Maternal Micronutrient Deficiencies in Early Pregnancy and Infant Nutritional Status in Urban South

190 Pages·2013·6.38 MB·English

TINU MARY SAMUEL
Maternal Micronutrient Deficiencies in
Early Pregnancy and Infant Nutritional Status in
Urban South India
ACADEMIC DISSERTATION
To be presented, with the permission of
the Board of the School of Health Sciences
of the University of Tampere,
for public discussion in the Auditorium of
School of Health Sciences, Medisiinarinkatu 3,
Tampere, on June 14th, 2013, at 12 o’clock.
UNIVERSITY OF TAMPERE
ACADEMIC DISSERTATION
University of Tampere, School of Health Sciences
Finland
St. John´s Research Institute, St. Johns National Academy of Health Sciences
India
Supervised by Reviewed by
Docent Suvi M. Virtanen Docent Riitta Freese
University of Tampere University of Helsinki
Finland Finland
Professor Anura V. Kurpad Professor Seppo Heinonen
St. John´s Research Institute University of Eastern Finland
India Finland
Copyright ©2013 Tampere University Press and the author
Cover design by
Mikko Reinikka
Acta Universitatis Tamperensis 1834 Acta Electronica Universitatis Tamperensis 1312
ISBN 978-951-44-9152-8 (print) ISBN 978-951-44-9153-5 (pdf)
ISSN-L 1455-1616 ISSN 1456-954X
ISSN 1455-1616 http://tampub.uta.fi
Suomen Yliopistopaino Oy – Juvenes Print
Tampere 2013
CONTENTS

S No. Contents Page
LIST OF ORIGINAL PUBLICATIONS 9

ABBREVIATIONS 10

ABSTRACT 12

1 INTRODUCTION 14

2 REVIEW OF LITERATURE 18

2.1 PREGNANCY AND MATERNAL MICRONUTRIENT DEFICIENCIES 18
2.1.1 Prevalence and aetiology of anaemia in pregnancy 24
2.1.2 Consequences of anaemia in pregnancy 29
2.1.3 Iron deficiency anaemia 29
2.1.4 Digestion, absorption, transport, storage and uptake of iron 30
2.1.5 Functions of iron 33
2.1.6 Causes of iron deficiency anaemia 33
2.1.7 Consequences of iron deficiency anaemia 34
2.1.8 Functions of vitamin B in the human body 35
12
2.1.9 Digestion, absorption and metabolism of vitamin B 35
12
2.1.10 Dietary sources of vitamin B 37
12
2.1.11 Vitamin B deficiency: biochemical measures for diagnosis 37
12
2.1.12 Vitamin B deficiency: Prevalence in India and other developing and 39
12
developed countries
2.1.13 Causes of vitamin B deficiency in pregnancy 42
12
2.1.14 Consequences of vitamin B deficiency in pregnancy 44
12

2.2 INFANT NUTRITIONAL STATUS 45
2.2.1 Infancy and childhood: 1000 days critical window period 45
2.2.2 Interventions to tackle child malnutrition 47
2.2.3 Advantages of breastfeeding for the mother and the child 49
2.2.4 Exclusive breastfeeding: prevalence and barriers 50
2.2.5 The Baby friendly hospital initiative 51
2.2.6 Methods of assessing breast milk intake in infants 52
2.2.7 Dose to mother deuterium dilution method 53
2.2.8 Breast milk intake in infants 56
2.2.9 Functions of zinc in human health 59
2.2.10 Sources of dietary zinc 62
2.2.11 Maternal zinc intake and breast milk zinc concentrations 62
3
2.2.12 Absorption and intake of zinc through breast milk 65
2.2.13 Zinc status and deficiency among breastfed infants 66

2.3 MATERNAL AND CHILD NUTRITION AND HEALTH IN INDIA 68

2.4 QUALITY OF MATERNAL HEALTH CARE IN INDIA 69
3 AIMS OF THE STUDY 71
4 STUDY METHODS 74

4.1 Subject recruitment and eligibility criteria 74
4.2 Characteristics of study subjects 75
4.3 Ethical considerations 76
4.4 Sociodemographic data and gestational age at recruitment 77
4.5 Maternal anthropometry 77
4.6 Infant anthropometry 78
4.7 Maternal dietary data 79
4.8 Infant dietary intake 81
4.9 Infant morbidity data 82
4.10 Haematology data 82
4.11 Biochemical and microbiological data 83
4.12 Statistical analyses 85

5 STUDY RESULTS 88

5.1 Haematological and biochemical characteristics of pregnant women in 88
early pregnancy.
5.2 Prevalence of anaemia and associated parameters in early pregnancy 89
5.3 Prevalence of vitamin B deficiency and associated biochemical 90
12
indicators in early pregnancy
5.4 Nutrient intake in pregnant women during early pregnancy 91
5.5 Food intake among pregnant women in early pregnancy 92
5.6 Nutritional and sociodemographic risk factors for anaemia among 93
pregnant women in early pregnancy
5.7 Nutritional, sociodemographic and anthropometric risk factors for low 95
plasma vitamin B concentrations among pregnant women in early
12
pregnancy
5.8 Nutritional, sociodemographic and anthropometric risk factors for 97
impaired vitamin B status among pregnant women in early pregnancy
12
5.9 Association between plasma vitamin B concentration and MMA level 99
12
and vitamin B concentration and Hcy level among South Indian
12
pregnant women

5.10 Infant weight and length at birth and up to 6 months of age 101
5.11 WHO standardised Z scores of infants at birth and until 6 months of age 102
4
5.12 Breast milk and non breast milk water intake of infants at months 1, 3 103
and 6
5.13 Compliance to exclusive breastfeeding based on “dose-to-mother” 104
deuterium dilution method
5.14 Transfer of breast milk zinc from mother to the infant and maternal and 105
infant serum zinc measures at months 1, 3 and 6

6 DISCUSSION 107

7 CONCLUSION 121

8 RECOMMENDATIONS FOR FUTURE RESEARCH 123

ACKNOWLEDGEMENTS 124

REFERENCES 126

5
LIST OF TABLES

Table
Table title
no. Page

1 Causes of micronutrient deficiencies
19

2 Prevalence and risk factors for anaemia among pregnant women from India
and other developing countries during early and late pregnancy 27

3 Prevalence of vitamin B deficiency among pregnant women from India and
12
other countries during early and late pregnancy. 40

4 Evidence based interventions to combat under nutrition developed by Scaling
Up Nutrition 47

5 Health benefits of breastfeeding for infant and the mother
49

6 Barriers to exclusive breastfeeding
51

7 Breast milk intakes of infants reported using the test weighment and “dose to
mother” deuterium dilution method 57

8 Salient features of the National Family Health survey 2005-2006 (maternal and
child nutrition) 69

9 Haematological and biochemical characteristics of pregnant women in early
pregnancy. 88

10 Mean (SD) nutrient intake in pregnant women during early pregnancy
91

11 Transfer of breast milk zinc from mother to the infant and maternal and infant
serum zinc measures at months 1, 3 and 6 105

6
LIST OF FIGURES

Figure Figure title Page
no.
1 Intergenerational effects of poor nutrition 20

2 Pathways through which maternal diet and micronutrient status 22
may affect the development of chronic disease in the offspring

3 Iron digestion, absorption, enterocyte use and transport 31
4 Determinants of child nutrition 46

5 Interventions to improve maternal and child nutrition 48

6 Two compartment model for transfer of human milk from mother 54
to the infant

7 Breast milk zinc concentration in lactating mothers from studies
across India and other countries 64

8 Framework of the thesis 72

9 Hosahalli Referral Maternity Health Care centre, Bangalore 75

10 St. Johns Medical College and Hospital, Bangalore 76

11 Measurement of maternal weight and height by trained research 78
assistants.

12 Administration of dietary data using standard cups and measures 81

13 Collection of blood sample and analyses for Hb and complete 83
blood count on an automated coulter

14 Prevalence of anaemia and associated parameters in early 89
pregnancy

15 Prevalence of vitamin B deficiency and associated biochemical 90
12
indicators in early pregnancy

16 Median intakes of food groups among pregnant women in early 92
pregnancy

17 Nutritional and sociodemographic risk factors for anaemia among 93
pregnant women in early pregnancy in the multivariable log
binomial regression analysis
7
18 Nutritional, sociodemographic and anthropometric risk factors for 95
low plasma vitamin B concentrations among pregnant women in
12
early pregnancy in the multivariable Poisson regression analysis

19 Nutritional, sociodemographic and anthropometric risk factors for 97
impaired vitamin B status among pregnant women in early
12
pregnancy in the multivariable log binomial regression analysis

20a Association between plasma vitamin B concentration and MMA 99
12
level and vitamin B concentration and Hcy level among South
12
Indian pregnant women

20b Association between plasma vitamin B concentration and Hcy 99
12
level among South Indian pregnant women.

21 Infant weight and length at birth and up to 6 months of age 101

22 WHO standardised Z scores of infants at birth and until 6 months 102
of age

23 Breast milk and non breast milk water intake of infants at months 103
1, 3 and 6

24 Compliance to exclusive breastfeeding based on “dose-to-mother” 104
deuterium dilution method

8
LIST OF ORIGINAL PUBLICATIONS

1) Tinu Mary Samuel, Tinku Thomas, Julia Finkelstein, Ronald Bosch, Ramya
Rajendran, Suvi M Virtanen , Krishnamachari Srinivasan, Anura V Kurpad, Christopher
Duggan (2012) Correlates of anaemia in pregnant urban South Indian women: a possible
role of dietary intake of nutrients that inhibit iron absorption. Pub Health Nutr May
11:1-9. DOI: http://dx.doi.org/10.1017/S136898001200119X.

2) Tinu Mary Samuel, Christopher Duggan, Tinku Thomas, Ronald Bosch, Ramya
Rajendran, Suvi M Virtanen, Krishnamachari Srinivasan, Anura V Kurpad (2013).
Vitamin B intake and status in early pregnancy among urban South Indian women.
12
Ann Nutr Metab 62:113–122. DOI: 10.1159/000345589.

3) TM Samuel, T Thomas, S Bhat, AV Kurpad (2012) Are infants born in baby-friendly
hospitals being exclusively breastfed until 6 months of age? Eur J Clin Nutr 66(4), 459-
65. DOI: 10.1038/ejcn.2011.179.

4) Tinu Mary Samuel, Tinku Thomas, Prashanth Thankachan, Swarnarekha Bhat, Suvi
M Virtanen, Anura V Kurpad (2012) Breast milk zinc transfer and early postnatal growth
among urban South Indian term infants using measures of breast milk volume and breast
milk zinc concentrations. Matern Child Nutr June 27. DOI: 10.1111/j.1740-
8709.2012.00421x.

9
ABBREVIATIONS

ACC/SCN Administrative Committee on Coordination/Sub-committee
on Nutrition

ANOVA Analysis of variance

RMANOVA Repeated measures analysis of variance

BFH Baby-friendly hospitals

BFHI Baby-friendly hospital Initiative

BMI Body mass index

CI Confidence interval

DCT Divalent cation transporter

DMT Divalent metal transporter

DOPA Dihydroxyphenylalanine

DRI Dietary reference intake

FAO Food and Agriculture Organization

FFQ Food frequency questionnaire

HAZ Height for age Z score

Hb Haemoglobin

Hcy Homocysteine

HCZ Head circumference for age Z score

Holo TC Holotranscobalamine

IAEA International Atomic Energy Agency

10