Maternal Nutrition, Body Composition and Gestational Weight Gain on Low Birth Weight and Small for Gestational Age-A Cohort Study in an Indian Urban Slum.

Maternal nutritional status and care during pregnancy are essential for adequate birth weight. In this prospective cohort study (N = 1061) in an urban slum, we investigated the association of maternal anthropometry, body composition, gestational weight gain and dietary intakes with low birthweight (LBW, <2.5 kg). About one-third of the women were short (<150 cm), 35% were underweight (<45 kg), 23% suffered from chronic energy deficiency (CED, BMI < 18.5 kg/m2) and another 30% were overweight/obese. The mean age and BMI were 23 years and 21.7 kg/m2, respectively, and haemoglobin was 10.73 g/dL. The mean birthweight (N = 605) was 2.81 ± 0.5 kg, and the average gestational age was 38 ± 2 weeks. About 15% of infants had LBW, and 48% were small for gestational age (SGA). Maternal body composition was assessed by skinfold thickness (SFT) in all trimesters. In the first trimester (N = 762), we found that mean fat-free mass (FFM), fat mass (FM) and body fat percentage (% BF) were 38.86 kg, 11.43 kg and 21.55%, respectively. Low birthweight was significantly associated with preterm deliveries (p < 0.001) and less fat free mass (p = 0.02) in the third trimester. Among other factors were age (p = 0.017), maternal anthropometry (height: p = 0.031; weight: p = 0.059) and fewer antenatal check-ups (p = 0.037). Small size (SGA) was consistently associated with maternal bodyweight at all trimesters (term I, p = 0.013, term II, p = 0.003 and term III, p < 0.001), fat mass in the third trimester (p < 0.001) and maternal height (p = 0.003).

Serum dehydroepiandrosterone and lipid peroxides in human volunteers of different age groups.

The objective of the present study was to evaluate the changes in serum dehydroepiandrosterone (DHEA) and lipid peroxide levels during ageing in human subjects. Random blood samples were collected from a total of 128 apparently normal human volunteers of both sexes, whose age ranged between 21-70 years. The subjects were divided into groups of a decade years of age difference. Serum levels of dehydroepiandrosterone (DHEA), lipid peroxides as malondialdehyde (MDA), and insulin were analysed in all the subjects recruited in the study. In the present study there was decrease in serum DHEA levels with age (11.30 to 7.99 ng/ml). However the differences were significant only after 50 years up to 70 years. Serum MDA levels of these subjects were higher (3.91 to 4.74 ng/ml) as compared to the values reported earlier (2.64 to 3.94 ng/ml). The serum MDA levels also showed an increasing trend with age but the increase was significant only in the 40-50 years age group and values plateaud off at later ages. The MDA and DHEA levels in women in general were lower than in men and this could be due to female hormones, which are known to protect lipid against peroxidation. There was a significant negative correlation between age and DHEA (r=-0.311 P<0.05) and positive correction between MDA and age (r=+0.405 P<0.01). No significant differences were seen in serum insulin, albumin and total protein levels. These preliminary findings support the possible utility of DHEA and MDA as markers for chronological ageing.

Socioeconomic status and prevalence of toxoplasmosis during pregnancy.

Two hundred and thirty-six women with previous bad obstetric history (BOH), belonging to different socio-economic groups were investigated for the presence of Toxoplasma specific antibodies (IgG/IgM) using commercial diagnostic kits. The study showed a higher percentage of IgG seropositivity in women of low socioeconomic group (LSG) compared to those of high socioeconomic group (HSG). Specific IgM positivity indicative of possible acute infection, was higher in women of HSG, emphasizing the need for educating pregnant mothers on preventive measures. However, there is a need to undertake in-depth studies to understand the significance of the presence of IgM in women with BOH.

Red palm oil supplementation: a feasible diet-based approach to improve the vitamin A status of pregnant women and their infants.

This double-blinded, randomized, controlled study was designed to study the effect of dietary supplementation with red palm oil during pregnancy on maternal and neonatal vitamin A status. A total of 170 women were recruited at 16 to 24 weeks of gestation and randomly assigned to an experimental group that received red palm oil to supply approximately one recommended dietary amount (RDA) (2,400 micrograms) of beta-carotene or to a control group that received an equivalent volume of groundnut oil. The women received the oils for a period of 8 weeks, starting at 26 to 28 weeks of gestation and extending to 34 to 36 weeks of gestation. The mean postintervention (34 to 36 weeks) levels of serum retinol were 1.20 +/- 0.22 (SD) mumol/L (95% CI, 1.15-1.25) in women receiving red palm oil and 0.73 +/- 0.15 mumol/L (95% CI, 0.69-0.77) in their infants; these levels were significantly higher than those in women receiving groundnut oil (1.07 +/- 0.26 mumol/L; 95% CI, 1.01-1.13; p < .01) and their infants (0.62 +/- 0.17 mumol/L; 95% CI, 0.57-0.67; p < .001). A significantly lower proportion of women in the red palm oil group than in the control group had vitamin A deficiency (serum retinol levels < 0.7 mumol/L) after intervention (1.5% vs. 9.7%). The proportion of women having anemia was significantly lower (p < .01) in the red palm oil-supplemented group (80.6%) than in the control group (96.7%). The mean birthweight and gestational age of the infants did not differ significantly between the two groups. An increased risk of low birth-weight (p = .003) and preterm delivery (p = .000) was observed with decreasing serum retinol levels in the third trimester of pregnancy. These results show that red palm oil supplementation significantly improved maternal and neonatal vitamin A status and reduced the prevalence of maternal anemia. Maternal vitamin A status in the later part of pregnancy is significantly associated with fetal growth and maturation. Hence red palm oil, a rich source of bioavailable vitamin A, could be used as a diet-based approach for improving vitamin A status in pregnancy.

Effects of vitamin A deficiency during pregnancy on maternal and child health.

OBJECTIVE: To examine the association between biochemical vitamin A deficiency in pregnancy and maternal and fetal health. DESIGN: A cross sectional clinical study. SETTING: Antenatal clinic of nutrition unit of Niloufer Hospital catering for a low socio-economic population, and a private nursing home (Swapna nursing home) catering for a high socio-economic population. POPULATION: 736 pregnant women in their third trimester of pregnancy belonging to low (n = 522) and high socio-economic groups (n = 214). METHODS: All the women were subjected to a detailed clinical, anthropometric and obstetric examination. Night blindness was assessed by administering the standard WHO questionnaire. Birthweight and gestational age of the infants, maternal anaemia and development of pregnancy-induced hypertension in the mother were recorded. Haemoglobin and serum retinol were estimated at the time of recruitment to the study. MAIN OUTCOME MEASURES: Serum retinol levels, anaemia, pregnancy-induced hypertension, birthweight and gestational age of the infant. RESULTS: Night blindness was observed in 2.9% of the women and subclincal vitamin A deficiency (serum retinol <20 microg/dL with no clinical signs) in 27% of the women. Moderate to severe anaemia was observed in 41.2% of the women, and 15.8% of the women developed pregnancy-induced hypertension. Sixty-one (9.4%) women delivered preterm. Univariate analysis identified a significant association between serum retinol <20 microg/dL and preterm delivery (OR = 1.74, 95% CI 1.03-2.96), maternal anaemia (OR = 1.82, 95% CI 1.28-2.60) and pregnancy-induced hypertension (OR = 1.56, 95% CI 1.02-2.83). After adjusting for the confounding variables (body mass index, parity, age and socio-economic status) in a multivariate analysis, the significant associations between serum retinol <20 microg/dL and preterm delivery (P = 0.02) and anaemia (P = 0.003) persisted, while that for pregnancy-induced hypertension disappeared (P = 0.71). CONCLUSION: The study suggests that subclinical vitamin A deficiency is a problem during the third trimester of pregnancy. Serum concentration of retinol <20 microg/dL appears to indicate a deficient status, and is associated with an increased risk of preterm delivery and maternal anaemia.

Prevalence of specific IGM due to toxoplasma, rubella, CMV and c.trachomatis infections during pregnancy.

One hundred and seventy five apparently normal asymptomatic pregnant women were studied prospectively and 247 women with different complications of pregnancy were screened at the time of delivery for infections like Chlamydia trachomatis, Toxoplasma, Rubella and cytomegalovirus (CMV). One hundred and forty two women with normal outcome of pregnancy served as controls. Specific IgM due to these agents were determined in the sera using commercial diagnostic kits. Results of the study showed that chlamydial infection was the most prevalent (29.8%) followed by Toxoplasmosis (13.1), Rubella (6.5%) and CMV (5.8%). Adverse outcome was seen among those seropositive for Chlamydia, Toxoplasmosis and Rubella. CMV showed no association with adverse outcome of pregnancy. Since Chlamydia and Toxoplasmosis are amenable to treatment with antibiotics, screening for these infections and appropriate treatment would improve outcome of pregnancy.

A new approach to differentiate recent vs chronic Toxoplasma infection: avidity ELISA in Toxoplasma serology.

The diagnosis of toxoplamosis during pregnancy is based on maternal serology, due to the asymptomatic nature of the disease. Detection of specific IgM although is the method used all over the world to detect acute infection, persistence of IgM for long periods poses problems in distinguishing acute from chronic infection, which is of crucial importance in pregnancy. Avidity ELISA is a method recently developed to distinguish IgG antibodies developed at an early stage of infection from those that reflect past immunity. The avidity assay uses protein-denaturing agents and is a modification of an ELISA. The usefulness of this technique was tested on sera of 113 pregnant women screened for Toxoplasma specific IgG/IgM antibodies. Nine of the sixteen sera positive for IgM/IgG antibodies and three sera positive for IgG alone were subjected to avidity ELISA. Only three sera were positive for low avidity IgG indicative of recent infection. All the three sera positive for IgG alone showed high avidity.

Effect of pyridoxine or riboflavin supplementation on plasma homocysteine levels in women with oral lesions.

BACKGROUND: A moderate increase in plasma homocysteine level has been reported to be involved in neural tube defects, which can be prevented with folic acid supplementation. Folic acid, vitamins B6- and B12-dependent enzymes are required to metabolize homocysteine. A study in rats showed higher tissue homocysteine levels in riboflavin as well as pyridoxine deficiency. We studied the effect of treatment with pyridoxine or riboflavin on plasma total homocysteine concentration in women with clinical and biochemical deficiencies of riboflavin and pyridoxine. METHODS: Plasma total homocysteine concentrations were measured in 20 women with glossitis and angular stomatitis before and after supplementation with pyridoxine or riboflavin. RESULTS: Pyridoxine treatment significantly reduced plasma homocysteine concentration while riboflavin treatment did not have a significant effect. CONCLUSIONS: Plasma total homocysteine levels tended to be higher in women with clinical and biochemical deficiency of vitamin B6 and therapy with pyridoxine reduced its level significantly. Riboflavin supplementation did not have a significant impact on plasma homocysteine concentration in women with glossitis and angular stomatitis.

Antithrombin III levels in pregnancy induced hypertension.

BACKGROUND: Antithrombin III deficiency is common as well as severe in both consumptive coagulopathy and conditions such as pregnancy induced hypertension. We determined antithrombin III levels in women suffering from pregnancy induced hypertension to determine its usefulness in assessing severity of the disease and outcome. METHODS: Forty-five pregnant women with mild and severe forms of pregnancy induced hypertension and 18 women with normal pregnancies matched for gestational age formed the study population. Fasting blood samples were collected and the plasma separated. Antithrombin III levels were estimated by the kinetic Berichrom antithrombin III method. RESULTS: The mean (SD) antithrombin III levels [0.76 (0.233) IU/ml] were significantly lower in pregnancy induced hypertension compared to the control group [0.97 (0.234) IU/ml]. Low antithrombin III and high diastolic blood pressure (> 110 mmHg) were related to poor pregnancy outcome in primigravidae. CONCLUSION: Mean antithrombin III levels were lower in pregnancy induced hypertension compared to a control group of women especially those who were primigravidae and had a diastolic blood pressure > 110 mmHg. Since low antithrombin III levels and a high diastolic blood pressure result in adverse pregnancy outcome monitoring of antithrombin III levels in pregnancy induced hypertension may help in assessing foetal jeopardy.

Iron nutritional status of preschool children.

Low hemoglobin and low MCHC levels were indicative of high incidence of iron deficiency in preschool children. The extent of iron deficiency as assessed by serum ferritin and free erythrocyte protoporphyrin showed a different trend. While FEP levels were highly suggestive of extensive iron deficiency (in 40-45% of children below the age of 5 years), low serum ferritin was seen in only 16-20% of children. The discrepant finding of high serum ferritin, and high erythrocyte protoporphyrin despite low MCHC in the present study, possibly reflects iron deficiency status along with chronic infection resulting in hyperferritinemia and hyperprotoporphyrinemia. It may be also due to associated folate deficiency resulting in non utilization of iron leading to the elevated levels of protoporphyrin.

Need for protection against rubella in India.

Reports from different parts of India highlight the existence of Rubella leading to fetal malformations and wastage. However, the need for routine immunization to control rubella has not been duly recognized. In the present study the prevalence of rubella was determined in different age groups of the population by estimating IgG antibodies to rubella virus using ELISA kit obtained from Diamedix. Two hundred and seventy four pairs of maternal blood samples were collected. Samples were also obtained from one hundred and thirty nine children aged 1-15 years and assayed for rubella antibodies. The sample was read as positive if the Elisa unit/ml was 15 EU/ml. The results showed that 94.9% of mothers and 94.1% of cord blood samples showed seropositivity. Children between 1 and 5 years showed the lowest seropositivity of 69.2% which gradually increased to reach near 95% levels by 15 years. These observations indicate the prevalence of rubella in children and thus suggest the need to protect susceptible women of reproductive age group.

Enzymatic evaluation of riboflavin status of infants.

Riboflavin status of solely breast-fed (SBF) infants aged 1-6 months (study 1) and solely or partially breast-fed (PBF) and weaned infants aged 6-24 months (study 2) was examined by the erythrocyte glutathione reductase activation test. Maternal riboflavin status and milk riboflavin content were also measured in study 1. Riboflavin status of the infants was significantly superior to that of their mothers. However, 35 per cent of SBF infants examined suffered from biochemical riboflavin deficiency as judged by the glutathione reductase test. Supplementary feeding of 6-8-month-old infants and weaning of older infants had positive effect on riboflavin status. There was no obvious relationship between riboflavin status and anthropometric status. Milk riboflavin concentration was comparable or only slightly lower than values reported for Western women, despite marked deficiency in the mothers.

PIP: Researchers compared the riboflavin status of 55 solely breast fed (SBF) 1-6 month old infants with 112 SBF, partially breast fed (PBF), or weaned 6-24 month old infants from low income families in India. They measured in vitro activation of erythrocyte glutathione reductase with its coenzyme FAD in blood samples from 6-12 month old infants and both the 1-6 month old infants and mothers to determine riboflavin status. They also analyzed the fore milk for riboflavin concentration. The riboflavin status of the 1-6 month old SBF infants was much greater than that of the mothers especially beginning with 3 month old infants (p.001-.02). Yet 35% of SBF 1-6 month old infants were biochemically deficient in riboflavin. In the 1st 2 months postpartum, however, the mothers had particularly good riboflavin status. The milk riboflavin level for SBF 1-6 month old infants peaked at 2 (26.9 mcg/dl) and 4 months (28.6 mcg/dl). It stood at 20 mcg/dl for 1 month old SBF infants. It fell from 18-14.3 mcg/dl between 5-6 months. The riboflavin status of 6-8 month old PBF infants stood greater than that of SBF 6-8 month old infants (p.001). Moreover 12 of the 29 (41%) 6-8 month old SBF infants were considered to be riboflavin deficient. No 6-8 month old infant was completely weaned. After 8 months, riboflavin status fell in PBF infants. In addition, the poorest infants (monthly family incomes of Rs500) had a much lower riboflavin status than the more privileged infants. The more privileged mothers (Rs 500) tended to begin supplemental feeding earlier than poorer mothers. The most significant finding was the beneficial effects of supplementary feeding on riboflavin status in 6-8 month old infants. Scientists suspect that riboflavin deficiency affects psychomotor functions and impairs collagen maturity and wound healing.

Pharmacokinetics of norethisterone from two different combination contraceptive pills in Indian women.

In view of our previous studies that the plasma elimination of norethisterone (NET) from mini pill is faster in low socio-economic group Indian women, the present studies were contemplated to find the least effective dosage of NET from combination pills. Pharmacokinetics of NET were evaluated in a total of twenty women of low socio-economic group taking pills containing NET-acetate (500 micrograms or 1 mg) and ethinyl estradiol (30 or 50 micrograms respectively) on empty stomach. Blood samples were drawn at different time intervals from 0.5 to 24 hr and plasma NET was estimated by a specific radio-immunoassay. In the women taking 1 mg NET-acetate containing pills peak plasma levels ranging from 6.2 to 20.8 ng/ml were observed at 1 hr whereas with 500 micrograms pill they ranged from 2.0 to 6.5 ng/ml and the peak was noted at 4 hr. Pharmacokinetic parameters of NET were more or less comparable between the two pills. The results suggest that pills containing 500 micrograms NET-acetate and 30 micrograms ethinyl estradiol provide adequate levels of NET even in low-socio-economic group women.

PIP: In view of the previous studies that determined that the plasma elimination of norethisterone (NET) from the minipill is faster in low socioeconomic bracket Indian women, the present studies were undertaken to find the least effective dosage of NET from combination pills. Pharmacokinetics of NET were evaluated in a total of 20 low socioeconomic women who were taking pills containing NET-acetate (500 mcg or 1 mg) and ethinyl estradiol (30 or 50 mcg respectively) on empty stomachs. Blood samples were drawn at different time intervals from 0.5-24 hours and plasma NET was estimated by a specific radioimmunoassay. In the women taking 1 mg NET-acetate containing pills peak plasma levels ranging from 6.2-20.8 ng/ml were observed at 1 hour whereas with the 500 mcg pills, they ranged from 2.0-6.5 ng/ml and the peak was noted at 4 hours. Pharmacokinetic parameters of NET were more or less comparable between the 2 pills. The results suggest that pills containing 500 mcg NET-acetate and 30 mcg ethinyl estradiol provide adequate levels of NET even among low socioeconomic women.

Reduced anaerobic glycolysis in oral contraceptive users.

Oral contraceptives containing combinations of estrogens and progestogens are known to impair glucose tolerance. The biochemical mechanisms underlying this lesion are speculative. In the present study women treated with OC for periods exceeding 10 cycles showed significant reduction in the activity of the key glycolytic enzyme phosphofructokinase (40%) and the levels of lactate (42%) in the erythrocytes compared to controls. These observations in women are analogous to those made earlier in female rats.

PIP: Combined oral contraceptives (30 mg ethinyl estradiol, 150 mg d-norgestrel) are known to reduce glucose tolerance. To study the possible mechanisms of this impairment, 20 women were divided into 3 groups based on length of contraceptive use -- 3-5 months, 6-11 months, and 12-36 months. Blood samples were analyzed for phosphofructokinase activity and levels of glycolytic metabolites. Changes in glucose tolerance are seen within 3-6 months of oral contraceptive use, but only the blood taken from the 3rd group (12-36 months) showed significantly lower levels of phosphofructokinase activity and lowered levels of fructose-1,6-diphosphate, lactate, and pyruvate. It is suggested that impaired glucose tolerance is due to reduced glycolysis due to lower levels of phosphofructokinase synthesis, which cannot be detected for at least a year in erythrocytes, since they do not synthesize the enzyme.

Relationship between maternal vitamins B2 and B6 status and the levels of these vitamins in milk at different stages of lactation. A study in a low-income group of Indian women.

Riboflavin and vitamin B6 status of mothers from a low-income group were assessed by erythrocyte glutathione reductase activation and erythrocyte aspartate aminotransferase activation tests respectively, at different stages of lactation. Levels of these vitamins in milk were also measured. The majority of the women had biochemical evidence of vitamins B2 and B6 deficiency. There was a bizarre reduction in erythrocyte glutathione reductase activation from 6 to 30 d post partum. Levels of riboflavin in milk were in general satisfactory, but vitamin B6 levels were lower than the values reported from developed countries. Clear-cut correlations between the enzymatic indices of vitamin status evaluation and milk levels of the corresponding vitamins were not apparent.

PIP: Riboflavin and vitamin B6 status of low-income mothers in Hyderabad, India, were assessed by erythrocyte glutathione reductase activation and erythrocyte aspartate aminotransferase activation tests, respectively, at different stages of lactation. Levels of these vitamins in milk also were measured. The 134 lactating women, who attended a maternal and child care clinic in a government hospital, were divided according to the duration of lactation into the following 6 groups: less than 5 days (Group I), 6-30 days (Group II), 1-6 months (Group III), 7-12 months (Group IV), 13-18 months (Group V), and more than 18 months (Group VI). 6 women had been using oral contraceptives (OCs) for 3-6 months (Group VII). Since OCs are not prescribed before 8 months of lactation, the lactational status of the OC users was comparable to that of the women in groups IV or V. Except for the pariurient mothers (Group I) who delivered in the hospital, the remainder of the women came to the hospital for routine pediatric care or contraceptive advice. Most women had had a frugal breakfast and had nursed their infants 2 hours prior to the sampling of blood and milk. 10 ml samples of foremilk (5 ml from each breast) were collected by manual expression. Samples of venous blood were draw after collecting the milk. Correlations between the maternal vitamin status and milk vitamin concentration were assessed by Pearson's correlation coefficient and frequency distribution. The majority of the women had biochemical evidence of riboflavin and pyridoxine deficiency, the incidence of the former being greater than the latter. Prolonged lactation did not worsen the vitamin status. Group II women showed a reduction in erythrocyte glutathione reductase activity (EGR-AC) values suggesting better riboflavin status than the other groups. A similar trend was not seen with regard to pyridoxal phosphate. Milk riboflavin concentration was similar in all the groups except Group II where the levels were significantly higher. Milk pyridoxine concentration increased 3-4 fold after 1 month of lactation and continued to be at that level beyond 18 months. There was no correlation between the maternal riboflavin and milk riboflavin status or maternal pyridoxine and milk pyridoxine status. The higher milk riboflavin concentration among the Group II women was seen regardless of the women's riboflavin status in that group. OC-treated women did not show any significant deviations from women not using OCs.

Immune status of anaemic pregnant women.

Immune status during the third trimester of pregnancy was investigated in relation to maternal haemoglobin levels. The proportion of T and B lymphocytes showed a tendency to fall in anaemic women which was significant when haemoglobin levels were less than 8 g/dl. Immunoglobin G showed the opposite trend. There were no alterations in phytohaemagglutinin-induced lymphocyte transformation in relation to haemoglobin concentration.

Nutrition--fertility interaction in lactating women of low income groups.

1. Duration of lactational amenorrhoea and interpregnancy interval were related to maternal body-weight in an urban low-income group population of 2250 women. 2. Breast-feeding practices were similar in all the women, none of whom had received any nutritional intervention. 3. In the study group the mean duration of lactation, lactational amenorrhoea and interpregnancy interval (months) were 20.7, 11.2 and 24.2 respectively. 4. Mean duration of lactation was significantly shorter in women whose body-weights were over 55 kg. Duration of lactational amenorrhoea increased with increasing duration of lactation (r 0.5164). 5. The duration of lactational amenorrhoea showed a progressive fall with increasing body-weight (r --0.8139) even when duration of lactation was kept constant. 6. The mean duration of post-partum amenorrhoea in women who did not lactate remained unaltered irrespective of body-weight. 7. The findings suggest that maternal nutritional status modifies return of menstruation only in lactating women.