Am J Clin Nutr 1981 Butte 2216 28

8/2/2019 Am J Clin Nutr 1981 Butte 2216 28

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T he Am er ican Jo urn a l o fC lin ica l N u trition 34 : O CTOBER 1981, pp . 2 216-2228 . P rin ted in U .S .A . 1981 Am erican So ciety for C lin ica l N u trit ion

rt -.

O rig in a l R e s e a rc h C o m m u n ic a tio n s -s u rv e y s

Nu tritiona l a sse ssm en t o f p regnan t and la c ta tin gN ava jo w om en1 2Na n cy F . B u tte ,3 P h .D ., D o ris H ow es C a iow a y ,4 P h .D ., a n d Jea n L . Va n D u zen ,5 M .D .

ABSTRACT N utritiona l pa ram ete rs o f 87 N av ajo wom en w ere a sse ssed at term and in 23 o fthese w om en after I m onth of lac tation . S erum lev els o f zin c, retino l , net ino l-b inding p rotein ,fo lac in , pro tein , H b , and fe rri tin and h air zin c con ten t w ere d eterm ined . Tw enty-fo ur-hou r ietaryreca lls w ere record ed for the subsam ple o f 23 w om en . M edian nutrien t in take s w e re less than 60%ofthe Recommended D ietary A llow ance ofcalc ium , m agne sium , z inc , co ppe r, v i tam ins A (lac tationonly), D , E , and B6 , b io tin , and fo lac in . Serum z inc fe ll b elow 50 jsg /d l in 6 8% of th e subsam p le atterm and rem ain ed below 65 g /d l in 4 3% during la cta tion . S erum ne tino l w as below no rm al (< 33pg ld l) in 24% of these w om en a t term and 23% at 1 m onth . Low serum fo lac in (< 6 ng/m h ) w asdetected in 9% at term and 24% a t I m on th . A nem ia w as p resent in 15 to 20% of the wom en. S erumpro tein , re tin o l-b in din g pro tein , fe rrit in , and ha ir zinc w ere essentially no rm a l. B iochem ical findingscon firm ed die tary inad equ acies am ong Navajo w om en and indicate needed nutr itio nal im p rov e-men t . Am . J . C lin . N u tr. 34: 2216 -2228, 1 981 .

K EY WORDS N avajo , nu trit ion al a sse ssm en t, p reg nan cy , lactatio n , ret ino l, fo lac in , fenr itin ,n etinol-b inding prote in , zinc

Introduct ionIn 1 97 6 to 19 77 , a to tal o f 5 9 d iagn ostic

m easu rem en ts o f se rum re tino l w e re re -q uested by m ed ica l s ta ff o f the Ind ian H ealthS e rv ice U n it a t T ub a C ity , A Z , o n the basiso f su ggestiv e eye les ions: 13 (22% ) w ere in thed efic ien t ran ge (< 20 tg /d l) and ano th er 20(34% ) w ere in the low -m arg ina l range (20 to3 0 g /d l) . F o u rteen cases o f x erosis an d co r-n ea l u lce ratio n , d iag nosed as v itam in A de -f icien cy le sion s, w e re trea ted w ith the rap eu ticd ose s o f re tino l. M ost o f th e pa tien ts re -spon ded to th e re tino l, b u t som e reco ve redo n ly a fte r the ad d ition al adm in istra tio n o fz in c sup plem en ts .

S ince eye le sions an d low se rum leve lsco nstitu te advanced m an ifes tatio ns o f v i-tam in A de fic iency , it w as th oug h t tha t in -ad eq ua te n u tr itu re am ong N ava jo co u ld h aveb een m ore p reva len t than reco gn ized . To de -fm e th e m agn itude an d sev erity o f th is ap -pa ren tly m ultifa cto ria l p rob lem , it w as nec-2216

essa ry to ex am ine the nu tr itiona l s ta tu s o f th eb ro ad er po pu la tion , pa rticu la r ly tho se th atmigh t hav e been a t h ig h risk . A t the requesto f th e Ind ian H ea lth S e rv ice , a stud y w asdesign ed to de te rm in e the p reva len ce o f spe -cif ic nu tr ien t de fic ienc ies am ong vu lne rab lem em bers o f th e the N ava jo tr ibe . Th is p ap e rp re sen ts fm d ing s from on e phase o f the stu dy

i From the D epa rtm en t of Nu tri tion al S cien ce s, U rn -v ers ity of C aliforn ia, B erk eley , CA 94720 ; and P ublicH ealth Serv ic e N av ajo A rea Indian H ealth Serv ic e, T ubaC ity , AR 86045 .

S upported in pa rt by U SPHS G rant AM O 7 lSSA -03and in collabo ration w ith th e In dian H ealth S erv ice andUSDA .

:i Gradua te s tud en t, D epa rtm ent of Nu trit ion al S ci-en ces . P re sen t add ress: D epa rtm ent o f P ediatr ics, N utri-tio n and G .I. Section , B ay lor C ollege of M edicin e, H ou s-to n , TX 77025. P rofesso r of Nu trit ion , D epar tm entofNu trit ion al S cien ce s. A dd ress reprin t requ ests to : D .H .C allow ay, D ept. o f N utritiona l S cience s, 119 M o rganHa ll, U n ive rsity of Ca lifo rn ia, B erkeley , CA94720. Consultan t , M aternal and Ch ild H ealth ,Tuba C ity Ind ian H ospita l, Tuba C ity , AR 86045.


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N A V A JO N UT R IT IO N A N D PR EGN A N CY 2 2 1 7

a Mean SD . A pril to S eptem ber, 1979.

w hich fo cused on pregnan t and lactating N a-v ajo w om en resid in g on the reserv atio n .

T h e N av ajo reserv atio n is a sem i-arid , p re -dom inan tly ru ral area o f the S ou thw est. T h isstudy w as condu cted w ith th e T uba C ityS erv ice U n it, w h ich has a land area o f 4 400square m iles and serv es 9766 p erson s (1977)(1 ) . T rad itio nally , subs isten ce on th e reser-v atio n w as organ iz ed around the sheep herdw ith som e seasonal f arm ing . D ue to in creas -in g popu latio n d en sity and an ov ergraz edland base , the N av ajo hav e b een fo rced toseek alte rn ativ e liv e liho ods . D esp ite m easur-ab le p rogress in edu cation and public 5 cr-v ices, th e econom y rem ains sev ere ly d e -p ressed . E conom ic d epriv atio n and poo r liv -in g cond itio ns are no t conduc iv e to ad equatenu tritu re . T h is research pro ject assessed thenu tritio nal s tatu s o f w om en con tend in g w ithincreased nu trien t needs o f pregnancy andlactation.Me th od sSubjects

N av ajo w om en atten din g the prenatal clin ic o f theT uba C ity In dian H ealth S erv ice Ho spital w ere ask ed toparticipate in th e s tud y . T he se lec ted w om en m et th ef o llow ing c riteria: ag e 16 to 35 y r; p arity 1 to 4 ; f ree f romany debil itat ing d isease; and w ith th e in ten tion of breas t-f eed ing . T w en ty - thre e N av ajo w om en, 16 to 23 y r of age,agreed to partic ipate in the stu dy . A n addit ion al 64N av ajo w om en w ere sc reened b iochem ically at preg-n an cy term in ord er to d ete rm ine if th e sam p le of 23w ere represen tativ e o f th e ch ild -bearing popu lation in

th e T uba C ity area. T he study w as condu cted during th ep erio d A pril th rough S ep tem ber, 1 979 . T h e w om en gav eth eir in f o rm ed con sen t to the pro tocol w hich w as ap -p rov ed b y the N av ajo T rib al H ealth Coun cil, Ind ianH ealth S erv ice R e search and Pub licatio ns Com m ittee,and the C om m ittee f or the Protection of H um an S ubjectso f the U niv ers ity o f C ali f orn ia, B erk eley .

B io statistics pertain ing to th e 468 births th at occurredin the T uba C ity In dian H osp ital du rin g the p erio d ,A pril to S eptem ber 1979 , w ere ex tracted f rom th e m cd -ical reco rd s. T he study sam ple (n 23) w as rep resenta-t iv e o f the ob ste trical populatio n (n 468) in te rm s ofth e v ariab les sum m ariz ed in T ableI (z test statistic). T hepopu lation m ean birth w eigh t w as 3407 524 g. O f the468 new born s, 1 6 (3% ) had birth w eights b elow 2.5 k g ;7 ( 1% ) w ere prem ature .Exper imental desi gn and procedures

N utritional statu s, inc lud ing d ietary , c lin ical, anthro -p om etric , b iochem ical, an d so cio econom ic param ete rs,w as assessed in the ho spital af te r de liv ery and in thehom e af ter appro x im ate ly 1 m on th o f lactatio n . S o cio -econom ic in form ation w as obtained b y in te rv iew .

Food habits and be lie f s w ere ascertained by m ean s o fa que stionnaire and f ood in tak e by a 24-h dietary recallre cord . In te rv iew fo rm s w ere no t pretes ted , but w erecom posed w ith the adv ice of local N ativ e A m ericans.T he nu trien t content o f the die ts w as analy z ed w ith theM IN IL IS T (2), w hich is a com pu teriz ed data bank of2 30 foods w ith 48 nutrien ts pe r f ood d ev ised at th eU niv ersi ty o f C alif orn ia, B e rk e ley , f rom U SD A Hand-book 8 (3) and oth er pub lischd and unpublish ed analy -ses. For fo od item s w ithout chem ical analy s is, nu trien tle v els hav e been appro x im ated f rom sim ilar f oods ; the re-f o re, th ere are no m issin g v alu es.

A com plete ph y sical e x am inatio n w as perf orm edpostpartum as described b y Jellif f e (4 ); the fo llow in ganth ropom etric ind ice s w ere m easu red : w eig ht, h eig ht;h ead , arm , and calf circum ferences; and triceps, b iceps,

T A B L E 1B io statistical com pariso n be tw een sam p le and g ene ralN av ajo ob stetric popu lation*

.Variable Population(n - 468 ) Samp le(n - 23 )M ate rnal age (y r) 24 .6 6.2 22 .4 4. 0A ge ofm enarche (y r) 13 .1 1.4 13 .5 1.3G rav id ity 2 .9 2.2 2 .3 1 .3Parity 1 .7 2.0 1 .1 1. 2G estation al duratio n (w k ) 39 .9 1.4 39.7 0.8M ate ran l height (cm ) 158 .9 5 .1 157 .9 4. 4Prep regnancy w eig ht (k g) 60 .2 1 0.9 59.0 9.4T erm w eigh t (k g ) 71 .9 11.2 72.4 9.5Pregnan cy w e igh t gain (k g) 1 1 .7 6.6 13.4 3.9T erm w eigh t/id eal b od y w eigh t 1 .3 0.2 1 .4 0.2B irthw e igh t (g ) 3 407 524 35 14 44 8S ex 0 .48M /0 .52F 0.52M /0 .48FA pgar score-i m m (1 -10 ) 7 .8 1.5 8 .3 0.7A pgar score-S m m (1 -10 ) 9 .0 0. 7 9. 0 0.4M atu ration rating (w k ) 39 .0 1.8 39.3 1. 7
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2 2 1 8 BUT T E ET AL .

su bscapu lar , an d supra ilia c sk info lds . B ody fa t w as es ti-m a ted from the form u la of Du rnin and Raham an (5) .Col lecl ion and pr epar at ion of samples

B lood sam ples w e re d raw n at th e tim e of d eliv ery o rw ith in 24 h pos tpa rtum from 86 Navajo w om en and atap pro xim ately 1 m onth po stp artum from th e subsam ple(n = 23) betw een th e hours 08:00 and 16 :00 . (B loodsam p le s ize w as not alw ays suff icien t fo r al l determ ina -tio ns so in som e in stance s the s tated n is sm aller.) U su -al ly , 20 m l v enous b lood was drawn into a M onove ttesy rin ge equ ipp ed w ith 20-gauge stain less ste el needle ; 3m l w as im m ed iately ejected in to a hep arin ized te st tub efo r a com ple te b lood count. For de term in atio n o f redblood cell (RBC ) folacin , I m l of h epanin ized b lood w astrans ferred to ano the r te st tub e w ith 5 m g sodium asco r-ba te. A liquots of se rum were frozen (-20#{176}C ) for p ro teinelec tro pho res is and for an aly sis o f retin o l, caro tene, n e-tino l-b inding pro tein , zin c, fe rrit in , an d fo lac in . T hela tte r w as pro tec ted w ith 5 m g sodium asco rba te andadju sted to pH 6 .0 w ith con cen trated N aOH .

A spo t u rin e specim en was co lle cted in a po lye thy lenecon tain er du ring th e postpartum hom e vis it.

M atern al h air sam ple s w ere cu t chose to the scalp inthe o ccip ita l a rea u sin g stain less s tee l scisso rs. T he infanthair sam ple w as taken random ly from a ll areas of th escalp .Sample analysis

To tal serum protein w as m easu red by a to ta l so lidsre fra ctom e ter. S erum pro teins w e re sep ara ted by ce llu -lo se ace tate e lec tro pho res is and quantif ied by den sitom -etry . A comp lete b lo od count w as pe rfo rm ed by au to-m a ted counte r in th e clin ica l laborato ry of the Tuba C ityIn dian Ho spital. This in clu ded Hb , hem ato cri t, a nd redand wh ite ce ll counts .

R e tin ol an d caro tene w ere d ete rm ined by the Ca rrP rice re action uti liz ing tr iflu ora cetic ac id (6). R etinol-b inding p rotein w as determ in ed by radia l imm unodif-fu sio n (M -Par tig en Retino l B in din g Pro tein A ccup akK it , B eh ring D iagnos tic s, Am erican H oechst Co rp .,Som e rville , N J 08876 ). S erum zin c w as de term in ed byd irec t asp ira tio n ofa w ater -d i lu ted sam ple in to an a tom icabso rp tion (AA ) spectro photom eter. S erum fern tin w asanalyzed by radio imm unoassay . (A naly ses p erfo rm ed atth e Hum an N utrition L abo ratory , U SDA /SEA , P .O .B ox 7 166 U niversity S tation , G rand Forks, ND 58201 .)

S erum and red b lood cell fo lac in w ere determ inedm icro bio log ica lly b y L actobaci l l us casei (A TCC 7469)( 7 ) .

U rin e w as ana lyzed fo r n itrogen con ten t (m icro -K jel-dah l), urea (au tom ated colo rim etn ic de term in atio n u til iz-in g diace ty lm onox im e), and creatin in e (au tom ated al-kahin e p icra te m e thod). U rin ary z inc w as de term in ed byd irec t asp ira tio n of w ater-d ilu ted sam ple s in to an AAspec tropho tom ete r. A fte r repeated w ashings w ith po larand nonpolar so lv en ts and dod ecyl sod ium sulfa te , theha ir sam ple s w ere ashed in a low tem pe rature ash en orm uff le furnace and ana lyzed by AA spectro photom e try .

Th e data w ere ana lyzed by SPSS program s on aC on tro l D ata 6400 compute r. Th e sig nif ican ce b etw eenm ean s and v ariances of populatio n and sub sam ple d ataw ere de term in ed by z test stat istic . R elat ion ships be tw eend ieta ry . an thro pom e tric , and bioch em ica l p aram e ters

w ere analyzed by th e Pearson corre lat ion coe ffic ien t.T he paired t sta tistic and t statis tic fo r tw o m ean s w erep erform ed to disce rn difference s b etw een sam pling p e-n od s and groups.

Resul tsSocioeconomic status

The ave rag e h ouseh o ld size w as fiv e pe r-sons cons is ting o f th ree adu lts and tw o ch il-d ren . T he m ean educa tion al leve ls a tta inedb y the fa th er and m oth er w ere 1 0 .7 3 .7 an d10.6 2 .7 y r , re spec tive ly . T he fa the rs w ereeng aged in occup atio ns o f coa l m in ing , con -s truc tion , eq u ipm en t ope ra tio n , m echan ic s ,and custo d ia l w ork . T he m ean in com e re -p o rted w as $ 13 0 p er cap ita /m on th . T he m e-d ian fo od exp end itu re w as $ 3 1 pe r cap ita/mon th .G eo grap h ically , 5 2% o f the fam ilie s rer-s ided in ru ral se ttings and 4 8% in tow ns. Th ety pe o f ho usin g w as q u ite va r iab le : 35% o fthe fam ilie s liv ed in su bstan tia l hom es o rm ob ile h om es; 26% in tra ile rs ; 26% in thetrad itio na l, o ne -room hogan , and 1 3% in o ne -room houses. O n ly 48% o f the hou seh o ldshad run n ing w a ter . M ost fam ilie s h ad p ri-va tely ow ned veh ic le s .D ietar y intake

A lth ou gh the 2 4 -h d ieta ry reco rd s in clu deda w ide v arie ty o f food item s, the re w as ap repo nde ran ce o f ce rta in fo ods w h ich cons ti-tu ted a d istinc tive m ea l pa ttern (a s ind ica tedby th e frequ en cy w ith w h ich a g iven food w asm en tioned ). T h e N av ajo w om en usua lly a teth ree m ea ls a d ay w ith occas iona l m idm orn -ing and ev en ing snacks. B reak fa st w as a sub -stan tia l m ea l con sis ting typ ica lly o f eg gs, b a-co n o r m u tton , ce real o r p o ta toe s, b read ,m ilk , an d o rang eju ice . T he lun ch an d d in ne rusua lly in c luded m ea t, p o ta toe s, b read , an da vege tab le . F requ en tly m en tion ed beve ragesw ere co ffee, te a , and so da po p . A lcoho licbeve rages w ere n o t consum ed by thesew om en . T he m ost po pu la r m ea ts w ere m ut-ton , b eef , ch icken , an d po rk . W hite b read , fryb read , o r to r tillas accom pan ied m o st m ea ls .O th er than p o ta toe s, f ru its and v eg etab lesw ere n o t consum ed in la rg e quan titie s . S o ftd r inks and o th e r sn ack item s w ere frequen tlypu rchased at th e trad in g posts . T he frequ en tuse o f re lativ ely low nu trien t den sity food
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N A V A JO N UT R IT IO N A N D PR EGN A N CY 2 2 1 9

item s such as w h ite b read , f ry b read , sodapop , lard -f ried po tatoes, and bak ed goodsten ded to d ilu te the nu trien t con ten t o f thediets .

H om e-g row n crops con tribu ted seasonallyto the f ood supp ly in5% of the househo lds.C orn , squash , bean s, m e lon s, p eaches, andap rico ts w ere am ong the f requen tly cu ltiv atedcrop s. A bou t half o f th e hou seho ld s ow nedliv estock , usually sheep and goats, and occa-sionally ho rses and cattle . T he sheep andgoats w ere com m only used f or f ood w hereasthe cattle and horses w ere reserv ed f or tran s-portatio n and com m erce.

Fed eral fo od assistance is av ailab le on th eN av ajo reserv ation; e lig ib le ind iv iduals h av ethe op tio n to e lect f ood stam p s o r f ood com -m oditie s. O nly th ree hou seho lds w ere receiv -in g f ood com m oditie s and tw o w ere rece iv in gf ood stam ps. In con trast, 70% of th e w om enpartic ip ated in th e S upp lem en tal Feed ingProgram f or W om en , In f an ts and C hild ren(W IC ) .

T h e w om en stated th at they d id no t alte rth eir f ood habits du rin g p regnan cy . T h is isco nsisten t w ith the N av ajo v iew of pregnancyas a natu ral ex perien ce . T he w om en did no tsp ec if y any fo od taboo s, although som e fo od

av o idances dev e loped af te r ep isod es o f heart-b urn , d iarrhea or nau sea. S tarchy , h ig h ly sea-so ned , and g reasy fo ods w ere com m on ly re -p orted to b e d isagreeab le durin g p regnan cy .

T h e w om en did no t recogn iz e an y fo ods asgalac tagogues, bu t m ention ed the im portanceo f su f f ic ien t liqu id s. M ilk , tea, ju ice , w ater,and b ro th w ere recom m ended . C hili an do ther sp icy f oods w ere av o ided as lik e ly tohav e adv erse e f f ects on the m ilk .

Nutr i ent i ntakeA cco rd ing to th e U S R ecom m ended D i-

e tary A llow ances (R D A ) (8 ), the g roup en-erg y in tak e w as ad equate at te rm pregnancy ,bu t in ad equate during lactation (T ab le 2).T h e group m edian energy in tak e at termpregnancy w as 2406 k cal/day and 19 1 1 k cal/day during lactation . T he energ y requ irem entfo r w om en , 19 to 22 y r o f ag e, is400 kca l/day during p regnan cy and 2600 k cal/daydurin g lactation . T heref ore , the d ie t pro v ided100% of th e energ y requ irem ent during p reg-nancy and 74% during lac tatio n . E nergy in -tak e w as no t sign if ican tly corre lated to m a-tern al body w eig h t or chang e in w e igh t.

T he pro te in in tak e w as 82 g /day (1 11%

T A B L E 2Daily f o od-nu trien t in tak e* o f 2 2 N av ajo w om en duringpregnancy and lactation

Nu tnen t Un i tA t p re g n a n c y te rm A t I m o p o s tp a rtu m

Med ian ( R D A ) M ea n (SD ) M e d ia n (% R D A ) Mean (SD)En e r g y k c a l 2 4 0 6 ( 1 0 0 ) 2 4 4 8 ( 8 8 7 ) 1 9 1 1 ( 7 4 ) 2 1 9 0 ( 9 9 0 )P r o t e i n g 8 2 ( 1 1 1 ) 9 5 ( 4 1 ) 9 1 ( 1 4 2 ) 8 7 ( 3 8 )Calcium m g 668 (56) 8 97 (515) 578 (48 ) 718 (458)Phosphoru s m g 1318 (110) 1421 (583) 1134 (95 ) 1 270 (559 )M agnes ium m g 230 (51) 241 (86) 212 (47 ) 221 (114 )Z in c m g 1 1.4 (5 7) 12 .5 (6 .9) 1 1 .7 (47) 12 .2 (5 .3)Coppe r m g 1.42 (57 ) 1 .57 (0 .66 ) 1 .44 (58 ) 1 .6 3 (0 .93 )Iron m g 16.2 (90 ) 15 .3 (4 .9) 14 .4 (80 ) 15 .2 (5 .9)V itam in A lU . 3554 (71) 4609 (2972 ) 2488 (41) 5467 (10 ,002)Vi t a mi n D l U. 1 2 1 ( 2 4 ) 1 6 6 ( 1 6 3 ) 1 1 6 ( 2 3 ) 1 3 6 ( 1 1 5 )V itam in E m g 3 .4 (34 ) 4 .2 (2 .9) 3 .5 (35 ) 4 .5 (3 .8)V itam inC m g 112 (140) 138 (130) 97 (97 ) 150 (165)Th iamin m g 1 .48 (99) 1 .53 (0 .52 ) 1 .31 (82 ) 1 .39 (0 .69 )R ib of lav in m g 1 .58 (99) 1 .86 (0 .85 ) 1 .48 (82 ) 1 .81 (1 .07 )Ni a c i n mg 1 8 . 9 ( 1 1 8 ) 2 1 . 4 ( 1 1 . 7 ) 1 9 . 4 ( 1 0 2 ) 2 0 . 1 ( 9 . 1 )V itam in B m g 1 .48 (5 7) 1 .45 (5 57 ) 1 .33 (5 3) 1 .44 (688)V itam in B ,2 ;.tg 4 .62 (1 16 ) 5 .28 (4 .2 3) 4 .4 0 (1 1 0) 7 .96 (1 .47 )Bi o t i n i g 5 4 ( 3 6 ) 6 7 ( 4 3 ) 4 6 ( 3 1 ) 5 4 ( 3 5 )Folacin , f ree itg 144 (36)t 1 40 (65) 1 34 (54) t 169 (1 39)Pan to thenate m g 5 .1 1 (9 3) 5 .30 (2164 ) 5 .26 (9 4) 5 .42 (3045)

a A naly s is ex clu des nutrien t su pplem entatio n tak en by som e w om en (see te x t).t W HO recom m ended in tak e used as re f erence standard (9 ).
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2220 B U T f E ET A L .

R DA ) at term pregnancy and 9 1 g/d ay (1 42%R DA ) during lac tation .

T he d istribu tio n o f calo rie s con trib u ted bypro te in (1 6% ), carbohy drate (4 7% ), and fat(3 7% ) d id no t d if f e r b etw een perio ds.D ie tary analy sis in d icated sub standard in -tak es o f sev eral v itam ins and essen tial m m -erals. T h e m edian nu trien t in tak es that w ereless than 60% of th e R DA w ere: calc ium ,m agnesium , z in c, co pper, v itam in A (lac ta-tio n on ly ), v itam in D , v itam in E , v itam in B b io tin , and f o lacin . T h e low er energ y in tak eduring lac tation w as assoc iated w ith a d im in-ished in tak e o f m ost nu trien ts.

A m ultiv itam in-m ineral tab le t6 and ferrou ssu lf ate w ere rou tine ly d ispensed in th e p re -natal c lin ic . D u rin g p regnan cy 61% of th e 23w om en repo rted to hav e tak en th ese supp le-m ents daily ; 1 7% too k them one to th ree tim esper w eek ; and 22% no t at all. U pon hosp itald ischarge , th e po stpartum w om en w ere g iv enH ex av itam in7 tab le ts and f errous su lf ate . A t1 m on th po stpartum , 6 1% o f th e w om en w erereported ly com p lian t; h ow ev er, o f the nu tri-en ts at risk , on ly v itam in A w as augm entedby the supp lem ent. T he in tak e o f th e nu trien tsu pp lem ents w as no t v erif ied . M ean serumlev e ls o f self -s tated users v ersu s nonusersw ere tested f or d if f e rences b y thestatisticfo r tw o m eans. S upp lem entation resu lted inno sig n if ican t d if f e ren ces in serum lev e ls o fretin o l, re tino l-b ind in g pro te in , f o lac in , o rz in c at te rm o r at 1 m on th postpartum .C lin ica l fin d ing s

In the postp artum ex am ination , 3 0% o f thew om en w ere c lassif ied as pale . C ases o f f luo -ros is (n = 7), w orn tee th (n= 4), and carioustee th (n = 1) w ere reco rd ed . S w ollen , redpap illae on the gum s w ere no ted in tw o of thew om en . O bserv atio ns o f slig h t ling ual p ap il-lary f ilif orm atroph y (n 6) and slig h t p ap-illary fu ng if orm hy p ertroph y (n 1 ) w erereco rd ed . A sligh tly en larged thy ro id w asno ted in one patien t w ith m alar p igm entation ,and en larged paro tid g lands in ano ther.T h ere w as one reported case each o f sligh tly -ridg ed f ing ernails and f ac ial hy p erp igm enta-t ion .

C ard iov ascu lar chang es that w ould be con-sidered patho lo g ical in th e absence o f preg -nancy w ere reco rd ed . M ild pre tib ial edem aw as seen in 48% o f th e w om en . S y sto lic b loodpressure ranged f rom 90 to 134 m m Hg and

T A B L E 3A nthropom etric characte rist ics o fN av ajo w om en

Variable Postpartum A t I m o n th la c ta ..l ionW eigh t (k g ) 66 .9 (9 .2) 63 .8 (9 .5 )tB od y fat ( % ) 34 (3 ) 34 (3)C ircum ferences (cm )

Head 55 .8 (1 .8 )A rm 28 .2 (2 .8) 27 .9 (3 .1 )Calf 33 .3 (3 .1) 3 2 .7 (2 .7)

S k in fo ld th ic k n ess (m m )T riceps 19 .6 (6 .0) 18 .3 (4 .4)B ic eps 12 .4 (4 .2) 1 1 .0 (4 .3 )S ub scapu lar 21 .0 (5 .2) 21 .0 (5 .8 )Supr a i h i a c 2 7 . 8 ( 4 . 1 ) 2 4 . 8 ( 5 . 8 ) t

a M ean (SD ).t Paired t test f o r d if f eren ce s b etw een p eriods , p 1 1 )(10 .0-10 .9)(40)

1 6 (80 )2(10)2(10)

1 1 .9 1.4 (12+)(10 .0-11 .9)

(1 1) 18 (69 ) 34 .2 5.5 (38+) 15 ( 71) 39 .0 4. 1(% ) Marginal

L ow(30-32)(


7/13

2 2 2 2 BUTTE ET AL.

w om en asse ssed , 1 5% had H b leve ls in them arg ina l range (10 to 1 1.9 g /d l). T he hem a-to cr it va lue s revealed a sligh tly h igh er in ci-d en ce o f m ild anem ia ; 1 9% w ere in th e m ar-g ina l ran ge (3 1 to 3 7% ) and 2% w ere in thelow ran ge (


8/13

N A V A JO N UT R IT IO N A N D PR EGN A N CY 2223

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2 2 2 4 BUT r E ET AL .

10 9 .0 tg /d l) (T ab le 5) . O ver h alf o f the 8 6w om en had va lue s b elow the p rov isio na llow er lim it (1 8 ) o f 50 j.tg /d l fo r p reg nancy ;2 6% w ere in the m arg ina l ran ge (4 0 to 49 g /d l); 2 4% w ere in the low ran ge (30 to 3 9 g /d l) ; and 2% w ere in the de ficien t rang e (


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N A V A JO N U T R IT ION A N D PR EGN A N CY 2 2 2 5

22% o f the v alu es f e ll be low the norm al lim it.T hree cases w ere in the range 30 to 33 g /d land tw o cases in the m arg in al rang e (2 0 to 29g /d l) . R B P v alues w ere w ith in th e norm alrang e in all po stpartum cases.A sig n if ican t (r= -0 .555 , < 0 .001 ) negativ ecorre lation w as seen be tw een serum re tino land z in c. R B P w as negativ e ly (r -0 .267 , p< 0 .0 07) corre lated to serum z inc . T hus itw ould appear th at in th ose cases w ith lowserum retin o l, z inc w as no t th e lim itin g f ac tor.

Discuss ionFood intake

T he fo od in tak e o f the N av ajo w om en w asn early adequate in energ y and pro te in , bu td ef ic ien t in sev eral o f the v itam in s and m in-erals . T h e m ed ian energy in tak e w as am pleat te rm , b u t decreased to 191 1 k cal/day at 1m onth pos tpartum . D ie tary 24-h recalls areno torious f or u nderrepo rting , w hich m ay beth e case here . T he w om en cou ld hav e beenf atig ued by all the in terv iew in g .

I f the recorded in tak es w ere v alid , it isu n lik e ly th at su ccessf u l lac tation w ou ld hav eb een sustained m uch longer at an energ y lev e lo f 34 k cal/k g /d ay . S tud ies o f w e ll-n ou rish edw om en hav e f ound 47 k cal/k g /day to becon sisten t w ith successfu l lac tation . L ac tatin gw om en reported ly increase the ir en ergy in -tak e app ro x im ate ly 6 00 k cal/d ay abo v e nor-m al, non lac tating lev e ls (21 , 22 ). T hese N a-v ajo w om en had consid erab le body stores tod raw upon for m ilk p roduc tion , b u t low en-ergy in tak es m ay proh ib it m ob iliz atio n o fad ip ose tissu e fo r m ilk p roduc tion . W h ich e-low (23) o bserv ed that w om en w ho consc i-en tio usly restric ted the ir food in tak e in o rd erto lose w e igh t w ere unab le to p roduce su f f i-c ien t m ilk f or the ir in f an ts.

T he substandard d ietary in tak es o f cal-c ium , m agnesium , z inc , copper, v itam in s A ,D , E , B and f o lac in do p resen t a sign if ican trisk o f d ef ic ien cy . T he in tak e o f th ese nu tri-en ts f e ll be low 60% o f the R D A (8). T hep renatal v itam in -m in eral supp lem en t thatw as d iscon tin ued during lac tatio n pro v idedall o f the abov e nu trien ts ex cep t z inc andcopper. T he bod y has a consid erab ly capac ityto store v itam ins A , D , E , and the m ineralscalc ium and m agnesium , bu t the reserv es o fv itam in B e ,, f o lac in , z inc , and copp er are lim -

ited . D ep leted reserv es no t rep len ished bye ither d ie t or supp lem entation w ou ld resu ltev en tually in a de f icien t state. A lth ough sup-p lem entation m ay com pen sate f or som e nu-trien t inadequac ies, it canno t pro v ide for allthe essen tial n u trien ts. S pec ial prob lem s o ftox icity and ill-de fm ed requ irem en t lev elsarise w hen d ealing w ith trace m inerals . Inth is stu dy , m arg in al z inc d e f ic iency w as iden-tif ied , b u t m o st lik e ly the in tak e o f o ther tracem inerals w as subop tim al as w ell.Cl ini cal fi ndings

T he c lin ical ex am ination s at te rm did no tde tect gross nu trien t de f icien cies. C lin icalfm d ings ten d to b e nonsp ec if ic and nond i-agno stic and , th ere fo re , shou ld be in terp re tedcau tiously . A num ber o fases o f sligh t p ap -illary f ih if orm atrophy and f ung if orm hy p er-tro phy w ere no ted . T h is m ay be caused by av arie ty o f de f ic ienc ies: iron , z inc , f o lac in , B 12 ,B n iacin , and ribo f lav in (24 ). Fluo ro sis w asobserv ed in sev eral o f the w om en . Parts o fth e reserv ation are k now n to hav e ex cessf luo ride in the w ell w aters.Biochemical r esul ts

Iron . S erum f erritin lev els prov id e an in -d irec t m e thod to assess body iron s tores. Ag radual dep le tion o f iron s tores resu lts in ap rog ressiv e d ec line in serum f erritin . T h eo -retically , lev els be low 12g /m l represen t anex hau stion o f iron sto res (25). Subsequen tly ,H b sy n th esis and transf errin satu ration de-crease , and f ree erythrocyte protoporphyrinrises . A ccord in g to th e standards o f the re f -e ren ce laborato ry , 13% of th e w om en hadunaccep tab le lev e ls (


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2 2 2 6 BUTTE ET AL.

Folacin . A lth oug h the m ean se rum fo lac inva lue s w ere w e ll abov e no rm al, 9% o f th ep regnan t N ava jo w om en had leve ls co nsid -e red m arg ina l o r de f icien t. R ep orts in th elite ra tu re h av e d ocum en ted sign s o f m ate rna lfo lic ac id d e fic ien cy w itho u t m ega lob la sticanem ia (2 6 ) . S ig ns seen la te in p reg nancyin clu ded low ered serum fo lacin , h ype rseg -m en tatio n o f neu troph ils , and e leva ted u ri-n ary fo rm im inog lu tam ic ac id a fte r a h is tid in eload . A ltho ugh the d efic it w as no t seve reen ou gh to cau se an em ia, specu la tions on pos -sib le un tow ard e ffects on the fe tu s h av e b eenfo rthcom ing w ithou t con clu sive resu lts . S om einvestiga to rs have fo und ab ru p tio p lacen tae ,fe ta l m alfo rm a tion , an d ab ortio n to be m orep rev alen t in p atien ts w ith fo lacin d e fic ien cy(2 6 ) . T he assoc ia tion b etw een p regn an cyw astage an d fo lac in de fic iency h as ye t to b esubstant iated.

Th e re w as a ten dency in th is s tud y fo rse rum fo lac in to decrease as lac ta tion p ro -g res sed . M etz (2 7 ) has sugg ested tha t la cta -tion is th e cond ition in g facto r tha t p rec ip i-tate s o ve rt m ega lob la stic anem ia in w om encon sum in g d ie ts m arg ina l in fo lic acid . S incese rum fo lac in is m ore a re flec tion o f recen td ie ta ry in take than o f tissue re se rv es , e ry th -ro cy te fo lac in leve ls w ere ana lyzed in 19 lac-tatin g w om en to con firm fin d ing s o f m arg in alfo lac in sta tu s . O fthe se w om en , 3 7% had RB Cfo lac in lev els in the low -de fic ien t rang es .

In o rd e r to m ee t the inc rea sed fo lacin re -qu irem en ts du ring p regnancy and lac ta tion ,fo lacin su pp lem en ta tion m ay be adv isab le,bu t sho u ld be accom pan ied b y nu tr ition ed -uca tion on g ood foo d sou rce s o f fo lic ac id ,s in ce d ie ta ry reco rd s w ere no ticeab ly low inlea fy g reen v eg e tab les and o the r fre sh vege -tab le s an d fru its .

Vi tamin A. In te rp re tatio n o f serum re tino lleve ls du ring p regn ancy and lac ta tion is com -p lica ted by in consis ten cie s in the lite ratu re(28 ). S om e investig ato rs have repo rted a fa lld u ring p regn ancy , fo llow ed by an inc rea sep ostp ar tum ; how eve r , o th ers con ten d tha t th isdeclin e is p reven ted by v itam in supp lem en-ta tion and th us no t phy sio lo g ical. A lte r-n ativ ely , som e stud ie s h av e sh ow n no s ign if i-can t chang es in se rum re tino l du rin g p reg -n an cy . C on flic ting rep o rts m ay be due p ar-tially to va ry in g fac to rs such as sea son of theyea r, v itam in sup p lem en ta tion , an d fe ta l sex .F o r in te rp reta tion o f the N av ajo da ta, th e

re fe ren ce standa rds p re sum e no a lte ra tion sdue to p regn an cy or lac ta tion .

U naccep tab ly low re tino l leve ls w ere seenin 1 0% o f the p opu latio n sc reened a t te rm ; anadd itio na l 29% of th e w om en had m arg ina lva lue s. R e tino l-b in d ing p ro tein w as h igh lya ssoc ia ted w ith se rum retin o l and w as de -p re ssed in 1 4% of the w om en . In th e lon g i-tud ina l s am ple , m arg in al leve ls w ere seen a tte rm and pe rsis ted af te r 1 m on th o f lac ta tion .

T he e tio log y of the low serum re tino lsap -pea red to be inadequ ate d ie ta ry sou rce s o fv itam in A . Id en tifiab le so u rce s w ere eggs ,bu tter o r m arg arine , and seaso na l fru its andvege tab le s . H ow eve r, the v eg etab le s co n -sum ed reg u la rly w ere poor sources of v itam inA .

Zinc. R eports in the lite ra tu re (18 ) ag reetha t p la sm a z inc dec line s d u rin g p regnancy ,bu t in te rp re tatio n o f p la sm a v alu es is con -fo un ded b y seve ral fac to rs . S ince 60 to 70%o f p la sm a z inc c ircu la te s lo ose ly bou nd toa lbum in , c ircu latin g lev els in pa rt are de te r-m in ed by se rum a lbum in con cen tra tion anda ffin ity o f a lbum in fo r zin c (2 9 ) . In h ypo al-bum inem ic cond itions such as p regnancy ,p lasm a z inc leve ls fa ll. F u rthe rm ore , e lev atedend ogeno us es trog en has an independ en t d e -p re ssin g e ffec t on se rum zin c. T he re fo re , it isd iff icu lt to de linea te to w h at ex ten t low se rumzin c lev e ls d u rin g p regnancy are p hysio log i-ca l o r d iet indu ced . H ow ev er , it ha s beenestim ated tha t p la sm a z inc d rop s app rox i-m ate ly 25% durin g norm a l p reg nancy (18 ) .P la sm a z inc no rm a lly lies be tw een 8 0 to 100.tg /d l. S erum zin c lev els a re g en era lly 5 to15% hig he r than p la sm a va lues. B ased onth ese ob se rva tion s a p rov is io na l low erim i tfo r p lasm a zin c du ring p regn an cy h as beendesigna ted a t 45 to 50 zg/dl .

In the p re sen t s tu dy , 52% of th e N av ajow om en had se rum z in c leve ls b elow the p ro -v is iona l low er lim it at p regn an cy te rm . Them ean se rum z inc lev el w as 2 4% be low theco rre sp ond ing con tro ls . It w ou ld appea r fromthe low nonp regn an t z inc va lue s (67 13 tg /d l) tha t th e N av ajo w om en a re en te r ing p reg -nancy w ith low se rum leve ls . T he h ypo a lbu -m inem ia o f p regnan cy w ou ld accou n t fo rapp rox im a tely 70% o f the dec line . N eve rth e-les s , th e low v alu es a ttain ed during p regn an cya re d is co nc er tin g.

T he m ed ica l reco rd s w ere rev iew ed fo r d e l-ete r ious effec ts as soc iated w ith the low serum
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N A V A JO N U T R IT ION A N D PR EGN A N CY 2 2 2 7

z in c v alu es. B irth w e igh t tended to in creaselinearly w ith serum z in c, bu t the co rrelation(r = 0 . 17 1 , p = 0 .0 66) d id no t attain s tatisticalsign if ican ce . M aternal age , parity , ho urs o flabor, and A pgar sco res w ere no t re lated tom aternal serum z inc . C om plicatio ns at dc liv -cry w ere reco rd ed am ong the 468 b irths. T heprev alence o f pos tpartum hem o rrhage w asstrik ing ly h ig h at a rate o f 0 . 130 . Preec lam p-sia, f e tal d istres s, and arrest in progress f o l-tow ed in o rd er o f f requency . T he sm all num -ber o f cases w ith com p lication s on w h ichb iochem ical in f orm ation w as av ailab le pre-clu ded any statistical analy s is .

M atern al and in fan t hair z in c v alu es d idno t re f lec t chron ic z in c depriv ation . H ow ev er,the d istribu tion o f m atern al lev e ls rev ealedthat 32% o f the w om en had lev els be low 150ppm z inc w hich som e in v estigators consid ermarg ina l .

T h e low serum z inc lev els ob serv ed in 42%of the sam p le af te r 1 m on th o f lac tatio n can -no t b e attrib u ted to hy poalbum inem ia. A l-though serum album in lev e ls had retu rn ed tonorm al, serum z inc lev els rem ained d e-pressed.

D ue to the w id e v ariab ility o b tained w ithurin ary z inc m easu rem ents , it h ad no t b eenconsidered a v ery accurate index o f z in c sta-tus. N ev erthe less, urine sam ples w ere ana-ly z ed af te r 1 m on th o f lac tatio n fo r z incconcen tratio n . D epressed urinary ex cretio no f z in c w as seen in f ou r o f the lac tatingw om en . T here w as no ev idence o f hy p erz in -curia.

M arg inal z in c status am ong these N av ajow om en appeared to be d ie t related . T h ew om en w ere consum ing be tw een 1 1 and 12m g z inc /day , deriv ed princ ipally f rom an im alproduc ts, eggs , and legum es. T h e v alid ity o fthe d ie t analy sis cou ld be qu es tioned , at-though a recen t unpub lished stu dy v erif iedcalcu lated in tak es based on the M IN IL IS Tby analy z ing th e z inc con ten t o f com po sited ie ts (K . T odd and D . H . C allow ay , unpub-lished resu lts).

Further con f irm atio n o f the d ie tary z incin tak es f o llow s f rom th e z inc /pro te in ratio .Z inc has b een show n to b e m ore h ig h ly re -lated to the p ro te in con ten t o f the d iet th anthe energy lev e l. A m ix ed d ie t prov ided ap -prox im ate ly 1 .5 m g z in c/lO g p ro tein (30 ). Inth is stu dy , 1 .3 to 1 .4 m g z in c/lO g pro te inw ere recorded . A lso , a h ig h ly sig n if ican t cor-

relation ex is ted be tw een d ie tary z inc and d i-e tary pro te in (r= 0 .9 44 at te rm , and r 0 .9 23at 1 m on th po stpartum ).

T he d iets reported by th e N av ajo w om enp rov ided on ly 57 and 47% of the R D A f orz inc du ring p regnan cy and lac tation , respec-tiv e ly . M ain tain ing th e sam e z in c/p ro tein ra-tio , the w om en w ou ld hav e to con sum e 154and 178 g pro te in /day during pregnancy andlac tatio n to m ee t the R D A . S uch an in creasem ay no t b e econom ically f easib le no r con-sisten t w ith so und nutritio n . H ow ev er, thelow serum z inc lev els ob serv ed in th is stud yind icate th at 12 m g z inc /day is in su f f ic ien t tom ain tain norm al serum lev e ls in pregnan tand lactatin g w om en . T here w ere no k now nprob lem s o f m alab sorp tion or in creased uri-nary and sw eat losses. T heref ore z in c supp le -m entation o f the d ie ts m ay be ind icated .Conclus ion

T hese d ie tary and b io ch em ical fm d ingsd em ons trated m arg in al nu trien t de f icienc ieso f z inc , v itam in A , f o lacin , and iron am ongth ese N av ajo w om en . T he s ligh test risk top regnan t and lac tatin g w om en is u naccep ta-b le. S topgap m easures can b e im plem en tedto am eliorate the situation , bu t th eir lim ita-tio ns need to be recogn iz ed . V itam in-m in eralsupp lem en tatio n is on e su ch in terv en tio n;h ow ev er, th is so lu tio n canno t prov id e fo r allth e essen tial nu trien ts. T h ef ood patterns inth is s tudy rev ealed f requen t use o f f oods lowin nu tritiv e v alue . Food selec tion is bound byeconom ic constrain ts, f oo d av ailab ility , an df ood pre f erences. O n the N av ajo reserv ationo ther fac tors af f ec ting fo od in tak e w ere lacko f transportatio n , re f rigeration , f ue l, and run -n ing w ater. G eog raph ical and w eath er prob-lem s restric t access to f ood and nutrition 5cr-v ices , w hich at b es t hav e an im pac t o n on lya po rtio n o f th e N av ajo popu lation . T he chat-len ge is f orm idab le , b u t the on ly f easib le, saf ew ay o f assuring ing estion o f all n u trien ts isthrough im prov em en t o f th e ov erall qualityo f the N av ajo d ie t.

T he coope ration of the N av ajo w om en partic ipatin gin the s tud y is gratef u lly ack now ledg ed. T he sub stantialco ntribu tion of labo ratory analy se s b y D r. H . H . S and -stead and M s. S andra Gallagher of the U SD A Hum anN u trit ion L abo ratory , G rand Fork s, N D , is g reatly ap-preciated . T he au tho rs th ank s are due to M rs . E lsie JimY az z ie and M s. B ernice W ille to f o r th eir partic ipatio nand gu idance on the reserv atio n , and to M s. Fran C osta
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2 2 2 8 BUTTE ET AL .

fo r h en sk illfu l techn ical as sis tan ce. A pp rec iation is alsoexp ressed to s taf f m em be rs of the T ub a C ity In dianH ealth Se rv ic e Ho spital for the ir su ppo rt and en thu si-a sm .

References1. N avajo H ea lth Sys tem s A gen cy and D iv isio n of

H ea lth Im p rov em ent S erv ice s, N ava jo T r ibe. N ava jom aste r h ealth p lan 1979.

2 . P ennin gto n JA . D ietary nutr ien t g uid e. W es tpo rt,CT : A vi Publish in g C o. 1976.

3 . W att BK , M erril l A L . Com po sit ion of food s: raw ,proce ssed , prepared . W ash ing ton , DC : U S G overn -m ent P rin ting O ffice, 1963 . (C onsum er and F oodEconom ic s Resea rch D ivision , A g ricu ltu ral R e -se arch Se rv ic e, U SDA , A gricu lture H andbook no . 8 ,r ev . )

4. Jel liffe DB . A ssessm ent o f nu tritiona l status of th ecomm un ity . G eneva: WHO , 1966. (WHO mono-g raph vol. 53 .)

5 . D u rnin JVGA , Rah am an MM . The asse ssm en t ofth e am ount o f fa t in the hum an body from measu re-m ents of sk in fo ld th ick ne ss. B r J N utr 1967 ;21 :68 1-9.

6 . N eeld JB , Pea rso n W N . M acro and m icrom eth odsfo r the de term in ation o f serum v itam in A us ingtr iflu oro ace tic a cid . J N utr 1963;7 9:4 54 -62 .

7 . Tam u ra T , S hin YS , W illiam s M A , S to ks tad ELR .Lactobacillus casei resp on se to pte royhpoly glu ta-m ate s. A nal B ioch em l972;49:5 l7 -21 .

8 . N ation al R esearch Coun cil, F ood and N utri tio nBoard . R ecommended dietary a llow an ces . 9 th ed .W ash in gto n , D C : N ationa l A cadem y o f S cience s,1 980 .

9 . R equ irem en ts of ascorb ic acid , v itam in D , vitam inB -12 , fo la te , an d iron . Jo in t FAO /W HO Exper tG roup, 1970 . G eneva : WHO . (W HO technic al ne -p ort ser ies , no . 452 .)10 . H e ilm an LM , Pri tch ard JA . O bstetrics. N ew Y ork :A ppleto n , C en tury C ro fts, 19 71.

11 . B ray GA . Obesity in perspective. Fogar ty In te rna -t ion al C en ter series o n p rev entive m edicin e. V o l. 2 ,P art I. W ashin gto n , D C : U .S . D ept. of H ealth , Ed -u cation and W elfa re, 1975. ID HEW public ation no.(N IH ) 75-708 .J

12 . Saube rlich H E , D ow dy R P, S kala JH . L abo ratoryte sts for the assessm ent o f n utri tio nal status . C leve -land , O H : CRC Press, Inc. 1974:9 4 .

13 . Bonsn es RW . N itro genou s indices . In : N a tion al R e -se arch Counc il, F ood and N utr itio n B oard . L abo-ra tory ind ice s of n utr itio na l status in pregn ancy.W ash in gto n , D C : N atio nal A cadem y o f S cience s,1 978 :8 9- 108.

14 . Fo lin 0 . A th eory of pro te in m etabolism . Am JPhys io l l905 ;13 :l 1 7-3 8 .

15 . B eard HH . C oeffic ien ts of co rrelatio n betw een then itro genou s constituents of ur ine a fte r inge stio n oflow , n orm al and high p ro tein diets . H um B io l 1935 ;7 :419-29 .16 . Saube rlich HE , D ow dy R P, Sk ala JH . L abo ratorytestss fo r th e assessm ent o f nu trition al statu s. C leve-land , O H : CRC Press , Inc, 1974:1 19 .

17 . Saub erlich H E , Dow dy R P, Sk ala JH . L abora torytests for the assessm ent o f n utri tio nal sta tus . C leve -land , O H : CRC Pre ss, Inc. 1974:5 3 .

18 . H amb idg e KM . M auer AM . T race e lem en ts. In :N ationa l R esearch Counc il, F ood and NutritionB oard . L abo rato ry indices of n utr itio nal statu s inpregnancy . W ashin gto n , D C : N atio nal A cad em y ofS cience s, 1978:1 57 -93 .

19 . H amb idg e KM , Hamb idg e C , Jacobs M , Baum JD .L ow lev els of z inc in h air, a no rexia, p oor grow th ,and hypogeusia in ch ild ren . P ediatr R es 1972;6 :868-7 4 .

20. S auber lich HE , D owdy RP , Sk ala JH . Laborato rytests for th e a sse ssm en t of n utr itio nal s tatu s. C lev e-lan d , OH : CRC P ress , In c. 1974:8 .

21 . Thom as AM , H yuen FE , B illew ic z W Z. T he en erg yco st of hum an lac tat ion . B r J N utr 1970;2 4:5 65 -72 .

2 2 . E ng lish R , H itch cook N . Nu trien t in tak es du ringpregnancy , la cta tion , and afte r c essation of la cta tionin a gro up o f Au stra lian w om en. B r J N utr 1968 ;22 :615-24 .

2 3 . W hichelow M i. C alo ric requ irem ents fo r success fu lbre ast- feedin g . A rch D is C hild l9 75;50:669.

2 4 . G oodha rt RS , S hils M E . M odern nutritio n in h ea lthand d ise ase . 5 th ed . Ph ilad elp hia : Lea and Feb ige r,1973.

2 5 . In te rna tio nal N utr itio nal A nem ia Consulta tiv eG roup. Gu ideline s fo r the eradic atio n of iron de fi-ciency anem ia . W ashington , D C : N utri tio n Foun -da tion , 1977.

2 6 . P ritcha rd JA . Anem ias com plicat ing pregnancy andth e pue rpe rium . In : N ationa l R e sea rch C oun cil ,F ood and N utr itio n Board . M a ternal n utr itio n andth e course of pregn ancy. W ashin gto n , DC : N a tio nalA cadem y of S ciences, 1970:74- 109.

2 7 . M etz J. Fo late def iciency condit ion ed by lactatio n .Am J C lin Nu tr 1970;2 3:8 43 -7 .

2 8 . S aub erlich H . V itam in indices . In : N ation al R e-se arch Counc il, Food and N utri tio n B oard . Labo-natony ind ice s o f nu tritiona l s tatu s in p regn an cy.W ashington , DC : N ationa l A cadem y of Sc ien ces ,1978:109-56 .

2 9 . S olom ons NW . On the assessm ent o fain c and coppernutritu re in m an . Am J Ch in Nu tr 1 979;3 2:8 56-71 .

3 0 . Sw an son CA , K ing JC . H um an z inc nu tri tion . JNu tr E d l979 ;2 :l8 l-2 .
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