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Public Health Nutrition: page 1 of 8 doi:10.1017/S1368980008003765
Impact of targeted food supplementation on pregnancy weight
gain and birth weight in rural Bangladesh: an assessment of
the Bangladesh Integrated Nutrition Program (BINP)
Shamsun Nahar†, CG Nicholas Mascie-Taylor* and Housne Ara Begum‡
Department of Biological Anthropology, University of Cambridge, Pembroke Street, Cambridge CB2 3RA, UK
Submitted 29 May 2007: Accepted 18 August 2008
Abstract
Objectives: To assess whether the Bangladesh Integrated Nutrition Programme
(BINP) correctly identified which pregnant women should be enrolled in the food
supplementation programme, whether supplementation commenced on time
and was taken on a regular basis. A second objective was to determine whether
food supplementation led to enhanced pregnancy weight gain and reduction in
the prevalence of low birth weight.
Design: A one-year community-based longitudinal study.
Setting: A rural union of Bhaluka Upazila, Mymensingh, located 110 km north-
west of Dhaka City, the capital of Bangladesh.
Participants: A total of 1104 normotensive, non-smoking pregnant women who
attended Community Nutrition Centres were studied from first presentation at the
centre until child delivery.
Results: Pregnant women who had a BMI of ,18?5kg/m
2
on first presentation
should have been selected for supplementary feeding (2512 kJ (600 kcal)/d for six
days per week) starting at month 4 (16 weeks) of pregnancy. However, of the 526
women who had BMI ,18?5kg/m
2
, only 335 received supplementation; so the
failure rate was 36?3 %. In addition, of those receiving supplementation, only 193
women (36?7 % of 526 women) commenced supplementation at the correct time, of
whom thirty-two (9?6 % of 335 women) received supplementation for the correct
number of days (100% days). There were no significant differences in mean weight
gain between BMI ,18?5 kg/m
2
supplemented or non-supplemented groups or
between the equivalent groups with BMI $18?5kg/m
2
. Weight gain was inversely
related to initial weight, so lighter women gained relatively more weight during
their pregnancy than heavier women. The mean birth weight in the supple-
mented and non-supplemented groups was 2?63 kg and 2?72 kg, respectively.
Mothers with BMI ,18?5 kg/m
2
who were or were not supplemented had almost
equal percentages of low-birth-weight babies (21 % and 22 %, respectively).
Conclusion: The study raises doubt about the efficiency of the BINP to correctly
target food supplementation to pregnant women. It also shows that food sup-
plementation does not lead to enhanced pregnancy weight gain nor does it
provide any evidence of a reduction in prevalence of low birth weight.
Keywords
Pregnancy weight gain
Food supplementation
Low birth weight
Intra-uterine growth and development is one of the most
vulnerable periods in the human life cycle. The weight of
an infant at birth is an important indicator of maternal
health and nutrition prior to, and during, pregnancy, and
a powerful predictor of infant growth and survival
(1)
.
Approximately 25 million babies are born each year
weighing less than 2500 g, the WHO cut-off for low birth
weight (LBW), of which 90 % are born in developing
countries
(2)
. Bangladesh is one such country, where 50 %
of childbearing women are suffering from malnutrition
defined by BMI ,18?5 kg/m
2
and more than 20 % are
severely stunted
(3)
. Bangladesh has the highest world-
wide prevalence of LBW with rates estimated at between
20 % and 60 %
(4,5)
.
The high prevalence of LBW in Bangladesh has enormous
implications for its future population. The World Bank
estimates that the rate of 40 % LBW and the corresponding
SPublic Health Nutrition
yCurrent address: National Institute of Preventive and Social Medicine,
Dhaka, Bangladesh.
zCurrent address: Institute of Health Economics, University of Dhaka,
Dhaka, Bangladesh.
*Corresponding author: Email nmt1@cam.ac.uk rThe Authors 2008
level of stunting alone will cost Bangladesh $US 10 billion in
lost productivity over a 10-year period
(6)
. The Government
of Bangladesh, with financial support from The World Bank,
initiated a supplementation programme known as the
Bangladesh Integrated Nutrition Programme (BINP) in 1995
with the aim of increasing weight gain in pregnancy up to
7 kg in 50 % of pregnant women and reducing LBW by half
from its then-current rate.
The BINP was implemented in forty out of a total of 460
thanas (administrative areas) in the country. The aim of the
programme was to reduce malnutrition, particularly among
women and children, by ensuring household food security
and through behavioural changes related to food intake,
infant feeding, growth monitoring and caring practice. All
children below 2 years of age were targeted for monthly
growth monitoring and for determination of nutritional
status. Pregnant women were also identified primarily
within the first trimester for regular monthly weighing. All
severely malnourished children or growth-faltering children
as well as malnourished pregnant mothers (defined by
BMI ,18?5kg/m
2
) received daily supplementary feeding
for six days per week. The malnourished pregnant women
received a ration of 2512 kJ (600 kcal)/d for six days per
week for up to 6 months during pregnancy and weekly Fe
supplementation and vitamin A within 14 d of delivery
(7)
.
The services were provided through Community Nutrition
Centres (CNC) located in villages.
The BINP Mid Term Evaluation
(8)
reported that, since
its inception, the programme has had notable success in
reducing the prevalence of malnutrition among young
children. Its effect on pregnant women, a second key
target group, has however been less clear to date. The
present study was designed to evaluate two main aspects
of the BINP: (i) the efficiency of the BINP in identifying
which women should be supplemented, whether sup-
plementation commenced on time and whether mothers
were compliant; and (ii) whether supplementation led to
greater maternal weight gain and fetal weight gain,
thereby reducing LBW prevalence.
Participants and methods
A one-year, longitudinal, rural community-based study
was conducted on all pregnant women who registered
between their second and sixth month of gestation as part
of the routine BINP assessment. The data were collected
from a rural union of Bhaluka Thana, Mymensingh,
located 110 km north-west of Dhaka City, the capital of
Bangladesh. A total of 1104 pregnant women were stu-
died from first presentation until child delivery. At first
registration women were weighed and had their height
measured. Thereafter weight was measured at approxi-
mately monthly intervals until delivery.
Pregnant women who have BMI ,18?5 kg/m
2
on first
presentation should receive supplementary feeding
starting at 4 months (16 weeks). Women who register
later in pregnancy with BMI ,18?5 kg/m
2
should start
supplementation immediately. The 2512 kJ (600 kcal)/d
food supplement consisted primarily of a cereal–pulse
mixture containing raw sugar (jaggery) and oil, which
comprises 80 % carbohydrate, 12 % protein and 8 % fat.
The food was prepared at the village level. Pregnant
mothers had to consume the supplement at a local CNC.
All anthropometric measurements were carried out using
standard methodology as described by Lohman et al.
(9)
.
Themeasurementsweremadewiththesubjectswearinga
minimum amount of clothing. Height was measured by
using a locally made stadiometer. The woman was asked to
maintain an upright and erect posture with her feet together
and the back of her heels touching the pole of the
anthropometer. The horizontal headpiece was lowered
onto the woman’s head (maintained in the Frankfurt plane)
and the measurement was taken to the nearest 0?1cm.The
UNICEF UNI-Scale was used to measure the weight of the
pregnant women and newborn babies. Newborn babies
were weighed within 24 h of delivery at the birth place.
The weighing machine was calibrated with known weights
up to 70kg at the beginning of each weighing session. The
women’s BMI was calculated using the formula: weight
(kg)/[height (m)]
2
.
The inter-observer error for height and weight were com-
puted at four different times during the study: before starting
the study, at months 5 and 9, and at the end of the study.
Ten subjects were used each time and the technical error of
measurement (TEM) and reliability were determined. The
TEM was obtained by measuring the same subject by each
research assistant. Reliabilities for all measurements were all
above 0?98 and higher than the 0?95 threshold given by
Ulijaszek and Kerr
(10)
. Thus the TEM was acceptable and
was not incorporated in the statistical analysis.
One of the problems with longitudinal data is that, in
order to examine incremental weight changes over time, the
numbers of days between visits need to be very similar.
Although this is potentially achievable in strictly research
projects, in operational programmes this is much less likely
to occur. Brush et al.
(11)
overcame the monthly variation in
days between measurements by computing the curvilinear
relationship between the anthropometric variable, e.g.
weight, and the actual days between measurements. As the
polynomial fits (adjusted R
2
)wereverygood,theycalcu-
lated the weight at fixed intervals. The same procedure was
used here because the ‘monthly’ variation between mea-
surements was between 22 and 35 d. Consequently an
individual polynomial regression curve was computed for
each woman, and like Brush et al. we found that the fit was
very good, with adjusted R
2
ranging from over 95 % to
nearly 100 %. As a result, the predicted weight at 28 d
intervals was computed and these predicted weights were
used in all subsequent analyses.
Gestational age was assessed by the Parkin method
(12)
,
which scores four external characteristics: skin colour,
SPublic Health Nutrition
2 S Nahar et al.
skin texture, ear firmness and breast development. The
scheme is simple, easy to use, less time-consuming and
appropriate for field workers.
A power test showed that these sample sizes were
sufficient to detect about a 10 % difference in the per-
centage of supplemented and non-supplemented women
gaining .1 kg per month during pregnancy or gaining
.7 kg at the end of pregnancy. A variety of statistical tests
was used, including univariate ANOVA and repeated-
measures ANOVA.
Results
BINP programmatic issues
Four indicators were used to measure the efficacy of the
BINP supplementation programme: (i) receiving supple-
mentation if BMI ,18?5 kg/m
2
; (ii) commencing supple-
mentation at the correct time; (iii) receiving daily
supplementation six days a week until the birth of the
child; and (iv) achieving targeted weight gain set by BINP
of .1 kg per month or .7 kg at the end of pregnancy.
As the women registered in different months the
amount of time they received supplementation varied. In
order to make comparisons, the extent of supplementa-
tion was computed (the number of days a women
received supplementation/the total number of possible
days of supplementation). The mean percentage com-
pliance was 91?0(
SD 9?9) % (range 54–100 %).
Table 1 presents a breakdown of supplementation
status by BMI cut-off. As can be seen, of the 526 women
with BMI ,18?5 kg/m
2
only 63?7 % were supplemented
while 4 % of women with BMI $18?5 kg/m
2
were incor-
rectly supplemented. Even so, of the 63?7 % who received
supplementation, only 193 (36?7 % of 526 women) com-
menced supplementation at the correct time, of whom
thirty-two women (9?6 % of 335 women) received the full
supplementation. Women with BMI ,18?5 kg/m
2
who
registered in months 3 and 4 were more likely to receive
supplementation than those registering later.
Sociodemographic and nutritional status of the
pregnant women at registration and outcome of
pregnancy
The primarily Muslim pregnant women and their families
living in this rural area of Bangladesh were mainly poor
with three-quarters of families spending £10–20/month,
mostly on food. About 20–25 % of husbands and wives
had received no education and the majority of husbands
were working as either day labourers or farmers. Most of
the pregnant mothers were between 20 and 34 years of
age. Over one-third of the women were nulliparous while
12?8 % were multiparous ($4 births). Most (93 %) mothers
registered between the third and fifth month of preg-
nancy and only 7 % registered in the sixth month. The
average birth interval, based on the last child, was about
2?5 years. About 47 % of women had BMI ,18?5 kg/m
2
on first registration, of whom 6 % were in the chronic
energy deficiency group (CED) III (BMI ,16?0 kg/m
2
),
11 % in CED II (BMI 516?0–16?9 kg/m
2
) and 30 % in
CED I (BMI 517?0–18?5 kg/m
2
). There were no sig-
nificant associations between BMI status and any of these
sociodemographic variables. Women with BMI ,18?5 kg/
m
2
had significantly (P,0?001) lower mean weight (on
average 6?8 kg), but their height was just significantly
greater (11?1 cm) than that of women with BMI $18?5
kg/m
2
. There was no significant difference between the
supplemented and non-supplemented groups with
BMI ,18?5 kg/m
2
in initial weight or stature nor was
there any difference between the two groups in weight
gain during pregnancy or birth outcome.
About 97 % of the 1104 deliveries occurred at home, of
which 95 % were live born, 3?3 % stillborn and 1?5 % were
perinatal deaths. Of the newborn babies 50?6 % were
male. No significant association was found between any
of the sociodemographic variables and birth outcome and
supplementation status.
Weight gain during pregnancy by BMI and
supplementation status groups
The existence of the four groups of women (see Table 1)
allowed more detailed comparisons between women
with BMI ,18?5 kg/m
2
and either correctly supplemented
(,18?5 sf) or incorrectly not supplemented (,18?5 nsf),
as well as between women with BMI $18?5 kg/m
2
cor-
rectly not supplemented ($18?5 nsf) and those incorrectly
supplemented ($18?5 sf). Table 2 presents the overall
mean weight gain of these four groups by month of
registration. As expected, the weight gain declined with
later registration month and was consistent across all four
BMI/supplementation status groups. ANOVA revealed
that only for mothers who registered in month 3 were
there significant differences between the four means, with
women with BMI ,18?5 kg/m
2
showing higher mean
SPublic Health Nutrition
Table 1 BMI cut-offs and supplementation status: rural, non-smoking, pregnant women enrolled in the Bangladesh
Integrated Nutrition Programme, studied from first presentation at the community nutrition centre until child delivery
BMI ,18?5 kg/m
2
BMI $18?5 kg/m
2
Total
Supplementation status n%n%n%
Yes 335 30?3232?1 358 32?4
No 191 17?3 555 50?3 746 67?6
Total 526 47?6 578 52?4 1104 100?0
Impact of targeted food supplementation during pregnancy in rural Bangladesh 3
weight gains than women with BMI $18?5kg/m
2
whether
supplemented or not. Post hoc tests showed that the
overall difference in means was mainly accounted for by
the greater weight gain of women in the BMI ,18?5kg/m
2
andsupplementedgroupcomparedwithwomeninthe
BMI $18.5 kg/m
2
and non-supplemented group (P50?002).
There were no significant differences in mean weight gain
between supplemented and non-supplemented women
with BMI ,18?5 kg/m
2
or between the equivalent groups
with BMI $18?5 kg/m
2
. After correction for initial weight,
the difference in weight gain between BMI ,18?5 kg/m
2
supplemented and BMI $18?5 kg/m
2
non-supplemented
groups fell further to only 100 g and was not significant.
The BINP sets weight gain targets of .1 kg per month
and overall weight gain of .7 kg at the end of pregnancy
in 50 % of pregnant women. However, as Table 3 shows,
these women failed to meet these targets especially for
.7 kg weight gain in pregnancy.
Repeated-measures ANOVA were used to examine
the change in monthly weights of the four BMI/supple-
mentation status groups and, as can be seen from Fig. 1,
the mean weights of the four groups tracked each other
and were more or less parallel. Thus there was no evi-
dence of any significant catch-up or catch-down, which
indicates that the food supplement was not impacting on
pregnancy weight gain.
The relationship between initial weight and weight
gain was examined for each registration month separately
and negative regression coefficients were found in all
analyses, i.e. women who had a higher initial weight
tended to show a lower weight gain. The magnitude of
the coefficients declined from registration months 3 to 6
as would be expected (20?41, 20?38, 20?22 and 20?18,
respectively). There were no significant differences in
regression coefficients between supplemented and non-
supplemented women at each registration month.
Birth weight and relationship with
sociodemographic variables and supplementation
status of the mother
The overall mean birth weight of both boys and girls was
2?69 kg (SD 0?36 kg and 0?37 kg, respectively). Analysis of
the birth weight of the newborn babies using the four BMI/
supplementation status groups revealed significant hetero-
geneity in mean birth weights between them (P,0?001).
One-way ANOVA showed that the overall difference in
means was mainly accounted for by the lower birth weight
of the babies whose mothers were in the BMI ,18?5kg/m
2
groups irrespective of supplementation status (Table 4).
SPublic Health Nutrition
Table 2 Total (absolute) weight gain (kg) by registration month according to BMI and supplementation status group: rural, non-smoking,
pregnant women enrolled in the Bangladesh Integrated Nutrition Programme, studied from first presentation at the community nutrition
centre until child delivery
BMI (kg/m
2
) and supplementation status group
,18?5sf ,18?5 nsf $18?5 nsf $18?5sf
Registration month Mean SD Mean SD Mean SD Mean SD FP
36?71 1?66?41 1?66?10 1?76?04 2?14?60 0?003
45?90 1?95?86 1?85?41 1?95?97 1?71?77 NS
54?58 1?64?83 1?54?68 1?54?95 1?41?97 NS
62?80 1?33?45 1?03?42 1?6– –1?06 NS
sf, supplemented; nsf, non-supplemented.
Table 3 Pregnancy weight gain in relation to the programmatic
targets (% of women achieving the target) by BMI and supple-
mentation status group: rural, non-smoking, pregnant women
enrolled in the Bangladesh Integrated Nutrition Programme,
studied from first presentation at the community nutrition centre
until child delivery
BMI (kg/m
2
) and
supplementation status group
Total weight
gain .7kg
Weight gain
.1 kg/month
,18?5sf 35 45
,18?5 nsf 28 39
$18?5 nsf 21 33
$18?5sf 18 45
sf, supplemented; nsf, non-supplemented.
Pregnancy month
9876543
Mean weight (kg)
54
52
50
48
46
44
42
40
38
36
Fig. 1 Monthly weight according to BMI (kg/m
2
) and supple-
mentation status group (- - K--,,18?5 supplemented (sf);
—n—, ,18?5 non-supplemented (nsf); — -&—-,$18?5 nsf;
2 212 2,$18?5 sf) in month 3: rural, non-smoking, pregnant
women enrolled in the Bangladesh Integrated Nutrition
Programme, studied from first presentation at the community
nutrition centre until child delivery
4 S Nahar et al.
However, there was no significant difference in mean birth
weights of babies born to mothers with BMI ,18?5kg/m
2
whether supplemented or non-supplemented, or between
the means of the equivalen t BMI $18?5kg/m
2
supple-
mented and non-supplemented groups.
The pattern of birth weight in the four BMI/supple-
mentation status groups was consistent (insignificant
interaction between sex of the baby and BMI groups,
P50?43). When the analyses were repeated for each sex
separately, the significant heterogeneity remained, more
so in females than males. In both sexes the main differ-
ence was the higher mean in mothers with BMI $18?5
kg/m
2
v. those with BMI ,18?5 kg/m
2
.
Low birth weight, supplementation status and
sociodemographic variables
Overall 17 % of babies were born with LBW (defined by
WHO as ,2?5 kg), and there were almost equal numbers
of LBW male and female (17?0% v.16?3 %) babies.
Gestational age calculated using the Parkin score revealed
that 96?4 % were born after 37 weeks of gestation, and so
intra-uterine growth retardation appears to be the major
contributor to LBW. No significant association was found
between LBW and any of the sociodemographic variables.
Women who had BMI ,18?5 kg/m
2
, irrespective of sup-
plementation status, had a significantly higher rate of
LBW babies than women who had BMI $18?5 kg/m
2
and
were not supplemented (Table 5, P,0?001). A sequential
logistic regression analysis which adjusted for the effect
of BMI (,18?5 and $18?5 kg/m
2
) first of all, and then
tested for the effect of supplementation status, confirmed
the insignificant effect of food supplementation on
birth weight.
In addition, malnourished women gained signifi-
cantly more weight during pregnancy (6?3 kg, 6?2kg
and 5?9 kg, CED grades III, II and I respectively; Table 6)
than non-malnourished women (5?4 kg). When the
birth weight and proportion of LBW in these groups
were compared, malnourished women in all three CED
categories had a lower mean birth weight and a higher
proportion of LBW babies than non-malnourished
women.
SPublic Health Nutrition
Table 4 Birth weight (kg) by sex of the newborn according to BMI and supplementation status group: rural, non-smoking, pregnant women
enrolled in the Bangladesh Integrated Nutrition Programme, studied from first presentation at the community nutrition centre until child
delivery
BMI (kg/m
2
) and supplementation status group
,18?5sf ,18?5 nsf $18?5 nsf $18?5sf
Sex nMean SD nMean SD nMean SD nMean SD FP
Male 174 2?65 0?37 90 2?62 0?37 274 2?74 0?35 11 2?73 0?36 3?65 0?012
Female 136 2?60 0?40 91 2?64 0?35 239 2?77 0?33 12 2?70 0?36 7?33 ,0?001
Total 310 2?62 0?37 181 2?63 0?36 513 2?75 0?34 23 2?71 0?35 10?76 ,0?001
sf, supplemented; nsf, non-supplemented.
Table 5 Birth weight by BMI and supplementation status group: rural, non-smoking, pregnant women enrolled in the
Bangladesh Integrated Nutrition Programme, studied from first presentation at the community nutrition centre until child
delivery
BMI (kg/m
2
) and supplementation Low birth weight Normal birth weight
status group n%n%x
2
P
,18?5sf 65 21?0 245 79?015?76 ,0?001
,18?5 nsf 40 22?1 141 77?9
$18?5 nsf 62 12?1 451 87?9
$18?5sf 4 18?21881?8
sf, supplemented; nsf, non-supplemented.
Table 6 Weight gain, birth weight and percentage of low birth weight (LBW) by level of chronic energy deficiency
(CED): rural, non-smoking, pregnant women enrolled in the Bangladesh Integrated Nutrition Programme, studied from
first presentation at the community nutrition centre until child delivery
Weight gain (kg) Birth weight (kg)
nMean SD Mean SD LBW (%)
CED III (BMI ,16?0 kg/m
2
)596?30 1?80 2?53 0?36 28?8
CED II (BMI 516?0–16?9 kg/m
2
) 119 6?21 1?89 2?61 0?42 19?8
CED I (BMI 517?0–18?4 kg/m
2
) 313 5?91 1?89 2?65 0?36 20?2
Normal (BMI $18?5 kg/m
2
) 535 5?38 1?95 2?75 0?34 12?3
Impact of targeted food supplementation during pregnancy in rural Bangladesh 5
Discussion
The present study, in keeping with a recent World Bank
report
(13)
, highlights serious deficiencies in the imple-
mentation of the BINP in this rural area with over 40 % of
women either not receiving supplementation or receiving
it incorrectly. In addition, of those receiving food sup-
plementation, nearly half started late and only about
one in ten women received the full supplementation. In
the BINP Monthly Monitoring Report
(14)
(June 2000), the
seven non-governmental organizations working for the
BINP had examined 107 845 pregnant women of whom
53 922 had BMI ,18?5 kg/m
2
. If the results of the present
study are extrapolated to the whole BINP, then over
50 000 women would either not have been supplemented
or, if so, would not start supplementation on time or
would not receive the full supplementation.
In this group of rural women, irrespective of supple-
mentation status, the total weight gain was 5?6 kg, which is
higher than the 4?8kgweightgainrecordedbyKrasovec
(15)
for Bangladeshi rural women but lower than values
reported in other south Asian countries (Taiwan, 7?6 kg;
India, 6?5 kg; East Java, 6?0 kg).
A recent study in Bangladesh
(16)
using monitoring data
from the BINP found that the absolute (total) weight gain
and monthly weight gain were higher in supplemented
(BMI ,18?5 kg/m
2
) than non-supplemented women
(7?5kg v.6?3 kg and 1?4kg v.1?3 kg, respectively). How-
ever, the weight gains and the monthly weight gains in
the present study were lower than those observed by
Ortolano et al.
(16)
. This may be because the latter study
(16)
did not take into account when mothers first registered at
the CNC and so its two groups are not strictly comparable.
More crucially, as noted by Kramer
(17)
, the comparison of
these two groups does not indicate success of the pro-
gramme since Ortolano et al.’s study did not control for
women with BMI ,18?5 kg/m
2
and not supplemented or
women with BMI $18?5 kg/m
2
and supplemented. As the
present study has demonstrated, comparison of all four
groups of women was able to show that women with
BMI ,18?5 kg/m
2
whether supplemented or not gained
more weight than women with BMI $18?5 kg/m
2
.
The targets set by the BINP of a weight gain .1kg per
month and .7 kg at the end of pregnancy in 50 % of
womenwerealsousedbyOrtolanoet al.
(16)
to monitor the
success of the BINP. They reported that, overall, 74?9% of
women in the supplemented group gained .1kg per
month and 61?8 % of the women in the non-supplemented
group gained .1 kg per month. They also reported that
69?5 % of the women in the supplemented group gained
.7 kg at the end of pregnancy while 49?0 % of the non-
supplemented group gained .7 kg, a nd was more likely to
be observed in primigravids. The present study, in keeping
with the Monthly Monitoring Report
(14)
, observed much
lower percentages: only 45?0 % of the women in the sup-
plemented group gained .7kg at the end of pregnancy
while in the non-supplemented only 34?7% gained .7kg
at the end of pregnancy in the present study.
The effect of supplementation on pregnancy weight
gain using BMI as an indicator for undernutrition needs to
be interpreted with caution, keeping in mind that pre-
pregnancy BMI or even early-pregnancy BMI is often
inversely associated with gestational weight gain
(18)
,
presumably as a physiological compensatory mechanism
for pre-pregnancy undernutrition. In the present study
weight gain was inversely correlated with BMI and initial
weight. Lighter women gained relatively more weight
during their pregnancy than heavier women, a result in
keeping with other studies in East Java, Indonesia
(19)
,
Pakistan
(20)
and Taipei, Republic of China
(21)
.
The present study showed that supplementation had
an insignificant effect on birth weight and LBW, in
keeping with some studies
(22–27)
, while other studies have
reported a significant impact of supplementation on birth
weight
(12,28–32)
. The most recent food supplementation
trial on undernourished women from the Gambia
(12)
reported considerably larger effects on birth weight. The
present study, however, was unable to show significant
improvement in birth weight and reduction in LBW pre-
valence. The difference may be explained by the much
higher energy (4258 kJ (1017 kcal)) and protein content
(22 g) of the Gambian supplement compared with that
used in Bangladesh (2512 kJ (600 kcal) and 8?0–9?4g,
respectively). The second explanation may be that the
food supplementation in the BINP may be a replacement
not a supplement, which is supported by the findings of
BINP operational research
(33)
that 30 % of the women
substituted at least part of their domestic food intake by
BINP food supplements. A WHO collaborative study
(34)
showed that weight gain of 1?5 kg/month during the last
two trimesters is consistent with good pregnancy out-
comes. However, the average monthly weight gain in the
present study was considerably lower, averaging only
0?92 kg/month in the second and third trimesters.
In his meta-analysis Kramer
(35)
showed no evidence that
supplementation had a larger effect in undernourished
women and concluded that the increment in birth weight
due to supplementation was no larger in those women
who were undernourished prior to or during pregnancy.
Several researchers have argued that the degree of mater-
nal undernutrition may affect the response to supple-
mentation
(20,36,37)
. They suggest that supplementation of
moderately malnourished women produces an increase in
birth weight but has little impact on maternal weight gain.
However, when seriously malnourished women are sup-
plemented they cannot ‘afford’ to direct the energy to the
fetus and therefore such supplementation improves
maternal weight gain more than birth weight. The results
of the present study also show that although malnourished
women gained significantly more weight in pregnancy,
they had a higher proportion of LBW babies compared
with non-malnourished women.
SPublic Health Nutrition
6 S Nahar et al.
In conclusion, the present study found that the food
supplementation programme in Bangladesh is inefficient
in targeting eligible women, failed to start on time and did
not achieve full compliance. Regular monitoring and
supervision of field staff is essential, as is motivating the
community to participate. There was a small but positive
impact of food supplementation on maternal weight gain,
but supplementation did not lead to improvement in
birth weight and there was no indication of a reduction
in prevalence of LBW babies. Further research is needed
to determine the appropriate quality and quantity of food
and micronutrient supplementation needed to reduce
LBW prevalence.
Acknowledgements
Financial support for the study was provided by the
Department for International Development administered
by The British Council and University of Cambridge. We are
very grateful to PROSHIKA (national non-governmental
organization in Bangladesh) who gave us permission to
work in their field centres, the officers who worked in
Bhaluka for the Bangladesh Integrated Nutrition Pro-
gramme and the field workers involved in the study. We
also thank the women who participated in the study.
There are no conflicts of interest. All three authors designed
the study. The fieldwork was carried out by S.N. and H.A.B.
The analyses were carried out primarily by S.N. and
C.G.N.M.-T. and the writing up of the results was a joint
effort by all three authors.
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