The interactive effects of dietary quality on the growth and attained size of young Mexican children.

Predictors of attained size at 30 mo and growth rate between 18 and 30 mo (eg, diet, maternal size, morbidity, age at weaning, and selected environmental factors) were investigated by using longitudinal data from 67 Mexican children aged 18-30 mo. These children were small because of growth stunting in early infancy. Between 18 and 30 mo they grew on average at the 50th percentile of National Center for Health Statistics references values for weight, and the 25th for length. Size at 30 mo and growth rates were unrelated to energy or protein intakes during the previous year, but positively related to consumption of animal-origin foods. Maternal weight predicted size and growth only for children with larger intakes of animal products. Individual rates of weight and length growth were uncorrelated on average, correlated negatively when animal-product intake was low, and positively only when more animal products were consumed. Integrated weight and length growth, and the influence of maternal size on growth, may be disrupted by poor dietary quality. Different children would be identified as malnourished depending on whether weight or length growth was measured.

Methodological issues for eliciting local signs/symptoms/illness terms associated with acute respiratory illnesses.

Acute respiratory infections (ARI) are among the principal causes of mortality of children under 5 years of age. Most deaths are due to pneumonia, which, when timely identified and properly treated, could be avoided. An effective case management scheme, based on early recognition of pneumonia and prompt antibiotic treatment, relies on early recognition of alarm signs by mothers and community health workers. For mothers to understand and act on advice from health workers, language and concepts commonly used by mothers should be utilized. The present study was carried out to compare the relative effectiveness of two different methods to elicit local terms used by mothers to refer to ARI symptoms/signs/treatments. A comparison was made among the terms elicited by a free listing of common terms mentioned by mothers in relation to ARI, and the terms they recognized when looking at a video that showed children with different ARI signs. The video was shown in a community and a clinical setting, in order to identify strengths and weaknesses of showing it in these settings. The video elicited more signs dealing with serious illness, respiratory distress and general malaise, but missed non-visual signs, such as fever, lack of appetite or pain. Also, mothers tended to be distracted by trivial signs, such as skin color. Free listing was easier to administer and elicited more non-life-threatening symptoms/signs, but mothers were more prone to drift away and mention terms not related to respiratory illness. Showing the video in the clinic elicited more medical-related terms, and was easier to show than in the community. In conclusion, choice of either of the two methods depends on the researcher's purpose. Using both methods produced a larger list of terms associated with ARI.

Determinants of body size perceptions and dieting behavior in a multiethnic group of hospital staff women.

OBJECTIVE: This study was designed to identify determinants of body size perceptions and their relationship to dietary behavior in a multiethnic group of women. DESIGN: A single interview consisting of the Massara and Stunkard body image cards (1979) and questionnaires on sociocultural background, anthropometry, and dieting history were administered to volunteers from the staff of a hospital. SUBJECTS: The sample was a convenience sample of 186 women representing a range of staff positions recruited from Methodist Hospital in Brooklyn, NY; 174 completed the study. Data on 150 women are presented in this article. RESULTS: Height and weight-for-height were stronger predictors of accuracy of perceived body size than ethnicity. Tall, slight women were more likely to overestimate and short, heavy women were more likely to underestimate actual body size. Ethnicity had an interactive effect with height as taller European Americans were more likely to perceive their body size as larger than actual compared with Afro-Caribbeans and African Americans. Women with a history of dieting were more likely to overestimate their size and to view it as different from what is perceived as attractive to others. APPLICATIONS/CONCLUSIONS: Based on the results, we conclude that body size is a stronger predictor of accuracy of perceived body size than ethnicity; and dieters overestimate their body size and believe it to be heavier than their social group would prefer.

Biological and sociocultural determinants of successful lactation among women in eastern Connecticut.

Postpartum factors affecting the duration of lactation were identified for 250 women through a telephone survey. The survey examined the behaviors and attitudes of women who had chosen to nurse and who were still nursing at 2 weeks postpartum. Sixty percent of the mothers nursed their infants after delivery. However, by 10 weeks postpartum, only 34% of the babies were still breast fed. By self-report, the most significant factors associated with the maintenance of lactation at 10 weeks were related to perinatal hospital protocol, especially letting the infant suckle soon after birth. Other significant predictors of successful lactation outcome included early milk "let down," little use of supplemental formula, the mother's expectation at parturition of an extended nursing period, her feeling well and being satisfied with her body weight, her previous successful experience with lactation, and her perception that she feeds her infant on demand. Few of the women who had stopped nursing after 2 weeks sought advice on breast feeding from anyone other than the pediatrician. Most coped with their nursing problems themselves. The data reinforce the importance of labor and delivery practices that support early maternal-infant contact. They also suggest the use of infant health indexes and weight and height percentile placement records rather than reliance solely on weight gain as the index of lactation adequacy. Further, they indicate the need for clinical intervention before 2 weeks postpartum.

Developing new options in home-delivered meals: the SMOC demonstration elderly nutrition project.

The purpose of this project was to design and test alternative approaches to in-home nutrition services for the elderly. Two meals systems--weekly delivery of five frozen meals and the daily delivery of hot meals--were evaluated for client approval, effect on clients' social contacts, and costefficiency. The alternative frozen meals system met with clients' acceptance, maintained clients' usual social patterns, and produced a cost savings of at least 16%. The development of a more flexible approach to home-delivered meals offers possibilities both for better serving clients' needs and for improving cost efficiency. It therefore has implications for elderly nutrition services nationwide.

Cultural issues in maternal and child health and nutrition.

Social science research on cultural issues in maternal and child health has stressed some aspects and neglected others. From the perspective of both policy applications and theory development, new research efforts could profitably be directed to the following areas: cultural adjustments to changed energy and nutrient requirements in pregnancy and lactation; maternal illness; the mother/infant dyadic interaction; emic views of growth and development; determinants of infant and young child feeding; management of childhood illnesses; popular medicine and childhood illnesses; intra-household food distribution; household composition and maternal and child health; and macrolevel/microlevel linkages and health.

Developing applied medical anthropology in Third World countries: problems and actions.

Recognition of the usefulness of ethnographic research in Third World community health projects and programs developed rapidly during the 1980s. As a result, the various agencies and organizations promoting community health programs (UNICEF, WHO, NGOs) have greatly increased their recruiting of social scientists, particularly medical anthropologists, for research and other programmatic activities in primary health care, child survival (especially diarrhea, acute respiratory infections, maternal and child nutrition, infectious disease, and AIDS). However, it has proved very difficult to identify well-trained anthropologists and/or other social scientists for these roles, particularly in Third World countries. This paper examines some of the background of this problem, and presents examples of methodological training (in both qualitative and quantitative research techniques) that seek to increase the skills of social scientists and other researchers in the arena of international community health.

Examining the gender gap in nutrition: an example from rural Mexico.

Gender differences in nutrient and food intake were examined in Mexican Nutrition CRSP (Collaborative Research Support Program) infants (N = 75), preschoolers (N = 80), and school children (N = 91). No significant gender differences in dietary quality or quantity were seen for infants and preschoolers. For school children, the contribution of various foods to total energy intake (dietary quality) was also quite similar for girls and boys. Equity in dietary quality remained even under conditions of economic and demographic stress. Nevertheless, school girls consumed significantly less energy per day than boys (-300 kcal/d or 1.3 mJ/d), and less of all micronutrients examined. Gender differences in estimated basal metabolic rates of school children were slight (-20 kcal/d), and body composition and size were similar. When energy intakes were expressed as a percent of estimated requirement (calculated from age, sex and weight using WHO/FAO/UNU equations), intakes were adequate and not significantly different between girls (mean = 111%) and boys (mean = 113%). Playground observations showed girls to be less active than boys, which may reflect both cultural and biological influences. Apparently due to this lower activity, school girls consumed less energy, and may have been at much higher risk than boys of micronutrient deficiency. The lower food intakes of girls did not appear to be due to purposeful dietary discrimination, but rather to culturally patterned sex roles involving lower activity.

Household size, food intake and anthropometric status of school-age children in a highland Mexican area.

Large household size is widely regarded as a risk factor for malnutrition in developing countries, particularly for infants and young children. This study examines the extent to which household size is related to nutritional status in school-age children in the Solis Valley in highland Mexico. The relationships of food intake, anthropometric measures, and household size are assessed in a sample of 110 children (7-9 years of age), who were followed longitudinally for a minimum of one year as part of the Collaborative Research Support Program on Food Intake and Human Function. Diets in the valley are characterized by very low intake of animal food products and are heavily dependent on maize, which is primarily home-produced. Growth faltering is pervasive; the mean Z score for height-for-age in the sample is--1.6 of the NCHS reference standard. Children from larger households are significantly shorter and consume diets of poorer quality, as assessed by intake of foods from animal sources. These relationships remain statistically significant in regression analyses that control for household economic status. It therefore appears that the resources available to households in the Solis Valley are inadequate to buffer children in even more advantaged households from the stresses of maintaining large families.

Rapid ethnographic assessment: applications in a diarrhea management program.

This paper reports on a rapid ethnographic assessment methodology (REA) that was developed as an essential component of the dietary management of diarrhea (DMD) program. The DMD program is an interdisciplinary research project that has been developed to design intervention programs to reduce or eliminate the nutritional complications of diarrhea in Peru and Nigeria. Anthropological data gathering was an important component of the intervention design, but time and budgetary constraints required a rapid methodological approach. This paper outlines the REA methodology, describes the advantages and disadvantages of the approach, and discusses future applications for international primary health care interventions.

Pulque intake during pregnancy and lactation in rural Mexico: alcohol and child growth from 1 to 57 months.

OBJECTIVE: To examine maternal intake of a mildly alcoholic beverage (pulque) during pregnancy and lactation, and its potential effect on postpartum child growth and attained size. DESIGN: A prospective cohort study that followed mothers (during pregnancy and lactation) and their offspring (from birth to approximately 57 months of age). SETTING: Six villages in rural, central Mexico. SUBJECTS: Subjects are 58 mother-child pairs. Pulque intake was measured as part of a dietary assessment that was conducted for 2days/month during pregnancy and early lactation. RESULTS: Most mothers consumed pulque during pregnancy (69.0%) and lactation (72.4%). Among pulque drinkers, the average ethanol intake was 125.1 g/week during pregnancy and 113.8 g/week during lactation. Greater pulque intake during lactation, independent of intake during pregnancy, was associated with slower weight and linear growth from 1 to 57 months, and smaller attained size at 57 months. Low-to-moderate pulque intake during pregnancy, in comparison to either nonconsumption or heavy intake, was also associated with greater stature at 57 months. CONCLUSIONS: Pulque intake during lactation may have adversely influenced postnatal growth in this population. Public health interventions are urgently needed in Mexico to reduce heavy intake of pulque by pregnant and lactating women, and to replace intake with foods that provide the vitamins and minerals present in the traditional alcoholic beverage.

Focused ethnographic studies in the WHO Programme for the Control of Acute Respiratory Infections.

Focused Ethnographic Studies (FESs), developed and sponsored by the World Health Organization (WHO) Programme for the Control of Acute Respiratory Infections (ARI), have facilitated ethnographic research dedicated to determining key household behaviors and understandings surrounding respiratory infections--particularly pneumonia--in children. The FES design emphasizes anthropological theory and methods while limiting the scope and duration of fieldwork to a specific "program-relevant" research problem. Findings from FES studies provide evidence of the rich vocabulary of ARI-related signs and concepts, and the interplay of structural and cultural factors that affect care-seeking for children with pneumonia.

Research on determinants of breastfeeding duration: suggestions for biocultural studies.

PIP: The main purpose of this paper is to suggest directions for future intra-cultural research on the factors that affect breastfeeding duration, especially policy-oriented research. A 2nd purpose is to call for a reexamination of the theoretical construct, biocultural determinants, with respect to infant feeding. The study compares determinants in 4 multivariate studies. One was carried out in Connecticut, 1 in a working class community in Scotland, another in England and the 4th in Sweden. Almost no biological factors are strongly associated with breastfeeding duration in any of the population studied. Of the external factors, those relating to social support and advice were the most consistent predictors. Socioeconomic status, income, and work outside the home were not good predictors. Maternal attitudes and experience are of great importance in predicting feeding duration. The general picture that emerged from all the studies is that if a mother wants to breastfeed, she can. Mothers breastfeed longer if they desire to breastfeed; they intend to do it for a longer period of time; they feel comfortable feeding in public; they are informed about breastfeeding; and they are not anxious about the process. There is also fairly strong evidence linking a number of biocultural factors to feeding duration. Whether the linkage is biological or behavioral has significant policy implications: if it is biological, successful intervention would require a change in hospital practices to earlier 1st feeding; if the linkage is behavioral, the problem might be resolved through improved maternal education.^ieng

Studying knowledge, culture, and behavior in applied medical anthropology.

In this article we argue that the concept of knowledge, as utilized by public health professionals, is best regarded as cultural belief, as defined in anthropology. The implications of this position are explored, particularly as it relates to the development of a decision-making approach to the understanding and analysis of health care behavior. The methodological challenges posed by the new theoretical perspective that has emerged from the emphasis on decision making is discussed from the perspective of applied research. The role of focused ethnographic studies is examined and contrasted with ethnomedicine and survey approaches. Some main features of focused ethnographic methods are described and illustrated with a case example of acute respiratory infection (ARI) in Gambia.

Plot and see! Maternal comprehension of growth charts worldwide.

OBJECTIVE: To evaluate maternal comprehension of growth charts used in growth monitoring and promotion (GMP), a worldwide programme with important budgets but contrasting results. METHODS: Systematic literature review through MEDLINE, POPLINE, Global Health, ERIC and the Cochrane Library with the keywords 'growth monitoring' or 'growth chart' limited to the title/abstract field and to the 0-5 years age range. RESULTS: Twenty studies from Asia (8), Africa (8) and Latin America/Caribbean (3) were included in the review. The results of the 14 non-intervention, cross-sectional studies provide convincing evidence that a third to three-fourths of carers in developing countries do not understand the growth charts. Literacy had a strong effect on women's ability to interpret the cards. Appropriate training and educational activities also increased substantially maternal comprehension as demonstrated in five of the six intervention trials. CONCLUSIONS: Many carers have poor comprehension of growth charts, but their comprehension increases not only with literacy, but also with training. Activities aimed at improving communication skills of health staff and at empowering parents to practice responsive parenting could greatly improve GMP outcomes.

The nutritional phenotype in the age of metabolomics.

The concept of the nutritional phenotype is proposed as a defined and integrated set of genetic, proteomic, metabolomic, functional, and behavioral factors that, when measured, form the basis for assessment of human nutritional status. The nutritional phenotype integrates the effects of diet on disease/wellness and is the quantitative indication of the paths by which genes and environment exert their effects on health. Advances in technology and in fundamental biological knowledge make it possible to define and measure the nutritional phenotype accurately in a cross section of individuals with various states of health and disease. This growing base of data and knowledge could serve as a resource for all scientific disciplines involved in human health. Nutritional sciences should be a prime mover in making key decisions that include: what environmental inputs (in addition to diet) are needed; what genes/proteins/metabolites should be measured; what end-point phenotypes should be included; and what informatics tools are available to ask nutritionally relevant questions. Nutrition should be the major discipline establishing how the elements of the nutritional phenotype vary as a function of diet. Nutritional sciences should also be instrumental in linking the elements that are responsive to diet with the functional outcomes in organisms that derive from them. As the first step in this initiative, a prioritized list of genomic, proteomic, and metabolomic as well as functional and behavioral measures that defines a practically useful subset of the nutritional phenotype for use in clinical and epidemiological investigations must be developed. From this list, analytic platforms must then be identified that are capable of delivering highly quantitative data on these endpoints. This conceptualization of a nutritional phenotype provides a concrete form and substance to the recognized future of nutritional sciences as a field addressing diet, integrated metabolism, and health.

The role of behavioral research in the prevention and management of invasive diarrheas.

Reduction in the prevalence of invasive diarrheal diseases can be facilitated by the development of models for systematic examination of behavioral risk factors that are associated with these illnesses. These factors include insufficient use of health care services, noncompliance with treatment, unhygienic behaviors, employment of poor feeding practices for infants and young children, and inappropriate handling of foods. Information on conditions that facilitate or constrain appropriate behaviors will assist the development of programs for the prevention and management of invasive diarrheas.

Integrated management of childhood illness: challenges from the community.

PIP: Following an integrated approach to the management of childhood illnesses provides an opportunity to increase the effectiveness of the delivery of primary health care services through the efficient use of case management interventions. However, the potential impact of this approach to morbidity and mortality depends ultimately upon its use, and various constraints to use exist. There are constraints that are characteristics of the services themselves (such as long waiting lines); there are constrains within households (ideational, psychological, and socioeconomic); and there are constraints within communities (systems of transportation as well as geographic and social barriers). Unfortunately, inadequate theory exists to facilitate efforts to overcome the constraints which require behavioral and social change. This is due, in part, to the low priority placed by societies on the development of applied social science, as contrasted with biomedical science. Whereas the main factors that affect the utilization of health resources are well known, the relative importance of these factors in different conditions and situations (and their mechanisms of interaction) are not understood. Therefore, strategies which work in one context fail in another. This situation will continue until efforts are made to develop more systematic approaches to these experiences. However, the main challenge is to apply existing research tools and techniques and develop new ones which will permit the measurement and analysis of social and behavioral variables in a way that contributes to our understanding of them. The successful institutionalization of integrated management of childhood illness will also require the adaptation of generic guidelines to local communities. This process depends upon information on community beliefs and practices as well as on ways to use such information. Current techniques, such as rapid assessment procedures and focused ethnographic studies, must be further refined to meet this challenge.^ieng