Dietary intake, nutrition, and fetal alcohol spectrum disorders in the Western Cape Province of South Africa
Introduction
During pregnancy, maternal alcohol consumption and dietary intake may have a profound impact on the health and development of the fetus. Malnutrition, food insecurity, and risky drinking patterns are pervasive in certain segments of the population of South Africa (ZA) [1], [2], [3], [4], [5], [6], [7], [8], [9], [10]. Low vitamin A intake, iron deficiency anemia, and stunted growth all represent significant health concerns for ZA [11]. Nutritional inadequacies in school-aged children are common, resulting in underweight (16.8%), wasted (2.5%), and stunted (23.5%) growth [12], [13].
Additionally, alcohol use among pregnant women is a major concern. Nearly half (42.8%) of pregnant women surveyed in a Western Cape Province (WCP) study reported drinking alcohol during pregnancy, and over half who drank consumed enough alcohol to place their unborn children at “high risk” for fetal alcohol syndrome (FAS) [7]. The prevalence of fetal alcohol spectrum disorders (FASD) in the Western and Northern Cape Provinces of ZA is among the highest in the world (135.1–207.5 per 1000) [14], [15], [16], [17], [18], many times higher than prevalence estimates for the United States and Europe [19].
Alcohol and food absorption are affected by multiple factors including: concurrent consumption, sex, hormones, pregnancy, and/or disease status. While food intake can, in the short term, exert a protective effect from the toxic effects of alcohol consumption [20], [21], [22], alcohol consumption over time can adversely affect the quality and quantity of proper nutrient supply and energy intake, particularly for women [23], [24]. Dietary intake among heavy drinkers is generally considered poor [25]. A recent study of Ukrainian and Russian mothers found lower mean blood plasma levels for most minerals and significant differences in zinc and copper between drinking mothers and non-drinking mothers [26].
Poor maternal nutrition during the prenatal period can cause low birth weight [27], [28]. Dietary intake and alcohol consumption during breastfeeding (median duration 18–24 months in ZA) may place newborns at an additional disadvantage due to inadequate delivery of nutrients through breastmilk and exposure to alcohol, a known teratogen [29]. The teratogenic effects of alcohol are increased under certain micronutrient deficiencies such as iron [30], zinc [26], and choline [31], [32]. Chronic alcohol use can affect micronutrient absorption and availability [33], but less is known about the effect of binge drinking (sporadic or regular drinking of four or five drinks or more per occasion). However, adequate nutrient intake may partially mitigate the harmful effects of alcohol on fetal development. Vitamin B3, folic acid, zinc, iron, and choline have all been shown to prevent and/or mitigate some of the effects of prenatal alcohol exposure [30], [31], [34], [35].
In three separate samples in this study community, the body mass index (BMI) of mothers of children with FASD was found to be significantly lower than that of controls, and mothers of children with FASD in most populations have been disproportionally of lower socioeconomic status (SES) [8], [9], [15], [16], [18], [36]. Dietary intake or other nutrition analyses have not been previously undertaken for mothers of children diagnosed with an FASD. This paper examines dietary and alcohol intake of mothers in a community in the WCP of ZA. Two questions are addressed. First, what proportion of the overall community maternal sample is likely deficient on essential macro and micronutrients? Second, is there a significant difference in dietary intake between mothers of children with FASD and mothers of controls?
Section snippets
Data collection and instruments
The data in this paper originate from a nested study in a larger epidemiologic inquiry of the prevalence and characteristics of FASD in a community in ZA. A two-tiered process in elementary schools, described fully elsewhere [8], [15], [18], identified children with FASD and randomly-selected, verified, not-FASD controls. All children in first grade classrooms of all thirteen community primary schools were screened for height, weight, and occipitofrontal head circumference (OFC). All children
Child and maternal characteristics
Detailed demographic, growth, and cognitive/behavioral results for the children in this sample (FASD and controls) have been presented elsewhere [18]. Randomly-selected control children were significantly taller, weighed more, had higher BMIs, larger heads, and much less dysmorphology than those children with FASD. Children with FASD performed significantly lower on verbal and non-verbal IQ tests, and had significantly more problem behaviors.
Maternal data in Table 1 indicate that mothers of
Environmental and nutritional influences on fetal development
The very high prevalence of FASD in this ZA community results from a unique confluence of variables reflecting the effect of drinking on a highly vulnerable population in terms of historic, socioeconomic, and nutritional factors [48], [49], [50]. In this study, there were significant differences in demographic and socioeconomic variables, and nutritional intake that all appear to negatively impact fetal development over and above the effects of alcohol intake by mothers.
The majority of women
Conclusions
The dietary intake profile and nutritional deficiencies in this sample are consistent with other studies in ZA. The proportion of women likely deficient on most micronutrients suggests nutritional interventions are warranted for women of childbearing age. While better living and more stimulating conditions in a majority of households in this community will be difficult to change in a short period of time, better diets and nutritional supplementation can be achieved quite quickly. These
Conflict of interest
The authors declare that there are no conflicts of interest.
Transparency document
Acknowledgements
Funding was provided by the NIAAA (RO1 AA09440, UO1 AA11685, and RO1/U01 AA 015134), the National Center on Minority Health Disparities (NCMHD), and the Foundation for Alcohol Related Research (FARR). We thank the women who provided the information for this study. We are also indebted to Denis Viljoen and Chris Shaw of FARR and to Loretta Hendricks, Leana Marais, and Dicky Naude who participated in the collection of the data. We also thank University of New Mexico student employees Jason
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