The overlap of overweight and anaemia among women in three countries undergoing the nutrition transition.

OBJECTIVE: To compare the odds of anaemia in overweight and obese (OVWT) (body mass index (BMI) > or =25) versus non-overweight (non-OVWT) (BMI<25) women in three countries at different stages of the nutrition transition. DESIGN: Analysis of cross-sectional data. SETTING: Nationally representative data from Mexico (1998 National Nutrition Survey), Peru and Egypt (2000 Demographic and Health Surveys) were analyzed. SUBJECTS: Data from non-pregnant women ages 18-49 years were used. ANALYSIS: Logistic regression was used to test whether the odds of anaemia differed by BMI category, controlling for sociodemographic factors. RESULTS: More than half of the women were OVWT in all three countries and the prevalence of OVWT reached 77% in Egypt. Anaemia prevalence was similar across countries (28, 31 and 23% in Egypt, Peru and Mexico respectively). In Egypt, OVWT women had significantly lower odds of anaemia than non-OVWT women (OR=0.78, 95% CI: 0.68, 0.90). Similar results were found in Peru, but the difference was smaller in magnitude (OR=0.83, 95% CI: 0.71, 0.96). In Mexico, there were no differences in the odds of anaemia by BMI group. CONCLUSIONS: These findings show that the iron needs of OVWT women in developing countries are not necessarily being met. The intakes of other micronutrients might also be insufficient. Diet quality remains an important issue even among women with sufficient energy intakes.

Poor maternal schooling is the main constraint to good child care practices in Accra.

Life in urban areas presents special challenges for maternal child care practices. Data from a representative quantitative survey of households with children < 3 y of age in Accra, Ghana were used to test a number of hypothesized constraints to child care including various maternal (anthropometry, education, employment, marital status, age and ethnic group) and household-level factors (income, availability of food, quality of housing and asset ownership, availability of services, household size and crowding). Three care indices were created as follows: 1) a child feeding index; 2) a preventive health seeking index; and 3) a hygiene index. The first two indices were based on data from maternal recall; the hygiene index was based on spot-check observations of proxies of hygiene behaviors. Multivariate analyses (ordinary least-squares regression for the child feeding index and ordered probit for the two other indices) showed that maternal schooling was the most consistent constraint to all three categories of child care practices. None of the household-level characteristics were associated with child feeding practices, but household socioeconomic factors were associated with better preventive health seeking and hygiene behaviors. Thus, poor maternal schooling was a main constraint for child feeding, health seeking and hygiene practices in Accra, but the lack of household resources was a constraint only for health seeking and hygiene. The programmatic implications of these findings for interventions in nutrition education and behaviors in Accra are discussed.

Precision, accuracy, and reliability of hemoglobin assessment with use of capillary blood.

BACKGROUND: Previous research has suggested that there may be significant within-subject variability, both site-to-site and over time, in hemoglobin concentrations in capillary blood. OBJECTIVE: This study examined the reliability of the portable hemoglobinometer (PHM) system with use of capillary blood and the implications of errors of the magnitude found for the classification of anemia status in individuals and population groups. The precision and accuracy of the method with use of venous blood were also tested. DESIGN: Three empirical data sets were used to measure reliability, precision, and accuracy of the PHM system [2 from Honduras (n = 87 and 141); 1 from Bangladesh (n = 73)]. Simulation data were used to assess the implications of errors for screening individuals for anemia and to estimate anemia prevalence. RESULTS: High within-subject variability (unreliability) was identified when capillary blood from the left hand was compared with that from the right hand (CV: 6.3%) and when measurements were taken on 4 consecutive days (CV: 7.0%). Reliability was only 69% and 50%, respectively. Precision and accuracy, however, were very high (concordance coefficients of 0.99 and 0.98 and CV < 1%). CONCLUSIONS: The simulation data showed that errors of the magnitude found due to unreliability can lead to misclassification of anemia status in individuals and small biases in anemia prevalence estimates. We recommend replicate sampling to reduce the influence of unreliability in the use of the PHM system with capillary blood.

Plant breeding: a long-term strategy for the control of zinc deficiency in vulnerable populations.

Because trace minerals are important not only for human nutrition but for plant nutrition as well, plant breeding holds great promise for making a significant, sustainable, low-cost contribution to the reduction of micronutrient deficiencies in humans. It may also have important spinoff effects for increasing farm productivity in developing countries in an environmentally beneficial way. This article describes ongoing plant breeding research that could increase the intake of bioavailable zinc from food staple crops in vulnerable populations in developing countries. The 3 most promising plant breeding strategies toward this goal are as follows: 1) increasing the concentration of zinc, 2) reducing the amount of phytic acid (a strong inhibitor of zinc absorption), and 3) raising the concentrations of sulfur-containing amino acids (thought to promote zinc absorption) in the plant. The agronomic advantages and disadvantages as well as the potential benefits and limitations of each approach for human nutrition are described. Research is currently underway to identify the optimal combination of these approaches that will maximize the effect on human zinc nutrition.

Zinc supplementation improves the growth of stunted rural Guatemalan infants.

The impact of zinc supplementation on the growth and body composition of Guatemalan infants was assessed in a community-based, double-blind intervention trial. Infants aged 6-9 mo were assigned randomly to receive 4 mL of a beverage containing 10 mg of zinc as zinc sulfate (n = 45) or a placebo (n = 44) daily (7 d/wk) for an average of 6.9 mo. The children's weight, length, mid-upper arm and head circumferences, and triceps skinfolds were measured at baseline and at 1-2 mo intervals until the end of supplementation. Midarm muscle area (MMA) was derived from the mid-upper arm circumference and triceps skinfolds measurements. Maternal anthropometry and family socioeconomic and demographic characteristics also were obtained. Zinc supplementation was associated with an overall increase of 0.61 cm2 in MMA (P = 0.02). Children who received zinc supplements had a mean length increment that was 0.75 cm greater than those who did not (P = 0.12). However, there was a significant interaction between treatment group and initial length-for-age status (P = 0.04), such that supplemented children who were stunted at baseline (length-for-age Z score less than -2) gained 1.40 cm more than stunted children who received the placebo. We conclude that zinc supplementation of these rural Guatemalan infants during 6. 9 mo increased accretion of fat-free mass and enhanced the linear growth of those who were stunted at baseline. Further research is required to determine whether zinc supplementation during longer periods of time may achieve larger and more generalized effects on physical growth.

Vitamin B-12 deficiency is very prevalent in lactating Guatemalan women and their infants at three months postpartum.

Vitamin B-12 status was evaluated in 113 Guatemalan women and their infants at 3 mo of lactation. Plasma vitamin B-12 was deficient or low in 46.7% of the mothers, and holotranscobalamin II (holo TC II) concentrations were low in 32.3%, which may indicate vitamin B-12 malabsorption. Only 9% had deficient or low plasma folate. Breast milk vitamin B-12 was low in 31%, and negatively correlated with infant urinary methylmalonic acid (UMMA, r = -0.22, P < 0.05, n = 88); UMMA was elevated in 12.2% of the infants, indicating vitamin B-12 deficiency. Mothers of the infants with elevated UMMA had significantly lower concentrations of vitamin B-12 in their breast milk compared with mothers of infants with normal UMMA concentrations (410.7 +/- 247.7 vs. 705.3 +/- 487.5 pmol/L, P = 0.05, n = 87). Mean maternal dietary intake of vitamin B-12 was significantly correlated with plasma vitamin B-12 (r = 0.20, P = 0. 05, n = 94) and was the main determinant of plasma vitamin B-12 in a linear regression model. Determinants of maternal holo TC II concentrations included dietary intake of vitamin B-12 and Giardia lamblia infection. There were no statistically significant determinants of infant UMMA concentrations. We conclude that vitamin B-12 deficiency is highly prevalent in these lactating women and is associated with depletion of the vitamin in their infants. The cause of the maternal deficiency is unknown, but malabsorption exacerbated by low dietary intake of the vitamin is a possibility.

PIP: This study evaluated vitamin B-12 status in 113 Guatemalan women and their infants at 3 months of lactation. Findings revealed that plasma vitamin B-12 was deficient or low in 46.7% of the mothers and that holotranscobalamin II (holo TC II) concentrations were low in 32.3%, which may indicate vitamin B-12 malabsorption. Only 9% had deficient or low plasma folate. Breast milk vitamin B-12 was low in 31% and negatively correlated with infant urinary methylmalonic acid (UMMA). UMMA was elevated in 12.2% of the infants, indicating vitamin B-12 deficiency. Mothers of the infants with elevated UMMA had significantly lower concentrations of vitamin B-12 in their breast milk compared with mothers of infants with normal UMMA concentrations. Mean maternal dietary intake of vitamin B-12 was significantly correlated with plasma vitamin B-12 and was the main determinant of plasma vitamin B-12 in a linear regression model. Determinants of maternal holo TC II concentrations included dietary intake of vitamin B-12 and Giardia lamblia infection. There were no statistically significant determinants of infant UMMA concentrations. This study concludes that vitamin B-12 deficiency is highly prevalent in these lactating women and is associated with the depletion of the vitamin in their infants. The cause of the maternal deficiency is unknown, but malabsorption, exacerbated by low dietary intake of the vitamin, is a possibility.

Zinc supplementation affects the activity patterns of rural Guatemalan infants.

Zinc deficiency has been associated with growth deficits, reduced dietary intake and appetite, and has been hypothesized to result in reduced activity. This randomized, double-blind, placebo-controlled study examined whether 10 mg of oral zinc as zinc sulfate, given daily for up to 7 mo, affected activity patterns of 85 Guatemalan infants recruited at 6-9 mo of age. Infant activity was assessed by time sampling-observation method at 10-min intervals during a 12-h data collection period, at base line, 3 and 7 mo follow-up. Motor development and the percentage of time infants were observed in various positions (being carried, lying down, sitting, crawling, standing or walking) and engaged in various activities (eating, sleeping, resting, crying/whining or playing) were compared by treatment group. No differences in motor development were observed by treatment group. However, at follow-up 2 (after 7 mo of supplementation), zinc-supplemented infants were significantly more frequently observed sitting up compared with lying down, and were playing during 4.18 +/- 1.95% (P < 0.05) more observations than unsupplemented infants. They were also somewhat less likely to be observed crying or whining (P < 0.10) compared with those receiving the placebo. These effects are independent of other factors including infant age, motor development, sex, maternal education, family socioeconomic status and nutritional status at base line. Further research must be conducted to determine the long-term developmental importance of these differences in activity patterns associated with zinc supplementation in this setting.

Impact of zinc supplementation on morbidity from diarrhea and respiratory infections among rural Guatemalan children.

OBJECTIVE: A community-based, randomized, double-blind intervention trial was conducted to measure the impact of zinc supplementation on young Guatemalan children's morbidity from diarrhea and respiratory infections. METHODS: Children aged 6 to 9 months were randomly assigned to receive 4 mL of a beverage containing 10 mg of zinc (as zinc sulfate) daily (7 d/wk) for 7 months (n = 45) or a placebo (n = 44). Morbidity data were collected daily. Diagnoses of diarrhea, fever, and anorexia were based on mothers' definitions. Respiratory infections were defined as the presence of at least two of the following symptoms: runny nose, cough, wheezing, difficulty breathing, or fever. RESULTS: High rates of diarrhea and respiratory infections were reported. Children from the placebo group had a 20% episodic prevalence of diarrhea, with 8 episodes/100 d, and a 7% episodic prevalence of respiratory infections, with 3 episodes/100 d. The median incidence of diarrhea among children who received zinc supplementation was reduced by 22% (Wilcoxon rank test), with larger reductions among boys and among children with weight-for-length at baseline lower than the median of the sample (39% reductions in both subgroups). Zinc supplementation also produced a 67% reduction in the percentage of children who had one or more episodes of persistent diarrhea (chi2 test). No significant effects were found on the episodic prevalence of diarrhea, the number of days per episode, or the episodic prevalence or incidence of respiratory infections. CONCLUSIONS: The large impact of zinc supplementation on diarrhea incidence suggests that young, rural Guatemalan children may be zinc deficient and that zinc supplementation may be an effective intervention to improve their health and growth.

Dietary studies in countries experiencing a health transition: Mexico and Central America.

Several countries, including Mexico, are experiencing changes in health patterns that are characterized by an increase in the prevalence of chronic diseases and changes in the principal causes of death, coexisting with deficiencies in the intake of energy and micronutrients, particularly in children. Several factors may explain these changes, including dietary habits. To evaluate food consumption in a population undergoing a health transition, a food-frequency questionnaire was developed, validated, and used to study the dietary determinants of chronic diseases in Mexico. Nutrient deficiency and the relation between maternal child-feeding behaviors and dietary intake by the child were evaluated with use of 24-h recalls, food-frequency methods. and estimation of food intake by observation. The observation method was extremely useful for studies in rural areas.

Validation of single daytime samples of human milk to estimate the 24-h concentration of lipids in urban Guatemalan mothers.

The large within- and between-sample variability in breast milk lipid content greatly complicates the collection of representative samples in field studies. The main purpose of this study was to validate the ability of individual daytime samples to predict the 24-h lipid concentration of breast milk. We also studied maternal, child, and other factors (time of day and interval between feeds) associated with the within- and between-mother variability in milk lipid content. Fifty-two primiparous urban Guatemalan women between 1 and 4 mo postpartum were studied. Milk samples were collected during six 2-h intervals from 0600 to 1800, and throughout the night when the child breast-fed. On average, the 24-h pooled milk samples contained 4.2 +/- 0.92% (mean +/- SD) lipids and the best concordance with this value was obtained with samples collected between 0600 and 0800 (concordance correlation coefficient = 0.60, P < 0.05). None of the regression equations to predict the 24-h lipid content of breast milk based on daytime samples reached a sufficiently high predictive power to be recommended for the estimation of individual child intake. Time of day and time elapsed since the last feeding were significant determinants of diurnal variations in milk lipid content, whereas between-mother variability was explained by maternal weight (P = 0.05) and body mass index (P < 0.05). For the collection of milk samples in surveys and pre-post studies, we recommend standardization of time of day and interval between feeds.

Growth retardation starts in the first three months of life among rural Guatemalan children.

OBJECTIVE: We tested the hypothesis that growth faltering in rural Guatemala starts earlier than between 3-6 months of life, as generally assumed. METHODS: The sample included children from the INCAP longitudinal trial (1969-1977), who had adequate birth weight (> -1 s.d.) (n = 79). Two groups were formed according to weight-for-age (WAZ) at 3 y: Group A: WAZ < -2 s.d. (growth-retarded), and Group B: WAZ > or = -2 s.d. Weight increments were computed and sex- and gender-specific deficits in weight increments from 0-36 months were calculated by comparing values of the WHO/CDC reference data. For the period between 0-12 months, weight increments were also compared to velocity standards: (1) the Fels data and (2) the WHO growth curves for breast fed infants. RESULTS: At 3 y of age, growth-retarded children were 3.6 kg smaller than the WHO/CDC median. Depending on the reference data used, between 19 and 34% of the deficit at 3 y of age was due to failure to thrive during the first 3 months of life, an additional 12-19% occurred between 3 and 6 months and 12-25% between 6 and 9 months. By 12 months of age, infants had accumulated 45-80% of their total deficit in weight at 3 y of age. Compared to group B, children from group A had greater morbidity during their first 9 months of life, and their mothers had poorer nutritional status at 3 months postpartum. There were indications that children from group A came from more deprived families. CONCLUSIONS: Growth faltering starts soon after birth in rural Guatemala and thus, effective interventions should be targeted to mothers and their infant as early as possible during the first year.

Screening for nutrition interventions: the risk or the differential-benefit approach?

The risk approach has been promoted to improve screening for nutrition interventions on the premise that indicators of risk also predict greater response to interventions. This study tested whether the determinants of the risk of poor growth (eg, low length-for-age) at 36 mo of age were the same as the determinants of differential benefit from food supplementation. The sample included 460 Guatemalan children who were exposed to either a high-energy, high-protein drink (atole) or a low-energy, no-protein drink (fresco) during their first 36 mo of life [INCAP (Institute of Nutrition of Central America and Panama) supplementation trial]. Low maternal stature, poor socioeconomic status, inadequate home diet, high diarrhea rates, and low anthropometry scores at 3 or 6 mo were all determinants of the risk of poor growth. Only indicators of child's thinness at 3 or 6 mo of age (low weight-for-age, weight-for-length, or midupper arm circumference) were determinants of differential benefit from supplementation. Thus, the development of screening indicators should be based on analyses of the predictors of differential benefit, not on conventional risk-factor analysis.

Length screens better than weight in stunted populations.

Stunting (low length-for-age) is the most widespread manifestation of growth retardation worldwide. Yet, most nutrition programs use weight-for-age for screening of at-risk children. This study tested whether weight-for-age was an effective screening tool in a severely stunted rural Guatemalan population, using data from the INCAP longitudinal supplementation trial (n = 400). Stunting was defined as length-for-age < -2 SD of the National Center for Health Statistics standards at 3 y of age. Sensitivity and specificity analyses and receiver operating characteristics curves were used to compare weight indicators (weight-for-age, weight velocity and weight-for-length) with length (length-for-age and length velocity) and arm and head circumferences measured during early infancy. Length indicators were clearly superior to weight in predicting stunting (Zda test), and velocities were consistently worse than attained growth. Length-for-age at 6 mo had the best performance, followed by length-for-age at 3 mo, and weight-for-age at 6 and at 3 mo. Velocities, weight-for-length and circumferences were all poor predictors of stunting. Using the cutoff of < -1 SD, length-for-age at 3 mo was the best screening indicator for the early detection of growth faltering. Thus, the current use of weight-for-age, which results in large proportions of at-risk children being missed by screening, greatly limits the potential for impact of nutrition interventions.

Age differences in the impact of nutritional supplementation on growth.

Supplementary feeding programs are common in developing countries. These programs often cannot demonstrate an impact on child growth, however, possibly because they tend to reach older children. This study examines the impact of nutritional supplementation on annual growth rates in length and weight from birth to 7 y of age in 1208 rural Guatemalan children. A series of multiple linear regression models is used to control for initial body size, diarrheal disease, home diet, socioeconomic status and gender. During the first year of life, each 100 kcal/d (418 kJ) of supplement was associated with approximately 9 mm in additional length gain and 350 g in additional weight gain; the benefit decreased to approximately 5 mm in length gain and 250 g in weight gain during the 2nd y of life. Between 24 and 36 mo of age, supplement only had a significant impact on length. There was no impact of nutritional supplementation on growth between 3 and 7 y of age. Patterns were the same if supplement intakes were expressed as a percent of recommended allowances or growth was expressed as a percent of the expected rate. These impacts of nutritional supplementation on growth coincide with the ages when growth velocities, as well as growth deficits, are greatest in this population.

Nutritional supplementation during the preschool years influences body size and composition of Guatemalan adolescents.

Effects of supplementary feeding during early childhood on body size and composition at adolescence are examined in a population with marked growth failure in the first 3 y of life. The data came from a supplementation trial conducted in rural Guatemala from 1969 to 1977 and a 1988-89 follow-up study of the same subjects at adolescence. Two pairs of villages participated in the trial. One village from each pair received a high protein-energy supplement (Atole), which significantly improved dietary intakes, whereas the other village of the pair received a low-energy, no-protein supplement (Fresco), which did not impact appreciably on dietary intakes. Children from Atole villages grew better during the preschool period than children from Fresco villages. At adolescence, subjects from Atole villages were taller, weighed more and had greater fat-free masses than subjects from Fresco villages. Differences in height at adolescence were slightly reduced in magnitude relative to differences at 3 y of age. However, differences in weight were increased in adolescence relative to 3 y of age.

Differential response to early nutrition supplementation: long-term effects on height at adolescence.

BACKGROUND: The classical risk approach to predicting who benefits from an intervention is unsound because it relies on the theoretical assumption that those at risk will necessarily benefit. A better approach to systematically test who benefits from nutrition supplementation is proposed using interactive models. METHODS: Differential effects of nutrition supplementation during early childhood on stature at adolescence were studied in 245 males and 215 females to identify determinants of long-term benefit from food supplementation. Factors studied included family socioeconomic status (SES) and children's home diet and diarrhoea during the first 3 years of life. To determine whether a factor conferred benefit, the statistical significance of the interaction between this factor and the intervention was tested. Data from the INCAP supplementation trial in Guatemala and from the follow-up of the same subjects at adolescence were used. RESULTS: Ordinary least squares (OLS) showed that high rates of diarrhoea in males and poor SES in females were significant determinants of benefit from supplementation at adolescence, and that the effects were mediated by length at 3 years old. Results of two-stage least squares (2SLS) analysis showed that length at 36 months, maturation and maternal height were significant determinants of height at adolescence but SES was not. CONCLUSIONS: Nutrition supplementation in early childhood has long-lasting effects on body size and the larger benefits acquired by some groups of children remain throughout early adulthood. The relevance of these findings for screening and targeting of nutritional interventions is discussed.

PIP: Differential effects of nutrition supplementation during early childhood on stature at adolescence were studied in 245 males and 215 females, 14-20 years old, who had been exposed to either a high-calorie, high-protein drink (Atole) in 2 villages or a low-calorie, non-protein drink (Fresco) in 2 other villages from birth to 3 years of age in order to identify determinants of long-term benefit from food supplementation. Factors studied included family socioeconomic status (SES), children's home diet, and diarrhea during the first 3 years of life. To determine whether a factor conferred benefit, the statistical significance of the interaction between this factor and the intervention was tested. Data from the Institute of Nutrition of Central America and Panama (INCAP) supplementation trial in Guatemala and from the follow-up of the same subjects at adolescence were used. In women differences between the groups were significant only for length at 36 months and height at adolescence. In males length at 36 months was statistically greater among the Atole group, but height in adolescence was not. Ordinary least squares (OLS) showed that high rates of diarrhea in males and poor SES in females were significant determinants of benefit from supplementation at adolescence, and that the effects were mediated by length at 3 years old. Male children who benefited from the supplementation were those with more diarrhea in early infancy. The difference in length at 36 months was 3.03 cm in favor of the Atole group compared to 0.98 cm for the groups with less diarrhea. 2-stage least squares analysis showed that length at 36 months, maturation, and maternal height were significant determinants of height at adolescence but SES was not. Nutrition supplementation in early childhood has long-lasting effects on body size, and the larger benefits acquired by some groups of children remain throughout early adulthood.

Growth charts only marginally improved maternal learning from nutrition education and growth monitoring in Lesotho.

A study done in Lesotho in 1985-1986 assessed whether growth charts increased the impact of nutrition education and growth monitoring on maternal learning about weaning practices and diarrhea. Seven hundred and seventy six mothers were given three monthly sessions of group nutrition education along with growth monitoring of children and individual counseling. Growth charts, which were taught to one of two groups, fostered learning but only on issues related to diarrhea and only among new clinic attendants, mothers with less than secondary schooling and mothers of malnourished children. These benefits, however, were small (differences less than 10%) compared with the overall impact of the nutrition education and growth monitoring intervention (increases between baseline and post-intervention were greater than 50% for some questions). Our findings suggest that well-designed clinic-based nutrition education and growth monitoring can have a significant impact on maternal nutrition knowledge. Teaching growth charts to mothers may not be necessary for obtaining such results in programs conducted under ideal conditions. More research is needed to determine under what circumstances, for what purposes and for whom growth charts may be beneficial.

PIP: Between December 1985 and November 1986, before and after 3 monthly sessions of group nutrition counseling and individual counseling about weaning and diarrhea management at 9 primary health clinics in Lesotho, researchers compared data on 575 mothers who received a growth chart to monitor their 2-year old children's growth with data on 201 mothers of 2-year old children who did not receive a growth chart. They wanted to learn whether growth charts promoted maternal learning and whether the growth charts better served some mothers than other mothers. Growth monitoring intervention improved knowledge of diarrhea management but not weaning practices. This improvement in learning about diarrhea management was limited to new clinic attendants, mothers with less than high school education, and mothers with malnourished children, however. Yet the differences in benefits between these 2 groups were 10% and insignificant. Nutrition education interventions had significantly improved knowledge of weaning practices and diarrhea management for both groups of mothers (range of improvement 3-119.2%; p.05). The greatest improvements occurred in correct responses to continuous feeding of solid foods during diarrhea (119.2% for mothers who did not receive charts and 85.2% for those who did) and to introduction of protein rich vegetables to children's diet (42.6% and 58.9%, respectively). Thus use of growth charts contributed only slightly to increased effectiveness of nutrition education. It appeared that the quality and specificity of educational projects and proper use of weight information during individual counseling contributed the most to improved maternal learning. Nevertheless further research is warranted to learn the circumstances, purposes, and target audience under which use of growth charts would bring the most benefits.

The mediating effect of maternal nutrition knowledge on the association between maternal schooling and child nutritional status in Lesotho.

The present study tested whether maternal nutrition knowledge was a mediating factor in the association between maternal schooling and child nutritional status, and whether the mechanism involved differed according to socioeconomic status. The data were collected in Lesotho on 921 mother-child pairs and included scores from a nutrition knowledge test, socioeconomic and demographic information, and the child's anthropometric data. A wealth factor derived from a factor analysis was used to stratify the sample into two socioeconomic groups. Two-stage least-squares estimation was used to test the mediating role of nutrition knowledge between maternal schooling and child weight-for-age. Results showed that both the importance of maternal schooling and the mechanism by which it affects the child's weight-for-age are contingent upon the family's socioeconomic status. While maternal schooling was positively associated with weight-for-age for both wealthier and poorer households, the size of the effect was much larger for the latter group. The effect of maternal schooling on weight-for-age was mediated by the mother's nutrition knowledge only among wealthier households. These results imply that, in Lesotho, nutrition education for mothers could contribute to improving children's growth, but only in households that have access to a minimum level of resources. For poorer households, nutrition education would not be sufficient.

Impact of a clinic-based growth monitoring programme on maternal nutrition knowledge in Lesotho.

An evaluation of the impact of a nationwide clinic-based growth monitoring (GM) programme was done in Lesotho to determine if clinic attendance was associated with improved maternal knowledge of weaning practices and diarrhoea. A total of 907 mothers from eight clinics were included in the study. Our results showed that mothers who had attended the clinics knew more about the appropriate timing for introducing animal protein-rich foods in the child's diet and about the use of oral rehydration salts for diarrhoea, than those who had not. The difference in knowledge between previous clinic attendants and new attendants was particularly marked among mothers with less than secondary schooling and mothers with young babies (less than 6 months). From observation in the clinics, we believe that group nutrition education, although it was not integrated with growth monitoring, was probably responsible for the positive association between clinic attendance and maternal knowledge. Prior clinic attendance was not specifically associated with improved knowledge about feeding during diarrhoea or the need to stop breastfeeding gradually. These need to be better incorporated into present clinic nutrition education. Whether improvements in growth monitoring would further significantly improve nutrition education remains to be seen.

PIP: Between December 1985-November 1986, survey data from 907 mothers of 2-year-old children in 8 Catholic Relief Services (CRS) clinics in Mahale's Hoek and Mafeteng districts in Lesotho were analyzed to determine if attendance at a typical nationwide clinic-based growth monitoring program improved maternal knowledge of weaning practices and diarrhea management. 85% of the mothers were Basotho women. At the clinics, the mothers did not undergo individual counseling or receive training in growth charts. Group nutrition education efforts did occur, however, but separately from the program. Mothers who attended a clinic had a significantly higher increased knowledge of the appropriate timing for introducing animal protein rich foods and about the use of oral rehydration salts than those who did not attend (p.05). This association was especially significant for mothers with only primary education and those with infants 6 months old. The mothers reported breast feeding a mean of 2 years. 85% knew to introduce cereals and liquids between 4-6 months old. Yet few mothers knew how to appropriately stop breast feeding. For example, 50% believed it should stop in 1 day. The researchers believed that the separate group nutrition activities contributed to the positive effect of clinic attendance on maternal knowledge of nutrition and diarrhea management. Other research needs to be done to determine if teaching of growth charts and individual counseling would significantly improve maternal knowledge. Clinic staff delivering improved educational messages could have a significant positive effect on the growth and health of Basotho children who are undergoing weaning.

Comparison of two growth charts in Lesotho: health workers' ability to understand and use them for action.

BACKGROUND: Two growth monitoring charts widely used for growth monitoring in Africa (the Road-to-Health (RTH) and the Growth Surveillance (GS] were compared in order to assist the Government of Lesotho to decide on an appropriate national growth chart. METHODS: Thirty-four health workers were taught and tested on the RTH during a first week of training and on the GS during a second week (the RTH-GS group), while the order was reversed for another 25 trainees (the GS-RTH group). The health workers were trained and tested on their ability not only to use and interpret the two charts, but also to make the right decisions about specific actions to be taken when growth faltering occurs. RESULTS: There was no difference between scores to the RTH and GS charts after one week of training. After the second week of training, the scores to the RTH chart improved and became better than those to the GS chart. The scores to the GS test did not increase with previous knowledge of the RTH chart. CONCLUSIONS: For this reason and others discussed in the paper, the RTH chart was recommended for nationwide use in Lesotho. The adoption of this recommendation was facilitated by the close involvement in this research of public and private agencies responsible for growth monitoring in Lesotho.