Associations of albumin and nutritional index factors with delirium in patients admitted to the cardiac intensive care unit.

Background: Limited data are available on the association of malnutrition with the occurrence of delirium in the cardiac intensive care unit (CICU). Thus, we aimed to analyze whether nutritional indices and their components can predict the development of delirium in CICU. Methods: We enrolled 2,783 patients admitted to the CICU of Samsung Medical Center for more than 24 h between September 2012 and December 2018. We assessed the nutritional status at admission using three indices, the Prognostic Nutrition Index (PNI), the Geriatric Nutritional Risk Index (GNRI), and the Controlling Nutritional Status (CONUT). Then, we compared predictive performances for the occurrence of delirium among nutritional indices using Delong's test. Results: Delirium developed in 678 patients (24.3%) assessed three times daily for 7 days of CICU stay. Nutritional indices had fair predictive performance for development of delirium in critically ill cardiac patients using the area under the receiver-operating characteristic curve (AUROC: 0.729 for the GNRI, 0.728 for PNI, and 0.762 for CONUT). Furthermore, the AUROC of albumin alone (0.77, 95% CI, 0.75-0.79) was significantly greater than that of either GNRI (p < 0.001) or PNI (p < 0.001). In a multivariable analysis including each component of nutritional indices, albumin was a significant predictor for delirium but not absolute lymphocyte count, bodyweight/ideal bodyweight, or total cholesterol level as a component of nutritional indices. Conclusion: Predictive performances of nutritional indices for the occurrence of delirium were acceptable in patients admitted to CICU. Albumin alone might be a helpful and straightforward indicator for the occurrence of delirium.

Significance of NLDA, the commixed index of inflammation, immune responses, hemostasis, and nutrition, for predicting metastatic non-small cell lung cancer prognosis and metastases.

PURPOSE: This study aimed to take a comprehensive review of the hematological indexes and discover a novel, comprehensive, and economical index for prognostic prediction. RESULTS: The predictive prognostic model revealed that an elevated value of NLDA (NLDA = neutrophil count/lymphocyte count × D-dimer count/albumin) was an independent risk factor for one-year adverse prognosis (hazard ratio = 3.038; 95% confidence interval [CI], 1.959-4.712; P < 0.001). The C-indexes of internal and external validation in nomogram were 0.738 (95% CI, 0.686-0.79) and 0.731 (95% CI, 0.631-0.831), respectively. The areas under the curves of the NLDA values in retrospective and prospective studies were 0.700 (95% CI, 0.631-0.769; P < 0.001) and 0.692 (95% CI, 0.535-0.822; P = 0.005), respectively. The cut-off value of NLDA was 0.15. NLDA was positively associated with M stage (P = 0.032), organ metastasis counts (P = 0.006), liver metastases (P = 0.019), and vertebrae metastases (P = 0.013). MATERIALS AND METHODS: This was a retrospective and prospective study. The clinicopathological characteristics and hematological parameters of stage IV non-small cell lung cancer patients were analyzed retrospectively and prospectively to establish a valid predictive prognostic model. The primary endpoint was the 1-year overall survival. The predictive prognostic model was established and validated by Cox Regression and nomogram. The cut-off and predictive prognostic values of the novel indexes were calculated through the receiver operating characteristic curves. The chi-square test was used to explore the correlation between the new prognostic hematological index and metastatic characteristics. CONCLUSIONS: In this study, NLDA, a new, comprehensive and economic parameter, was found to be an independent adverse prognostic factor for stage IV non-small cell lung cancer patients, and was positively associated with organ metastases.

The Nutritional Assessment in Children: Understanding of Anthropometric Assessment and Biochemical Indexes in Children / 대한소아소화기영양학회지

Nutritional assessment is based on anthropometric, clinical, dietary and biochemical data. There is a lack of studies about the propriety of biochemical indexes for the nutritional assessment in children despite biochemical data in pediatric population are different from them in adult's in many respects. Serum albumin is useful index to evaluate the severity of malnutrition. Hemoglobin and hematocrit tend to decrease in malnutrition on account of defect of iron metabolism and to increase in metabolic syndrome on account of enhancement of erythropoiesis. But, unlike adult, total lymphocyte count is not so useful biochemical indexes in children. We should consider pediatric characteristic when interpret biochemical indexes for nutritional assessment in children, and nutritional status in children should be assessed comprehensively with anthropometric, clinical, dietary and biochemical data.

Bolivia 1998: results from the Demographic and Health Survey.

PIP: This document presents the results of the Bolivia Demographic and Health Survey (DHS), or Encuesta Nacional de Demografia y Salud 1998, conducted by the Instituto Nacional de Estadistica, La Paz, Bolivia, within the framework of the DHS Program of Macro International. Data were collected from 12,109 households and complete interviews were conducted with 11,187 women aged 15-49. A male survey was also conducted, which collected data from 3780 men aged 15-64. The information collected include the following: 1) general characteristics of the population, 2) fertility, 3) fertility preferences, 4) current contraceptive use, 5) contraception, 6) marital and contraceptive status, 7) postpartum variables, 8) infant mortality, 9) health: disease prevention and treatment, and 10) nutritional status: anthropometric measures.^ieng

Nicaragua 1998: results from the Demographic and Health Survey.

PIP: This article presents summary statistics gathered from the 1998 Nicaragua Demographic and Health Survey (Encuesta Nicaraguense de Demografia y Salud 1998, ENDESA-98). Data from the nationally representative ENDESA-98 were collected from 11,528 households. Interviews were conducted with 13,634 women aged 15-49 years and 2912 men aged 15-59 years between December 1, 1997, and May 31, 1998. The statistics presented were on fertility trends, fertility differentials, age-specific fertility, fertility preferences, current contraceptive use, contraception, marital and contraceptive status, differentials in median age at first birth, postpartum variables, and infant mortality. In addition, statistical data on the health and nutritional status of children were also presented.^ieng

Philippines 1998: results from the Demographic and Health Survey.

PIP: This article presents summary statistics gathered from the 1998 Philippine National Demographic and Health Survey. The National Statistics Office and the Department of Health within the framework of the Demographic Health Survey Program of Macro International conducted the survey. The nationally representative survey collected data from 12,407 households. Interviews were also conducted with 13,983 women aged 15-49 years between March 3 and the first week of May 1998. The statistical data presented were on fertility trends, fertility differentials, age-specific fertility, fertility preferences, current contraceptive use, contraception, marital and contraceptive status, postpartum variables, infant mortality trends and differentials, and children's health.^ieng

Nutritional status of breastfed infants in rural Zambia: comparison of the National Center for Health Statistics growth reference versus the WHO 12-month breastfed pooled data set.

Cross-sectional data for breastfed infants in rural Zambia were used to evaluate the effect of applying two different data sets as a reference, i.e. the WHO 12-month breastfed pooled data set and the National Center for Health Statistics (NCHS) growth reference in terms of prevalence of malnutrition (stunting, underweight, and wasting). A total of 518 infants who were attending mother-and-child health clinics were included. Age, weight and length were recorded. Anthropometric Z-scores were calculated in two ways: by applying the NCHS growth reference and by using the WHO breastfed data set. Anthropometric Z-scores calculated using the breastfed data set were lower during the first 6-7 months of life compared with those calculated by applying the NCHS growth reference. This resulted in a higher proportion of children aged 0-6 months being classified as stunted and underweight using the breastfed data set versus the NCHS growth reference. After the age of 7 months, similar prevalences of stunting or underweight were observed. Relatively few infants were classified as wasted. In order to adequately assess the prevalence of stunting and underweight in breastfed infants, it is recommended that a new growth reference be developed, as has been initiated by WHO.

Establishing a standard definition for child overweight and obesity worldwide: international survey.

OBJECTIVE: To develop an internationally acceptable definition of child overweight and obesity, specifying the measurement, the reference population, and the age and sex specific cut off points. DESIGN: International survey of six large nationally representative cross sectional growth studies. SETTING: Brazil, Great Britain, Hong Kong, the Netherlands, Singapore, and the United States. SUBJECTS: 97 876 males and 94 851 females from birth to 25 years of age. MAIN OUTCOME MEASURE: Body mass index (weight/height(2)). RESULTS: For each of the surveys, centile curves were drawn that at age 18 years passed through the widely used cut off points of 25 and 30 kg/m(2) for adult overweight and obesity. The resulting curves were averaged to provide age and sex specific cut off points from 2-18 years. CONCLUSIONS: The proposed cut off points, which are less arbitrary and more internationally based than current alternatives, should help to provide internationally comparable prevalence rates of overweight and obesity in children.

PIP: This study aimed to develop an internationally acceptable definition of child overweight and obesity, specifying the measurement, reference population, and age and sex specific cut off points. Data on body mass index (weight/height) were obtained from 6 large nationally representative cross sectional surveys on growth from Brazil, Great Britain, Hong Kong, the Netherlands, Singapore, and the US. The study included 97,876 males and 94,851 females from birth to 25 years of age. For each of the surveys, centile curves were drawn that at age 18 years passed through the widely used cut-off points of 25 and 30 kg/sq. m for adult weight and obesity. The resulting curves were averaged to provide age- and sex-specific cut-off points from 2 to 18 years. The proposed cut off points, which are less arbitrary and more internationally based than current alternatives, should help to provide internationally comparable prevalence rates of overweight and obesity in children.

Influence of parental height and sociodemographic factors on adolescent height in Brazil.

OBJECTIVE: To analyze the influence of parental stature and environmental factors on the stature of adolescents from a national survey sample. METHODS: A nationwide survey was carried out in 1989 among a stratified, two-stage, probability cluster sample of 14,455 Brazilian households to provide estimates of anthropometric deficits for urban and rural populations from the five regions of the country. Stature was measured for 5681 boys and girls age 14-18 years, 78.9% of their fathers, and 93.8% of their mothers. Associations between explanatory variables and adolescent height in centimeters were assessed by fitting multiple linear models to the data. RESULTS: The predicted effects of parental stature and environmental conditions together sum to a total of 17 cm when comparing a boy born to parents with stature below the median and living in the underdeveloped rural Northeast region (1.56 m) with one born to parents with stature above the median and living in the partially industrialized urban South region (1.73 m). For girls, this estimated difference was 12 cm. For boys, the overall influence of parents' stature was 10 cm (R(2)= 0.40) and the sociodemographic factors had an overall influence of 7 cm (R(2) = 0.29). For girls, these values were 7 cm (R(2)= 0.35) for the parental influence and 5 cm (R(2) = 0.11) for the sociodemographic factors. CONCLUSIONS: Mother's stature had the same influence on adolescent's stature as father's stature. Independent of parental stature, environmental factors have a strong influence on adolescent stature, particularly among boys.

Women's education can improve child nutrition in India.

PIP: Child malnutrition has long been recognized as a serious problem in India, but national-level data on levels and causes of malnutrition have been scarce. Hence, during 1992-93, a National Family Health Survey was carried out to examine the levels and determinants of child malnutrition in the country. More specifically, this survey estimated the levels of child malnutrition and examined the effects of mother's education and other demographic and socioeconomic factors on the nutritional status of children in India. Based on standards developed by the WHO, 52% of children under age 4 years are stunted, 17% are wasted, and 54% are underweight. Maternal education has the strongest independent influence on child malnutrition. Children whose mothers have little or no education tend to have a lower nutritional status than do children of more-educated mothers, even after controlling potentially confounding demographic and socioeconomic variables. The age of the child, birth order, and household economic status all have independent effects on nutritional status. Considering the very strong impact of maternal education on child nutrition, women's education and literacy programs could play an important role in improving the nutritional status of children.^ieng

Chad 1996-97: results from the Demographic and Health Survey.

PIP: The Chad Demographic and Health Survey (DHS), or Enquete Demographique et de Sante (EDS) Tchad 1996-97, was conducted by the Bureau Central du Recensement, Direction de la Statisque, des Etudes Economiques et Demographiques, Ministere du Plan et de l'Amenagement du Territoire N'Djamena, Chad, within the framework of the DHS Program of Macro International. Data for the EDS were collected from 6840 households, and complete interviews were conducted with 7454 women aged 15-49 and 2320 men aged 15-59. The interviews took place between December 1996 and July 1997. The summary statistics presented were taken from the Chad country report, with exceptions as noted. Included in this article are table and charts presenting valuable data on the general characteristics of the Chad population, fertility, fertility preferences, contraceptive use, knowledge about contraception, marital and contraceptive status, postpartum variables, infant mortality, health, and nutritional status.^ieng

Indonesia 1997: results from the Demographic and Health Survey.

PIP: The Indonesia Demographic and Health Survey (DHS) was conducted by the Central Bureau of Statistics, State Ministry of Population/National Family Planning Coordinating Board, and Ministry of Health, Jakarta, Indonesia, within the framework of the DHS Program of Macro International. Data from the DHS were collected from 34,255 households and complete interviews were conducted with 28,810 women aged 15-49. The interviews took place between September 1, 1997 and December 31, 1997. The summary statistics presented were taken from the Indonesia country report with exception as noted. Included in this article are table and charts presenting valuable data on Indonesia general characteristics of the population, fertility, contraceptive use, and knowledge about contraception, marital and contraceptive status, infant mortality, and health.^ieng

Nutritional status and mortality of refugee and resident children in a non-camp setting during conflict: follow up study in Guinea-Bissau.

OBJECTIVE: To study the effects on children of humanitarian aid agencies restricting help to refugee families (internally displaced people). DESIGN: Follow up study of 3 months. SETTING: Prabis peninsular outside Bissau, the capital of Guinea-Bissau, which has functioned as a refugee area for internally displaced people in the ongoing war, and the study area of the Bandim health project in Bissau. PARTICIPANTS: 422 children aged 9-23 months in 30 clusters. MAIN OUTCOME MEASURES: Mid-upper arm circumference and survival in relation to residence status. RESULTS: During the refugee situation all children deteriorated nutritionally, and mortality was high (3.0% in a 6 week period). Rice consumption was higher in families resident in Prabis than in refugees from Bissau but there was no difference in food expenditure. Nutritional status, measured by mid- upper arm circumference, was not associated with rice consumption levels in the family, and the decline in circumference was significantly worse for resident than for refugee children; the mid-upper arm circumference of refugee children increased faster than that of resident children. For resident children, mortality was 4.5 times higher (95% confidence interval 1.1 to 30.0) than for refugee children. Mortality for both resident and refugee children was 7.2 times higher (1.3 to 133.9) during the refugee's stay in Prabis compared with the period after the departure of the refugees. CONCLUSION: In a non-camp setting, residents may be more malnourished and have higher mortality than refugees. Major improvements in nutritional status and a reduction in mortality occurred in resident and refugee children as soon as refugees returned home despite the fact that there was no improvement in food availability.

PIP: This paper examines the nutritional status and mortality of refugee and resident children in a non-camp setting during the war in Guinea-Bissau. Subjects included 422 children aged 9-23 months in 30 clusters. Results showed that, during the refugee situation, all the children deteriorated nutritionally and mortality was high (3.0% in a 6-week period). Rice consumption was higher in families residing in Prabis than in refugees from Guinea-Bissau, but there was no difference in food expenditure. Nutritional status, measured by mid-upper-arm circumference, was not associated with rice consumption levels in the family, and the decline in circumference was significantly worse for resident than for refugee children; the mid-upper-arm circumference increased faster than that of resident children. For resident children, mortality was 4.5 times higher than for refugee children. Mortality for both resident and refugee children was 7.2 times higher during the refugee's stay in Prabis compared with the period after the departure of the refugees. Finally, major improvements in nutritional status and reduction in mortality occurred in resident and refugee children as soon as refugees returned home despite the fact that there were no improvements in food availability.

Nutritional status and nutrient intake of preschool children in northern Ghana.

OBJECTIVE: To determine the nutritional status and nutrient intake of preschool children in a sub-Sahelian setting so as to ascertain whether they meet the acceptable standards. DESIGN: Prospective/investigative study. SETTING: The study was carried out in Saboba, a rural sub-Sahelian village in northern Ghana. SUBJECTS: Five hundred and eighteen preschool children (2.5-6 years) drawn from three kindergartens and five other localities were used. INTERVENTION: Anthropometric measures of age, weight, and height were assessed. Blood and stool samples were taken for analyses. RESULTS: The nutritional status was generally poor, with 27% (140/519) stunted, 4.4% (23/519) wasted and 1.9% (10/519) wasted and stunted. Majority of the children (92%) were anaemic and 16.3% had deficient level of vitamin A (< 10 micrograms/dL). Total caloric intake was low (only 26.5% met RDA values) and apart from protein and iron whose RDA were met by the majority of the children (> 90%), the intake of other nutrients-calcium, vitamin C, vitamin A and provitamin A, were low and unacceptable, compared to their respective RDA values. In the case of iron, even though intake was adequate, the high anaemic rate of 92% was due to high incidence of malaria (32%), hookworm infestation, low intake of vitamin C and low bioavailability of iron from the mainly cereal diet. CONCLUSION: The poor nutritional status of the children was largely due to the low intake of essential nutrients.

PIP: This prospective study assessed the nutritional status and nutrient intake of preschool children in rural Saboba, northern Ghana. Study sample consisted of 518 preschool children aged 2.5-6 years drawn from 3 kindergartens and 5 other localities. Anthropometric measures of age, weight, and height were determined. Blood and stool samples were taken for analyses. Findings revealed that the nutritional status of these preschool children was poor, with 27% (140/519) stunted, 4.4% (23/519) wasted, and 1.9% (10/519) wasted and stunted. The majority (92%) of the children were anemic and 16.3% had a deficient level of vitamin A (10 mcg/dl). Total caloric intake was low (only 26.5% met the Recommended Dietary Allowance (RDA) values). Apart from protein and iron, whose RDA values were met in the majority of children (90%), the intake of other nutrients such as calcium, vitamin C, vitamin A, and provitamin A were low and unacceptable compared to their RDA values. Although intake of iron was sufficient, the high anemic rate (92%) was due to high incidence of malaria (32%), hookworm infestation, low vitamin C intake, and low bioavailability of iron from the mainly cereal diet. From these findings researchers concluded that the poor nutritional status of the children was due largely to the low intake of essential nutrients.

Integrated Child Development Services scheme (ICDS) and its impact on nutritional status of children in India and recent initiatives.

Integrated Child Development Services (ICDS) scheme is the largest national programme for the promotion of the mother and child health and their development in the world. The beneficiaries include children below 6 years, pregnant and lactating mothers, and other women in the age group of 15 to 44 years. The package of services provided by the ICDS scheme includes supplementary nutrition, immunization, health check-up, referral services, nutrition and health education, and pre-school education. The distribution of iron and folic acid tablets and megadose of vitamin A is also undertaken, to prevent iron deficiency anaemia and xerophthalmia respectively. The scheme services are rendered essentially through the Anganwadi worker (AWW) at a village centre called "Anganwadi". The ICDS had led to (i) reduction in prevalence of severe grades of malnutrition and (ii) better utilization of services of national nutritional anaemia prophylaxis programme and the national programme for prevention of nutritional blindness due to vitamin A deficiency by ICDS beneficiaries. The ICDS scheme is being modified continuously to strengthen the programme.

PIP: This article presents the impact of Integrated Child Development Services (ICDS) on the nutritional status of mothers and of children under 6 years old in India. ICDS is the first and probably the only program in the country that aims at the holistic development of an individual. The reduction in prevalence of severe malnutrition is comparatively more significant in ICDS scheme population than in other population groups. There has been an extensive improvement in the nutritional status of children living in rural, urban and tribal areas and in those belonging to depressed sections of the community. The new initiative schemes for supplementary nutrition include: (a) improved monitoring mechanisms, (b) increased and improved norms of nutrition, (c) improved acceptability of supplementary recipes, (d) care of the severely malnourished, (e) the formation of a state level committee of experts, (f) inspection of quality, and (g) the introduction of community growth charts for malnourished children. The distribution of iron and folic tablets together with megadoses of vitamin A has also been undertaken for iron deficiency anemia and xerophthalmia prevention. Professionals, administrators, and politicians should feel obliged to continue making their contributions to the effective implementation of ICDS.

Growth of children in Iran.

Weights and Heights of 22,349 children and adolescents aged 2 to 18 in Iran are reported. Data are from the 1990-1992 National Health Survey, a random cluster sample survey of 1 in 1000 families in all provinces of Iran. Multilevel models (Goldstein 1995) which take account of the survey design, reveal significant differences between provinces and between urban and rural children. Differences between urban and rural children, like differences between girls and boys, persist across all provinces and are certainly real. Differences between provinces may be partly due to differences in calibration. Charts based on the homogeneous subset of children living in urban Tehran may be used for all urban children, and in modified form, for all rural children. All the centiles of these charts are substantially below those of the NCHS charts, but the spread is similar so that there is no suggestion that the difference is due to the prevalence of gross malnutrition. The difference shows that the use of locally based growth charts are essential for assessing the growth of children in Iran.

PIP: This study explored the growth of Iranian children 2-18 years old by using weight and height measurements. Data were obtained from a National Health Survey of families in 1990-92, which covered all provinces of Iran. After excluding discordant measurements, the data set included measurement on 22,349 individuals; 11,159 (49.9%) boys and 11,190 (50.1%) girls. Weights were recorded to the nearest kilogram, and heights to the nearest centimeter. Multilevel models were constructed to investigate regional variations in growth patterns. In the results, the interaction terms of sex with age show that the girls were putting on weight significantly faster than the boys and also growing slightly faster on average. The differences between provinces may be partly due to differences in calibration. Charts based on the homogenous subset of children living in urban Tehran may be used for all urban children and, in modified form, for all rural children. All the centiles of these charts were substantially below those of the National Center for Health Statistics charts, but the spread was similar so that there was no suggestion that the difference was due to the prevalence of gross malnutrition. The difference showed that the use of locally based growth charts was essential for assessing the growth of children in Iran.

Ecological and geographic characteristics predict nutritional status of communities: rapid assessment for poor villages.

The quality of poverty alleviation programmes relies heavily on appropriate targeting and priority setting. Major problems in assessing poverty include identification of the indicators of poverty and the methods used for its assessment. Nutritional status, expressed by anthropometric indices, has been proposed as a poverty indicator because of its validity, objectivity, reliability and feasibility. This study was conducted to explore the application of remote sensing to poverty mapping based on nutritional status at the community level. Relationships between the nutritional status within a community and the ecological characteristics of the community were investigated. Multiple linear regression tests were executed, and the resultant equations were tested for their validity in predicting communities with poor nutritional status. Among geographical and ecological indicators used, distance to the nearest market, main soil type, rice field area, and perennial cultivation area were found to be most useful predictors for the ranking of the communities by nutritional status. Among non-ecological determinants, food consumption, health service status and living conditions were also found as predictors. The highest correlation was found if total population was also taken into account in the regression model (R2 = 0.69; p < 0.0001). In the assessment of the sensitivity and specificity of the eight models studied, 'undernutrition' was defined as a condition where a community belongs in the first quartile for nutritional status (highest prevalence of undernutrition), and the baseline nutritional survey was considered as a standard method for final diagnosis. Most models which included only ecological factors in the equations had lower sensitivity and specificity than models which included all determinant factors in the equations. All models which took into account the total population had higher sensitivity and specificity than those that did not take total population into account. The best model of those that took into account only the geographical and ecological characteristics of the community's living environment had similar sensitivity and specificity (80% and 94.1%, respectively) as the models that considered non-geographical and non-ecological variables in addition to geographical and ecological variables. In the case of West Sumatra, only four ecological and geographic characteristics were sufficient to predict poverty in village. Since these characteristics could be surveyed by remote sensing, it may well be possible to use remote sensing for a rapid method for poverty mapping.

PIP: The quality of poverty alleviation programs depends heavily upon appropriate targeting and priority setting. However, to assess poverty, the indicators of poverty and the methods used for assessment must first be identified. Findings are presented from a study of the application of remote sensing to poverty mapping based upon nutritional status at the community level. Sampling 43 villages, relationships between the nutritional status within a community and the ecological characteristics of the community were investigated. Multiple linear regression tests were executed and the resultant equations tested for their validity in predicting communities with poor nutritional status. Of the geographical and ecological indicators used, distance to the nearest market, main soil type, rice field area, and perennial cultivation area were found to be the most useful predictors for ranking communities by nutritional status. Among non-ecological determinants, food consumption, health service status, and living conditions were also determined to be predictors. The strongest correlation was found when total population was also considered in the regression model. Most models which included only ecological factors in the equations had lower sensitivity and specificity than models which included all determinant factors in the equations. All models which accounted for total population had higher sensitivity and specificity than those which did not take such consideration. If not the nutritional status in absolute terms, at least the rank of communities can be predicted solely by geographical and ecological factors.

Nutrition in reproductive health.

This article reviews nutrition-related issues affecting women and their reproductive health. Health care providers must be able to perform a basic nutritional assessment to identify risk factors and develop a plan of care to reduce those risk factors and improve health. Guidelines are provided to assist in performing a nutritional status assessment. Nutritional assessment of women of reproductive age should identify factors that may affect fertility, periconceptional health, and pregnancy outcome. Recommendations are provided to assist the health care provider in counseling women regarding the relationship of food choices and exercise to health, fitness, and optimal bodily function. Controversies surrounding the effect of micronutrient deficits and excesses on reproduction and correction for these imbalances are discussed. Women should be encouraged to initiate dietary and other lifestyle changes to allow for optimal reproductive outcomes.

A model to standardise mortality of severely malnourished children using nutritional status on admission to therapeutic feeding centres.

OBJECTIVE: To determine a simple model to calculate the number of deaths which could be expected in a therapeutic feeding centre from the height, weight and oedema of children on admission. DESIGN: Admission weight, height, presence of oedema of the children and outcome were prospectively recorded. SETTING: Data were recorded in 18 feeding centres set-up during emergency operations in Africa. Ten of the feeding centres were selected, a priori, as reference centres and eight centres as test centres. SUBJECTS: Data for 3858 children were recorded. 837 children absconded from the centres and were excluded from the analysis. Analysis was performed on data from 2753 children who left the centre after recovery and 268 children who died during treatment. INTERVENTIONS: The relation between the risk of death and, anthropometric measurements and presence of oedema has been determined in a previous paper. The maximum likelihood estimate of the constant of the model was determined from global analysis of the data of the reference centres. The model was applied to the data of the reference and test centres. RESULTS: The model to predict the individual probability of death was: P(death) = 1/(1 + exp[-(20.63 - 9.99 1n(weight/height1.74) + 1.36 oedema)]) The predicted number of deaths was close to the recorded number of deaths for each reference centre. For three of the eight test centres there was a significant excess of observed deaths over predicted. CONCLUSION: This model can be easily used by the supervisor of a centre to assess the expected number of deaths during treatment of malnutrition from simple measurements on children that are routinely taken on admission and thus help to determine the nature of variation in observed mortality rates.

PIP: Data on children treated at 18 emergency feeding centers in 9 African countries were used to develop a simple model to calculate the number of child deaths expectable in severely malnourished children on the basis of height, weight, and edema at admission. Overall crude mortality was 7.6% at the 10 reference centers and 11.3% in the 8 test centers. Included in the analysis were 2753 children treated at the feeding centers and released and 268 children who died during treatment. The association between mortality and the anthropometric measurements and presence of edema had been determined in a previous study. The maximum likelihood estimate of the constant of the model was determined from global analysis of data from the reference centers. The model to predict the individual probability of death was: P(death) = 1/(1 = exp[-(20.63 - 9.99 in optimal ratio of weight to height + 1.36 edema)]). The predicted number of deaths closely approximated the actual number at each reference center, while there was a significant excess of observed over predicted deaths at 3 of the 8 test centers. This simple tool can be used to calculate the predicted number of deaths, evaluate the efficacy of a feeding center, and examine mortality trends over time or in relation to administrative changes.

Evaluation of biochemical indicators of vitamin A status in breast-feeding and non-breast-feeding Indonesian women.

Indicators of vitamin A status were evaluated in nonpregnant breast-feeding (n = 265) and nonpregnant non-breast-feeding (n = 49) Indonesian women. The concentration of vitamin A (not including provitamin A carotenoids) and fat in breast milk was 30% and 20% higher, respectively, for women with a breast-fed child 7-18 mo old than for women with an infant 3-6 mo old. The vitamin A content of milk fat was constant throughout lactation. Breast-milk vitamin A was most sensitive to changes in vitamin A status when expressed per volume. Sensitivity and specificity for detecting serum retinol concentrations < 0.70 mumol/L were < 75% for the concentration of breast-milk vitamin A and serum retinol binding protein (RBP). The modified-relative-dose-response (MRDR) method suffers from a relatively large intraindividual variation in the ratio of dehydroretinol to retinol because of vulnerability of the dehydroretinol concentration to laboratory errors and to variation in dosing and absorption. Within categories of dehydroretinol:retinol, serum retinol concentration was lower in breast-feeding women than in non-breast-feeding women. Thus, it may be necessary to use different cutoff values for the ratio and for serum retinol concentration. Serum retinol concentration, which was just above marginal (0.85 mumol/L), had the smallest within-person variation and was also the most sensitive indicator for detecting a difference between groups in change in vitamin A status postintervention, requiring only 19 subjects per group. Serum RBP concentration, breast-milk vitamin A expressed per volume or per gram milk fat, and the MRDR method required groups of 35, 36, 139, and 53 subjects, respectively.

PIP: Although serum retinol concentration is the most widely used biochemical method for assessing vitamin A status, it is not sensitive to changes over a wide range of vitamin A status and is temporarily lowered during infections. Alternative indicators of vitamin A status--breast milk vitamin A concentration, serum retinol binding protein (RBP) concentration, and the modified relative dose response (MRDR) method--were evaluated in a cross-sectional and intervention study of 265 breast feeding women and 49 nonpregnant, non-breast-feeding women from West Java, Indonesia. Concentrations of vitamin A and fat in breast milk were 30% and 20% higher, respectively, for women with a breast-fed child 7-18 months of age than for mothers of a 3-6 month old infant. Sensitivity and specificity for detecting serum retinol concentrations under 0.70 mcmol/l were less than 75% for the concentration of breast milk vitamin A and serum RBP. The MRDR method yielded large intra-individual variation in the ratio of dehydroretinol to retinol because of vulnerability to laboratory errors and variation in dosing and absorption. Within categories of this ratio, serum retinol concentrations were 20-25% lower in breast-feeding women. This finding suggests a need for different cutoff values for the ratio and for serum retinol concentration. Serum retinol concentration had the smallest within-person variation and was the most sensitive indicator for detecting a difference between groups in change in vitamin A status post-nutritional intervention. However, more data are required on breast milk composition and its changes throughout lactation before conclusions can be drawn about how to use breast milk vitamin A as an indicator of vitamin A status.