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Background: Delayed onset of lactogenesis (OL) is most common in primiparas and increases the risk of excess neonatal weight loss, formula supplementation, and early weaning. Objective: We examined variables associated with delayed OL among first-time mothers who delivered at term and initiated breastfeeding (n = 431). Design: We conducted in-person interviews during pregnancy and at days 0, 3, and 7 postpartum and extracted obstetric and newborn information from medical records. We defined OL as delayed if it occurred after 72 h and used chi-square analysis to examine its association with potential risk factors across 6 dimensions: l) prenatal characteristics, 2) maternal anthropometric characteristics, 3) labor and delivery experience, 4) newborn characteristics, 5) maternal postpartum factors, and 6) infant feeding variables. We examined independent associations by using multivariable logistic regression analysis. Results: Median OL was 68.9 h postpartum; 44% of mothers experienced delayed OL. We observed significant bivariate associations between delayed OL and variables in all 6 dimensions (P < 0.05). In a multivariate model adjusted for prenatal feeding intentions, independent risk factors for delayed OL were maternal age [greater than or equal to] 30 y, body mass index in the overweight or obese range, birth weight >3600 g, absence of nipple discomfort between 0-3 d postpartum, and infant failing to 'breastfeed well' [greater than or equal to] 2 times in the first 24 h. Postpartum edema was significant in an alternate model excluding body mass index (P < 0.05). Conclusions: The risk factors for delayed OL are multidimensional. Public health and obstetric and maternity care interventions are needed to address what has become an alarmingly common problem among primiparas. doi: 10.3945/ajcn.2010.29192

Background: Information is needed on the minimum energy density and feeding frequency of complementary foods that can provide adequate energy intakes (EIs) for healthy breastfed children. Objectives: The objectives of the study were to evaluate the effects of various energy densities and feeding frequencies of complementary foods on EI from these foods, breast milk consumption, and total EI from both sources. Design: During 9 separate, randomly ordered dietary periods lasting 3-6 d each, we measured intakes of food and breast milk by 18 healthy breastfed children 8-11 mo of age who, 3, 4, or 5 times/d, were fed porridge with a coded energy density of 0.5, 1.0, or 1.5 kcal/g. Food intake was measured by weighing the feeding bowl before and after meals, and breast milk intake was measured by test weighing. Results: The mean amounts of complementary foods consumed were inversely related to their energy density and positively related to the number of meals/d (P < 0.001 for both); EIs from foods were positively related to both factors. Breast milk intake decreased slightly but progressively, with greater energy density and feeding frequency of complementary foods; total EIs (kcal/d) increased in relation to both factors (P < 0.001 for both). Conclusions: The energy density and feeding frequency of complementary foods affect infants' total daily EI and breast milk consumption. Recommendations can be developed for the appropriate combinations of these dietary factors that are compatible with adequate EI, although longer-term effects of complementary feeding practices on breast milk intake and breasffeeding duration need further community-based studies.

Background: No studies have examined the independent effects of current and longer-term dietary zinc intakes on zinc absorption. Objective: We determined the effects of current compared with longer-term zinc intake on fractional zinc absorption (FZA). Design: We studied 9 men whose usual zinc intakes were > 11 mg/d. FZA was measured at baseline, depletion (0.6 mg Zn/d for 1 wk and 4 mg Zn/d for 5 wk), and repletion (11 mg Zn/d for 4 wk with 20 mg supplemental Zn/d for first 7 d). During 2 successive days after each dietary period, subjects consumed either adequate-zinc meals (11 mg Zn/d) with a zinc stable isotope tracer for 1 d, followed by low-zinc meals (4 mg Zn/d) with zinc tracer, or vice versa. Five days after oral dosing, a zinc tracer was infused intravenously. FZA was measured with the use of a modified double isotope tracer ratio method with urine samples collected on days 5-7 and 10-12 of absorption studies. Results: Plasma and urinary zinc did not vary by dietary period. Mean FZA was greater from low-zinc meals than from adequate-zinc meals (60.9% [+ or -] 13.8% compared with 36.1% [+ or -] 8.9%; P < 0.0001), whereas mean total absorbed zinc was greater from adequate-zinc meals than from low-zinc meals (3.60 [+ or -] 0.91 compared with 2.48 [+ or -] 0.56; P < 0.0001), regardless of the longer-term dietary period. Conclusions: FZA was inversely related to current zinc intake, but there was no detectable effect of longer-term dietary zinc. If longer-term zinc intake does modify FZA, such changes are smaller than those caused by current zinc intake, or they occur only after more severe zinc depletion.

Background: Glutamate carboxypeptidase II (GCPII) encodes for intestinal folate hydrolase and brain N-acetylated [alpha]-linked acidic dipeptidase. Previous studies provided conflicting results on the effect of the GCPII 1561C[right arrow]T polymorphism on folate and total homocysteine (tHcy) concentrations. Objective: We aimed to determine the potential effects of 2 polymorphisms of GCPII on plasma folate and tHcy concentrations, cognition, anxiety, and depression in a large aging cohort of Norwegians enrolled in the Hordaland Homocysteine Study. Design: DNA samples were genotyped for the GCPII 1561C[right arrow]T and 484A[right arrow]G polymorphisms, and the results were linked to plasma folate and tHcy concentrations and to scores for cognition, anxiety, and depression. Results: The 2 polymorphisms were in linkage disequilibrium and were associated with concentrations of tHcy. After adjustment for covariates, persons in the CT or combined CT and TT groups of the 1561C[right arrow] T polymorphism had higher plasma folate concentrations and lower tHcy concentrations than did those in the CC group. Subjects with the TT genotype had lower Symbol Digit Modalities Test (SDMT) scores than did subjects with the CC genotype. Compared with abstainers, moderate alcohol drinkers had higher plasma folate concentrations and higher scores on the Mini Mental State Examination. However, women abstainers with the CTgenotype had lower SDMT scores than did abstainers with the CC genotype or moderate drinkers with the CT genotype. Conclusions: The 1561C[right arrow]T polymorphism is associated with higher plasma folate and lower tHcy concentrations and with lower SDMT cognitive scores in women who abstain from alcohol. Am J Clin Nutr 2007;86:514-21. KEY WORDS Glutamate carboxypeptidase II, GCPII, folate, homocysteine, cognition, gene polymorphisms

Background: Zinc supplementation decreases morbidity from infections and increases growth of stunted children, but there is little information on functional responses to zinc delivered in fortified foods. Objective: The aim was to examine the effects of zinc fortification on the growth, morbidity from infections, and plasma zinc concentrations of young children. Design: We compared the physical growth, morbidity, and micro-nutrient status of 6-8-mo-old Peruvian children with initial length-for-age z score (LAZ) < -0.50 who were randomly assigned to receive one of the following treatments daily for 6 mo: 1) 30 g dry weight of an iron-fortified cereal porridge and a separate dose of an aqueous multivitamin (MV) supplement between meals (control group), 2) the same porridge and MV with 3 mg Zn added to the supplement dose (ZnSuppl group), or 3) the porridge with added zinc (150 mg/kg dry weight) and MV without zinc (ZnFort group). Results: The children consumed a mean of 22-26 g dry porridge/d and 96% of the possible MV doses. After adjustment for small baseline differences in socioeconomic status and morbidity, no significant differences in weight or length increments were observed between the groups, even among the subset with an initial LAZ < - 1.5, and no significant differences in the rates of common illnesses were observed. Mean plasma zinc concentrations decreased in the control group (-3.9 [micro]g/dL), increased in the ZnSuppl group (4.3 [micro]g/dL), and did not change significantly in the ZnFort group (-1.5 [micro]g/dL; P < 0.001 for group-wise comparison). Conclusions: Provision of additional zinc, either in an aqueous supplement or a fortified porridge, did not significantly affect the children's physical growth or morbidity from infections, possibly because they were not sufficiently growth-restricted or zinc-deficient initially or because the level of zinc intake or absorption was inadequate. Additional studies of the functional effect of zinc-fortified foods are needed in populations that are known to respond to zinc supplements. KEY WORDS Zinc, fortification, supplementation, growth, diarrhea, infants

Background: Information is needed to design studies of the effects of complementary feeding regimens on children's intakes of complementary foods (CFs) and breast milk. Objective: We evaluated the effects of varied energy density of CFs on the time until stabilization of dietary intakes and on total daily energy intakes (EIs) and breast-milk intakes. Design: CFs with low [0.4 kcal/g (LD)] and high [1.5 kcal/g (HD)] energy density were fed 3 times/d to 10 children (aged 9-18 mo) during 2 randomly assigned sequences of three 8-d diet periods (HD-LD-HD or LD-HD-LD) along with ad libitum breastfeeding. CF and breast-milk intakes were measured. Results: Intakes of the HD diet and breast milk did not vary by day of period, but intake of the LD diet increased progressively. During days 5-7 of the last 2 diet periods in each sequence, more of the LD than of the HD diet was consumed (752 [+ or -] 252 and 439 [+ or -] 111 g/d, respectively; P < 0.001), but EIs from CFs were greater with the HD diet. Breast-milk consumption was slightly less (192 [+ or -] 115 and 234 [+ or -] 121 g/d, respectively; P = 0.03) but total daily El was greater (774 [+ or-] 175 and 441 [+ or -] 85 kcal/d, respectively: P < 0.001) during the HD than during the LD diet period. Conclusions: New information on the effects of newly introduced diets on daily intakes of these diets and of breast milk can be used to design future studies. Total daily Els were greater with the HD diet despite its negative effects on breast-milk intakes. KEY WORDS Infant feeding, complementary food, energy density, breast milk, breastfeeding

Background: Information is needed on the fractional absorption of zinc (FAZ) and absorbed zinc (AZ) during prolonged exposure to zinc-fortified foods. Objective: The objective was to measure FAZ and AZ from diets fortified with different amounts of zinc and to determine whether zinc absorption changes over [approximately equal to] 7 wk. Design: Forty-one stunted, moderately anemic children received daily, at breakfast and lunch, 100 g wheat products fortified with 3 mg Fe (ferrous sulfate) and 0 (group Zn-0), 3 (group Zn-3), or 9 (group Zn-9) mg Zn (zinc sulfate) per 100 g flour. FAZ was measured on days 2-3 and 51-52; meal-specific AZs were calculated as the product of FAZ and zinc intake. Results: For the breakfast and lunch meals combined, mean total zinc intakes were 2.14, 4.72, and 10.04 mg/d in groups Zn-0, Zn-3, and Zn-9, respectively, during the initial absorption studies; mean ([+ or -] SD) FAZ values were 0.341 [+ or -] 0. l 11,0.237 [+ or -] 0.052, and 0.133 [+ or -] 0.041, respectively, on days 2-3 (P < 0.001) and did not change significantly on days 51-52 in the subset of 31 children studied twice. Mean initial AZ was positively related to zinc intake (0.71 [+ or -] 0.18, 1.11 [+ or -] 0.21, and 1.34 [+ or -] 0.47 mg/d, respectively; P < 0.001); final values did not differ significantly from the initial values. Conclusions: AZ from meals containing zinc-fortified wheat products increases in young children relative to the level of fortification and changes only slightly during [approximately equal to] 7-wk periods of consumption. Although consumption of zinc-fortified foods may reduce FAZ, zinc fortification at the levels studied positively affects total daily zinc absorption, even after nearly 2 mo of exposure to zinc-fortified diets. KEY WORDS Zinc, iron, wheat, fortification, absorption, stable isotopes, children

Background: It is not known whether daily consumption of vitamin A-containing foods is efficacious for treating nightblindness. Objective: We assessed the effect of supplementation with vitamin A from food or synthetic sources on dark adaptation and plasma retinol concentrations in nightblind pregnant Nepali women. Design: Nightblind pregnant women were randomly assigned to 1 of 6 treatment groups to receive 6 d/wk for 6 wk either 850 [micro]g retinol equivalents/d as retinyl palmitate, vitamin A-fortified rice, goat liver, amaranth leaves, or carrots or 2000 [micro]g retinol equivalents/d as retinyl palmitate. Dark adaptation was assessed weekly by using the pupillary threshold (PT) test: plasma retinol concentrations were measured before and after the intervention. These outcomes were also assessed in a comparison group of nonnightblind pregnant women. Results: In the nightblind women, the mean PT improved significantly (P < 0.0001) from -0.71 [+ or -] 0.04 to -1.42 [+ or -] 0.02 log cd/[m.sup.2], and the final mean PT did not differ significantly from that in the nonnightblind women (-1.43 [+ or -] 0.04: P = 0.55). Improvement in dark adaptation was greater in the liver group than in the vitamin A-fortified rice group (P < 0.02). Plasma retinol concentrations increased significantly (P < 0.0001) from 0.95 [+ or -] 0.05 to 1.07 [+ or -] 0.05 [micro]mol/L. The plasma retinol response was greater in the higher-dose capsule and liver groups than in the vegetable groups and significantly greater in the liver group than in the vitamin A-fortified rice group (both: P < 0.05). Conclusion: Improvement in dark adaptation did not differ significantly between women who received vitamin A as liver, amaranth leaves, carrots, or retinyl palmitate. KEY WORDS Nightblindness, pregnancy, vitamin A status, supplementation, pupillary threshold, dark adaptation, Nepal, vitamin A, [beta]-carotene, food-based interventions

Background: Recent evidence suggests that the vitamin A equivalency of [beta]-carotene from plant sources is lower than previously estimated. Objective: We assessed the effect of 60 d of daily supplementation with 750 [micro]g retinol equivalents (RE) of either cooked, pureed sweet potatoes; cooked, pureed Indian spinach (Basella alba); or synthetic sources of vitamin A or [beta]-carotene on total-body vitamin A stores in Bangladeshi men. Design: Total-body vitamin A stores in Bangladeshi men (n = 14/group) were estimated by using the deuterated-retinol-dilution technique before and after 60 d of supplementation with either 0 [micro]g RE/d (white vegetables) or 750 [micro]g RE/d as sweet potatoes, Indian spinach, retinyl palmitate, or [beta]-carotene (RE = 1 [micro]g retinol or 6 [micro]g [beta]-carotene) in addition to a low-vitamin A diet providing [approximately equal to] 200 [micro]g RE/d. Mean changes in vitamin A stores in the vegetable and [beta]-carotene groups were compared with the mean change in the retinyl palmitate group to estimate the relative equivalency of these vitamin A sources. Results: Overall geometric mean ([+ or -] SD) initial vitamin A stores were 0.108 [+ or -] 0.067 mmol. Relative to the low-vitamin A control group, the estimated mean changes in vitamin A stores were 0.029 mmol for sweet potato (P = 0.21), 0.041 mmol for Indian spinach (P = 0.033), 0.065 mmol for retinyl palmitate (P < 0.001), and 0.062 mmol for [beta]-carotene (P < 0.002). Vitamin A equivalency factors ([beta]-carotene:retinol, wt:wt) were estimated as [approximately equal to] 13:1 for sweet potato, [approximately equal to]10:1 for Indian spinach, and [approximately equal to]6:1 for synthetic [beta]-carotene. Conclusion: Daily consumption of cooked, pureed green leafy vegetables or sweet potatoes has a positive effect on vitamin A stores in populations at risk of vitamin A deficiency. Am J Clin Nutr 2004;80:705-14. KEY WORDS Deuterated retinol dilution, stable isotope, bioavailability, vitamin A status, [beta]-carotene, vitamin A stores, green leafy vegetables, sweet potatoes, Bangladesh

Background: Zinc supplements reduce childhood morbidity in populations in whom zinc deficiency is common. In such populations, deficiencies in other micronutrients may also occur. Objective: The objective was to determine whether the administration of other micronutrients with zinc modifies the effect of zinc supplementation on children's morbidity and physical growth. Design: Two hundred forty-six children aged 6-35 mb with persistent diarrhea were randomly assigned to 1 of 3 groups to receive a daily supplement of 10 mg Zn alone (Zn; n = 81), zinc plus vitamins and other minerals at 1-2 times recommended daily intakes (Zn+VM; n = 82), or placebo (n = 83) for [approximately equal to] 6 mo after the diarrhea episode ended. Morbidity information was collected on weekdays. Weight, length, and other anthropometric indicators were measured monthly, and plasma zinc and other indicators of micronutrient status were measured at baseline and 6 mo. Results: Supplement consumption was high ([approximately equal to] 90%) in all groups, although slightly more vomiting was reported in the Zn+VM group (P < 0.0001, analysis of variance). The change in plasma zinc from baseline to 6 mo was greater in the 2 zinc groups (6.1, 27.3, and 16.2 [micro] g/dL in the placebo, Zn, and Zn+VM groups, respectively; P < 0.000l, analysis of variance). The Zn group had fewer episodes of diarrhea, dysentery, and respiratory illness and a lower prevalence of fever and cough than did the Zn+VM group and a lower prevalence of cough than did the placebo group (P = 0.05), No significant effects of supplementation on growth were observed. Conclusion: Morbidity was greater after supplementation with zinc plus multivitamins and minerals than it was after supplementation with zinc alone. KEY WORDS Zinc supplementation, zinc deficiency, diarrhea, respiratory infection, growth

Background: Iron, zinc, and calcium can interact with each other in a way that inhibits their respective absorption. On the other hand, mineral fortification has been used to improve simultaneous iron and zinc absorption from food supplements. Objective: We evaluated the effect of a novel fortificant mixture consisting of NaFeEDTA, zinc methionine, ascorbic acid, and citric acid on iron and zinc absorption from a dry food supplement designed for preschool children. Design: The standard food supplement contained cereal and legume flour, dried milk, and a mixture of micronutrients including ferrous sulfate and zinc sulfate as sources of supplemental iron and zinc, respectively. Standard and novel food products were prepared as porridge with or without the addition of 200 mg Ca as calcium phosphate. Iron absorption and zinc absorption from the food products were evaluated simultaneously in 13 nonpregnant, adult women by extrinsically labeling the products with radioisotopes of iron and zinc and carrying out whole-body counting 7 d after the food products were consumed in random order. Results: The absorption of iron from the NaFeEDTA-containing (novel) food product was 1.7 times that from the ferrous sulfate-containing (standard) product (P = 0.015). There was no significant effect of dietary calcium on iron absorption. Zinc absorption was not associated with the form of zinc consumed, but higher dietary calcium was marginally associated with lower zinc absorption (P = 0.071). Conclusions: A mixture of fortificants containing NaFeEDTA, zinc sulfate or zinc methionine, ascorbic acid, and citric acid, but without calcium, can improve iron and zinc absorption from food products. A cost-benefit analysis of the novel fortificant mixture needs to be performed. KEY WORDS Iron, zinc, phytic acid, calcium, iron absorption, zinc absorption, food products

Background: The risk of zinc deficiency in populations can be estimated by comparing serum zinc data with statistically defined lower cutoffs derived from a presumably healthy population. Serum zinc data are available from a large sample of the US population assessed during the second National Health and Nutrition Examination Survey (NHANES II). Although the original analysis of these data considered fasting status and the time of day of blood sampling, it did not account for potentially confounding variables that may affect the serum zinc concentration, such as age, sex, and health status. Objective: The objective was to describe variations in serum zinc concentration by age, sex, and other characteristics and to recommend lower cutoffs for presumably healthy persons. Design: Serum zinc data from NHANES II were analyzed by using analysis of variance and covariance models to identify and describe variables significantly associated with serum zinc concentration; 2.5th percentile curves were produced and used to establish age-and sex-based lower cutoffs. Results: Age and sex were significant confounders of serum zinc concentration, so separate lower cutoffs were derived for children and adolescent and adult males and females. Other minor confounding variables were identified. Tentative lower cutoffs for pregnancy and oral contraceptive use were also derived. Conclusions: The interpretation of population serum zinc data with the use of lower cutoffs should account for the age and sex of the subjects, pregnancy and oral contraceptive use, and fasting status and time of day of blood collection. KEY WORDS Serum zinc, zinc deficiency, second National Health and Nutrition Examination Survey, NHANES II

Background: The deuterated-retinol-dilution technique provides a quantitative estimate of total-body vitamin A (TBVA) stores in adults. To apply the technique to children, information on plasma retinol kinetics in this age group is needed. Objectives: We described the plasma retinol kinetics of an oral dose of [[sup.2][H.sub.4]]retinyl acetate in a population of Peruvian children (12-24 mo of age) in order to examine the relation between TBVA stores and individual plasma isotopic ratios 3 d after the dose and to estimate 1) the time required for the isotope dose to mix with endogenous vitamin A, 2) the fractional catabolic rate for retinol, and 3) TBVA stores. Design: An oral dose of [[sup.2][H.sub.4]]retinyl acetate (14 [micro]mol retinol equivalents) was administered to children (n = 107) to construct a population-level kinetic curve of the plasma ratio of [[sup.2][H.sub.4]]retinol to retinol to estimate equilibration time and the fractional catabolic rate. TBVA stores were estimated by using a modification of the isotope dilution equation for adults. Results: The dose of [[sup.2][H.sub.4]]retinyl acetate fully mixed with endogenous vitamin A 8 d after the dose. The fractional catabolic rate was 0.022/d (95% CI: 0.014, 0.030/d). Mean ([+ or -] SD) TBVA stores were estimated as 0.097 [+ or -] 0.081 mmol (range: 0.016-0.392 mmol). Plasma ratios of [[sup.2][H.sub.4]]retinol to retinol 3 d after the dose were correlated with the inverse of estimated TBVA stores (r = -0.74, P < 0.0001). Conclusions: Compared with previous results in adults, the equilibration time occurred earlier and the estimated system fractional catabolic rate was higher in this population of children. The modified isotope dilution equation provided estimates of hepatic vitamin A concentration that are similar to values reported in US children at autopsy. KEY WORDS Vitamin A stores, children, stable isotope, vitamin A, plasma kinetics, [[sup.2][H.sub.4]]retinyl acetate, Peru

Background: Multiple studies have been carried out to assess the effect of zinc supplementation on children's growth. The results of these studies are inconsistent, and the factors responsible for these varied outcomes are unknown. Objective: Meta-analyses of randomized controlled intervention trials were therefore completed to assess the effect of zinc supplementation on the physical growth and serum zinc concentrations of prepubertal children. Design: A total of 33 acceptable studies with appropriate data were identified by MEDLINE (National Library of Medicine, Bethesda, MD) searches and other methods. Weighted mean effect sizes (expressed in SD units) were calculated for changes in height, weight, weight-for-height, and serum zinc concentration by using random-effects models; factors associated with effect sizes were explored by meta-regression techniques. Results: Zinc supplementation produced highly significant, positive responses in height and weight increments, with effect sizes of 0.350 (95% CI: 0.189, 0.511) and 0.309 (0.178, 0.439), respectively. There was no significant effect of zinc on weight-for-height indexes [weighted mean effect size: -0.018 (-0.132, 0.097)]. Zinc supplementation caused a large increase in the children's serum zinc concentrations, with an effect size of 0.820 (0.499, 1.14). Growth responses were greater in children with low initial weight-for-age z scores and in those aged > 6 mo with low initial height-for-age z scores. Conclusions: Interventions to improve children's zinc nutriture should be considered in populations at risk of zinc deficiency, especially where there are elevated rates of underweight or stunting. The population mean serum zinc concentration is a useful indicator of the successful delivery and absorption of zinc supplements in children. Am J Clin Nutr 2002;75:1062-71. KEY WORDS Zinc, growth, serum zinc, zinc deficiency, nutritional assessment, indicators, children, meta-analysis

Hepatic stores of vitamin A were estimated in 31 Bangladeshi surgical patients (15 males and 16 females) by the deuterated-retinol-dilution (DRD) technique and by analysis of the vitamin A concentration of a liver biopsy specimen obtained during previously scheduled abdominal surgery. Patients ranged in age from 21 to 65 y and had an average body mass index (BMI; in kg/[m.sup.2]) of 17.7 [+ or -] 3.4. They received 0.753 [Mu]mol [[.sup.2][H.sub.4]] retinyl acetate/kg body wt orally 9-11 d before surgery. Hepatic vitamin A reserves were estimated according to Furr et al (Am J Clin Nutr 1989;49:713-6) by using a single plasma isotopic-ratio measurement (18-25 d postdose). Estimated mean hepatic vitamin A stores were similar by both techniques, 0.110 [+ or -] 0.072 mmol (by DRD) compared with 0.100 p[+ or -] 0.067 mmol (by biopsy). Regression analysis was used to compare results of the DRD and biopsy techniques. A significant linear relation was found between the two techniques (r = 0.75, P [is less than] 0.0001), and the least-squares regression line was not significantly different from y = x (P = 0.09). The results indicate that the DRD technique provided a very good estimate of hepatic vitamin A reserves for this population. However, a wide prediction interval was observed for estimates of hepatic vitamin A reserves for individual subjects. Thus, further refinement of the prediction model is necessary to improve estimates of hepatic vitamin A reserves for individual subjects.

Coffee is one of the first liquids given to infants in Guatemala. To evaluate whether this practice has an adverse effect on iron status, 160 children 12-24 mo of age who had received coffee for [is greater than or equal to] 2 mo and had at least one indicator of iron deficiency were stratified by initial hemoglobin concentration (anemic, or nonanemic, ie, hemoglobin [is greater than or equal to] 105 g/L) and randomly assigned to a control (continuation of coffee; coffee) or intervention (provided with a substitute consisting of sugar and coloring; substitute) group for 5 mo. Anemic children were provided with iron supplements for 2-3 mo. Hematologic and anthropometric measurements were made before and after the intervention and dietary and morbidity data were collected every 2 wk. A total of 139 children completed the study: 45 coffee, nonanemic; 56 substitute, nonanemic; 19 coffee, anemic; and 19 substitute, anemic. Compliance with the procedures was good: median coffee intake was 891 mL/wk in the coffee group compared with 18 mL/wk in the substitute group (P = 0.0001). There was no significant effect of discontinuing coffee consumption on changes in hemoglobin, hematocrit, ratio of zinc protoporphyrin to heme or plasma iron, zinc or copper in either nonanemic or anemic children, or plasma ferritin in children who did not take iron supplements. In children who took iron supplements, change in plasma ferritin was significantly greater in the substitute group than in the coffee group (106% compared with 1%, P [is less than] 0.05). This implies that coffee interferes with the utilization of supplemental iron. It is likely that the amount and strength of coffee consumed by Guatemalan toddlers are too low to significantly affect the other indexes of iron status. Am J Clin Nutr 1997;66:168-76.

To investigate the potential effects of maternal infection during lactation on breast-milk quantity and composition, we examined low-income Peruvian women who had an acute febrile infection and were exclusively breast-feeding a child from l to 6 mo of age (n = 36). Women who were not ill (n = 38) served as controls; all women had body mass indexes (in kg/[m.sup.2]) > 19.5. Blood and milk samples were collected on days 1, 7, and 14 after identification of the episode of illness. C-reactive protein in maternal serum was significantly elevated by infection, whereas two other acute-phase reactants, ceruloplasmin and [alpha.sub.2]-macroglobulin, showed no change. Serum zinc concentrations were significantly lower in ill women than in women who were not ill, whereas serum copper concentrations were elevated initially in ill women. Serum iron concentrations increased significantly with time, but there was no significant difference between groups. Milk intake, as assessed by 12-h test-weighing, was not affected by the infection. Concentrations of milk total protein, casein, and whey proteins were similar in the two groups and there was no significant effect of illness on milk trace element concentrations. Thus, acute maternal infections during established lactation did not affect milk volume, milk protein, or trace clement concentrations, despite expected changes in serum protein and trace element concentrations.

To develop recommendations for the design of special foods for young children, we measured total daily energy consumption from semisolid food mixtures with energy densities of 1.67, 2.93, 4.18, or 6.28 kJ/g (0.4, 0.7, 1.0, or 1.5 kcal/g) and that were fed ad libitum three, four, or five times per day to 18 fully weaned children from 6 to 18 mo of age who were recovering in the hospital from malnutrition. The diets were generally indistinguishable by sensory qualities, and were fed in a randomized sequence. The mean amounts consumed (g . kg body [wt.sup.-1].[d.sup.-1]) were significantly less with successively greater energy density of the diet (P < 0.001). The total daily consumption was [double tilde]16% more when the number of meals was increased from three to four per day, with energy density controlled for (P < 0.001), and 7% more when the feeding frequency rose from four to five meals per day (P = 0.005). The total daily energy intakes (kJ . kg body [wt.sup.-1].[d.sup.-1]) increased significantly with the more concentrated diets (P < 0.001) and varied positively in relation to feeding frequency (P < 0.001). Approximately 15-20 min were required per meal for the children to reach satiety. The total amount of time required to feed the children each day was related to the number of meals served (P < 0.001) and not to energy density. Implications for child feeding are discussed.

To assess the validity of maternal reports of poor infant appetite, these histories were compared with measured energy consumption on 1621 d of observation of 131 Peruvian infants in a low-income community. Mean ([+ or -]SD) total energy intakes on days with reported anorexia were 338 [+ or -] 88 kJ/kg body wt in infants 1--6 mo of age and 299 [+ or -] 92 kJ/kg body wt in infants aged >6 mo compared with 395 [+ or -] 92 and 342 [+ or -] 88 kJ/kg body wt in the respective age groups when appetites were reportedly normal (P < 0.001). Energy intake from non-brest-milk sources was more affected than energy from breast milk. The epidemiology of poor appetite was assessed in 153 infants who were monitored longitudinally during their first year of life. The prevalence of reported anorexia increased progressively from 22 to 317/1000 d of observation from

Alpha-tocopherol and [gamma]-tocopherol were monitored in human adipose by using needle biopsies in four subjects during a 1-y supplementation trial with 800 mg all-rac-[alpha]-tocopherol/d, and for 1 additional year after cessation of supplement. Some increase in adipose [alpha]-tocopherol (per milligram adipose cholesterol) and a more consistent decrease in [gamma]-tocopherol were observed during the supplementation period. The [alpha]-tocopherol/[gamma]-tocopherol ratio rose consistently during supplementation and fell only gradually after the supplement was stopped. We estimate that [less than or equal to] y are required for the [alpha]-tocopherol/[gamma] toccopherol ratio to reach a new steady state after a change in [alpha]-tocopherol intake. In a cross-sectional measurement in five subjects who reported long-term use of a [alpha]-tocopherol supplements ([greater than or equal to] 250 mg/d), and in five other subjects who reported no supplement use, the adipose [alpha]-tocopherol/[gamma]-tocopherol ratio clearly discriminated between the two groups (P < 0.002). This ratio may be of value in ranking individuals according to long-term [alpha-tocopherol intake.

To examine the effects of concurrent infection on population-based assessment of trace element status, we collected data on clinical signs and laboratory indicators of infection when obtaining blood for serum zinc, copper, and ferritin analyses in 153 Peruvian children aged 11 - 19 mo. Fifty-two (34.7%) of the children had some reported sign of infection and 43 (28.3%) had elevated C-reactive protein concentrations or leukocytosis. Children with any evidence of infection had marginally lower mean ([+ or -] SD) serum zinc concentrations (7.0 [+ or -] 2.3 vs 7.5 [+ or -] 2.0 [micro]mol/L, P = 0.16) and significantly greater serum copper (24.7 [+ or -] 4.7 vs 22.7 [+ or -] 4.2 [micro]mol/L, P = 0.006) and serum ferritin concentrations (10.0 [+ or -] 12.9 vs 3.9 [+ or -] 4.4 [micro]g/L, P < 0.001) than did those without infections. Infection caused an underestimation in the rate of low copper status by 1 percentage point and low iron status by 12 percentage points. Thus, the effect of concurrent infections is of variable magnitude and may differ by nutrient, nutritional status of the population, and prevalence and severity of infections.

Intake and growth were compared between matched cohorts of infants either breast-fed (BF) or formulated (FF) until [is greater than or equal to] 12 mo of age. Total energy intake at 3, 6, 9, and 12 mo averaged 0.36, 0.34, 0.35, and 0.38 MJ . [kg.sup.-1] . [d.sup.-] (85.9, 80.1, 83.6, and 89.8 kcal . [kg.sup.-1] . [d.sup.-]) among BF infants vs 0.41, 0.40, 0.39, and 0.41 MJ . [kg.sup.-1] . [d.sup.-1] (98.7, 94.7, 93.6, and 98.0 kcal . [kg.sup.-1] . [d.sup.-1]) among FF infants, respectively. Protein intake was 66-70% higher in the FF than in the BF group during the first 6 mo. Differences in energy and protein intakes were significant at 3, 6, and 9 mo. Gains in weight and lean body mass were lower in BF than in FF infants from 3 to 9 mo. BF infants gained more weight and lean body mass per gram protein intake but not per megajoule intake. Although growth differences between groups were related to differences in intake, there is no evidence of any functional advantage to the more rapid growth of FF infants. Am J Clin Nutr 1993;58:152-61.

Anthropometric indexes from 1 to 24 mo were compared between matched cohorts of infants either breast-fed (BF, n = 46) or formula-fed (FF, n = 41) until [is greater than or equal to] 12 mo. Neither group received solid foods before 4 mo. Weight-for-length was significantly greater among FF infants from 7 to 24 mo. In both groups, skinfold thickness (triceps, biceps, subscapular, flank, and quadriceps) and estimated percent body fat (%FAT) increased rapidly during the first 6-8 mo and declined thereafter. At all sites except biceps, FF infants had larger skinfold thicknesses in later infancy (particularly 9-15 mo) than did BF infants; %FAT was significantly higher from 5 to 24 mo. Lower energy intake among BF infants explained the difference between groups. Maternal and infant fatness were positively correlated at 12-24 mo. Breast-milk lipid and energy concentration were unrelated to infant fatness. These results indicate that infants BF for [is greater than or equal to] 12 mo are leaner than their FF counterparts. Am J Clin Nutr 1993;57:140-5.

To determine the effect of dietary viscosity on energy consumption by young children, 56 Peruvian children 9-20 mo of age with acute diarrhea were randomly assigned to either a liquid or semisolid diet, with or without added amylase to reduce viscosity. Intakes of the study diet, breast milk, and other foods were measured for 2 consecutive d during and again after illness. Total 24-h energy intake ([x bar] [+ or -] SD) during diarrhea, 349.4 [+ or -] 121.8 kJ/kg (83.6 [+ or -] 29.1 kcal/kg) was 18% less than intake after recovery, 428.9 [+ or -] 141.0 kJ/kg (102.6 [+ or -] 33.7), P < 0.001. In the ANOVA breast-fed children consumed significantly less total energy (P = 0.008) and energy from the study diet (P = 0.02) than non-breast-fed children. Breast milk intake did not change with illness. There was no significant relationship between viscosity of the study diet and either total energy intake or intake of energy from the study diet. Energy intake by these children was primarily determined by health status and breast-feeding practice, not by dietary viscosity. Am J Clin Nutr 1993;57:218-23.

We compared growth, dietary intake, and morbidity of infants breast-fed for [is greater than or equal to] 12 mo from two populations: Davis, CA (n = 46) and Huascar, Peru (n = 52). When compared against WHO reference data (based primarily on formula-fed infants), Huascar infants appeared to falter as early as 3-4 mo, but when compared with Davis breast-fed infants, the curves for weight and length were very similar in girls until 10-12 mo and in boys until 6-9 mo. Thereafter, Huascar infants grew less rapidly than did Davis infants. Breast milk intake was very similar between groups, but in Huascar the amount and nutrient density of complementary foods consumed after 6 mo were lower and morbidity rates were much higher than in Davis. These results indicate that growth faltering of Huascar infants, when judged against breast-fed infants in the United States, occurs primarily after the first 6 mo of life and is not due to poor lactation performance. Am J Clin Nutr 1992;56:1012-8.

The observed variances in monthly weight and length gains of 96 Peruvian infants were compared with predicted variances obtained by applying the reference curve-fitting methods to the same Peruvian data. Predicted variance estimates were significantly less (P < 0.0001) than the observed variances from 2 to 12 mo of age. The extent of underestimation in total variance that occurred when 1-mo growth-increment reference data were generated by curve-fitting and interpolation was approximated. This underestimation, caused by not taking into account infants' random deviations from their own growth trajectories. ranged from 59% to 94% and resulted in misclassification of ;w 24-67% of infants as abnormal gainers (below the 5th percentile or above the 95th percentile with respect to existing reference data) in the intervals evaluated. Am J Clin Nutr 1992;56:58-64.

Background: Low-fat diets can increase plasma triacylglycerol and reduce HDL cholesterol. Changes in energy intake and body weight can influence the lipoprotein response. Objective: We sought to prospectively examine the effects of euenergetic and ad libitum dietary fat restriction on plasma lipoproteins in healthy postmenopausal women. Design: Participants first received a controlled euenergetic diet in which dietary fat was reduced stepwise from 35% to 25% to 15% over 4 mo. Thereafter, participants followed an ad libitum 15%-fat diet for 8 mo; 54 women completed the intervention. Results: During the controlled euenergetic diet, plasma triacylglycerol increased from 1.70 [+ or -] 0.10 to 2.30 [+ or -] 0.16 mmol/L, total cholesterol decreased from 5.87 [+ or -] 0.13 to 5.53 [+ or -] 0.13 mmol/L, LDL cholesterol decreased from 3.41 [+ or -] 0.10 to 2.87 [+ or -] 0.10 mmol/L, HDL cholesterol decreased from 1.76 [+ or -] 0.08 to 1.50 [+ or -] 0.08 mmol/L, and apolipoprotein (apo) A-I decreased from 5.11 [+ or -] 0.14 to 4.78 [+ or -] 0.14 mmol/L (P [is less than] 0.0001 for all changes). Hormone replacement therapy did not affect the relative change in HDL cholesterol. Plasma glucose, insulin, hemoglobin A[.sub.1C] free fatty acid, and apo B concentrations did not change significantly. During the ad libitum 15%-fat diet, participants lost 4.6 [+ or -] 0.4 kg. Plasma triacylglycerol and LDL cholesterol returned to baseline values (1.77 [+ or -] 0.12 and 3.31 [+ or -] 0.08 mmol/L, respectively), whereas HDL cholesterol and apo A-I remained low (1.40 [+ or -] 0.08 and 4.82 [+ or -] 0.18 mmol/L, respectively). HDL cholesterol and apo A-I concentrations stabilized in subjects who were not receiving hormone replacement therapy but continued to decline in women who were receiving hormone therapy. Conclusions: The ad libitum 15%-fat diet resulted in significant weight loss. The euenergetic but not the ad libitum diet caused hypertriacylglycerolemia. HDL cholesterol decreased during both low-fat diets. Am J Clin Nutr 2000;71:1439-47. KEY WORDS Low-fat diet, lipoproteins, postmenopausal women, high-carbohydrate diet, lipoprotein response, triacylglycerol, HDL cholesterol, high-density-lipoprotein cholesterol, triglycerides, weight reduction, hormone replacement therapy, apolipoprotein A-I, free fatty acids, glucose, insulin, hemoglobin [A.sub.1C]

Background: The deuterated-retinol-dilution (DRD) technique provides a quantitative estimate of total body stores of vitamin A. However, it is not known whether the technique can detect changes in vitamin A pool size in response to different intakes of vitamin A. Objective: Our objective was to determine the responsiveness of the DRD technique to 3 different daily supplemental vitamin A intakes during a period of 2.5-4 mo. Design: Two oral doses of [[sup.2][H.sub.4]]retinyl acetate [52.4 [micro]mol retinol equivalent (RE)] were administered on study days 1 and 91 to 26 men (18-32 y of age) who were consuming controlled, low-vitamin A diets, and receiving daily either 0, 5.2, or 10.5 [micro]mol RE of unlabeled supplemental retinyl palmitate during a 75- or 129-d period. Plasma isotopic ratios of [[sup.2][H.sub.4]]retinol to retinol on day 115 were used to estimate final vitamin A body stores per Furr et al (Am J Clin Nutr 1989;49:713-6). Results: Final ([bar] [x] [+ or -] SD) estimated vitamin A pool sizes were 0.048 [+ or -] 0.031, 0.252 [+ or -] 0.045, and 0.489 [+ or -] 0.066 [micro]mol in the treatment groups receiving 0, 5.2, and 10.5 [micro]mol RE/d, respectively (P [is less than] 0.001). Estimated mean changes in vitamin A pool sizes were similar to those expected for the vitamin A-supplemented groups [estimated:expected (95% CI of change in pool size): 1.08 (0.8, 1.2) and 1.17 (1.0, 1.3)]. Conclusions: The DRD technique can detect changes in total body stores of vitamin A in response to different daily vitamin A supplements. However, abrupt changes in dietary vitamin A intake can affect estimates of total-body vitamin A stores. Am J Clin Nutr 1999;70:874-80. KEY WORDS Vitamin A, deuterated-retinol-dilution technique, DRD technique, pool size, isotope dilution, stable-isotope study, supplementation, Bangladesh

Background: Koko, a fermented maize porridge used as the primary complementary food in Ghana, has been implicated in the high prevalence of child malnutrition. Weanimix, a cereal-legume blend developed by the United Nations Children's Fund and the Ghanaian government, has been promoted as an alternative. Objective: We evaluated the effect of feeding Weanimix and 3 other locally formulated, centrally processed complementary foods on the nutritional status of 208 breast-fed infants. Design: Infants were randomly assigned to receive 1 of 4 foods from 6 to 12 mo of age: Weanimix (W), Weanimix plus vitamins and minerals (WM), Weanimix plus fish powder (WF), and koko plus fish powder (KF). Dietary and anthropometric data were collected regularly. Blood was collected at 6 and 12 mo of age to assess iron, zinc, vitamin A, and riboflavin status. Before and after the intervention, cross-sectional data on the anthropometric status of infants not included in the intervention (NI; n = 464) were collected. Results: There were no significant differences between intervention groups in weight or length gain or in hemoglobin, hematocrit, transferrin saturation, plasma zinc, or erythrocyte riboflavin values between 6 and 12 mo of age. From 9 to 12 mo of age, z scores were lower in NI infants than in the combined intervention groups [at 12 mo: -1.71 [+ or -] 0.90 compared with -1.19 [+ or -] 0.93 for weight and -1.27 [+ or -] 1.02 compared with -0.63 [+ or -] 0.84 for length (P [is less than] 0.001 for both), respectively]. The percentage of infants with low ferritin values increased significantly between 6 and 12 mo of age in groups W, WF, and KF but not in group WM. Change in plasma retinol between 6 and 12 mo of age was significantly greater in group WM than in the other 3 groups combined (0.14 [+ or -] 0.3 compared with -0.04 [+ or -] 0.3 [micro]mol/L, P = 0.003). Conclusions: All 4 foods improved growth relative to the NI group. Infants fed WM had better iron stores and vitamin A status than those fed nonfortified foods. Am J Clin Nutr 1999;70:391-404. KEY WORDS Complementary feeding, breast-feeding, infant growth, micronutrient status, iron, zinc, vitamin A, riboflavin, Ghana, energy density, Weanimix, koko, fermented maize porridge

Background: Results of prior studies of the effect of viscosity reduction of high-energy-density, starch-containing diets on young children's energy intakes are inconsistent, possibly because of differences in the characteristics of the unmodified diets with which the low-viscosity diets were compared. Objective: Our objective was to determine the effects of dietary viscosity and energy density on total daily energy consumption by young, non-breast-fed children. Design: We measured the amount of food consumed and the duration of meals during 3 substudies, in each of which 3 study diets were offered for 4 consecutive days each in random sequence: high energy density, high viscosity (HD-HV); high energy density, low viscosity (HD-LV); and low energy density, low viscosity (LD-LV). The viscosity and energy density of the unmodified starch-containing HD-HV diet were varied across substudies to determine whether the effect of amylase liquefaction was related to the initial characteristics of the HD-HV diet. The viscosity of the HV diets ranged from 79 000 to 568 000 mPa s; energy density of the HD diets ranged from [approximately equals] 4.18 to 4.93 kJ (1.00-1.18 kcal)/g. Viscosity of the LV diets was [approximately equals] 3000 mPa s and the energy density of the LD diets was [approximately equals] 2.47 kJ (0.6 kcal)/g. Results: In each substudy, children consumed more of the LD-LV diet (g [multiplied by] kg body [wt.sup.-1] [multiplied by] [d.sup.-1]) than of the other diets and more of the HD-LV diet than of the HD-HV diet (P [less than] 0.001). Energy consumption from the HD-LV diet was greater than from the other diets (P [less than] 0.001), but the energy intakes from the latter diets were not significantly different. Conclusion: Amylase liquefaction of HD-HV porridges resulted in increased energy consumption by young children.