Worldwide timing of growth faltering: implications for nutritional interventions.

OBJECTIVE: It is widely assumed that growth faltering starts at around 3 months of age, but there has been no systematic assessment of its timing using representative national datasets from a variety of countries. METHODOLOGY: The World Health Organization Global Database on Child Growth and Malnutrition includes the results of 39 nationally representative datasets from recent surveys in developing countries. Based on these data, mean z scores of weight for age, length/height for age, and weight for length/height were compared with the National Center for Health Statistics and Cambridge growth references, for children younger than 60 months. RESULTS: Mean weights start to falter at about 3 months of age and decline rapidly until about 12 months, with a markedly slower decline until about 18 to 19 months and a catch-up pattern after that. Growth faltering in weight for length/height is restricted to the first 15 months of life, followed by rapid improvement. For length/height for age, the global mean is surprisingly close to National Center for Health Statistics and Cambridge references at birth, but faltering starts immediately afterward, lasting well into the third year. CONCLUSIONS: These findings highlight the need for prenatal and early life interventions to prevent growth failure.

Who has a high vitamin A intake from plant foods, but a low serum retinol concentration? Data from women in Indonesia.

OBJECTIVE: To examine whether the relationship between vitamin A intake, from plant and animal foods, and vitamin A status is the same throughout a population. DESIGN: Analysis of cross-sectional data on vitamin A intake, vitamin A status, physiological condition and socio-economic status. SETTING: Central Java, Indonesia. SUBJECTS: Women with a child < or =24 months old (n = 600). RESULTS: Mean serum retinol concentration of women with animal vitamin A intake below or above the median (50 RE/d) was 1.28 and 1.38 micromol/L, respectively (P<0.05). For those with intake above the median the distribution curve for serum retinol concentration was shifted towards the right, to higher concentrations. Serum retinol concentration of women with plant vitamin A intake below or above the median (279 RE/d) was 1.30 and 1.36 micromol/L, respectively (P<0.05). Again, the distribution curve for serum retinol was shifted towards higher concentrations for women with an intake above the median, except for the subgroup of 25% with the lowest serum retinol concentration (<1.10 micromol/L). These women did not seem to benefit from their relatively high vegetable intake. They also had the lowest socio-economic status. CONCLUSIONS: The subgroup that was most in need of vitamin A could not obtain it from plant foods. It may well be that, because of their lower socio-economic status, their hygiene conditions were worse and therefore host-related factors that affect carotene bioavailability, such as parasitic infestation, were less favourable in this group. They depended on supplements and, if affordable, on animal foods, fruits and/or fortified products.

Impact of a social marketing campaign promoting dark-green leafy vegetables and eggs in central Java, Indonesia.

In order to work towards further reduction of vitamin A deficiency in central Java, Indonesia, a social marketing campaign promoting eggs and dark-green leafy vegetables was initiated in March 1996. The nutritional surveillance system (December 1995-December 1996) found the following. The campaign's messages were well noticed. Consumption of at least one egg in the past week increased from 80% to 92% in mothers and from 78% to 92% in children 12-36 months old. It increased in all socio-economic groups and was independent of ownership of chickens. Most eggs had been purchased. The quantity of vegetables prepared increased from 93 to 111 g/person daily and most was purchased. Vitamin A intake increased from 335 to 371 RE/d for mothers and from 130 to 160 RE/d for children. Serum retinol levels increased after the start of the campaign, and were related to egg consumption and vitamin A intake. Because 1. data were collected in such a way that respondents were not aware of the link between data collected and the campaign, and 2. vitamin A status increased and was related to increased consumption of eggs and vitamin A intake, we conclude that the social marketing campaign was successful.

Reappraisal of the role of vegetables in the vitamin A status of mothers in Central Java, Indonesia.

Food-based approaches for controlling vitamin A deficiency and its consequences, such as increased mortality, more severe morbidity, and anemia, have become increasingly important, thus prompting a reassessment of the relation between vitamin A intake and status. A nutrition surveillance system in Central Java, Indonesia, assessed the vitamin A intake and serum retinol concentration of women with a child < or =24 mo old with a semiquantitative 24-h recall method that categorized vitamin A-containing foods into 3 categories of plant foods and into 2 categories of animal foods and identified portions as small, medium, or large. Median vitamin A intake was 335 retinol equivalents (RE)/d (n = 600) and vitamin A intake from plant foods was 8 times higher than from animal foods. Serum retinol concentration was related to vitamin A intake in a dose-response manner. The multiple logistic regression model for predicting the chance for a serum retinol concentration greater than the observed median (> or = 1.37 micromol/L) included physiologic factors, vitamin A intake from plant [odds ratio (95% CI) per quartile: 1st, 1.00: 2nd, 1.23 (0.75, 2.02); 3rd, 1.60 (0.97, 2.63); and 4th, 2.06 (1.25, 3.40)] and animal [1st and 2nd, 1.00; 3rd, 1.31 (0.86, 2.02); and 4th, 2.18 (1.40. 3.42)] foods, home gardening [(no, 1.00; yes, 1.71 (1.12, 2.60)], and woman's education level [< or =primary school, 1.00; > or =secondary school, 1.51 (1.02, 2.22)]. Despite the fact that plant foods contributed 8 times as much vitamin A as did animal foods, serum retinol concentrations did not reflect this large difference. Home gardening and woman's education level seemed to reflect longer-term consumption of vitamin A-rich plant and animal foods, respectively.

Moderate zinc and vitamin A deficiency in breast milk of mothers from East-Jakarta.

OBJECTIVE: To gain information about the micronutrient status of urban, middle-income, breast-feeding mothers in relation to zinc and selected fat-soluble vitamins in plasma and breast milk and to assess possible interaction between the measured micronutrients. DESIGN: Cross-sectional study. SUBJECTS: 91 mothers and their infants living in middle-income areas of Jakarta, Indonesia. RESULTS: None of the measured anthropometric data of the mothers (e.g. BMI: 22.0+/-3.1 kg/m2) and their infants (birth weight: 3.2+/-0.5 kg) gave any indication of undernutrition. The mean concentrations in blood were 124+/-18 g/l for hemoglobin, 385+/-111 microg/l for retinol, 34+/-23 microg/l for alpha-carotene, 104+/-72 microg/l for beta-carotene, 7.7+/-3.3 mg/l for alpha-tocopherol, 0.57+/-0.23 mg/l for gamma-tocopherol, 855+/-242 microg/l for zinc, and the median concentration of lycopene was 29 microg/l. The median breast milk concentrations were 420 microg/l for retinol, 7.8 microg/l for beta-carotene, and 2.7 mg/l for zinc. With increased duration of lactation, vitamin A and zinc concentrations significantly decreased in breast milk whereas plasma zinc concentration increased. Plasma alpha- and beta-carotene were positively correlated (P < 0.0001) with each other and with plasma lycopene. Breast milk beta-carotene was positively correlated with breast milk retinol and with plasma beta-carotene (P < 0.0001). There was no correlation between zinc and vitamin A in either breast milk or plasma. Forty per cent of the mothers were anemic, 29.1% had a low plasma zinc concentration, and 23.7% had a moderately low plasma vitamin A concentration. Breast milk from 70% of the women had a low concentration of vitamin A and that from 66% had a low concentration of zinc. CONCLUSIONS: Multi-micronutrient intervention should be considered to provide a sufficient supply of zinc and vitamin A for growth of exclusively breast-fed infants.

The role of information in the planning, management and evaluation of community nutrition programmes.

Protein-energy malnutrition has many diverse location-specific causes which make if difficult to solve through uniform interventions implemented through vertical programmes. This paper investigates the role of information in the planning, management and evaluation of several community nutrition programmes judged to be successful. The programmes come from Tanzania (Iringa), India (Tamil Nadu), Dominican Republic and Colombia. The review finds that the initial conceptualization and design of these programmes benefited from the results of earlier surveys and experience with similar programmes in the same or other countries. Strong capacity for operations research is important to assist with a myriad of small but important programme design details and larger mid-term re-orientations. The impact of this information depends upon the flexibility of the programme and receptivity of its management towards a learning-by-doing approach. Information for on-going programme management differs widely and conforms to the overall character of the individual programme. Thus, Iringa employs a simple system based on community growth monitoring, primarily to catalyze intervention planning and action at household and community levels. Tamil Nadu's system is far more complex and is primarily intended to assist in the delivery of centrally planned interventions. Programme evaluation benefited from information generated within the programme, but more rigorous impact evaluation requires stronger designs and more in-depth analysis than is usually provided. Overall, the review suggests that characteristics like community participation, empowerment and growth monitoring are less important in the short/medium term than strong management, a learning-by-doing approach, and the existence of some method for informing programme design and management about community needs and responses to the programme. The former characteristics may well be important for the longer-term sustainability of programmes.

Influence of enteral parasites on the blood vitamin A levels in preschool children orally supplemented with retinol and/or zinc.

A sample of 471 pre-school children who frequented schools and crêches in a poor district of Manaus (Amazonas), Brazil, were randomly submitted to faecal parasitological tests. Two-hundred-and-forty children from both sexes between the ages of 3 and 7 years with Ascaris lumbricoides and/or Giardia lamblia were selected. The objective of the study was to determine the possible influence of these two intestinal parasites and vitamin A and/or zinc supplementation on the serum retinol levels of primary school children. The children were submitted to clinical and anthropometric examinations, dietary interviews and biochemical examinations of retinol and carotene in the serum and of zinc in the hair. The parasitic incidence was 85.0% and about 54% of the children were polyparasitic. During the pretreatment phase, the retinol and carotene serum levels were 36% and 57%, respectively, below the normal levels. Using the Waterlow classification, the anthropometric analyses revealed that 88% of the children showed normal growth. A significant effect was observed of the anti-parasitic medicine on the serum retinol levels.

Alimentaçäo no desmame em áreas periurbanas de quatro capitais brasileiras: resultados preliminares

Säo analisadas as dietas e o estado nutricional de 466 crianças abaixo de dois anos de idade, em áreas periurbanas de quatro capitais brasileiras. A principal mistura de alimentos encontrada foi de leite artificial, amido, e açucar (68%), sendo os alimentos da dieta da família pouco utilizados no processo de desmame das crianças. As dietas säo inadequadas quantitativamente, especialmente no segundo ano de vida quando a maioria das crianças (57%) näo conseguiram 80% das suas necessidades energéticas. As dietas foram inadequadas qualitativamente em zinco e ferro, sendo adequadas para proteína, vitamina A e vitamina C, desde que preenchidas as necessidades energéticas. A desnutriçäo mostrou-se mais grave nos locais (Nordeste) e faixas etárias (segundo ano) onde a dieta se apresentou mais inadequada

Stable isotope metabolic studies of zinc nutrition in slum-dwelling lactating women in the Amazon valley.

1. Zinc metabolism has been studied in a group of undernourished, slum-dwelling, lactating women in Manaus, Brazil, by means of modified metabolic balance techniques and the stable isotope 67Zn. 2. The subjects were found to be consuming a diet which provided an average of 34% of the recommended dietary allowance for lactating women, but six of the seven appeared to achieve Zn balance. In five of the subjects use of 67Zn in a stable isotope dilution manner demonstrated that they were absorbing a high proportion of the dietary Zn (proportional absorption ranged from 0.59 to 0.84), suggesting an adaptation to the chronically low intake. 3. Two subjects had marginally low plasma Zn concentrations, although hair, urine and milk Zn contents were all within accepted normal values. 4. Preliminary findings on the rate of plasma Zn turnover and the size of the exchangeable body Zn pool obtained using 67Zn suggest that these subjects may have a reduction in both.

Food consumption and dietary adequacy according to income in 1,200 families, Manaus, Amazonas, Brazil, 1973-1974.

Data from a household expenditure survey of 1,200 Manaus families performed by the Amazonas State Government in 1973-74 are analyzed by income group. The per cent frequency of families buying different foods and the daily per capita consumption of each were calculated. The daily per capita intakes of energy, protein, vitamin A, thiamine, riboflavin, nicotinic acid, ascorbic acid, calcium, phosphorus, iron and zinc were estimated and their adequacy evaluated. In contrast to the south and northeast of Brazil, the main bulk of the diet was derived from cereals and fish. The quantities of eggs, meats, fruit and vegetables consumed per person, increased 50-100% as income improved, whereas fish consumption decreased 30%. The nutrients quantitatively most deficient were zinc, vitamin A, calcium, thiamine and riboflavin, with 60-80% of low and middle income families not achieving safe levels of intake for zinc and vitamin A. The beneficial effect of income on the adequacy of calcium, thiamine and riboflavin intake was quantitative. For zinc and vitamin A, increased income was associated with a qualitative improvement in the diet, principally due to the increased consumption of meat and liver. These results are discussed in relation to existing clinical evidence of deficiency states in the region.

Aspectos nutritivos de alguns peixes da Amazonia. / Nutritive aspects of some Amazonian fishes

Onze especies de peixes, os mais consumidos pela populacao de Manaus em 1973-74, foram analisados quanto aos seus conteudos de: umidade, cinzas, proteina, gordura, energia e zinco. Os peixes carnivoros como Tucunare, Pirarucu e a Pescada eram magros enquanto Pacu, Sardinha, Curimata, Matrincha e Branquinha foram considerados como gordos. Os peixes representavam alto teor proteico, com razoes proteina/energia muito alem das recomendadas (FNB-USA). As razoes zinco/energia eram altas somente nos peixes menos gordurosos, ou nos peixes carnivoros como Tucanare e Pescada.Estes peixes sao colocados entre os mais caros no mercado de Manaus. Os peixes herbivoros e/ou onivoros como Matrincha, Curimata, Tambaqui e Branquinha apresentaram uma razao zinco/energia abaixo do nivel recomendado. Discutem-se as possiveis importancias desses resultados

Resistencia do Plasmodium falciparum ao fansidar, quinina e tetraciclina. / Resistance of Plasmodium falciparum to fansidar, quinine and tetracycline

Descreve-se pela primeira vez uma cepa amazonica de Plasmodium falciparum resistente ao Fansidar (pirimetamina mais sulfadoxina) e quinino mais tetraciclina simultaneamente. O paciente, com 13 anos de idade, residia ha cinco anos em Ariquemes, Estado de Rondonia, na Amazonia brasileira. A infeccao foi curada com dose elevada de cloroquina administrada em dose unica intravenosa (IV). E evidenciado o alto valor da cloroquina na cura da malaria falciparum resistente, quando administrada em doses maiores que as usadas nos esquemas convencionais de tratamento

Niveis sericos de vitamina "A" em operarios de Manaus, Amazonas. / Serum levels of vitamin A in workers in Manaus, Amazonas - Brazil

O estado nutricional relacionado a vitamina "A" foi estudado em 382 operarios de ambos os sexos, de classe socio-economico baixa em qua tro fabricas de Manaus, atraves da utilizacao dos niveis de retinol e caroteno sericos e inquerito alimentar nas ultimas 24 horas. Pode-se constatar que os niveis sericos "abaixo de aceitaveis" de retinol em operarios de tres fabricas foi acima de 15% e o caroteno nos operarios das quatro fabricas foi de 51,1%. Os niveis sericos nao mostraram diferencas significativas por faixa de renda, mas o consumo de vitamina "A" equivalentes em operarios com niveis sericos de retinol alto eram significativamente mais alto do que os com niveis sericos de retinol baixo. A adequacao de consumo de vitamina "A" nas duas fabricas que ofereciam alimentacao foi superior as necessidades recomendadas, enquanto as outras duas apresentaram um deficit de consumo de, aproximadamente, 45%