Maternal Nutrition and Birth Size among Urban Affluent and Rural by fdh56iuoui


									Original Research

Maternal Nutrition and Birth Size among Urban Affluent
and Rural Women in India

A.N. Kanade, PhD, S. Rao, PhD, R.S. Kelkar, MCM, S. Gupte, MD
Biometry & Nutrition Unit, Agharkar Research Institute (A.N.K., S.R., R.S.K.), Gupte Clinic (S.G.), Pune, INDIA
Key words: birth size, India, maternal nutrition, micronutrient rich foods

                      Background: Varying results of worldwide intervention programs to pregnant mothers necessitate the need
                  to understand the relationship between maternal nutrition and birth size among well nourished and undernour-
                  ished mothers.
                      Objective: To examine this relationship among urban affluent mothers and to compare the findings with
                  those on rural Indian mothers.
                      Subjects: Data collected on urban affluent mothers (n 236) was compared with rural mothers (n 633).
                      Design: Mothers were contacted at 18 2 and 28 2 wk of gestation for anthropometry, dietary intakes
                  [24-hr recall, Food Frequency Questionnaire (FFQ)] and after delivery for neonatal anthropometry.
                      Results: Despite large differences in nutritional status of urban and rural mothers ( pre-pregnant weight
                  55.9 9.2 Vs 41.5 5.2 kg, respectively) maternal fat intakes at 18 wk were associated with birth weight (p
                  0.05), length (p 0.01) and triceps skin fold thickness (p 0.05) of the newborn in urban and rural mothers.
                  Consumption of fruits was associated with birth length (p 0.05) in urban (18wk) and with birth weight (p
                  0.01) and length (p 0.01) in rural (28wk) mothers, when their energy intakes were low. Maternal consumption
                  of milk too, was associated with newborn’s triceps (p 0.01) in urban (28wk) while with birth weight (p 0.05)
                  and length (p 0.05) in rural (18wk) mothers. The findings mainly underscore the importance of consumption
                  of micronutrient rich foods, when energy intakes are limiting during pregnancy, for improving birth size.
                      Conclusions: Creating nutritional awareness and motivating rural mothers for consuming micronutrient rich
                  foods like green leafy vegetables and seasonal fruits that are easily available in rural areas, will be a much
                  affordable solution for combating the problem of low birth weight rather than waiting for improvement in the
                  existing nationwide programs for pregnant women.

INTRODUCTION                                                                  worldwide studies of supplementation of these nutrients during
                                                                              pregnancy have produced variable and sometimes conflicting re-
   About 30 percent of babies born in India are low birth                     sults [11]. Associations of maternal fat intakes with birth size are
weight [1,2]. Short term consequences of low birth weight                     rarely examined [12] and there are hardly any data for fat reported
(LBW) such as higher neonatal and postnatal infant mortality                  as an entity separate from energy.
are well documented [3,4]. However, recently it has been                          Reported studies on pregnant women in India [13,14] have
shown [5–9] that LBW is associated with increased risk for                    examined micronutrients supplementation with folate, iron and
coronary heart disease and related disorders such as hyperten-                zinc in pregnancy and have shown beneficial impact on fetal
sion and non-insulin-dependent diabetes mellitus.                             growth. However, there are limited data from controlled trials
   Relationship of maternal nutrition with birth size is influenced           examining effects of other micronutrients on fetal growth. In
by many biological as well as socio-economic factors. In India,               fact, in our recent study [15] on the rural undernourished Indian
poor fetal growth has been attributed to widespread maternal                  women, strong associations of birth size were not observed
under-nutrition [10]. Although energy and protein are believed to             with maternal consumption of macronutrients but only with
be the major macronutrients that are associated with birth size,              consumption of micronutrient rich foods such as green leafy

Address correspondence to: Dr. (Mrs) Shobha Rao, Head, Animal Science Division, Agharkar Research Institute, G.G. Agarkar Road, Pune 411 004. E-mail:

Journal of the American College of Nutrition, Vol. 27, No. 1, 137–145 (2008)
Published by the American College of Nutrition

Maternal Nutrition and Birth Size: Urban & Rural Comparison

vegetables (GLV) and fruits. In view of the considerable rural-     actually enrolled after ensuring their income class. The drop out
urban differences that exist with regard to the food consump-       of the enrolled women in subsequent visits was mainly due to
tion patterns and more importantly with respect to nutritional      the fact that they were not available in a defined window of
status of women it would be important to investigate this           visits. The study was approved by Institutional Research Ad-
relationship among women from urban affluent populations in         visory Committee.
India. Maternal consumption of micronutrients may perhaps be
equally important as that of macronutrients in determining fetal    Maternal Nutritional Status
growth regardless nutritional status, social class or place of
                                                                       At both the visits women were measured for weight (Atco
residence of mothers. Therefore the aim of this study was to
                                                                    India, 200 g least count), skinfold thickness (triceps and biceps,
examine this relationship prospectively among urban affluent
                                                                    Langes Caliper, least count 0.1 mm), mid-arm and head cir-
mothers and compare the findings with those obtained earlier
                                                                    cumference (non-stretchable tapes, 0.1 cm least count) and
from a rural prospective study [15].
                                                                    height (Stadiometer UNA, India 0.1 cm least count). Pre-
                                                                    pregnancy weight recorded before 10th wk of gestation was
                                                                    obtained from hospital records.
                                                                    Dietary Intake
Rural Study
                                                                        Estimates of dietary intakes using a conventional 24-hr
    Study was conducted during June 1994 till April 1996, on
                                                                    recall method depend on correct recall of the foods consumed,
women from six different villages near Pune in a rural study
                                                                    their portion sizes and nutrient contents. The precision of the
[15]. Field workers visited married eligible women (15– 40 y)
                                                                    estimate needs not only skilled interviewing, but also the ob-
every month for accurate recording of the date of their last
                                                                    jective assessment for the portion sizes of the food consumed
menstrual period. Ultrasound sonography was done of women
                                                                    and their nutritive values. We therefore generated a database on
who missed 2 successive periods to record sonographic gesta-
                                                                    weights of portion sizes using food models (for a staple food
tional age. Of the 1102 women enrolled 797 women were
                                                                    like roti) and standard spoons used in urban community for
studied after omitting abortion/termination (112), major fetal
                                                                    serving various food items. The nutrient contents of the foods
anomalies (8), multiple pregnancies (3), incomplete pre-preg-
                                                                    consumed were obtained using the food composition tables
nant anthropometry (14) and pregnancy detected later than 21
                                                                    [16]. Thus using modified 24-hr recall method, daily intakes of
wks of gestation (168). Data on 770 normal live deliveries was
                                                                    macronutrient i.e. energy, protein, fat & carbohydrate were
obtained and for the purpose of comparison that on 633 full-
                                                                    estimated for each women twice during their pregnancy (18
term babies was considered.
                                                                    2 and 28 2 wk of gestation). In addition, to have information
    Anthropometry (weight, height, skin folds at four sites and
                                                                    on habitual pattern of diet, food frequency questionnaire (FFQ)
head and mid-arm circumference) for women, before and dur-
                                                                    was also administered. Frequencies of consumption of various
ing pregnancy at 18 2 and 28 2 wk gestation, as well as
                                                                    (111) foods in 10 food categories, ranging from “never’ to
for newborns was obtained. During pregnancy women were
                                                                    “twice/thrice a day’ were obtained for the reference period of
assessed for dietary intake (24 hr recall, FFQ) and activity as
                                                                    one month prior to each visit. The 10 food categories were:
well. Methods for these measurements were kept similar in the
                                                                    chapati / roti, rice, pulses / legumes, other / green leafy vege-
urban study and are described below.
                                                                    tables, fruits, meat/fish, dairy products, snacks (sweet & spicy),
                                                                    fats, foods eaten outside home. These food categories were
Urban Study                                                         mutually exclusive. Frequency of consumption of individual
    Mothers. Pregnant women coming for antenatal care in a          food item was converted into score and then score for each food
private hospital situated in an elite area of Pune city which was   category was obtained by adding the scores of various foods in
catering mainly to high income class, were studied during           it. Thus, in our study while 24 hr recall offered objective
March 1998 to March 2001. Women were listed (n               265)   estimates of macronutrients, FFQ allowed us to compare the
before 12 wk of gestation after seeking their consent to partic-    groups of women consuming relatively low and high frequency
ipate in the study. During the first visit (18 2 wk of gestation)   of specific food groups.
detailed information on socio-economic variables was ob-                Similarly, physical activity was assessed with the use of
tained. The information on occupation, education of self and        activity questionnaire consisting of four major categories such
spouse and possession of economic assets such as owning a           as resting, domestic, occupational and recreational activities
house, car, telephone etc. was obtained on 3-point scale each so    with several activities listed in each major category. Using
as to discriminate between income classes. Women then iden-         published data for the energy expenditure of activities [17] a
tified from affluent class were enrolled and visited at their       weighted score was derived, which reflected as a base unit an
house second time during their pregnancy (28             2 wk of    activity level of 1 kcal per minute for a 30 minute slot of time.
gestation). Thus out of 265 women who gave consent 236 were         For example, walking for 60 minutes would have a score of 6.8

138                                                                                                                 VOL. 27, NO. 1
                                                              Maternal Nutrition and Birth Size: Urban & Rural Comparison

(2 3.4; 2 slots 30 min. each & 3.4 Kcal/min is energy cost for                 measurements were skewed and required log-transformation to
walking). The scores were computed for each individual activ-                  satisfy assumptions of normality. Analysis was carried out
ity in the questionnaire and adding over all the activities per-               using SPSS/PC , version 11.0. Values unless otherwise stated
formed in a day, total daily activity score was obtained for each              are Mean SD.
women, at both time points (i.e. 18         2 and 28    2 wk of
Neonatal Anthropometry
    Of the enrolled 236 mothers, 4 reported abortions, 4 deliv-
ered twins and 2 could not be contacted after the delivery for                     Majority of the women in the study had higher education
neonatal measurements. Of the 226 live deliveries, complete                    (92% were at least graduate), their spouse had a good occupa-
neonatal anthropometry (weight, length, triceps skin fold thick-               tional status (76% were either businessman, professionals or on
ness, mid-arm & head circumference obtained on all singleton                   higher posts) and many possessed economic assets such as
births within 72 hr. after delivery) was available on 165 babies               house (86% owned the house with more than 4 rooms), tele-
(omitting 34 deliveries that took place outside Pune, 8 in other               phone (96%) and at least one car (51%) confirming that they
hospitals, 14 could not be contacted within 72 hours and 5 were                belonged to high socio-economic class. Mean age at conception
refusals). However, for these 61 omitted cases, parents reported               was 27.1      3.5 yr and 59% had first parity, 40% had second
birth weight of their baby.                                                    parity while only 1% had third parity. Average spacing between
                                                                               two pregnancies was 4.43 yr.
Statistical Methods                                                                Pre-pregnancy nutritional status of urban mothers (Table 1)
                                                                               was good and the average BMI was 22.6 3.6 kg/m2. Only 1%
    Differences between group means were tested using t-test
                                                                               women were below 38 kg and below 145 cm height, i.e. the
and ANOVA. Multiple regression analysis was used to exam-
                                                                               cut-offs below which risk for LBW is considered to be high
ine trends in birth-size according to maternal dietary intakes,
                                                                               [18]. Mean weight gain during pregnancy up to 18th wk ges-
and to assess the relative contributions of other factors to the
                                                                               tation was however low, 2.07        2.6 kg, but it increased to
variability in birth measurements. In regressions, birth mea-
                                                                               7.53 3.4 kg by 28th wk of gestation.
surements, maternal measurements and macronutrient intakes
were analyzed as continuous variables while intake of specific
food categories based on the food frequency questionnaire was
analyzed as grouped variable. For example, the frequency of                        Out of 226 normal live births 15(6.6%) were premature
consumption of non-vegetarian food with categories as never                    giving us data on 211 full term babies for analysis. Average
eating, less than once a week & more than once a week was                      birth weight of full term babies was 3.03 0.39 kg (Table 1)
considered as a grouped variable with values 0,1 & 2 respec-                   and was close to 30th percentile of NCHS standard [19] and the
tively. Neonatal measurements were significantly higher                        prevalence of LBW ( 2.5 kg) was 7.11 %. Birth weight and
among boys (p       0.05) and of the mothers with multiparous                  length were associated with pre-pregnant weight (r 0.2259;
(p 0.05) and having higher gestation (p 0.05). All analy-                      p     0.01 and r    0.2349; p     0.01 respectively) and height
ses, therefore, were adjusted for the sex (of the baby), gesta-                (r 0.1933; p 0.01 and r 0.2556; p 0.01 respectively)
tional age at delivery, and maternal parity. Neonatal skin folds               and indicates importance of pre-pregnant nutritional status.

Table. 1. Maternal and Neonatal Nutritional Profile of the Urban Affluent Women

                                                           Maternal anthropometry                                       Neonatal Anthro.
                                        Pre-pregnancy                18th wk                      28th wk                 (Full term)
                                          (n 236)                   (n 233)                      (n 193)                  (n 211)
       Weight (kg)                       55.7       9.1             57.7        9.3            63.5       9.6**        3.03   0.39
       Height (m)                        1.57       0.05                   -                          -                49.0   2.6 (161)
       BMI (kg/m2)                       22.6       3.6             23.5        3.8            25.6       3.8**        25.7   4.1$ (161)
       Head circum. (cm)                        -                   53.4        2.8                   -                33.7   1.7 (159)
       Triceps skinfold (mm)                    -                   20.7        6.9            21.8       6.4ns         5.9   1.9 (150)
       Biceps skinfold (mm)                     -                   11.3        5.6            12.1       5.2ns                -
       Mid-arm circum. (cm)                     -                   25.3        3.7            25.9       3.1ns        10.1   0.9 (158)
       Weight gain (kg)                         -                   2.07        2.6            7.53       3.4**                -
 Ponderal Index (kg/m3).
** p 0.01.
ns not significant.

JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION                                                                                               139
Maternal Nutrition and Birth Size: Urban & Rural Comparison

Birth weight increased with gestational age (r       0.2318; p          Since there are other major confounding variables viz. ges-
0.01). This was also true for other measurements except triceps.    tation at delivery, parity, sex of the newborn, the relationship
All measurements were smaller in babies born to primiparous         between maternal nutritional intakes and birth size was exam-
than in babies born to multiparous mothers but the differences      ined (Table 4) after controlling for these variables using mul-
were significant for birth weight (p      0.02) and length (p       tiple regression analysis (MLRA). It was seen that energy
0.05). Birth weight (p      0.001), length (p     0.01) and head    intakes (18th wk) were associated with length (p          0.02) and
circumference (p 0.0001) were greater in boys than girls. In        head circumference (p 0.03). Protein intakes at early gesta-
our analysis of birth size in relation to nutritional intakes, we   tion (18th wk) were associated with head circumference (p
therefore adjusted for gestational age at delivery, baby’s sex      0.05), at late gestation (28th wk) with birth weight (p 0.01)
and maternal parity.                                                and throughout with length (p 0.05). Similarly, fat intakes at
                                                                    early gestation, were associated with length (p           0.01) and
                                                                    triceps skin fold (p 0.01) but throughout gestation with birth
Maternal Intakes                                                    weight (p 0.05). However, carbohydrate intakes at 18th week
    Macronutrients (24 h Recall). Mean energy and protein           showed association only with head circumference (p 0.05).
intakes at 18th wk gestation were inadequate and were low               Food Groups (FFQ). Consumption of various food groups
(8.09 2.47 MJ, 51.2 17.3 g respectively) as compared to             from FFQ reflects variety in the diet (Table 5). Almost 77%
RDA for Indian pregnant women [20]. The intakes were low            women had fruits at least once a day and 74% women had milk
mainly due to high prevalence of nausea (50.8%) reported            twice a day. Similarly, 39% women had some snacks other than
within first 3–4 months. However, intakes improved consider-        lunch every day while 50% women used to eat biscuits and
ably by 28th wk of gestation (9.03          2.37 MJ of energy,      pastry every day. However, about 50% women were non-
57.9     18.7 g of protein) meeting the nutrient requirements.      vegetarian and 36% were eating non-vegetarian more than once
Their diets were rich in fats (31% of total energy) but were low    a week, whereas 65% women were having green leafy vegeta-
in carbohydrates (58% of total energy). Milk, fried snacks,         bles every alternate day and 75% women had pulses or legumes
sweets and bakery products were major contributors (20 %) to        every day in their diet.
dietary fat intakes. Apart from cereals and pulses, milk and            Among the food groups considered in the FFQ, significant
non-vegetarian items contributed about 13 % to protein intakes.     relationships with birth size were found with fruit and milk
The activity pattern remained similar throughout the pregnancy      consumption only.
(Table 2).                                                              Fruits. Fruit consumption in urban affluent women was rela-
    Simple product moment correlations (Table 3) showed that        tively high. Commonly consumed fruits were apple (55%), banana
birth weight of babies was not related to maternal energy           (49%), sapota (38%), mango (24%) and orange/sweet lemon
intakes, nor to physical activity at 18 and 28 wk gestation.        (32%) etc. It was observed that the frequency of consumption of
Protein intake (28th wk) and fat intake (18th wk); absolute as      fruits at 18th wk was related to birth length (p         0.05) after
well as percent of total energy; were related to birth weight       adjusting for gestation, sex and parity (Table 6). The association
(p     0.05). Additionally, fat intakes were correlated with        remained significant even after adjusting for prepregnant weight
triceps skin fold thickness (p      0.01). In contrast, percent     (height or BMI). The relative risk of delivering short (lower tertile
calories from carbohydrates (18th wk) were inversely corre-         of length) babies was 2.8 (95% CI, 1.32–5.79) times higher in
lated with birth weight and triceps (p 0.001). These associ-        mothers who ate fruits less than once a day than in mothers who
ations remained significant even after adjustment for maternal      had higher consumption of fruits (more than once a day). Fruits are
size (pre-pregnant weight / height / body mass index).              rich sources of micronutrients especially vitamins and antioxidants
                                                                    and its association at 18th wk when energy intakes are low as-
                                                                    sumes significance.
Table 2. Nutritional Intakes of Urban Affluent Women                    Dairy. Milk was consumed consciously during pregnancy
during Pregnancy                                                    by majority of women. In fact, 40% women used to drink it
          Variable             18th wk            28th wk           thrice a day. Consumption of milk at 28th wk was associated
                                                                    (p      0.05) with triceps skinfold (Table 6). The odds ratio
   n                            233                    193
   Energy (MJ/d)             8.09 2.47          9.03     2.37**     delivering thin (lower tertile of triceps skinfold) babies was
   Protein (g/d)             51.2 17.3          57.9     18.7**     0.36 (95% CI, 0.77–1.48) in mothers who took milk thrice a
   Fat(g/d)                  69.2 31.1          75.6     28.9**     day compared with 1.0 in mothers who took it less than twice
   Carbohydrate (g/d)       276.5 80.0         311.7     77.9**     a day.
   % energy from pro.        10.6 1.5           10.7     1.6ns
   % energy from fat         31.4 7.5           30.9     6.7ns
   % energy from carb.       58.1 7.6           58.4     6.9ns
                                                                    Comparison with Rural Women
   Activity scores           73.9 26.1          73.3     23.8ns
** p 0.01.                                                              Comparison with the rural data [15] shows that rural moth-
ns not significant.                                                 ers were significantly thin (41.5 5.2 kg), and short (1.52

140                                                                                                                   VOL. 27, NO. 1
                                                                              Maternal Nutrition and Birth Size: Urban & Rural Comparison

Table 3. Correlation Coefficients of Birth Size# with Maternal Nutritional Intakes (24-hr Recall) and Other Parameters

                                                                                                    Birth size
                                        Birth weight                Length               Triceps skinfold               Head Circum.              Mid-arm Circum.
     Parity                                0.1839**                 0.1699*                         -                          -                           -
     Sex of newborn                        0.2263**                 0.2047**                        -                       0.3211**                       -
     Gestation at delivery                 0.2318**                 0.2982**                        -                       0.2041**                   0.2589**
     Prepregnancy weight                   0.2259**                 0.2349**                        -                          -                           -
       Height                              0.1933**                 0.2556**                        -                          -                           -
     Nutritional Intakes
     Energy 18 wk                             -                        -                          -                               -                        -
       28 wk                                  -                        -                          -                               -                        -
     Protein 18 wk                            -                     0.1541*                       -                               -                        -
       28 wk                               0.1544*                     -                          -                               -                        -
     Fat 18 wk                             0.1657*                     -                       0.2276**                           -                        -
       28 wk                                  -                        -                          -                               -                        -
     Carbohydrate 18 wk                       -                        -                          -                               -                        -
       28 wk                                  -                        -                          -                               -                        -
     % protein 18 wk                          -                        -                          -                               -                        -
       28 wk                               0.1618*                     -                          -                               -                        -
     % fat 18 wk                           0.1555*                     -                       0.2483**                           -                        -
       28 wk                                  -                        -                          -                               -                        -
     % CHO 18 wk                           0.1687**                    -                       0.2575**                           -                        -
       28 wk                                  -                        -                          -                               -                        -
* p 0.05, ** p 0.01.
  full term babies.

Table 4. Maternal Macroutrients Intakes (24-hr Recall) and Birth Size# Relationship@ (Multiple Regression Model)

                                  Birthweight (g)                        Length (cm)                             Triceps (mm)                   Head Circum (cm)
                            R2                      se           R2                     se               R2                     se         R2                      se
                                                                           Urban (n          211)
   18th wk
   Energy                   -                   -               18.7          0.63    0.28*               -                 -             22.2         0.04        0.02*
   Protein                  -                   -               19.6          0.03    0.01**              -                 -             22.2         0.01        0.005*
   Fat                     20.8         2.54     0.81**         18.8          0.01    0.005**            5.4         1.00       0.9**      -                   -
   Carbohydrate             -                   -                -                    -                   -                 -             21.9        0.002        0.001*
   28th wk
   Energy                   -                   -                -                 -                      -                 -               -                  -
   Protein                 17.9         3.65     1.50**         18.9          0.03 0.01*                  -                 -               -                  -
   Fat                     16.9         1.95     0.95*           -                 -                      -                 -               -                  -
   Carbohydrate             -                   -                -                 -                      -                 -               -                  -
                                                                           Rural (n 633)
   18th wk
   Energy                   -                   -                -                    -                   -                 -               -                  -
   Protein                  -                   -                -                    -                   -                 -               -                  -
   Fat                     28.9         1.92     0.86*          26.9          0.02    0.005**            9.8         1.00       0.9*        -                  -
   Carbohydrate             -                   -                -                    -                   -                 -               -                  -
   28th wk
   Energy                    -                  -                -                    -                   -                 -               -                  -
   Protein                   -                  -                -                    -                   -                 -               -                  -
   Fat                       -                  -               25.6          0.01    0.005*              -                 -               -                  -
   Carbohydrate              -                  -                -                    -                   -                 -               -                  -
* p 0.05, ** p 0.01.
  full term babies.
   After controlling for sex, parity, gestation at delivery, pre-pregnant weight in urban and additionally for weight gain at 28th wk and activity in case of rural mothers.

0.05 m); p   0.001 for both, as compared to urban affluent                                size (2.67 0.35 kg birth weight, 47.9    2.3 cm length and
women (Fig. 1) and many were chronically energy deficient                                 4.1 0.9 mm triceps skinfold thickness) was also significantly
(34% below 17 BMI) before conception. The rural neonatal                                  (p 0.001) lower in almost all anthropometric measurements

JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION                                                                                                                            141
Maternal Nutrition and Birth Size: Urban & Rural Comparison

Table 5. Frequency (%) of Consumption of Various Foods among Urban Affluent Women

                                                                                   18th wk                       28th wk
            Food groups                            Frequency
                                                                                  (n 233)                       (n 193)
         Roti                                   Twice a day                          21.2                          13.0
                                                  Twice a day                        78.8                          87.0
         Rice                                   Twice a day                          38.1                          33.7
                                                  Twice a day                        61.9                          66.3
         Pulses/Legumes                         Once a day                           23.8                          14.0
                                                   Twice a day                       48.5                          42.0
                                                  Twice a day                        27.7                          44.0
         Green Leafy Veg.                       Alternate day                        35.9                          38.3
                                                   Once a day                        35.1                          32.1
                                                  Once a day                         29.0                          29.5
         Non-veg.                             Never                                  48.5                          47.7
                                                   Once a week                       15.2                          17.6
                                                  Once a week                        36.4                          34.7
         Milk products                          Twice a day                          26.8                          25.9
                                                   Thrice a day                      40.7                          33.7
                                                  Thrice a day                       32.5                          40.4
         Fruits                                 Once a day                           24.2                          23.3
                                                   Twice a day                       69.7                          75.6
                                                  Twice a day                         6.1                           1.0
         Bakery                                 Once a week                           9.1                           8.3
                                                   Once a day                        39.8                          40.9
                                                  Once a day                         51.1                          50.8
         Snacks                                 Alternate day                        33.3                          29.5
                                                   Once a day                        27.7                          21.8
                                                  Once a day                         39.5                          48.7

except head circumference (33.3         1.3 cm). Prevalence of     of fruits in late gestation and milk in early gestation. Addition-
LBW (26.9%) and prematurity (12.3%) among rural mothers            ally, birth weight (p 0.01), length (p 0.01) and triceps (p
was significantly (p       0.05) higher as compared to urban       0.01) was associated with consumption of green leafy vegeta-
mothers. Maternal energy and protein intakes were low (below       bles at 28 wk [15].
70% of RDA, ICMR [20]) at 18th wk and did not improve by               Commonly consumed GLVs by rural mothers were
28th wk of gestation unlike that seen in case of urban mothers.    fenugreek (57%), spinach (33%), colocasia (15%), coriander
Similarly, the consumption of foods which are important            (16%) and onion stalk which are rich source of iron, folate and
sources of micronutrients was lower in rural women as com-         other micronutrients. While fruits consumed (eaten more than
pared to urban women. For example, the frequency of having         once a wk) were those which were also rich in micronutrients
milk at least once a day (29.7% Vs 100%), frequency of having      and especially antioxidants like Vit C. These fruits were rarely
fresh fruits once a day (40% Vs 76%) and frequency of having       purchased as they were freely available in the fields e.g. tam-
green leafy vegetables every alternate day (30% Vs 64%) was        rind (48% of women ate), country guava (40%), custard apple,
significantly (p 0.001 for all) lower.                             zizapus (58%) etc. Association of consumption of these food
    Although there were large differences in the pre-pregnant      groups with birth size is therefore, indicative of the importance
nutritional status and dietary pattern among urban affluent and    of combinations of micronutrients when maternal diets are
rural undernourished mothers, there were similarities in the       inadequate in energy.
relationship of maternal intakes of macronutrients and birth
size. For example, birth size was associated with fat intakes at
early gestation in urban as well as rural mothers (Table 4).       DISCUSSION
Similarly, association of consumption of specific foods with
birth size was compared for urban and rural mothers. It was           We have studied prospectively the relationship between
observed that birth size was associated with frequency of          maternal nutrition and birth outcome among urban affluent
consumption of fruits at 18th wk and with consumption of dairy     mothers. Maternal intakes (24-h recall and FFQ) were assessed
products at 28th wk in urban mothers (Table 6). Among rural        twice during pregnancy. The results are compared with those
mothers, similar food groups showed association with birth size    from a study on rural Indian mothers. One of the limitations of
but at different times during gestation viz. birth weight (p       the study is that in the urban set up the logistics of enrolling a
0.05) and length (p 0.05) was associated with consumption          subject and keeping continuous direct contact for follow up

142                                                                                                                VOL. 27, NO. 1
                                                                             Maternal Nutrition and Birth Size: Urban & Rural Comparison

Table 6. Relation between Frequency of Consumption of Fruits and Milk with Neonatal Anthropometry among Urban
and Rural Mothers

                                                                                                  Neonatal measurements
        Food group                  Frequency             N
                                                                  Birthweight         Length      Head circumference      Mid-arm       Triceps Skinfold
                                                                      (g)              (cm)              (cm)              (cm)              (mm)
                                                                         Urban mothers
  Fruits, Wk 18                    Once a day             49      3014   319    48.7 1.9               33.9    1.4        10.2    1.2       5.8      1.8
                                   Once a day            157      3038   412    49.4 2.2               33.8    1.3        10.1    0.9       6.2      1.8
                                                           p       0.34          0.05                   0.56               0.79             0.22
  Milk products, Wk 28            Twice a day             47      3057   355    48.9 1.9               34.0    1.3        10.1    0.7       5.5      1.4
                                 Twice a day              62      3013   392    49.3 2.0               33.9    1.3        10.2    1.0        5.8     1.7
                                  Thrice a day            70      3034   419    49.1 2.4               33.7    1.2        10.2    1.0        6.6     1.9
                                                           p       0.64          0.26                   0.69               0.23             0.01
                                                                         Rural mothers
  Fruits, Wk 18                   Once/wk                 44      2598 340      47.5 1.7               32.7 1.1           9.7 0.8           4.1      1.2
                                 Once/wk                 363      2633 355      47.5 2.0               32.9 1.2           9.6 0.9           4.1      1.2
                                  Once/day               202      2721 357      48.1 1.9               33.4 1.2           9.8 0.8           4.1      1.2
                                                           p       0.01          0.01                  0.001              0.09              0.44
  Milk products, Wk 28           Never                    95      2643 369      47.5 2.0               32.9 1.2            9.6 1.0          4.2      1.2
                                  Once/wk                134      2618 356      47.6 2.0               33.0 1.2            9.7 0.9           4.1     1.2
                                 Once/wk                 116      2639 344      47.6 2.0               33.0 1.1            9.5 0.8           4.1     1.2
                                  Alternate days         281      2704 361      48.0 2.0                33.2 1.3           9.8 0.9           4.1     1.2
                                                           p          0.05          0.05                   0.01               0.05            0.90
Values are mean SD.
p values after controlling for sex, parity, gestational age at delivery using MLRA.

visits was complicated unlike that in a rural study. Addition-                         from animal studies [25,26]. In addition, our observation also
ally, seeking cooperation of mothers from affluent class in                            indicates preservation of length in rural babies highlighting
urban area was relatively difficult thus leading to a smaller                          similar importance for skeletal growth in the event of maternal
sample size for urban study compared to that for rural study.                          undernutrition.
Nevertheless, it did not seem to be a major limitation as the                              Maternal intakes of energy and protein of urban affluent
rural-urban contrast with respect to pre-pregnant nutritional                          mothers were low at 18th wk of gestation, and were not
status and dietary intakes was clearly brought out. In spite of                        associated with birth size. However, fat intakes at 18th wk of
large rural-urban disparity, our study observed significant re-                        gestation were associated with birth size among urban mothers.
lationship of consumption of foods rich in micronutrients with                         Although fat intake has been shown previously to correlate
birth size in both the regions, highlighting importance of mi-                         with birth weight [12], there are few data for fat, reported as an
cronutrients for improving birth size in India.                                        entity separate from energy. The role of specific fatty acids is
     Urban affluent mothers had a good pre-pregnant nutritional
                                                                                       shown to be important for fetal growth [27,28]. Therefore, it
status and their weight, height were comparable to those of
                                                                                       cannot be judged whether it was due to the role of fat as
urban affluent women from other parts of India [21–23].
                                                                                       macronutrient or fatty acids as micronutrient.
Weight gain (18th wk or 28th wk of gestation) was not asso-
                                                                                           Fruits are rich in micronutrients especially, vitamin C and
ciated with birth weight or length but pre-pregnant nutritional
                                                                                       other antioxidants. We observed strong association of birth
status was strongly related with birth weight in rural as well as
                                                                                       length with consumption of fruits at 18th wk of gestation in
urban mothers indicating importance of good pre-pregnant nu-
tritional status.                                                                      urban mothers and at 28 wk among rural mothers. The relative
     The neonatal size observed for urban babies was also com-                         risk of delivering short (lower tertile of length) babies was 2.8
parable to that reported in other well-to-do Indian populations                        (95% CI: 1.32–5.79) times higher in urban and 2.1 (95% CI:
[24] and was closer to the 30th percentile of NCHS standards.                          1.44 –3.07) times higher in rural mothers who ate fruits less
Rural babies had significantly low birth weight, skin fold                             than once a day than in mothers who had higher consumption
thickness at triceps and ponderal index in comparison to urban                         of fruits (more than once a day). In addition to fruits, increased
babies, but had comparable mean values for length, head cir-                           consumption of green leafy vegetables and milk products in
cumference and mid-arm circumference. Preservation of head                             rural women was also associated with better neonatal size. The
circumference in rural babies in spite of chronic undernutrition                       observations therefore, suggest that consumption of foods rich
of their mothers renders some support to the observations of                           in micronutrients may be beneficial for improving birth size
brain sparing on pups born to undernourished dams, reported                            when maternal intakes are limited in macronutrients.

JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION                                                                                                               143
Maternal Nutrition and Birth Size: Urban & Rural Comparison

Fig 1. Comparison of data on urban affluent and rural mothers. Urban-Rural differences were significant (p   0.01) for all maternal & neonatal
measurements except gestation & ponderral index.

    Susser [29] and Stein [30] have reported that the relation-           be conditioned by maternal intakes of macronutrients in addi-
ship between maternal energy intake and birth weight was not              tion to their pre-pregnant nutritional status.
seen among non-famine Dutch women but was seen among                           In view of the strong relationship between pre-pregnancy nu-
those who experienced famine conditions. We observed that                 tritional status and birth size, it may be worthwhile to have
although same nutrients or foods were associated with birth               programs to improve nutritional status of mothers before concep-
size, their associations differed at different times in gestation         tion than supplementing during pregnancy. Alternatively, our ob-
and with different neonatal measures among urban well nour-               servations suggest that the existing nationwide programs provid-
ished and rural undernourished mothers. For example, fat in-              ing energy-protein supplementation to pregnant women may be
takes at 28 wk were associated with birth weight in urban                 modified to improve it’s qualitative aspect (micronutrients). Sim-
mothers but with birth length in rural mothers. Similarly, con-           ple food based interventions may be feasible solution for combat-
sumption of fruits at 18 wk was observed to be associated with            ing the problem of low birth weight in rural India. It is however,
length in urban mothers, but at 28 wk with birth weight as well           beyond doubt that further research is needed for understanding the
as length in rural mothers. Energy intakes of the mothers in              relationship of different micronutrients at different time points in
both places were drastically low at these times, and may indi-            gestation with different neonatal measures in undernourished
cate important role of antioxidants present in fruits. Milk con-          mothers for planning effective interventions.
sumption too shows significant associations with triceps in
urban group (at 28 wk) but with birth weight and length in rural
mothers (at 18 wk). Additionally, strong associations of GLV              ACKNOWLEDGMENTS
consumption were seen with birth size in rural mothers but not
in urban mothers. The observations thus indicate that relation-              We are thankful to the mothers enrolled in the study and
ships of maternal intakes of micronutrients with birth size may           their families for their co-operation. We are grateful to Dr.

144                                                                                                                        VOL. 27, NO. 1
                                                                   Maternal Nutrition and Birth Size: Urban & Rural Comparison

V. S. Rao, Director, ARI, for providing the facilities to carry                 babies at birth: Pune Maternal Nutrition Study. J Nutr 131:1217–
out the field study. Thanks are also due to Mrs. Neelima                        1224, 2001.
Karandikar for help in data collection.                                   16.   Rao S: “Nutritive Values of Some Indian Food Preparations.” Pune
                                                                                India: Maharashtra Association for the Cultivation of Science,
                                                                          17.   FAO/WHO/UNU: “Energy and Protein Requirements. Report of a
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JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION                                                                                                  145

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