DETERMINATION OF POSSIBLE CAUSES OF NUTRITIONAL
ANAEMIA AMONG PREGNANT WOMEN IN TAMALE
METROPOLIS, GHANA
BY
CHARLES BENATIFAM JAWEEN
(10364080)
THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA,
LEGON, IN PARTIAL FULFILMENT OF THE REQUIREMENT
FOR THE AWARD OF MSC DIETETICS DEGREE
JULY, 2013
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ii
DECLARATION
This is to certify that this thesis is the result of research undertaken by Charles
Benatifam Jaween towards the award of the Master of Science Degree in Dietetics in the
Department of Dietetics, School of Allied Health Sciences, College of Health Sciences,
and University of Ghana.
…………………………………………….
CHARLES BENATIFAM JAWEEN
(STUDENT)
………………………………...
DR. CHARLES BROWN
(SUPERVISOR)
………………………………...
DR. MATILDA ASANTE
(SUPERVISOR)
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DEDICATION
This work is dedicated to my family, especially my lovely wife, Doris Debri for her
moral support and encouragement, whose relentless love and care have brought me this
far, in whom I see the challenge to work harder.
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ACKNOWLEDGEMENTS
I wish to express my profound gratitude to all those who have contributed in diverse
ways to make this work possible. I am particularly indebted to my supervisor Dr.
Charles Brown, without whose immense suggestions and guidance, this work would not
have been possible. I am also grateful to Dr. Matilda Asante, Head of Dietetics
Department of University of Ghana for offering various useful suggestions towards this
work. My thanks also go to my friends for their support and encouragement during this
research. Above all, I wish to give glory to the Almighty Omnipotent God for making it
possible for me to come to a successful end.
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vABSTRACT
Background: Anaemia is an important public health problem worldwide and the most
vulnerable group, are pregnant women and children. Anaemia associated with
pregnancy is a serious health problem and its control requires the initial identification of
the major factors responsible. Determination of the possible causes of nutritional
anaemia among pregnant women is important to ensure satisfactory birth outcomes. In
Ghana there is little data on the usual dietary intake among pregnant women in the
Northern Region of Ghana.
Aim: The aim of this study was to determine the possible causes of nutritional anaemia
among pregnant women reporting for antenatal care at the Tamale Teaching Hospital.
Methods: A cross-sectional study was used to survey 175 pregnant women attending
antenatal clinic in Tamale Teaching Hospital. A structured questionnaire was used to
collect information on their socio-demographic characteristics. Their dietary intakes
were assessed using three 24-hour recalls and a validated food frequency questionnaire
(FFQ). The questionnaires were administered on Mondays, Wednesdays, and Fridays
for the previous day’s food eaten. In order to get the true eating pattern of respondents,
dietary assessment using 24-hour recall was carried out three times for each respondent,
each on a different day of the week for three weeks. To make it easier for the
respondents to recall accurately the previous day’s food eaten, portion sizes handy
measures were used and later converted to grams for the analysis. The most recent
results of laboratory tests for Hb level, malaria status and worm infestation were
extracted from selected pregnant women hospital records. Their sickling status was also
noted.
Results: Except for vitamin C, the majority of the respondents did not meet the mean
percentage of the recommended daily allowance (RDA) for energy, protein, fiber,
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vitamin B12, folate, vitamin E, calcium, copper, iron and zinc. Forty seven percent
(47%) of the respondents were anaemic as judged by their Hb level, with 40% of them
having mild anaemia (10-10.9g/dl) and 7% having moderate anaemia (7.9-9.9g/dl). The
income, profession, age and spouse profession were significantly associated with
prevalence of anaemia.
Conclusion: Dietary intakes of pregnant women in Tamale Metropolis do not meet
their RDAs. Nutrition education for pregnant women should be intensified. It is
recommended that girl child education should be encouraged, nutrition professionals
provided by Ministry of Health to all ante-natal care units and if possible food
fortification should be done by the food industries in Ghana. Further research should
also be carried out to evaluate various Ghanaian local food sources rich in
micronutrients to improve maternal nutrition.
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TABLE OF CONTENTS
DECLARATION .............................................................................................................. ii
DEDICATION................................................................................................................. iii
ACKNOWLEDGEMENTS............................................................................................. iv
ABSTRACT...................................................................................................................... v
TABLE OF CONTENTS................................................................................................vii
LIST OF FIGURES .......................................................................................................... x
LIST OF TABLES........................................................................................................... xi
ABBREVIATIONS ........................................................................................................xii
CHAPTER ONE............................................................................................................... 1
1.0 INTRODUCTION ...................................................................................................... 1
1.1 BACKGROUND .................................................................................................... 1
1.2 PROBLEM STATEMENT..................................................................................... 2
1.3 SIGNIFICANCE OF STUDY ................................................................................ 3
1.4 HYPOTHESIS ........................................................................................................ 4
1.5 AIM AND SPECIFIC OBJECTIVES .................................................................... 4
1.5.1 Aim .................................................................................................................. 4
1.5.2 Specific Objectives .......................................................................................... 4
CHAPTER TWO .............................................................................................................. 5
2.0 LITERATURE REVIEW ........................................................................................... 5
2.1 NUTRITIONAL STATUS ..................................................................................... 5
2.2 NUTRITIONAL CONSIDERATIONS DURING PREGNANCY........................ 6
2.2.1 Energy needs of pregnant women.................................................................... 6
2.2.2 Macronutrients ................................................................................................. 6
2.2.2.1 Carbohydrates ........................................................................................... 7
2.2.2.2 Protein....................................................................................................... 8
2.2.2.4 Lipids ........................................................................................................ 8
2.2.3 Micronutrients.................................................................................................. 9
2.2.3.1 Vitamins.................................................................................................... 9
2.2.3.1.1 Folate ................................................................................................. 9
2.2.3.1.2 Vitamin C......................................................................................... 10
2.2.3.1.3 Vitamin D ........................................................................................ 10
2.2.3.1.4 Vitamin A ........................................................................................ 11
2.2.3.1.5 Vitamin B1 (Thiamin) ...................................................................... 11
2.2.3.1.6 Vitamin B2 (Riboflavin)................................................................... 11
2.2.3.1.7 Vitamin B3 (Niacin) ......................................................................... 12
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2.2.3.1.8 Vitamin B6 ....................................................................................... 12
2.2.3.1.9 Vitamin B12 ...................................................................................... 12
2.2.3.1.1.10 Vitamin E.................................................................................... 13
2.2.4 Minerals ......................................................................................................... 13
2.2.4.1 Iron.......................................................................................................... 13
2.2.4.2 Calcium................................................................................................... 15
2.2.4.3 Zinc ......................................................................................................... 16
2.2.4.4 Copper..................................................................................................... 16
2.2.4.5 Iodine ...................................................................................................... 16
2.2.5 Fibre ............................................................................................................... 17
2.3 ALCOHOL INTAKE DURING PREGNANCY ................................................. 17
2.4 PICA (NON- FOOD SUBSTANCES INTAKE DURING PREGNANCY) ....... 18
2.5 FOOD AVERSIONS ............................................................................................ 18
2.6 MATERNAL WEIGHT GAIN ............................................................................ 18
2.7 TYPES OF NUTRITIONAL ANAEMIA ............................................................ 20
2.7.1 Iron Deficiency Anaemia............................................................................... 20
2.7.2 Folic Acid Deficiency Anaemia .................................................................... 21
2.7.3 Vitamin B12 Deficiency and Pernicious Anaemia ......................................... 21
2.7.5 Copper-Deficiency Anaemia ......................................................................... 21
2.7.6 Sideroblastic (Pyridoxine-Responsive) Anaemia .......................................... 22
2.7.7 Vitamin E-Response Haemolytic Anaemia ................................................... 22
2.8 24-HOUR RECALL OF DIETARY INTAKE ASSESSMENT .......................... 22
2.9 FOOD FREQUENCY QUESTIONNAIRE (FFQ) .............................................. 23
CHAPTER THREE ........................................................................................................ 25
3.0 METHODS ............................................................................................................... 25
3.1 STUDY DESIGN ................................................................................................. 25
3.2 STUDY SITE........................................................................................................ 25
3.3 SAMPLE SIZE CALCULATION........................................................................ 26
3.4 SAMPLING TECHNIQUE .................................................................................. 26
3.5 PARTICIPANTS .................................................................................................. 26
3.5.1 Inclusion criteria ............................................................................................ 26
3.5.2 Exclusion criteria ........................................................................................... 27
3.6 DATA COLLECTION ......................................................................................... 27
3.6.1 Questionnaire administration......................................................................... 27
3.6.2 Laboratory data .............................................................................................. 27
3.7 ETHICS ................................................................................................................ 28
3. 8 DATA ANALYSIS.............................................................................................. 28
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CHAPTER FOUR........................................................................................................... 29
4.0 RESULTS ................................................................................................................. 29
4.1 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS........... 29
4.2 DIETARY HABITS OF RESPONDENTS .......................................................... 31
4.2.1 Pica practice ................................................................................................... 31
4.2.2 Food craving .................................................................................................. 31
4.2.3 Food aversions ............................................................................................... 31
4.3 SUBSTANCES THAT AFFECT IRON ABSORPTION .................................... 35
4.4 BEHAVIOURS THAT PRECIPITATE OR PREVENT INCIDENCE OF
ANAEMIA.................................................................................................................. 35
4.5 TRIMESTER OF RESPONDENTS AND MALARIA OCCURRENCE............ 35
4.6 DE-WORMING FREQUENCY OF RESPONDENTS BEFORE PREGNANCY
.................................................................................................................................... 35
4.7 SICKLING STATUS OF RESPONDENTS ........................................................ 39
4.8 TRIMESTER OF RESPONDENTS AND THE HB LEVEL ESTIMATION..... 39
4.9 CHANGES IN THE NUMBER OF TIMES RESPONDENTS ATE IN A DAY
BEFORE PREGNANCY EXCLUDING SNACKS................................................... 39
4.10 NUTRIENTS ADEQUACY RATIO OF THE RESPONDENTS ..................... 39
4.11 NUTRIENTS REQUIREMENTS AND HB LEVEL ESTIMATION ............... 42
4.12 FREQUENCY OF CONSUMPTION OF FOODS FROM THE FOOD
GROUPS BY RESPONDENTS................................................................................. 42
4.13 ASSOCIATION BETWEEN SOCIO-DEMOGRAPHIC FACTORS,
SELECTED NUTRIENTS AND ANAEMIA............................................................ 46
CHAPTER FIVE ............................................................................................................ 48
5.0 DISCUSSION AND CONCLUSION ...................................................................... 48
5.1 DISCUSSION....................................................................................................... 48
5.2 CONCLUSIONS .................................................................................................. 56
REFERENCES ............................................................................................................... 58
APPENDIXES ................................................................................................................ 63
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xLIST OF FIGURES
Figure 1 Trimester of respondents and malaria occurrence
Figure 2 Frequency of respondents de-worming before pregnancy
Figure 3 Trimester of respondents and Hb level estimation
Figure 4 Number of respondents who met and did not meet the RDAs
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LIST OF TABLES
Table 1 Socio-demographic characteristics of respondents
Table 2 Pica practice among pregnant women in Tamale
Table 3 Food craving among pregnant women in Tamale
Table 4 Food aversions among pregnant women in Tamale
Table 5a Substances that enhances Hb level
Table 5b: Substances that enhance Hb level
Table 6 Behaviours that precipitate or prevent incidence of anaemia
Table 7 Number of times respondents ate in a day before pregnancy excluding
snacks
Table 8a Nutrients adequacy ratio of the respondents (N = 175) compared to
standards
Table 9 Nutrients requirements and Hb level estimation
Table 10 Frequency of consumption of foods from the food groups by
respondents
Table 11 Association between socio-demographic factors, selected nutrients and
anaemia
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xii
ABBREVIATIONS
ACC/SCN
AI
ADA
BMI
Administrative Committee on Co-ordination/Sub-committee on Nutrition
Adequate Intakes
American Dietetic Association
Body Mass Index
ANC Ante-natal Clinic
DH Department of Health
FAO Food and Agricultural Organization
FAS Foetal Alcohol Syndrome
GHS
GSS
Ghana Health Service
Ghana Statistical Service
Hb Haemoglobin
IOM Institute of Medicine
MOH Ministry of Health
RBC Red Blood Cells
RDA Recommended Daily Allowance
SAHS School of Allied Health Sciences
SP Sulfadoxine Pyremethamine
TTH Tamale Teaching Hospital
WCBA Women of Child Bearing Age
WHO World Health Organization
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1CHAPTER ONE
1.0 INTRODUCTION
1.1 BACKGROUND
Anaemia is defined as a reduced amount of haemoglobin (Hb) in the blood. It is a
deficiency in the size or number of red blood cells (RBCs) or the amount of Hb they
contain (Mahan et al., 2012). Haemoglobin is a substance in the blood that transports
oxygen from the lungs to all parts of the body. The most common type of anaemia, iron
deficiency anaemia, is usually caused by low iron intake or absorption and/or excessive
iron loss (Thomas & Bishop, 2007); iron forms an essential component of the Hb
molecule. Nutritional anaemia results from an inadequate intake of iron, protein,
vitamin B12, folic acid, pyridoxine, ascorbic acid, and copper (Mahan et al., 2012).
Anaemia is classified based on Hb content as hypochromic (pale colour from deficiency
of Hb) and normochromic (normal colour), and described according to cell size as
macrocytic (larger than normal), normocytic (normal), and microcytic (small).
Haemoglobin levels vary with age, sex, pregnancy, altitude and smoking. Different
levels of Hb are considered normal for different categories of people, below which an
individual can be classified as anaemic. For example, the normal Hb level for pregnant
women at sea level is 11g/dl or 110g/L. A pregnant woman with Hb level below 11g/dl
or 110g/L, is said to be anaemic (WHO, 2008). A pregnant woman with anaemia will
present with any of the following: angular stomatitis, pallor, glossitis spoon shaped
nails, dizziness, fatigue and shortness of breath. The burden of anaemia in pregnant
women remains serious and unacceptably high (GHS Annual Report, 2004). Reducing
this anaemia burden in pregnant women has progressed minimally, especially in African
countries and Ghana is no exception.
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2Anaemia is an important public health problem worldwide and the most vulnerable
group, are pregnant women and children. The causes of anaemia include genetic factors,
nutritional deficiencies, and infectious agents. Of the nutritional causes of anaemia, iron
deficiency is probably the most common and important because the physiological
changes associated with pregnancy exert a demand for additional iron needed for
transfer to the foetus (Webster-Gandy et al, 2012). Infections, including malaria, worm
infestations are also involved in the pathogenesis of anaemia in pregnancy (GHS
Annual Report, 2004). Pregnant women are particularly susceptible to malaria in
endemic populations and often have higher prevalence as well as severity including
anaemia (Amenger-Glover et al., 2005). The changes in the immune system associated
with pregnancy have been suggested as the reason mentioned above. Worm infestations
on the other hand impair micronutrient absorption thus increasing the susceptibility of
pregnant women to anaemia. The emergence of HIV is an additional risk factor for
anaemia among pregnant women. Most studies aimed at identifying the causes of
anaemia in pregnancy have focused on specific categories of factors such as excessive
blood loss and excessive breakdown of erythrocytes (Amenger-Glover et al., 2005).
1.2 PROBLEM STATEMENT
Anaemia was the leading cause of maternal mortality in the 2010 annual report of the
Tamale Teaching Hospital with the prevalence of 68.2%. Anaemia is very common
among pregnant women in Ghana (GHS Annual Report, 2004). In Ghana the prevalence
of anaemia among pregnant women is 65% (GDHS Report, 2008). Anaemia is
considered to be high in countries with a prevalence of greater than 40% (WHO, 2008).
The Ghana Demographic and Health Survey (GDHS) Report (2008) has estimated that
by the year 2020, about 9000 mothers in Ghana will die of anaemia if its levels during
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3pregnancy are not improved. In many African countries, chronic protein energy
malnutrition, poor weight gain during pregnancy, anaemia, and other hidden hunger
deficiencies are common among women (Huffman et al., 2001).  Despite this, few
studies have assessed the possible causes of anaemia among pregnant women in the
Tamale Metropolis. In order to reduce this trend, it is necessary to determine possible
causes of anaemia, especially due to nutrition, in the Tamale Metropolis.
1.3 SIGNIFICANCE OF STUDY
Anaemia is reported among the top ten diseases in Ghana (GHS Annual Report, 2004).
In the Northern Region it ranked fourth on the admission list in 2010 and 2011 with an
increase in the cases of anaemia from 1196 to 1422 respectively in the Tamale Teaching
Hospital. Maternal deaths may occur because of under nutrition. In many African
countries, chronic energy deficiencies, poor weight gain in pregnancy, anaemia, and
other micronutrient deficiencies are common among women (Huffman et al., 2001).
This leads to anaemia in pregnancy, premature labour, low birth weight and increased
susceptibility to infection after birth.
The burden of anaemia in pregnant women remains serious and unacceptably high.
Reducing the anaemia burden in pregnant women has progressed minimally, especially
in African countries and Ghana is no exception. A healthy diet ensures that adequate
nutrients are supplied to the whole body to help the body withstand diseases. Sub-
Saharan Africa leads the world with the highest fertility rates and the highest percentage
of adolescent pregnancies, HIV/AIDS infections, and malaria cases (Barker et al.,
2002). Despite these advantages, the warning signs and symptoms of poor nutrition are
often overlooked.  In order to reduce the trend of events, it is necessary to determine the
possible causes, the prevalence and effects of anaemia among pregnant women in the
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4Tamale Metropolis. Findings from this study will be useful in providing appropriate
preventive measures to reduce the maternal mortality of which anaemia is the leading
cause in Ghana (GHS Annual Report, 2004).
1.4 HYPOTHESIS
There is no relationship between dietary intake and anaemia status of pregnant women
in the Tamale Metropolis.
1.5 AIM AND SPECIFIC OBJECTIVES
1.5.1 Aim
The aim of study was to determine the causes of nutritional anaemia among pregnant
women in the Tamale Metropolis.
1.5.2 Specific Objectives
The specific objectives of the study were:
1 To measure nutrient intakes of pregnant women and compare with the
recommended daily intakes as well as dietary pattern.
2 To determine the relationship between dietary iron intake and anaemia in the
pregnant women.
3 To assess the prevalence of anaemia among the pregnant women.
4 To determine the effects of confounding factors (parasitic infestation and sickling
status) on anaemia in the pregnant women.
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5CHAPTER TWO
2.0 LITERATURE REVIEW
2.1 NUTRITIONAL STATUS
Nutritional status and health in pregnancy is very important. A mother’s nutritional
status is critical three (3) months before conception (preconception) and 2-3 months
after conception (peri-conception). Maternal nutrition significantly affects a woman’s
health growth and development of the foetus (Admad et al., 2008). The foetus is most
vulnerable to nutritional deficiencies in the first trimester of pregnancy, often before a
woman realizes that she is pregnant. There is evidence that poor maternal nutrition has
both immediate such as low birth weight and long-term consequences such as stunting.
The so-called “foetal origins” or “Baker” hypothesis proposes that foetal growth plays a
major role in determining the risk of some dietary related non communicable diseases
such as cardiovascular diseases and type II diabetes in adulthood (Webster-Gandy et al.,
2012).
Haemoglobin is formed from nutrients that we obtain from our food. The major nutrient
needed in the production of haemoglobin is iron. Other nutrients play a minor but
important role either in the formation of blood, its transport or utilization. Among these
are: protein, folic acid, vitamin B6, vitamin B12, vitamin A, iodine, calcium, zinc and
vitamin C. In 2008, the Ghana Demographic and Health Survey said the prevalence of
anaemia among pregnant women was 70%. The marked increase in maternal blood
supply during pregnancy greatly increases the demand for iron. The developing foetus
draws enough iron from the mother to last it through the first six months of life after
birth so a woman has an increased need for iron during pregnancy (Institute of
Medicine, Food and Nutrition Board, 2001). Adequate intakes of rich food sources of
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6vitamin C such as oranges, mangoes, pawpaw etc. are needed to help in iron absorption.
Though iron can be found in a variety of foods, what really matters is the amount of
iron consumed that is bioavailability to the body cells. A diet of low bioavailability can
cause anaemia, and the bioavailability of iron present in the diet can be determined by
the type or form of iron present in the diet and other components (GHS Annual Report,
2004). Malaria and worm infestation and nutrient mal-absorption may interfere with
iron absorption.
2.2 NUTRITIONAL CONSIDERATIONS DURING PREGNANCY
2.2.1 Energy needs of pregnant women
Additional energy is required during pregnancy to support the metabolic demands of
pregnancy and foetal growth. Metabolism increases by 15% in the singleton pregnancy
(Mahan et al., 2012). The 2002 daily recommended intakes (DRIs) for energy for the
pregnant woman in the first trimester is the same requirements for the non-pregnant
woman. However, this should be increased by 340-360 kcal/day during the second
trimester and by another 112 kcal/day in the third trimester (Institute of Medicine, Food
and Nutrition Board, 2001). If maternal weight gain is within the desirable limits, the
range of acceptable energy intakes varies widely, given individual differences in energy
output and basal metabolic rate (Mahan et al., 2012). Maternal energy restriction
impairs lactation after birth (Dewey et al., 2010).
2.2.2 Macronutrients
The foetus is most susceptible to nutritional imbalance during the first trimester of
pregnancy (Keen, 2003). The first trimester is the period during which rapid cell
differentiation and the establishment of embryonic systems and organs are taking place
(Marieb & Hoehn, 2010). The extra nutritional requirements imposed by pregnancy
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7must be met by dietary intake and body stores (Butte & King, 2005). Foetal growth
depends on the health and nutritional status of the mother before conception, degree of
energy demand placed on her during pregnancy and the growth, energy and nutrient
demands of the products of conception at different stages of gestation (Webster-Gandy
et al., 2012). But it is worth remembering that there are a number of ways in which the
nutrient supply to foetus may be regulated, such as changes in maternal food choices
and dietary intake, maternal metabolic adaptation, altered maternal absorption, maternal
loss (foetal uptake) and varying placental transfer (Nyaruchucha, 2009).
Dietary recommendations are the same as for the normal healthy diet, where energy is
25-35kcal/day, folic acid 0.2mg/d, protein 51g, vitamin D 40mg and vitamin A 0.6mg
except for additional requirements for six nutrients of protein, energy, folic acid,
vitamins A, C and D (Mahan et al., 2012). The additional requirements include: energy
+0.8MJ/day, folic acid +0.4mg (first trimester) and +0.1 (2nd and 3rd trimesters), protein
+6g, vitamin C +10mg (3rd trimester), vitamin D +0.01mg and vitamin A +0.1mg
(Mahan et al., 2012).
2.2.2.1 Carbohydrates
DRIs for carbohydrates in pregnancy are estimated average requirements (EARs) at
135g/day; the RDA is 175g/day (Institute of Medicine, Food and Nutrition Board,
2001). These requirements (135 to 175/day) are recommended to provide enough
calories in the diet to prevent ketosis and maintain appropriate blood glucose during
pregnancy. With an average 2000 kcal/day regimen, 175g translates to 700kcal or 35%
calories. The amount of carbohydrate may be greater in women consuming more
calories, but careful choices are needed to meet all the daily nutrients for pregnancy.
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82.2.2.2 Protein
Pregnancy increases protein requirement to support the synthesis of maternal and foetal
tissues, but the magnitude of this increase is uncertain (Mahan et al., 2012). Protein
requirement increases throughout gestation and is maximized during the third trimester.
The current RDA of 0.8g/kg/day of protein for pregnant women is the same as that for
the non-pregnant women in the first half of pregnancy. Nutritional needs increase in the
second half to 71g/day, based on 1.1g/kg/day of pre-pregnant weight (Institute of
Medicine, Food and Nutrition Board, 2001). For each additional foetus, another 25g/day
of protein is recommended; this may be as much as 175g/day for the normal- weight
women carrying a twin gestation that is consuming 3500kcal/day (Goodnight &
Newman, 2009). Protein deficiency during pregnancy has adverse consequences.
Limited intakes of protein and energy usually occur together, making it difficult to
separate the effects of energy deficiency from those of protein deficiency.
2.2.2.4 Lipids
There is no DRI for lipids during pregnancy. The amount of fat in the diet should have
effects on energy requirements for proper weight gain. However, there is a
recommendation of an adequate intake (AI) of 13g/day for the amount of omega-6
polyunsaturated fatty acids (linoleic acid) and an IA of 1.4g/day for the amount of
omega-3 polyunsaturated fatty acids in the diet (Institute of Medicine, Food and
Nutrition Board, 2001). The recommendation for docosahexaenoic acids is 300mg/day.
Essential fatty acid requirements can usually be met by one to two portions of fish per
week (Simpson et al., 2010).
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92.2.3 Micronutrients
2.2.3.1 Vitamins
All vitamins are needed for optimal pregnancy outcome. In some instances the
provision of these specific vitamins may be met through the diet. Some studies have
reported that in developing countries micronutrients intake of pregnant women were
inadequate as a result of poor quality of diet (Zeng et al., 2008). For others supplement
is necessary. Peri-conceptional multivitamin supplementation has been documented to
reduce the risk of heart defects in infants if started very early in pregnancy (Mahan et
al., 2012). Most vitamin and mineral recommendations increase approximately 15%
from non-pregnant values.
2.2.3.1.1 Folate
There is now conclusive evidence that folic acid is of crucial importance in early
pregnancy to help protect against neural tube defects (NTD) (DH, 2000) and that there
is an inverse dose-response relationship between folate status and risk of neural tube
defect (Wald, 2004). Women who have not been supplementing their diet with folic
acid and become pregnant should immediately start supplementation and continue until
the 12th week of pregnancy. To prevent recurrence of NTDs in the offspring of women
or men with NTD, women who may become pregnant should take a daily supplement of
5mg of folic acid. Although it has been suggested that periconceptional intake of other
vitamins may also be relevant to some types of structural malformations (Czeizel,
1993), at present the evidence is that the influence of folate is of paramount importance.
Women are therefore encouraged to take specific folate supplements rather than
combinations of multivitamins and folate because some of the latter preparations may
not contain sufficient folate to be protective. In addition to the preconceptional need for
folic acid supplementation, the requirement for folate is also increased during
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10
pregnancy. In order to prevent megaloblastic anaemia, the dietary reference value for
folate during pregnancy is increased from 200mcg/day for non- pregnant women to
600mcg/day for pregnant women (Institute of Medicine, Food and Nutrition Board,
1998). This level of increase can be achieved by advising a well-balanced diet
containing folate-rich foods such as green leafy vegetables, granary bread, yeast extract
and breakfast cereals which are fortified with folate.
2.2.3.1.2 Vitamin C
Vitamin C aids in the absorption of non-haem sources of iron and the recommended
vitamin C intake is increased by 10mg during the third trimester of pregnancy to
85mg/day (Brown et al., 2008). Pregnant women are encouraged to include some source
of vitamin C at each meal, particularly from fruit and vegetables. If consumption of
these foods tends to be low, fruit juice or vitamin C-enriched fruit squash are
encouraged. Vitamin C intakes have been found to be lower amongst women who
smoke during pregnancy (Haste et al., 1990) and particular attention should be paid to
them to ensure that they achieve an adequate intake.
2.2.3.1.3 Vitamin D
Vitamin D is essential to sustain the heightened calcium absorption and utilization
during pregnancy. Normally, the body’s requirement for vitamin D is met through
exposure to sunlight and to a lesser extent, dietary sources such as vitamin D-enriched
margarine, cheese, fatty fish and eggs. The current recommendation is that pregnant
women should take a supplement providing 0.01mg/day (FSA, 2005). Supplements are
particularly important for at risk individuals, especially Asian women, who are
particularly likely to compromised vitamin D status as a result of low sunlight exposure
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11
and reduced metabolic synthesis of the active forms of the vitamin. The recommended
daily allowance is 15mcg.
2.2.3.1.4 Vitamin A
A recommendation of 0.1mg/day throughout pregnancy is to enhance maternal stores
and allow for rapid foetal growth of late pregnancy (Institute of Medicine, Food and
Nutrition Board, 1998). Good sources of vitamin A and beta-carotene include milk and
milk products, eggs, green leafy vegetables and carrots. However, due to the known
teratogenic effects of high retinol intakes, pregnant women are advised to avoid liver
and liver products such as liver paste and liver sausage and not to take supplements
containing vitamin A or fish liver oils (FSA, 2005b).
2.2.3.1.5 Vitamin B1 (Thiamin)
Vitamin B1 functions as coenzyme in the metabolism of carbohydrates, alcohol, and
some amino acids. It is also required for growth and maintenance of nerve and muscle
tissues. The recommended daily allowance during pregnancy is 1.4mg. Rich sources
include: cereals, paster, bread, liver, pork, milk, cheese, yogurt, dried beans and nuts
(Brown et al., 2008).
2.2.3.1.6 Vitamin B2 (Riboflavin)
Vitamin B2 promotes growth and repair of tissues, serves as coenzyme in cell division
and energy metabolism and also promote normal vision. Rich sources include; liver,
fish, beef, eggs, grains and cereals. The recommended daily allowance during
pregnancy is 1.4mg (Brown et al., 2008).
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2.2.3.1.7 Vitamin B3 (Niacin)
Vitamin B3 primary function is to help normal nervous system functions and also serves
as coenzyme for energy metabolism and synthesis of body fat. Rich sources include:
meat, grains and cereals, milk, cheese, yogurt and potatoes. The recommended daily
allowance during pregnancy is 18mg (Brown et al., 2008).
2.2.3.1.8 Vitamin B6
Vitamin B6 functions as a cofactor in approximately 50 decarboxylase and transaminase
enzymes, especially in amino acid metabolism (Mahan et al., 2012). Although this
vitamin catalyzes a number of reactions involving neurotransmitter production, it is not
known whether this function is involved in the relief of nausea or vomiting. Meat, fish,
and poultry are good dietary sources. Deficiency is not common and routine prenatal
vitamins are sufficient (Simpson et al., 2010). The RDI during pregnancy is 1.9mg.
2.2.3.1.9 Vitamin B12
Cobalamin is a complex molecule that contains cobalt, it occurs naturally in usual forms
(Williams & Schlenker, 2003). Cyanocobalamin is the commercially available form,
which is converted to the natural forms. It requires salivary haptoccrrin and “ intrinsic
factor” to be absorbed (Gropper, et al., 2005). “Intrinsic factor” is secreted by the
parietal cells of the stomach. Vitamin B12 does not occur in plant foods, and therefore
vegans and strict vegetarians are at risk of deficiency. The functions of vitamin B12
include recycling of folate coenzymes, normal myelination of nerves and synthesis of
methionine from homocysteine (Gibney et al., 2006). Few pregnant women exhibit
deficiency symptoms as vitamin B12 is also manufactured by intestinal bacteria. The
most common cause of deficiency is mal-absorption due to atrophy of the gastric
mucosa, which leads to inadequate production of “intrinsic factor” or diseases of the
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ileum (Mahan, et al., 2012). Deficiency results in pernicious anaemia or neurological
problems. The anaemia is morphologically the same as that seen in folate deficiency and
biochemical tests are necessary to establish the cause (Holdsworth et al., 2012). The
neuropathy is characterized by loss of sensation and motor power in the limbs due to
degeneration of myelin. Good sources of vitamin B12 include meat and meat products,
eggs, milk and dairy products, fish and fish products, yeast products and fortified
vegetables extracts and fortified breakfast cereals. The recommended daily allowance
intake during pregnancy is 2.6mcg.
2.2.3.1.1.10 Vitamin E
Vitamin E requirements are increased during pregnancy. Deficiency during pregnancy
is speculated to cause miscarriage, preterm birth, and intrauterine growth retardation
(Gagne et al., 2009). Vitamin E deficiency has not yet been reported in human
pregnancy. Vitamin E is an important lipophilic antioxidant. The recommended daily
allowance intake during pregnancy is 15mg (Mahan et al., 2012).
2.2.4 Minerals
2.2.4.1 Iron
Pregnancy is a period of a significant increase in iron requirement over and above the
non-pregnant state (Zavaleta et al., 2000). Although iron requirements are reduced in
the first trimester because of the absence of menstruation, they rise steadily thereafter
from approximately 0.8 mg per day in the first month to approximately 10 mg per day
during the last 6 weeks of pregnancy (Bothwell, 2000). The increased iron requirement
is due to expansion of maternal red blood cell mass for increased oxygen transport,
including transfer of iron, to both the growing foetus and the placental structures, and as
a needed reserve for blood loss and lochia at parturition (Beaton, 2000). Due to
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increased iron requirements, pregnancy is also a period of increased risk for anaemia.
Thus, a high proportion of women become anaemic during pregnancy (Mahan et al.,
2012). During pregnancy, iron is needed for the manufacture of haemoglobin in both
maternal and foetal red blood cells. The foetus accumulates most of its iron during the
last trimester and, at term, a normal weight infant has about 246mg of iron in blood and
body stores. Maintenance of erythropoiesis is one of the few instances during pregnancy
when the foetus acts as true parasite by ensuring its own production of haemoglobin,
drawing iron from its mother (Mahan et al., 2012). Maternal iron deficiency, does not
usually result in an infant that is anaemic at birth (Brown et al., 2008). The most
common cause of iron deficiency anaemia in infants is prematurity, as an infant who has
a short gestation simply does not have enough time to accumulate sufficient iron during
the last trimester (Holdsworth, et al., 2012). The current recommended reference values
(Department of Health, UK, 1991) for iron in adult women is with no recommended
increase during pregnancy. In theory, the increased in demand for iron in pregnancy is
met through the combined actions of mobilization of maternal iron stores, increased
dietary absorption, and savings made in basal iron losses due to cessation of
menstruation.
In women who begin pregnancy with adequate iron reserves, these adaptations allow the
additional iron requirements to be met without the necessity for an increased dietary
iron intake (Department of Health, UK, 1991). The current intake of iron from dietary
sources has been found to be below the lower recommended nutrient intake in over 40%
of 19-64 year old women (Henderson et al.,2003), therefore it is recommend that
women planning pregnancy should ensure they achieve adequate iron intake (FSA,
2005). Iron absorption from the gastrointestinal tract is increased during pregnancy.
However, the bioavailability of dietary iron is of greater importance than the actual
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amount of iron in the diet (Hallberg, 1994). Haem iron from the haemoglobin and
myoglobin of animals is absorbed more efficiently than non-haem iron because the
entire porphrin ring containing the iron is taken up by the mucosal cells, hence the iron
is protected from factors that inhibit its absorption. Non-haem is found in vegetables,
cereals, eggs, milk, and its bioavailability is affected by the balance of dietary factors
enhancing and inhibiting iron absorption. Vitamin C increases bioavailability and
calcium and iron-binding polyphenols such as tannins from tea, phytate from cereals
decrease it (Robinson et al., 1998).
2.2.4.2 Calcium
A baby at birth contains 25-30g of calcium, most of which is stored in the last 10 weeks
of pregnancy. There is a consensus that the concentration of maternal free (biological
active) 1,25-dihydroxy vitamin D3 is raised during pregnancy (Misra & Anderson,
1990), increasing net calcium absorption (Holdsworth et al., 2012). The recommended
Reference Nutrient Intake (RNI) for calcium for adult women of ages between 19-50
years is 700mg/day and 800mg for those aged 15-18 years (Department of Health, UK,
1991). The RNI for calcium for 11-18 year old girls is 100mg more per day than for
adult women (Department of Health, UK, 1991). This is to take into account the need
for calcium during the increase in bone mass and development which occurs during
adolescence. It does not take into account, however, the needs of the foetus in the
pregnant adolescent. Although there is some physiological adaptation to allow enhanced
absorption of calcium from the gut during pregnancy, the calcium intake of the pregnant
teenager needs to be carefully monitored and advice given as to how to increase calcium
intake if necessary (Mahan et al., 2012).
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2.2.4.3 Zinc
Animal studies have shown that deficiency of zinc is associated with abnormalities in
pregnancy, but this has not been clearly demonstrated in humans. There is no evidence
that extra zinc is required during pregnancy and the UK RNI for zinc is 7mg/day with
no increment during (Department of Health, UK, 1991). Zinc intakes tend to parallel
protein intake and rich sources of zinc include meat, fish, pulses and whole grain
cereals.
2.2.4.4 Copper
Diets of pregnant women are often marginal in copper. Copper deficiency alters embryo
development and induced-copper deficiency has been shown to be tetratogenic. Not
only are there genetic mutations, as in Menkes disease, but also secondary deficiency
differences from excessive zinc or iron intake, certain drugs, and bariatric surgery (Uria-
Adams, 2010). These inadequacies cause decreased activity of cupro-enzymes,
increased oxidative stress, altered iron metabolism, abnormal protein cross-linking,
decreased angiogenesis and altered cell signalling (Uria-Adams, 2010). Copper is an
essential mineral required by the body for bone and connective tissue production. Foods
containing copper include liver, oysters, sesame seeds, nuts.
2.2.4.5 Iodine
Iodine is part of the thyroxine molecule, with a critical role in the metabolism of
micronutrients. Adequate gestational iodine is associated with a higher intelligence
quotient in the child and attention deficit may be associated with milder iodine
deficiency (Hoy- Rosas, 2009). In instances where preconception iodine intake cannot
be ensured, supplementation before the end of the second trimester protects the foetal
brain from effects of deficiency. To ensure adequate iodine, food is often fortified with
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iodized salt. If urinary iodine levels are low, supplementation is needed (Simpson et al.,
2010). Pregnant women are advised to use iodized table salt when cooking (Glinoer,
2007).
2.2.5 Fibre
Daily consumption of whole-grain breads and cereals, leafy green and yellow
vegetables, and fresh and dried fruits should be encouraged to provide additional
minerals, vitamins, and fibre. The DRI for fibre during pregnancy is 28g/day (Institute
of Medicine, Food and Nutrition Board, 2001) and if met, will help a great deal in
managing the constipation that often accompanies pregnancy.
2.3 ALCOHOL INTAKE DURING PREGNANCY
The term foetal alcohol syndrome (FAS) is used to describe the congenital
malformations associated with excessive maternal alcohol intake. These include growth
retardation, abnormal craniofacial features and developmental problems (Beattie, 1992).
FAS is likely to occur in the offspring of mothers regularly drinking more than 80g of
pure alcohol per day. Current optimal advice of abstinence in pregnancy, is especially
important in the first trimester, however, occasional drinking of small quantities, less
than or equal to 1-2 units, once or twice a week but less than or equal to 2 units at any
sitting is likely to harm the foetus. Excessive binge drinking is most dangerous and can
have teratogenic effects leading to FAS which affects 1-2/1000 births/ year. Risk is
elevated in women drinking greater than 8 units /day. Pregnant women are advised not
to get drunk (Thomas & Bishop, 2007).
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2.4 PICA (NON- FOOD SUBSTANCES INTAKE DURING PREGNANCY)
Pica is persistent craving for non- food substances, ranging from coal, clay, candles,
matchboxes, to soil. Pica can be harmful if the item craved and eaten is toxic or eaten in
large enough quantities to have an impact on nutritional status. Eating soil could carry
the risk of toxoplasmosis. Pica is often associated with iron deficiency but it is uncertain
whether iron deficiency causes pica or conversely whether pica causes iron deficiency
because of its effects on decrease iron absorption (Holdsworth et al., 2012).
2.5 FOOD AVERSIONS
Aversions are relatively common for tea, coffee, fried foods, and eggs. Food cravings
can be strong but depend on the individual. There are no nutritional implications as long
as craving does not involve eating a lot of energy-dense foods that result in excessive
weight gain (Mahan et al., 2012).
2.6 MATERNAL WEIGHT GAIN
Weight gained in pregnancy is a combination of maternal and foetal tissues and fluid, as
well as maternal fat stores (Artal, 2010). Rate of weight gain is usually not constant; this
is around 2kg in the first trimester and the rest throughout the second and third
trimesters at a rate of approximately 0.4kg/week (Webster-Gandy et al., 2012). A
normal weight gain over the course of pregnancy is around 10-12kg for women who
have a healthy pre-conception weight (Begum, 2008).
To account for this increase in energy demands, the Department of Health (DH,
England) makes a blanket recommendation for pregnant women to consume an extra
200kcal/day in the last trimester, but the best advice is to encourage pregnant women to
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eat well and monitor weight gain within the appropriate ranges. An average weight gain
of 10-16kg is recommended for women of normal BMI (18.5-24.9).
Both too little and too much weight gain can adversely affect the foetus. Too much
maternal weight gain during pregnancy lead to post-partum maternal obesity, possibility
of caesarean, infant macrosomia and increase risk of gestational diabetes. Too little
maternal weight gain can lead to low birth weight with subsequent effects on long-term
health.
Women who are overweight or obese should not attempt to lose weight during
pregnancy. Institute of Medicine, Food and Nutrition Board (USA) recommends that,
based on pre-pregnancy and BMI, overweight women should limit weight gain to 5-9kg
(Institute of Medicine, Food and Nutrition Board, 2001). Overweight and obese
pregnant women need regular monitoring as there is increased risk of pre-eclampsia,
gestational diabetes mellitus and hypertension as BMI increases. At birth there is
increased likelihood of caesarean section, poor post-operative complications, low Apgar
score, excessive birth weight of new born (macrosomia), increase peri-natal mortality
by three- fold, and neural tube defects. Women carrying twins or more will gain even
more weight than women carrying one foetus. The Institute of Medicine advised that
normal weight pregnant women carrying twins should gain 17-25kg, overweight women
should gain 14-23kg, and obese women should gain 11-19kg during pregnancy
(Institute of Medicine, Food and Nutrition Board, 2001). A healthy weight gain is
particularly important in multiple pregnancies as they carry higher risk of premature
birth and low birth weight.
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2.7 TYPES OF NUTRITIONAL ANAEMIA
2.7.1 Iron Deficiency Anaemia
This is characterized by the production of microcytic erythrocytes and a diminished
level of circulating haemoglobin (Mahan et al., 2012). This microcytic anaemia is
actually the last stage of iron deficiency, and it represents the end point of iron
deprivation (Gibney et al., 2006). The iron deficiency anaemia may be due to
inadequate ingestion, inadequate absorption, inadequate utilization, increased
requirement, increased blood loss or excretion and increased destruction resulting in
decreased release from stores (Thomas & Bishop, 2007).
As iron-deficiency becomes more severe, defects arise in the structure and function of
the epithelial tissues, especially of the tongue, nails, mouth, and stomach. The skin may
appear pale, and the inside of the lower eyelid may be light pink instead of red (Brown
et al., 2008). Mouth changes include atrophy of lingual papillae, burning, redness, and
in severe cases a completely smooth, waxy and glistening appearance of the tongue
(glossitis). Angular stomatitis may also occur. Gastritis occurs frequently and may result
in achlorhydria. Fingernails can become thin and flat, and eventually koilonychias
(spoon-shaped nails).
The management of iron deficiency anaemia includes; increase of absorbable iron in the
diet, inclusion of vitamin C at every meal, inclusion of meat, fish, or poultry at every
meal and decrease of tea and coffee consumption (Mahan et al., 2012).
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2.7.2 Folic Acid Deficiency Anaemia
It is associated with tropical sprue, can affect pregnant women, and occurs in infants
born to mothers with folic acid deficiency. Folic acid deficiency in early pregnancy can
also result in an infant with neural tube defect (Holdsworth et al., 2012). Prolonged
inadequate diets, faulty absorption and use of folic acid, and increased requirements
resulting from growth are believed to be the most frequent causes (Mahan et al., 2012).
Rich sources of folate include: green leafy vegetables, mushrooms, roots, tubers, fruits,
liver, kidney, meat, egg yolk, among others (Thomas & Bishop, 2007).
2.7.3 Vitamin B12 Deficiency and Pernicious Anaemia
Pernicious anaemia is a megaloblastic, macrocytic anaemia caused by a deficiency of
vitamin B12, most commonly from a lack of intrinsic factor (Mahan et al., 2012). It is
common among vegetarians (Williams & Schlenker., 2003).
2.7.4 Anaemia of Protein-Energy Malnutrition
Protein is essential for the proper production of haemoglobin and red blood cells
(Latham, 1997). Diet lacking in protein is usually deficient in iron, folic acid, and less
frequently, vitamin B12 (Mahan et al., 2012).
2.7.5 Copper-Deficiency Anaemia
Copper and other heavy metals are essential for the proper formation of haemoglobin.
Ceruloplasmin, a copper containing protein, is required for normal mobilization of iron
from its storage sites to the plasma. In a copper deficient state, iron cannot be released,
this leads to low serum iron and haemoglobin levels, even in the presence of normal
iron stores (Mahan et al., 2012). Other consequences of copper deficiency suggest that
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copper proteins are needed for use of iron by the developing erythrocyte and for optimal
functions of the erythrocyte membrane.
2.7.6 Sideroblastic (Pyridoxine-Responsive) Anaemia
This is characterized by a derangement in the final pathway of heme synthesis, leading
to a build-up of iron-containing immature red blood cells (RBCs). The neurologic and
cutaneous manifestations of vitamin B6 deficiency are not observed. The anaemia
responds to the administration of pharmacologic doses of pyridoxine and thus
distinguishes it from anaemia caused by a dietary vitamin B6 deficiency (Mahan et al.,
2012).
2.7.7 Vitamin E-Response Haemolytic Anaemia
It occurs when defects in RBC membranes lead to oxidative damage and eventually to
cell lysis. This anaemia is caused by shortened survival of mature RBCs. Vitamin E, an
antioxidant, involved in protecting the membrane against oxidative damage, is one of
the few signs noted in vitamin E deficiency is early hemolysis of RBCs (Mahan et al.,
2012).
2.8 24-HOUR RECALL OF DIETARY INTAKE ASSESSMENT
The 24-hour recall of dietary intake assessment is a formal method that a trained
interviewer uses to assess the subject through their food intake recall over the previous
24-hour. It is a quick retrospective method of dietary assessment, but cannot be used to
classify a subject’s usual intake as it is not necessarily representative of the subject’s
normal eating pattern.
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To overcome these problems the 24-hour recall was repeated for three days which
includes early week day, mid-week day and week end day to estimate nutrient intake
.This is considered more representative of the usual intake than estimates from a single
day (Margetts & Nelson, 1997).
The limitations of this method include the fact that it is prone to underestimate
consumption due to omissions, and a single observation provides a poor measure of the
individual intake.
2.9 FOOD FREQUENCY QUESTIONNAIRE (FFQ)
This is a retrospective review of intake frequency. Printed questionnaires are used and
interviewees ticks the category that approximates to their usual consumption out of a list
of foods, that is never eaten, eaten once a month, eaten once a fortnight and the number
of times eaten per week. This is quantified and the intake is estimated.
Food frequency questionnaire can be conducted via post. The number of foods can vary;
sometimes only a few are used when assessing a food group or nutrient (Mahan et al.,
2012). These are sometimes called screeners. FFQs are often used in large surveys. It is
necessary to validate FFQs against a more precise method such as weighed food intake.
There are three main types of FFQ:
1. qualitative: this does not use portion size.
2. semi-quantitative: standard portion size is used.
3. quantitative: interviewers are asked to record data on portion size.
This tool is helpful in relation to particular disease risk or incidence by helping
determine the use of specific groups of food over an extended period of time. It is
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suitable for large-scale surveys, can be posted and short versions can focus on specific
foods, e.g. fruit and vegetables.
The limitations include:
1. requires validation in relation to reference
2. literacy and numeracy skills are required if self-completed
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CHAPTER THREE
3.0 METHODS
3.1 STUDY DESIGN
The research design for the study was descriptive cross-sectional. This was chosen
because all information except the repeated 24-recall was used to collect data at one
point in time.
3.2 STUDY SITE
Data for the survey was collected from the antenatal clinic of Tamale Teaching Hospital
in the Tamale Metropolis. Tamale is one of the twenty six districts of the Northern
Region, and it is the Regional capital. Tamale Teaching Hospital is located in the
Tamale South Constituency and at the north-eastern part of Tamale on the main
Tamale-Yendi road, opposite the Kukuo market. The metropolis has a population of
537,986 (Ghana Statistical Service, 2010) of which 10% constitute older adolescent (15-
19 years) and women constitute 274,373 with expected pregnancy of 4,292 per year.
The people of Tamale metropolis are indigenous Dagombas and they speak the Dagbani
language with other minority tribes like Gonja, Konkomba, Dagaare and Twi. They
practice the patrilineal lineage system. Majority of people are Muslims with a few
Christians and African traditionalists. Most men are polygamous and in general
endogamous marriages are encouraged among the people.
Tamale Teaching Hospital is the only referral centre in the three northern regions of
Ghana. The metropolis has one Teaching Hospital, three (3) district hospitals, five (5)
health centres and other private clinics. Data for the survey was collected from the
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antenatal clinic of Tamale Teaching Hospital in the Tamale Metropolis. The maternity
department provides antenatal services, has a labour ward, lying-in ward and postnatal,
maternal and child health units. The average daily attendance to the antenatal clinic is
100.
3.3 SAMPLE SIZE CALCULATION
Sample size was selected based on calculation using Cochran’s sample size formula.
n = t2 x p(1-p)/m2 where
n = required sample
t= (the z-score associated with the confidence level required) = 1.96
p ( is occurrence (events) rate within the population) = 0.65
m (margin of error (the required precision) = 0.05
Therefore n = (1.96)2 x 0.65 (1-0.65)/0.05 = 349.58 = 350.
However, due to time constraint and financial limitations, 50% of the sample size, 175,
was used.
3.4 SAMPLING TECHNIQUE
Convenient sampling procedure was employed. Pregnant women who met the inclusion
criteria and agreed to participate were interviewed when they came for their antennal
visits. This was done daily over a period of ten days.
3.5 PARTICIPANTS
3.5.1 Inclusion criteria
Pregnant women between the ages of 18-50 years attending antenatal clinic in Tamale
Teaching Hospital for routine care were recruited.
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3.5.2 Exclusion criteria
Pregnant women with severe nutrition related problems such as Hyperemesis
gravidarium were excluded.
3.6 DATA COLLECTION
3.6.1 Questionnaire administration
A questionnaire was designed and used for data collection. The questionnaire was made
up of six sections: Section A was on food habits of respondents; Section B gathered
information on precipitants of anaemia; Section C collected data on socio-demographic
characteristics; Section D collected data on food intake by 24-hour recall and food
frequency questionnaire; and Section E was an intervention on healthy eating.
The questionnaire was pre-tested at the Tamale Teaching Hospital among ten pregnant
women who met the criteria for the main study to determine the validity and clarity, and
to also eliminate possible ambiguity. The necessary corrections were effected on the
questionnaire for better understanding by the respondents. The questionnaires were
administered on Mondays, Wednesdays and Fridays for the previous day’s food eaten.
In order to get the true eating pattern of a respondent, dietary assessment using 24-hour
recall was carried out three times for each respondent, each on a different day of the
week for three weeks. To make it easier for the respondents to recall accurately the
previous day food eaten, portion sizes handy measures were used and later converted to
grams for the analysis.
3.6.2 Laboratory data
The most recent results of laboratory tests for Hb level, malaria status and worm
infestation was extracted from respondent’s hospital records. Their sickling status was
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also extracted. Anaemia was classified as mild (Hb of 10-10.9g/dl), moderately anaemic
(Hb of 7.9-9.9g/dl), severely anaemic (Hb of 4-6.9 g/dl) and very severely (Hb of less
than 4g/dl) (UNICEF, UNU & WHO, 2001).
3.7 ETHICS
Approval of the study was obtained from the Ethics and Protocol Review Committee,
School of Allied Health Sciences. A consent form was attached to the questionnaire to
ask for each participant’s consent. Data collected during the survey from each study
participant and results of laboratory tests were kept confidential.
3. 8 DATA ANALYSIS
Data collected was analysed using statistical programs such as SPSS version 19,
Microsoft Excel 2010 and Epi-info 7. Descriptive variables such as mean, mode, and
standard deviation were used to analyse demographic data. Point estimation of
prevalence, worm infestation and malaria infection and odd ratios with 95% confidence
interval was computed to compare each of the two variables using chi- square test.
Multi variable logistic regressions were employed for variables, have significant
association with disease outcome to determine the main predictors of infection. A p-
value of less than or equal to 0.05 was considered significant. Esha-F Processing was
used to determine the nutrients intake of participants.
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CHAPTER FOUR
4.0 RESULTS
4.1 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS
A total of 175 pregnant women (respondents) were recruited for the study. Table 1
shows the socio-demographic characteristics of the respondents. The age profile shows
that few of the pregnant women (4%) were in the age group of 18-19 years, whereas
majority of the pregnant women (68.7%) were in the age range of 20-34.
Over one – quarter (30.9%) of the study population had no formal education, while
those with Junior High School, Senior High School, and Tertiary had 27.4%, 10.9%,
and 30.9% respectively. The majority (38.3%) of the respondents were professionals
while those who were unemployed were the least (2.9%). The majority of the
respondents’ spouses were also professionals (67.8%).  The monthly income levels
generally were low; the majority (43%) earned between GHC50 -100 and only 2.9%
earned above GHC1000. The majority of the respondents’ spouse’s (44.4%) had income
between GHC50-100 and only 10.5% earned above GHC1000.  Forty eight percent
(48%) of the respondents were in the third trimester of pregnancy, 47% were in the
second trimester, with only 5% in their first trimester. Anaemia was more prevalent in
the second and third trimesters of pregnancy.
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Table 1: Socio-demographic characteristics of respondents
Variable N % Mean
Age 18-19
20-24
25-29
30-34
35 and above
Total
7
31
47
44
46
175
4.0
17.7
26.9
25.1
26.3
100.0
29.77
Educational background Never attended school
Elementary/JHS
SHS
Tertiary
Total
54
48
19
54
175
30.9
27.3
10.9
30.9
100.0
N/A
Occupation Professional
Trading
Vocational
Jobless
Other
Total
67
65
21
5
17
175
38.3
37.1
12.0
2.9
9.7
100.0
N/A
Spouse’s Occupation Professional
Trading
Vocational
Total
116
41
14
171
67.8
24.0
8.2
100.0
N/A
Monthly income (GHC) Less than 50
Between 50-100
Between 100-300
Between 300-500
Between 500-1000
Above 1000
Total
29
74
9
14
41
5
172
16.9
43.0
5.2
8.2
23.8
2.9
100.0
287.35
Monthly income of spouse
(GHC)
Less than 50
Between 50-100
Between 100-300
Between 300-500
Between 500-1000
Above 1000
Total
12
76
11
14
40
18
171
7.0
44.4
6.4
8.3
23.4
10.5
100.0
361.40
Trimester First=1-12wks
Second=13-24wks
Third=25-40wks
Total
8
83
84
175
4.6
47.4
48.0
100.0
N/A
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4.2 DIETARY HABITS OF RESPONDENTS
4.2.1 Pica practice
Majority of the respondents (78.9%) practiced some form of pica and the items mostly
eaten were chewing stick/wooden sponge (48.6%) and about 46.9% of the respondents
started in the second trimester (Table 2). The main reasons for practicing the pica were
to prevent nausea (39.7%) and for satisfaction (30.1%).
4.2.2 Food craving
Food craving was a common practice among the respondents (Table 3). Most of them
(85.7%) craved for a particular food at a point in time in any of the trimesters. The items
mostly craved was fizzy drinks (33.5%) and the least craved for was chocolate (8.2%).
The respondents also craved for local foods like banku, pepper, roasted yam, smoked
fish and leafy vegetables. Food craving was highest (58.2%) at the second trimester and
least at the third trimester (5.7%). The reason for craving by 63.1% of the respondent
was for satisfaction while 10% did not know why.
4.2.3 Food aversions
Majority of the respondents (76.7%) reported that they avoided some foods, mostly in
second trimesters (72.5%) [Table 4]. Meat or fish was what mostly avoided (48.6%)
whilst were fruits the least (1.4%). The highest reason for the avoidance was
smell/aroma (48.6%) with other reasons being the least (1.3%).
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Table 2: Pica practice among pregnant women in Tamale
Variable N %
Do you practice any form of pica? Yes
No
Total
138
37
175
78.9
21.1
100.0
What respondents eat as a form
of pica
Chewing stick/wooden
sponge
Uncooked maize
dough/starch
Chalk
Clay
Cola nuts
Other
Total
85
6
3
66
9
6
175
48.6
3.4
1.7
37.7
5.1
3.4
100.0
Stage of pregnancy at which
respondent start practicing pica
1-3 months
4-6 months
7-9 months
Not sure
Total
63
82
15
15
175
36.0
46.9
8.6
8.6
100.0
Why respondents practice pica To prevent nausea
To prevent vomiting
For satisfaction
To prevent salivation
Other
Total
54
25
41
14
2
136
39.7
18.4
30.1
10.3
1.5
100.0
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Table 3: Food craving among pregnant women in Tamale
Variable N %
Do you crave for
any food?
Yes
No
Total
150
25
175
85.7
14.3
100.0
What respondents
crave for
Chocolate
Toffees/candies
Ice cream
Fizzy beverages
Other
Total
13
16
37
53
39
158
8.2
10.1
23.4
33.5
24.7
100.0
Stage of pregnancy
respondents start
craving
1-3 months
4-6 months
7-9 months
Not sure
Total
47
92
9
10
158
29.7
58.2
5.7
6.3
100.0
Why respondents
crave
To prevent nausea/vomiting
For satisfaction
Don't know
Total
43
101
16
160
26.9
63.1
10.0
100.0
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Table 4: Food aversions among pregnant women in Tamale
Variable N %
Do you avoid taken any food? Yes
No
Total
132
40
172
76.7
23.3
100.0
Foods respondents avoid Meat/Fish
Eggs
Milk
Fruits
Other
Total
69
36
11
2
24
142
48.6
25.4
7.7
1.4
16.9
100.0
Time of pregnancy respondents
avoid certain foods
1-2wks
13-24wks
25-40wks
Total
34
103
5
142
23.9
72.5
3.5
100.0
Why respondents avoid certain
foods
Taste of food
Poor appetite
Don't know
Smell/aroma
Other
Total
5
33
37
73
2
150
3.3
22.0
24.7
48.7
1.3
100.0
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4.3 SUBSTANCES THAT AFFECT IRON ABSORPTION
Tea/coffee intake was high (92.2%) among the respondents (Table 5a). Over half
(63.8%) of the respondents took it once a day. Those who took it once a month were the
least (0.7%). Majority of the respondents (81.8%) also took supplements, with
multivitamin intake being the highest (35.2%) and herbal preparations the lowest
(11.7%) [Table 5b].
4.4 BEHAVIOURS THAT PRECIPITATE OR PREVENT INCIDENCE OF
ANAEMIA
Few of the respondents (7.3%) had experienced some form of blood loss mainly due to
injuries (58.3%) [Table 6]. Majority of the respondents (98.3%) attended antenatal
regularly and monthly attendance was 82.7% while 17.3% either attended once every
three months or not at all [Table 6]. The majority of the respondents (95.2%) took their
ANC drugs regularly and only 4.8% were not taking their routine drugs regularly. A
high percentage (83%) of the respondents took their multivitamins, iron and folic acid
supplements and 15% took their SP medication for malaria prevention.
4.5 TRIMESTER OF RESPONDENTS AND MALARIA OCCURRENCE
Twenty eight percent (28%) of the respondents had malaria in any of the trimesters with
an increase in the prevalence from the first to third trimester (Fig. 1).
4.6 DE-WORMING FREQUENCY OF RESPONDENTS BEFORE PREGNANCY
The majority of respondents (76.1%) never de-wormed before pregnancy, 5.2% used to
de-worm every 3 months and 13.6% used to de-worm every six months before
pregnancy (Fig. 2). Ninety percent (90%) of respondents routine stool examination was
negative for parasitic worms.
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Table 5a: Substances that inhibit iron absorption.
Variable N %
Do you take tea or coffee? Yes
No
Total
153
13
166
92.2
7.8
100.0
How often respondents take tea or coffee Once a day
twice a day
Weekly
Monthly
Sometimes
Total
97
45
6
1
3
152
63.8
29.6
3.9
0.7
2.0
100.0
Do you take some food supplements or any
herbal preparation?
Yes
No
Total
121
27
148
81.8
18.2
100.0
Table 5b: Substances that enhance Hb level
Variable N %
Food supplements respondents take Folic acid
Iron
Multivitamin
Herbal
Total
34
43
51
17
145
23.4
29.7
35.2
11.7
100.0
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Table 6: Behaviours that precipitate or prevent incidence of anaemia
Variable N %
Have you experienced
blood loss?
Yes
No
Total
12
153
165
7.3
92.7
100.0
Type of blood loss Bleeding from injuries
Coughing out blood
Other
Total
7
2
3
12
58.3
16.7
25.0
100.0
Do you attend ANC
regularly
Yes
No
Total
170
3
173
98.3
1.7
100.0
How often respondents
attend ANC
Monthly
Every 3 months
Other
Total
134
4
24
162
82.7
2.5
14.8
100.0
Do you take your routine
ANC drugs?
Yes
No
Total
160
8
168
95.2
4.8
100.0
ANC drugs respondents
take
Iron supplements
Folic acid
Multivitamins
SP
Other
Total
49
46
37
24
4
160
30.6
28.8
23.1
15.0
2.5
100.0
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Figure1: Trimester of respondents and malaria occurrence
Figure 2: The frequency of respondents de-worming before pregnancy
0
5
10
15
20
25
30
35
40
First Second Third
Fre
qu
enc
y (%
)
Trimester of respondents
Yes
No
0
10
20
30
40
50
60
70
80
Every 3 months Every 6 months Not at all Other
Fre
qu
enc
y (%
)
Deworming pratice
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4.7 SICKLING STATUS OF RESPONDENTS
Ten percent (10%) of the respondents were sickling positive and their Hb-
electrophoresis indicated they were all sickle cell disease carriers.
4.8 TRIMESTER OF RESPONDENTS AND THE HB LEVEL ESTIMATION
Forty seven percent (47%) of the respondents were anaemic (Hb less than 11g/dl). The
anaemia rate increased as the trimester increased, with 2% in the first trimester and 23%
in the third trimester [Fig. 3]. Although close to half of the respondents were anaemic,
40% were mild (Hb of 10-10.9g/dl) and 7% were moderately anaemic (Hb of 7.9-
9.9g/dl). None of the respondents was severely anaemic (Hb of 4-6.9 g/dl) and very
severely (Hb of less than 4g/dl).
4.9 CHANGES IN THE NUMBER OF TIMES RESPONDENTS ATE IN A DAY
BEFORE PREGNANCY EXCLUDING SNACKS
Most of the respondents (78.7%) indicated that the number of times they ate in a day
changed [Table 7]. Those who previously ate twice a day (85.5%) were those who
reported the greatest change.
4.10 NUTRIENTS ADEQUACY RATIO OF THE RESPONDENTS
Nutrients adequacy ratio of the respondents compared to standards is shown in Table
8a. Only vitamin C had a mean above the RDA. The number of respondents who met
and did not meet the RDAs is shown in Fig, 4. More than 60 % of the respondents did
not meet the RDAs for the nutrients with exception of vitamin C.
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Figure 3: Trimester of respondents and Hb level estimation
Table 7: Number of times respondents ate in a day before pregnancy excluding snacks
Number of times respondents eat in a
day before pregnancy excluding
snack
Has the number of times you
eat in a day changed since
you became pregnant?
TotalYes (%) No (%)
Two times 59 (85.5) 10 (14.5) 69 (100.0)
Three times 70 (78.7) 19 (21.3) 89 (100.0)
Four to Five times 8 (50.0) 8 (50.0) 16 (100.0)
Total 137 (78.7) 37 (21.3) 174 (100.0)
0
5
10
15
20
25
30
First Second Third
Fre
qu
en
cy 
(%
)
Trimester
Anaemic
Normal
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Table 8a: Nutrients adequacy ratio of the respondents (N = 175) compared to standards
Variables RDA Minimum Maximum Mean Std. Deviation
Energy (Kcal) 2400 2003.00 2986.00 2284.22 246.52
Protein (g) 71 29.70 143.00 59.22 23.36
Fibre (g) 28 0.39 134.00 25.33 23.42
Vitamin B12 (mcg) 2.6 0.00 4.65 1.16 0.96
Folate (mcg) 600 0.00 628.00 58.99 35.99
Vitamin C (mg) 85 16.70 214.00 98.96 49.53
Vitamin E (mg) 15 0.00 19.90 2.16 0.96
Calcium (mg) 1000 104.00 1411.00 503.71 252.88
Copper (mcg) 800 0.10 3.57 0.99 0.63
Iron (mg) 27 0.00 61.10 25.69 10.30
Zinc (mg) 11 3.68 22.40 9.78 4.18
*Source: Krause’s Nutrition Care Process (2012)
Fig. 4: Number of respondents who met and did not meet the RDAs
0% 20% 40% 60% 80% 100%
Energy (Kcal)
Protein (g)
Fibre (g)
Vitamin B12 (mcg)
Folate (mcg)
Vitamin C (mg)
Vitamin E (mg)
Calcium (mg)
Copper (mcg)
Iron (mg)
Zinc (mg)
Frequency  (%)
Nu
trie
nt
Respondents
who met
the RDA (%)
Respondents
who did not
meet the
RDA (%)
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4.11 NUTRIENTS REQUIREMENTS AND HB LEVEL ESTIMATION
In all, 95% of respondents who did not meet the RDA were anaemic whilst only 5%
who met the RDA were anaemic [Table 9]. For folate, all the respondents who did not
meet the requirement were anaemic whereas about 99% of respondents who met their
RDA were not anaemic. Forty three percent (43%) of respondents who did not meet
their RDA were anaemic, whereas 57% who met their RDA were also anaemic for
vitamin C. All the respondents who did not meet the RDA were all anaemic, while 74%
of those respondents who met their RDA had their Hb above 11g/dl for vitamin E. For
calcium. Ninety-six percent (96%) of respondents who did not meet their RDA were
anaemic and only 4% who met their RDA were anaemic.
4.12 FREQUENCY OF CONSUMPTION OF FOODS FROM THE FOOD
GROUPS BY RESPONDENTS
Tables 10a and 10b show frequency of consumption of foods from the food groups by
respondents. Majority of the respondents consumed maize (77%), rice (70%) and bread
(70%) on a daily basis. About half of the respondents consumed fish, meat and milk on
a daily basis. For legumes, 46% of respondents consumed groundnut, 40% consumed
agushie (melon seed) and 19% consumed beans on a daily basis. Generally, there was
low consumption of fruits on a daily basis with the consumption of orange being the
highest (27%). Majority of the respondents consumed vegetables: 95% consumed
pepper, 93% consumed tomatoes, 83% green leaves and 77% okro.
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Table 9: Nutrients requirements and Hb level estimation
Variable Hb level estimation
Nutrient requirements
Total
Does not meet
RDA (%)
Meets
RDA (%)
Energy Anaemic (<11g/dl) 67 (75.3) 22 (24.7) 89
Normal (11+g/dl) 60 (72.0) 26 (28.0) 93
Protein Anaemic (<11g/dl) 64(78.0) 18(22.0) 82
Normal (11+g/dl) 21 (22.6) 72 (77.4) 93
Fiber Anaemic (<11g/dl) 62 (75.6) 20 (24.4) 82
Normal (+11g/dl) 60 (64.5) 33 (35.5) 93
Vitamin
B12
Anaemic (<11g/dl) 78 (95.1) 4(4.9) 82
Normal (+11g/dl) 7 (7.5) 86 (92.5) 93
Folate Anaemic (<11g/dl) 82 (100) 0 (0) 82
Normal (+11g/dl) 1 (1.1) 92 (98.9) 93
Vitamin
C
Anaemic (<11g/dl) 35 (42.7) 47 (57.3) 82
Normal (+11g/dl) 34 (36.6) 59 (63.4) 93
Vitamin
E
Anaemic (<11g/dl) 92 (100) 0 (0) 92
Normal (+11g/dl) 22 (26.5) 61 (73.5) 83
Calcium Anaemic (<11g/dl) 79 (96.3) 3 (3.7) 82
Normal (+11g/dl) 8 (8.6) 85 (91.4) 93
Iron Anaemic (<11g/dl) 56 (68.3) 26 (31.7) 82
Normal (+11g/dl) 40 (43.0) 53 (57) 93
Zinc Anaemic (<11g/dl) 65 (79.3) 17 (20.7) 82
Normal (+11g/dl) 34 (36.6) 59 (63.4) 93
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Table 10a: Frequency of consumption of foods from the food groups by respondents
Food Group
Frequency of consumption (%)
Not often 1-2x/ week 3-4x/ week 5-6x/
week
Daily
Starchy roots and
plantains
Cassava 57.7 23.2 6.5 0 12.5
Cocoyam 88.2 10.2 0 0.6 0.6
Yam 28 44.0 11.3 2.4 14.3
Cereals and grains Maize 0 9.9 12.9 0.6 76.6
Rice0.6 0.6 16.4 12.3 0.6 70.2
Bread 14.4 12.6 2.4 0.6 70.1
Animal Products Fish 34.9 10.1 4.1 0 50.9
Meat 39.9 15.0 3.5 0 41.6
Poultry 68.9 9.8 2.4 0 18.9
Egg 53.8 22.0 6.9 0 17.3
Milk 51.6 6.4 1.3 0 40.8
Crab 91.3 4.8 1.6 0 2.4
Legumes, nuts and
oil seeds
Beans 15.9 50.0 9.4 5.9 18.8
Groundnut 13.0 28.4 5.9 6.5 46.2
Bambara
beans
51.8
30.4
7.7 1.2 8.9
Agushie
(melon seed)
34.9 16.4 4.6 4.6 39.5
Fruits Orange 51.5 14.0 6.4 1.2 26.9
Mangoes 58.0 23.7 0.6 8.3 9.5
Pawpaw 64.3 22.0 2.4 0 11.3
Banana 58.2 18.8 2.4 0.6 20.0
Watermelon 76.6 14.6 3.2 0 5.7
Vegetables Tomatoes 1.8 1.2 1.2 2.9 93.0
Pepper 2.4 1.2 1.8 0 94.7
Garden eggs 13.5 5.9 1.2 2.4 77.1
Okro 4.7 12.9 2.9 2.3 77.2
Green leaves 1.2 9.4 6.4 0.6 82.5
Fat and oils Palm oil 10.3 66.7 5.7 1.1 16.1
Refined
vegetable oil
10.4 67.6 1.7 3.5 16.8
eg coconut oil
Margarine 28.3 61.8 2.9 1.2 5.8
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Table 10b: Frequency of consumption of foods from the food groups by respondents
Food Groups
Frequency of consumption (%)
Not often
1-2x/
week
3-4x/
week
5-6x/
week
Daily Not
Applicable
Food high in
refined sugar
Coca cola 2.3 47.4 2.9 0 2.3 45.1
Biscuits 2.9 33.3 24.7 0 14.4 24.7
Cakes 4.6 38.7 21.4 1.2 4.0 30.1
Sprite 5.2 48.0 3.5 3.5 0 39.9
Fanta 4.6 52.6 10.4 0 3.5 28.9
Sugar 0 4.8 6.0 2.4 73.5 13.3
Don Simon/
Minute Maid
etc.
7.2 24.0 6.6 0 5.4 56.9
Malt 4.6 45.7 17.3 0 5.8 26.6
Other soft
drinks
0 0 8.0 0 12.0 80.0
Alcoholic
beverages
Beer 0 8.7 0 0 0 91.3
Guinness 0 8.0 0 0 0 92.0
Spirit 0 0 0 0 0.6 99.4
Wine 0 0.6 0 0 0.6 98.9
Punch 0 0 0 0 0.6 99.4
Others 0 0 0 0 0.7 99.3
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Generally, alcohol consumption was low because majority of the respondents were
Muslims (Table 10b). But for foods high in refined sugar, 74% of respondents
consumed sugar, 14% consumed biscuits, and 12% consumed other soft drinks
respectively on a daily basis.
4.13 ASSOCIATION BETWEEN SOCIO-DEMOGRAPHIC FACTORS,
SELECTED NUTRIENTS AND ANAEMIA
Anaemia was significantly associated with a respondents’ profession (p=0.031),
spouses’ profession (p=0.000), income levels of GHC300 and above (p=0.020) and ages
between 20-24 years (p=0.001) [Table 11]. With the exception of vitamin C, all the
other nutrient were significantly associated (all p –values <0.05) with anaemia (Table
11).
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Table 11: Association between socio-demographic factors, selected nutrients and
anaemia
Parameter p –value*
Educational level Never attended school 0.811
Elementary/JHS 0.590
Senior High School 0.098
Tertiary
Occupation of respondent Professional 0.031*
Trading 0.870
Vocational 0.364
Jobless 0.739
Other
Occupation of spouse Professional 0.000*
Trading 0.000*
Jobless
Monthly income of respondent Less than GHC50 0.765
GHC50-GHC100 0.909
GHC100-GHC300 0.784
GHC300-GHC500 0.020*
GHC500-1000 0.011*
Monthly income of spouse Less than GHC50 0.657
GHC50-GHC100 0.324
GHC100-GHC300 0.999
GHC300-GHC500 0.288
GHC500-1000 0.068
Number of times respondents
eat in a day
Two times 0.424
Three times 0.300
Four to Five times
Age categories 18-19 0.915
20-24 0.001*
25-29 0.168
30-34
35 and above
0.424
Selected Nutrients Energy
Protein
Vitamin B12
Vitamin C
Iron
Zinc
0.030*
0.000*
0.007*
1.391
0.000*
0.050*
* Significant at (p < 0.05)
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CHAPTER FIVE
5.0 DISCUSSION AND CONCLUSION
5.1 DISCUSSION
A mother’s nutritional status is critical three months before conception and 2-3 months
after conception. The foetus is most vulnerable to nutritional deficiencies in the first
trimester of pregnancy, often before a woman realizes that she is pregnant (Webster-
Gandy et al., 2012). Maternal nutrition is an important factor affecting pregnancy
outcome. During this period extra energy and nutrients are required for the growth of a
developing foetus, expanding maternal blood supply and preparation for lactation
(Aboagyeh-Aggrey, 2011). This study was conducted to find out the dietary habits,
nutrients intake, prevalence of anaemia and causes and effects of anaemia among 175
pregnant women in Tamale, the Northern Regional Capital of Ghana. The effects of
dietary intakes on nutritional status were also examined.
Majority (70%) of the women were within the age range of 20-34 which agrees with the
active reproductive age in Ghana which is between 20-35 years (GDHS Report, 2008).
It was observed that 31% of respondents had no formal education, thus it was most
likely that these women would have had little knowledge about their health and
nutritional needs. The fact that majority of the respondents’ spouses (68%) were
professionals was encouraging as it indicates that most of the respondents will have
responsible partners who will be ready to support financially. Income levels generally
were low among the pregnant women: the highest range (43%) was between GHC 500-
1000 per month. With such low incomes it is likely that many of the subjects lacked the
financial resources to purchase adequate amounts of nutritious food. Forty eight percent
(48%) of respondents were in the third trimester of pregnancy, while 47% of
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respondents were in the second trimester, with only 5% in the first trimester. It was not
surprising to find most of the pregnant women in the third trimester because of weekly
attendance.
Generally, majority of the pregnant women perceived pregnancy as a period for dietary
change. Seventy nine percent (79%) of the respondents practiced pica eaten and
majority (83%) started either in the second and third trimesters of pregnancy. Simpson
et al. (2011) reported that 38% of American pregnant women who practiced pica daily
were significantly more likely to have lower prenatal haematocrit than women who did
not.
Food craving was a common practice among the respondents with 80% craving for a
particular food at one point in time in any of the trimesters. They craved for food items
like ice cream (23%), fizzy drinks (34%), toffees (10%) and chocolate (8%). The
respondents also craved for local Ghanaian foods like pepper, banku, kenkey, roasted
yam, peanut, smoked fish and leafy vegetables. The reason for craving, 63% of
respondents said, was for satisfaction, while 27% said it was to prevent nausea and
vomiting. Food cravings may have a positive or negative influence on nutritional status
depending on the nutritional quality of the foods (Belzer et al., 2010). Majority of the
respondents (90%) reported they avoided some nutritious foods, such as meat, fish,
eggs, milk and fruit, which are essential in blood production. Some of the reasons for
the avoidance, for example due to aroma (48.6%) and poor appetite (22%), were all due
to certain physiological changes taking place due to hormonal imbalances in the
respondents. Ninety two percent (92%) of respondents said they took diets containing
substances called inhibitors such as phytates and polyphenols that bind the iron and
prevent easy absorption. A good number of respondents (94%) either took these
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substances that contain the inhibitors either once a day or twice a day and this might
have contributed to the Hb levels of the respondents.
From the findings of the study, the pregnant women were consuming mostly foods rich
in non-haem iron. Absorption of non-haem iron obtained from plant sources like millet,
maize, beans, groundnuts, may be as low as 5% (Mahan et al., 2012). A plant-based diet
which has little animal foods is said to be of low bioavailability (GHS Report, 2004).
The cultural and dietary practices of the pregnant women were apparently in favour of
the consumption of foods rich in non-haem iron. Clearly a close link may be said to
exist between prevalence of anaemia among the pregnant women and their dietary
characteristics. The pregnant women were not obtaining enough iron and other essential
nutrients through their food intake to meet their increased demand in physiological
requirements hence leading to the anaemia prevalence 47% among them.
Blood loss as a precipitant of anaemia was insignificant in the present study as only 7 of
the respondents had some form of injuries resulting in heavy bleeding. Majority of the
respondents (98%) attended their antenatal clinic regular and 95% took their routine
drugs daily as prescribed by the health care professionals.
Twenty eight percent (28%) of the respondents had malaria in any of the trimesters.
This was not surprising because the respondents live in a malaria endemic area. In
addition, most of the pregnant women (75%) did not take their SP medication.
All the respondents with worm infestation were anaemic. It is likely they had
hookworms. According to Latham (1997), one of the most prevalent and important
causes of blood loss is hookworm which can be present in very large numbers. The
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worms suck blood and also damage the intestinal walls, causing blood leakage. Ten
percent (10%) of the respondents were sickling positive but this was insignificant, and
therefore could not be attributed to be the underlying factor for the anaemia status of the
respondents.
The anaemia rate increased as the trimester increased. This could be because nutritional
requirements increase as the pregnancy progresses from the first trimester to the third
trimester. Due dietary problems like heartburn and bloating, which is common among
30-50% of pregnant women, they might have intentionally restricted or reduced their
food intake especially in the third trimester when most nutrients requirements are
needed in the highest amounts for the growing foetus (Webster-Gandy et al., 2012).
Seventy five percent (75%) of respondents did not meet their energy requirement. It is
therefore most likely that the energy needed for free iron to be converted to ferritin was
not available and hence this might have led to the low Hb level in the respondents
(Mahan et al., 2012). Additional energy is required during pregnancy to support the
metabolic demands of pregnancy and foetal growth. Metabolism increases by 15% in
the singleton pregnancy (Institute of Medicine, Food and Nutrition Board, 2001).
Protein is necessary for the conversion of free iron into ferritin, which is required for red
blood cells production (Mahan et al, 2012). Findings from the study indicated that
majority of respondents did not meet their RDA which could have therefore led to 78%
of the subjects being anaemic. Protein is essential for the proper production of Hb and
red blood cell production (Latham, 1997). A diet lacking in protein is usually deficient
in iron, folic acid and less frequently vitamin B12 (Mahan et al, 2012). There is an
additional protein requirement for pregnancy to support the synthesis of maternal and
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foetal tissues, but the magnitude of this increase is uncertain. Protein requirement
increases throughout gestation and is maximized during the third trimester (Goodnight
& Newman, 2009).
The majority (81.7%) of the pregnant women avoided animal protein sources of food,
which are of high biological value for pregnant women to support the synthesis of
maternal and foetal tissues. This finding agrees with Andersen et al. (2008) which
concluded that the diet of women before pregnancy was different from that during
pregnancy in terms of quality, quantity and the frequency of consuming food groups.
Protein deficiency during pregnancy has adverse consequences. Limited intakes of
protein and energy usually occur together, making it difficult to separate the effects of
energy deficiency from protein deficiency (Mahan et al., 2012). The RDA for most
nutrients was not met by the respondents. The high intakes of vitamin C was
encouraging. Since the majority of the respondents’ staple foods were cereals, which
contain non-haem iron, it will help make the iron bioavailable for absorption. There is
the need to educate all pregnant women planning to get pregnant to start folic acid
supplementation two (2) months prior to pregnancy to prevent neural tube defects
(GHS, 2004).
Foods consumed by the respondents were based on the locally available staple food
groups such as starchy roots and plantain, cereals and grains, animal products, legumes,
nuts and oil seeds, fruits and vegetables, and finally fats and oils. The common daily
consumed foods by respondents from this group were yam (14%), cassava (13%) and
cocoyam (1%). These food items were cooked and eaten with stew or were eaten in the
form of “fufu” (a popular Ghanaian dish) prepared by pounding cooked cassava,
cocoyam or yam. This was eaten with soup, depending on the individual’s choice.
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These foods produced energy needed for the increased basal metabolic rate, for the
greater energy cost of physical activity and for the normal accumulation of fat as energy
reserve during pregnancy.
Majority of the respondents main staples were locally available staple food groups. The
daily consumption were maize (77%), rice (70%) and bread (70%). The maize was
usually fermented and milled into or dough which was used to prepare any of the local
Ghanaian dishes, e.g. “tuoozaafi, kokoo, banku, akpele and kenkey”. The fermentation
of the maize was a good practice because researches have shown that the fermentation
helps make certain micronutrients such as non-haem iron in the cereals bioavailable to
the body. Rice was either cooked and eaten with stew or moulded into rice balls and
eaten with groundnut or palm nut soup, which was also a good practice for the pregnant
women. According to GHS (2004), that the absorption of certain micronutrients such as
iron may be affected by inhibitors like phytate and polyphenols which are mostly found
in cereals and grains. The polyphenols and the phytate can be reduced depending on the
preparation of the food, and the micronutrients absorption can also be enhanced
depending on the combination of the diet eaten, e.g. with a vitamin C source food.
Over half (51%) of the respondents consumed fish daily which was good for the
pregnant women because fish contains omega-3-fatty acids which are good for the
development of brain cells of the foetus (Mahan et al., 2012). This consumption pattern
agrees with the locally available foods within the area. The frequent consumption of fish
was encouraging.
Majority (46%) of the respondents consumed groundnuts on daily basis. This was either
in the form of soup, stew or roasted in combination with a cereal or starchy root food
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item, e.g. plantain. This was a good practice because it was a cheaper source of protein
and other micronutrients in that part of Ghana. While agushie (melon seed) 40% and
beans (28%) were also consumed daily which was also encouraging, there needs to be
improved. There is thus the need for health professionals to educate the pregnant
women on the need to plan meals that will be adequate and well balanced to meet their
nutritional needs.
Fruits were consumed occasionally: orange (27%), banana (20%), pawpaw (11%),
mango (10%) and watermelon (6%). It was surprising to realize that only a relatively
few number of respondents were consuming watermelon because it was the most
commonly grown fruit in the area. The other fruits were mostly transported from other
parts of Ghana to the area, and this might have possibly led them having being more
expensive thereby making it impossible for the respondents to purchase and consume
them on a daily basis. The low level of consumption of foods from this group with high
consumption of plant sources of iron might have been the reason why majority of the
respondents had their Hb lower than 11g/dl according to GHS report (2004). This is
because nutrients needed to increase the absorption of non-haem iron were not usually
consumed on a daily basis. Low fruits and vegetables intake have been reported to be
the main contributor to micronutrient deficiencies in the developing world, especially in
populations with low intakes of nutrient dense animal source foods such as meat and
meat products (FAO, WHO, 2004).
Majority of the respondents consumed vegetables like pepper (95%), tomatoes (93%),
green leaves (83%) and okro /garden eggs (77%) on a daily basis, which was a good
practice. This was expected since these are basic ingredients in most Ghanaian soups,
stews and sauces. Most of the vegetables consumed were a good source of folate,
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vitamin A, vitamin C, and iron, which are needed for tissue growth, prevent anaemia,
and also prevent neural tube defects.
Fats and oils such as coconut oil (17%), palm oil (16%) and margarine (6%) were
consumed by the pregnant women. The low fat and oils intake was not a problem if the
energy requirements can be obtained from other macronutrients. The essential fatty
acids can usually be met by one to two portions of fish per week (Simpson et al., 2010).
With over 50% of the respondents consuming fish on a daily basis, there was a high
possibility of a majority of respondents meeting their recommended daily allowances.
Majority (74%) of the respondents consumed sugar on a daily basis. The high sugar
consumption may be due to majority of the respondents eaten a locally prepared
fermented cooked maize porridge (koko) as their breakfast. Sugar was mostly added to
improve upon the taste to enable them consume it. The study area is dominated by
Islamic practice therefore majority (99%) of the respondent did not consume any form
of alcoholic beverage. This is something that they needed to be recommended for to
keep since in order to promote a good healthy lifestyle.
The study confirmed that respondents who did not meet the essential nutrients intake,
zinc (79%), iron (68%), folate (99%), vitamin B12 (95%), and protein (78%), were at a
higher risk of becoming anaemic than those who met their RDA of these nutrients.
A nominal logistic regression analysis showed insignificant effects of educational level,
monthly income of less than GHC300, monthly income of spouse, number of times
respondents eat and ages below twenty (20) and above twenty five (25) years of
respondents on anaemia. However, it showed significant association (p=0.031) of
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respondents professional with anaemia. It has also indicated that respondents spouse
professional had significant association (p=0.000) with anaemia. The study also a
significant association of income levels of GHC300 and above (p=0.020) and ages
between 20-24 years (p=0.001) of respondents with anaemia.
In conducting the study the following challenges were encounted:
i. Esha F-pro software used could not analyse certain local foods, hence similar
foods were chosen to replace these food items.
ii. Due to limited finances a larger sample size could not be used and moreover
some respondents expected a reward after an interview was granted.
iii. Under estimation and overestimation of meals might have occurred in the 24-
hour food recall.
5.2 CONCLUSIONS
Forty seven percent (47%) of the respondents were anaemic (Hb less than 11g/dl). The
anaemia rate increased as the trimester increased. With the exception of vitamin C, the
majority of the respondents did not meet the mean percentage of the RDA for energy,
protein, fibre, vitamin B12, folate, vitamin E, calcium, copper, iron and zinc. In all, 95%
of respondents who did not meet the RDA were anaemic whilst only 5% who met the
RDA were anaemic. Thus the pregnant women were not able to obtain essential
nutrients through their food intake to meet the increased demand in the physiological
requirements, hence the high prevalence of anaemia among them.
There was a significant association between anaemia and a respondents’ profession
(p=0.031), spouses’ profession (p=0.000), income levels of GHC300 and above
(p=0.020) and ages between 20-24 years (p=0.001).
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Based on the findings, the following recommendations have been made:
1. Girl-child education should be encouraged and promoted by the Ministry of
Education and non-governmental organizations (NGOs), since an educated
professional woman is in a better position to understand and take responsibility
of her nutrition and health status.
2. The Ministry of Health and Ghana Health Service should make nutrition health
professionals available to every health facility in Ghana so that nutritional
education for pregnant women will be intensified especially at the ante-natal
clinics.
3. The possibility of food fortifications by food industries should be encouraged by
the Government of Ghana and food based strategies for reducing anaemia should
be explored and developed by Ministry of Health and Ministry of Food and
Agriculture.
4. Further researches should be done by NGOs and food research institutions in
Ghana to evaluate the various Ghanaian local food sources rich in micronutrients
to improve maternal nutrition. It is also important for similar studies be carried
out across the entire country to confirm the present study.
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APPENDIXES
Appendix I
CONSENT FORM
This study is investigating possible causes of nutritional anaemia among pregnant
women. If I volunteer to take part in this study, I will be asked to answer questions
about my dietary practices, how often I de-worm before pregnancy and I will also be
asked to provide some personal information.
“POSSIBLE CAUSES OF NUTRITIONAL ANAEMIA AMONG PREGNANT
WOMEN IN TAMALE, GHANA”
I, ………………………………………………………………………….., agree to
participate in this study being conducted by CHARLES JAWEEN from the Dietetics
Department, of School of Allied Health Sciences, College of Health Sciences,
University of Ghana under the supervision of Dr. Charles Brown and Dr. Matilda
Asante of Ghana, Legon- Accra. I understand that my participation is voluntary.
The main focus of this proposed study is to assess the possible causes of nutritional
anaemia among pregnant women in Tamale Metropolis, Ghana. If I volunteer to take
part in this study, I will be asked to answer questions about my food intake, dietary
practices and also provide some information about myself. All these will be kept
confidential.
I will also be asked to provide 3ml of blood sample (half teaspoonful) for some
laboratory tests. A qualified health professional will take the blood sample. There is a
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small risk of minor discomfort resulting from the blood being taken from a vein on my
arm. All medical and personal information will not be disclosed to any individual or
organization without my consent. Blood samples will be coded and only investigators
will hold the key to linking addresses of participants. The principal investigator will be
available to answer any further questions about the research, now or during the course
of the project.
I agree that the research project named above has been explained to my satisfaction and
I agree to take part in the study. I understand that I am agreeing by my signature
/thumbprint on this form to take part in this research project and understand that I will
receive a signed copy of this consent form for my records.
Name of Investigator: CHARLES JAWEEN…………………….Signature
Tel No 0233668841
Date………………………………………………….............................
Name of participant………………………………………………………
Signature/Thumbprint……………………………………..........................
Date………………………….....................................................................
Mobile No……………………………………………………………….....
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Appendix II
QUESTIONNAIRE
UNIVERSITY OF GHANA SCHOOL OF ALLIED HEALTH SCIENCES
QUESTIONNAIRE
POSSIBLE CAUSES OF NUTRITONAL ANAEMIA AMONG PREGNANT
WOMEN IN TAMALE METROPOLIS, GHANA
Date_____/ _____ /2013   Location:
_____________________________________No__
Trimester of respondent [1] First =1-12wks [2] Second =13-24wks [3] Third=25-
40wks
SECTION A: FOOD HABITS
1. Do you practice any form of pica?  [ 1 ] Yes [ 2 ] No
2. If yes, what do you eat?
[1] Chewing stick/wooden sponge     [3] chalk    [5] cola nuts
[2] Uncooked maize dough/starch      [4] clay]    [6] others
3. What stage of your pregnancy did you start this practice?
[1] 1-3 months   [2] 4-6 months             [3] 7-9 months   [4] not sure
4. Why do you practice pica?
[1] To prevent nausea     [2] to prevent vomiting   [3] for satisfaction
[4] To prevent salivation   [5] others, specify ----------------
5. Do you crave for any food? [ 1 ] Yes        [ 2 ] No
6. If yes, what do you crave for?
[1]  chocolate       [ 2 ] toffees/ candies      [ 3 ] ice cream    [ 4 ] fizzy beverages
[ 5 ] alcoholic beverages            [ 6 ] others ----------------------------------
7. What stage of your pregnancy did you start craving?
[ 1] 1-3 months     [ 2 ] 4-6 months        [ 3 ] 7-9 months   [4] not sure
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8. Why do you crave?
[ 1] to prevent nausea/vomiting        [ 2 ] for satisfaction    [ 3 ] Don’t know  why
[ 4 ] others -----------------------
9. Do you avoid taken any food?  [ 1 ] Yes   [ 2 ] No
10. If yes, what food do you avoid?
[ 1 ] meat/fish   [ 2 ] eggs      [ 3 ] milk    [ 4 ] fruits [ 5 ] others ----------------------
11. At what time of the pregnancy did you avoid these foods?
[ 1 ] 1-2wks  [ 2 ] 13-24wks      [ 3 ] 25-40 wks
12. Why do you avoid these foods?
[ 1] taste of food     [ 2 ]poor appetite   [ 3 ] Don’t know why   [ 4 ] smell/aroma
others---------------
13. Please do you take any alcoholic beverage?   [ 1 ] Yes      [ 2 ] No
14. When did you start it?  [ 1 ] before pregnancy   [ 2 ] during pregnancy
15. What type of alcoholic beverage do you take?
[ 1 ] pito   [ 2 ] beer/guiness   [ 3 ] locally distilled alcohol     [4]
others……………………………………
16. How often do you take?    [ 1 ] once a day  [ 2 ] twice a day    [ 3 ] weekly
[ 4] monthly     [ 5 ] others……………………………………………………….
17. Quantity
[ 1] 300ml beer bottle or tumble        [ 2 ] large beer bottle…….  [ 3 ] one calabash   [ 4]
a tot              others............................................
18. Do you take tea and coffee?   [ 1 ] Yes       [ 2 ] No
19. If yes, how often do you take it?   [ 1 ] once a day [ 2 ] twice a day   [ 3] weekly
[ 4] monthly    [ 5 ] sometimes    [ 6 ] not at all
20. Do you take some food supplements or any herbal preparation   [ 1 ] Yes  [ 2 ] No
21.If yes which of  these   [ 1 ] folic acid    [ 2 ] iron    [ 3 ] multivitamin    [ 4 ] herbal..
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SECTION B: PRECIPITANTS OF ANAEMIA
22. Have you experienced blood loss from the body in the past  2  months ?  [ 1 ] Yes   [
2 ] No
23. If yes, which of these [ 1 ] injuries that result in heavy bleeding [ 2 ] blood
loss in urine   [ 3] blood loss in stool      [ 4 ] coughing out blood           [ 5 ] vomiting
out blood      [ 6 ] others ( specify )…………………………….
24. Do you attend ANC regularly?     [1] Yes      [ 2 ] No
25. If yes how often?   [1] monthly      [ 2 ] every 3 months [ 3 ] not at all
[  ] others  ( specify) ……………………………………………………………..
26. Do you take your routine ANC drugs?    [ 1 ] Yes       [ 2 ] No
27. If yes indicate      [ 1] iron supplements    [ 2 ] folic acid     [ 3 ] multivitamins      [4
] SP [ 5 ] others (specify}……………………………………….
You may choose more than one.
28. Have you had malaria recently?   Yes [ ]   no [  ]
If yes how often do you  get  malaria
[1]   once a month   [ 2] twice a month    [ 3 ] thrice a month        [ 4 ] not at all
28. How often were you de-worming before pregnancy ?     [ 1 ] every 3 months
[ 2 ] every 6 months     [ 3 ] not at all           [ 4 ] others ( specify)……………….
29.  Results of laboratory investigations of the client?
[ 1 ] Hb level……………..  [ 2] sickling test………………… [ 3 ] BF for MPs
[ 4 ] urine RE……………[ 5] stool
RE……………………………………………
30. If sickling positive then, Hb – electrophoresis…………………………
SECTION C: Socio-Demographic characteristics
31. Age………………( Yrs}
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32. Educational background
[ 1 ] Never attended school    [ 2 ] Elementary/ Junior High School
[ 3 ] Senior  High School       [ 4 ] Tertiary   [ 5 ] others ( specify)
33. Occupation of client:  [ 1 ] professional    [ 2 ] trading    [ 3 ] vocational
[4] jobless [ 5 ] others (specify)............................................s
34.Position............................................................................................................
35. Spouse occupation: [ 1] professional   [ 2 ] trading  [ 3 ] vocational  [ 4 ] jobless
36. Position....................................................................................
37. Monthly income of participant ( GH CEDI)
[ 1 ] Less than 50     [ 2 ] between 50-100     [ 3 ] between 100-300
[ 4 ] between 300- 500   [ 5 ] between 500-1000   [ 6 ] above 1000
38. Monthly income of spouse (GH CEDI)
[ 1] Less than 50     [ 2 ] between 50-100    [ 3 ] between 100-300
[ 4] between 300-500    [ 5 ] between 500- 1000      [ 6 ] above 1000.
SECTION C: FOOD INTAKE (THREE 24-HOUR RECALL)
39. Please how many times do you eat in a day before pregnancy excluding snack?
[1] Two times [2] Three times [3] Four to five [4] More than five
times
40. Has it changed since you became pregnant? [Yes] [2] No
41. If Yes How many times now?
[1] Two time [2] three times [3] Four to five times [4] More than five times
[5] Find it difficult eating
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Appendix III
24 –HOUR RECALL
WEEK DAY 1
Menu Food Handy Measure Weight (g)
BREAKFAST 1.
2.
3.
4.
SNACK 1.
2.
3.
LUNCH 1.
2.
3.
4.
SNACK 1.
2.
3.
SUPPER 1.
2.
3.
4.
SNACK 1.
2.
3.
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Appendix IV
FOOD FREQUENCY QUESTIONNAIRE (FFQ) WEEKLY CONSUMPTION
Food Groups Not often 1-2x 3-4x 5-6x Daily
Starchy roots and plantains
Cassava
Cocoyam
Yam
Cereals and grains
Maize
Rice
Bread
Animal Products
Fish
Meat
Poultry
Egg
Milk
Crab
Legumes, nuts and oilseeds
Beans
Groundnut
Bambara
Agushie (melon seed)
Fruits
Orange
Mangoes
Pawpaw
Banana
Watermelon
Vegetables
Tomatoes
Pepper
Garden eggs
Okro
Green leaves
Fat and oils
Palm  oil
Refined vegetable oil eg coconut
oil
Margarine
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FOOD HIGH IN REFINED SUGAR Number of times per week Not applicable
Coca cola
Biscuits
Cakes
Sprite
Fanta
Sugar
Don simon/ ceres/ minute maid etc
Malt
Others
ALCOHOLIC BEVERAGES
Beer
Guinness
Spirit
Wine
Punch
Others
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INTERVENTIONS GIVEN
1 Daily calorie
2 Type of diet given
3 Advice on alcohol
4 Advice on smoking
5 Advice on physical
activity
6 Advice on fruits and
vegetables
7 Advice on timing of
meals
a. Morning
b. Afternoon
c. Evening
d. Snack 1
e. Snack 2
f. Others
Total number of
meals in a day
8 Total number of snacks
in a day
9
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Health Education for pregnant women:
Some fruits inhibit the absorption of iron although they are rich in ascorbic acid
because of their high phenol content e.g strawberry , banana and melon.
Food fermentation aids iron absorption by reducing the phytate content of diet
Foods containing ascorbic acid like citrus fruits, broccoli & other dark green
vegetables enhances iron absorption because ascorbic acid reduces iron from
ferric to ferrous forms, which increases its absorption.
Foods containing muscle protein enhance iron absorption due to the effect of
cysteine containing peptides released from partially digested meat, which
reduces ferric to ferrous salts and form soluble iron complexes.
Food with polyphenol compounds which may inhibit iron absorption include:
Cereals like sorghum & oats
Vegetables such as spinach and spices
Beverages like tea, coffee, cocoa and wine.
A single cup of tea taken with meal reduces iron absorption by up to 11%.
Food containing phytic acid i.e. Bran, cereals like wheat, rice, maize & barely.
Legumes like soya beans,  black beans & peas.
Cow’s milk due to its high calcium & casein contents.
The dietary phenols & phytic acids  are:  compounds which bind to iron
decreasing  free iron in the gut & forming complexes that are not absorbed.
Cereal milling to remove bran reduces its phytic acid content by 50%.
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APPENDIX V:
ETHICAL CLEARANCE
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