socioeconomic groups of apparently healthy, young primigravidae in the third trimester of pregnancy may be expected to produce valid results. Dietary information was obtained from a weighing-inventory survey conducted during 2 consecutive days. This method was adopted as a result of the study of published experiences from elsewhere which indicate that, in areas where dietary patterns are monotonous, the first 2-4 days provide practically all the information of a 7-day survey (26, 27) and that the diet of the individual primigravida remains very similar in two widely separated weeks (28). Recent analysis of data from several surveys at the Ethiopian Nutrition Institute seems to confirm these observations (unpublished observations). In both the groups studied the main meal consisted of the typical highland Ethiopian items “injera” and “wot.” “Injera” prepared from the cereal teff, has proved to be a unique source of dietary iron (29, 30). the exceedingly high iron intake of the Ethiopian highh&.nd population, discussed at length by Hofvander (29), contributes to the striking rarity of nutritional anemia among highland Ethi-
I
considered
privi’eged compared
with
FAO/WHO
recommendations.
opians, including pregnant women (31, 32). Teff has a higher iron content than any other cereal. In addition, a considerable amount of iron-containing particles adhere to the teff seeds during the traditional process of threshing but the availability ofthe iron is low (29). The difference between the two groups resides in the ingredients added to the “wot.” In the privileged group this abounds in animal protein, fat and vegetables with riboflavin and calcium the only nutrients below the recommendations. The nonprivileged group, however, add almost no animal protein or fresh vegetables and over 80% of all energy was derived from carbohydrates. The calcium intake in both groups was very low because of the scarcity of milk and its products. Satisfactory adaption to lower 1evels of calcium intake has been convincingly demonstrated in man (33). A habitually low intake of this mineral does not appear to be deleterious to man, neither does an increase result in clinically detectable benefits (34). The deficiency in vitamins and minerals would have been greater had allowances for losses during food preparation and cooking been made. In both groups starch was the main source of energy and even in the privileged refined sugars were consumed in very limited quan-
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90
GEBRE-MEDHIN
I 326
3of
n
AND
GOBEZIE
%of n
Vitamin
Energy
100
80 60 40
4O4O
1%
rLrIrI
., adequacy
80%etodequacy
RibofLavin
Calcium ‘3’
‘3, 40 20’ ‘0
#{163}0.10 >80’.
at adequacy
80%
40-80
Ascorbic
ot adequacy
80%
of tryptophan
of adequacy not
80 ‘3
40 20
LI
80%
of subjects Three classes
0
nonprivileged
U
priviLeged
at adequacy
consuming of adequacy:
different 80.
and
nutrients
compared
with
3
Percentage
of energy Group
Nonpnivileged Privileged
derived Cereals 65.5 41.2
from
different Legumes 16.1 4.1
food
sources Fats
Fruits and vegetables
10.7 24.7
l.I 4.2
tities generally confined to the addition of sugar (sucrose) to tea or coffee. Although generous quantities of meat and butter were contained in the diet of the privileged group,
Sugar
Roots
Others
1.1 1.2
1.2 2.5
4.3 22.0
Total 100.0 100.0
only 25% of their energy was derived from fat. This may be due to the fact that Ethiopian meat has a mean fat content of about 1.3% (19), whereas the United States stan-
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iii
IL
20
A
DIETARY TABLE
distribution
of protein
Group
from
animal
Animal
protein
Nonpnivileged
PREGNANCY
and
plant
I 327
Plant
roots,
TABLE S Percentage distribution
of carbohydrate Glucose
Nonpnivileged Privileged
legumes
58.2
33.8
cereals
legumes
35.8
9.0
SS.2
Lactose
Starch
Fructose
S 7
Sucrose I 2
2
3800
.1:
3Z0 S
#{149}1#{149}
280C
nonprivileged n=10, Meon=3110 SD ±245
S
*
privileged
n=9
240C 3. Distribution
of birth
others
8.0
00.0 100.0
others 100.0
sources
4
FIG.
cereals
54.3
4400
2X
100.0
etc.
Group
360C
Total
weights
Mean=3580 S D ± 305 of hospital
born
infants.
dard grade meat contains 21% and prime grade meat 41% fat (35). In the face of such widely divergent levels of nutrient intake one would have expected marked differences in body weight or other anthropometric data between the two groups, but this was not the case. It is conceivable that both groups of women had similar nutritional experiences during early childhood resulting in permanent stunting of growth. It is more difficult to find an explanation for the similarity in the mean weights. Possibly the nonprivileged group had just a marginal energy supply before conception
2
94 87
Total 100.0 100.0
which could still cover basic needs at the beginning of the third trimester whereas the privileged group easily responded to increasing demand, maybe even with excess intake. From this point of view it would have been interesting to have access to dietary as well as anthropometric data for the two groups both in pre- or early pregnancy period and at the very end of the gestation period. One wonders also whether the possibility of increased water retention should be considered, especially in view of the low protein content of the diet of the nonprivileged group which, in addition, might have been used in part for energy needs. Judging from the birth weights alone, it would seem that in the nonprivileged group the fetus has suffered from the effect of undernutrition during gestation. The newborns in this group would seem to be characterized by intrauterine growth retardation (Fig. 3). Further investigation is needed to throw more light on this important public health issue in Ethiopia. Summary The dietary intake during the third trimester of pregnancy among 20 nonprivileged and 10 privileged primigravidae in Addis Ababa was studied in a 2 day weighing-inventory survey. With the exception of iron and thiamm, the nonprivileged group consumed a
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fruits,
protein
97.3
45.7
Vegetables,
34X
sources
2.7
Privileged
i
IN
4
Percentage
a
INTAKE
GEBRE-MEDHIN
1328
AND
diet that was deficient in all nutrients, with an average daily protein and energy intake below 60% of the FAO/WHO Recommendations.
The privileged
group
was found
Kebkabe in interviewing the mothers and in the dietary calculations. The collaboration of the staff at the Ethiopian Nutrition Institute and the Lideta Maternal and Child Health Demonstration and Training Centre is gratefully acknowledged.
References Committee
on
Nutrition
National Defense. Ethiopia-Nutrition Washington, D. C.: U.S. Govt. Printing 1959. 2. SLl.1NLs, R., A. GoBIzli:, K. E. KNL’TSSON VAHLQLIST.
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1962. A. K. pregnancy
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Bost. Effect on obstetrical
of low nutrient performance
J. Clin. Nutr. Il: 586, 1962. M. N. SLSSER. Low birth weight and prenatal nutrition: an interpretative review. Pediatrics 46: 946, 1970. IS. Committee on Maternal Nutrition/Food and Nutnition Board, National Research Council-National Academy of Sciences. Maternal nutrition and the course of pregnancy: summary report. U.S. Dept. of Health, Education and Welfare, Rockville, Md., 1970. 16. LEcIITIG, A., i-P. HABICIIT, E. LEoN AND G. 14.
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BERGNER,
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GUZMAN.
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de Ia nutnicion
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sobre
el
crecimento fetal en poblaciones rurales de Guatemala. II. Supplementacion Alimentania. Arch. Latinoamer. Nutn. 22:1 17, 1972. 17. Statistical Abstract. Imp. Ethiopian Govt. Centr. Stat. Off., Addis Ababa, 1971, p. 140. 18. Statistical Abstract. Imp. Ethiopian Govt. Centr. Stat. Off., Addis Ababa, 1971, p. 120. 19. AGREN, G., ANI) R. GIBsoN. Food Composition Table for Use in Ethiopia. Swedish Intern. Develop. Authority, 1968. 20. Food and Agriculture Organization. Food Composition Table for Use in Africa. Washington, D. C.: U.S. Dept. Health, Education Welfare, 1968. 21.
dietary
pattern among the Rift Valley Ansi Galla. Am. J. Clin. Nutr. 24: 365, 1971. StI.1NLS, R., G. AwAI.o1 ANt) A. GoaizlF. Dietary studies in Ethiopia. II. Dietary pattern in two rural communities in N. Ethiopia. A study with special attention to the situation in young children. Acta Soc. Med. Upsal. 76: 17. 197l. Sut.1NLs, R., A. GoBEzii ANI) B. VA1H.QLIST. Dietany studies in Ethiopia. III. Dietary pattern among the Sidamo ethnic group. A study of villagers in the enset monoculture area in S. Ethiopia with special attention to the situation in young children. Acta Soc. Med. Upsalien. 76:158, 1971. CATiPoic A. Address presented at the Eighth Annual Conference of the Ethiopian Medical Association. Addis Ababa, 1972. HoFv,\NlR, Y. A survey of 3000 children examined at the “ Mobile Child Health Centre” in Addis Ababa in 1962. Ethiopian Med. J. 1:156, 1963. Y0UN(,, P. N. Birth weights of hospital-delivered infants in Addis Ababa and Gondar. Ethiopian Med. J. 6:15, 1968. LARSSON, U. Mimeographed Ann. Report. Lidetta Mother and Child Health Demonstration and Training Centre, Addis Ababa. 1969. GEBRI-MEliiiN, M., S. GuRovsk\ Al) L. BoNuisTAM. Association of maternal age and parity with birth weight, sex ratio, stillbirths and multiple births in an Ethiopian sample. To be published. GEBR-MEuiii’, M. Body weight at birth of viable infants from non-privileged and privileged women in Addis Ababa, Ethiopia. To be published. GoPAI..;N, C. Effect of nutrition on pregnancy and lactation. Bull. World Health Organ. 26: 203. 1962.
26:193,
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Report of a joint FAO/WHO Ad Hoc Expert Committee: Energy and protein requirements. World Health Organ. Tech. Rept. Sen. no. 522, Rome, I973. Report ofjoint FAO/WHO Expert Group: Calcium Requirements. World Health Organ. Tech. Dept. Sen. no. 230, Geneva, 1962. Report of a joint FAO/WHO Expert Group: Requinements of vitamin A, thiamine, riboflavin and niacin. World Health Organ. Tech. Rept. Sen. no. 362, Geneva, 1967. Report of a joint FAO/WHO Expert Group: Vita-
mm and mineral
requirements.
Food
Agni.
Organ.
U.N. Nutn. Newsletter 7:3, 1969. 25. Amino acid content of foods and biological data on proteins. Food Agni. Organ. U.N., Rome, 1968. 26. CELLI1R, K. M., ANI) M. E. HANKIN. Studies on nutrition in pregnancy. I. Some considerations in collecting dietary information. Am. J. Clin. Nutn. 13: 55, 1963. 27. LECIITIG, A., i-P. HABIcIIT, E. LEoN, G. GLZMAN AND M. FLORES. Influencia de Ia nutnicion materna sobre el cnecimiento fetal en poblaciones nunales de Guatemala. I. Aspectos Dieteticos. Arch. Latinoam. Nutr. 22: 101, 1972. 28. THoisoN, A. M. Diet in pregnancy: I. Dietary survey technique and the nutritive value of diets taken
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by pnimignavidae. Bnit. J. Nutn. 12: 446, 1958. Y. Hematological investigations in Ethiopia with special reference to high iron intake. Acta Med. Scand. Suppl. 494, 1968. ALMGARD, G. High content of iron in tef, Enagnostis abyssinica link, and some other crop species from Ethiopia - a result of contamination. Ann. Agni. Coil. Sweden 29: 215, 1963. GEBR-MEIIiIN, M., ANt) B. VAIIL.QLIST. Serum HOFVANL)ER,
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We wish to express our sincere thanks to Professor Bo Vahlquist for valuable guidance and encouragement through all the stages of the study and to Professor Goran Stenky for his advice during preparation of the manuscript. We are indebted to Dr. Sam Ross for allowing us to interview his patients and to Woizenit
its effect
Organ. 13.
P. S. Maternal nutritional on the newborn. Bull. World
VENKATACI-JALAM,
and
to meet the
recommendations for all nutrients except for calcium and riboflavin. Infants born to the nonprivileged women had significantly lower mean birth weight when compared with the infants born to the privileged women.
I . Interdepartmental
12.
GOBEZIE
DIETARY iron,
32.
binding
capacity,
folate
and vitamin
IN
B,2 in
pregnancy: a study of non-privileged women in Addis Ababa, Ethiopia. To be published. Ross, S. M. Haemoglobin and haematocnit values in pregnant women on high iron intake and living at a high altitude. J. Obstet. Gynaecol. Bnit. Commonwealth 79:1103, 1972. MALM. 0. 5. Calcium requirement and adaptation in adult men. Scand. J. Clin. Lab. Invest. 10: Suppl. 36,
PREGNANCY
1329
1958.
34.
A. R. P. The human requirement should low intakes be supplemented? Nutn. 25:518, 1972. 35. WATT, B. K., AND A. L. MERRIE.. Composition Foods-Raw, Processed, Prepared. Agr. Res. Handbook No. 8, U.S. Dept. Agn. Washington, C.: U.S. Govt. Printing Office, 1963. WALKER,
calcium: J. Clin.
of Am. of Serv. D.
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33.
iron
INTAKE
