No abstract

Summary. The effect of two levels of energy supplementation in the last trimester of pregnancy on birthweight was tested in a controlled randomized trial in three villages in Madura, East Java. The high and low energy supplements provided 1·95 MJ (465 kcal) and 218 kj (52 kcal) per day respectively. In the baseline period the home diet provided on average 6·28 MJ (1500 kcal) (SD 2·1 MJ (499 kcal)) and41g(SD 13 g) of protein. The mean birthweight was 2835 g and the rate of low birth‐weight 12·2%. In the experimental period the home diet was better. The average intake ranged from 6·45 to 7·19 MJ (1541–1717 kcal) and 41·4–44·2 g per day, depending on the degree of compliance. Mean birth‐weight increased by 100 g and the rate of low birthweight dropped to 9·5%. There was no difference between the high and low energy supplemented group as a whole, probably due to the masking effect of the better home diet in the experimental period. It is likely that a positive effect of energy supplementation on birthweight was restricted to the group of pregnant women with the lowest home dietary intake and/or a low prepregnant weight. In this community targeting of supplementation to lean seasons and/or to women with a low prepregnant weight may be cost‐effective.

Based on the dietary energy supply per person per d and a minimum energy requirement of 1.4 X basal metabolic rate (BMR), it is estimated that 11-32% of adults in developing countries were undernourished (Food and Agriculture Organization, 1990). Even if adequate amounts of food are available, unequal food distribution favouring men over women and cultural taboos may restrict food intake of women. Since they are usually engaged in productive activities which entail a substantial energy expenditure (McGuire & Popkin, 1989), it is likely that the majority of undernourished adults in developing countries are women. Indeed, most publications from developing countries report low energy intakes of women, particularly during pregnancy and lactation. The high incidence of low birth weight and growth faltering at an early age have been attributed to maternal undernutrition. While there is no disagreement about the adverse effects of acute and severe energy deficits on the outcome of pregnancy and lactation (Stein et al. 1975;Prentice, 1980), no consensus has yet been reached on the relationship between maternal nutrition and reproductive performance in communities having marginal energy intakes either seasonally or chronically (Rush, 1983; National Academy of Sciences, 1990Sciences, , 1991. Maternal depletion over the course of numerous reproduction cycles is an often hypothesized but little measured phenomenon (Merchant et al. 1990a,b).Results of recent studies indicate that, in industrialized countries, healthy pregnant and lactating women who can eat to appetite do not increase their dietary energy intake to the degree recommended (World Health Organization, 1985), with no resulting impairment of their reproductive function (Whitehead et al. 1981;Durnin, 1987; National Academy of Sciences, 1990;van Raaij et al. 1991). The longitudinal study on energy requirements of apparently healthy pregnant women which included three developing countries (The Philippines, Thailand, The Gambia) did not show a consistent pattern of reproductive physiology (Durnin, 1987). The main problem lies in the concept of 'apparently healthy'. On the other hand, the extra energy requirement during lactation in developing countries may approach the dietary recommendation (Frigerio et aI. 1991;Madhavapeddi & Rao, 1992).The calculated energy requirements in pregnancy and lactation (World Health Organization, 1985) or observed energy intakes of apparently healthy women in industrialized countries bear little relationship to the needs of many Third World women who are poorly nourished to start with. For practical purposes it is more relevant to assess at which level of maternal energy status, child and maternal outcomes of reproduction are compromised.Studies in The Gambia show that seasonal fluctuations in energy intake were reflected in concomitant weight changes of pregnant and lactating women, mean birth weight and the quantity and quality of breast milk were reduced, the incidence of low birth weight increased (Prentice, 1980). The improve...

The effect of prenatal energy supplementation on maternal anthropometry was assessed in a controlled, randomized trial in Madura, East Java. At 26-28 wk of gestation women were either given 465 kcal/d (HE group) or 52 kcal/d (LE group). Two hundred seventy-six women were enrolled in the HE group and 266 women, in the LE group. Supplement intake was variable. Testing of effect by treatment and compliance was thus done by subcategories (HE 1-3 and LE 1-3, corresponding to less than 45, 45-89, and greater than or equal to 90 packets of supplement consumed). Analysis of variance did not show significant differences among the six subcategories in third-trimester weight gain, sum of skinfold thicknesses, 4-wk postpartum weight, or body mass index. In this population energy supplementation for the short duration of the last 90-110 d of pregnancy was not sufficient to improve maternal nutrition as judged by anthropometry.

Between January 1987 and July 1988, all children born in two villages on the island of Madura, Indonesia were visited weekly by a field worker trained to interview mothers on disease symptoms. The maximum recall period was 1 week. All infants were measured (weight and height) at monthly intervals. Information on growth and morbidity is analysed for infants from birth until the age of 11 months. Morbidity, defined as acute respiratory tract infection (ARI), diarrhoea, fever and other diseases, is analysed over 4-week periods and related to growth performance. In total, there are 1373 4-week reporting periods with morbidity information from birth to the age of 12 months. Of all the diseases recorded (1021), 47% were ARI, 13% diarrhoea, 14% fever and 26% other diseases. The average (SD) duration of diarrhoea was 7 (11) days, ARI 14 (9) days, fever 6 (4) days and 16 (10) days for other diseases. The most striking results in this analysis are: (i) the lack of a relationship between morbidity and growth (either linear or weight) during the 1st 6 months of life; (ii) the existence of a relationship between illness and weight increment for which only ARI showed significant influence for infants of 6 months and more; (iii) the lack of a relationship between morbidity and linear growth performance at all ages; and (iv) the fact that no cumulative effect of disease on growth performance was found to explain the observations.