Evaluation of hospital dietic services in seven Caribbean countries

OBJECTIVE: To improve the delivery of dietic services in hospitals in the Caribbean, an assessment was carried out of the extent to which nutrition intervention was included in the medical management of patients. METHODS: The documentation of the nutritional intervention at secondary care facilities was the focus of a medical record audit of hospitalised patients. Medical records from 491 patients in 88 wards from 15 hospitals in Monsterrat, Jamaica, Guyana, British Virgin Islands, Grenada, Dominica and St. Vincent were audited. In each hospital at least 20 percent of the medical records of inpatients were audited. The medical records were randomly selected from each ward and were audited for selected anthropometric data, height and weight measurements, laboratory and clinical data, diagnosis, diet prescription and documentation of a "nutrition note" by dietetic personnel as well as nutrition-specific information in the "progress notes" and "nurses notes". RESULTS: The provision of nutrition intervention was relatively low or not adequately documented by any category of the relevant health care staff (medical, nursing and dietetic) in any of the countries. Except for anthropometric data, there was adequate baseline information (diagnosis, laboratory and clinical data) to initiate nutrition intervention. The absence of a diet prescription by the physician in more than 50 percent of the records in most countries indicated that insufficient attention is being paid to the contribution of nutrition in the delivery of medical care. Of the 15 hospitals assessed, 8 were operating without a professional dietitian or nutritionist. CONCLUSIONS: While primary prevention remains a main focus, we must provide adequate care and rehabilitation for those already afflicted. The study shows that there is a clear need to strengthen the nutritional care offered to hospitalized clients in the Caribbean so as to facilitate their early rehabilitation and quick return to productivity in society. At the forefront of realizing this goal is the availability of adequate resources in nutrition, specifically, human resources. (AU)

Influence of ascorbic acid on iron absorption from a iron-fortified, chocolate-flavored milk drink in Jamaican children

The influence of ascorbic acid on iron absorption from an iron-fortified, chocolate-flavored milk drink (6.3 mg total Fe per serving) was evaluated with a stable-isotope technique in 20 6-7-y-old Jamaican children. Each child received two test meals labeled with 5.6 mg 57Fe and 3.0 mg 58Fe as ferrous sulfate on 2 consecutive days. Three different doses of ascorbic acid (0, 25, and 50 mg per 25-g serving) were evaluated in two separate studies by using a crossover design. Iron isotope ratios were measured by negative thermal ionization mass spectrometry. In the first study, iron absorption was significantly greater (P < 0.001) after the addition of 25 mg ascorbic acid; geometric mean iron absorption was 1.6 percent (range; 0.9-4.2 percent) and 5.1 percent (2.2-17.3 percent) for the test meals containing 0 and 25 mg ascorbic acid, respectively. In the second study, a significant difference (P < 0.05) in iron absorption was observed when the ascorbic acid content was increased from 25 to 50 mg: geometric mean iron absorption was 5.4 percent (range: 2.7-10.8 percent) compared with 7.7 percent (range: 4.7-16.5 percent), respectively. The chocolate drink contained low iron absorption without added ascorbic acid shows that chocolate milk is a poor vehicle for iron fortification unless sufficient amounts of an iron-absorption enhancer are added. Regular consumption of iron-fortified chocolate milk drinks containing added ascorbic acid could have a possible effect on iron nutrition in population groups vulnerable to iron deficiency(AU)

The Jamaican childhood cardiovascular risk status study; blood pressure in Jamaican school children, relationship to body size and composition - abstract

Hypertension is one of the most prevalent chronic cardiovascular diseases and is the leading cause of death in the Caribbean as well as in the developed countries. Childhood blood pressure is predictive of hypertension in adulthood. Risk factors for hypertension, including body composition, are often present in childhood when they may be modified in order to contribute to primary prevention of hypertension. As part of a study of risk factors for cardiovascular disease, we measured blood pressure (BP) and anthropometry in Jamaican schoolchildren. Anthropometric and demographic variables were analysed to explain the variance of blood pressure in the children. A total of 2332 children (1046 males; 1286 females) were studied. Their ages ranged from 6 to 16 years. Boys and girls were similar in age. Mean diastolic and systolic blood pressures were similar in boys and girls' pulse rate was significantly higher than in boys. Boys had significantly greater Waist-Hip Ratio (0.82 vs 0.76; p<0.0001) and Lean Body Mass (34.2 vs 33.20 kg; p=0.006). Girls had significantly greater weight (42.3 vs 39.5; p<0.0001); Height (150.6 vs 148.9; p=0.005); BMI (18.2 vs 17.3; p<0.0001); MUAC (21.5 vs 20.8; p<0.0001); Hip Circumference (79.5 vs 73.9; p<0.0001); Triceps Skinfold (11.6 vs 8.3; p<0.0001); Per cent Body Fat (19.5 vs 11.6; p<0.0001); Fat Weight (9.1 vs 5.2; p<0.0001). Systolic BP increased steadily with age from 101 ñ 9.9 mm Hg at 6 years to 112 ñ 8.5 mm Hg at 16 years. Systolic BP was significantly correlated with weight, height, BMI, MUAC, WH Ratio, fat mass and lean body mass on univariate analysis but only weight and lean body mass were independently correlated (p<0.0001 for both variables). There was a significant age-sex interaction on Systolic BP (p<0.0001) but only at age 15 years were the mean BPs significantly different (boys vs girls = 119 ñ 15.2 vs 107.8 ñ 10.8; p<0.001). Diastolic BP increased less steeply with age. Significant predictors were MUAC and hip circumference (p<0.0001 and p<0.002, respectively). The data reveal significant correlation between anthropometric variables and blood pressure. This could provide an opportunity for intervention and primary prevention of hypertension (AU)

The Jamaican childhood cardiovascular risk status study: serum total cholesterol concentration in Jamaican schoolchildren - abstract

The pathogenesis of atherosclerosis occurs over decades and begins in childhood. Hypertension, elevated serum cholesterol levels and obesity are major risk factors for the development of cardiovascular disease. In population-based studies, the presence of these two risk factors in childhood has been shown to be predictive of hypertension and hypercholesterolaemia in adulthood and ultimately of coronary heart disease mortality rates. There is evidence that much of the risk of developing hypercholesterolaemia is due to exposure to an unfavourable environment. Therefore it should be possible to reduce or eliminate this risk. In this study of 2337 Jamaican school children aged 6 to 16 years, girls were found to have higher cholesterol levels than boys (4.2ñ0.82vs4.1ñ0.83mM;p<0.003). At all ages (except 11), the cholesterol concentration in girls was higher than in boys, and girls had significantly more body fat. Cholesterol levels were found to be associated with socio-economic status (SES), 4.0mM in children from the lowest SES and 4.4mM in those from the highest (p<0.0000). Multiple regression analysis revealed signigicant correlation between cholesterol, weight, body fat and SES. This result for SES is different from studies in the developed world which report an inverse relationship between cholesterol and SES. In our population there was also correlation between SES and height and weight. Obesity and weight are important contributors to the risk of developing hypercholesterolaemia. Differences in dietary intake and levels of activity between the SES groups may contribute to this difference. The greater adiposity evident from the first decade of life is also worthy of note. Combined with the higher serum total of cholesterol levels, this may be an important indicator of the likelihood of future cardiovascular disease in this group (AU)

Vitamin E status in oedematous and non-oedematous malnourished children - abstract

The antioxidant function of vitamin E is essential for maintaining the integrity of cell membranes. During the early phase of recovery from severe malnutrition, we measured the plasma levels of Vitamin E in 58 children on admission (A), and after metabolic recovery (B). A total of 19 marasmic children, and 34 with oedematous malnutrition (19 with marasmic-kwashiorkor and 15 with kwashiorkor) were studied. A further group of 5 oedematous children who were clinically assessed as extremely sick received daily vitamin E supplements. The children were all fed on the same dietary regimen. The results indicated that although vitamin E intake was greater in the non-oedematous (marasmic) children, the rate of change of concentration in the plasma did not differ between the two groups. This could possibly be attributed to a difference in the absorption or utilization of the vitamin between the groups. In the group receiving supplements, there was a significant increase in plasma vitamin E concentration between A and B. However, the rate of increase and the concentration at B did not differ from that in the two groups of unsupplemented children. We conclude that in malnourished children: (1) plasma viatmin E levels are low on admission, (2) values normalize by time B, and (3) supplementation with alpha-tocopherol in oil did not affect the rate of increase in plasma vitamin E. The supplement did not seem to be bioavailable (AU)

Evaluation of a diet for use in the rehabilitation of severely malnourished children

The recovery diet used at the Tropical Metabolism Research Unit, although correcting some of the abnormalities associated with malnutrition, has for several years been known to be unsuitable for this purpose. The standard regime is deficient in several vitamins, minerals, trace elements and even water; rehabilitation on this diet results in some abnormalities in blood biochemistry and an inadequate rate of lean tissue deposition with an excessive accumulation of adipose tissue. In addition, the preparation and dispensation of the feeds is difficult as several additions have to be made. The need was therefore seen for a diet which would contain the nutrients lacking in the standard regimen, promote rapid growth of normal composition, and which could be easily prepared and dispensed. The test diet proposed for this purpose was fed to eight severely malnourished children throughout recovery, and the data collected were compared with that on several children previously recovered on the standard regimen. The results showed that although the test diet, MGM, was of a lower energy density than the standard diet, the energy intake was similar on both diets. The test children therefore compensated for the reduced energy density by increasing their volume of intake. Blood biochemistry of the children on the test diet was found to improve. They experienced no additional oxidant stress and their antioxidant status improved. Plasma concentrations of the trace elements zinc, copper and selenium increased during the period of rehabilitation. Recovery on the test diet resulted in a weight and height gain, cost of growth and rate of weight gain similar to that on the standard diet. The diet was found to be well absorbed, and the biochemistry of the blood improved. Other advantages are: the feeds are easily prepared, as all nutrients, vitamins and minerals are contained in the milk powder, and it is necessary only to add water. The risk of errors which are sometimes introduced due to weighing is therefore minimized. Energy content of the feed is 100 kcal/100g, thus providing for ease in calculation of prescribed intake, and energy content of feed taken. The test diet was found to be an improvement over the existing ward regimen, and with its easy preparation and dispensation was found to be suitable for use in hospitals, rehabilitation centres, and for rehabilitation in the home (AU)

A new recovery diet for use in the treatment of malnutrition - abstract

The standard high energy formula used in the rehabilitation of malnourished children does not promote optimal tissue synthesis. This may be attributed to an inadequate supply of certain nutrients in the diet. A new diet containing adequate amounts of nutrients was therefore fed to eight malnourished children throughout their stay in hospital and their dietary intakes carefully monitored. Measurements of weight, height, blood chemistry and body composition (using whole body impedance) were carried out. These data were compared to similar measurements made on thirteen children who had recovered on the standard recovery diet. Age and weight-for-height of the two groups of children were not significantly different on admission. Results showed a mean (ñSD) weight gain of 2.36ñ0.69 kg on the test diet. This was significantly greater (p<0.05) than the weight gain on the standard diet (1.71 ñ 0.54 kg). Mean rate of weight gain (RWG) on the test diet was 10.1 ñ 0.7 g/kg/day). This was not significantly different (p=0.05) from the RWG on the standard diet (11.7 ñ 0.9 g/kg/day). Mean cost of growth (COG) also did not differ on either diet. COG in test subjects was 5.1 ñ 0.5 kcal/g, while COG in control subjects was 4.8 ñ 0.5 kcal/g. Body composition of test and control subjects was the same at discharge: 21.8 per cent fat and 78.2 per cent lean tissue. Gain in lean tissue was 57 per cent on the test diet and 61.5 per cent on the standard diet. This difference was not significant. Measurements done on red blood cell glutathione, and plasma zinc, copper, glutathione peroxidase, glutathione-S-transferase and vitamin E showed that there was an improvement in the blood chemistry of children on the test diet in comparison to the standard diet. In conclusion, biochemical recovery occurred on the test diet; the growth and body composition achieved was similar on the test and standard diets (AU)