During the past 25 years, the number of deaths in infants under 1 year of age has been markedly reduced. The number of deaths in the first few weeks of life, however, has been altered very little. Apart from congenital abnormalities, birth trauma and prematurity, there still remain a number of unexplainable deaths. This study was undertaken in order to determine the effect of poor and good prenatal diets upon the outcome of pregnancy and condition of infant during first months of life. Only patients who had not reached the end of the sixth month of pregnancy and those patients who signified their intention of being confined in the Toronto General Hospital were included in the study. If any major disease was found that patient was excluded.
Briefly, the method of study was as follows: (1) An analysis of the patient’s food record was made at the beginning of observation; (2) this analysis was repeated 2 months later; (3) patients were classified into three groups, namely, those receiving a poor diet throughout, or having a supplemented diet, or subsisting on a good diet and receiving advice; (4) blood examinations were made for hemoglobin, vitamin C and phosphatase; (5) obstetrical rating was given each patient for (a) the prenatal period, during labor and convalescence, and with respect to (b) condition of baby at birth, (c) follow-up examination of the mother, (d) ability of mother to nurse infant, and (e) the whole course of pregnancy from beginning to end of observation; (6) babies were examined at 6 months and at 12 months of age, and records were kept of illnesses, general condition and eruption of teeth.
Each patient at the first interview was given a record form containing a space for each meal for 7 days. In this she was instructed to write down the kind and amount of each food eaten at each meal for 7 days. She was instructed to record weights of food, where possible; otherwise, to record in common measures, such as tablespoonful, cupful, ounces, or measure of solid foods in inches, or as large, medium or small vegetable or fruit. The patient then returned with this record and was interviewed by the dietitian. Each detail on the record was checked by means of questioning and comparison with amounts bought and amounts served at each meal to the whole family. Recipes were also discussed and methods of cooking. Social workers visited the homes of many of the patients in the Supplemented Group in order to check the consumption of the foods being sent. A trained worker visited the home of a small number of patients in each group and weighed the food after it had been estimated and recorded. Having arrived at the approximate amounts consumed, the foods were then totalled for the week under the following headings: eggs, meat (to include fish and fowl), milk, cheese, cream, butter, oil, bread (white and brown), cereals, potatoes, vegetables, cooked and raw, fruits (citrus and others), sugar, and miscellaneous. This list formed the basis for scoring the diet as “good,” “fair” or “poor”. A consultation was then held and with this diet record, knowledge of the family income, rent, and number of dependents, each patient was considered for further study.
If the diet was poor and the income low, each alternate patient was selected for help from a special fund. Those who did not receive help were left on their poor diets, were given no dietary advice, and will be referred to as the Poor Diet Group. There were 120 in this group. Those who had been on an equally poor diet until the fourth or fifth month of pregnancy and then received extra food from us, will be referred to as the Supplemented-to-Good Diet Group. There were ninety of these. It was found that approximately one-half of the patients in the clinic were on moderately good diets and had sufficient income to provide a good diet if given advice. Advice in detail was then given. These will be referred to as the Good Diet Group. There were 170 of these studied.
As a basis for planning reasonable food requirements during pregnancy, we aimed at the following amounts of the essential foods: daily, 40 ounces of milk, 1 ounce cheese, 1 egg, an average serving of butter and meat, 2 servings of vegetables in addition to potato, one orange or one-half grapefruit, or 5 ounces of tomato juice, one-half of the cereals and bread consumed to be in whole grain form, 2 teaspoonfuls of cod liver oil or equivalent in concentrate, liver once a week, salt to be iodized, and medicinal iron to be used if indicated. Two tablespoonfuls of wheat germ daily were advised.
We advised those patients with sufficient income in the Good Diet Group to try to obtain the amounts given.
To the patients in the Supplemented-to-Good Group we sent daily, 30 ounces of milk, 1 egg and 1 orange. Once a week, we also sent two 16-ounce tins of factory canned tomatoes and ½ pound of cheddar cheese. At the clinic we distributed a palatable dried wheat germ which contained malt, and added iron. Two tablespoonfuls contained 12 mg. of iron. Viosterol capsules containing 2000 international units of vitamin D were supplied, with instructions to take one daily. Advice in detail was given to the women in this group regarding the use of this extra food, and instruction was given in planning the remainder of the diet from the family income.
The average cost of the extra food supplied to the ninety women in the Supplemented-to-Good Diet Group for an average period of 4.7 months was $25.00 per patient.
In order to offset any possible psychological factor due to the taking of medicine, patients not receiving supplemental food were given gelatin capsules resembling the viosterol capsules, but containing instead plain corn oil.
The additional food supplied to the patients in the Supplemented-to-Good Group gave the following daily average values: protein, 45 gm.; fat, 46 gm.; carbohydrate, 60 gm.; calories, 840; calcium, 1.45 gm.; iron, 15 mg.; vitamin C, 50–80 mg.; vitamin B₁, 350–400 I.U., and vitamin D, 2000 I.U.
In order to eliminate errors in judgment and to offset the number of dietitians interviewing the patients, each diet record was later calculated for protein, fat, carbohydrate, calories, calcium and iron. The material was arranged in such a form that information regarding the vitamin content could also be calculated.
The average duration of observation in the Prenatal Clinic was 4.4 months in the Poor Diet Group, 4.7 months in the Supplemented Group and 4.4 months in the Good Diet Group. The economic status of the patients in the three diet groups is shown. Three per cent of the patients in the Good Diet Group were receiving from other sources extra milk, meat, vegetables and fruits in addition to the relief ration, which allowed them to be in the group improved by education. The past obstetrical records of the multiparous patients showed a much higher incidence of previous major complications in the Poor Diet and Supplemented Groups than in the Good Diet Group. Those in the Supplemented Diet Group had experienced more miscarriages, stillbirths and premature births in previous pregnancies than the Poor Diet Group.
The obstetrician in charge of the patients in the Prenatal Clinic and in the Hospital has given his rating of the condition and progress of the patient in each period of pregnancy. He was unaware of the diet group to which each patient belonged. A “good” or “fair” rating indicated that in his opinion the patient had progressed satisfactorily or with minor complications only. “Poor” or “bad” meant that many or major complications had arisen. The rating during the prenatal period, during the actual labor, and during the 2 weeks of convalescence in the hospital is shown. The obstetrician’s rating of the whole course of pregnancy from the time that the patient first came under observation in the Prenatal Clinic until she was seen 6 weeks after the birth of her baby is also presented. The mothers in the Supplemented-to-Good Diet Group proved to be better obstetrical risks. The average duration of labor was 5 hours shorter in this group than in the Poor Diet Group. We noted a marked improvement in the general mental attitude of the patients in the Supplemented Group; many of them lost their minor aches and pains, and no longer had numerous complaints.
During the prenatal period there were more cases of anemia, toxemia, and threatened miscarriage in the Poor Diet Group, while the total number of complications in this group was almost double that in the Supplemented-Good Group. The complications which affected the rating during labor in the Poor Diet Group were chiefly 6% of miscarriages, 8% of premature births, and 3.4% of stillbirths, while in the Supplemented Good Group there were only 2.2% of prematures and no miscarriages or stillbirths. After delivery there were fewer cases of uterine or breast infections in the Supplemented-Good Group.
The effect of prenatal diet is reflected in the average levels of hemoglobin, vitamin C and phosphatase in the blood of the mother at the time of delivery. The average amount of hemoglobin at the time of delivery was slightly higher in the Supplemented-Good Group. The average level of ascorbic acid in the mother’s blood at term and in the cord blood was proportional to the vitamin C obtained by consumption of citrus fruit and tomatoes. Phosphatase is an enzyme which has to do with the laying down of new bone. Phosphatase is increased when there are difficult or abnormal conditions in bone formation. Thus we have found that the phosphatase of the mother’s blood is more than double the average values from the sixth month to term when twins are present. The phosphatase in the mother’s blood was appreciably lower in the Supplemented Group than in the other two groups. This became apparent from the seventh month onward after the Supplemented Group had been receiving viosterol capsules, while the other two groups had not received a source of vitamin D. This seemed to indicate that expectant mothers receiving vitamin D and an adequate diet were better able to provide for new bone in the developing fetus.
The average birth weight of the babies born of mothers in the Poor Diet Group was 7 pounds 10 ounces; in the Supplemented Group, 7 pounds 7 ounces; and in the Good Diet Group 7 pounds 6½ ounces. The additional calories do not appear to have influenced the size of the baby.
An attempt is being made to follow the progress of the babies born of the mothers in this study to determine the influence, if any, of prenatal diet upon the future condition of the baby. These observations are not completed, but a brief summary can be given of the first 250 babies followed to the age of 6 months. The increased incidence of minor and major diseases in the babies born of mothers in the Poor Diet Group is quite striking. The general condition of the babies in the Supplemented and Good Diet Groups was on the whole much better. In a large proportion one could tell the diet group of the mother by looking at her baby. Two of the three infant deaths in the Poor Diet Group resulted from pneumonia, and the other from prematurity.
SUMMARY
The prenatal diets of 400 women with low incomes were studied. One group found to be on a poor diet was left as a control, a second group on a poor diet was improved by supplying food during the last 3 or 4 months of pregnancy, and a third group, found to have moderately good prenatal diets was improved by education alone.
During the whole course of pregnancy the mothers on a good or supplemented diet enjoyed better health, had fewer complications and proved to be better obstetrical risks than those left on poor prenatal diets.
The incidence of miscarriages, stillbirths and premature births in the women on poor diets was much increased.
The incidence of illness in the babies up to the age of 6 months and the number of deaths resulting from these illnesses were many times greater in the Poor Diet Group.
CONCLUSION
While it is recognized that there are other important factors in the successful outcome of pregnancy, this study suggests that the nutrition of the mother during the prenatal period influences to a considerable degree the whole course of pregnancy, and in addition directly affects the health of the child during the first 6 months of life.