Associations between mothers' use of food to soothe, feeding mode, and infant weight during early infancy.

Weight status and rate of weight gain in the first six months postpartum are strong predictors of later obesity; thus, infant feeding practices are an important target for obesity prevention efforts. The use of food to soothe (FTS) is associated with less-favorable eating habits and weight outcomes for older infants and children. However, few studies have examined correlates of use of FTS during early infancy. The primary aim of this cross-sectional study was to explore associations between use of FTS and infant weight status in the first 6 months postpartum. A secondary aim was to identify the combination of maternal and infant characteristics that predicted use of FTS. Mothers of infants aged 6 months or younger (N = 134) completed questionnaires assessing use of FTS, bottle-feeding intensity (i.e., percentage of daily feedings from bottles versus directly from the breast), levels of responsive and pressuring feeding styles, dimensions of infant temperament and eating behaviors, and family demographics. Dyads were observed during feeding to assess maternal sensitivity to infant cues and responsiveness to infant distress and infant clarity of cues and responsiveness to the mother. Infant weight and length at study entry were assessed by a trained research assistant. Use of FTS was not associated with infant weight for age z-score (WAZ), even when bottle-feeding intensity was considered as a moderator. More frequent use of FTS was predicted by the combination of greater levels of pressuring feeding style (p = .005) and infant temperamental negative affectivity (p = .001), and lower levels of infant temperamental surgency/extraversion (p = .018). In conclusion, use of FTS was associated with dimensions of infant temperament and maternal feeding style, but not with WAZ during early infancy.

Nutrition Screening, Reported Dietary Intake, Hospital Foods, and Malnutrition in Critical Care Patients in Malawi.

In low-income countries there are few data on hospital malnutrition. Reduced food intake combined with nutrient-poor foods served in hospitals contribute to nutritional risk. This study investigated whether reported dietary intake and disease state of hospitalized adults in critical care units was related to malnutrition determined by mid-upper arm circumference (MUAC). Adult in-patients (n = 126) in tuberculosis, burn, oncology, and intensive care units in two public tertiary hospitals in Malawi were screened for nutritional status using MUAC and a question on current dietary intake. The hospital menu was reviewed; portion sizes were weighed. The prevalence of moderate and severe malnutrition was 62%. Patients with organ-related diseases and infectious diseases had the highest rates of reduced reported dietary intake, 71.4% and 57.9%, respectively; however, there was no association between reported dietary intake and MUAC. In those unable to eat, however, the rate of severe malnutrition was 50%. The menu consisted of porridge and thickened corn-based starch with fried cabbage; protein foods were provided twice weekly. There was a nutrient gap of 250 calories and 13 gm protein daily. The findings support the need for increasing dietetic/nutrition services to prevent and treat malnutrition in hospitals using simple screening tools.

Effect of Nutritional Interventions on Micronutrient Status in Pregnant Malawian Women with Moderate Malnutrition: A Randomized, Controlled Trial.

Micronutrient deficiencies during pregnancy are common in Africa and can cause adverse outcomes. The objective was to measure micronutrient status and change in moderately malnourished pregnant Malawian women randomized to one of three nutritional interventions. Serum vitamin B12, 25-hydroxyvitamin D, folate, retinol, ferritin, zinc, albumin and C-reactive protein were measured in pregnant women with MUAC ≥20.6 cm and ≤23.0 cm at enrollment (n = 343) and after 10 weeks (n = 229) of receiving: (1) ready-to-use supplementary food (RUSF); (2) fortified corn-soy blend (CSB+) with multiple-micronutrient supplement (CSB+UNIMMAP); or (3) CSB+ with iron and folic acid (CSB+IFA). Each provided 100⁻300% Recommended Dietary Allowance of most micronutrients and 900 kcal/day. Birth length was measured in 272 infants. Enrollment measurements indicated deficiencies in vitamin B12 (20.9%) and zinc (22.3%), low values of ferritin (25.1%) and albumin (33.7%), and elevated CRP (46.0%). Vitamin B12 is known to decrease in the third trimester; the RUSF group had the smallest decrease from enrollment to week 10 (3%), compared to 20% decrease in the CSB+IFA group and 8% decrease in the CSB+UNIMMAP group (p = 0.001). Mean serum 25-hydroxyvitamin D increased most in the RUSF group (+6.4 ng/mL), compared to CSB+IFA (+1.7 ng/mL) and CSB+UNIMMAP (+2.7 ng/mL) (p < 0.001). Micronutrient deficiencies and inflammation are common among moderately malnourished pregnant women and had little improvement despite supplementation above the RDA, with the exception of vitamins B12 and D.

Adolescent pregnancy and nutrition: a subgroup analysis from the Mamachiponde study in Malawi.

Young age at childbearing (≤19 years) is common and associated with poor birth outcomes. A trial among Malawian pregnant women with moderate malnutrition was used to determine outcomes of young adolescents (≤18 years), older adolescents (18-20 years), and adults (>20 years). Women received one of three supplementary foods that provided ∼900 kcal/day and 33-36 g protein/day and returned every 2 weeks. Newborn/maternal measurements were taken at delivery and after 6 and 12 weeks. Upon enrollment, adolescents had greater body mass index than adults (19.9 ± 1.3 versus 19.5 ± 1.4 kg/m2 , P < 0.001). Young adolescents received more rations of food and enrolled and delivered with a lower fundal height than adults (21.7 ± 5.2 versus 23.0 ± 5.6, P = 0.00 enrollment; 30.2 ± 3.1 versus 31.0 ± 2.8, P < 0.001 delivery). Among newborns, length for age was lowest in young adolescents, greater in older adolescents, and greatest in adults (Z-scores -1.7 ± 1.2, -1.4 ± 1.2, and -1.1 ± 1.1, respectively; P < 0.001). These differences persisted in length for age at 6 and 12 weeks of age for infants. Adolescents enrolled earlier in pregnancy and appeared more nutritionally adequate than adults; adolescent outcomes were inferior to those of adults, suggesting that they were subject to more physiologic stressors and/or different nutritional needs.

Trial of ready-to-use supplemental food and corn-soy blend in pregnant Malawian women with moderate malnutrition: a randomized controlled clinical trial.

Background: Malnutrition during pregnancy in sub-Saharan Africa is associated with poor birth outcomes. Objective: This study compared maternal and offspring anthropometry for moderately malnourished pregnant women receiving ready-to-use supplemental food (RUSF), a fortified corn-soy blend (CSB+) with a daily multiple micronutrient antenatal supplement [United Nations International Multiple Micronutrient Preparation (UNIMMAP)], or standard of care comprising CSB+ and iron and folic acid (IFA). Design: A single-blind randomized controlled clinical trial was conducted in southern Malawi among 1828 pregnant women with moderate malnutrition, defined as a midupper arm circumference (MUAC) ≥20.6 and ≤23.0 cm. Women received 1 of 3 dietary treatment regimens that provided ∼900 kcal/d and 33-36 g protein/d. Maternal and infant anthropometry were followed until the child was 3 mo old. Results: Newborns had a mean length-for-age z score of -1.3 ± 1.2 and 22% were stunted at birth. Mothers receiving RUSF had the highest weight gain during supplementation (3.4 ± 2.6, 3.0 ± 2.2, and 3.2 ± 2.4 kg for the RUSF, CSB+ with UNIMMAP, and CSB+ with IFA groups, respectively; P = 0.03). Newborn birth weights and lengths were similar across intervention groups, but the incidence of newborns with a birth weight <2.4 kg (weight-for-age z score <-2) was higher in the CSB+ with UNIMMAP group than the other groups (17%, 18%, and 24% for the CSB+ with IFA, RUSF, and CSB+ with UNIMMAP groups, respectively; P = 0.02). At birth, HIV-exposed newborns had a similar length and weight as newborns without HIV exposure, but their head circumference was smaller (34.0 ± 1.5 and 34.3 ± 1.6 cm, respectively; P = 0.02). At 3 mo of age, HIV-exposed infants had smaller weights, lengths, and head and arm circumferences than infants without HIV exposure. Conclusions: RUSF improved maternal weight gain compared with CSB+ with UNIMMAP. The large amount of food given and the modest effect on linear growth in newborns suggests that stunting in utero is unlikely to be reduced by supplemental food alone. This trial was registered at clinicaltrials.gov as NCT02120599.

How maternal malnutrition affects linear growth and development in the offspring.

Maternal malnutrition is common in the developing world and has detrimental effects on both the mother and infant. Pre-pregnancy nutritional status and weight gain during pregnancy are positively related to fetal growth and development. Internationally, there is no agreement on the method of diagnosis or treatment of moderate or severe malnutrition during pregnancy. Establishing clear guidelines for diagnosis and treatment will be essential in elevating the problem. Possible anthropometric measurements used to detect and monitor maternal malnutrition include pre-pregnancy BMI, weight gain, and mid upper arm circumference. Food supplements have the potential to increase gestational weight gain and energy intake which are positively associated with fetal growth and development. Overall more studies are needed to conclude the impact of food/nutrient supplements on infant growth in undernourished pregnant women in developing countries. Currently, a study underway may provide much needed documentation of the benefits of treating malnutrition in pregnancy.

Food fortification improves the intake of all fortified nutrients, but fails to meet the estimated dietary requirements for vitamins A and B6, riboflavin and zinc, in lactating South African women.

OBJECTIVE: To investigate the impact of fortification by comparing food records and selected biochemical indicators of nutritional status pre- and post-fortification. DESIGN: Mean intake from 24 h recalls (n 142) was compared with the Estimated Average Requirement (EAR) to determine the proportion with inadequate intake. In a subsample (n 34), diet and serum retinol, folate, ferritin and Zn were compared pre- and post-fortification for fortified nutrients vitamin A, thiamin, riboflavin, niacin, folic acid, Fe and Zn. SETTING: South Africa. SUBJECTS: Breast-feeding women (ninety-four HIV-infected, forty eight HIV-uninfected) measured at ~6, 14, 24 weeks, and 9 and 12 months postpartum. RESULTS: Pre-fortification, >80 % of women did not meet the EAR for vitamins A, C, D, thiamin, riboflavin, niacin, B6, B12 and folate and minerals Zn, iodine and Ca. Dietary intake post-fortification increased for all fortified nutrients. In post-fortification food records, >70 % did not meet the EAR for Zn and vitamins A, riboflavin and B6. Serum folate and Zn increased significantly post-fortification (P < 0.001 for both), with no change in ferritin and a reduction in retinol. Post-fortification marginal/deficient folate status was reduced (73.5 % pre v. 3.0 % post; P < 0.001), as was Zn deficiency (26.5 % pre v. 5.9 % post; P < 0.05). Pre- and post-fortification, >93 % were retinol replete. There was no change in Fe deficiency (16.7 % pre v. 19.4 % post; P = 0.728). CONCLUSIONS: Micronutrient intake improved with fortification, but >70 % of lactating women did not meet the EAR for Zn, vitamins A, riboflavin and B6. Although 100 % exceeded the EAR for Fe after fortification, Fe status did not improve.

Micronutrient status during lactation in HIV-infected and HIV-uninfected South African women during the first 6 mo after delivery.

BACKGROUND: Little information on the micronutrient status of HIV-infected (HIV-positive) breastfeeding women is available. OBJECTIVE: The objective was to compare the protein and micronutrient status of South African breastfeeding women by HIV status. DESIGN: Serum albumin, prealbumin, vitamin B-12, folate, retinol, alpha-tocopherol, hemoglobin, ferritin, and zinc concentrations were compared between 92 HIV-positive and 52 HIV-uninfected (HIV-negative) mothers 6, 14, and 24 wk after delivery. C-reactive protein and alpha1-acid glycoprotein were used as proxy indicators of an inflammatory process. RESULTS: Mean albumin and prealbumin were significantly lower in HIV-positive mothers, and a higher proportion of HIV-positive mothers had low albumin concentrations (< 35 g/L). Less than 45% of the mothers were vitamin B-12 or folate sufficient. Significantly more HIV-positive (70.5%) than HIV-negative (46.2%) mothers had marginal vitamin B-12 status (P < 0.05), and mean folate concentrations were lower in HIV-positive mothers (P = 0.05). Mean serum retinol was significantly lower in HIV-positive mothers, even after control for the acute phase response. At 24 wk, 70% of both groups had an alpha-tocopherol deficiency (< 11.6 micromol/L), but no significant difference by HIV status was observed. More HIV-positive (33.3%) than HIV-negative (8.7%) mothers had anemia (P = 0.018), whereas 25% of all mothers had low serum ferritin concentrations. After the acute phase response was controlled for, zinc deficiency was more common in HIV-positive (45.0%) than in HIV-negative (25.0%) mothers (P = 0.05). CONCLUSIONS: Deficiencies in vitamins B-12, folate, alpha-tocopherol, ferritin, and zinc are common in South African breastfeeding mothers. HIV-positive mothers had lower mean serum concentrations of albumin, prealbumin, folate, retinol, and hemoglobin than did HIV-negative mothers.

Body composition changes during lactation in HIV-infected and HIV-uninfected South African women.

BACKGROUND: The nutritional consequences of HIV infection in lactating women are unknown. OBJECTIVE: To measure the body composition of South African lactating women in relation to HIV status. METHODS: Fat-free mass (FFM) and fat mass (FM) using bioimpedance spectrometry (BIS) and anthropometric measurements were obtained at 8 and 24 weeks postpartum in 92 HIV-infected (HIVpos) and 50 HIV-uninfected (HIVneg) lactating mothers. RESULTS: At 8 weeks, HIVpos and HIVneg mothers were not significantly different in height (159.7 vs. 158.9 cm), weight (62.7 vs. 63.9 kg), body mass index (BMI; 24.6 vs. 25.3 kg/m), FFM (40.7 vs. 42.8 kg), or FM (21.6 vs. 22.0 kg), respectively. In HIVpos women, the median CD4 count was 621 (range: 101-1585) cells/muL; 95% had CD4 counts >200 cells/muL. Between 8 and 24 weeks, HIVpos mothers had a mean weight loss of 1.4 kg in contrast to a 0.4-kg weight gain in HIVneg mothers (P < 0.01). There were no significant group differences with regard to change in FFM (0.3 vs. 0.1 kg; P = 0.9) and FM (-1.5 vs. -0.3 kg; P = 0.2). CONCLUSION: HIVpos South African breast-feeding mothers without severe immune suppression lost weight and subcutaneous fat between 8 and 24 weeks postpartum, whereas HIVneg mothers gained weight. FFM was maintained postpartum in HIVpos and HIVneg mothers.

Comparison of isotope dilution with bioimpedance spectroscopy and anthropometry for assessment of body composition in asymptomatic HIV-infected and HIV-uninfected breastfeeding mothers.

BACKGROUND: The effect of breastfeeding on the nutrition of HIV-infected (HIV+) mothers is unknown. Simple, valid methods are needed for body-composition assessment of HIV+ women. OBJECTIVE: We compared the ability of bioimpedance spectroscopy (BIS) and anthropometry with that of isotope dilution (2H2O) to measure fat-free mass (FFM) and fat mass (FM) in HIV+ and HIV-uninfected (HIV-) breastfeeding South African mothers. DESIGN: Total body water (TBW) content of 68 lactating mothers (20 HIV+, 48 HIV-) was measured 10 wk after delivery by using BIS and 2H2O to measure FFM and FM. Anthropometric measurements included body mass index (BMI; in kg/m2), midupper arm circumference (MUAC), and 4 skinfold thicknesses. RESULTS: TBW, FFM, and FM measurements determined by BIS were correlated with 2H2O measurements in HIV+ (r = 0.664, 0.621, and 0.872, respectively; P < 0.01) and HIV- (r = 0.876, 0.868, and 0.932, respectively; P < 0.001) mothers. TBW measured by BIS was greater than that measured by the 2H2O method in both HIV+ (1.8 L) and HIV- (1.5 L) women; FM or FFM did not differ significantly by method. BMI, MUAC, and all skinfold-thickness measurements correlated strongly (r > 0.62, P < 0.001) with FM measured by 2H2O in both groups. BMI and MUAC correlated (r > 0.64, P < 0.001) with FFM in HIV- mothers but not in HIV+ mothers. CONCLUSIONS: In HIV+ and HIV- breastfeeding mothers, BIS provides an estimate of body composition comparable to that obtained with the 2H2O method. BMI and MUAC are useful in predicting FM in both groups but are not valid measures of FFM in HIV+ mothers.