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Maternal and infant nutrition attitudes and practices of physicians in British Columbia 1975

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MATERNAL AND INFANT NUTRITION ATTITUDES AND PRACTICES OF PHYSICIANS IN BRITISH COLUMBIA ELIZABETH MACLEOD JOHNSTON B . S c , A c a d i a U n i v e r s i t y , Nova S c o t i a , 1968 M.S., C o r n e l l U n i v e r s i t y , New York, 1970 A DISSERTATION SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY i n the D i v i s i o n of ' Human N u t r i t i o n School of Home Economics We accept t h i s d i s s e r t a t i o n as conforming t o the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA AUGUST, 1975 In presenting this thesis in partia l fulfilment of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library shall make i t freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Home Economics D i v i s i o n o f Human N u t r i t i o n The University of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 August 19, 1975 ABSTRACT P e r i o d s of r a p i d growth are p e r i o d s o f s p e c i a l v u l n e r - a b i l i t y t o n u t r i t i o n a l i n j u r y . Growth d u r i n g pregnancy and i n the f i r s t two y e ars of l i f e i s more r a p i d than at any o t h e r stage i n the l i f e c y c l e and hence, optimum n u t r i t i o n i s v i t a l a t t h i s time. P h y s i c i a n s are f r e q u e n t l y the primary p r o f e s s i o n - a l s concerned w i t h the d i s s e m i n a t i o n o f n u t r i t i o n a d v i c e t o pregnant women and mothers o f new i n f a n t s . However, t h e r e are no s t u d i e s i n the l i t e r a t u r e t h a t a s s e s s the q u a l i t y of n u t r i - t i o n i n f o r m a t i o n p r o v i d e d by p h y s i c i a n s i n t h i s important area of maternal and i n f a n t n u t r i t i o n . A study was designed to i n v e s t i g a t e the n u t r i t i o n a t t i - tudes and p r a c t i c e s o f g e n e r a l p r a c t i t i o n e r s , p e d i a t r i c i a n s and o b s t e t r i c i a n s i n the p r o v i n c e of B r i t i s h Columbia. The i n f l u - ence of s e l e c t e d v a r i a t e s upon the c r i t e r i o n v a r i a b l e s , n u t r i - t i o n a t t i t u d e s and p r a c t i c e s , was a s s e s s e d . V a r i a t e s s t u d i e d i n c l u d e d demographic and p r o f e s s i o n a l d a t a on c o u n t r y of m e d i c a l t r a i n i n g , sex of respondent, l o c a t i o n and type of p r a c t i c e , y e a r s of p r a c t i c e , number o f p a t i e n t s seen weekly, sources o f n u t r i t i o n i n f o r m a t i o n c o n s u l t e d , attendance at c o n t i n u i n g e d u c a t i o n programs, a d d i t i o n a l t r a i n i n g f o r s p e c i a l i z a t i o n , and i n c l u s i o n of n u t r i t i o n i n m e d i c a l s c h o o l e d u c a t i o n . The n ature of the r e l a t i o n s h i p between n u t r i t i o n a t t i t u d e s and p r a c t i c e s was a l s o a s s e s s e d . In March 1975, q u e s t i o n n a i r e s were m a i l e d t o a l l 1981 p r a c t i s i n g g e n e r a l p r a c t i t i o n e r s , p e d i a t r i c i a n s and o b s t e t r i - i i c i a n s i n t h e p r o v i n c e o f B r i t i s h C o lumbia. Q u e s t i o n n a i r e s were r e t u r n e d by 724 ( 41.3% ) g e n e r a l p r a c t i t i o n e r s , 69 ( 62.7% ) p e d i a t r i c i a n s and 51 ( 4 3 . 2 % ) o b s t e t r i c i a n s . Responses from c o m p l e t e d q u e s t i o n n a i r e s were a n a l y z e d by computer; a l l t e s t s were c o n d u c t e d a t t h e 5% l e v e l o f s i g n i f i c a n c e . R e s u l t s were r e p o r t e d a t t h e h i g h e s t l e v e l o f s i g n i f i c a n c e . Mean s c o r e s f o r n u t r i t i o n a t t i t u d e s f o r g e n e r a l p r a c - t i t i o n e r s , p e d i a t r i c i a n s and o b s t e t r i c i a n s were 72%, 81% and 64% r e s p e c t i v e l y . N u t r i t i o n p r a c t i c e s ' s c o r e s were 60%, 66% and 65% f o r g e n e r a l p r a c t i t i o n e r s , p e d i a t r i c i a n s and o b s t e t r i c i a n s r e s p e c t i v e l y . R e g r e s s i o n a n a l y s i s i n d i c a t e d t h a t n u t r i t i o n a t t i t u d e and p r a c t i c e s c o r e s o f g e n e r a l p r a c t i t i o n e r s were s i g n i f i c a n t l y h i g h e r f o r p h y s i c i a n s who: (a) were femal e (b) c o n s u l t e d w i t h a n u t r i t i o n i s t - d i e t i t i a n (c) had a d d i t i o n a l t r a i n i n g (d) a t t e n - ded c o n t i n u i n g e d u c a t i o n programs and (e) had n u t r i t i o n i n t h e i r m e d i c a l s c h o o l e d u c a t i o n . G e n e r a l p r a c t i t i o n e r s who were i n p r a c t i c e more t h a n 10 y e a r s s c o r e d s i g n i f i c a n t l y l o w e r on t h e a t t i t u d e and p r a c t i c e t e s t s . N u t r i t i o n p r a c t i c e s c o r e s were s i g n i f i c a n t l y h i g h e r f o r p e d i a t r i c i a n s t r a i n e d i n Canada w h i l e n u t r i t i o n a t t i t u d e s c o r e s were h i g h e r f o r p e d i a t r i c i a n s who were i n p r a c t i c e more th a n f i v e b u t fewer t h a n 10 y e a r s . O b s t e t r i c i a n s ' a t t i t u d e s c o r e s were s i g n i f i c a n t l y l o w e r f o r p h y s i c i a n s who were i n p r a c t i c e more t h a n 10 y e a r s . O b s t e t r i c i a n s who c o n s u l t e d w i t h non-human s o u r c e s o f n u t r i t i o n i n f o r m a t i o n o t h e r t h a n p r o f e s - s i o n a l j o u r n a l s and human s o u r c e s o f i n f o r m a t i o n o t h e r t h a n i i i n u t r i t i o n i s t - d i e t i t i a n s scored s i g n i f i c a n t l y h i g h e r on the n u t r i t i o n p r a c t i c e t e s t . C o r r e l a t i o n a n a l y s i s showed t h a t n u t r i t i o n a t t i t u d e s were s i g n i f i c a n t l y c o r r e l a t e d t o n u t r i t i o n p r a c t i c e s f o r g e n e r a l p r a c t i t i o n e r s ( r = 0.370 ), p e d i a t r i c i a n s ( r = 0.259 ) and o b s t e t r i c i a n s ( r = 0.424 ). Student t - t e s t a n a l y s i s i n d i c a t e d t h a t p e d i a t r i c i a n s ' and o b s t e t r i c i a n s ' p r a c t i c e t e s t s c o r e s were s i g n i f i c a n t l y h i g h e r than those o f g e n e r a l p r a c t i t i o n e r s . There were no s i g - n i f i c a n t d i f f e r e n c e s among the n u t r i t i o n a t t i t u d e s c o r e s f o r the t h r e e groups. I m p l i c a t i o n s f o r n u t r i t i o n e d u cators i n c l u d e d the need f o r n u t r i t i o n i n the m e d i c a l s c h o o l c u r r i c u l u m , the i n c o r p o r - a t i o n o f n u t r i t i o n i n t o c o n t i n u i n g e d u c a t i o n programs and the need f o r n u t r i t i o n i s t s t o a c t as c o n s u l t a n t s t o p h y s i c i a n s . i v TABLE OF CONTENTS ABSTRACT ............. i i LIST OF TABLES v i i LIST OF FIGURES x i i ACKNOWLEDGEMENTS .. • x i i i Chapter I. INTRODUCTION ............. 1 Background and Need 1 Statement o f the Problem 7 Hypotheses . 9 D e f i n i t i o n s o f terms 11 Assumptions . .. 13 I I . REVIEW OF THE LITERATURE 15 N u t r i t i o n i n Pregnancy 15 E f f e c t of n u t r i t i o n on the outcome of pregnancy . 15 Weight g a i n i n pregnancy . 20 Sodium r e s t r i c t i o n .. . 23 Iron i n t a k e 25 D i e t a r y P r a c t i c e s o f Pregnant Women ......... 27 N u t r i t i o n E d u c a t i o n f o r Pregnancy .. 31 N u t r i t i o n i n Infancy 36 Importance of n u t r i t i o n i n i n f a n c y ........ 36 Iron d e f i c i e n c y 38 B r e a s t - f e e d i n g , , 41 I n t r o d u c t i o n o f s o l i d s 43 I n f a n t D i e t a r y P r a c t i c e s .................... 45 N u t r i t i o n E d u c a t i o n f o r Infancy ............. 48 Role o f P h y s i c i a n i n N u t r i t i o n E d u c a t i o n 50 A t t i t u d e s and P r a c t i c e s 54 Survey Research by M a i l Q u e s t i o n n a i r e ....... 58 Techniques, advantages and disadvantages 58 Response r a t e 60 Non response 63 Summary 65 I I I . DESIGN OF THE STUDY • • • r ? • • r 67 Research Design 68 P o p u l a t i o n • • • - 68 Data C o l l e c t i o n 69 Data c o l l e c t i o n instruments . ............... 69 Procedure 73 Data A n a l y s i s 75 v IV. FINDINGS AND INTERPRETATIONS , 78 Rates of Response 78 Comparison o f E a r l y and Late Respondents 79 General P r a c t i t i o n e r s 81 D e s c r i p t i o n of respondents 81 N u t r i t i o n a t t i t u d e s and p r a c t i c e s 89 The r e l a t i o n s h i p of s e l e c t e d v a r i a t e s t o n u t r i t i o n a t t i t u d e s and p r a c t i c e s 97 Summary of g e n e r a l p r a c t i t i o n e r s ' r e s u l t s 108 P e d i a t r i c i a n s and O b s t e t r i c i a n s 109 D e s c r i p t i o n of respondents 109 N u t r i t i o n a t t i t u d e s and p r a c t i c e s 116 The r e l a t i o n s h i p o f s e l e c t e d v a r i a t e s t o n u t r i t i o n a t t i t u d e s and p r a c t i c e s 124 Summary of p e d i a t r i c i a n s ' and o b s t e t r i c i a n s ' r e s u l t s 133 Comparison o f N u t r i t i o n A t t i t u d e s and P r a c t i c e s o f General P r a c t i t i o n e r s , P e d i a t r i c i a n s and O b s t e t r i c i a n s 134 V. SUMMARY AND IMPLICATIONS 137 Summary 137 I m p l i c a t i o n s 147 LITERATURE CITED . . . 150 APPENDICES A. Data C o l l e c t i o n Instruments and Follow-Up P o s t c a r d s 165 B. V a l i d a t i o n Q u e s t i o n n a i r e and Correspondence w i t h V a l i d a t o r s 189 C. P r e t e s t Q u e s t i o n n a i r e 196 D. P h y s i c i a n s ' Comments on Q u e s t i o n n a i r e s 198 E. Answer Keys f o r N u t r i t i o n A t t i t u d e and P r a c t i c e T e s t s 201 F. Mean Scores f o r N u t r i t i o n A t t i t u d e and P r a c t i c e T e s t s 208 v i LIST OF TABLES I. Percentage of pregnant women with "inadequate" and "less-than-adequate" intakes of nutrients 29 II. Percentage of pregnant women i n B r i t i s h Columbia with less than two-thirds of the recommended dietary intake 30 I I I . Percentage of children zero to four years of age with "inadequate" and "less-than-adequate" intakes of nutrients.... 4 7 IV. Scoring system for n u t r i t i o n attitude t e s t 70 V. Scoring system for n u t r i t i o n p r a c t i c e t e s t 72 VI. Summary of response rates from physicians 79 VII. Number and percentage of physicians designated as early and l a t e respondents 80 VIII. Comparison of early and l a t e respondents on basis of mean percentage t e s t scores 81 IX. D i s t r i b u t i o n of general p r a c t i t i o n e r s by country of medical t r a i n i n g 82 X. D i s t r i b u t i o n of general p r a c t i t i o n e r s by l o c a t i o n of p r a c t i c e 83 XI. D i s t r i b u t i o n of general p r a c t i t i o n e r s by years of pract i c e 83 XII. D i s t r i b u t i o n of general p r a c t i t i o n e r s by type of pract i c e 84 XIII. D i s t r i b u t i o n of general p r a c t i t i o n e r s by number of patients seen weekly 84 XIV. Number and percentage of general p r a c t i t i o n e r s i n d i c a t i n g sources of n u t r i t i o n information 85 XV. Number and percentage of general p r a c t i t i o n e r s having a d d i t i o n a l t r a i n i n g for s p e c i a l i z a t i o n 86 XVI. Number and percentage of general p r a c t i t i o n e r s i n d i - cating attendance at continuing education programs... 87 XVII. Number and percentage of general p r a c t i t i o n e r s i n d i c a t i n g type of n u t r i t i o n education i n medical schools 88 v i i X V I I I . Mean p e r c e n t a g e s c o r e s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s f o r g e n e r a l p r a c t i t i o n e r s 90 XIX. Statements m e a s u r i n g n u t r i t i o n a t t i t u d e s f o r w h i c h g e n e r a l p r a c t i t i o n e r s r e c e i v e d l o w e s t mean s c o r e s 91 XX. Statements m e a s u r i n g n u t r i t i o n c o u n s e l l i n g p r a c t i c e s f o r w h i c h g e n e r a l p r a c t i t i o n e r s r e c e i v e d l o w e s t mean s c o r e s 92 XXI. Comparison o f n u t r i t i o n a t t i t u d e s and p r a c t i c e s o f g e n e r a l p r a c t i t i o n e r s c o n c e r n i n g b r e a s t - f e e d i n g . . 95 X X I I . Comparison o f n u t r i t i o n a t t i t u d e s and p r a c t i c e s o f g e n e r a l p r a c t i t i o n e r s c o n c e r n i n g e a r l y i n t r o d u c t i o n o f s o l i d s 96 X X I I I . Mean p e r c e n t a g e s c o r e s o f g e n e r a l p r a c t i t i o n e r s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on l o c a t i o n o f t r a i n i n g 98 XXIV. Mean p e r c e n t a g e s c o r e s o f g e n e r a l p r a c t i t i o n e r s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on sex o f r e s p o n d e n t 98 XXV. Mean p e r c e n t a g e s c o r e s o f g e n e r a l p r a c t i t i o n e r s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on l o c a t i o n o f p r a c t i c e 99 XXVI. Mean p e r c e n t a g e s c o r e s o f g e n e r a l p r a c t i t i o n e r s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on y e a r s o f p r a c t i c e 99 X X V I I . Mean p e r c e n t a g e s c o r e s o f g e n e r a l p r a c t i t i o n e r s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on type, o f p r a c t i c e 100 X X V I I I . Mean p e r c e n t a g e s c o r e s o f g e n e r a l p r a c t i t i o n e r s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on number o f p r e n a t a l p a t i e n t s seen w e e k l y 100 XXIX. Mean p e r c e n t a g e s c o r e s o f g e n e r a l p r a c t i t i o n e r s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on number o f i n f a n t s seen w e e k l y 101 XXX. Mean p e r c e n t a g e s c o r e s o f g e n e r a l p r a c t i t i o n e r s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on a d d i t i o n a l t r a i n i n g f o r s p e c i a l i z a t i o n 101 XXXI. Mean p e r c e n t a g e s c o r e s o f g e n e r a l p r a c t i t i o n e r s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on a t t e n d a n c e a t c o n t i n u i n g e d u c a t i o n programs... 102 v i i i XXXII. Mean percentage scores of general p r a c t i t i o n e r s for n u t r i t i o n a t t i t u d e and pra c t i c e tests based on number of continuing education programs attended... 103 XXXIII. Mean percentage scores of general p r a c t i t i o n e r s f o r n u t r i t i o n attitude and practice tests based on n u t r i t i o n education i n medical school 103 XXXIV. Stepwise regression r e s u l t s f o r variates s i g n i - f i c a n t l y r e l a t e d to mean percentage scores achieved by general p r a c t i t i o n e r s on the n u t r i t i o n a t t i t u d e t e s t 105 XXXV. Stepwise regression r e s u l t s for variates s i g n i f i - cantly r e l a t e d to mean percentage scores achieved by general p r a c t i t i o n e r s on the n u t r i t i o n p r a c t i c e t e s t 107 XXXVI. D i s t r i b u t i o n of p e d i a t r i c i a n s and obs t e t r i c i a n s by country of medical t r a i n i n g 109 XXXVII. D i s t r i b u t i o n of p e d i a t r i c i a n s and obste t r i c i a n s by sex 110 XXXVIII. D i s t r i b u t i o n of p e d i a t r i c i a n s and ob s t e t r i c i a n s by loc a t i o n of pr a c t i c e 110 XXXIX. D i s t r i b u t i o n of p e d i a t r i c i a n s and ob s t e t r i c i a n s by years of pr a c t i c e I l l XL. D i s t r i b u t i o n of p e d i a t r i c i a n s and ob s t e t r i c i a n s by type of pra c t i c e I l l XLI. D i s t r i b u t i o n of p e d i a t r i c i a n s and ob s t e t r i c i a n s by number of patients seen weekly 112 XLII. Number and percentage of pe d i a t r i c i a n s and obste- t r i c i a n s i n d i c a t i n g sources of n u t r i t i o n information 113 XLIII. Number and percentage of p e d i a t r i c i a n s and obste- t r i c i a n s i n d i c a t i n g a d d i t i o n a l t r a i n i n g for s p e c i a l i z a t i o n 114 XLIV. Number and percentage of p e d i a t r i c i a n s and obste- t r i c i a n s i n d i c a t i n g attendance at continuing education programs 115 XLV. Number and percentage of pe d i a t r i c i a n s and obste- t r i c i a n s i n d i c a t i n g type of n u t r i t i o n education i n medical school 115 XLVI. Mean percentage scores f o r n u t r i t i o n a t t i t u d e and prac t i c e tests for p e d i a t r i c i a n s and o b s t e t r i c i a n s . 117 ix XLVII. Statements measuring n u t r i t i o n a t t i t u d e s f o r which p e d i a t r i c i a n s a c h i e v e d lowest mean sc o r e s 118 XLVIII. Statements measuring n u t r i t i o n a t t i t u d e s f o r which o b s t e t r i c i a n s a c h i e v e d lowest mean s c o r e s 119 XLIX. Statements measuring n u t r i t i o n p r a c t i c e s f o r which p e d i a t r i c i a n s a c h i e v e d lowest mean sc o r e s , 120 L. Statements measuring n u t r i t i o n p r a c t i c e s f o r which o b s t e t r i c i a n s achieved lowest mean s c o r e s 121 L I . Comparison of a t t i t u d e s and p r a c t i c e s f o r p e d i a t r i c i a n s c o n c e r n i n g n u t r i t i o n a l a d v i c e 122 L I I . Comparison of a t t i t u d e s and p r a c t i c e s f o r o b s t e t r i c i a n s c o n c e r n i n g n u t r i t i o n a l a d v i c e . . , , . , , , 123 L I I I . Mean percentage s c o r e s of p e d i a t r i c i a n s and o b s t e t r i c i a n s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on l o c a t i o n of m e d i c a l t r a i n i n g 124 LIV. Mean percentage s c o r e s of p e d i a t r i c i a n s and o b s t e t r i c i a n s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on sex of respondent 125 LV. Mean percentage s c o r e s of p e d i a t r i c i a n s and o b s t e t r i c i a n s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on l o c a t i o n o f p r a c t i c e 126 LVI. Mean percentage s c o r e s o f p e d i a t r i c i a n s and o b s t e t r i c i a n s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on years of p r a c t i c e 126 LV I I . Mean percentage s c o r e s o f p e d i a t r i c i a n s and o b s t e t r i c i a n s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on type o f p r a c t i c e 127 L V I I I . Mean percentage s c o r e s of p e d i a t r i c i a n s and o b s t e t r i c i a n s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on number of p a t i e n t s seen weekly.,..., 127 LIX. Mean percentage s c o r e s of p e d i a t r i c i a n s and o b s t e t r i c i a n s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on a d d i t i o n a l t r a i n i n g f o r s p e c i a l i z a t i o n 128 LX. Mean percentage s c o r e s o f p e d i a t r i c i a n s and o b s t e t r i c i a n s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on attendance a t c o n t i n u i n g e d u c a t i o n programs 129 LXI. Mean percentage s c o r e s of p e d i a t r i c i a n s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on number o f c o n t i n u i n g e d u c a t i o n programs attended.,, - 129 x L X I I . Mean percentage s c o r e s o f p e d i a t r i c i a n s and o b s t e t r i c i a n s f o r n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s based on n u t r i t i o n e d u c a t i o n i n m e d i c a l s c h o o l 130 L X I I I . Stepwise r e g r e s s i o n r e s u l t s f o r v a r i a t e s s i g n i f i c a n t l y r e l a t e d t o mean percentage s c o r e s achieved by p e d i a t r i c i a n s on the n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s 132 LXIV. Stepwise r e g r e s s i o n r e s u l t s f o r v a r i a t e s s i g n i f i c a n t l y r e l a t e d t o mean percentage s c o r e s achieved by o b s t e t r i c i a n s on the n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s 133 LXV. Comparison o f mean percentage s c o r e s f o r n u t r i t i o n a t t i t u d e s and p r a c t i c e s between g e n e r a l p r a c t i t i o n e r s and p e d i a t r i c i a n s ; 135 LXVI. Comparison o f mean percentage s c o r e s f o r n u t r i t i o n a t t i t u d e s and p r a c t i c e s between g e n e r a l p r a c t i t i o n e r s and o b s t e t r i c i a n s 135 x i LIST OF FIGURES The v i c i o u s c i r c l e o f n u t r i t i o n t e a c h i n g i n m e d i c a l s c h o o l s x i i ACKNOWLEDGEMENTS The author wishes to express her a p p r e c i a t i o n to her major a d v i s o r , Dr. Nancy Schwartz , f o r her suppor t and en- couragement d u r i n g the p e r i o d of graduate s tudy and f o r her e x p e r t i s e i n the development of t h i s t h e s i s . Members o f the t h e s i s committee, Dr. E l e a n o r Va ines and Dr. M o l l y T o w e l l , are g r a t e f u l l y acknowledged f o r t h e i r a s s i s t a n c e and suppor t i n the p r e p a r a t i o n o f t h i s r e p o r t . A p p r e c i a t i o n i s a l s o expres sed to Dr. D. B. J e l l i f f e o f U. C. L. A. f o r s e r v i n g as e x t e r n a l examiner. S i n c e r e thanks are extended to D r s . G l a s s , P a t t e r s o n and W i l f o r d f o r a u t h o r i z i n g t h i s s tudy on b e h a l f o f the B r i t i s h Columbia M e d i c a l A s s o c i a t i o n , Mr. C h r i s t o p h e r Webber . for computer programming, the graduate s tudent s i n Human N u t r i t i o n f o r a s s i s t a n c e i n p r e t e s t i n g and encouragement throughout the s tudy and to the many p h y s i c i a n s who p a r t i c i - pa ted i n the su rvey . Above a l l , the author would l i k e to g i ve s p e c i a l thanks to her son , Mark, and husband, D a v i d , whose c o n t i n u a l encouragement and e x t e n s i v e c o n t r i b u t i o n s to t h i s t h e s i s were i n v a l u a b l e . x i i i CHAPTER I INTRODUCTION Background and Need N u t r i t i o n d u r i n g pregnancy and the f i r s t y ears of l i f e i s o f the utmost importance t o the h e a l t h and w e l l - b e i n g o f the i n f a n t . The g e n e r a l p h y s i c a l c o n d i t i o n o f the young c h i l d , and p a r t i c u l a r l y h i s n u t r i t i o n a l s t a t u s , are c e n t r a l t o the f u l f i l m e n t of h i s mental and p h y s i c a l c a p a c i t i e s ( B i r c h and Gussow, 1970 ). In r e c e n t y e a r s , a t t e n t i o n has been f o c u s e d on the r e l a t i o n s h i p o f a number o f maternal f a c t o r s t o the outcome o f pregnancy. One o f g r e a t s i g n i f i c a n c e i s the g e n e r a l change i n a t t i t u d e r e g a r d i n g maternal weight g a i n i n pregnancy. The once p o p u l a r p r a c t i c e o f r e s t r i c t i n g weight g a i n t o fewer than 20 pounds f o r the normal pregnant woman i s no l o n g e r recommended. The Committee o f M a t e r n a l N u t r i t i o n , Food and N u t r i t i o n Board i n the U.S.A. (1970) has suggested a t o t a l maternal weight g a i n of a pproximately 24 pounds, w h i l e prominent r e s e a r c h e r s i n England recommend 27.5 pounds as a reasonable average weight g a i n f o r p r i m i g r a v i d a e ( Hytten and L e i t c h , 19 71 ). Indeed, the B r i t i s h Columbia M e d i c a l A s s o c i a t i o n has endorsed the p o s i t i o n paper e s t a b l i s h e d by the N u t r i t i o n i n Pregnancy Committee o f the H e a l t h P l a n n i n g C o u n c i l of B r i t i s h Columbia (1973) t h a t recommends an average weight g a i n of 24 pounds. However, the 1 2 r e s u l t s from N u t r i t i o n Canada showing the s p e c i f i c f i n d i n g s i n B r i t i s h Columbia (1975) i n d i c a t e t h a t c a l o r i c i n t a k e s f o r p r e g - nant women i n t h i s p r o v i n c e are g e n e r a l l y below the a c c e p t a b l e l e v e l s t h a t would promote t h i s optimum weight g a i n . In a d d i t i o n , pregnancy i s no lo n g e r thought t o be an a p p r o p r i a t e time f o r obese women to p r a c t i s e weight r e d u c t i o n s i n c e l i m i t i n g weight g a i n a t t h i s time may have adverse e f f e c t s on the f e t u s . F e l i g (1973) has demonstrated t h a t a f t e r an over- n i g h t f a s t , ketonemia i n pregnancy i s t h r e e times g r e a t e r than i n the non-gr a v i d s t a t e . T h i s suggests t h a t severe c a l o r i c r e s t r i c t i o n s hould not be undertaken i n pregnancy and weight r e d u c t i o n programs i n v o l v i n g a s e v e r e l y l i m i t e d i n t a k e o f carbohydrates must be av o i d e d . S i m i l a r l y , r e c e n t i n f o r m a t i o n demands a r e - e v a l u a t i o n o f i n d i s c r i m i n a n t s a l t r e s t r i c t i o n d u r i n g pregnancy. Hytten and L e i t c h (1971) observed t h a t pregnant women w i t h edema had a lower i n c i d e n c e o f low b i r t h weight i n f a n t s and a s l i g h t l y r e - duced r a t e o f i n f a n t m o r t a l i t y . They concluded t h a t i t was reasonable t o r e g a r d edema as having p h y s i o l o g i c r a t h e r than p a t h o l o g i c s i g n i f i c a n c e i n pregnancy. Thus, r e s t r i c t i o n o f sodium i s not warranted f o r the g e n e r a l p o p u l a t i o n and pregnant women sh o u l d be all o w e d t o s a l t t h e i r food to t a s t e ( Lindheimer and Katz, 1974 ). The importance o f optimum n u t r i t i o n d u r i n g i n f a n c y i s g a i n i n g new impetus as evidence i s mounting t h a t m a l n u t r i t i o n 3 d u r i n g t h i s stage of l i f e may a d v e r s e l y a f f e c t l e a r n i n g and i n t e l l i g e n c e ( Stoch and Smythe, 1963; C r a v i o t o and Robales, 1965; C r a v i o t o e t a l . , 1966; Chase and M a r t i n , 1970; Winick, 1973 ). S t u d i e s have i n d i c a t e d t h a t severe u n d e r n u t r i t i o n i n the f i r s t y e a rs of l i f e w i l l cause permanent r e d u c t i o n - i n the t o t a l number o f b r a i n c e l l s ( Winick and Rosso, 1969; Rosso e t a l . , 1970 ) but the consequences of m i l d u n d e r n u t r i t i o n d u r i n g t h i s p e r i o d are l e s s c l e a r . N u t r i t i o n i s t s are a l s o q u e s t i o n i n g the p r a c t i c e of e a r l y i n t r o d u c t i o n of s o l i d foods i n t o the i n f a n t ' s d i e t . E a r l y weaning to s o l i d s may encourage overconsumption of foods which i n t u r n may r e s u l t i n e x c e s s i v e f a t accumulation i n the i n f a n t ( T a i t z , 1971; Shukla e t a l . , 1972; Oates, 1973; Dwyer and Mayer, 1973 ). In a d d i t i o n , the i n t r o d u c t i o n of s o l i d s g e n e r a l l y e n t a i l s a s w i t c h from a d i e t h i g h i n f a t t o one h i g h i n carbo- hydrate, and i n e x p e r i m e n t a l a n i m a l s , a t l e a s t , t h i s i s c o n s i - dered to be d e t r i m e n t a l ( Hahn, 1973 ). The p r a c t i c e o f f e e d i n g skim m i l k t o i n f a n t s f o u r to s i x months o f age i n an e f f o r t t o t r e a t r e a l or imagined o b e s i t y i s a l s o c a u s i n g concern. Fomon (1974) suggested t h a t such i n f a n t s p r o b a b l y d e p l e t e t h e i r f a t s t o r e s and hence have no r e s e r v e s t o f a l l back on i n the event of i l l n e s s . They may a l s o r e c e i v e an inadequate supply of the e s s e n t i a l f a t t y a c i d , l i n o l e i c a c i d . I r o n d e f i c i e n c y anemia among i n f a n t s and t o d d l e r s i s another f a c t o r of i n c r e a s i n g importance ( F u e r t h , 1971; Owen 4 et a l . , 1971; Lanzkowsky, 1974 )'. Some p e d i a t r i c academies are recommending use of i r o n - f o r t i f i e d formulas from b i r t h i f the i n f a n t i s not b e i n g b r e a s t - f e d . Supplementation w i t h i r o n - e n r i c h e d c e r e a l s from approximately s i x t o 18 months of age i s a l s o being advocated. Since r e c e n t i n f o r m a t i o n has brought s i g n i f i c a n t changes i n our recommendations f o r n u t r i t i o n d u r i n g pregnancy and d u r i n g the f i r s t y e a r s of l i f e , i t appears important to d e t e r - mine i f t h i s i n f o r m a t i o n i s r e a c h i n g the maternal p o p u l a t i o n . The American C o l l e g e of O b s t e t r i c i a n s and G y n e c o l o g i s t s (1974) s t a t e t h a t : . . . the p r e n a t a l p a t i e n t r e p r e s e n t s an i d e a l o p p o r t u n i t y f o r n u t r i t i o n e d u c a t i o n which can have b e n e f i t s extending f a r beyond her p r e s e n t pregnancy ( p. 1 ). V a r i o u s i n v e s t i g a t o r s have p o i n t e d out t h a t the p h y s i c i a n i s the primary p r o f e s s i o n a l upon whom homemakers r e l y f o r n u t r i - t i o n i n f o r m a t i o n ( Young e t aT. , 1956; Fox e t al_. , 1970 ). G i f f t e t a l . (1972) i n d i c a t e t h a t p h y s i c i a n s ares . . . t r u s t e d and looked up to as a u t h o r i t i e s i n matters p e r t a i n i n g t o h e a l t h (and) are h i g h l y r e s p e c t e d l e g i t i m i z e r s of n u t r i t i o n i n f o r m a t i o n ( P- 355 ).. However, p h y s i c i a n s g e n e r a l l y are not n u t r i t i o n e x p e r t s . P h i l l i p s (1971) showed t h a t second year m e d i c a l students were not f a m i l i a r w i t h many of the b a s i c concepts and p r i n c i p l e s of n u t r i t i o n . K j e l l m a n (19 74) demonstrated t h a t knowledge o f n u t r i t i o n among m e d i c a l students was poor but r e s u l t s from f i f t h 5 year students were s i g n i f i c a n t l y worse than those from t h i r d year s t u d e n t s . Although these s t u d i e s ( P h i l l i p s , 1971; Kjellman, 1974 ) i n v e s t i g a t e d the n u t r i t i o n knowledge of medi c a l s t u d e n t s , there do not appear t o be any s t u d i e s t h a t i n v e s t i g a t e d the n u t r i t i o n knowledge o f p r a c t i s i n g p h y s i c i a n s . Yet, the American C o l l e g e o f O b s t e t r i c i a n s and G y n e c o l o g i s t s (1974) s t a t e t h a t : . . . the u l t i m a t e r e s p o n s i b i l i t y f o r e n s u r i n g a high q u a l i t y n u t r i t i o n component of m a t e r n i t y care s e r v i c e s r e s t s w i t h the p h y s i c i a n as the l e a d e r o f the maternal h e a l t h c a r e team. The p h y s i c i a n must t h e r e f o r e possess knowledge and s k i l l s i n n u t r i t i o n a l assessment and management ( p . 9 ). N u t r i t i o n knowledge, however, i s not always a good i n d i c a t o r o f n u t r i t i o n a t t i t u d e s and n u t r i t i o n p r a c t i c e s . In a study by Emmons and Hayes (1973) i n v e s t i g a t i n g the r e l a t i o n - s h i p of mothers' n u t r i t i o n knowledge t o the f e e d i n g p r a c t i c e s o f t h e i r c h i l d r e n , no r e l a t i o n s h i p was found between n u t r i t i o n knowledge and n u t r i t i o n p r a c t i c e s . S i m i l a r l y , Schwartz (1975) found t h a t t h e r e was no c o r r e l a t i o n between the n u t r i t i o n know- ledge and the n u t r i t i o n p r a c t i c e s o f Ohio h i g h s c h o o l graduates who had s t u d i e d n u t r i t i o n i n Home Economics c o u r s e s . On the ot h e r hand, J a l s o e t al_. (1970), i n a study o f the n u t r i t i o n a t t i t u d e s and p r a c t i c e s o f 340 s u b j e c t s who were members of v a r i o u s community o r g a n i z a t i o n s i n New York S t a t e , found a h i g h p o s i t i v e c o r r e l a t i o n between t h e i r n u t r i t i o n a t t i t u d e s and t h e i r n u t r i t i o n p r a c t i c e s . Thus, a t t i t u d e s were d i r e c t l y r e l a t e d t o p r a c t i c e s . 6 P h y s i c i a n s g e n e r a l l y p r o v i d e a low response r a t e t o survey r e s e a r c h even when the s u b j e c t o f the r e s e a r c h i s c o n s i d e r e d t o be of a n o n - t h r e a t e n i n g nature ( Deutscher, 1953; G u l l e n and G a r r i s o n , 19 73; S c h i l l e r and V i v i a n , 197 4 ). Research d e a l i n g w i t h the l e s s t h r e a t e n i n g area o f n u t r i t i o n a t t i t u d e s and p r a c t i c e s may e l i c i t a g r e a t e r response than would s i m i l a r r e s e a r c h attempting t o assess the more t h r e a t e n - i n g area o f n u t r i t i o n knowledge. Review of the e x i s t i n g l i t e r a t u r e i n d i c a t e s t h a t i n f o r - mation c o n c e r n i n g maternal and i n f a n t n u t r i t i o n i s r a p i d l y changing. S i n c e the p h y s i c i a n i s the primary p r o f e s s i o n a l source o f n u t r i t i o n a d v i c e f o r many mothers, an i n v e s t i g a t i o n o f p h y s i c i a n s ' a t t i t u d e s and c o u n s e l l i n g p r a c t i c e s i s needed t o assess the k i n d o f n u t r i t i o n i n f o r m a t i o n being d i s s e m i n a t e d t o the maternal p o p u l a t i o n . 7 Statement of the Problem A survey was conducted among p e d i a t r i c i a n s , g e n e r a l p r a c t i t i o n e r s and o b s t e t r i c i a n s i n the p r o v i n c e of B r i t i s h Columbia to a s c e r t a i n t h e i r c u r r e n t a t t i t u d e s and p r a c t i c e s r e g a r d i n g maternal and i n f a n t n u t r i t i o n . Comparisons were made between the c r i t e r i o n v a r i a b l e s , n u t r i t i o n a t t i t u d e s and p r a c t i c e s , and v a r i o u s demographic and p r o f e s s i o n a l v a r i a t e s . T h i s study was conducted w i t h the c o - o p e r a t i o n and a p p r o v a l of the B r i t i s h Columbia M e d i c a l A s s o c i a t i o n . The f o l l o w i n g o b j e c t i v e s were e s t a b l i s h e d f o r i n v e s t i - g a t i n g the problem: 1. To a s s e s s the q u a l i t y of maternal and i n f a n t n u t r i t i o n i n f o r m a t i o n b e ing d i s s e m i n a t e d t o the m aternal p o p u l a t i o n by g e n e r a l p r a c t i t i o n e r s , p e d i a t r i c i a n s and o b s t e t r i c i a n s . 2. To determine whether s i g n i f i c a n t d i f f e r e n c e s e x i s t i n the n u t r i t i o n a t t i t u d e s and p r a c t i c e s o f p e d i a t r i c i a n s , o b s t e t r i c i a n s and g e n e r a l p r a c t i t i o n e r s i n the p r o v i n c e o f B r i t i s h Columbia as r e l a t e d t o : (a) l o c a t i o n of m e d i c a l t r a i n i n g (b) sex o f respondent (c) l o c a t i o n o f p r a c t i c e (d) y e a r s of p r a c t i c e (e) type of p r a c t i c e 8 (f) number o f p r e n a t a l p a t i e n t s and /o r i n f a n t s seen weekly (g) s ou rce s o f n u t r i t i o n i n f o r m a t i o n (h) a d d i t i o n a l s p e c i a l i z a t i o n o r t r a i n i n g ( i ) number and type o f c o n t i n u i n g e d u c a t i o n programs w i t h a n u t r i t i o n component a t t ended i n the l a s t two y e a r s (j) e x t e n t o f n u t r i t i o n e d u c a t i o n i n m e d i c a l s c h o o l t r a i n i n g 3. To de te rmine among p e d i a t r i c i a n s , o b s t e t r i c i a n s and g e n e r a l p r a c t i t i o n e r s the n a t u r e o f the r e l a t i o n s h i p o f n u t r i t i o n a t t i t u d e s t o n u t r i t i o n p r a c t i c e s . 4. To de termine whether s i g n i f i c a n t d i f f e r e n c e s e x i s t between the n u t r i t i o n a t t i t u d e s and p r a c - t i c e s o f g e n e r a l p r a c t i t i o n e r s as compared t o p e d i a t r i c i a n s and o b s t e t r i c i a n s . T h i s s tudy was de s i gned t o meet these o b j e c t i v e s and to mod i fy and deve l op a p p r o p r i a t e d a t a c o l l e c t i o n i n s t rument s f o r t h i s t ype o f assessment. Hypothese: The f o l l o w i n g n u l l hypothese; There w i l l be no s i g n i f i c a n t t e s t s o f n u t r i t i o n a t t i t u d e s p r a c t i t i o n e r s , o b s t e t r i c i a n s on l o c a t i o n o f t h e i r m e d i c a l There w i l l be no s i g n i f i c a n t t e s t s o f n u t r i t i o n a t t i t u d e s p r a c t i t i o n e r s , o b s t e t r i c i a n s on sex o f the respondent. There w i l l be no s i g n i f i c a n t t e s t s o f n u t r i t i o n a t t i t u d e s p r a c t i t i o n e r s , o b s t e t r i c i a n s on l o c a t i o n o f p r a c t i c e . There w i l l be no s i g n i f i c a n t t e s t s o f n u t r i t i o n a t t i t u d e s p r a c t i t i o n e r s , o b s t e t r i c i a n s on years o f p r a c t i c e . There w i l l be no s i g n i f i c a n t t e s t s o f n u t r i t i o n a t t i t u d e s p r a c t i t i o n e r s , o b s t e t r i c i a n s on type of p r a c t i c e . There w i l l be no s i g n i f i c a n t t e s t s of n u t r i t i o n a t t i t u d e s were t e s t e d : d i f f e r e n c e s a c h i e v e d i n and p r a c t i c e s of g e n e r a l and p e d i a t r i c i a n s based t r a i n i n g . d i f f e r e n c e s achieved i n and p r a c t i c e s of g e n e r a l and p e d i a t r i c i a n s based d i f f e r e n c e s a c hieved i n and p r a c t i c e s of g e n e r a l and p e d i a t r i c i a n s based d i f f e r e n c e s a c h i e v e d i n and p r a c t i c e s o f g e n e r a l and p e d i a t r i c i a n s based d i f f e r e n c e s a c h i e v e d i n and p r a c t i c e s of g e n e r a l and p e d i a t r i c i a n s based d i f f e r e n c e s a c h i e v e d i n and p r a c t i c e s o f g e n e r a l 10 p r a c t i t i o n e r s , o b s t e t r i c i a n s and p e d i a t r i c i a n s based on number of p r e n a t a l p a t i e n t s and/or i n f a n t s seen weekly. 7. There w i l l be no s i g n i f i c a n t d i f f e r e n c e s achieved i n t e s t s of n u t r i t i o n a t t i t u d e s and p r a c t i c e s of general p r a c t i t i o n e r s , o b s t e t r i c i a n s and p e d i a t r i c i a n s based on sources of n u t r i t i o n i n f o r m a t i o n c o n s u l t e d . 8. There w i l l be no s i g n i f i c a n t d i f f e r e n c e s achieved i n t e s t s of n u t r i t i o n a t t i t u d e s and p r a c t i c e s of general p r a c t i t i o n e r s , o b s t e t r i c i a n s and p e d i a t r i c i a n s based on undertaking o f a d d i t i o n a l s p e c i a l i z a t i o n or t r a i n i n g . 9. There w i l l be no s i g n i f i c a n t d i f f e r e n c e s achieved i n t e s t s of n u t r i t i o n a t t i t u d e s and p r a c t i c e s of general p r a c t i t i o n e r s , o b s t e t r i c i a n s and p e d i a t r i c i a n s based on the number and type o f c o n t i n u i n g education programs attended i n the l a s t two years. 10. There w i l l be no s i g n i f i c a n t d i f f e r e n c e s achieved i n t e s t s of n u t r i t i o n a t t i t u d e s and p r a c t i c e s of general p r a c t i t i o n e r s , o b s t e t r i c i a n s and p e d i a t r i c i a n s based on the extent of i n c l u s i o n of n u t r i t i o n i n t h e i r medical school t r a i n i n g . 11. There w i l l be no s i g n i f i c a n t c o r r e l a t i o n among the scores f o r n u t r i t i o n a t t i t u d e s and n u t r i t i o n p r a c t i c e s achieved by the general p r a c t i t i o n e r s , o b s t e t r i c i a n s 11 and p e d i a t r i c i a n s . 12. There w i l l be no s i g n i f i c a n t d i f f e r e n c e i n the s c o r e s f o r n u t r i t i o n a t t i t u d e s and p r a c t i c e s between the g e n e r a l p r a c t i t i o n e r s and the p e d i a - t r i c i a n s . There w i l l be no s i g n i f i c a n t d i f f e r e n c e i n the s c o r e s f o r n u t r i t i o n a t t i t u d e s and p r a c - t i c e s between the g e n e r a l p r a c t i t i o n e r s and o b s t e t r i c i a n s . D e f i n i t i o n s o f Terms The f o l l o w i n g terms are d e f i n e d f o r the purpose of t h i s -.1 study: General P r a c t i t i o n e r - Conducts m e d i c a l examinations, makes d i a g n o s i s , p r e s c r i b e s medicines and g i v e s o t h e r m e d i c a l treatments f o r v a r i o u s d i s e a s e s , d i s o r d e r s and i n j u r - i e s o f the human body. Examines p a t i e n t and o r d e r s o r performs v a r i o u s t e s t s , a n a l y s e s , and X-rays t o p r o v i d e i n f o r m a t i o n on the p a t i e n t ' s c o n d i t i o n . Ana- l y z e s r e p o r t s and f i n d i n g s of t e s t s and examination and diagnoses c o n d i t i o n . A d m i n i s t e r s and p r e s c r i b e s treatments and drugs. I n o c u l a t e s and v a c c i n a t e s p a t i e n t t o immunize from communicable d i s e a s e s . Pro- v i d e s p r e n a t a l c a r e , d e l i v e r s b a b i e s , and p r o v i d e s p o s t n a t a l c a r e t o mother and i n f a n t . Promotes h e a l t h by a d v i s i n g p a t i e n t c o n c e r n i n g d i e t , hygiene, and methods of p r e v e n t i o n of d i s e a s e . Makes house and emergency c a l l s t o a t t e n d t o p a t i e n t unable t o v i s i t o f f i c e o r c l i n i c . Reports b i r t h s , deaths, and out- break o f co n t a g i o u s d i s e a s e s t o governmental author - i t i e s . May r e f e r p a t i e n t s t o s p e c i a l i s t s and a s s i s t a t s u r g i c a l p rocedures. May conduct p h y s i c a l exam- i n a t i o n s o f a p p l i c a n t s f o r i n s u r a n c e t o determine h e a l t h and r i s k i n v o l v e d . May conduct pre-employment examinations f o r company or o r g a n i z a t i o n such as p o l i c e f o r c e , and examine s t a f f t o determine e l i g i b i l i t y f o r s i c k l e a v e or d i s a b i l i t y c l a i m s . May p r o v i d e c a r e f o r passengers and crew aboard s h i p . P h y s i c i a n , General P r a c t i c e , Family Doctor. ( Canadian C l a s s i f i c a t i o n and D i c t i o n a r y of Occupations, 1971 ) 12 P e d i a t r i c i a n - C a r r i e s out me d i c a l care f o r c h i l d r e n from b i r t h through adolescence t o a i d i n p h y s i c a l and mental growth and development: examines p a t i e n t s to determine presence o f d i s o r d e r t o e s t a b l i s h p r e v e n t i v e h e a l t h p r a c t i c e s . A s c e r t a i n s nature and ext e n t o f ai l m e n t , d i s e a s e or i n j u r y ; p r e s c r i b e s and a d m i n i s t e r s m e d i c a t i o n s , immunizations, and ot h e r m e d i c a l treatments; and a d v i s e s c l i e n t s . A c t s as c o n s u l t a n t t o ot h e r m e d i c a l p r a c t i t i o n e r s i n i l l n e s s o f c h i l d r e n . May diagnose and t r e a t p r e n a t a l a b n o r m a l i t i e s and malfor m a t i o n s . C h i l d S p e c i a l i s t . ( Canadian C l a s s i f i c a t i o n and D i c t i o n a r y o f Occupations, 1971 ). O b s t e t r i c i a n - G y n e c o l o g i s t - T r e a t s women d u r i n g p r e n a t a l , n a t a l , and p o s t n a t a l p e r i o d s and diagnoses and t r e a t s d i s e a s e s o f the female r e p r o d u c t i v e t r a c t . Examines p a t i e n t t o a s c e r t a i n c o n d i t i o n , u t i l i z i n g p h y s i c a l f i n d i n g s , r e s u l t s o f l a b o r a t o r y t e s t s , and p a t i e n t ' s statements as d i a g n o s t i c a i d s . Determines need f o r m o d i f i e d d i e t and p h y s i c a l a c t i v i t i e s , and recommends p l a n . Examines p a t i e n t p e r i o d i c a l l y , and p r e s c r i b e s m e d i c a t i o n o r surg e r y , i f i n d i c a t e d . D e l i v e r s i n f a n t and c a r e s f o r mother, f o r p r e s c r i b e d p e r i o d o f time, f o l l o w i n g c h i l d b i r t h . Diagnoses and t r e a t s female p a t i e n t s f o r d i s e a s e s o f the r e p r o d u c t i v e t r a c t , u s i n g s u r g i c a l procedures as r e q u i r e d . May l i m i t p r a c t i c e t o d i a g n o s i n g and t r e a t i n g d i s e a s e s o f the female r e p r o d u c t i v e t r a c t , o r t r e a t i n g women d u r i n g p r e n a t a l , n a t a l , and p o s t n a t a l p e r i o d s and be d e s i g n a t e d a c c o r d - i n g l y . ( Canadian C l a s s i f i c a t i o n and D i c t i o n a r y o f Occupations, 1971 ). N u t r i t i o n A t t i t u d e s - P h y s i c i a n s ' a t t i t u d e s towards the import- ance o f v a r i o u s a s p e c t s o f n u t r i t i o n d u r i n g the p r e - n a t a l p e r i o d and d u r i n g i n f a n c y . An a t t i t u d e i s a "l e a r n e d , e m o t i o n a l l y toned p r e d i s p o s i t i o n t o r e a c t i n a p a r t i c u l a r way toward something" ( Redman, 1968, p. 67 ). N u t r i t i o n P r a c t i c e s - P h y s i c i a n s ' p r a c t i c e s i n c l u d i n g the techniq u e s and i n f o r m a t i o n p e r t a i n i n g t o maternal and 13 i n f a n t n u t r i t i o n used i n c o u n s e l l i n g expectant mothers and mothers or guardians o f i n f a n t s . T h i s i n c l u d e s c o u n s e l l i n g on food s e l e c t i o n and sources of n u t r i e n t s . C l i n i c P r a c t i c e - An e s t a b l i s h m e n t where p a t i e n t s are admitted f o r treatment by a group of p h y s i c i a n s p r a c t i s i n g medicine t o g e t h e r . P r i v a t e P r a c t i c e - An e s t a b l i s h m e n t where p a t i e n t s are admitted f o r treatment by a s i n g l e p h y s i c i a n . I n f a n t - A baby r a n g i n g i n age from b i r t h t o two y e a r s . M e t r o p o l i t a n Area - The c i t y of Vancouver and immediately surrounding a r e a . C i t y - Settlement o f over 5,000. Town - Settlement o f not l e s s than 2,500 and not more than 5,000. V i l l a g e - Settlement of l e s s than 2,500. Assumptions The f o l l o w i n g assumptions have been made f o r the purpose o f t h i s study: 1. The p o p u l a t i o n s t u d i e d , which accounts f o r 97% of a l l p r a c t i s i n g p e d i a t r i c i a n s , o b s t e t r i c i a n s and g e n e r a l p r a c t i t i o n e r s i n B r i t i s h Columbia, i s r e p r e s e n t a t i v e of the e n t i r e p o p u l a t i o n of p r a c - t i s i n g p e d i a t r i c i a n s , o b s t e t r i c i a n s and g e n e r a l 14 p r a c t i t i o n e r s i n the province of B r i t i s h Columbia. 2. The p h y s i c i a n s were i n v o l v e d i n c o u n s e l l i n g expec- t a n t mothers and/or mothers of i n f a n t s on matters of n u t r i t i o n . 3. The p h y s i c i a n s completed the q u e s t i o n n a i r e i n good f a i t h and without any help from books, col l e a g u e s or other resources. CHAPTER II REVIEW OF THE LITERATURE Good h e a l t h throughout the l i f e c y c l e i s important f o r every i n d i v i d u a l and n u t r i t i o n i s a v i t a l component of good h e a l t h . I t has l o n g been known t h a t p e r i o d s of r a p i d growth are p e r i o d s o f s p e c i a l v u l n e r a b i l i t y t o n u t r i t i o n a l i n j u r y . Two such p e r i o d s of r a p i d growth occur d u r i n g pregnancy and i n i n f a n c y . Hence, s p e c i a l c a r e must be taken t o ensure optimum n u t r i t i o n f o r the pregnant woman and her f e t u s and f o r the i n f a n t . I t i s the r e s p o n s i b i l i t y of the h e a l t h p r o f e s s i o n a l s concerned w i t h maternal and i n f a n t c a r e t o r e c o g n i z e the impor- tance of n u t r i t i o n a t these stages of the l i f e c y c l e and t o encourage, c o u n s e l and d i r e c t the m a t e r n a l p o p u l a t i o n i n the attainment o f proper n u t r i t i o n a l h a b i t s . N u t r i t i o n i n Pregnancy E f f e c t of N u t r i t i o n On the Outcome of Pregnancy Optimum n u t r i t i o n d u r i n g pregnancy can have f a r - r e a c h i n g e f f e c t s on the h e a l t h and w e l l - b e i n g of the mother and i n f a n t . Formerly i t was thought t h a t the f e t u s was a t o t a l p a r a s i t e from a n u t r i t i o n a l p o i n t o f view, growing normally at the expense of the mother. I t i s apparent now, however, t h a t both the mother and the f e t u s are a f f e c t e d by the q u a n t i t y and q u a l i t y of 15 16 the maternal d i e t . The e f f e c t s of extreme n u t r i t i o n a l d e p r i v a t i o n d u r i n g pregnancy on the m o r t a l i t y and m o r b i d i t y of the o f f s p r i n g have been amply demonstrated i n animal experiments. For obvious e t h i c a l reasons, such experiments cannot be performed on humans. Many s t u d i e s t h a t have attempted t o a ssess the impact o f n u t r i t i o n on the course and outcome o f human pregnancy have shown a c o r r e l a t i v e r a t h e r than a c a u s a t i v e e f f e c t . ( For reviews see Committee on M a t e r n a l N u t r i t i o n , 1970; Bergner and Susser, 1970; Osofsky, 1975 ). N e v e r t h e l e s s , t h i s c o r r e l a t i v e r e l a t i o n s h i p i s so c o n s i s t e n t t h a t i t p r o v i d e s c o n v i n c i n g evidence t h a t the p r e n a t a l d i e t does a f f e c t the h e a l t h o f the o f f s p r i n g . A number o f the e a r l y works t h a t suggest a d e f i n i t e r e l a t i o n s h i p between maternal n u t r i t i o n and the outcome of pregnancy were o b t a i n e d from l a r g e - s c a l e o b s e r v a t i o n s . During World War I I severe n u t r i t i o n a l d e p r i v a t i o n o c c u r r e d f o r c e r t a i n segments o f the European p o p u l a t i o n . In r e t r o s p e c t i v e s t u d i e s , Antonov (1947) i n L e n i n g r a d and Smith (1947) i n H o l l a n d , a s s e s s e d the impact o f wartime s t a r v a t i o n on the maternal popu- l a t i o n . The r e s u l t s i n d i c a t e d a marked decrease i n the f e r t i l - i t y r a t e , s i g n i f i c a n t i n c r e a s e s i n the p r e m a t u r i t y and s t i l l - b i r t h r a t e s and an i n c r e a s e i n n e o n a t a l m o r t a l i t y d u r i n g the p e r i o d of d e p r i v a t i o n . 17 In Great B r i t a i n the wartime s i t u a t i o n c o n t r a s t s w i t h Leningrad and Ho l l a n d but str e n g t h e n s the h y p o t h e s i s t h a t n u t r i t i o n i s important t o r e p r o d u c t i v e e f f i c i e n c y . A t t h i s time, the B r i t i s h government i n t r o d u c e d a p o l i c y o f food r a t i o n i n g i n which pregnant women were g i v e n s p e c i a l p r i o r i t y ( B a i r d , 1965 ). The q u a l i t y o f the d i e t o f pregnant women, e s p e c i a l l y those i n the low income groups, was s i g n i f i c a n t l y enhanced. Subsequently, the s t i l l b i r t h r a t e f e l l a n o t a b l e 25% d u r i n g t h i s p e r i o d o f improved n u t r i t i o n a l i n t a k e . Other s t u d i e s o f n u t r i t i o n d u r i n g pregnancy have been conducted when d i e t a r y i n t a k e was not regimented ( Ebbs e t a_l. , 1942; Burke e t ajL. , 1943; B a l f o u r , 1944; Cameron and Graham, 1944; Dieckman e t a l . , 1951; Jeans e t a l . , 1955 ). In g e n e r a l , the f i n d i n g s o f these s t u d i e s support the t h e s i s t h a t "good" d i e t s have a more f a v o u r a b l e e f f e c t on the outcome of pregnancy than do "poor" d i e t s . In most cases a f a v o u r a b l e e f f e c t on the outcome o f pregnancy was c o n s i d e r e d t o be a r e d u c t i o n i n the i n c i d e n c e o f p r e m a t u r i t y , s t i l l b i r t h s and n e o n a t a l m o r t a l i t y . G e n e r a l l y , no c o n s i d e r a t i o n was g i v e n t o the s t a t u s o f the mother a t the t e r m i n a t i o n o f pregnancy. Not a l l s t u d i e s , however, have shown such a d i r e c t r e l a t i o n s h i p between n u t r i t i o n and i n f a n t v i a b i l i t y ( W i l l i a m s and F r a l i n , 1942; McGanity e t a l . , 1953; Macy e t a l . , 1954; 18 Tompkins e t a l . , 1955; Crump e t al., 1959 ). One of the most comprehensive o f these s t u d i e s was conducted by McGanity and co-workers on over 2,000 pregnant women at V a n d e r b i l t U n i v e r s i t y i n Tennessee. A complete n u t r i t i o n a l e v a l u a t i o n o f the g r a v i d a , i n c l u d i n g p h y s i c a l examination, b i o c h e m i c a l d e t e r - m i n a t i o n s o f body f l u i d s and a seven day d i e t a r y r e c o r d , was conducted d u r i n g each t r i m e s t e r o f pregnancy. The f i n d i n g s o f the study i n d i c a t e d no d i r e c t r e l a t i o n s h i p between n u t r i t i o n and o b s t e t r i c and f e t a l a b n o r m a l i t i e s . The authors concluded t h a t e i t h e r t h e r e was no d i r e c t c a u s a t i v e r e l a t i o n s h i p between m a l n u t r i t i o n and the outcome o f pregnancy o r t h a t the s u b j e c t s o f t h i s study were above any such l e v e l o f n u t r i t i o n r e q u i r e d to p r e c i p i t a t e a d e t r i m e n t a l e f f e c t . I t s hould be noted t h a t i n t h i s study the i n c i d e n c e o f low b i r t h weight was s l i g h t l y below the n a t i o n a l average, which suggests t h a t t h i s group was c e r t a i n l y not a t r i s k . F u r t h e r - more, the d i e t s o f these women were c o n s i d e r e d t o be " g r a t i f y - i n g l y v a r i e d " and 27% of the women w i t h the lowest n u t r i t i o n a l i n t a k e s were g i v e n v i t a m i n o r m i n e r a l supplements. These supplements were not i n c l u d e d i n c a l c u l a t i n g n u t r i e n t i n t a k e s and thus, d e f i c i e n c i e s may have been r e c o r d e d when i n f a c t t h e r e were none. Because o f the i n c o n s i s t e n c i e s i n the r e s u l t s , r e s e a r c h i n t h i s area was c u r t a i l e d u n t i l r e c e n t l y . Habicht e t al. (1974) r e p o r t e d the r e s u l t s of a n u t r i t i o n a l supplementation program i n 19 Guatemala. The data i n d i c a t e d t h a t t h e r e were no s i g n i f i c a n t d i f f e r e n c e s i n b i r t h weight of o f f s p r i n g based on p r o t e i n i n t a k e of mother. However, women who had i n g e s t e d g r e a t e r than 20,000 c a l o r i e s i n the form of a supplement throughout the e n t i r e pregnancy had b a b i e s w i t h b i r t h weights s i g n i f i c a n t l y g r e a t e r than those who had i n g e s t e d fewer than 20,000 c a l o r i e s o f supplement. The authors concluded t h a t c a l o r i e s r a t h e r than p r o t e i n appeared t o be the l i m i t i n g f a c t o r i n i n f l u e n c i n g b i r t h weight of the o f f s p r i n g . H i g g i n s (1972) i n M o n t r e a l r e p o r t e d r e s u l t s on over 1,500 p a t i e n t s seen a t the Montreal D i e t Dispensary from 1963-71. P a t i e n t s ' d i e t s were e v a l u a t e d f o r n u t r i t i o n a l i n t a k e and the p a t i e n t s were i n d i v i d u a l l y c o u n s e l l e d on methods o f improving t h e i r d i e t s . Mothers on low incomes were p r o v i d e d w i t h f o o d supplements. The r e s u l t s i n d i c a t e d t h a t the r a t e s of p e r i n a t a l m o r t a l i t y and p r e m a t u r i t y were s i m i l a r t o those o f the p r i v a t e p a t i e n t s and s i g n i f i c a n t l y lower than f o r o t h e r p u b l i c c l i n i c p a t i e n t s . Although the f i n d i n g s o f the above s t u d i e s show some c o n f l i c t i n g r e s u l t s , these i n c o n s i s t e n c i e s may be r e l a t e d t o problems i n methodology and d e s i g n r a t h e r than b e i n g i n d i c a t i v e o f a l a c k o f an a s s o c i a t i o n between maternal d i e t and outcome of pregnancy. A d d i t i o n a l l y , Calloway (1974) has noted t h a t : 20 . . . most s t u d i e s have based assessment of e f f i c i e n c y o f treatments d u r i n g pregnancy s o l e l y on the s i z e and c o n d i t i o n of the newly- born c h i l d and have shown a s u r p r i s i n g l a c k of a p p r e c i a t i o n f o r the c o n d i t i o n of the mother ( P . 91 ). Women can and do bear v i a b l e o f f s p r i n g a t l e s s than o p t i m a l n u t r i t i o n a l i n t a k e s but the c o s t t o the mother i n terms of maternal d e p l e t i o n or d e l a y e d r e c o v e r y r a t e may be c o n s i d e r a b l e . T h i s i s p a r t i c u l a r l y t r u e f o r the pregnant a d o l e s c e n t who r e q u i r e s a h i g h n u t r i e n t i n t a k e f o r her own growth as w e l l as f o r t h a t of the f e t u s . Pregnant a d o l e s c e n t s are known t o have a p a r t i c u l a r l y h i g h i n c i d e n c e o f toxemia ( Aznar and Bennett, 1961; Mussio, 1962; I s r a e l and Woutersz, 19 63; Claman and B e l l , 19 64; Committee on M a t e r n a l N u t r i t i o n , 1970 ) and anemia ( I s r a e l and Woutersz, 1963; Committee on M aternal N u t r i t i o n , 1970 ). Poor d i e t s as w e l l as inadequate p r e n a t a l care are o f t e n mentioned as important f a c t o r s c o n t r i - b u t i n g t o the toxemia i n these v e r y young mothers ( Claman and B e l l , 1964; Committee on M a t e r n a l N u t r i t i o n , 1970 ). Weight Gain In Pregnancy Although "good" n u t r i t i o n or supplementation has not been c o n s i s t e n t l y r e l a t e d t o an improved outcome of pregnancy, t o t a l weight g a i n d u r i n g pregnancy i s s t r o n g l y r e l a t e d to b i r t h weight of the i n f a n t ( Eastman and Jackson, 1968; S i n g e r et al^. , 1968; H i g g i n s , 1972 ). As weight g a i n d u r i n g pregnancy i n c r e a s e s so does b i r t h weight. Low b i r t h weight i s w e l l e s t a b l i s h e d as an antecedent o f i n c r e a s e d m o r t a l i t y i n i n f a n t s , and o f mental r e t a r d a t i o n and ot h e r n e u r o l o g i c a l d i s o r d e r s ( Bergner and Susser, 1970; Simpson et aJL. , 1975 ). In a review of weight g a i n d u r i n g pregnancy, Hytten and L e i t c h (1971) concluded t h a t a weight g a i n o f 25-30 pounds i s c o n s i s t e n t w i t h improved r e p r o d u c t i v e e f f i c i e n c y . These authors reviewed e a r l i e r works and based many of t h e i r c o n c l u - s i o n s on a l a r g e - s c a l e study o f normal p r i m i g r a v i d a e e a t i n g a c c o r d i n g t o t h e i r a p p e t i t e s ( Thomson and B i l l e w i c z , 1957 ). The average weight g a i n f o r these women was 27.5 pounds or 12.5 kilogr a m s . The average weight g a i n f o r m u l t i g r a v i d a e was approximately two pounds fewer. A f t e r an e x t e n s i v e review o f the l i t e r a t u r e , t he Committee on Ma t e r n a l N u t r i t i o n (1970) r e p o r t e d 24 pounds or 10.9 kilograms as an optimum weight g a i n d u r i n g pregnancy. T h i s v a l u e was a l s o adopted by the N u t r i t i o n i n Pregnancy Committee (1973) i n B r i t i s h Columbia. Although t h i s f i g u r e i s taken as the average weight g a i n f o r a normal woman, t h e r e does not seem t o be any harm w i t h i n t a k e s somewhat g r e a t e r than t h i s . Recent work does not bear out the c l a i m t h a t a d d i t i o n a l f a t accumula- t i o n d u r i n g pregnancy p r e d i s p o s e s t o toxemia o r i n c r e a s e d o b s t e t r i c a l d i f f i c u l t i e s i n the normal pregnant woman ( Committee on M a t e r n a l N u t r i t i o n , 1970 ). Moreover, S i n g e r e t _ a l . (1968) have shown t h a t e x c e s s i v e weight g a i n i n pregnancy i s a s s o c i a t e d 22 wi t h i n c r e a s e d i n f a n t b i r t h weight and with improved i n t e l l e c - t u a l a b i l i t y o f the c h i l d i n l a t e r l i f e . A d e t e r r e n t t o pregnant women g a i n i n g an e x c e s s i v e amount of weight ( g r e a t e r than 35 pounds ) i s the p o s s i b l e r e l a t i o n s h i p o f e x c e s s i v e f a t accumulation i n pregnancy and subsequent l a t e r o b e s i t y . Some f a t accumulation i s a n a t u r a l p h y s i o l o g i c a l consequence o f pregnancy ( Hytten and L e i t c h , 1971 ) t h a t one sho u l d not attempt t o a v o i d . In r e t u r n i n g t o i d e a l weight a f t e r p a r t u r i t i o n the Food and N u t r i t i o n Board of the N a t i o n a l Academy o f S c i e n c e s (1974) i n i t s l a t e s t recommen- ded allowances, have advocated a r e d u c t i o n i n t o t a l c a l o r i c i n t a k e d u r i n g l a c t a t i o n so t h a t t h i s s t o r e d energy might be used f o r m i l k p r o d u c t i o n . Intakes o f o t h e r n u t r i e n t s must remain adequate. For women who e n t e r pregnancy i n a s t a t e o f o b e s i t y , no attempt should be i n i t i a t e d e i t h e r t o reduce weight o r t o r e s t r i c t t h e i r weight g a i n ( Committee on Ma t e r n a l N u t r i t i o n , 1970; P i t k i n e t a l . , 1972 ). Marked c a l o r i c r e s t r i c t i o n , even w i t h adequate p r o t e i n i n t a k e , can r e s u l t i n u t i l i z a t i o n o f p r o t e i n f o r energy, thus making i t u n a v a i l a b l e f o r t i s s u e growth and r e p a i r . In a d d i t i o n , i t has been suggested t h a t a c e t o n u r i a , produced by the c a t a b o l i s m o f maternal f a t s t o r e s , may be a s s o c i a t e d w i t h i n t e l l e c t u a l impairment i n the o f f s p r i n g ( C h u r c h i l l , 1970 ). 23 Sodium R e s t r i c t i o n Toxemia o f pregnancy i s g e n e r a l l y a s s o c i a t e d w i t h edema and abnormal sodium r e t e n t i o n . The r o u t i n e r e s t r i c t i o n o f s a l t d u r i n g pregnancy i n the hope of a v o i d i n g o r r e d u c i n g edema for m a t i o n has gained widespread acceptance i n me d i c a l p r a c t i c e . Although the r e l a t i o n s h i p o f sodium i n t a k e t o the treatment o f toxemia remains u n c l e a r , the d i e t a r y r e s t r i c t i o n o f s a l t i n t a k e w i t h the aim o f p r e v e n t i n g p r e - e c l a m p s i a i s i n e f f e c t i v e ( Committee on Mate r n a l N u t r i t i o n , 1970; P i t k i n e t a l . , 1972; Lindheimer and Katz, 1974 ) . The evidence f o r u t i l i z i n g sodium r e s t r i c t i o n i n the treatment o f toxemia i s c o n f l i c t i n g . In a t l e a s t one study i n v o l v i n g h i g h and low sodium i n t a k e s f o r the treatment o f acute toxemia, no d i f f e r e n c e s i n the c l i n i c a l c ourses were apparent ( Mengert and T a c c h i , 1961 ). "Abnormal" weight g a i n , p r e v i o u s l y c o n s i d e r e d the hallmark o f t h i s d i s e a s e , may not occur, and o v e r t edema may not be pr e s e n t even when o t h e r m a n i f e s t a t i o n s of p r e - e c l a m p s i a are severe ( Lindheimer and Katz, 1974 ) . Rhodes ( 1962 ) demonstrated t h a t the severe forms o f toxemia were a s s o c i a t e d w i t h an abnormally low weight g a i n i n pregnancy. On the o t h e r hand, many normal pregnancies are accom- panied by some degree o f edema. Thomson e t a l . (1967) conducted a r e t r o s p e c t i v e study of over 24,000 s i n g l e l e g i t i m a t e b i r t h s and found t h a t n e a r l y 40% of the mothers o f these i n f a n t s 24 expe r i e n c e d some evidence o f edema. Moreover, women w i t h edema had babies w i t h g r e a t e r b i r t h weights and reduced r a t e s o f p e r i n a t a l m o r t a l i t y . These d i f f e r e n c e s , however, were not s t a t i s t i c a l l y s i g n i f i c a n t . Hytten and L e i t c h (1971), a f t e r r e v i e w i n g the data on t o t a l body water concluded t h a t : . . . i t seems re a s o n a b l e t o r e g a r d edema as having p h y s i o l o g i c a l r a t h e r than p a t h o l o g i c a l s i g n i f i c a n c e i n pregnancy ( p. 348 ). Thus, r e s t r i c t i o n o f sodium i n an attempt t o e l i m i n a t e edema i s unwarranted. Sodium, l i k e o t h e r e s s e n t i a l n u t r i e n t s , i s needed d u r i n g pregnancy f o r normal f e t a l growth and development. Data from s t u d i e s on pregnant r a t s ( P i k e , 1964; Pi k e and Gursky, 1970 ) i n d i c a t e d t h a t sodium r e s t r i c t i o n may tax the p h y s i o l o g i c a l me- chanisms o f sodium c o n s e r v a t i o n thereby p r e v e n t i n g b l o o d volume from expanding and l e a d i n g t o hyponatremia. Sodium d e p l e t i o n o f the muscle, bone and b r a i n of the maternal organism was e v i - dent i n the r e s t r i c t e d animals and f e t u s e s o f these pregnant r a t s had an i n c r e a s e d m o i s t u r e c o n t e n t , p o s s i b l y i n d i c a t i n g f e t a l immaturity ( K i r k s e y e t a_l. 1962 ) . Although the r e s u l t s o f s t u d i e s w i t h l a b o r a t o r y animals must be i n t e r p r e t e d j u d i c i o u s - l y , i t appears r e a s o n a b l e t o suspect t h a t severe sodium r e s t r i c - t i o n may have d e l e t e r i o u s e f f e c t s i n the human. Lindheimer and Katz (19 74) s t a t e t h a t t h e r e are some pregnant women who t o l e r a t e sodium r e s t r i c t i o n p o o r l y and t h a t r o u t i n e s a l t r e s t r i c t i o n as a means o f l i m i t i n g edema and hence, weight g a i n i s unnecessary. Since c l a i m s t h a t s a l t r e s t r i c t i o n reduces the i n c i d e n c e o f toxemia are un c o n v i n c i n g , these authors conclude t h a t : . • . . the pregnant woman should be allowed t o s a l t her food to t a s t e ( p. 4 38 ). In a d d i t i o n , i t should be noted t h a t i n Canada, because of compulsory i o d i z a t i o n , s a l t p r o v i d e s a s i g n i f i c a n t amount o f i o d i n e t o r e s i d e n t s of r e g i o n s low i n t h i s n u t r i e n t . Routine r e s t r i c t i o n o f s a l t may, t h e r e f o r e , d e p r i v e pregnant women o f an important source o f an e s s e n t i a l n u t r i e n t . I r o n Intake Pregnancy imposes a c o n s i d e r a b l e burden on i r o n needs, not o n l y f o r the i n c r e a s e d requirements o f the f e t u s but a l s o to compensate f o r the a d d i t i o n a l needs f o r i n c r e a s e d maternal blo o d volume. Red c e l l volume i n c r e a s e s approximately 30% wh i l e plasma volume i n c r e a s e s about 50%. T h i s r e s u l t s i n a decrease i n hemoglobin l e v e l s because o f h e m o d i l u t i o n . Some workers have s p e c u l a t e d t h a t t h i s d i l u t i o n might be ne c e s s a r y to f a c i l i t a t e blood flow through the maternal organism and p l a c e n t a ( Hytten and L e i t c h , 1971; H a l l , 1974 ). Most i n v e s t i - g a t o r s d i s a g r e e , however, and suggest t h a t a hemoglobin l e v e l above 12 g per 100 ml i s an a p p r o p r i a t e l e v e l d u r i n g the l a t t e r p a r t o f pregnancy. M a i n t a i n i n g hemoglobin l e v e l s above t h i s v a l u e r e q u i r e s an a d d i t i o n a l 700 mg of i r o n ( C o u n c i l on Food 26 and N u t r i t i o n , 1968 ), most of i t i n the l a t t e r h a l f of preg- nancy. Iro n s t o r e s i n h e a l t h y young women may be i n s u f f i c i e n t t o supply t h i s a d d i t i o n a l i r o n . S c o t t and P r i t c h a r d (19 67) s t u d i e d 114 c o l l e g e women who had never been pregnant and who were from a r e l a t i v e l y h i g h socio-economic background. Ir o n s t o r e s were "scant o r absent" ( 350 mg or l e s s ) i n t w o - t h i r d s of the sample. De Leeuw e t a l . (1966) s t u d i e d the i r o n r e s e r v e s of pregnant women and found t h a t by the t h i r d t r i m e s t e r i r o n s t o r e s were absent i n the m a j o r i t y o f women. At the time of d e l i v e r y 84% had no measurable r e s e r v e s . S i n c e body r e s e r v e s o f i r o n may not be adequate t o meet the a d d i t i o n a l demands of pregnancy, i r o n i n t a k e must be i n - creased s u b s t a n t i a l l y . The Canadian D i e t a r y Standard (1974) has e s t a b l i s h e d a recommended d a i l y i n t a k e o f 15 mg d u r i n g pregnancy w h i l e the Food and N u t r i t i o n Board i n the U n i t e d S t a t e s (19 74) suggests a d a i l y i n t a k e g r e a t e r than 18 mg. These i n t a k e s can be somewhat d i f f i c u l t t o o b t a i n from d i e t alone s i n c e foods commonly consumed by women c o n t a i n approximately 6 mg o f i r o n per 1,000 c a l o r i e s . Pregnant women i n the Un i t e d S t a t e s i n g e s t approximately 13 o r 14 mg o f i r o n per day from d i e t a r y sources ( P r i t c h a r d , 1970 ). Consequently, i r o n supplements d u r i n g pregnancy appear t o be nece s s a r y ( P r i t c h a r d , 1970; Chanarin and Rothman, 1971; P i t k i n e t a l . , 1972; S c o t t e t a l . , 1975 ). Si n c e most of t h i s i r o n i s needed i n the l a t t e r h a l f o f preg- 27 nancy and i n view of the recent warning about the teratogenic e f f e c t of iron given i n the f i r s t 56 days of pregnancy ( Nelson and Forfar, 1971 ), i t would seem appropriate to r e s t r i c t supplements to the l a s t h a l f of pregnancy. Dietary Practices of Pregnant Women The n u t r i t i o n a l requirements of the pregnant woman are greatly increased over those of the non-gravid state. In order to meet the increased nutrient allowances set by the Canadian Dietary Standard (1974) or the Food and N u t r i t i o n Board (1974) i n the United States, i t i s necessary to choose foods c a r e f u l l y so as not to exceed the optimum c a l o r i c intake but s t i l l obtain the necessary protein, vitamins and minerals. Several older studies have reported on the nutrient intakes of pregnant women ( Ebbs et a l . , 1941; Burke et a l . , 1943; Jeans et a l . , 1952; Murphy and Wertz, 1954; Stevens and Ohlson, 1967 ). The major findings of these studies indicated that d i e t s for expectant mothers were frequently inadequate i n calcium, protein and ir o n . Vitamin and mineral supplementation increased the iron intake but did not a l l e v i a t e the lack of calcium and protein i n the d i e t s of these women. More recent studies ( Bartholomew and Poston, 1970; Nobmann and Adams, 1970; H a r r i l l et a l . , 1973; N u t r i t i o n Canada, 1973; Thompson et a l . , 1974 ) have demonstrated that nutrient intakes during pregnancy remain below desirable l e v e l s . This i s p a r t i c u l a r l y 28 t r u e f o r the pregnant a d o l e s c e n t ( Weigley, 1975 ). Bartholomew and Poston (1970) r e p o r t e d t h a t i n t a k e s o f p r o t e i n , i r o n , v i t a m i n A and v i t a m i n C were below recommended d i e t a r y standards i n a group o f 200 p a t i e n t s r e g i s t e r e d i n a p r e n a t a l c l i n i c i n South C a r o l i n a . The poor n u t r i t i o n was a t t r i b u t e d p r i m a r i l y t o n u t r i t i o n i g n o r a n c e , and secondly , t o s p e c i f i c d i s l i k e s f o r v a r i o u s foods. S u p e r s t i t i o n s and b i z a r r e food customs p l a y e d a s m a l l e r y e t important r o l e . In 1970, Nobmann and Adams r e c o r d e d the d i e t a r y i n t a k e of 46 p r e n a t a l p a t i e n t s and found the i n t a k e s o f i r o n , c a l c i u m , v i t a m i n A and r i b o f l a v i n t o be below t w o - t h i r d s o f the recom- mended d i e t a r y i n t a k e f o r over 20% o f the sample. V i t a m i n - m i n e r a l p r e p a r a t i o n s i n c r e a s e d the i n t a k e s o f a l l n u t r i e n t s t o a c c e p t a b l e l e v e l s except f o r p r o t e i n and c a l c i u m . The n u t r i t i v e v a l u e o f foods s e l e c t e d by a group o f 30 p a t i e n t s i n Colorado was as s e s s e d by H a r r i l l and co-workers (1973). Comparison of mean d i e t a r y i n t a k e w i t h the recommended d i e t a r y allowances showed t h a t c a l c i u m , i r o n and t h i a m i n were the n u t r i e n t s l e a s t s u p p l i e d by the foods eaten. Most p a t i e n t s took v i t a m i n - m i n e r a l supplements but the co n t e n t o f these p r e p a r a t i o n s was not i n c l u d e d i n the c a l c u l a t i o n of n u t r i e n t i n t a k e . The r e p o r t from N u t r i t i o n Canada (1973) on the n u t r i t i o n - a l s t a t u s o f pregnant women i n d i c a t e s t h a t n u t r i e n t i n t a k e s are s t i l l inadequate i n a s i g n i f i c a n t p o r t i o n o f the maternal p o p u l a t i o n . The data on d i e t a r y i n t a k e ( Table I ) i s based on a t o t a l sample o f 894 pregnant women who were r e f e r r e d t o N u t r i t i o n Canada by l o c a l h e a l t h u n i t s . TABLE I PERCENTAGE OF PREGNANT WOMEN WITH INADEQUATE AND LESS-THAN-ADEQUATE INTAKES OF NUTRIENTS N u t r i e n t General P o p u l a t i o n Inadequate Less-than-Adequate P r o t e i n 3.3 8.5 I r o n 24.8 22.6 Calcium 19.9 18.6 P o t e n t i a l V i t a m i n D 28.9 28.6 V i t a m i n A 10.9 14.9 V i t a m i n C 2.0 8.2 Thiamin 3.9 21.5 R i b o f l a v i n 5.0 17.0 N i a c i n 0.8 3.9 Source: N u t r i t i o n Canada, N a t i o n a l Survey, Department of N a t i o n a l H e a l t h and Welfare, Ottawa, Canada. 1973, p. 110. B i o c h e m i c a l e v a l u a t i o n f o r a number of n u t r i e n t s suppor- t e d the d i e t a r y f i n d i n g s . T h i r t y p e r c e n t of the pregnant women i n the g e n e r a l p o p u l a t i o n were c l a s s i f i e d as "at r i s k " because of low v a l u e s f o r t o t a l serum p r o t e i n . However, the decrease i n serum p r o t e i n l e v e l s i s a normal occurrence d u r i n g pregnancy 30 so t he s i g n i f i c a n c e o f t h i s f i n d i n g r ema i n s u n c l e a r . Hemog lob in v a l u e s showed a mode ra te r i s k o f anemia ( v a l u e s between 9.0 - 10.5 g p e r 100 m l ) i n 25% o f t h e g e n e r a l p o p u l a t i o n ; 25% o f t h e sample a l s o had i n a d e q u a t e i n t a k e s o f v i t a m i n D. The s p e c i f i c f i n d i n g s f o r B r i t i s h C o l u m b i a ( T a b l e I I ) showed t h a t c a l o r i c i n t a k e , p r o t e i n and v i t a m i n D were b e l o w adequa te f o r a s i g n i f i c a n t p r o p o r t i o n o f t h e sample p o p u l a t i o n . However, e x c e s s i v e i n t a k e s o f v i t a m i n D were a l s o o b s e r v e d i n a s m a l l number o f p r e g n a n t women. TABLE I I PERCENTAGE OF PREGNANT WOMEN IN BRIT ISH COLUMBIA WITH LESS THAN TWO-THIRDS OF THE RECOMMENDED DAILY INTAKE OF NUTRIENTS N u t r i e n t Recommended D a i l y I n t a k e % W i t h Le s s Than 2/3 R.D. I . C a l o r i e s 2,400 21% P r o t e i n 61 grams 12% P o t e n t i a l V i t a m i n D 400 I .U . 40% I r o n 15 mg 15% S o u r c e : N u t r i t i o n Canada, The B r i t i s h C o l u m b i a Su rvey R e p o r t , Depar tment o f N a t i o n a l H e a l t h and W e l f a r e , O t t a w a , Canada, 1975, p. A p p e n d i x T a b l e s f o l l o w i n g p. 152. a Based on C a n a d i a n D i e t a r y S t a n d a r d , 1974. May be h i g h e r t h a n a c t u a l i n t a k e . 31 I t should be noted t h a t pregnant women i n t h i s survey d i d not c o n s t i t u t e a p r o b a b i l i t y sample and may t h e r e f o r e : . . . show a s u p e r i o r p i c t u r e o f h e a l t h compared t o t h a t which a c t u a l l y e x i s t s i n the pregnant p o p u l a t i o n ( N u t r i t i o n Canada, 1973, p. 103 ). N u t r i t i o n E d u c a t i o n F o r Pregnancy E f f e c t i v e n u t r i t i o n e d u c a t i o n i s n e c e s s a r y i n o r d e r t o ensure optimum n u t r i t i o n f o r the mother and the b e s t p o s s i - b l e n u t r i t i o n a l s t a r t f o r the i n f a n t . I t i s e v i d e n t from the p r e v i o u s s t u d i e s t h a t the d i e t a r y h a b i t s of many pregnant women are l e s s than adequate. In r e c e n t y e a r s the most common approach to t h i s problem o f d i e t a r y inadequacy appears t o have been the i n d i s c r i m i n a n t use o f v i t a m i n and m i n e r a l supplements by a l l pregnant p a t i e n t s r e g a r d l e s s of n u t r i e n t i n t a k e ( King e t a l . , 1972; P i t k i n e t a l . , 1972; Thompson e t a l . , 1974 ). In some cases the v i t a m i n - m i n e r a l p r e p a r a t i o n s d i d not c o n t a i n the nu- t r i e n t s which were most d e f i c i e n t i n the d i e t ( Jeans e t a l . , 1952; H a r r i l l e t a l . , 1973 ), w h i l e i n o t h e r s the c o n t r i b u t i o n from the supplement alone exceeded the recommended allowance by 500% ( Thompson e t a l . , 1974 ). H a r r i l l e t a_l. (1973) commented on the o v e r - r e l i a n c e by pregnant women on v i t a m i n - m i n e r a l supplementation and s t a t e d t h a t : . . . i t has long been r e c o g n i z e d t h a t i n c r e a s e d i n t a k e of one or more n u t r i e n t s may i n c r e a s e the need o f o t h e r n u t r i e n t s which may o r may not be p r o v i d e d by the supplementation ( p. 165 ). 32 E x c e s s i v e i n t a k e s of some v i t a m i n s and m i n e r a l s may be poten- t i a l l y dangerous. High l e v e l s of v i t a m i n D d u r i n g pregnancy are p o s s i b l y r e l a t e d t o h y p e r c a l c e m i a i n the i n f a n t ( P i t k i n e t a l . , 1972 ); e x c e s s i v e i n t a k e s of v i t a m i n C may induce a h i g h requirement f o r a s c o r b i c a c i d i n the o f f s p r i n g ( Cochrane, 19 6 5 ); and h i g h l e v e l s of v i t a m i n supplements as w e l l as i r o n p r e p a r a t i o n s have been r e l a t e d to an i n c r e a s e d i n c i d e n c e of a b n o r m a l i t i e s i n the f e t u s ( Nelson and F o r f a r , 1971 ). P i t k i n e t a l . (1972) suggested t h a t an a d d i t i o n a l reason f o r the avoidance o f r o u t i n e supplementation i s t h e : . . . f a l s e sense of s e c u r i t y i t may convey to e i t h e r p a t i e n t or p h y s i c i a n r e g a r d i n g d e f i c i e n c i e s o f e s s e n t i a l n u t r i t i o n a l elements o t h e r than v i t a m i n s . V i t a m i n s w i l l c e r t a i n l y not compensate f o r poor food h a b i t s ( p. 775 ) . Since r o u t i n e supplementation does not appear to be a p p r o p r i a t e , n u t r i t i o n e d u c a t i o n i n the form of i n c r e a s i n g n u t r i t i o n know- ledge by d i e t a r y i n s t r u c t i o n may have a b e n e f i c i a l e f f e c t on improving food h a b i t s d u r i n g pregnancy. The l i t e r a t u r e on t h i s t o p i c , a l t h o u g h somewhat l i m i t e d , suggests t h a t d i e t i n s t r u c t i o n can a f f e c t n u t r i e n t i n t a k e i n a p o s i t i v e way. One o f the e a r l i e s t s t u d i e s on the e f f e c t s of d i e t e d u c a t i o n d u r i n g pregnancy was conducted by B e r r y e_t a l . (19 52) . During a d i e t a r y i n t e r v i e w , d i e t s were c l a s s i f i e d as e i t h e r "good", " f a i r " o r "poor". P a t i e n t s who were randomly s e l e c t e d f o r the e x p e r i m e n t a l group were g i v e n i n s t r u c t i o n s a t t h r e e p e r i o d s throughout the pregnancy on s p e c i f i c ways t o improve t h e i r d i e t s . At the end of pregnancy, more p a t i e n t s i n the ' i n s t r u c t e d ' group had 'good' d i e t s than d i d those i n the ' c o n t r o l ' group but t h i s d i f f e r e n c e was not s i g n i f i c a n t . How- ever, the i n c r e a s e i n the percentage of good d i e t s over the percentage a t the f i r s t i n t e r v i e w was s i g n i f i c a n t f o r ' i n s t r u c - t e d ' p a t i e n t s but not f o r ' c o n t r o l s ' . G r e a t e r improvement by ' i n s t r u c t e d ' p a t i e n t s was found f o r i n t a k e s of c a l c i u m , i r o n , v i t a m i n A, t h i a m i n and a s c o r b i c a c i d . In a study by Mason and R i v e r s (1970) on p a t i e n t s a t t e n d i n g a p r e n a t a l c l i n i c i n New York, the r e l a t i o n s h i p between d i e t a r y i n s t r u c t i o n and plasma a s c o r b i c a c i d l e v e l s was a s s e s s e d . M u l t i p l e r e g r e s s i o n a n a l y s e s of the data i n d i c a t e d t h a t d i e t a r y i n s t r u c t i o n made a s i g n i f i c a n t d i f f e r e n c e i n plasma l e v e l s of a s c o r b i c a c i d . A h i g h s c o r e on the n u t r i t i o n knowledge t e s t a l s o c o n t r i b u t e d t o maintenance o f adequate plasma a s c o r b i c a c i d l e v e l s . In C a l i f o r n i a , Nobmann and Adams (19 70) s t u d i e d the e f f e c t i v e n e s s of d i e t i n s t r u c t i o n o f f e r e d by p h y s i c i a n s a t p r e - n a t a l c l i n i c s . On the i n i t i a l v i s i t the e x p e r i m e n t a l group l i s t e n e d t o a 20 minute p r e s e n t a t i o n by the p h y s i c i a n on the importance and e s s e n t i a l s of an adequate d i e t d u r i n g pregnancy. At subsequent v i s i t s , p a t i e n t s were, encouraged to m a i n t a i n an adequate d i e t a r y i n t a k e . P h y s i c i a n s f o r the c o n t r o l group o f f e r e d l i t t l e d i e t a r y i n s t r u c t i o n . The r e s u l t s i n d i c a t e d t h a t 34 f o r the p a t i e n t s who r e c e i v e d more c o n s i s t e n t d i e t a r y a d v i c e , the i n t a k e s o f the major n u t r i e n t s i n c r e a s e d . Even so, changes i n the d i e t s were not l a r g e enough f o r many o f the women t o meet the recommended d i e t a r y a l l owances. The women i n d i c a t e d t h a t i n c r e a s e d a p p e t i t e was the major reason f o r i n c r e a s i n g t h e i r food i n t a k e . F or the women who r e c e i v e d d i e t a r y i n s t r u c t i o n , p h y s i c i a n s were more important than f a m i l y members or o t h e r h e a l t h p r o f e s s i o n a l s i n i n f l u e n c i n g d i e t a r y change. S i m i l a r r e s u l t s are r e p o r t e d by H a r r i l l e t a l . (1973). D i e t a r y i n s t r u c t i o n s were g i v e n t o 28 p r e n a t a l p a t i e n t s by t h e i r a t t e n d i n g p h y s i c i a n s . In a d d i t i o n , 14 of these 28 p a t i e n t s r e c e i v e d a d d i t i o n a l i n s t r u c t i o n i n n u t r i t i o n by e i t h e r a t t e n - dance a t p r e n a t a l c l a s s e s o r for m a l i n s t r u c t i o n i n n u t r i t i o n . The r e s u l t s o f t h i s study i n d i c a t e d t h a t t he 14 women who had a d d i t i o n a l i n s t r u c t i o n had a b e t t e r n u t r i e n t i n t a k e i n the second and t h i r d t r i m e s t e r s o f pregnancy than those who had not had such i n s t r u c t i o n . R e s u l t s o f these s t u d i e s suggest t h a t n u t r i t i o n educa- t i o n can be e f f e c t i v e i n pr o d u c i n g a d e s i r a b l e change i n d i e t a r y h a b i t s d u r i n g pregnancy. Although the change i n many cases was sm a l l i t was i n a p o s i t i v e d i r e c t i o n . In most cases the improve- ment i n d i e t a r y h a b i t s d i d l e a d t o an i n c r e a s e i n two important n u t r i e n t s - c a l c i u m and p r o t e i n . These n u t r i e n t s are u s u a l l y d i f f i c u l t t o o b t a i n from r o u t i n e supplementation and are f r e - q u e n t l y l a c k i n g i n the maternal d i e t . 35 Pregnant women, p a r t i c u l a r l y p r i m i g r a v i d a e , are thought t o be more r e c e p t i v e t o n u t r i t i o n e d u c a t i o n than any o t h e r group ( Stearns, 1958; G i f f t e t a l . , 1972 ). Even i f the mother i s not motivated t o improve her d i e t a r y i n t a k e f o r the sake of her own h e a l t h , she w i l l f r e q u e n t l y do i t f o r the wel- f a r e o f her o f f s p r i n g . A p o s i t i v e a t t i t u d e toward n u t r i t i o n , sound n u t r i t i o n a l a d v i c e , and a s s i s t a n c e i n i n t e r p r e t i n g and a p p l y i n g t h i s a d v i c e t o i n d i v i d u a l l i f e s t y l e s can y i e l d numer- ous b e n e f i t s i n promotion of p o s i t i v e n u t r i t i o n a l p r a c t i c e s . N u t r i t i o n e d u c a t i o n a t t h i s time i n the l i f e c y c l e may have a p o s i t i v e and l a s t i n g e f f e c t on food h a b i t s f o r both the pregnant woman and her f a m i l y . I t would then be hoped t h a t t h i s mother would s t a r t the next pregnancy i n a s t a t e o f improved n u t r i - t i o n a l h e a l t h . 36 N u t r i t i o n i n Infancy Importance of N u t r i t i o n i n Infancy One of the most c r i t i c a l p e r i o d s f o r optimum n u t r i t i o n i s d u r i n g the f i r s t two years o f l i f e when growth and develop- ment are p r o c e e d i n g a t a r a p i d pace. There are numerous r e p o r t s i n the l i t e r a t u r e c o n c e r n i n g the severe consequences of p r o t e i n - c a l o r i e m a l n u t r i t i o n (PCM) and i t s e f f e c t s on growth, mental development and behaviour ( Monckeberg, 1968; Chase and M a r t i n , 1970; C r a v i o t o and Robales, 1965; Winick, 1973; K a l l e n , 1973 ). Winick (1968) demonstrated t h a t organ growth o c c u r s i n one of t h r e e main phases: (1) h y p e r p l a s i a alone (2) hyper- p l a s i a accompanied by hypertrophy (3) hypertrophy a l o n e . I t i s d u r i n g the f i r s t two p e r i o d s when c e l l d i v i s i o n i s o c c u r r i n g t h a t n u t r i t i o n a l d e p r i v a t i o n i s most c r i t i c a l . When m a l n u t r i - t i o n o c c u r r e d d u r i n g t h i s time, i r r e v e r s i b l e impairment o f mental a b i l i t y o f i n f a n t s was a p p a r e n t l y e v i d e n t ( Chase and M a r t i n , 1970 ). Monckeberg (19 68) showed t h a t i n f a n t s who were r e h a b i l i t a t e d from marasmus i n e a r l y l i f e s t i l l lagged behind normal i n f a n t s i n v e r b a l performance. However, many o f the s t u d i e s s u p p o r t i n g the h y p o t h e s i s t h a t m a l n u t r i t i o n i s asso- c i a t e d w i t h e i t h e r a l a g o r a d e f i c i t i n i n t e l l e c t u a l d e v e l o p - 37 ment are c o m p l i c a t e d by u n f a v o u r a b l e socio-economic v a r i a b l e s . Thus, i t i s i m p o s s i b l e t o say how much m a l n u t r i t i o n per se c o n t r i b u t e s to the depressed c o g n i t i v e development and how much may be a r e s u l t o f u n f o r t u n a t e s o c i a l and environmental c o n d i t i o n s . In Western c o u n t r i e s , severe PCM i s r e l a t i v e l y r a r e . N u t r i t i o n Canada (1973) r e p o r t e d o n l y 2 cases o f severe PCM ( body weights l e s s than 60% of the median f o r t h e i r age ) i n a t o t a l sample of 1,331. For i n f a n t s and t o d d l e r s from b i r t h to f o u r y e a r s o f age, 3.6% had c l i n i c a l evidence o f moderate PCM. The f i n d i n g s f o r the p r o v i n c e of B r i t i s h Columbia ( N u t r i t i o n Canada, The B r i t i s h Columbia Survey Report, 1975 ) showed no evidence o f PCM. Most s u b j e c t s i n t h i s age c a t e g o r y i n g e s t e d two to t h r e e times t h e i r p r o t e i n requirements. N u t r i t i o n a l i n a d e q u a c i e s o t h e r than p r o t e i n and c a l o r i e d e f i c i t s do o c c u r i n North America a l t h o u g h c l i n i c a l m anifes- t a t i o n s are seldom e v i d e n t . In most cases i t i s extremely d i f f i c u l t t o a s s e s s the consequences o f these m i l d e r forms o f m a l n u t r i t i o n . N e v e r t h e l e s s , n u t r i e n t d e f i c i e n c i e s such as v i t a m i n D r e s u l t e d i n 38 ' f u l l blown 1 cases o f r i c k e t s i n a major c i t y o f Canada ( Barsky, 1968 ). In 1974, N u t r i t i o n Canada r e p o r t e d t h a t 42.5% o f the i n f a n t s and t o d d l e r s had l e s s than adequate i n t a k e s o f v i t a m i n D. Exposure t o s u n l i g h t i s g e n e r a l l y c o n s i d e r e d t o be an u n r e l i a b l e source o f v i t a m i n D 38 ( Kodicek, 1973 ). T h i s may be p a r t i c u l a r l y p e r t i n e n t t o c e r t a i n p a r t s of Canada where exposure to s u n l i g h t may be l i m i t e d . Other d e f i c i e n c i e s such as i r o n deserve s p e c i a l a t t e n t i o n . I r o n D e f i c i e n c y The normal f u l l term i n f a n t has s u f f i c i e n t i r o n s t o r e s t o l a s t from t h r e e to s i x months o f age. Consequently, i n f a n t s over s i x months o f age are more v u l n e r a b l e to i r o n d e f i c i e n c y . The i n c i d e n c e of i r o n d e f i c i e n c y reaches a peak i n the second year of l i f e and then drops o f f i n the l a t e r p r e - s c h o o l y e a r s . Ir o n d e f i c i e n c y o c c u r s i n t h i s age group a t a l l l e v e l s o f s o c i o - economic s t a t u s , but i t i s most p r e v a l e n t among c h i l d r e n from low-income f a m i l i e s . ( F o r reviews see Lanzkowsky, 1974 and Theuer, 1974 ). The i n c i d e n c e of anemia i n i n f a n t s v a r i e s d i r e c t l y w i t h the s t a n d a r d used t o d e s c r i b e anemia. Hemoglobin l e v e l s of l e s s than 10 g per 100 ml were p r e v i o u s l y used t o a s s e s s anemia. Using t h i s standard, F u e r t h (1971) r e p o r t e d an i n c i d e n c e of 3% i n n i ne month o l d i n f a n t s seen i n p r i v a t e p r a c t i c e and Owen e t a l . (1971) observed an o v e r a l l i n c i d e n c e of 5% i n i n f a n t s 12 to 23 months o f age i n the U n i t e d S t a t e s . More r e c e n t l y , a hemoglobin l e v e l o f l e s s than 11 g per 100 ml was c o n s i d e r e d t o be i n d i c a t i v e of anemia. The 39 r e s u l t s o f a study u t i l i z i n g t h i s v a l u e i n d i c a t e d an i n c i d e n c e of 16% i n i n f a n t s f o u r t o 2 4 months of age from low income f a m i l i e s ( Haddy e t aJ.. 1974 ) . An a d d i t i o n a l 51% of the sample was c o n s i d e r e d t o have i r o n d e f i c i e n c y without anemia, d e f i n e d i n t h i s survey as a hemoglobin l e v e l o f 11 g per 100 ml o r above but a t r a n s f e r r i n s a t u r a t i o n l e v e l below 17%. In a sample of Canadian i n f a n t s s i x t o 18 months of age of a l l socio-economic c l a s s e s , 29% had hemoglobin l e v e l s below 10 g per 100 ml and 57% had hemoglobin l e v e l s l e s s than 11 g per 100 ml ( M i l n e e t a l . 1971 ). N u t r i t i o n Canada (1973) r e p o r t e d t h a t 4.4% of the i n f a n t s and t o d d l e r s i n the g e n e r a l p o p u l a t i o n had hemoglobin l e v e l s o f l e s s than 10 g per 100 ml. U t i l i z a t i o n o f the same hemoglobin standa r d demonstrated t h a t o n l y 1.7% o f t h i s age group were c o n s i d e r e d anemic i n B r i t i s h Columbia. However, 23.2% had hemoglobin l e v e l s below 11 g per 100 ml ( N u t r i t i o n Canada, The B r i t i s h Columbia Survey Report, 1975 ). The c l i n i c a l consequences of i r o n d e f i c i e n c y anemia are c o n t r o v e r s i a l . Owen e t a_l. (1971) r e p o r t e d t h a t i r o n d e f i c i e n c y may be a s s o c i a t e d w i t h measurable underachievement i n somatic growth. P r e - s c h o o l c h i l d r e n i n P h i l a d e l p h i a who had i r o n d e f i c i e n c y anemia had poor a t t e n t i v e n e s s i n s c h o o l and l a c k e d m o t i v a t i o n ( B e l l e r and Howell, 1971 ). Webb and Osk i (1973) have found a c o r r e l a t i o n between i r o n d e f i c i e n c y 40 anemia and poor s c h o l a s t i c performance i n a d o l e s c e n t s . F u e r t h (19 72) i n d i c a t e d t h a t mothers of i n f a n t s g i v e n an i r o n s u p p l e - ment had fewer complaints about t h e i r i n f a n t ' s daytime i r r i t a b i l i t y and s l e e p p a t t e r n s . J u d i s c h e t a l . (1966) observed t h a t abnormal a p p e t i t e i s commonly seen i n i n f a n t s who are i r o n d e f i c i e n t . Although none of these s t u d i e s a c t u a l l y proves a cause and e f f e c t r e l a t i o n s h i p , attainment of hemoglobin l e v e l s of 11 g per 100 ml or above f o r i n f a n t s does appear t o be a reaso n a b l e and r e a l i s t i c g o a l . The Committee of N u t r i t i o n o f the American Academy o f P e d i a t r i c s (1971) has recommended i r o n - f o r t i f i e d formulas from b i r t h t o 12> months o f age i f the i n f a n t i s not being b r e a s t - f e d . Since b r e a s t - f e e d i n g i s the optimum form of i n f a n t f e e d i n g i t i s p o s s i b l y more a p p r o p r i a t e t o recommend the i n c l u s i o n of i r o n - f o r t i f i e d foods or i r o n drops i n the i n f a n t ' s d i e t u n t i l 18 months of age. An i r o n - f o r t i f i e d food f r e q u e n t l y recommended i s i r o n - e n r i c h e d c e r e a l s . Many of these c e r e a l s have i r o n added as sodium i r o n pyrophosphate and e a r l y work ( S c h u l t z and Smith, 1958 ) i n d i c a t e d t h a t i r o n i n t h i s form was r e a d i l y absorbed from i n f a n t c e r e a l s . Recent work ( Rios e t a l . 1975 ), however, demonstrated t h a t h e a l t h y i n f a n t s absorbed o n l y about 1% o f i r o n i n the pyrophosphate form. Fomon (19 74) r e p o r t e d t h a t some i n f a n t c e r e a l s i n the U n i t e d S t a t e s c o n t a i n e l e c t r o l y t i c i r o n t h a t i s reasonably w e l l - a b s o r b e d . The use of c e r e a l s w i t h 41 t h i s new form of i r o n should i n c r e a s e i r o n a b s o r p t i o n substan- t i a l l y . U n f o r t u n a t e l y , many of these c e r e a l s are not y e t on the market i n Canada. B r e a s t - F e e d i n g The m i l k o f each s p e c i e s i s c o n s i d e r e d t o be the optimum food f o r i t s newborn and the human i s no e x c e p t i o n . The de- c l i n e i n b r e a s t - f e e d i n g throughout the world i s viewed with d e s p a i r by n u t r i t i o n i s t s . In underdeveloped c o u n t r i e s the de- c l i n e f r e q u e n t l y p a r a l l e l s an i n c r e a s e i n i n f a n t m o r t a l i t y ( Plank and M i l a n e s i , 1973 ) but i n developed c o u n t r i e s the con- sequences are l e s s severe. There have been numerous reviews c i t i n g the c o n s i d e r a b l e advantages of b r e a s t - f e e d i n g ( Gunther, 1963; J e l l i f f e , 1968; MacKeith, 1969; Davies, 1969; Baum, 1971; J e l l i f f e and J e l l i f f e , 1971; J e l l i f f e and J e l l i f f e , 1975 ). The most important advan- tages f o r developed c o u n t r i e s appear t o be (1) easy a v a i l a b i l i t y , making i t a convenient method o f f e e d i n g f o r mother and c h i l d (2) w e l l balanced n u t r i e n t c o n t e n t ( w i t h the p o s s i b l e e x c e p t i o n of v i t a m i n D ) (3) l e s s expensive than b o t t l e - f e e d i n g ( J e l l i f f e and J e l l i f f e , 1975 ) (4) improved m o t h e r - c h i l d i n t e r a c t i o n ( Newton, 1971 ) (5) as a d e t e r r e n t t o i n f a n t i l e o b e s i t y ( T a i t z , 1971; Shukla e t a l . , 1972; J e l l i f f e and J e l l i f f e , 1975 ) (6) reduced i n c i d e n c e o f a l l e r g i e s ( G e r r a r d , 1974 ). In a d d i t i o n , b r e a s t m i l k p r o v i d e s c o n s i d e r a b l e p r o t e c t i o n a g a i n s t e a r l y i n f a n t i n f e c t i o n s ( Mata and Wyatt, 1971, G e r r a r d , 1974 ). G e n e r a l l y t h i s i s c o n s i d e r e d t o be f a r more important i n under- developed c o u n t r i e s where standards of hygiene are low but G e r r a r d (1974) c a u t i o n e d t h a t t h i s r e a d i l y a p p l i e d t o p a r t s of Canada, such as the I n d i a n R e s e r v a t i o n s i n Saskatchewan. Schaefer (1971) a l s o found a h i g h e r i n c i d e n c e of middle ear i n f e c t i o n s i n Canadian Eskimos who were b o t t l e - f e d than i n i n - f a n t s who were b r e a s t - f e d . B r e a s t m i l k i s a l s o r e l a t i v e l y h i g h i n c h o l e s t e r o l ( 500 mg c h o l e s t e r o l per 100 g f a t ) as compared t o cow m i l k ( 300 mg per 100 g f a t ) and v e g e t a b l e f a t formulas ( approx- i m a t e l y 50 mg per 100 g f a t ) Kuzdzai - Savoie, 1973 ). S i n c e c h o l e s t e r o l i s an important c o n s t i t u e n t o f the b r a i n and ner- vous system, Schubert (1973) has s p e c u l a t e d t h a t h y p o c h o l e s t e r - o l e m i a d u r i n g the f i r s t months of l i f e may l e a d t o abnormal development. R e i s e r (1973) showed t h a t the b l o o d c h o l e s t e r o l l e v e l s o f a d u l t male r a t s were i n v e r s e l y p r o p o r t i o n a l to the amount o f c h o l e s t e r o l i n the b r e a s t m i l k on which they were r a i s e d . Hence, c h o l e s t e r o l c h a l l e n g e d u r i n g i n f a n c y may be r e q u i r e d f o r the development of the c h o l e s t e r o l d e g r a d a t i o n mechanisms. De s p i t e the apparent advantages of b r e a s t - f e e d i n g , b o t t l e - f e e d i n g appears to be i n c r e a s i n g i n p o p u l a r i t y . In the 1940's, approximately 65% o f i n f a n t s i n the U n i t e d S t a t e s were 43 b r e a s t - f e d d u r i n g the newborn p e r i o d ( Bain, 1948 ). By 1972 o n l y 10% t o 15% of i n f a n t s were b r e a s t - f e d ( M a r t i n e z , 1974 ) i n the same count r y . Maslansky e t a l . (19 74) i n a study i n New York C i t y , r e p o r t e d t h a t o n l y 17% of mothers who attended c h i l d h e a l t h c l i n i c s b r e a s t - f e d t h e i r c h i l d a t any one time. In D u b l i n , K a l a p e s i and Kevany (1974) i n d i c a t e d t h a t 11% of mothers i n t h e i r sample were b r e a s t - f e e d i n g a t the time o f d i s c h a r g e from h o s p i t a l . Only 6.3% of a group o f i n f a n t s i n England r e c e i v e d b r e a s t m i l k beyond 12 weeks of age ( Shukla e t a l . 1972 ). Applebaum (1975) noted, however, t h a t t h e r e i s a t r e n d from "the b o t t l e back to the b r e a s t " i n the i n d u s t r i a l i z e d c o u n t r i e s . T h i s i n c r e a s e i n b r e a s t - f e e d i n g i s more p r e v a l e n t among the upper s o c i a l c l a s s e s ( R i v e r a , 19 71 )., c o l l e g e gradu- a t e s ( Ladas, 1972 ), and p h y s i c i a n s ( H a r r i s and Chan, 1969 ). The p h y s i c i a n i s thought t o p l a y a v e r y important r o l e i n the success or f a i l u r e of b r e a s t - f e e d i n g . T h i s w i l l be d i s - cussed i n a l a t e r s e c t i o n of the review. I n t r o d u c t i o n o f S o l i d s Recent surveys have shown t h a t s o l i d foods, mainly i n the form of c e r e a l s and f r u i t s , become a p a r t of the i n f a n t ' s d i e t a r y i n t a k e as e a r l y as one week o f age ( T a i t z , 1974 ). T h i s e a r l y consumption of s o l i d foods l e a d s t o a h i g h c a l o r i c i n t a k e and subsequent f a t accumulation ( T a i t z , 1971; Shukla 44 et a l . , 1972; Dwyer and Mayer, 1973 ). A number of s t u d i e s ( L l o y d , 1961; Asher, 1966; E i d , 1970 ) have demonstrated t h a t f a t ba b i e s g e n e r a l l y remain f a t throughout c h i l d h o o d . Although o b e s i t y i s a d i s e a s e o f " m u l t i p l e o r i g i n s " , i t has been suggested t h a t the degree of o b e s i t y i s l a r g e l y dependent on the number of f a t c e l l s p r e s e n t i n the body ( H i r s h and K n i t t l e , 1970; Brook, 1972 ). In humans, c e l l s are b e l i e v e d t o i n c r e a s e i n number ( h y p e r p l a s i a ) d u r i n g g e s t a t i o n and the f i r s t year of l i f e ( Winick, 1968 ); f u r t h e r growth r e s u l t s from an i n c r e a s e i n c e l l s i z e (hypertrophy). Brook (1972) found t h a t c h i l d r e n who became obese a f t e r the f i r s t year of l i f e had more f a t c e l l s than those becoming obese a f t e r one year o f age. Thus, o v e r f e e d i n g i n e a r l y i n f a n c y may have long-term d e t r i m e n t a l e f f e c t s . The r e s u l t s o f a survey o f 300 normal i n f a n t s up t o one year of age i n England showed t h a t 16.7% of these i n f a n t s were s u f f e r i n g from i n f a n t i l e o b e s i t y and a f u r t h e r 27.7% were overweight ( Shukla e t aT. 1972 ). S o l i d foods were g i v e n t o 39.7% o f these i n f a n t s b e f o r e they were f o u r weeks o l d . Oates (1973) , i n a study of 100 i n f a n t s under s i x months of age, demonstrated t h a t s o l i d foods were g e n e r a l l y i n t r o d u c e d to the i n f a n t a t t h r e e t o f o u r weeks of age. E x c e s s i v e weight ga i n s were more p r e v a l e n t i n a r t i f i c i a l l y - f e d than b r e a s t - f e d i n f a n t s i n a study of s i x week o l d i n f a n t s r e p o r t e d by T a i t z 45 (1971). In t h i s study, most i n f a n t s r e c e i v e d s o l i d s i n the f i r s t week of l i f e . P o s s i b l y of more s e r i o u s p h y s i o l o g i c a l consequence i s the e x c e s s i v e r e n a l s o l u t e l o a d produced by the f e e d i n g of s o l i d s t o v e r y young i n f a n t s ( Davies, 1973; T a i t z , 1974 ). Davies (1973) s t u d i e d 60 i n f a n t s from one t o t h r e e months o f age and found the i n c i d e n c e of h y p e r o s m o l a r i t y ( plasma osmolar- i t y g r e a t e r than 300 mOsm per l i t e r ) i n b r e a s t - f e d i n f a n t s , f o r m u l a - f e d i n f a n t s and i n f a n t s f e d formulas p l u s s o l i d ' foods t o be 0%, 11.1% and 40.5% r e s p e c t i v e l y . The author emphasized t h a t t h i s h i g h s o l u t e l o a d g r e a t l y s t r e s s e d the c a p a c i t y o f the kidney t o m a i n t a i n the normal t o n i c i t y of body f l u i d s . I n t r o d u c t i o n of s o l i d s i n t o the i n f a n t ' s d i e t a t an e a r l y age does not appear t o have any n u t r i t i o n a l b e n e f i t f o r the h e a l t h y i n f a n t . In view of the i n c r e a s e i n the i n c i d e n c e o f i n f a n t i l e o b e s i t y and the dangers o f h y p e r o s m o l a r i t y i n the v e r y young i n f a n t , s o l i d s s h o u l d not be i n t r o d u c e d u n t i l f o u r t o s i x months o f age. I n f a n t D i e t a r y P r a c t i c e s The g e n e r a l d e c l i n e i n b r e a s t - f e e d i n g , w i t h the con- comitant i n c r e a s e i n the e a r l y i n t r o d u c t i o n of s o l i d s c h a r a c - t e r i s t i c of the i n d u s t r i a l i z e d n a t i o n s , has l e d t o over-con- sumption of many n u t r i e n t s i n i n f a n c y ( Shukla e t a l . , 1972; Dwyer and Mayer, 1973 ). The one major e x c e p t i o n i s i r o n 46 ( F i l e r and M a r t i n e z , 1964; Maslansky, 1974 ). F i l e r and M a r t i n e z (1964) s t u d i e d 4,146 i n f a n t s a t s i x months of age i n the U n i t e d S t a t e s and concluded t h a t more than h a l f of the i n f a n t s d i d not r e c e i v e adequate i r o n i n t a k e s . A p p a r e n t l y the s o l i d foods i n g e s t e d were poor i n i r o n c o n t e n t . P u r v i s 1 (1973) d a t a on i n f a n t s one t o 13 months of age support these e a r l i e r f i n d i n g s . The l a c k o f i r o n i n the d i e t s was a t t r i b u t e d mainly t o the d i s c o n t i n u a n c e of i r o n - e n r i c h e d c e r e a l products a t approximately s i x months of age. V i t a m i n s u p p l e - ments appeared t o be an economic and n u t r i t i o n a l waste s i n c e they e l e v a t e d n u t r i e n t i n t a k e s w e l l beyond recommended l e v e l s . In New York C i t y , a survey of i n f a n t s under one year of age i n d i c a t e d t h a t d i e t a r y n u t r i e n t s were adequate except f o r i r o n and n i a c i n ( Maslansky e t a_l. 1974 ). Iron i n t a k e was p a r t i c u l a r l y low among g i r l s aged nine t o 12 months and r e p r e - sented o n l y 37% of the recommended d i e t a r y allowances. V i t a m i n supplements were taken by 80% of the i n f a n t s but o n l y 47% of these supplements c o n t a i n e d i r o n . T h i s survey r e v e a l e d a number of i n t e r e s t i n g f i n d i n g s r e g a r d i n g i n f a n t f e e d i n g p r a c t i c e s . More than h a l f o f the i n f a n t s had s o l i d s i n t r o d u c e d w i t h i n the f i r s t month o f l i f e . A l s o , more than 50% of the c h i l d r e n were giv e n s o l i d s added t o the b o t t l e s . By 11 months of age, sweets i n the form o f sugar, candy, cake and c o o k i e s c o n t r i b u t e d a g r e a t e r p r o p o r t i o n o f the c a l o r i e s t o the i n f a n t ' s d i e t than d i d 47 v e g e t a b l e s . The authors s t a t e t h a t : . . . i n too many i n s t a n c e s foods o f low n u t r i t i v e q u a l i t y become p a r t o f the d i e t i n the ve r y young and i n c r e a s e i n consumption w i t h each month ( p. 785 ). N u t r i t i o n Canada (1973) r e p o r t e d low i n t a k e s o f i r o n and v i t a m i n D i n the g e n e r a l p o p u l a t i o n o f zero t o f o u r year o l d s ( Table I I I ). TABLE I I I PERCENTAGE OF CHILDREN ZERO TO FOUR YEARS OF AGE WITH INADEQUATE AND LESS-THAN-ADEQUATE INTAKES OF NUTRIENTS N u t r i e n t General P o p u l a t i o n Inadequate Less-than-Adequate P r o t e i n 1.1 1.6 Iron 23.5 20.7 Calcium 13.1 13.0 P o t e n t i a l V i t a m i n D 17.9 42.5 Vi t a m i n A 3.2 6.3 Vi t a m i n C 3.9 6.6 Thiamin 1.4 15.0 R i b o f l a v i n 0.7 4.6 N i a c i n 0.3 2.0 Source: N u t r i t i o n Canada, N a t i o n a l Survey, Department of N a t i o n a l H e a l t h and Welfare, Ottawa, Canada, 1973, p. 66. T r a n s f e r r i n s a t u r a t i o n l e v e l s r e v e a l e d t h a t 12.7% 48 of t h i s p o p u l a t i o n group were at h i g h r i s k of i r o n d e f i c i e n c y . Serum v i t a m i n A v a l u e s c l a s s i f i e d 22.8% of i n f a n t s and t o d d l e r s a t moderate r i s k . The s p e c i f i c f i n d i n g s f o r B r i t i s h Columbia were somewhat s i m i l a r ( N u t r i t i o n Canada, The B r i t i s h Columbia Survey Report, 197 5 ). Although some i n f a n t s were below the standard f o r v i t a m i n D i n t a k e s , 13.2% of the i n f a n t s under one year of age had more than 1, 000 I. U. per day as a r e s u l t o f the e x c e s s i v e use of v i t a m i n supplements. E d u c a t i o n i n t h e proper management of v i t a m i n - m i n e r a l p r e p a r a t i o n s i s o b v i - o u s l y needed. N u t r i t i o n E d u c a t i o n f o r Infancy The young i n f a n t depends e x c l u s i v e l y on o t h e r s f o r h i s n u t r i e n t i n t a k e . Hence, the f e e d i n g b e h a v i o r on the p a r t of the mother i s c r u c i a l t o the n u t r i t i o n a l and emotional w e l l - b e i n g of the i n f a n t . Mothers need guidance, a c c u r a t e up-to- date a d v i c e and e n t h u s i a s t i c support r e g a r d i n g i n f a n t f e e d i n g t o h e l p them s e l e c t from the preponderance of i n f o r m a t i o n con- c e r n i n g i n f a n t f e e d i n g p r a c t i c e s . E d u c a t i o n i s needed f o r mothers r e g a r d i n g the many advan- tages o f b r e a s t - f e e d i n g . Evidence t h a t such e d u c a t i o n would be of b e n e f i t was p r o v i d e d by S l o p e r e t a l . (1975). These workers r e p o r t e d t h a t h o l d i n g ward seminars on the advantages o f b r e a s t - f e e d i n g produced a 23% i n c r e a s e i n the number o f i n f a n t s b e i n g t o t a l l y b r e a s t - f e d . T h i s i n c r e a s e was s t a t i s t i c a l l y s i g n i f i c a n t . 49 For mothers who do not e l e c t t o b r e a s t - f e e d , e d u c a t i o n i s needed i n the p r e p a r a t i o n of formulas. Numerous i n v e s t i g a t o r s have r e p o r t e d hypernatremia and even death because of over-anxious or unknowing mothers g i v i n g c o n c e n t r a t e d formulas t o t h e i r i n - f a n t s ( T a i t z and Byers, 1972; R o l o f f and S t e r n , 1971; Coodin et a l . , 1971; Smith, 1974 ). Mothers must a l s o be educated t o the f a c t t h a t a " f a t " baby i s not the d e s i r e d g o a l of i n f a n t n u t r i t i o n . Furthermore, use of v i t a m i n supplements i s over-em- ph a s i z e d i n i n d u s t r i a l i z e d c o u n t r i e s and although i n many cases t h i s r e s u l t s o n l y i n economic waste, i n some cases i t c o n s t i t u t e s a p o t e n t i a l hazard t o l i f e . The shaping o f food h a b i t s i s thought to begin i n the e a r l y y e a r s o f l i f e . The way i n which new foods are i n t r o d u c e d and the t i m i n g o f t h i s procedure c o n t r i b u t e to the development o f good e a t i n g h a b i t s . G i f f t e t a l . (1972) p o i n t out t h a t : . . . the food h a b i t s , a t t i t u d e s toward food and n u t r i t i o n knowledge of the p a r e n t s form the framework w i t h i n which the c h i l d develops h i s own food h a b i t s . T h i s process begins d u r i n g e a r l i e s t i n f a n c y ( p. 350 ). S p e c i f i c food l i k e s and d i s l i k e s of the parents w i l l almost c e r t a i n l y be conveyed to the c h i l d as the c h i l d begins e a t i n g s o l i d foods. Even i f a mother o f f e r s a food t h a t she d i s l i k e s , her f e e l i n g s w i l l l i k e l y be communicated t o the baby. Thus, a mother who i s fond of sweets may c o n d i t i o n her c h i l d t o a p r e f e r e n c e f o r sweet foods. By the time the c h i l d e n t e r s s c h o o l the b a s i s f o r l i f e t i m e e a t i n g p a t t e r n s i s w e l l e s t a b l i s h e d 50 ( G i f f t e t a l . , 1972; Walker e t a l . , 1973 ). I t i s t h e r e f o r e : . . . v i t a l t o the f u t u r e n u t r i t i o n a l h e a l t h of c h i l d r e n t h a t p a r e n t s a t l e a s t be made aware t h a t they are shaping a l i f e t i m e food p a t t e r n by the way they i n f l u e n c e e a t i n g e x p e r i e n c e s d u r i n g the e a r l y years ( G i f f t e t a l . , p. 350, 1972 ). Role of the P h y s i c i a n i n N u t r i t i o n E d u c a t i o n The p h y s i c i a n i s i n an important p o s i t i o n t o i n f l u e n c e the d i e t a r y i n t a k e , and hence, the n u t r i t i o n a l s t a t u s of the pregnant and l a c t a t i n g woman and the young i n f a n t . He i s regarded by much of s o c i e t y as the l e g i t i m i z e r of i n f o r m a t i o n on a l l a s p e c t s of h e a l t h and i s g e n e r a l l y looked up t o as a l e a d e r i n these m a t t e r s . Numerous i n v e s t i g a t i o n s have i n d i c a t e d t h a t the p h y s i c i a n i s e i t h e r the primary o r one o f the most important p r o f e s s i o n a l s from whom homemakers and o t h e r s d e r i v e t h e i r n u t r i t i o n i n f o r m a t i o n ( Young e t a l . , 1956; Fox e t a l . , 1970; G i f f t e t a l . , 1972; Cho e t a l . , 1974 ). Cosper and W a k e r f i e l d (19 75) r e p o r t e d t h a t the p h y s i c i a n was an important p r o f e s s i o n - a l along w i t h the n u t r i t i o n i s t i n i n f l u e n c i n g the food c h o i c e s of young women. Fox e t a l . (1970), i n a survey of the d i e t s of p r e s c h o o l c h i l d r e n , observed t h a t 70% of the mothers r e p o r t e d a c c e p t i n g a d v i c e from the p h y s i c i a n d u r i n g the f i r s t y ear of the c h i l d ' s l i f e . G i f f t e t a l . (1972) emphasize t h a t : 51 . . . the physician i s i n a c r u c i a l p o s i t i o n to influence the behavior of parents in r e l a t i o n to feeding t h e i r c hildren, for he i s one of the primary sources that most parents have for i n - formation and guidance about what and how to feed t h e i r children ( p. 351 ). Members of the American College of Obstetricians and Gyneco- l o g i s t s (1974) have s i m i l a r f e e l i n g s about the o v e r a l l impor- tance of the physician i n prenatal n u t r i t i o n care. The physician must possess knowledge of n u t r i t i o n management and either provide these necessary services or delegate them to some other q u a l i f i e d p r o f e s s i o n a l . It i s , however: . . . v i t a l f or the physician to demonstrate to the patient his or her concern with t h i s important aspect of care ( p. 11 ). Baric (1970), i n an analysis of the physician's respon- s i b i l i t y i n health education, indicated that the physician has a r e s p o n s i b i l i t y to l e g i t i m i z e 'preventive' measures i n the attainment of optimum health and to give i t a status r e l a t i v e to 'curative' medicine. In order to do t h i s , the physician needs to be r e l a t i v e l y c e r t a i n of the benefit of any preventive mea- sures that he recommends just as he must be with therapeutic measures. He must also take the i n i t i a t i v e i n c e r t a i n b e n e f i c i a l health matters such as breast-feeding. Unfortunately, t h i s f r e - quently i s not done. Shukla et a l . (1972), i n a study of infant feeding p r a c t i c e s , noted that 81% of the mothers reported that neither doctor nor nurse advised them to breast-feed t h e i r i n - fants. A further 16% said that breast-feeding was mentioned by 52 the d o c t o r o n l y c a s u a l l y . Applebaum (1975) noted t h a t : . . . many mothers who wish t o nurse are d i s - couraged because o f the p h y s i c i a n ' s i n d i f f e r - ence t o or ignorance of the matter ( p . 98 ). I t appears, however, t h a t the p h y s i c i a n does d e s i r e to p l a y an a c t i v e r o l e i n the d i s s e m i n a t i o n o f n u t r i t i o n know- ledge t o the p u b l i c . The Lay A d v i s o r y Committee o f the B. C. Chapter of the C o l l e g e of Family P h y s i c i a n s o f Canada r e p o r t e d on the r o l e o f the f a m i l y p h y s i c i a n i n B r i t i s h Columbia ( Larsen, 1974 ). T h i s r e p o r t i n d i c a t e d t h a t 93% o f the m e d i c a l d o c t o r s surveyed b e l i e v e d t h a t the p a t i e n t should see the p h y s i c i a n f o r h e l p w i t h non-medical problems b e f o r e approaching o t h e r r e s o u r c e p e r s o n n e l . . . . i t appears . . . t h a t the m a j o r i t y o f both consumers and d o c t o r s expect p h y s i c i a n s (to) have r e f e r r a l o r c o u n s e l l i n g r o l e s w i t h r e s p e c t to . . . n u t r i t i o n a l m atters ( p. 103 ). . P a r a d o x i c a l l y , m e d i c a l s c h o o l t r a i n i n g g e n e r a l l y p l a c e s a minor r o l e , i f any, on the importance o f n u t r i t i o n i n the medical c u r r i c u l u m ( M u e l l e r , 19 67; N u t r i t i o n a l S c i e n c e s T r a i n i n g Committee, 197 0; Committee on N u t r i t i o n E d u c a t i o n i n M e d i c a l F a c i l i t i e s , 1971; C o u n c i l on Foods and N u t r i t i o n , 1973; Wen e t a l . , 1973; Dutra de O l i v e i r a , 1974; Dwyer and S t a r e , 1974 ). N u t r i t i o n i s f r e q u e n t l y o n l y i n c l u d e d as p a r t o f o t h e r c o u r s e s , such as b i o c h e m i s t r y , o r i f a f a c u l t y member has a p a r t i c u l a r i n t e r e s t i n the s u b j e c t . Many argue t h a t t h e r e i s no room f o r i t i n a c u r r i c u l u m t h a t i s a l r e a d y f i l l e d w i t h e s s e n t i a l m e d i c a l 53 c o u r s e s , w i t h the r e s u l t t h a t o n l y a few m e d i c a l s c h o o l s i n the world are t e a c h i n g n u t r i t i o n ( Dutra de O l i v e i r a , 1974 ). I n t e g r a t i o n o f n u t r i t i o n i n f o r m a t i o n w i t h o t h e r s u b j e c t matter does not appear t o be adequate ( Dutra de O l i v e i r a , 19 74 ). Surveys t h a t have i n v e s t i g a t e d the n u t r i t i o n knowledge of medical students i n d i c a t e d t h a t t h e i r knowledge of n u t r i t i o n was poor ( P h i l l i p s , 1971; K j e l l m a n , 1974 ). M e d i c a l students are i n c r e a s i n g l y concerned w i t h the s o c i a l and p r e v e n t i v e a s p e c t s of medicine and f r e q u e n t l y show a d e s i r e t o l e a r n n u t r i t i o n ( G i f f t e t a l . 1972 ). As y e t , t h i s w i l l i n g n e s s t o l e a r n n u t r i t i o n a p p a r e n t l y has not r e s u l t e d i n an i n c r e a s e d knowledge o f n u t r i t i o n ( F i g u r e 1, Dutra de O l i v e i r a , 1974 ). M e d i c a l Students Are W i l l i n g t o Learn N u t r i t i o n N u t r i t i o n Should Be M e d i c a l Schools Say Taught i n M e d i c a l Schools They Are, Teaching N u t r i t i o n Students and P h y s i c i a n s Have Poor Knowledge of N u t r i t i o n F i g u r e 1 The v i c i o u s c i r c l e o f n u t r i t i o n t e a c h i n g i n m e d i c a l s c h o o l s . Dutra de O l i v e i r a (1974) commented t h a t u n t i l n u t r i t i o n i s r e c o g n i z e d as a s u b j e c t important enough to be taught indepen- d e n t l y , i t w i l l not r e c e i v e adequate emphasis or j u s t i c e i n the 54 medical school c u r r i c u l u m . A t t i t u d e s and P r a c t i c e s A t t i t u d e s are acquired p r e d i s p o s i t i o n s to r e a c t i n a c h a r a c t e r i s t i c way, u s u a l l y favourably or unfavourably, toward a given type of person, s i t u a t i o n , o b j e c t or i d e a l ( K i l a n d e r , 19 68 ). P r a c t i c e s are overt gestures i n d i c a t i n g an i n d i v i d u a l ' s preference and commitment i n some observable a c t i v i t y ( Rogers, 1 9 7 3 ). An a t t i t u d e i s a p r e d i s p o s i t i o n t o a c t , whereas a p r a c t i c e i s o v e r t . According to D i l l e h a y ( 1 9 6 5 ), a t t i t u d e s have three major components: 1 . b e l i e f s or c o g n i t i o n about the o b j e c t 2. a f f e c t or f e e l i n g s toward the o b j e c t 3 . b e h a v i o r a l tendencies t o act Since a t t i t u d e s are comprised of these three components they are o f t e n thought of as systems. A change i n any one p a r t of the system, such as a f f e c t , w i l l u s u a l l y l e a d t o changes i n the other components i . e . , b e l i e f s and b e h a v i o r a l tendencies. As systems, a t t i t u d e s w i l l e x h i b i t v a r y i n g degrees of c o n s i s - tency. I f an a t t i t u d e t o p i c i s s a l i e n t f o r an i n d i v i d u a l , the degree of con s i s t e n c y among the three components w i l l be gr e a t e r than i f the t o p i c i s considered unimportant or i s i n f r e q u e n t l y confronted ( D i l l e h a y , 1 9 6 5 ; S c o t t , 1 9 6 9 ). Thus, i f n u t r i t i o n i s considered to be important by a p h y s i c i a n he may have beha- 55 v i o r a l t e n d e n c i e s t o p r a c t i c e n u t r i t i o n e d u c a t i o n . A t t i t u d e s are based on one of t h r e e m o t i v a t i o n a l s u p p o r t s : ( D i l l e h a y , 1965 ): 1. knowledge, e i t h e r f a c t u a l or gained from e x p e r i e n c e 2. ego-defence, p r o t e c t i o n o f one's sense o f adequacy 3. s o c i a l adjustment A l l t h r e e m o t i v a t i o n a l bases may be a c t i n g s i m u l t a n e o u s l y . Only when an a t t i t u d e i s based on knowledge alone w i l l newly a c q u i r e d i n f o r m a t i o n b r i n g about a change i n t h a t a t t i t u d e . When a t t i t u d e s are based on defence of the ego the a t t i t u d e i s d i f f i c u l t t o change and g e n e r a l l y cannot be a l t e r e d s o l e l y t h r o u g h i n f o r m a t i o n or knowledge about the o b j e c t of the a t t i t u d e . A t t i t u d e s formed through s o c i a l adjustment may be sus- c e p t i b l e t o change through o p i n i o n l e a d e r s . The o p i n i o n l e a d e r s are g e n e r a l l y i n d i v i d u a l s of h i g h c r e d i b i l i t y because of a d d i - t i o n a l e x p e r i e n c e or e d u c a t i o n ( G i f f t e t a l . , 1972; Rogers, 1973 ). The p h y s i c i a n i s f r e q u e n t l y regarded as an o p i n i o n l e a - der s i n c e he i s p e r c e i v e d as being extremely knowledgeable ( G i f f t e t a l . , 1972 ). As an o p i n i o n l e a d e r , the p h y s i c i a n i s i n an unique p o s i t i o n t o i n f l u e n c e the a t t i t u d e s of o t h e r s . T h i s i s p a r t i c u l a r l y t r u e w i t h the p r a c t i c e of b r e a s t - f e e d i n g where a t t i t u d e s toward b r e a s t - f e e d i n g seem t o be d i r e c t l y r e l a t e d to o v e r t p r a c t i c e s . Newton and Newton (1950) i n v e s t i g a t e d the r e l a t i o n s h i p of maternal a t t i t u d e s toward b r e a s t - f e e d i n g t o 56 success o f b r e a s t - f e e d i n g . A t t i t u d e s were determined by means of an i n t e r v i e w u s u a l l y h e l d w i t h i n 24 hours of d e l i v e r y . Behavior was a s s e s s e d by measuring the amount of m i l k t h a t each i n f a n t r e c e i v e d . Mothers w i t h p o s i t i v e a t t i t u d e s toward f e e d i n g gave s i g n i f i c a n t l y more m i l k than mothers w i t h d o u b t f u l or nega- t i v e a t t i t u d e s . Success o f b r e a s t - f e e d i n g was a l s o r e l a t e d t o mothers' a t t i t u d e s . Mothers who had p o s i t i v e a t t i t u d e s were 74% s u c c e s s f u l w h i l e on l y 26% of those who had n e g a t i v e a t t i - tudes s u c c e s s f u l l y b r e a s t - f e d t h e i r i n f a n t s . S i m i l a r l y , Emmons and Hayes (1974) noted t h a t mothers who h e l d the a t t i t u d e , " n u t r i t i o n i s important", had c h i l d r e n who consumed a s i g n i f i - c a n t l y g r e a t e r amount of c a l c i u m than d i d c h i l d r e n of mothers who d i d not f e e l t h a t " n u t r i t i o n i s important". Thus, a t t i t u d e s were r e l a t e d to p r a c t i c e s . Although a t t i t u d e s do a f f e c t o v e r t b ehavior ( Rogers, 1973 ), c a u t i o n must be used i n i n f e r r i n g a t t i t u d e s from b e h a v i o r o r i n f o r e c a s t i n g b e h a v i o r from a t t i t u d e s . Many oth e r f a c t o r s such as s o c i a l i n f l u e n c e s , e d u c a t i o n and p e r s o n a l needs may have a b e a r i n g on b e h a v i o r ( D i l l e h a y , 1965 ). In c o n t r a s t , b e h a v i o r may be the m o t i v a t i n g f o r c e i n molding a t t i t u d e s ( F e s t i n g e r , 19 64 ). A c c o r d i n g to the t h e o r y of c o g n i t i v e dissonance, i f an i n d i v i d u a l behaves i n a way t h a t i s d i s c r e p a n t w i t h h i s b e l i e f s , the b e l i e f s may change so as t o be more c o n s i s t e n t w i t h h i s a c t i o n s . The d i s c r e p a n c y i s b e l i e v e d 57 to be uncomfortable and consequently m o t i v a t e s a change i n a t t i t u d e s . The dissonance i s reduced when a t t i t u d e s are brought i n t o l i n e w i t h a c t i o n s . There are no s t u d i e s i n the l i t e r a t u r e t h a t r e l a t e p h y s i c i a n s ' a t t i t u d e s t o t h e i r c o u n s e l l i n g p r a c t i c e s . I t c o u l d be s p e c u l a t e d t h a t p h y s i c i a n s , b e i n g i n t e l l i g e n t i n d i - v i d u a l s , would have a t t i t u d e s c o n s i s t e n t w i t h t h e i r p r a c t i c e s ( Wicker, 19 69 ). On the o t h e r hand, a t t i t u d e q u e s t i o n s o f a g e n e r a l n a t u r e may not be r e f l e c t e d i n s p e c i f i c b e h a v i o r a l p r a c t i c e s ( Wicker, 1969 ). 58 Survey Research by M a i l Q u e s t i o n n a i r e The m a i l q u e s t i o n n a i r e i s a data c o l l e c t i o n instrument t h a t i s completed by the respondent r a t h e r than the r e s e a r c h e r , and c o l l e c t e d through the m a i l w i t h no d i r e c t c o n t a c t between the respondent and the r e s e a r c h e r . The primary j u s t i f i c a t i o n f o r the use of t h i s method o f data c o l l e c t i o n i s t h a t t h e r e i s a need f o r i n f o r m a t i o n t h a t cannot re a s o n a b l y be o b t a i n e d i n another way ( C l a r k e , 1970 ). Such i s the case when data are being c o l l e c t e d from a l a r g e sample of i n d i v i d u a l s over a wide g e o g r a p h i c a l a r e a . Techniques, Advantages and Disadvantages The most important a s p e c t of t h i s type of r e s e a r c h i s the q u e s t i o n n a i r e i t s e l f . The q u e s t i o n n a i r e statements must encompass a l l the necessary i n f o r m a t i o n , be unambiguous and e a s i l y answered ( H a r r i s , 1960 ). I t must a l s o be r e l i a b l e , t h a t i s , y i e l d c o n s i s t e n t r e s u l t s and be a c c u r a t e , or v a l i d , measuring what i t p u r p o r t s to measure. A c c o r d i n g to S c o t t (1969) the q u e s t i o n n a i r e can u t i l i z e e i t h e r an 'open-question' method or a ' c l o s e d - q u e s t i o n ' technique. T h i s author concluded t h a t the s t r o n g e s t advantage of c l o s e d q u e s t i o n s i s t h a t they f o r c e the respondents' r e p l i e s onto the dimension of i n t e r e s t o f the r e s e a r c h e r , thereby l i m i t i n g the p r o p o r t i o n o f uncodable answers. The s t r o n g e s t 59 disadvantage appears t o be the t h r e a t t o r a p p o r t s i n c e many respondents f i n d l o n g l i s t s o f c l o s e d q u e s t i o n s t e d i o u s and even i n s u l t i n g . Deutscher (1953), i n a study o f p h y s i c i a n s ' r e a c t i o n s t o a m a i l e d q u e s t i o n n a i r e , noted t h a t : . . . men w i t h above average i n t e l l i g e n c e and ed u c a t i o n tend t o r e b e l i f asked t o make s t e r e o - t y p i c a l judgements (p. 601). Advantages and disadvantages of m a i l q u e s t i o n n a i r e s are d i s c u s s e d by Wallace (1954) and M i l l e r (1970). The primary advantage to u s i n g t h i s technique i s t h a t i t permits a r e s e a r c h - e r t o survey a l a r g e group of people i n a r e l a t i v e l y s h o r t p e r i o d o f time. I t i s g e n e r a l l y more e c o n o m i c a l l y f e a s i b l e than o t h e r methods of survey r e s e a r c h and may be even 60 times l e s s expensive than the i n t e r v i e w technique ( Jackson, 1961 ). I t i s o f t e n e a s i e r to reach busy people by m a i l than t o i n t e r v i e w them p e r s o n a l l y . I t a l s o ensures anonymity t o the respondents so t h a t they a re more l i k e l y t o answer c a n d i d l y . With the m a i l q u e s t i o n n a i r e the problem o f i n t e r v i e w e r and respondent b i a s e s are e l i m i n a t e d . T h i s prevents the i n t e r v i e w e r from r e c o r d i n g a b i a s e d i n t e r p r e t a t i o n o f the response and g e n e r a l l y c u r t a i l s the respondent from g i v i n g more s o c i a l l y a c c e p t a b l e responses ( Colombotos, 1970 ). Wallace (1954) p o i n t s out t h a t m a i l q u e s t i o n n a i r e s are p a r t i c u l a r l y s u i t e d f o r p o p u l a t i o n s t h a t are somewhat homogeneous. There are a l s o a number o f weaknesses o r disadvantages to u s i n g m a i l q u e s t i o n n a i r e s . The respondent may not answer 60 h o n e s t l y or may d i s r e g a r d the i n s t r u c t i o n s and not answer p r o p e r l y . Assurances o f good i n t e n t and anonymity u s u a l l y encourage honesty ( Rummel, 1964 ). The s i n g l e major disadvantage i s t h a t the m a i l q u e s t i o n n a i r e o f f e r s no c o n t r o l over who w i l l r e p l y . The i n d i v i d u a l s who do not choose t o respond may be markedly d i f f e r e n t i n important c h a r a c t e r i s t i c s from those who do. T h i s can i n t r o d u c e a v e r y s i g n i f i c a n t non-response b i a s t h a t must be c o n t r o l l e d i n the a n a l y s i s o f the r e s u l t s . Response Rate Response t o m a i l q u e s t i o n n a i r e s can v a r y w i d e l y . Longsworth (1953) noted t h a t the response r a t e c o u l d be as low as 7%. Many s t u d i e s t h a t are conducted by p r i v a t e o r g a n i z a - t i o n s or u n s k i l l e d p e r s o n n e l y i e l d a response r a t e of 10% t o 25% ( M i l l e r , 1970 ). Other surveys conducted by p r o f e s s i o n a l s on a s m a l l number o f h i g h l y m o t i v a t e d respondents y i e l d e d 100% response ( L e v i n e and Gordon, 1958 ). A l i m i t e d number o f s t u d i e s r e p o r t i n g the response r a t e o f p h y s i c i a n s t o m a i l q u e s t i o n n a i r e s i n d i c a t e v a l u e s between these two extremes. Deutscher (1953) noted t h a t 57% o f 379 p h y s i c i a n s r e t u r n e d q u e s t i o n n a i r e s on ' P u b l i c Images of Female Occupations'. G u l l e n and G a r r i s o n (1973) r e p o r t e d an o v e r a l l p h y s i c i a n response r a t e o f 45.1% on m e d i c a l d o c t o r s ' a t t i t u d e s towards a d m i n i s t r a t i v e p r a c t i c e s i n c o n t i n u i n g e d u c a t i o n . In a survey on p h y s i c i a n s ' r e c e p t i v i t y t o i n n o v a t i o n s to h e a l t h c a r e , an o v e r a l l response r a t e of 66% was o b t a i n e d a f t e r f o u r reminders to r e t u r n the q u e s t i o n n a i r e ( Mechanic, 1974 ). S c h i l l e r and V i v i a n (1974) r e p o r t e d 36.4% of 2,000 p h y s i c i a n s r e t u r n e d q u e s t i o n n a i r e s on the r o l e of the d i e t i t i a n i n the h e a l t h c a r e team. I n t e r e s t i n , or f a m i l i a r i t y w i t h , the s u b j e c t matter of the survey i s one of the most important f a c t o r s i n e l i c i t i n g a response ( Longsworth, 1953; Wallace, 1954; M i l l e r , 1970 ). I n d i v i d u a l s who are more h i g h l y educated or who are p r o f e s s i o n - a l s are a l s o much more l i k e l y t o respond ( M i l l e r , 1970 ). L i t e r a t u r e i n the s o c i a l s c i e n c e s suggests numerous ways i n which responses can be i n c r e a s e d ( Longsworth, 1953; M i l l e r , 1970; D i l l m a n , 1972; H a c k l e r and Bourgette, 1973 ). The most important of these a r e : 1. i n c l u s i o n of a cover l e t t e r 2. endorsement by a sponsor 3. o b j e c t i v e type q u e s t i o n s 4. i n c l u s i o n of a stamped, s e l f - a d d r e s s e d envelope 5. p r i n t e d q u e s t i o n n a i r e with an a t t r a c t i v e format 6. f o l l o w - u p reminders Champion (1969), i n a study o f the g e n e r a l p o p u l a t i o n , showed t h a t adhesive postage stamps produced a s l i g h t l y b e t t e r response t h a t bulk postage. G u l l a h o r n and G u l l a h o r n (1963), i n a survey o f c o l l e g e graduates, showed t h a t h i g h e r c l a s s e s of postage produced a h i g h e r y i e l d , a l t h o u g h the d i f f e r e n c e s 62 were small. When questionnaires are long of necessity, they should be made to look as short as possible ( Levine and Gordon, 1958; Dillman, 1972 ). This can be accomplished through p r i n t i n g rather than mimeographing and use of both sides of the page. Kelsey and Acheson (1971) found no s i g n i f i c a n t d i f f e r - ence i n the response rate from surgeons to either mimeographed or typed questionnaires. A personalized cover l e t t e r did not increase the response rate i n t h i s survey. Follow-up i s very important, and according to M i l l e r (1970), can increase response rate by as much as 40%. Eckland (1965) increased h i s returns from 67% to 94% by persistent follow-up. Inducements such as a promise of the summary of the findings or the i n c l u s i o n of money may increase the returns. Hackler and Bourgette (1973) demonstrated that the i n c l u s i o n of one d o l l a r s i g n i f i c a n t l y increased the response rate of a questionnaire sent to the mothers of school c h i l d r e n . Gullen and Garrison (1973) investigated factors i n f l u - encing the rates of response to mail questionnaires by prac- t i s i n g physicians. The purpose was to determine whether the assumptions made i n the consumer and s o c i a l sciences l i t e r a - ture on increasing response rate to mail questionnaires could be applied to physicians. This survey assessed the attitudes, of physicians i n private practice regarding c e r t a i n common administrative practices i n continuing education. The two main treatment variables were format ( including both design and reproduction process ) and postage ( f i r s t class compared with t h i r d c l a s s ). There were a t o t a l of seven sub-treatments. The r e s u l t s showed that the response rate ranged from a low of 34.2% for a mimeographed two-part t e a r - o f f post card sent by bulk mail, to a high of 57.1% for a business-style l e t t e r sent by metered f i r s t c l a s s mail. Use of adhesive pos- tage stamps did not produce an increase i n response rate over metered postage. It was concluded by the authors that assump- tions usually made by epidemiologists i n designing mail surveys may be applied to the physician i n private p r a c t i c e . Non-Response Non-response to mail questionnaires can e x i s t i n one of two forms: complete non-response or p a r t i a l non-response. Complete non-response may r e s u l t from eith e r f a i l u r e to receive the questionnaire or f a i l u r e to complete i t . P a r t i a l non- response r e f e r s to a returned questionnaire with one or more relevant questions unanswered. Donald (1960) and Mayer and Pratt (1966) indicate that people who are not interested or personally involved i n the subject matter of the survey are un l i k e l y to respond. Gannon et a l . (1971) studied response rates i n a survey of food store workers and found a lower response rate from those workers who were less educated, single and male. This confirmed the e a r l i e r r e p o r t t h a t females and those w i t h h i g h e r e d u c a t i o n a l l e v e l s have h i g h e r response r a t e s ( E l l i s e t a l . 1970 ). A survey o f smoking h a b i t s ( S e l t z e r et a l . 1975 ) showed t h a t non-respondents were more l i k e l y t o be c i g a r e t t e smokers than non-smokers. T h i s t r e n d p e r s i s t e d even when 87% o f the q u e s t i o n n a i r e s were r e t u r n e d . The r e s u l t s of a survey by Mechanic (1974) on p h y s i c i a n s ' a t t i t u d e s toward i n n o v a t i o n s i n m e d i c a l - c a r e d e l i v e r y showed t h a t non-respondents i n c l u d e d a h i g h e r p r o p o r t i o n of o l d e r d o c t o r s , those who graduated from m e d i c a l s c h o o l i n 19 35 or e a r l i e r , those who were l i c e n s e d to p r a c t i c e i n 1940 or b e f o r e , and those who were o n . f u l l time s a l a r i e s . Non-respondents were a l s o l e s s l i k e l y t o belong t o a t l e a s t one s p e c i a l t y o r g a n i z a - t i o n . None o f these d i f f e r e n c e s , however, was s t a t i s t i c a l l y s i g n i f i c a n t . S i n c e c e r t a i n segments of the sample may not respond t o the q u e s t i o n n a i r e the d a t a may not be r e p r e s e n t a t i v e of the o r i g i n a l p o p u l a t i o n . Hence, a non-response b i a s i s i n t r o d u c e d . I f the sample p o p u l a t i o n i s r e l a t i v e l y homogeneous, t h a t i s , they have a s i m i l a r l e v e l of e d u c a t i o n and the same o c c u p a t i o n , the p o s s i b i l i t i e s o f non-response b i a s are decreased ( Wallace, 1953 ). Mayer and P r a t t (1966) suggested t h a t non-response b i a s may be a d j u s t e d by weighing the a c t u a l responses t o r e p r e s e n t the e n t i r e sample o r by e x t r a p o l a t i n g t r e n d s a c r o s s response 65 waves. Both of these methods assume that non-respondents are the same as respondents. Other workers ( Larson and Catton,- 1959 ) have noted that late responders may be i n d i c a t i v e of non-responders. According to these workers, i t i s possible to check for a non-response bias by comparing the early and l a t e returns. If no s i g n i f i c a n t differences i n the scores are evident then one can assume that there i s no non-response bias. Harris (19 60) noted that an 80% response rate i s necessary before the e f f e c t s of non-response bias can be negated. At t h i s rate of response the s t a t i s t i c a l r e s u l t s are the same as i f 100% of the survey population responded. Summary This b r i e f review of the l i t e r a t u r e demonstrates the s i g n i f i c a n t e f f e c t of n u t r i t i o n during the prenatal and postnatal periods on the l a t e r growth and development of the inf a n t . Pregnant women and mothers must be made aware of the importance of n u t r i t i o n at t h i s time i n the l i f e cycle and take measures to ensure the best possible n u t r i t i o n a l s t a r t f o r t h e i r infant. It i s the r e s p o n s i b i l i t y of health professionals i n the areas of maternal and infant n u t r i t i o n to advise and d i r e c t pregnant women and new mothers i n the attainment of these 66 goals. Physicians as leaders of the health care teams should be cognizant of the current information available on n u t r i - t i o n and promote the acceptance of good n u t r i t i o n a l habits i n these patients. Determination of the attitudes and practices of those physicians most involved with maternal and infant n u t r i t i o n w i l l elucidate the kind of n u t r i t i o n information being disseminated to the maternal population and assess the need for n u t r i t i o n services i n t h i s v i t a l area. CHAPTER I I I DESIGN OF THE STUDY Th i s study was designed t o i n v e s t i g a t e the n u t r i t i o n a t t i t u d e s and c o u n s e l l i n g p r a c t i c e s of g e n e r a l p r a c t i t i o n e r s , p e d i a t r i c i a n s and o b s t e t r i c i a n s i n the p r o v i n c e o f B r i t i s h Columbia. The nature o f the r e l a t i o n s h i p between the c r i t e r i o n v a r i a b l e s ( n u t r i t i o n a t t i t u d e s and p r a c t i c e s ) was asse s s e d and the e f f e c t o f s e l e c t e d , non-manipulable v a r i a t e s upon the c r i t e r i o n . v a r i a t e s was determined. T h i s study was designed as a p i l o t p r o j e c t t o a s c e r t a i n the k i n d o f n u t r i t i o n i n f o r m a t i o n being d i s s e m i n a t e d t o mothers and hence, t o e x p l o r e the impact of r e c e n t developments i n maternal and i n f a n t n u t r i t i o n on the n u t r i t i o n a t t i t u d e s and p r a c t i c e s o f g e n e r a l p r a c t i t i o n e r s , p e d i a t r i c i a n s and o b s t e t r i c i a n s . The survey was conducted w i t h the c o - o p e r a t i o n of the B r i t i s h Columbia M e d i c a l A s s o c i a t i o n . Research Design A s t a t u s , non-experimental study t o e s t a b l i s h the r e l a - t i o n s h i p between the c r i t e r i o n v a r i a b l e s and the non-manipulable v a r i a t e s was conducted u t i l i z i n g survey r e s e a r c h t e c h n i q u e s ( Baker and Schutz, 1972 ). The c r i t e r i o n ( dependent ) v a r i a b l e s were: (I) a t t i t u d e s toward n u t r i t i o n and (2) n u t r i t i o n c o u n s e l l i n g p r a c - 67 68 t i c e s . The n o n - m a n i p u l a b l e ( i n d e p e n d e n t ) v a r i a b l e s were c a t e g o r i z e d a s : (1) demograph i c d a t a w h i c h i n c l u d e d c o u n t r y o f m e d i c a l t r a i n i n g , l o c a t i o n o f p r a c t i c e and sex o f r e s p o n - d e n t and (2) p r o f e s s i o n a l d a t a w h i c h i n c l u d e d y e a r s and t y p e o f p r a c t i c e , number o f p a t i e n t s seen w e e k l y , s o u r c e s o f n u t r i - t i o n i n f o r m a t i o n c o n s u l t e d , s p e c i a l i z a t i o n o f t r a i n i n g , c o n - t i n u i n g e d u c a t i o n programs a t t e n d e d and t h e i n c l u s i o n o f n u t r i t i o n i n m e d i c a l s c h o o l t r a i n i n g . The n a t u r e o f t h e r e l a t i o n s h i p between t h e c r i t e r i o n v a r i a b l e s and t h e v a r i a t e s was a s s e s s e d . I n a d d i t i o n , t h e n a t u r e o f t h e r e l a t i o n s h i p between t h e c r i t e r i o n v a r i a b l e s t h e m - s e l v e s was d e t e r m i n e d . P o p u l a t i o n F o r t h i s s u r v e y t h e s t u d y p o p u l a t i o n was t h e e n t i r e p o p u l a t i o n o f p r a c t i s i n g g e n e r a l p r a c t i t i o n e r s , p e d i a t r i c i a n s , and o b s t e t r i c i a n s r e g i s t e r e d w i t h t h e B r i t i s h C o l u m b i a M e d i c a l A s s o c i a t i o n and p r a c t i s i n g i n B r i t i s h C o l u m b i a . T h i s r e p r e - s e n t e d 97% o f a l l p r a c t i s i n g g e n e r a l p r a c t i t i o n e r s , p e d i a - t r i c i a n s and o b s t e t r i c i a n s i n t h e p r o v i n c e . There were 1,753 g e n e r a l p r a c t i t i o n e r s , 110 p e d i a t r i c i a n s and 118 o b s t e t r i c i a n s f o r a t o t a l sample o f 1,981 p h y s i c i a n s . 69 Data C o l l e c t i o n Data C o l l e c t i o n Instruments Data were c o l l e c t e d by means of s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e s ( Appendix A ). The q u e s t i o n n a i r e s were de- signed t o measure s e p a r a t e l y , n u t r i t i o n a t t i t u d e s and n u t r i t i o n p r a c t i c e s as w e l l as t o c o l l e c t demographic i n f o r m a t i o n and p r o f e s s i o n a l data. A q u e s t i o n n a i r e t h a t measured n u t r i t i o n a t t i t u d e s and p r a c t i c e s c o n c e r n i n g maternal n u t r i t i o n was completed by o b s t e t r i c i a n s w h i l e a q u e s t i o n n a i r e t h a t measured the n u t r i t i o n a t t i t u d e s and p r a c t i c e s o f i n f a n t n u t r i t i o n was completed by p e d i a t r i c i a n s . Both q u e s t i o n n a i r e s were combined and completed by the g e n e r a l p r a c t i t i o n e r s . A t t i t u d e s toward n u t r i t i o n A t t i t u d e s o f o b s t e t r i c i a n s toward n u t r i t i o n were mea- sured by a data c o l l e c t i o n instrument developed f o r t h i s study. The q u e s t i o n n a i r e c o n s i s t e d o f 10 statements r e f l e c t i n g the importance of n u t r i t i o n throughout pregnancy. T h i s t e s t was v a l i d a t e d by a group o f n u t r i t i o n e x p e r t s who had exp e r i e n c e i n the area o f p r e n a t a l n u t r i t i o n . The q u e s t i o n n a i r e was p r e - t e s t e d by a group of a d u l t n u t r i t i o n e x p e r t s . The s c o r i n g system ( Table IV ) v a l i d a t e d by Schwartz (1973) was u t i l i z e d . T h i s system p r o v i d e d f o r two responses t o each statement; the f i r s t response i n d i c a t e d whether the respondent agreed o r d i s a - 70 greed and the second response indicated the degree of confidence with which the respondent agreed or disagreed. Each statement , was scored from 0 to 7 with a possible attitude score between 0 and 70. TABLE IV SCORING SYSTEM FOR NUTRITION ATTITUDE TEST Scale Agree Disagree Response Degree of Certainty Very Moderately Moderately Very Doubtful Doubtful Confident Confident 1 2 3 4 Agree Disagree Disagree Agree P e d i a t r i c i a n s ' n u t r i t i o n attitudes were measured by a data c o l l e c t i o n instrument developed f o r t h i s study. The questionnaire consisted of 10 statements r e f l e c t i n g the impor- tance of n u t r i t i o n throughout the f i r s t 2 years of l i f e . This te s t was validated by a group of n u t r i t i o n experts who had experience i n infant n u t r i t i o n . The pretest and scoring system 71 were analogous t o t h a t u t i l i z e d f o r the assessment of o b s t e - t r i c i a n s ' a t t i t u d e s . A t t i t u d e s of g e n e r a l p r a c t i t i o n e r s were measured by combining the d a t a c o l l e c t i o n instrument f o r o b s t e t r i c i a n s ' a t t i t u d e s w i t h the t e s t f o r p e d i a t r i c i a n s ' a t t i t u d e s ( Appendix A ). N u t r i t i o n p r a c t i c e s N u t r i t i o n p r a c t i c e s of o b s t e t r i c i a n s were assessed by a d a t a c o l l e c t i o n instrument developed f o r t h i s study. The q u e s t i o n n a i r e c o n s i s t e d of 20 statements r e g a r d i n g n u t r i t i o n c o u n s e l l i n g p r a c t i c e s f o r pregnant women. T h i s t e s t was v a l i d a t e d by a group o f n u t r i t i o n e x p e r t s who had e x p e r i e n c e i n the area o f p r e n a t a l n u t r i t i o n . The q u e s t i o n n a i r e was p r e - t e s t e d by a group o f a d u l t n u t r i t i o n e x p e r t s . The s c o r i n g system, ( Table V ) i n d i c a t e d the frequency of a s p e c i f i c p r a c - t i c e and took the form of 'always', ' f r e q u e n t l y ' , 'sometimes', or 'never'. For t h i s r e s e a r c h , 'always' was d e s i g n a t e d as g r e a t e r than 95% of the time; ' f r e q u e n t l y ' meant 50% t o 95% of the time; 'sometimes' i n d i c a t e d 5% t o 49% o f the time; and 'never' assumed t h a t the p r a c t i c e was conducted l e s s than 5% of the time. Each statement was scored from 0 t o 3, w i t h a p o s s i b l e t o t a l s c o r e between 0 and 60. 72 TABLE V SCORING SYSTEM FOR NUTRITION PRACTICE TEST Scale Response Score Always 4 3 Frequently 3 2 Always Sometimes 2 1 Never 1 0 Never 1 3 Sometimes 2 2 Never Frequently 3 1 Always 4 0 P e d i a t r i c i a n s ' n u t r i t i o n p r a c t i c e s were assessed by a data c o l l e c t i o n instrument developed f o r t h i s study. The qu e s t i o n n a i r e c o n s i s t e d of 20 statements regarding n u t r i t i o n c o u n s e l l i n g p r a c t i c e s f o r i n f a n t s . This t e s t was v a l i d a t e d by a group of n u t r i t i o n experts who had experience i n the area of i n f a n t n u t r i t i o n . The p r e t e s t and s c o r i n g system were s i m i l a r to t h a t u t i l i z e d f o r the assessment of o b s t e t r i c i a n s ' n u t r i t i o n p r a c t i c e s . N u t r i t i o n c o u n s e l l i n g p r a c t i c e s of general p r a c t i t i o n e r s were measured by combining the t e s t f o r o b s t e t r i c i a n s ' n u t r i t i o n c o u n s e l l i n g p r a c t i c e s w i t h the t e s t f o r p e d i a t r i c i a n s ' p r a c t i c e s . Demographic i n f o r m a t i o n and p r o f e s s i o n a l data Demographic and p r o f e s s i o n a l data ( non-manipulable v a r i a t e s ) were obtained i n a separate s e c t i o n of the ques- 73 t i o n n a i r e . T h i s s e c t i o n was composed of 11 q u e s t i o n s on the p h y s i c i a n ' s country o f medi c a l t r a i n i n g , sex, l o c a t i o n and type of p r a c t i c e , y e a r s i n p r a c t i c e and number of p r e n a t a l p a t i e n t s and i n f a n t s seen weekly. Sources of n u t r i t i o n i n f o r - mation, a d d i t i o n a l s p e c i a l i z a t i o n or t r a i n i n g , attendance a t c o n t i n u i n g e d u c a t i o n programs and the i n c l u s i o n o f n u t r i t i o n i n the medi c a l s c h o o l program were a l s o s t u d i e d . Procedure The data c o l l e c t i o n instruments were v a l i d a t e d by n u t r i t i o n e x p e r t s i n Canada and the U n i t e d S t a t e s ( Appendix B ). A v a l i d a t i o n q u e s t i o n n a i r e ( Appendix B ) was designed and used t o c o l l e c t i n f o r m a t i o n on c l a r i t y , p r e c i s i o n and c o n t e n t of the d a t a c o l l e c t i o n i n s t r u m e n t s . S i x t e e n of the 20 v a l i d a t o r s ( 80% ) r e t u r n e d the v a l i d a t i o n q u e s t i o n n a i r e s . Fourteen o f these were r e c e i v e d i n time f o r i n c o r p o r a t i o n o f t h e i r sugges- t i o n s i n t o the f i n a l q u e s t i o n n a i r e . Statements t h a t two or more v a l i d a t o r s d i s a g r e e d w i t h were d e l e t e d from the q u e s t i o n - n a i r e . Other statements were r e v i s e d i n o r d e r t o e l i m i n a t e a m b i g u i t i e s . The v a l i d a t e d q u e s t i o n n a i r e was p r e t e s t e d i n March, 197 5, by graduate students and f a c u l t y members i n Human N u t r i - t i o n a t the U n i v e r s i t y of B r i t i s h Columbia. S i x t e e n graduate students and f a c u l t y members completed the q u e s t i o n n a i r e along 74 w i t h a p r e t e s t q u e s t i o n n a i r e ( A p p e n d i x C ) . The q u e s t i o n n a i r e s were a g a i n r e v i s e d t o improve t h e c l a r i t y o f t h e q u e s t i o n s and t o i n c l u d e t h e s u g g e s t i o n s o f t h e p r e t e s t s u b j e c t s . Packages c o n t a i n i n g a q u e s t i o n n a i r e , a c o v e r l e t t e r e l i c i t i n g s u p p o r t and s t a t i n g t h e a u t h o r i z a t i o n f o r the s t u d y , and an a d d r e s s e d , s tamped, r e t u r n e n v e l o p e were m a i l e d t o t h e s u b j e c t s o f t h i s s t u d y i n March 27, 1975. R e t u r n o f t h e q u e s t i o n n a i r e s by A p r i l 15, 1975, was r e q u e s t e d . A f t e r t h e f i r s t d e a d l i n e e l a p s e d , a p o s t - c a r d r e m i n d e r , s t a t i n g a new d e a d l i n e , was m a i l e d t o a l l s u b j e c t s ( A p p e n d i x A ) . A second p o s t - c a r d r e m i n d e r was m a i l e d t o a l l s u b j e c t s i n May. The f i n a l c u t - o f f d a t e was s e t a t May 27, 1975, w h i c h was 60 days f r o m the i n i t i a l m a i l i n g . Upon r e c e i p t o f t h e m a i l q u e s t i o n n a i r e s t h e r e s p o n s e s were coded and t h e q u e s t i o n n a i r e s s u b m i t t e d t o the K e y - p u n c h i n g S e r v i c e o f t h e Computing C e n t e r a t the U n i v e r s i t y o f B r i t i s h C o l u m b i a . S c o r i n g o f the n u t r i t i o n a t t i t u d e s and p r a c t i c e s t e s t s , f r e q u e n c y d i s t r i b u t i o n s and s t a t i s t i c a l a n a l y s e s were p e r f o r m e d by an IBM 370/168 c o m p u t e r , u s i n g programmes d e s i g n e d o r f u r n i s h e d f o r t h i s s t u d y , by p e r s o n n e l i n t h e comput ing C e n t e r . The programmes s e l e c t e d f o r s t a t i s t i c a l a n a l y s e s i n c l u d e d the U n i v e r s i t y o f B r i t i s h C o l u m b i a T r i a n g u l a r R e g r e s - s i o n Package ( B j e r r i n g and S e a g r a v e s , 1974 ) as w e l l as t h e S t a t i s t i c a l Package f o r t h e S o c i a l S c i e n c e s ( N i e e_t a_l. 1975 ) . A t i m e s c h e d u l e was d e s i g n e d i n o r d e r t o f a c i l i t a t e 75 completion of t h i s study. Schedule Stage 1 - Planning and P r e p a r a t i o n 1. Design Study 2. Develop q u e s t i o n n a i r e 3. V a l i d a t i o n of q u e s t i o n n a i r e by n u t r i t i o n experts 4. Write and p r i n t cover l e t t e r s and reminder cards 5. P r e t e s t v a l i d a t e d q u e s t i o n n a i r e s 6. Revise and p r i n t q u e s t i o n n a i r e s 7. Develop coding scheme o Stage 2 - Data C o l l e c t i o n 1. Assemble q u e s t i o n n a i r e packages 2. M a i l q u e s t i o n n a i r e s t o p h y s i c i a n s 3. M a i l reminders Stage 3 - Data Analyses and I n t e r p r e t a t i o n 1. Code q u e s t i o n n a i r e responses, check coding 2. Key-punch from coded q u e s t i o n n a i r e s 3. Data a n a l y s i s by computer 4. R e s u l t s and f i n a l r e p o r t December '74 January 175 February 175 February '75 March '75 March ' 7 5 March '75 March March A p r i l - May A p r i l - May May June June- J u l y •75 '75 '75 •75 •75 •75 •75 Data A n a l y s i s Data c o l l e c t e d were coded, key-punched onto cards, and t r e a t e d s t a t i s t i c a l l y by computer a n a l y s i s , t o t e s t the f o l l o w - i n g hypotheses: 1. The r e l a t i o n s h i p of n u t r i t i o n a t t i t u d e s t o n u t r i t i o n c o u n s e l l i n g p r a c t i c e s f o r general p r a c t i t i o n e r s , p e d i a t r i c i a n s and o b s t e t r i c i a n s ( hypothesis 11 ) was determined by c o r r e l a t i o n a n a l y s i s . 2. Comparison of n u t r i t i o n a t t i t u d e s and p r a c t i c e scores of general p r a c t i t i o n e r s and p e d i a t r i c i a n s was con- ducted by t - t e s t f o r s i g n i f i c a n t d i f f e r e n c e s i n the group means. Comparison of n u t r i t i o n a t t i t u d e s and p r a c t i c e scores of general p r a c t i t i o n e r s and o b s t e t r i c i a n s was conducted by t - t e s t f o r s i g n i f i c a n t d i f f e r e n c e s i n group means ( hypothesis 12 ). 3. Stepwise r e g r e s s i o n analyses were c a r r i e d out on the two c r i t e r i o n v a r i a b l e s , n u t r i t i o n a t t i t u d e s and p r a c t i c e s , to determine whether the non-manipulable v a r i a t e s were f a c t o r s which r e l a t e d t o the c r i t e r i o n v a r i a b l e s ( o b j e c t i v e 2 ). 4. The r e l a t i o n s h i p of each of l o c a t i o n of medical t r a i n i n g , l o c a t i o n and type of p r a c t i c e , years of p r a c t i c e , sex of respondent, number of p a t i e n t s seen weekly, sources of n u t r i t i o n i n f o r m a t i o n , number and type of c o n t i n u i n g education programs attended and i n c l u s i o n of n u t r i t i o n education i n medical 77 school t r a i n i n g to n u t r i t i o n attitudes and practices of general p r a c t i t i o n e r s , p e d i a t r i c i a n s and ob s t e t r i c i a n s ( hypotheses 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 ) was tested by a one-way analysis of variance for s i g n i f i c a n t differences i n group means for each of the c r i t e r i o n v a r i a b l e s . 5. Comparison of n u t r i t i o n attitudes and practices of general p r a c t i t i o n e r s , p e d i a t r i c i a n s and obs t e t r i c i a n s who attended one continuing education programme to those who attended more than one programme was determined by t - t e s t for s i g n i f i c a n t differences i n group scores. In addition, a t - t e s t was used to determine i f there was a difference between early and la t e respondents for general p r a c t i t i o n e r s , p e d i a t r i c i a n s and o b s t e t r i c i a n s . A l l r e s u l t s were reported at the highest l e v e l of s i g n i f i c a n c e . CHAPTER IV FINDINGS AND INTERPRETATIONS In t h i s study o f g e n e r a l p r a c t i t i o n e r s , p e d i a t r i c i a n s and o b s t e t r i c i a n s i n the p r o v i n c e of B r i t i s h Columbia, the nature of the r e l a t i o n s h i p of n u t r i t i o n a t t i t u d e s and n u t r i - t i o n c o u n s e l l i n g p r a c t i c e s to s e l e c t e d environmental v a r i a t e s was e x p l o r e d . The r e l a t i o n s h i p between the two c r i t e r i o n v a r i a b l e s ( n u t r i t i o n a t t i t u d e s and p r a c t i c e s ) was a l s o i n v e s t i g a t e d . Rates o f Response Q u e s t i o n n a i r e s were sent to 1,9 81 p r a c t i s i n g p h y s i c i a n s r e g i s t e r e d w i t h the B r i t i s h Columbia M e d i c a l A s s o c i a t i o n . A t o t a l of 844 q u e s t i o n n a i r e s were r e t u r n e d , r e p r e s e n t i n g an o v e r a l l response r a t e o f 42.5% ( Table VI ). T h i s r a t e of r e - sponse compares f a v o u r a b l y w i t h o t h e r s r e p o r t e d i n the r e c e n t l i t e r a t u r e ( G u l l e n and G a r r i s o n , 1973; S c h i l l e r and V i v i a n , 1974 ). Of the q u e s t i o n n a i r e s r e c e i v e d , 60 ( 3.0% ) were r e t u r n e d unanswered, m a i n l y because the p h y s i c i a n was no l o n g e r engaged i n the p r a c t i c e of o b s t e t r i c s or p e d i a t r i c s . Twenty q u e s t i o n n a i r e s were i n c o m p l e t e l y answered, thus making t h e i r t a b u l a t i o n i m p o s s i b l e . 78 79 TABLE VI SUMMARY OF RESPONSE RATES FROM PHYSICIANS P h y s i c i a n Number Sent Number Received % Received General P r a c t i t i o n e r s 1,753 724 41.3 P e d i a t r i c i a n s 110 69 62.7 O b s t e t r i c i a n s 118 51 43.2 T o t a l 1,981 844 42.6 Comparison of E a r l y and Late Respondents The major disadvantage o f the m a i l q u e s t i o n n a i r e as a survey r e s e a r c h instrument i s the r e s e a r c h e r ' s l a c k o f c o n t r o l over who responds. I f non-respondents d i f f e r s i g n i f i c a n t l y from respondents on the i s s u e s b e i n g s t u d i e d , a non-response b i a s may be i n t r o d u c e d which c o u l d i n v a l i d a t e the i n t e r p r e t a t i o n of the survey. R e s u l t s of s t u d i e s have i n d i c a t e d t h a t i n d i v i - d u a l s who respond l a t e t o q u e s t i o n n a i r e s are s i m i l a r t o those who do not respond a t a l l ( Larson and Catton, 1959; Roeher, 1963 ) . Of the 647 g e n e r a l p r a c t i t i o n e r s who r e t u r n e d a comple- ted q u e s t i o n n a i r e , 467 d i d so by the f i r s t d e a d l i n e date and 80 hence, were designated as early respondents. The f i n a l 180 ( 28% ) general p r a c t i t i o n e r s to return questionnaires before the f i n a l cut-off date were considered to be l a t e respondents. Questionnaires from p e d i a t r i c i a n s and o b s t e t r i c i a n s were divided i n an analogous manner for early and l a t e respondents ( Table VII ). TABLE VII NUMBER AND PERCENTAGE OF PHYSICIANS DESIGNATED AS EARLY AND LATE RESPONDENTS Physician Early Late General P r a c t i t i o n e r 467 ( 72% ) 180 ( 28% ) P e d i a t r i c i a n 59 ( 87% ) 9 ( 13% ) Obstetrician 37 ( 77% ) 11 ( 23%') Results of t - t e s t analyses for s i g n i f i c a n t differences i n group means of t e s t scores for early and l a t e respondents showed no s i g n i f i c a n t differences at the 1% l e v e l for n u t r i t i o n attitude scores or n u t r i t i o n p r a c t i c e scores for general p r a c t i - tioners, p e d i a t r i c i a n s and o b s t e t r i c i a n s ( Table VIII ). Thus, i f l a t e respondents may be considered s i m i l a r to non-respondents the non-response i n t h i s study should not bias the i n t e r p r e t a t i o n of the r e s u l t s . 81 TABLE VIII COMPARISON OF EARLY AND LATE RESPONDENTS ON BASIS OF MEAN PERCENTAGE TEST SCORES Physician Mean Test Scores Significance Early Late General P r a c t i t i o n e r s ' N u t r i t i o n Attitudes 72.75 72. 32 / N.S. Nut r i t i o n Practices 60.11 59.87 N.S. Ped i a t r i c i a n s ' N u t r i t i o n Attitudes 81.58 81.10 N.S. Nut r i t i o n Practices 65.75 64.46 N.S. Obstetricians' N u t r i t i o n Attitudes 62.43 69.99 N.S . N u t r i t i o n Practices 64.15 66.52 N.S. General P r a c t i t i o n e r s Description of Respondents Univariate frequency tables were designed to describe the demographic and professional c h a r a c t e r i s t i c s of the general p r a c t i t i o n e r s who responded to t h i s survey. Country of medical t r a i n i n g Most general p r a c t i t i o n e r s who r e p l i e d to the question- 82 n a i r e r e c e i v e d the m a j o r i t y o f t h e i r m e d i c a l t r a i n i n g i n Canada ( Table IX ) . TABLE IX DISTRIBUTION OF GENERAL PRACTITIONERS BY COUNTRY OF MEDICAL TRAINING Country of M e d i c a l T r a i n i n g Number % Canada 449 70.0 Great B r i t a i n . 121 18.8 U n i t e d S t a t e s 14 2.2 I r e l a n d 1 9 1.4 A u s t r a l i a 7 1.1 Germany 5 0.8 I n d i a 3 0.5 Others 33 5.2 T o t a l 641 100.0 Sex D i s t r i b u t i o n o f respondents a c c o r d i n g t o sex showed t h a t 593 ( 91.9% ) of the respondents were male w h i l e 52 ( .8.1% ) were female. L o c a t i o n o f p r a c t i c e The h i g h e s t percentage of respondents were from c i t i e s ( e x c l u d i n g Vancouver ) w i t h p o p u l a t i o n s g r e a t e r than 5000 ( Table X ). 83 TABLE X DISTRIBUTION OF GENERAL PRACTITIONERS BY LOCATION OF PRACTICE L o c a t i o n Number % Vancouver 228 35.3 Other C i t y 300 46.4 Town 66 10.2 V i l l a g e 52 8.1 T o t a l 646- 100.0 Years of p r a c t i c e The m a j o r i t y of the g e n e r a l p r a c t i t i o n e r s responding t o the q u e s t i o n n a i r e were i n p r a c t i c e f o r more than 10 years ( Table XI ). TABLE XI DISTRIBUTION OF GENERAL PRACTITIONERS BY YEARS OF PRACTICE Years of P r a c t i c e Number % <5 years 181 28.0 but < 10 131 20.2 >10 y e a r s 335 51.8 T o t a l 647 100. 0 Type of p r a c t i c e More than 50% of the respondents were i n c l i n i c o r group p r a c t i c e ( Table XII ). 84 TABLE XII DISTRIBUTION OF GENERAL PRACTITIONERS BY TYPE OF PRACTICE Type Number % P r i v a t e 305 47.6 C l i n i c 336 52.4 T o t a l 641 100.0 P a t i e n t s seen weekly The m a j o r i t y of g e n e r a l p r a c t i t i o n e r s ( 79.1% ) see fewer than 10 pregnant women weekly but most p h y s i c i a n s t r e a t more than 10 i n f a n t s per week ( Table X I I I ). TABLE X I I I DISTRIBUTION OF GENERAL PRACTITIONERS BY THE NUMBER OF PATIENTS SEEN WEEKLY Number of P r e n a t a l P a t i e n t s Number % <10 507 79.1 > 10 but < 25 132 20.6 >25 2 0.3 T o t a l 641 100.0 Number of I n f a n t s Number % <10 231 36.0 >10 but < 25 344 53.7 >25 66 10.3 T o t a l 641 100.0 85 Sources o f n u t r i t i o n i n f o r m a t i o n Of the respondents, 636 g e n e r a l p r a c t i t i o n e r s i n d i c a t e d t h a t they use r e s o u r c e m a t e r i a l f o r n u t r i t i o n i n f o r m a t i o n ( Table XIV ). P r o f e s s i o n a l j o u r n a l s were u t i l i z e d more than any oth e r source. Most p h y s i c i a n s r e f e r r e d t o more than one source of i n f o r m a t i o n . C o n s u l t a t i o n w i t h a c o l l e a g u e was r e p o r t e d more f r e q u e n t l y than c o n s u l t a t i o n w i t h a n u t r i t i o n i s t - d i e t i t i a n . TABLE XIV NUMBER AND PERCENTAGE OF GENERAL PRACTITIONERS INDICATING SOURCES OF NUTRITION INFORMATION Source Number % P r o f e s s i o n a l j o u r n a l s 588 91.7 Government p u b l i c a t i o n s 399 62.2 P r o f e s s i o n a l b u l l e t i n s 379 58.6 Books 356 55.5 He a l t h agency p u b l i c a t i o n s 349 54.4 Co l l e a g u e 284 44. 3 N u t r i t i o n i s t - D i e t i t i a n 277 43.2 Pha r m a c e u t i c a l companies' brochures 227 35.4 Magazines 207 32.2 Food manufacturers' brochures 163 25.4 A u d i o v i s u a l a i d s 143 22.3 P u b l i c H e a l t h Nurse 113 17.6 Radio 94 14.6 T e l e v i s i o n 86 13.4 Home Economist 18 2.8 Other 28 4.4 86 S p e c i a l i z a t i o n Table XV i n d i c a t e s t h a t approximately 25% of the respondents had a d d i t i o n a l t r a i n i n g f o r s p e c i a l i z a t i o n i n areas t h a t may be r e l a t e d t o n u t r i t i o n . Some p h y s i c i a n s had a d d i t i o n - a l t r a i n i n g i n p e d i a t r i c s or o b s t e t r i c s a l t h o u g h they s t i l l p r a c t i c e d as g e n e r a l p r a c t i t i o n e r s . S p e c i a l i z a t i o n s grouped t o g e t h e r under the heading 'other' i n c l u d e d t r a i n i n g i n t r o p i c a l medicine or i n t e r n a l medicine. General p r a c t i t i o n e r s who had t r a i n i n g i n surgery o r a n e s t h e s i o l o g y were not i n c l u d e d i n Table XV. TABLE XV NUMBER AND PERCENTAGE OF GENERAL PRACTITIONERS HAVING ADDITIONAL TRAINING FOR SPECIALIZATION T r a i n i n g f o r S p e c i a l i z a t i o n Number % O b s t e t r i c s 38 5 . 9 Family P r a c t i c e 27 4 . 2 Neonatology 24 3 . 7 P e d i a t r i c s 19 2 . 9 P u b l i c H e a l t h Diploma 13 2 . 0 Other 50 7 . 7 T o t a l 1 6 1 * 2 5 . 1 * Ten o f these p h y s i c i a n s had more than one s p e c i a l i z a t i o n . C o n t i n u i n g e d u c a t i o n The m a j o r i t y o f p h y s i c i a n s responding d i d not a t t e n d 87 c o n t i n u i n g e d u c a t i o n programs ( Table XVI ). Only 18.8% o f the respondents attended these programs and j u s t 20 p h y s i c i a n s r e g i s t e r e d f o r more than one program. The two c o n t i n u i n g e d u c a t i o n programs l i s t e d , "Care of the High Risk Foetus and Newborn" and " E a r l y N u t r i t i o n and L a t e r L i f e " , were programs o f f e r e d i n the p r o v i n c e o f B r i t i s h Columbia. However, many o f the g e n e r a l p r a c t i t i o n e r s attended c o n t i n u i n g e d u c a t i o n programs presented i n oth e r Canadian p r o v i n c e s or i n the U n i t e d S t a t e s . TABLE XVI NUMBER AND PERCENTAGE OF RESPONDENTS INDICATING ATTENDANCE AT CONTINUING EDUCATION PROGRAMS Co n t i n u i n g E d u c a t i o n Programs Number % Care of the High Risk Foetus and Newborn 43 6.6 E a r l y N u t r i t i o n and L a t e r L i f e 14 2.2 Other 84 13.0 T o t a l 121* 18. 8* * Twenty o f these p h y s i c i a n s attended more than one program. N u t r i t i o n i n me d i c a l e d u c a t i o n Most of the respondents had never taken a course on n u t r i t i o n ( Table XVII ). Some p h y s i c i a n s i n d i c a t e d t h a t n u t r i - t i o n was i n t e g r a t e d w i t h m a t e r i a l i n b i o c h e m i s t r y courses and 88 had l i t t l e p r a c t i c a l r e l e v a n c e . ( See Appendix D f o r p h y s i c i a n s ' comments t o q u e s t i o n n a i r e s ). F o r t y p e r c e n t of the respondents had no formal n u t r i t i o n e d u c a t i o n . TABLE XVII NUMBER AND PERCENTAGE OF GENERAL PRACTITIONERS INDICATING TYPE OF NUTRITION EDUCATION IN MEDICAL SCHOOL Format of N u t r i t i o n E d u c a t i o n Number % Course on N u t r i t i o n 14 2.1 S e r i e s o f l e c t u r e s 101 15.6 I n t e g r a t e d w i t h o t h e r s u b j e c t matter 338 52.2 No formal n u t r i t i o n e d u c a t i o n 262 40.5 it 89 N u t r i t i o n A t t i t u d e s and P r a c t i c e s Method of s c o r i n g The t e s t o f n u t r i t i o n a t t i t u d e s ( Appendix A ) con- s i s t e d o f 20 statements each answered by 'Agree' or " D i s a g r e e 1 and by the degree of c e r t a i n t y f o r each response. Each s t a t e - ment was score d between 0 and 7 ( Table IV ). The mean t o t a l s c o r e f o r the a t t i t u d e t e s t was c a l c u l a t e d by adding respon- dents' a t t i t u d e s c o r e s and d i v i d i n g by 630. T h i s f i g u r e r e p r e - sents the t o t a l number of p h y s i c i a n s who completed a t l e a s t 19 of the 20 o p i n i o n statements. Q u e s t i o n n a i r e s w i t h more than one response m i s s i n g were e l i m i n a t e d from the a n a l y s i s . Mean sc o r e s f o r each statement on the t e s t were o b t a i n e d by t o - t a l l i n g i n d i v i d u a l statement s c o r e s and d i v i d i n g by the t o t a l number of answered statements. Those q u e s t i o n n a i r e s w i t h one unanswered statement were a s s i g n e d the mean sc o r e s f o r t h a t p a r t i c u l a r statement. A separate s e c t i o n o f the q u e s t i o n n a i r e c o n s i s t i n g o f 40 statements on n u t r i t i o n c o u n s e l l i n g p r a c t i c e s ( Appendix A ) was answered by i n d i c a t i n g the frequency w i t h which the p r a c - t i c e was performed. The c a t e g o r i e s u t i l i z e d were 'always', ' f r e q u e n t l y 1 , 'sometimes' and 'never* and were score d from 0 t o 3 ( Table V ). A t o t a l of 620 respondents completed a t l e a s t 38 of the 40 p r a c t i c e statements. The p r a c t i c e t e s t was scored i n a manner analogous t o t h a t of the n u t r i t i o n o p i n i o n t e s t . Scores from both t e s t s were converted t o percentages so 90 t h a t the two v a r i a b l e s c o u l d be analyzed from a common base. R e s u l t s of t e s t s The mean sco r e s f o r t e s t s o f n u t r i t i o n a t t i t u d e s and p r a c t i c e s are p r e s e n t e d i n Table XVIII. A t t i t u d e s c o r e s were c o n s i d e r a b l y h i g h e r than p r a c t i c e s c o r e s f o r g e n e r a l p r a c t i - t i o n e r s . TABLE XVIII MEAN PERCENTAGE SCORES FOR NUTRITION ATTITUDE AND PRACTICE TESTS FOR GENERAL PRACTITIONERS Test Mean Score A t t i t u d e s 72.64 + 8.75 a P r a c t i c e s 60.05 + 7.49 a Standard D e v i a t i o n N u t r i t i o n A t t i t u d e s : The mean t e s t s c o r e f o r n u t r i t i o n a t t i t u d e s was 72.64% w i t h a range from 42.9% t o 92.1%. General p r a c t i t i o n e r s s c o r e d lowest on items 3, 8, 9 and 10 ( Table XIX ) . A p p a r e n t l y , few p h y s i c i a n s f e e l t h a t l a c t a t i o n i s an a p p r o p r i a t e time t o e l i m i n a t e excess f a t accumulated d u r i n g pregnancy even when the n u t r i e n t i n t a k e remains adequate. T h i s i s i n d i r e c t con- t r a s t t o the recommendations o f the Food and N u t r i t i o n Board of the N a t i o n a l Research C o u n c i l (1973) which recommended a d a i l y i n c r e a s e d energy i n t a k e of o n l y 500 c a l o r i e s d u r i n g l a c t a - t i o n t o permit readjustment o f maternal b o d y - f a t s t o r e s . ( Answer key f o r a l l statements i s i n Appendix E ). 91 TABLE XIX STATEMENTS MEASURING NUTRITION ATTITUDES FOR WHICH GENERAL PRACTITIONERS RECEIVED LOWEST MEAN SCORES Statement C o r r e c t Response P o s s i b l e Score Mean Score 10. L a c t a t i o n i s a good time t o get r i d o f excess weight accumulated d u r i n g pregnancy as l o n g as nu- t r i e n t i n t a k e remains adequate • • I f e e l t h a t pregnant women need so much f o l i c a c i d t h a t i t i s d i f f i - c u l t t o get i t from d i e t alone P r o v i d e d t h a t they e n t e r pregnancy w i t h adequate hemoglobin l e v e l s , women need t o i n c r e a s e t h e i r i r o n i n t a k e o n l y d u r i n g the l a s t h a l f o f p r e g - nancy I f e e l t h a t t h e r e i s l i t - t l e p r a c t i c a l , a c c u r a t e i n f o r m a t i o n on maternal n u t r i t i o n i n the c u r r e n t s c i e n t i f i c j o u r n a l s and books Agree Agree Agree D i s - agree 7.0 7.0 7.0 7.0 3.2 3.2 2.8 2.9 S u r p r i s i n g l y , many p h y s i c i a n s f e l t t h a t there.was l i t t l e a c c u r a t e , p r a c t i c a l i n f o r m a t i o n i n the c u r r e n t s c i e n t i f i c j o u r - n a l s and books and y e t they l i s t e d the s c i e n t i f i c j o u r n a l s as t h e i r major source o f n u t r i t i o n i n f o r m a t i o n ( Table XIV ). The h i g h e s t mean a t t i t u d e s c o r e ( 6.6 ) was achieved on statement 6 c o n c e r n i n g p h y s i c i a n s i n f o r m i n g pregnant women about b r e a s t - f e e d i n g . Average s c o r e s f o r a l l a t t i t u d e q u e s t i o n s have been l i s t e d i n Appendix F. N u t r i t i o n p r a c t i c e s : General p r a c t i t i o n e r s had a mean p r a c t i c e t e s t s c o r e o f 60.05% w i t h a range from 33.3% t o 88.3%. Lowest mean s c o r e s were ac h i e v e d on statements 4, 8, 15, 22, 28, 30, 33, 34, and 38 ( Table XX ). TABLE XX STATEMENTS MEASURING NUTRITION COUNSELLING PRACTICES FOR WHICH GENERAL PRACTITIONERS RECEIVED LOWEST MEAN SCORES Statement C o r r e c t Response P o s s i b l e Score Mean Score 4. I a d v i s e h e a l t h y expec- t a n t women who do not d r i n k m i l k t o take a Never 3.0 0.9 8. I encourage the average pregnant woman t o g a i n approximately 1 pound per week i n the l a s t 20 Always 3.0 1.1 15. I p r e s c r i b e a m u l t i - v i t a m i n supplement f o r my p r e n a t a l p a t i e n t s even when t h e i r d i e t a r y i n t a k e appears adequate.. Never 3.0 0.9 22. I ask mothers from what sources t h e i r 1 - 2 year o l d s o b t a i n Always 3.0 1.1 Table XX (continued) 93 .Statement C o r r e c t Response P o s s i b l e Score Mean Score 28. I recommend t h a t human m i l k alone i s adequate i n n u t r i e n t content f o r the f i r s t two months of l i f e 30. I recommend t h a t i r o n f o r t i f i e d foods or i r o n drops be a p a r t o f the i n f a n t ' s d i e t a r y r e g i - men d u r i n g the 2nd year o f l i f e - 33. I recommend t h a t by the time the c h i l d i s 5 months o f age he should be e a t i n g c e r e a l s , f r u i t s , v e g e t a b l e s and meats 34. I recommend t h a t a m u l t i - v i t a m i n s u p p l e - ment be g i v e n to h e a l t h y i n f a n t s 38. I encourage mothers t o i n c l u d e about 25 grams of p r o t e i n i n the d a i l y d i e t o f a 1 - 2 year o l d Never Always Never Never Always 3.0 3.0 3.0 3.0 3.0 0.9 1.2 0.8 1.2 1.1 I t i s e v i d e n t t h a t v i t a m i n p r e p a r a t i o n s ( statements 15 and 34 ) are recommended w i d e l y even when d i e t a r y i n t a k e i s adequate. Yet i r o n - f o r t i f i e d foods or i r o n drops are not gener- a l l y recommended f o r i n f a n t s ( statement 30 ). The r e s u l t s o f numerous s t u d i e s ( F i l e r and M a r t i n e z , 1964; P u r v i s , 1973; N u t r i t i o n Canada, 1973; Maslansky e t a l . , 1974 ) have shown t h a t i t i s i r o n r a t h e r than v i t a m i n s which i s most l i k e l y t o be 94 l a c k i n g i n the i n f a n t ' s d i e t . Few p h y s i c i a n s encourage a weight g a i n o f approximately one pound per week i n the l a s t 20 weeks of pregnancy f o r the normal pregnant woman ( statement 8 ). T h i s i s c o n t r a r y t o the recommendations o f s e v e r a l committees and i n v e s t i g a t o r s ( Committee on Maternal N u t r i t i o n , 197 0; Hytten and L e i t c h , 1971; N u t r i t i o n i n Pregnancy Committee, 1973 ) who suggest a t o t a l weight g a i n i n the v i c i n i t y o f 24 t o 2 8 pounds. G e n e r a l l y , f o u r t o e i g h t pounds are gained d u r i n g the f i r s t 20 weeks o f preg- nancy, l e a v i n g approximately 20 pounds t o accumulate d u r i n g the l a t t e r p a r t . R e l a t i o n s h i p o f a t t i t u d e s t o p r a c t i c e s A h i g h l y s i g n i f i c a n t p o s i t i v e c o r r e l a t i o n ( r = 0.370 ) was found between n u t r i t i o n a t t i t u d e s and p r a c t i c e s o f g e n e r a l p r a c t i t i o n e r s . T h i s c o r r e l a t i o n was s i g n i f i c a n t a t the 1% p r o b a b i l i t y l e v e l . These r e s u l t s c o n f i r m the e a r l i e r work of J a l s o e t a l . , (1965) who found a s t r o n g p o s i t i v e c o r r e l a t i o n between n u t r i t i o n o p i n i o n s and p r a c t i c e s ( r = 0.63 ) f o r a d u l t members of community o r g a n i z a t i o n s i n New York S t a t e . Other workers ( Newton and Newton, 19 50; Schwartz, 197 5 ) have found a s i m i l a r p o s i t i v e r e l a t i o n s h i p between n u t r i t i o n a t t i t u d e s and p r a c t i c e s . I t i s g r a t i f y i n g t o observe t h a t many p h y s i c i a n s f e e l t h a t pregnant women should be informed about b r e a s t - f e e d i n g and encourage b r e a s t - f e e d i n g among t h e i r pregnant p a t i e n t s 95 ( statements 6, 2 and 31 i n Table XXI ). T h i s i s i n c o n t r a s t to r e p o r t s i n the r e c e n t l i t e r a t u r e t h a t p h y s i c i a n s a p p a r e n t l y d i d l i t t l e t o encourage b r e a s t - f e e d i n g ( Shukla e t a l . , 1972; Applebaum, 1975 ). However, few p h y s i c i a n s r e a l i z e d t h a t b r e a s t m i l k i s inadequate i n some n u t r i e n t s ( p a r t i c u l a r l y V i t a m i n D ) and must be supplemented ( Kodicek, 1973; Fomon, 1974; Committee on N u t r i t i o n a l M i s i n f o r m a t i o n , 1975 ). TABLE XXI COMPARISON OF NUTRITION ATTITUDES AND PRACTICES OF GENERAL PRACTITIONERS CONCERNING BREAST-FEEDING Statement C o r r e c t Response P o s s i b l e Score Mean Score A t t i t u d e 6. Pregnant women should be informed about the pros and cons o f b r e a s t - f e e d i n g Agree 7.0 6. 6 P r a c t i c e s 2. I c o n s i d e r the p o s s i b i l - i t y o f b r e a s t - f e e d i n g w i t h the pregnant women I see i n my p r a c t i c e Always Never 3.0 2.8 28. I recommend t h a t human m i l k alone i s adequate i n n u t r i e n t content f o r the f i r s t two months o f l i f e 3.0 0.9 31. I encourage h e a l t h y mo- t h e r s o f i n f a n t s t o b r e a s t - f e e d f o r the f i r s t s i x months Always 3.0 2.1 96 A t t i t u d e s and p r a c t i c e s on the i n t r o d u c t i o n o f s o l i d s i n t o the i n f a n t ' s d i e t showed t h a t most p h y s i c i a n s do not f e e l p r e s s u r e d by mothers t o i n t r o d u c e s o l i d s a t an e a r l y age; they appear t o do so on t h e i r own i n i t i a t i v e ( Table XXII ). TABLE XXII COMPARISON OF NUTRITION ATTITUDES AND PRACTICES OF GENERAL PRACTITIONERS CONCERNING EARLY INTRODUCTION OF SOLIDS Statement C o r r e c t Response P o s s i b l e Score Mean Score A t t i t u d e 17. Many mothers are anxious t o have t h e i r i n f a n t s i n g e s t s o l i d s as soon as p o s s i b l e and I f e e l t h a t i t i s bes t t o go along D i s - agree 7.0 5.1 P r a c t i c e s 23. I encourage mothers t o g i v e c e r e a l s added t o the b o t t l e f o r a h e a l t h y i n - f a n t who i s n ' t s a t i s f i e d Never 3.0 1.6 25. I recommend the e a r l y ( w i t h i n 2 months of b i r t h ) i n t r o d u c t i o n o f s o l i d s such as c e r e a l s Never 3.0 1.6 33. I recommend t h a t by the time the c h i l d i s 5 months o f age he should be e a t i n g c e r e a l s , f r u i t s , Never 3.0 0.8 97 The R e l a t i o n s h i p of Sel e c t e d V a r i a t e s t o N u t r i t i o n A t t i t u d e s and P r a c t i c e s The r e l a t i o n s h i p of the non-manipulable v a r i a t e s t o the c r i t e r i o n v a r i a b l e s ( n u t r i t i o n a t t i t u d e s and p r a c t i c e s ) were i n v e s t i g a t e d i n two ways: by one-way a n a l y s i s of va r i a n c e using Scheffe's t e s t and a n a l y s i s of va r i a n c e using stepwise m u l t i p l e r e g r e s s i o n . Scheffe's t e s t allows m u l t i p l e comparisons of a number of means taken two at a time, even when the means are from groups of unequal s i z e . In order t o reduce the t o t a l number of v a r i a t e s , a number of s i m i l a r v a r i a t e s were grouped under one heading. Stepwise r e g r e s s i o n a n a l y s i s determined which of the v a r i a t e s s t u d i e d had a s i g n i f i c a n t e f f e c t on the c r i t e r i o n v a r i a b l e s . This e f f e c t i s independent of the e f f e c t of a l l other v a r i a t e s . One-way a n a l y s i s of va r i a n c e L o c a t i o n of medical t r a i n i n g : Table XXIII i n d i c a t e s t h a t l o c a t i o n of medical t r a i n i n g was not s i g n i f i c a n t l y r e - l a t e d t o n u t r i t i o n a t t i t u d e s and p r a c t i c e s . Since 8 8.8% of the general p r a c t i t i o n e r s were t r a i n e d i n e i t h e r Canada or Great B r i t a i n ( Table IX ), the remaining c o u n t r i e s were grouped together as one category. TABLE X X I I I 98 MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON LOCATION OF MEDICAL TRAINING T e s t C o u n t r y S i g n i f i c a n c e Canada G r e a t B r i t a i n O t her A t t i t u d e s 73.01 72. 38 71.04 N.S. P r a c t i c e s 59.88 60.48 60.17 N.S. Sex: Female g e n e r a l p r a c t i t i o n e r s s c o r e d s i g n i f i c a n t l y h i g h e r on t e s t s o f n u t r i t i o n a t t i t u d e s and p r a c t i c e s t h a n d i d t h e i r male c o u n t e r p a r t s ( T a b l e XXIV ). TABLE XXIV MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON SEX OF RESPONDENT T e s t Sex S i g n i f i c a n c e Male Female P < 0.01 A t t i t u d e s 72.36 76.21 S. P r a c t i c e s 59. 64 65.08 S. L o c a t i o n o f p r a c t i c e : There was no s i g n i f i c a n t d i f f e r - ence i n t h e s c o r e s on t h e n u t r i t i o n a t t i t u d e s and p r a c t i c e s t e s t s based on l o c a t i o n o f p r a c t i c e ( T a b l e XXV ). 99 TABLE XXV MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON LOCATION OF PRACTICE Test L o c a t i o n o f P r a c t i c e S i g n i - f i c a n c e Vancouver Other C i t y Town V i l l a g e A t t i t u d e s 72. 85 73.04 70. 69 72.04 N.S. P r a c t i c e s 60.28 59.79 60.82 59.60 N.S. Years o f p r a c t i c e : One way a n a l y s i s of v a r i a n c e i n d i - c a t e d t h a t g e n e r a l p r a c t i t i o n e r s who were i n p r a c t i c e f o r more than 10 y e a r s s c o r e d s i g n i f i c a n t l y lower on the n u t r i t i o n a t t i - tude and p r a c t i c e t e s t s than p h y s i c i a n s who were i n p r a c t i c e f o r fewer than f i v e y e a r s and between f i v e and 10 ye a r s ( T a b l e XXVI ) . TABLE XXVI MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON YEARS OF PRACTICE Test Years o f P r a c t i c e S i g n i f i c a n c e <C.5 years 5 y e a r s - C l O ^>10 ye a r s P<0.001 A t t i t u d e s 73.41 74. 81 71.32 S. P r a c t i c e s 61.46 61.06 58.85 S. Type of p r a c t i c e : Table XXVII i n d i c a t e s t h a t type o f 100 p r a c t i c e had no s i g n i f i c a n t e f f e c t on t h e a t t i t u d e s and p r a c t i c e s o f g e n e r a l p r a c t i t i o n e r s . TABLE XXVII MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON TYPE OF PRACTICE T e s t Type o f P r a c t i c e S i g n i f i c a n c e P r i v a t e C l i n i c A t t i t u d e s 72. 31 72.87 N.S. P r a c t i c e s 59.94 60.05 N.S. Number o f p r e n a t a l p a t i e n t s : There was no s i g n i f i c a n t d i f f e r e n c e i n t h e s c o r e s o f n u t r i t i o n a t t i t u d e s and p r a c t i c e s based on number o f p a t i e n t s seen w e e k l y ( T a b l e X X V I I I ). A l - though p h y s i c i a n s who see more t h a n 25 p a t i e n t s w e e k l y appear t o have h i g h e r s c o r e s , t h e r e were o n l y two p h y s i c i a n s i n t h i s group ( T a b l e XIV ). TABLE X X V I I I MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON NUMBER OF PRENATAL PATIENTS SEEN WEEKLY T e s t Number o f P r e n a t a l P a t i e n t s S i g n i f i c a n c e <10 > 10 b u t < 2 5 > 25 A t t i t u d e s 72.42 73.39 80.35 N.S. P r a c t i c e s 59.60 61. 62 64.15 N.S. 1 0 1 Number o f i n f a n t s : The number of i n f a n t s seen weekly had no s i g n i f i c a n t e f f e c t on the t e s t s cores of respondents ( Table XXIX ). TABLE XXIX MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON NUMBER OF INFANTS SEEN WEEKLY T e s t N u m b e r o f I n f a n t s S i g n i f i c a n c e < C l O i n f a n t s y>10 i n f a n t s b u t < 2 5 > 2 5 A t t i t u d e s 7 2 . 5 0 7 2 . 64 7 3 . 0 5 N . S . P r a c t i c e s 5 9 . 5 9 6 0 . 1 4 6 0 . 5 6 N . S . A d d i t i o n a l t r a i n i n g f o r s p e c i a l i z a t i o n : P h y s i c i a n s who had a d d i t i o n a l t r a i n i n g s c o r e d s i g n i f i c a n t l y h i g h e r than g e n e r a l p r a c t i t i o n e r s w i t h o u t any a d d i t i o n a l s p e c i a l i z a t i o n ( Table XXX ) . TABLE XXX MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON ADDITIONAL TRAINING FOR SPECIALIZATION Tes t T r a i n i n g f o r S p e c i a l i z a t i o n S i g n i f i c a n c e T r a i n i n g No T r a i n i n g P < 0 . 05 A t t i t u d e s 7 4 . 0 0 7 2 . 2 6 S. P r a c t i c e s 6 2 . 3 4 5 9 . 3 1 S. C o n t i n u i n g E d u c a t i o n : Respondents who had attended one 102 or more c o n t i n u i n g e d u c a t i o n programs were grouped under one heading and compared t o respondents who had not attended any c o n t i n u i n g e d u c a t i o n programs. A n a l y s i s of v a r i a n c e i n d i c a t e d t h a t t h e r e was a s i g n i f i c a n t d i f f e r e n c e i n the n u t r i t i o n a t t i - tude and p r a c t i c e t e s t s based on these two groups ( Table XXXI ) . TABLE XXXI MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON ATTENDANCE AT CONTINUING EDUCATION PROGRAMS ATTENDED Test C o n t i n u i n g E d u c a t i o n Programs S i g n i f i c a n c e Attendance No Attendance P < 0.01 A t t i t u d e s 75.04 72.16 S. P r a c t i c e s 63.07 59.40 S. Mean t e s t s c o r e s o f p h y s i c i a n s who attended more than one c o n t i n u i n g e d u c a t i o n programs were compared t o g e n e r a l p r a c - t i t i o n e r s who attended o n l y one program. Table XXXII i n d i c a t e s t h a t t h e r e was no s i g n i f i c a n t d i f f e r e n c e i n the t e s t s c o r e s o f these two groups. 103 TABLE XXXII MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON NUMBER OF CONTINUING EDUCATION PROGRAMS ATTENDED Te s t Number of Co n t i n u i n g E d u c a t i o n Programs S i g n i f i c a n c e 1 > 1 A t t i t u d e s 74.73 76.78 N.S. P r a c t i c e s 62. 60 65.93 N.S. N u t r i t i o n i n m e d i c a l s c h o o l : G e n e r a l p r a c t i t i o n e r s who had no formal n u t r i t i o n e d u c a t i o n s c o r e d s i g n i f i c a n t l y l e s s than those who had some t r a i n i n g i n n u t r i t i o n ( Table XXXIII ). TABLE XXXIII MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON NUTRITION EDUCATION IN MEDICAL SCHOOL Te s t N u t r i t i o n i n Me d i c a l School S i g n i f i c a n c e N u t r i t i o n No N u t r i t i o n P < 0.05 A t t i t u d e s 73.46 71.61 S. P r a c t i c e s 60.60 59.25 S. 104 Stepwise r e g r e s s i o n r e s u l t s The r e l a t i o n s h i p o f the non-manipulable v a r i a t e s t o the two c r i t e r i o n v a r i a b l e s was i n v e s t i g a t e d by stepwise m u l t i p l e r e g r e s s i o n . As most v a r i a t e s were not o r d i n a l , but nominal, bases f o r comparison were s e l e c t e d . The base f o r comparison of country of m e d i c a l t r a i n i n g t o n u t r i t i o n a t t i t u d e s and p r a c - t i c e s was Canada. In a l i k e manner, bases were chosen f o r the oth e r v a r i a t e s ; sex base - male; l o c a t i o n o f p r a c t i c e - Vancouver; years o f p r a c t i c e - fewer than f i v e y e a r s ; type of p r a c t i c e - p r i - v a t e ; number of p r e n a t a l p a t i e n t s - fewer than 10; number o f i n f a n t p a t i e n t s - fewer than 10; and n u t r i t i o n i n m e d i c a l s c h o o l t r a i n i n g - no n u t r i t i o n . Sources of n u t r i t i o n i n f o r m a t i o n , a d d i t i o n a l s p e c i a l i z a t i o n and attendance a t c o n t i n u i n g e d u c a t i o n programs needed no bases f o r comparison. N u t r i t i o n a t t i t u d e t e s t : The r e s u l t s o f stepwise r e g r e s - s i o n a n a l y s i s f o r the n u t r i t i o n a t t i t u d e t e s t are r e p o r t e d i n Table XXXIV. General p r a c t i t i o n e r s who d i d not r e c e i v e t h e i r m e d i c a l t r a i n i n g i n the c o u n t r i e s l i s t e d under 'demographic i n - fo r m a t i o n ' were c a t e g o r i z e d i n t o groups. One group c o n s i s t e d o f p h y s i c i a n s from I r e l a n d ; a second group l i s t e d m e d i c a l d o c t o r s from Germany; a t h i r d c o n s i s t e d o f a l l o t h e r g e n e r a l p r a c t i t i o n - e r s , most of whom were from European c o u n t r i e s and the O r i e n t . Stepwise r e g r e s s i o n a n a l y s i s showed t h a t respondents l i s t e d i n the t h i r d c a t e g o r y ( from a l l o t h e r c o u n t r i e s ) scored s i g n i - f i c a n t l y lower on the n u t r i t i o n a t t i t u d e t e s t when compared to 105 physicians trained i n Canada.. Physicians who were i n practice for more than 10 years scored s i g n i f i c a n t l y lower than those who were i n pra c t i c e for less than f i v e years. TABLE XXXIV STEPWISE REGRESSION RESULTS FOR VARIATES SIGNIFICANTLY RELATED TO MEAN PERCENTAGE SCORES ACHIEVED BY GENERAL PRACTITIONERS ON THE NUTRITION ATTITUDE TEST Variate C o e f f i c i e n t Proba- b i l i t y Constant 70. 63 Location of medical t r a i n i n g : Other country -6. 21 ! < 0.001 Sex: Female 3. 71 : < 0.01 Years of p r a c t i c e : J>10 -2. 35 ' < 0.001 Number of prenatal patients: >25 14. 06 <0.05 Sources of n u t r i t i o n information: Books Consultation with a n u t r i t i o n i s t - d i e t i t i a n 2. 3. 75 00 < 0.001 <: 0.001 Additional s p e c i a l i z a t i o n or t r a i n i n g : P e d i a t r i c s Family Practice i 4. 4. 31 84 <0.05 <0.01 Nu t r i t i o n education: Research or extra courses in n u t r i t i o n 11. 83 < 0.05 Female general p r a c t i t i o n e r s scored s i g n i f i c a n t l y higher 106 than t h e i r male counterparts as did those physicians who had additional t r a i n i n g i n p e d i a t r i c s or family p r a c t i c e . Medical doctors who had research t r a i n i n g i n n u t r i t i o n or had under- taken addi t i o n a l n u t r i t i o n courses also had s i g n i f i c a n t l y higher t e s t scores. Physicians who consulted books or a n u t r i - t i o n i s t - d i e t i t i a n scored s i g n i f i c a n t l y higher on the n u t r i t i o n attitude t e s t s . 2 The c o e f f i c i e n t of determination ( r ) for the stepwise regression analysis of the n u t r i t i o n attitude scores was 0.134. Thus, the variates studied accounted for only 13.4% of the variance i n n u t r i t i o n a t t i t u d e s . N u t r i t i o n p r a c t i c e t e s t : Stepwise regression analysis indicated that a number of variates were s i g n i f i c a n t l y r e l a t e d to n u t r i t i o n practice t e s t scores ( Table XXXV ). Most of these were the same variates that were s i g n i f i c a n t l y related to a t t i - tude scores. Physicians who were from 'other' countries scored s i g n i - f i c a n t l y lower when compared to general p r a c t i t i o n e r s who had received t h e i r t r a i n i n g i n Canada. S i g n i f i c a n t l y lower scores were also achieved by general p r a c t i t i o n e r s who were i n practice for more than 10 years and those who consulted pharmaceutical brochures for information on n u t r i t i o n . 107 TABLE XXXV STEPWISE REGRESSION RESULTS FOR VARIATES SIGNIFICANTLY RELATED TO MEAN PERCENTAGE SCORES ACHIEVED BY GENERAL PRACTITIONERS ON THE NUTRITION PRACTICE TEST V a r i a t e C o e f f i c i e n t Proba- b i l i t y Constant L o c a t i o n of m e d i c a l t r a i n i n g : Other c o u n t r i e s Sex: Female Years of p r a c t i c e : >10 Sources of n u t r i t i o n i n f o r m a t i o n : Government p u b l i c a t i o n s P h a r m a c e u t i c a l brochures Books C o n s u l t a t i o n w i t h a n u t r i t i o n i s t - d i e t i t i a n A d d i t i o n a l s p e c i a l i z a t i o n o r t r a i n i n g : P e d i a t r i c s C o n t i n u i n g e d u c a t i o n programs: Care of the High Risk Foetus -Ea r l y N u t r i t i o n and L a t e r Development Other N u t r i t i o n e d u c a t i o n Research o r e x t r a courses i n n u t r i t i o n 57.20 -4.10 5.04 -2.11 1.48 •1.26 3.22 1.54 4.25 3.44 4.19 2.33 10.58 <0.01 <0.001 < 0.001 <0.05 <0.05 <0.001 <0.01 <0.01 <0.01 <0.05 <0.01 <0.05 108 S i g n i f i c a n t l y higher t e s t scores were obtained by female physicians when compared with males. General p r a c t i - tioners who u t i l i z e d government publications, books or a n u t r i - t i o n i s t - d i e t i t i a n for n u t r i t i o n information also scored s i g n i - f i c a n t l y higher. Additional t r a i n i n g i n p e d i a t r i c s and atten- dance at continuing education programs s i g n i f i c a n t l y increased the scores of respondents. 2 The c o e f f i c i e n t of determination ( r ) was 0.192. Hence, only 19.2% of the variance i n the n u t r i t i o n practice t e s t was a t t r i b u t e d to the variates studied. Summary of General P r a c t i t i o n e r s ' Results The findings from t h i s survey on general p r a c t i t i o n e r s ' n u t r i t i o n attitudes and practices support hypothesis 3 ( no r e l a t i o n s h i p between the c r i t e r i o n variables and l o c a t i o n of practice ) and hypothesis 5 ( type of practice ). Hypothesis 1 ( location of medical t r a i n i n g ); 2 ( sex of respondent ); 4 ( years of practice ); 6 ( number of patients seen weekly ); 7 ( sources of n u t r i t i o n information ); 8 ( a d d i t i o n a l t r a i n i n g ); 9 ( attendance at continuing education programs ); and 10 ( i n c l u s i o n of n u t r i t i o n i n medical school t r a i n i n g ) were a l l p a r t i a l l y rejected. Furthermore, hypothesis 11 ( c o r r e l a t i o n between attitudes and practices ) was also rejected for general p r a c t i t i o n e r s . 109 P e d i a t r i c i a n s and O b s t e t r i c i a n s D e s c r i p t i o n o f Respondents U n i v a r i a t e frequency t a b l e s were designed to d e s c r i b e the demographic and p r o f e s s i o n a l c h a r a c t e r i s t i c s o f the p e d i a - t r i c i a n s and o b s t e t r i c i a n s who responded t o t h i s survey. Country of m e d i c a l t r a i n i n g The m a j o r i t y of p e d i a t r i c i a n s and o b s t e t r i c i a n s respon- d i n g t o the q u e s t i o n n a i r e o b t a i n e d t h e i r m e d i c a l t r a i n i n g i n Canada ( Table XXXVI ). TABLE XXXVI DISTRIBUTION OF PEDIATRICIANS AND OBSTETRICIANS BY COUNTRY OF MEDICAL TRAINING Country P e d i a t r i c i a n s O b s t e t r i c i a n s No. % No. % Canada 35 54.6 22 50.0 Great B r i t a i n 17 26.6 17 38.6 A u s t r a l i a 1 1.6 1 2.3 U n i t e d S t a t e s 0 0 3 6.8 Other 11 17 .2 1 2.3 T o t a l 64 100.0 44 ioo. b Sex of respondent Most p e d i a t r i c i a n s and o b s t e t r i c i a n s who r e t u r n e d ques- t i o n n a i r e s were males ( Table XXXVII ). 110 TABLE XXXVII DISTRIBUTION OF PEDIATRICIANS AND OBSTETRICIANS BY SEX P e d i a t r i c i a n s O b s t e t r i c i a n s Sex No. % No. Q . "O Male 63 92.6 45 93.8 Female 5 7.4 3 6.2 T o t a l 68 100.0 48 100.0 L o c a t i o n o f p r a c t i c e Only two l o c a t i o n s ( Vancouver and o t h e r c i t y ) were re p r e s e n t e d by the respondents ( Table XXXVIII ). TABLE XXXVIII DISTRIBUTION OF PEDIATRICIANS AND OBSTETRICIANS BY LOCATION OF PRACTICE P e d i a t r i c i a n s O b s t e t r i c i a n s L o c a t i o n No. % No. % Vancouver 42 62.7 29 60.4 Other c i t y 25 37.3 19 39.6 T o t a l 67 100.0 48 100.0 Years o f p r a c t i c e D i s t r i b u t i o n of respondents a c c o r d i n g t o years o f p r a c - t i c e i n d i c a t e d t h a t the m a j o r i t y o f p e d i a t r i c i a n s and o b s t e - I l l t r i c i a n s have been i n p r a c t i c e more t h a n 10 y e a r s ( T a b l e XXXIX ) . TABLE XXXIX DISTRIBUTION OF PEDIATRICIANS AND OBSTETRICIANS BY YEARS OF PRACTICE Years o f p r a c t i c e P e d i a t r i c i a n s O b s t e t r i c i a n s No. % No. % <^5 y e a r s > 5 b u t < 10 ^>10 y e a r s T o t a l 5 7.4 8 11.8 55 80.8 7 14.6 5 10.4 36 75.0 68 100.0 48 100.0 Type o f p r a c t i c e The m a j o r i t y o f s p e c i a l i s t s r e s p o n d i n g t o t h i s s u r v e y were engaged i n p r i v a t e p r a c t i c e ( T a b l e XL ). TABLE XL DISTRIBUTION OF PEDIATRICIANS AND OBSTETRICIANS BY TYPE OF PRACTICE P e d i a t r i c i a n s O b s t e t r i c i a n s Type of. p r a c t i c e No. % No. % P r i v a t e 49 73.1 35 74.5 C l i n i c 18 26.9 12 25.5 T o t a l 67 100.0 47 100.0 112 Number of p a t i e n t s As expected, p e d i a t r i c i a n s see more p a t i e n t s weekly than do o b s t e t r i c i a n s ( Table XLI ). Almost 50% of the o b s t e t r i c i a n s see fewer than 10 p a t i e n t s weekly w h i l e approx- i m a t e l y 40% o f the p e d i a t r i c i a n s see more than 25 i n f a n t s weekly. TABLE XLI DISTRIBUTION OF PEDIATRICIANS AND OBSTETRICIANS BY NUMBER OF PATIENTS SEEN WEEKLY Number of P a t i e n t s ( i n f a n t & p r e n a t a l ) P e d i a t r i c i a n s O b s t e t r i c i a n s No. Q. "5 No. % <^10 15 22.1 23 48.9 > 1 0 but<C 25 26 38.2 17 36.2 > 2 5 27 39.7 7 14.9 T o t a l 68 100.0 47 100.0 Sources o f n u t r i t i o n i n f o r m a t i o n Of the respondents, 65 ( 95.6% ) p e d i a t r i c i a n s and 47 ( 97.9% ) o b s t e t r i c i a n s i n d i c a t e d t h a t they use r e s o u r c e mater- i a l f o r n u t r i t i o n i n f o r m a t i o n ( Ta b l e XLII ). P r o f e s s i o n a l j o u r n a l s were u t i l i z e d more than any o t h e r source and c o n s u l - t a t i o n w i t h a n u t r i t i o n i s t - d i e t i t i a n ranked f i f t h w i t h both groups of s p e c i a l i s t s . 113 TABLE X L I I NUMBER AND PERCENTAGE OF PEDIATRICIANS AND OBSTETRICIANS INDICATING SOURCES OF NUTRITION INFORMATION Sources o f N u t r i t i o n I n f o r m a t i o n P e d i a t r i c i a n s O b s t e t r i c i a n s No. % No. % P r o f e s s i o n a l j o u r n a l s 64 98.4 44 93.6 P r o f e s s i o n a l b u l l e t i n s 51 78.4 34 72.3 Books 48 73.8 27 57.4 Government p u b l i c a t i o n s 44 67.6 28 59.5 N u t r i t i o n i s t - D i e t i t i a n 43 66.1 19 42.5 P h a r m a c e u t i c a l companies' b r o c h u r e s 32 49.2 16 34.0 H e a l t h agency p u b l i c a t i o n s 31 47.6 15 31.9 Food m a n u f a c t u r e r s ' b r o c h u r e s 30 46.1 4 8.5 C o l l e a g u e 27 41.5, 10 21.2 A u d i o v i s u a l a i d s 24 36.9 12 25.5 Magazines 21 32.3 16 34.0 T e l e v i s i o n 12 18.4 5 10.6 Radio 10 15.3 6 12.7 P u b l i c H e a l t h Nurse 10 15.3 3 6.3 Home Economist 3 4.6 1 2.1 Other 4 6.1 1 2.1 114 A d d i t i o n a l t r a i n i n g f o r s p e c i a l i z a t i o n Table XLIII i n d i c a t e s t h a t approximately 47% of the p e d i a t r i c i a n s and 20% of the o b s t e t r i c i a n s had a d d i t i o n a l t r a i n i n g . S p e c i a l i z a t i o n s grouped under the t i t l e 'other' included, t r a i n i n g i n c a r d i o l o g y , a l l e r g i e s , i n t e r n a l medicine and nephrology. TABLE X L I I I NUMBER AND PERCENTAGE OF PEDIATRICIANS AND OBSTETRICIANS INDICATING ADDITIONAL TRAINING FOR SPECIALIZATION T r a i n i n g For P e d i a t r i c i a n s O b s t e t r i c i a n s S p e c i a l i z a t i o n No. % No. % Neonatology 14 20.5 6 12.5 Family P r a c t i c e 2 2.9 2 4.1 P u b l i c H e a l t h Diploma 1 1.4 0 0.0 Other 18 26.4 2 4.1 T o t a l 32* 47.0* 10 20.7 * Three p h y s i c i a n s had more than one of the above s p e c i a l t i e s . C o n t i n u i n g e d u c a t i o n Approximately o n e - h a l f o f the respondents attended a t l e a s t one c o n t i n u i n g e d u c a t i o n program ( Table XLIV ). 115 TABLE XLIV NUMBER AND PERCENTAGE OF PEDIATRICIANS AND OBSTETRICIANS INDICATING ATTENDANCE AT CONTINUING EDUCATION PROGRAMS C o n t i n u i n g E d u c a t i o n P e d i a t r i c i a n s O b s t e t r i c i a n s Programs No. % No. Q. "6 Care o f t h e Hi g h R i s k F o e t u s and Newborn 17 25.0 18 37.5 E a r l y N u t r i t i o n and L a t e r L i f e 13 19.1 1 2.1 Other 10 14.7 5 10.4 T o t a l 34* 50.0* 23 47.9 * S i x p e d i a t r i c i a n s a t t e n d e d more t h a n one c o n t i n u i n g e d u c a t i o n program. N u t r i t i o n e d u c a t i o n i n m e d i c a l s c h o o l s A p p r o x i m a t e l y 30% o f t h e p e d i a t r i c i a n s and 56% o f t h e o b s t e t r i c i a n s r e s p o n d i n g t o t h e q u e s t i o n n a i r e had r e c e i v e d no f o r m a l n u t r i t i o n e d u c a t i o n ( T a b l e XLV ). TABLE XLV NUMBER AND PERCENTAGE OF PEDIATRICIANS AND OBSTETRICIANS INDICATING TYPE OF NUTRITION EDUCATION IN MEDICAL SCHOOL Format o f N u t r i t i o n P e d i a t r i c i a n s O b s t e t r i c i a n s E d u c a t i o n No. % No. % Course on N u t r i t i o n 0 0.0 0 0.0 S e r i e s o f l e c t u r e s 13 19.1 2 4.1 I n t e g r a t e d w i t h o t h e r s u b j e c t m a t t e r 34 50.0 22 45.8 No f o r m a l n u t r i t i o n e d u c a t i o n 20 29.4 25 52.1 116 N u t r i t i o n A t t i t u d e s and P r a c t i c e s Method of s c o r i n g The t e s t of n u t r i t i o n a t t i t u d e s f o r p e d i a t r i c i a n s ( Appendix A ) c o n s i s t e d of 10 statements, each answered by 'Agree' or "Disagree' and the degree of c e r t a i n t y f o r the response. Each statement was s c o r e d between 0 and 7 ( Table IV ). The mean t o t a l s c o r e f o r the a t t i t u d e t e s t was c a l c u l a t e d by adding respondent a t t i t u d e s cores and d i v i - d i n g by 65. T h i s f i g u r e i s the t o t a l number of p e d i a t r i c i a n s who completed a t l e a s t n i n e o f the 10 statements. Q u e s t i o n n a i r e s w i t h more than one response m i s s i n g were e l i m i n a t e d from the study. Mean s c o r e s f o r each statement on the t e s t were ob- t a i n e d by t o t a l l i n g i n d i v i d u a l statement s c o r e s and d i v i d i n g by the t o t a l number o f answered statements. Those q u e s t i o n - n a i r e s w i t h an unanswered statement were a s s i g n e d the mean sco r e f o r t h a t p a r t i c u l a r statement. The t e s t o f n u t r i t i o n a t t i t u d e s f o r o b s t e t r i c i a n s ( Appendix A ) was s c o r e d i n an analogous manner. A t o t a l o f 4 8 o b s t e t r i c i a n s completed a t l e a s t n ine of the 10 a t t i t u d e statements. N u t r i t i o n p r a c t i c e t e s t s c o n s i s t e d of 20 statements t h a t were answered 'always', ' f r e q u e n t l y ' , 'sometimes' and 'never'. Q u e s t i o n n a i r e s w i t h more than one. unanswered statement were e l i m - i n a t e d from a n a l y s i s . Thus, a t o t a l o f 67 p e d i a t r i c i a n s and 46 o b s t e t r i c i a n s completed a t l e a s t 19 o f the 20 p r a c t i c e statements. Again those q u e s t i o n n a i r e s w i t h one unanswered 117 statement were a s s i g n e d the mean score f o r t h a t statement. R e s u l t s of t e s t s The mean percentage s c o r e s f o r p e d i a t r i c i a n s and o b s t e - t r i c i a n s on the n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s are shown i n Table XLVI. O b s t e t r i c i a n s ' s c o r e s f o r n u t r i t i o n a t t i t u d e s and p r a c t i c e s were very s i m i l a r ( 64.16% and 64.72% r e s p e c t i v e - l y ). P e d i a t r i c i a n s ' s c o r e s were much h i g h e r on the a t t i t u d e t e s t than on the p r a c t i c e t e s t ( 81.51% and 65.57% r e s p e c t i v e l y ) . TABLE XLVI MEAN PERCENTAGE SCORES FOR NUTRITION ATTITUDE AND PRACTICE TESTS FOR PEDIATRICIANS AND OBSTETRICIANS P e d i a t r i c i a n s O b s t e t r i c i a n s T e s t Mean Scores Mean Scores A t t i t u d e s 81.51 + 11.88 a 64.16 + 11.23 P r a c t i c e s 65.57 + 6.67 64.72 + 10.36 a s t a n d a r d d e v i a t i o n N u t r i t i o n a t t i t u d e s : The mean t e s t s c o r e s f o r p e d i a - t r i c i a n s ' n u t r i t i o n a t t i t u d e s was 81.5% w i t h a range from 45.7% to 100.0%. P e d i a t r i c i a n s s c o r e d lowest on statements 3, 6 and 10 ( Table XLVII ). A number of p h y s i c i a n s f e l t t h a t i t was i m p o s s i b l e f o r an i n f a n t t o be a l a c t o - o v o v e g e t a r i a n and s t i l l be w e l l - n o u r i s h e d . Although these i n f a n t s may have d i f f i c u l t y o b t a i n i n g s u f f i c i e n t i r o n , i r o n drops or i r o n - f o r t i f i e d foods are r e a d i l y a v a i l a b l e . Some p h y s i c i a n s do not appear t o be aware 118 of the h i g h q u a n t i t y o f s a l t found i n many commercially prepared i n f a n t foods. Although r e c e n t l e g i s l a t i o n i n the U n i t e d S t a t e s decreased s u b s t a n t i a l l y the a c c e p t a b l e s a l t l e v e l f o r i n f a n t foods, no comparable measures have been taken i n Canada. TABLE XLVII STATEMENTS MEASURING NUTRITION ATTITUDES FOR WHICH PEDIATRICIANS ACHIEVED LOWEST MEAN SCORES Statement 3. I b e l i e v e t h a t many com- m e r c i a l l y prepared i n f a n t foods c o n t a i n too h i g h a q u a n t i t y of s a l t , 6. I t i s important t o i n v e s - t i g a t e the i n f a n t ' s d i - e t a r y i n t a k e a t each o f f i c e v i s i t 10. In my o p i n i o n , i t i s im- p o s s i b l e f o r an i n f a n t t o be a l a c t o - o v o vege- t a r i a n ( e a t s eggs and m i l k p r o d u c t s but no meat, f i s h o r p o u l t r y ) and s t i l l be w e l l - n o u r - i s h e d • C o r r e c t Response P o s s i b l e Score Mean Score Agree 7.0 4.5 Agree 7.0 4.9 D i s - agree 7.0 4.3 The mean s c o r e f o r n u t r i t i o n a t t i t u d e s a c h i e v e d by o b s t e - t r i c i a n s was 64.16% w i t h a range from 34.3% t o 90.0%. S t a t e - ments 3, 8, 9 and 10 had the lowest mean s c o r e s ( Table XLVIII ). Some o b s t e t r i c i a n s are a p p a r e n t l y unaware of the h i g h recommended allowances s e t f o r f o l i c a c i d i n Canada and the U n i t e d S t a t e s . The Food and N u t r i t i o n Board of the N a t i o n a l Academy of S c i e n c e s 119 (1974) and the Canadian D i e t a r y Standard (1974) have suggested i n t a k e s o f approximately 800 d a i l y . T h i s q u a n t i t y i s ex- tremely d i f f i c u l t t o o b t a i n from d i e t a r y sources ( Hoppner e t a l . 1972 ) and a supplement i s f r e q u e n t l y recommended ( Committee on Maternal N u t r i t i o n , 1970; American D i e t e t i c A s s o c i a t i o n P o s i t i o n Paper, 1975 ). TABLE XLVIII STATEMENTS MEASURING NUTRITION ATTITUDES FOR WHICH OBSTETRICIANS ACHIEVED LOWEST MEAN SCORES • Statement C o r r e c t P o s s i b l e Mean Response Score Score 3. L a c t a t i o n i s a good time to get r i d of excess weight accumulated i n pregnancy as long as nu- t r i e n t i n t a k e remains Agree 7.0 2.6 8. I f e e l t h a t pregnant wo- men need so much f o l i c a c i d t h a t i t i s d i f f i - c u l t t o get i t from d i e t Agree 7.0 3.0 9. P r o v i d e d t h a t they e n t e r pregnancy w i t h adequate hemoglobin l e v e l s , women need t o i n c r e a s e t h e i r i r o n i n t a k e o n l y d u r i n g the l a s t h a l f of preg- - Agree 7.0 2.3 10. I f e e l t h a t t h e r e i s l i t - t l e p r a c t i c a l , a c c u r a t e i n f o r m a t i o n on maternal n u t r i t i o n i n the c u r r e n t s c i e n t i f i c j o u r n a l s and D i s - agree 7.0 2.9 120 N u t r i t i o n p r a c t i c e s : The mean score f o r p e d i a t r i c i a n s on the n u t r i t i o n p r a c t i c e t e s t was 65.6% w i t h a range from 51.7% to 83.3%. P e d i a t r i c i a n s scored lowest on statements 8, 10, 13 and 14 ( Table XLIX ). Many p e d i a t r i c i a n s p r e f e r the e a r l y i n - t r o d u c t i o n of s o l i d s and favour m u l t i v i t a m i n supplements f o r h e a l t h y i n f a n t s . . I t appears t h a t a number of p e d i a t r i c i a n s are not c o g n i z a n t of the f a c t t h a t i t i s i r o n r a t h e r than v i t a m i n s which i s g e n e r a l l y low i n i n f a n t s ' d i e t s . The mean score f o r each p r a c t i c e statement i s l i s t e d i n Appendix F. TABLE XLIX • STATEMENTS MEASURING NUTRITION PRACTICES FOR WHICH PEDIATRICIANS ACHIEVED LOWEST MEAN SCORES Statement C o r r e c t Response P o s s i b l e Score Mean Score 8. I recommend t h a t human m i l k alone i s adequate i n n u t r i e n t c ontent f o r the f i r s t two months of l i f e . . Never 3.0 0.9 10. I recommend t h a t i r o n f o r - t i f i e d foods or i r o n drops be a p a r t o f the i n f a n t ' s d i e t a r y regimen d u r i n g the Always 3.0 1.1 13. I recommend t h a t by the time the c h i l d i s 5 months of age he should be e a t i n g c e r e a l s , f r u i t s , vege- Never 3.0 0.7 14. I recommend t h a t a m u l t i - v i t a m i n supplement be g i v e n t o h e a l t h y i n f a n t s . . Never 3.0 1.2 On the n u t r i t i o n p r a c t i c e t e s t o b s t e t r i c i a n s o b t a i n e d a mean t e s t score o f 64.7% w i t h a range from 36.7% to 81.7%. Lowest s c o r e s were ac h i e v e d on statements 4, 8, 15 and 19 ( Table L ). Some degree o f weight r e s t r i c t i o n ( statement 8 ) 121 appeared t o be e v i d e n t . R e s t r i c t i n g d i e t a r y c arbohydrates t o 50 g d a i l y ( statement 19 ) may indeed be d e t r i m e n t a l t o the o f f - s p r i n g ( C h u r c h i l l , 1970; F e l i g , 1973 ). Again t h e r e i s evidence of an o v e r - r e l i a n c e on m u l t i v i t a m i n supplements d u r i n g pregnancy. TABLE L STATEMENTS MEASURING NUTRITION PRACTICES FOR WHICH OBSTETRICIANS ACHIEVED LOWEST MEAN SCORES Statement C o r r e c t Response P o s s i b l e Score Mean Score 4. I a d v i s e h e a l t h y expec- t a n t women who do not d r i n k m i l k t o take a Never 3.0 1.0 8. I encourage the average pregnant woman t o g a i n approximately 1 pound per week i n the l a s t 20 Always 3.0 1.3 15. I p r e s c r i b e a m u l t i v i - tamin supplement f o r my p r e n a t a l p a t i e n t s even when t h e i r d i e t a r y i n t a k e appears adequate... Never 3.0 0.9 19. When my p r e n a t a l pa- t i e n t s are g a i n i n g too much weight I recommend t h a t they r e s t r i c t d i - e t a r y carbohydrates t o approximately 50 grams Never 3.0 1.6 Comparison of a t t i t u d e s t o p r a c t i c e s A s i g n i f i c a n t p o s i t i v e c o r r e l a t i o n ( r = 0.259 ) was found between n u t r i t i o n a t t i t u d e s and p r a c t i c e s f o r p e d i a t r i c i a n s . 122 T h i s c o r r e l a t i o n was s i g n i f i c a n t a t the 5% l e v e l . O b s t e t r i c i a n s a l s o achieved a h i g h l y s i g n i f i c a n t p o s i t i v e c o r r e l a t i o n ( r = 0.424 ) between a t t i t u d e s and p r a c t i c e s which was s i g n i f i c a n t a t the 1% l e v e l . A t t i t u d e s g e n e r a l l y appeared t o be r e f l e c t e d i n the p h y s i c i a n s ' c o u n s e l l i n g p r a c t i c e s . One important e x c e p t i o n f o r p e d i a t r i c i a n s ( Table L I ) and o b s t e t r i c i a n s ( Table L I I ) con- cerned the s u b s t i t u t i o n o f m u l t i v i t a m i n supplements f o r d i e t a r y a d v i c e . Both groups of s p e c i a l i s t s had the a t t i t u d e t h a t i t was important t o g i v e n u t r i t i o n a l a d v i c e - b u t a much s m a l l e r p er- centage o f p h y s i c i a n s a c t u a l l y gave t h i s a d v i c e t o t h e i r p a t i e n t s . TABLE L I COMPARISON OF ATTITUDES AND PRACTICES FOR PEDIATRICIANS CONCERNING NUTRITIONAL ADVICE Statement C o r r e c t Response P o s s i b l e Score Mean Score A t t i t u d e 2. I f an i n f a n t i s r e c e i v i n g a m u l t i v i t a m i n supplement, I f e e l t h a t I don't need t o be concerned about h i s D i s - agree 7.0 6.4 P r a c t i c e s 2. I ask mothers from what sources t h e i r 1 - 2 year o l d s o b t a i n v i t a m i n C Always 3.0 1.8 20. I encourage mothers t o i n c l u d e a t l e a s t 2 g l a s - ses (16 oz.) of m i l k i n a l - 2 year o l d ' s d i e t . . . Always 3.0 1.9 123 TABLE L I I COMPARISON OF ATTITUDES AND PRACTICES FOR OBSTETRICIANS CONCERNING NUTRITIONAL ADVICE Statement C o r r e c t Response P o s s i b l e Score Mean Score A t t i t u d e As long as the expectant mother takes a m u l t i v i - tamin supplement, I do not need t o g i v e a d v i c e on n u t r i t i o n P r a c t i c e s I recommend t h a t expectant p a t i e n t s i n c l u d e a c i t r u s f r u i t o r j u i c e i n t h e i r d a i l y d i e t 10 I recommend t h a t my p r e - n a t a l p a t i e n t s i n c l u d e an i r o n - r i c h food ( i . e . organ meats ) i n t h e i r weekly d i e t s 12 14. I g i v e pregnant a d o l e s c e n t s s p e c i f i c i n s t r u c t i o n s on food sources of p r o t e i n . . . . I encourage my p r e n a t a l p a t i e n t s t o have f o u r g l a s s e s o f m i l k o r the e q u i v a l e n t i n d a i r y p r o - ducts d a i l y D i s - agree Always Always Always Always 7.0 3.0 3.0 3.0 3.0 6.3 1.8 1.8 1.9 1.7 124 The R e l a t i o n s h i p o f S e l e c t e d V a r i a t e s t o N u t r i t i o n A t t i t u d e s and P r a c t i c e s The r e l a t i o n s h i p o f t h e n o n - m a n i p u l a b l e v a r i a t e s t o t h e c r i t e r i o n v a r i a b l e s ( n u t r i t i o n a t t i t u d e s and p r a c t i c e s ) was i n v e s t i g a t e d by one-way a n a l y s i s o f v a r i a n c e u s i n g S c h e f f e ' s t e s t and by s t e p w i s e m u l t i p l e r e g r e s s i o n . One-way a n a l y s i s o f v a r i a n c e L o c a t i o n o f m e d i c a l t r a i n i n g : T a b l e L I I I i n d i c a t e s t h a t l o c a t i o n o f m e d i c a l t r a i n i n g was n o t s i g n i f i c a n t l y r e l a t e d t o n u t r i t i o n a t t i t u d e and p r a c t i c e s f o r o b s t e t r i c i a n s n o r t o p e d i a - t r i c i a n s ' n u t r i t i o n a t t i t u d e s . P e d i a t r i c i a n s t r a i n e d i n Canada s c o r e d s i g n i f i c a n t l y h i g h e r on t h e p r a c t i c e t e s t t h a n d i d phy- s i c i a n s t r a i n e d i n G r e a t B r i t a i n . However, p e d i a t r i c i a n s t r a i n e d i n G r e a t B r i t a i n s c o r e d s i g n i f i c a n t l y h i g h e r t h a n p e d i a t r i c i a n s t r a i n e d i n a l l o t h e r c o u n t r i e s combined. TABLE L I I I MEAN PERCENTAGE SCORES OF PEDIATRICIANS AND OBSTETRICIANS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON LOCATION OF MEDICAL TRAINING T e s t C o u n t r y S i g n i f i c a n c e P < 0.01 Canada G r e a t B r i t a i n O t her P e d i a t r i c i a n s ' A t t i t u d e s 83.98 79.46 79. 89 N.S. P r a c t i c e s 67.75 64.01 61.66 S. O b s t e t r i c i a n s ' A t t i t u d e s 62.71 63.94 72. 83 N.S. P r a c t i c e s 64.29 64.90 65 . 33 N.S. I 125 Sex of respondent: There were no s i g n i f i c a n t d i f f e r - ences i n the mean n u t r i t i o n a t t i t u d e and p r a c t i c e t e s t s c o r e s f o r p e d i a t r i c i a n s and o b s t e t r i c i a n s based on sex of the respon- dents ( Table LIV ). • TABLE LIV MEAN PERCENTAGE SCORES OF PEDIATRICIANS AND OBSTETRICIANS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON SEX OF RESPONDENT Test Sex of Respondent S i g n i f i c a n c e Male Female P e d i a t r i c i a n s ' A t t i t u d e s 81. 68 79.45 N.S. P r a c t i c e s 65.58 65.40 N.S. O b s t e t r i c i a n s ' A t t i t u d e s 63.77 70.00 N.S. P r a c t i c e s 64.08 73.90 N.S. L o c a t i o n o f p r a c t i c e : P h y s i c i a n s who p r a c t i c e i n Vancouver d i d not have s c o r e s s i g n i f i c a n t l y d i f f e r e n t from p h y s i c i a n s who p r a c t i s e d i n o t h e r c i t i e s on e i t h e r the a t t i - tude or p r a c t i c e t e s t s ( Table LV ). TABLE LV 126 MEAN PERCENTAGE SCORES OF PEDIATRICIANS AND OBSTETRICIANS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON LOCATION OF PRACTICE T e s t L o c a t i o n S i g n i f i c a n c e Vancouver Other C i t y P e d i a t r i c i a n s 1 A t t i t u d e s 81.02 82.50 N.S. P r a c t i c e s 65.65 65.40 N.S. O b s t e t r i c i a n s 1 A t t i t u d e s 65.26 62.47 N.S. P r a c t i c e s 66.32 62.23 N.S. Ye a r s o f p r a c t i c e : One-way a n a l y s i s o f v a r i a n c e d i d n o t i n d i c a t e any s i g n i f i c a n t d i f f e r e n c e s i n mean t e s t s c o r e s o f p e d i a - t r i c i a n s and o b s t e t r i c i a n s based on y e a r s o f p r a c t i c e ( T a b l e LVI ) . TABLE L V I MEAN PERCENTAGE SCORES OF PEDIATRICIANS AND OBSTETRICIANS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON YEARS OF PRACTICE T e s t Y e a r s o f P r a c t i c e S i g n i f i c a n c e <i5 y e a r s > 5 bu t < 10 ^>10 y e a r s P e d i a t r i c i a n s ' A t t i t u d e s 82.85 89.62 80.13 N.S. P r a c t i c e s 69.02 65.00 65.33 N.S. O b s t e t r i c i a n s * A t t i t u d e s 70.00 69.97 62.21 N.S. P r a c t i c e s 67.15 57.02 65.35 N.S. 127 Type of pr a c t i c e : There were no s i g n i f i c a n t differences in the mean n u t r i t i o n attitude and practice scores for p e d i a t r i - cians and obs t e t r i c i a n s based on type of practice ( Table LVII ). TABLE LVII MEAN PERCENTAGE SCORES OF PEDIATRICIANS AND OBSTETRICIANS . FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON TYPE OF PRACTICE Test Type of Practice Significance Private C l i n i c P e d i a tricians * Attitudes 81.54 80.97 N.S. Practices 64.86 67.59 N.S. Obstetricians 1 Attitudes 65.21 61.89 N.S. Practices 65.64 62.28 N.S. Number of patients: Number of patients seen weekly d i d not have a s i g n i f i c a n t e f f e c t on the mean tes t scores f o r a t t i - tudes or practices of p e d i a t r i c i a n s and o b s t e t r i c i a n s ( Table LVIII ). TABLE LVIII MEAN PERCENTAGE SCORES OF PEDIATRICIANS AND OBSTETRICIANS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON NUMBER OF PATIENTS SEEN WEEKLY No. of infants or prenatal patients S i g n i - Test < 1 0 >10 but <25 > 2 5 ficance P e d i a t r i c i a n s 1 Attitudes 78.46 82.79 81.74 N.S. Practices 65.10 64.74 66.60 N.S. Obstetricians 1 - Attitudes 61.23 67.47 66.47 N.S. Practices 63.34 68.34 62.40 N.S. 128 Sp e c i a l i z a t i o n or t r a i n i n g : Physicians who had addi- t i o n a l t r a i n i n g were compared to those physicians with no such t r a i n i n g ( Table LIX ). There was no s i g n i f i c a n t difference between these two groups based on mean t e s t scores. TABLE LIX MEAN PERCENTAGE SCORES OF PEDIATRICIANS AND OBSTETRICIANS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON ADDITIONAL SPECIALIZATION OR TRAINING Test S p e c i a l i z a t i o n or Training Significance Training No Training P e d i a t r i c i a n s 1 Attitudes 82.85 81.60 N.S. Practices 65.75 65.86 N.S. Obstetricians' Attitudes 67.27 63.33 N.S. Practices 64.68 64.73 N.S. Continuing education: Table LX indicates a s i g n i f i c a n t difference between practice t e s t scores of obs t e t r i c i a n s who attended continuing education programs compared to those who did not. There were no s i g n i f i c a n t differences i n n u t r i t i o n a t t i - tude scores for o b s t e t r i c i a n s . Attendance at continuing educa- t i o n programs did not have a s i g n i f i c a n t e f f e c t on the n u t r i t i o n attitude and practice scores for p e d i a t r i c i a n s . 129 TABLE LX MEAN PERCENTAGE SCORES OF PEDIATRICIANS AND OBSTETRICIANS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON ATTENDANCE AT CONTINUING EDUCATION PROGRAMS Continuing Education Programs S i g n i f i c a n c e Test Attendance No Attendance P < 0.05 P e d i a t r i c i a n s 1 A t t i t u d e s 81.46 83.04 N.S. P r a c t i c e s 64.81 66.94 N.S. O b s t e t r i c i a n s ' A t t i t u d e s 65.71 62.73 N.S. P r a c t i c e s 68.50 61.25 S. P e d i a t r i c i a n s who attended more than one c o n t i n u i n g education program d i d not score s i g n i f i c a n t l y d i f f e r e n t l y from p h y s i c i a n s who attended only one program ( Table LXI ). S i m i l a r a n a l y s i s c ould not be performed f o r o b s t e t r i c i a n s because the sample group was too s m a l l . TABLE LXI MEAN PERCENTAGE SCORES OF PEDIATRICIANS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON NUMBER OF CONTINUING EDUCATION PROGRAMS ATTENDED Test Number of Continuing Education Programs S i g n i f i c a n c e 1 > 1 A t t i t u d e s 82.95 73.14 N.S. P r a c t i c e s 64.55 66.32 N.S. 130 Nu t r i t i o n education in medical t r a i n i n g : On the a t t i - tude and practice t e s t s , p e d i a t r i c i a n s and obs t e t r i c i a n s who had some n u t r i t i o n education i n t h e i r medical school t r a i n i n g did not have scores s i g n i f i c a n t l y d i f f e r e n t from physicians who had no n u t r i t i o n education ( Table LXII ). TABLE LXII MEAN PERCENTAGE SCORES OF PEDIATRICIANS AND OBSTETRICIANS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON NUTRITION EDUCATION IN MEDICAL SCHOOL Test N u t r i t i o n Education Significance N u t r i t i o n No N u t r i t i o n P e d i a t r i c i a n s 1 Attitudes 82.21 81.18 N.S. Practices 66.00 65.49 N.S. Obstetricians' Attitudes 65.64 62.79 N.S. Practices 63.27 66.05 N.S. Stepwise regression analysis The r e l a t i o n s h i p of the non-manipulable variates to the two c r i t e r i o n variables was investigated by stepwise multiple regression. The number of variates was reduced by combining a number of s i m i l a r variates into one group. Countries of medical 131 t r a i n i n g were reduced t o t h r e e groups: Canada, Great B r i t a i n and o t h e r s , w i t h Canada b e i n g used as a base f o r comparison. Sources of n u t r i t i o n i n f o r m a t i o n were combined i n t o 4 groups: Group 1 was p r o f e s s i o n a l j o u r n a l s ; Group 2 c o n s i s t e d of a l l o t h e r non-human sources of i n f o r m a t i o n ; Group 3 was c o n s u l t a t i o n w i t h a n u t r i t i o n i s t - d i e t i t i a n ; and Group 4 c o n t a i n e d a l l o t h e r human sources of i n f o r m a t i o n . Other v a r i a t e s were grouped as t o a d d i t i o n a l t r a i n i n g or no such t r a i n i n g ; attendance a t c o n t i n u - i n g e d u c a t i o n programs o r no attendance; and n u t r i t i o n i n m e d i c a l s c h o o l or no n u t r i t i o n . P e d i a t r i c i a n s : The r e s u l t s of stepwise r e g r e s s i o n a n a l - y s i s f o r p e d i a t r i c i a n s are r e p o r t e d i n Table L X I I I . On the a t t i - tude t e s t p h y s i c i a n s who were i n p r a c t i c e more than f i v e y e a r s but fewer than 10 years s c o r e d s i g n i f i c a n t l y h i g h e r than p e d i a - t r i c i a n s who were i n p r a c t i c e fewer than f i v e y e a r s . P e d i a t r i c i a n s t r a i n e d i n Great B r i t a i n and i n o t h e r c o u n t r i e s s c o r e d s i g n i f i c a n t l y lower on the n u t r i t i o n p r a c t i c e t e s t than d i d p h y s i c i a n s t r a i n e d i n Canada. 2 The c o e f f i c i e n t of d e t e r m i n a t i o n ( . r ) f o r the a t t i - tude t e s t was 0.06 and f o r the p r a c t i c e t e s t 0.144. Thus, the v a r i a t e s s t u d i e d accounted f o r 6% and 14.4% r e s p e c t i v e l y , o f the v a r i a n c e . 132 TABLE L X I I I STEPWISE REGRESSION RESULTS FOR VARIATES SIGNIFICANTLY RELATED TO MEAN PERCENTAGE SCORES ACHIEVED BY PEDIATRICIANS ON THE NUTRITION ATTITUDE AND PRACTICE TESTS V a r i a t e . C o e f f i c i e n t Proba- b i l i t y A t t i t u d e Test Constant 80.373 Years of p r a c t i c e < 0.05 > 5 but < 10 9.251 P r a c t i c e T e s t Constant 67.742 Country < 0.05 Great B r i t a i n -3.735 Other c o u n t r i e s -6.086 < 0.01 O b s t e t r i c i a n s : O b s t e t r i c i a n s who were i n p r a c t i c e more than 10 years s c o r e d s i g n i f i c a n t l y lower than p h y s i c i a n s who were i n p r a c t i c e fewer t h f i v e y e a r s on the n u t r i t i o n a t t i t u d e t e s t ( Table LXIV ). Phy. :ians who u t i l i z e d sources of n u t r i - t i o n i n f o r m a t i o n from Group 2 ( non-human sources o t h e r than p r o f e s s i o n a l j o u r n a l s ) score d s i g n i f i c a n t l y h i g h e r on the a t t i - tude t e s t . Stepwise r e g r e s s i o n r e s u l t s f o r the p r a c t i c e t e s t showed t h a t o b s t e t r i c i a n s who c o n s u l t e d n u t r i t i o n i n f o r m a t i o n from Group 2 and Group 4 ( human sources of i n f o r m a t i o n e x c l u d i n g n u t r i t i o n i s t - d i e t i t i a n ) scor e d s i g n i f i c a n t l y h i g h e r than those who c o n s u l t e d o t h e r r e s o u r c e s . 2 The c o e f f i c i e n t of d e t e r m i n a t i o n ( r ) f o r the a t t i t u d e 133 tude test was 0.204 and for the practice t e s t 0.260. Thus, the variates studied accounted f o r 20.4% and 26.0% res p e c t i v e l y , of the variance. TABLE LXIV STEPWISE REGRESSION RESULTS FOR VARIATES SIGNIFICANTLY RELATED TO MEAN PERCENTAGE SCORES ACHIEVED BY OBSTETRICIANS ON THE NUTRITION ATTITUDE AND PRACTICE TESTS Variate C o e f f i c i e n t Proba- b i l i t y Attitude Test Constant 58.55 Years of Practi c e >10 -9.30 < 0.01 Sources of n u t r i t i o n information Group 2 13.72 <0.05 Practice Test Constant 53.34 Sources of n u t r i t i o n information Group 2 Group 4 9.88 8.98 <0.05 <0.01 Summary of P e d i a t r i c i a n s ' and Obstetricians' Results The findings from t h i s survey on n u t r i t i o n attitudes and practices support hypothesis 2 ( no r e l a t i o n s h i p between the c r i t e r i o n variables and sex of respondent ); 3 ( location of practice ); 5 ( type of practice );. 6 ( number of patients ); 7 ( sources of n u t r i t i o n information ); 8 ( addit i o n a l t r a i n i n g ); 9 ( attendance at continuing education programs ) and 10 ( i n c l u - 134 sion of n u t r i t i o n i n medical school curriculum ) for pedia- t r i c i a n s . Hypothesis 1 ( loc a t i o n of medical t r a i n i n g ); hypo- thesis 4 ( years of pra c t i c e ) and hypothesis 11 ( c o r r e l a t i o n between attitude and practices ) were a l l rejected for pedia- t r i c i a n s . For o b s t e t r i c i a n s , the r e s u l t s of t h i s study support hypothesis 1 ( no r e l a t i o n s h i p between c r i t e r i o n variables and location of medical t r a i n i n g ); 2 ( sex of respondent ); 3 ( loc a t i o n of practice ); 5 ( type of pra c t i c e ); 6 ( number of patients ); 8 ( add i t i o n a l t r a i n i n g ); 10 ( i n c l u s i o n of n u t r i - t i o n i n medical school t r a i n i n g ). Hypothesis 4 ( years of practice ); 7 ( sources of n u t r i t i o n information ); 9 ( atten- dance at continuing education programs ) and 11 ( c o r r e l a t i o n between attitudes and practices ) were a l l rejected for obste- t r i c i a n s . Comparison of N u t r i t i o n Attitudes and Practices of General P r a c t i t i o n e r s , P e d i a t r i c i a n s , and Obstetricians Comparisons of tes t scores for n u t r i t i o n attitudes and practices were made between general p r a c t i t i o n e r s and pedia- t r i c i a n s and between general p r a c t i t i o n e r s and o b s t e t r i c i a n s . The attitude test f o r general p r a c t i t i o n e r s was divided into two tests of 10 statements each. The f i r s t 10 statements were iden- t i c a l to the 10 atti t u d e statements completed by o b s t e t r i c i a n s ; the l a s t 10 statements were the same as those completed by pe- d i a t r i c i a n s . Thus, comparisons were made between the o b s t e t r i - cians' t e s t and the f i r s t 10 statements of the general p r a c t i - tioners' t e s t ; the p e d i a t r i c i a n s ' tests was compared to the f i n a l 135 10 s t a t e m e n t s o f t h e g e n e r a l p r a c t i t i o n e r s ' t e s t . The p r a c t i c e t e s t f o r g e n e r a l p r a c t i t i o n e r s was d i v i d e d and compared t o t h e p e d i a t r i c i a n s and o b s t e t r i c i a n s ' t e s t i n an ana l o gou s manner. A n a l y s i s f o r s i g n i f i c a n t d i f f e r e n c e s b e - tween mean s c o r e s a r e r e p o r t e d i n T a b l e s LXV and L X V I . TABLE LXV COMPARISON OF MEAN PERCENTAGE SCORES FOR NUTRITION ATTITUDES AND PRACTICES BETWEEN GENERAL PRACTITIONERS AND PEDIATRICIANS T e s t P h y s i c i a n S i g n i f i c a n c e P < 0.001 G e n e r a l P r a c t i t i o n e r P e d i a t r i c i a n A t t i t u d e s 79.91 81.51 N.S. P r a c t i c e s 60.02 65.57 S. TABLE LXV I COMPARISON OF MEAN PERCENTAGE SCORES FOR NUTRITION ATTITUDES AND PRACTICES BETWEEN GENERAL PRACTITIONERS AND OBSTETRICIANS P h y s i c i a n S i g n i f i c a n c e T e s t G e n e r a l P r a c t i t i o n e r O b s t e t r i c i a n P < 0 . 0 1 A t t i t u d e s 65.38 64.16 N.S. P r a c t i c e s 60.17 64.72 S. P e d i a t r i c i a n s and o b s t e t r i c i a n s s c o r e d s i g n i f i c a n t l y h i g h e r t h a n g e n e r a l p r a c t i t i o n e r s on t h e n u t r i t i o n p r a c t i c e 136 t e s t s . However, there were no s i g n i f i c a n t d i f f e r e n c e s among the 3 groups on the n u t r i t i o n a t t i t u d e t e s t s . A t t i t u d e scores f o r p e d i a t r i c i a n s were c o n s i d e r a b l y higher than those f o r o b s t e t r i c i a n s ( 81.5 and 64.1 r e s p e c t i v e l y ) but these scores are not d i r e c t l y comparable because d i f f e r e n t t e s t instruments were used. P r a c t i c e t e s t scores of 60.0%, 64.7% and 65.6% f o r general p r a c t i t i o n e r s , , o b s t e t r i c i a n s and p e d i a t r i c i a n s respec- t i v e l y , do appear low. I t i s , however, important to r e a l i z e t h a t these low scores are not n e c e s s a r i l y i n d i c a t i v e of i n - appropriate n u t r i t i o n p r a c t i c e s ; they may i n some cases simply represent the l a c k of n u t r i t i o n c o u n s e l l i n g by the p h y s i c i a n . CHAPTER V SUMMARY AND IMPLICATIONS This chapter i s a b r i e f review of the objectives, design and major findings of t h i s study. Implications that became apparent from the i n t e r p r e t a t i o n of the findings were also discussed. Summary This study was designed to investigate the nature of the r e l a t i o n s h i p of selected variates to the maternal and infant n u t r i t i o n attitudes and practices of general p r a c t i - tioners, p e d i a t r i c i a n s and obs t e t r i c i a n s i n the province of B r i t i s h Columbia. The r e l a t i o n s h i p of n u t r i t i o n attitudes to practices was also assessed. The following objectives were established for i n v e s t i - gating the problem: 1. To assess the q u a l i t y of maternal and infant n u t r i t i o n information being disseminated to the maternal population by general p r a c t i t i o n e r s , p e d i a t r i c i a n s and o b s t e t r i c i a n s . 2. Td determine whether s i g n i f i c a n t differences e x i s t i n the n u t r i t i o n attitudes and practices of p e d i a t r i c i a n s , o b s t e t r i c i a n s and general p r a c t i t i o n e r s i n the province, of B r i t i s h Columbia as related to: 137 138 (a) l o c a t i o n o f m e d i c a l t r a i n i n g (b) sex o f r e s p o n d e n t (c) l o c a t i o n o f p r a c t i c e (d) y e a r s o f p r a c t i c e (e) t y p e o f p r a c t i c e (f) number o f p r e n a t a l p a t i e n t s a n d / o r i n f a n t s seen weekly (g) s o u r c e s o f n u t r i t i o n i n f o r m a t i o n (h) a d d i t i o n a l t r a i n i n g f o r s p e c i a l i z a t i o n ( i ) number and t y p e of c o n t i n u i n g e d u c a t i o n programs w i t h a n u t r i t i o n component a t t e n d e d i n t h e l a s t two y e a r s (j) e x t e n t o f n u t r i t i o n e d u c a t i o n i n m e d i c a l s c h o o l t r a i n i n g 3 . . To d e t e r m i n e among p e d i a t r i c i a n s , o b s t e t r i c i a n s and g e n e r a l p r a c t i t i o n e r s t h e n a t u r e o f t h e r e l a t i o n s h i p o f n u t r i t i o n a t t i t u d e s t o n u t r i t i o n p r a c t i c e s . 4. To d e t e r m i n e whether s i g n i f i c a n t d i f f e r e n c e s e x i s t between the n u t r i t i o n a t t i t u d e s and p r a c - t i c e s o f g e n e r a l p r a c t i t i o n e r s as compared t o p e d i a t r i c i a n s and o b s t e t r i c i a n s . Data c o l l e c t i o n i n s t r u m e n t s were d e s i g n e d f o r t h i s s t u d y t o a s s e s s the n u t r i t i o n a t t i t u d e s and p r a c t i c e s o f p h y s i c i a n s . In March 1975, v a l i d a t e d q u e s t i o n n a i r e s were s e n t t o a l l p r a c t i c i n g g e n e r a l p r a c t i t i o n e r s , p e d i a t r i c i a n s and 139 o b s t e t r i c i a n s registered with the B r i t i s h Columbia Medical Association. The sample consisted of 1753 general practitioners, 110 p e d i a t r i c i a n s and 118 o b s t e t r i c i a n s . Questionnaires were returned from 724 ( 41.3% ) general p r a c t i t i o n e r s , 69 ( 62.7% ) pe d i a t r i c i a n s and 51 ( 43.2% ) o b s t e t r i c i a n s . N u t r i t i o n attitudes of p e d i a t r i c i a n s were assessed by a test c o n s i s t i n g of 10 statements related to the importance of n u t r i t i o n during the f i r s t two years of l i f e . A s i m i l a r t e s t also c o n s i s t i n g of 10 statements was designed to measure the n u t r i t i o n attitudes of ob s t e t r i c i a n s toward prenatal n u t r i t i o n . Both tests were combined to measure general p r a c t i t i o n e r s ' n u t r i t i o n a t t i t u d e s . Assessment of n u t r i t i o n counselling practices was conducted by a t e s t of 20 statements r e f l e c t i n g the n u t r i t i o n advice disseminated by p e d i a t r i c i a n s . N u t r i t i o n counselling practices of ob s t e t r i c i a n s were investigated by a s i m i l a r t e s t of 2 0 statements on n u t r i t i o n advice given to prenatal patients. Again both tests were combined and administered to general p r a c t i t i o n e r s . Demographic and professional data concerning the selec- ted environmental variates were c o l l e c t e d i n a separate section of the questionnaire. The data were treated s t a t i s t i c a l l y to t e s t the follow- ing hypotheses: The following n u l l hypotheses were tested: 1. There w i l l be no s i g n i f i c a n t differences achieved i n 140 t e s t s of n u t r i t i o n a t t i t u d e s and p r a c t i c e s of general p r a c t i t i o n e r s , o b s t e t r i c i a n s and p e d i a t r i c i a n s based on l o c a t i o n of t h e i r medical t r a i n i n g . There w i l l be no s i g n i f i c a n t d i f f e r e n c e s achieved i n t e s t s of n u t r i t i o n a t t i t u d e s and p r a c t i c e s of general p r a c t i t i o n e r s , o b s t e t r i c i a n s and p e d i a t r i c i a n s based on sex of the respondent. There w i l l be no s i g n i f i c a n t d i f f e r e n c e s achieved i n t e s t s of n u t r i t i o n a t t i t u d e s and p r a c t i c e s of general p r a c t i t i o n e r s , o b s t e t r i c i a n s and p e d i a t r i c i a n s based on l o c a t i o n of p r a c t i c e . There w i l l be no s i g n i f i c a n t d i f f e r e n c e s achieved i n t e s t s of n u t r i t i o n a t t i t u d e s and p r a c t i c e s of general p r a c t i t i o n e r s , o b s t e t r i c i a n s a n d . p e d i a t r i c i a n s based on years of p r a c t i c e . There w i l l be no s i g n i f i c a n t d i f f e r e n c e s achieved i n t e s t s of n u t r i t i o n a t t i t u d e s and p r a c t i c e s of general p r a c t i t i o n e r s , o b s t e t r i c i a n s and p e d i a t r i c i a n s based on type of p r a c t i c e . There w i l l be no s i g n i f i c a n t d i f f e r e n c e s achieved i n t e s t s of n u t r i t i o n a t t i t u d e s and p r a c t i c e s of general p r a c t i t i o n e r s , o b s t e t r i c i a n s and p e d i a t r i c i a n s based on number of p r e n a t a l p a t i e n t s and/or i n f a n t s seen weekly. There w i l l be no s i g n i f i c a n t d i f f e r e n c e s achieved i n t e s t s of n u t r i t i o n a t t i t u d e s and p r a c t i c e s of general p r a c t i t i o n e r s , o b s t e t r i c i a n s a n d p e d i a t r i c i a n s b a s e d o n s o u r c e s o f n u t r i t i o n i n f o r m a t i o n c o n s u l t e d . 8. T h e r e w i l l b e n o s i g n i f i c a n t d i f f e r e n c e s a c h i e v e d i n t e s t s o f n u t r i t i o n a t t i t u d e s a n d p r a c t i c e s o f g e n e r a l p r a c t i t i o n e r s , o b s t e t r i c i a n s a n d p e d i a t r i c i a n s b a s e d o n u n d e r t a k i n g o f a d d i t i o n a l s p e c i a l i z a t i o n o r t r a i n i n g . 9. T h e r e w i l l b e n o s i g n i f i c a n t d i f f e r e n c e s , a c h i e v e d i n t e s t s o f n u t r i t i o n a t t i t u d e s a n d p r a c t i c e s o f g e n e r a l p r a c t i t i o n e r s , o b s t e t r i c i a n s a n d p e d i a t r i c i a n s b a s e d o n t h e n u m b e r a n d t y p e o f c o n t i n u i n g e d u c a t i o n p r o g r a m s a t t e n d e d i n t h e l a s t t w o y e a r s . 10. T h e r e w i l l b e n o s i g n i f i c a n t d i f f e r e n c e s a c h i e v e d i n t e s t s o f n u t r i t i o n a t t i t u d e s a n d p r a c t i c e s o f g e n e r a l p r a c t i t i o n e r s , o b s t e t r i c i a n s a n d p e d i a t r i c i a n s b a s e d o n t h e e x t e n t o f i n c l u s i o n o f n u t r i t i o n i n t h e i r m e d i c a l s c h o o l t r a i n i n g . 11. T h e r e w i l l b e n o s i g n i f i c a n t c o r r e l a t i o n among t h e s c o r e s f o r n u t r i t i o n a t t i t u d e s a n d n u t r i t i o n p r a c t i c e s a c h i e v e d b y t h e g e n e r a l p r a c t i t i o n e r s , o b s t e t r i c i a n s a n d p e d i a t r i c i a n s . 12. T h e r e w i l l b e n o s i g n i f i c a n t d i f f e r e n c e i n t h e s c o r e s f o r n u t r i t i o n a t t i t u d e s a n d p r a c t i c e s b e t w e e n t h e g e n e r a l p r a c t i t i o n e r s a n d t h e p e d i a t r i c i a n s . T h e r e w i l l b e n o s i g n i f i c a n t d i f f e r e n c e i n t h e s c o r e s f o r n u t r i t i o n a t t i t u d e s a n d p r a c t i c e s b e t w e e n t h e g e n e r a l p r a c t i t i o n e r s a n d o b s t e t r i c i a n s . 142 The r e l a t i o n s h i p of the non-manipulable variates to the two c r i t e r i o n variables ( n u t r i t i o n attitudes and practices ) was determined by one-way analysis of variance using Scheffe's te s t and stepwise regression analysis. Correlation analysis was employed to determine the r e l a t i o n s h i p of n u t r i t i o n attitudes to n u t r i t i o n counselling p r a c t i c e s . Comparison of n u t r i t i o n attitude and practice scores between general p r a c t i - tioners and p e d i a t r i c i a n s and between general p r a c t i t i o n e r s and o b s t e t r i c i a n s was conducted by t - t e s t for s i g n i f i c a n t d i f f e r - ences i n group means. A l l hypotheses were tested at the 5% l e v e l of s i g n i f i c a n c e . Results were reported at the highest l e v e l of s i g n i f i c a n c e . The major findings of t h i s study for general p r a c t i - tioners were: 1. The mean test scores for n u t r i t i o n attitudes and practices of general p r a c t i t i o n e r s were 72.6% and 60.0% r e s p e c t i v e l y . 2. The lowest mean scores were achieved for n u t r i t i o n practices r e l a t e d to: (a) use of multivitamin supplements during pregnancy and infancy (b) early introduction of s o l i d s (c) n u t r i t i o n advice for infancy (d) weight gain during pregnancy 3. Female general p r a c t i t i o n e r s scored s i g n i f i c a n t l y higher on the attitude and p r a c t i c e tests than t h e i r male counterparts. 143 4. General p r a c t i t i o n e r s who were i n p r a c t i c e f o r more than 10 years s c o r e d s i g n i f i c a n t l y lower on both t e s t s than p h y s i c i a n s who were i n p r a c t i c e l e s s than 10 y e a r s . 5. M e d i c a l d o c t o r s who had a d d i t i o n a l s p e c i a l i z a - t i o n o r t r a i n i n g s c o r e d s i g n i f i c a n t l y h i g h e r on t e s t s o f n u t r i t i o n a t t i t u d e s and p r a c t i c e s than g e n e r a l p r a c t i t i o n e r s w i t h no a d d i t i o n a l t r a i n i n g f o r s p e c i a l i z a t i o n . 6. P h y s i c i a n s who attended c o n t i n u i n g e d u c a t i o n programs s c o r e d s i g n i f i c a n t l y h i g h e r than p h y s i - c i a n s who d i d not a t t e n d any programs. General p r a c t i t i o n e r s who attended more than one c o n t i n u i n g e d u c a t i o n program d i d not scor e s i g n i f i c a n t l y d i f f e r e n t from those who had attended one program. 7. S i g n i f i c a n t l y h i g h e r s c o r e s were o b t a i n e d on the a t t i t u d e and p r a c t i c e t e s t s by p h y s i c i a n s who had n u t r i t i o n i n t h e i r m e d i c a l s c h o o l t r a i n i n g than by p h y s i c i a n s who had no n u t r i t i o n . 8. General p r a c t i t i o n e r s who c o n s u l t e d books or a n u t r i t i o n i s t - d i e t i t i a n scored s i g n i f i c a n t l y h i g h e r on the a t t i t u d e and p r a c t i c e t e s t s than p h y s i c i a n s who d i d not c o n s u l t these sources of n u t r i t i o n . 9. General p r a c t i t i o n e r s who were t r a i n e d i n 'other' c o u n t r i e s s c o r e d s i g n i f i c a n t l y lower on the a t t i - 144 tude and p r a c t i c e t e s t s t h a n d i d p h y s i c i a n s t r a i n e d i n Canada. 10. No s i g n i f i c a n t c o n s i s t e n t r e l a t i o n s h i p was found between l o c a t i o n o f p r a c t i c e , t y p e o f p r a c t i c e , number o f p r e n a t a l p a t i e n t s and number o f i n f a n t s and t h e two c r i t e r i o n v a r i a b l e s . 11. N u t r i t i o n a t t i t u d e s were p o s i t i v e l y c o r r e l a t e d ( r = 0.370 ) t o n u t r i t i o n c o u n s e l l i n g p r a c t i c e s f o r g e n e r a l p r a c t i t i o n e r s . The major f i n d i n g s o f t h i s s t u d y f o r p e d i a t r i c i a n s were: 1. The mean p e r c e n t a g e t e s t s c o r e s f o r n u t r i t i o n a t t i t u d e s and p r a c t i c e s were 81.5 and 65.5 r e s p e c t i v e l y . 2. The l o w e s t mean s c o r e s were a c h i e v e d f o r n u t r i - t i o n p r a c t i c e s r e l a t e d t o : (a) e a r l y i n t r o d u c t i o n o f s o l i d s (b) s u p p l e m e n t a t i o n o f b r e a s t m i l k (c) use o f m u l t i v i t a m i n supplements d u r i n g i n f a n c y 3. P e d i a t r i c i a n s who were t r a i n e d i n Canada s c o r e d s i g n i f i c a n t l y h i g h e r on t h e n u t r i t i o n p r a c t i c e t e s t t h a n p h y s i c i a n s t r a i n e d i n a l l o t h e r c o u n t r i e s . No c o n s i s t e n t s i g n i f i c a n t r e l a t i o n s h i p was e v i d e n t between c o u n t r y o f m e d i c a l t r a i n i n g and t h e s c o r e s 145 a c h i e v e d on t h e a t t i t u d e t e s t . 4. P e d i a t r i c i a n s who were i n p r a c t i c e f o r more t h a n 5 y e a r s b u t l e s s t h a n 10 s c o r e d s i g n i f i c a n t l y h i g h e r on t h e n u t r i t i o n a t t i t u d e t e s t t h a n p h y s i c i a n s who were i n p r a c t i c e l e s s t h a n 5 y e a r s . No c o n s i s t e n t s i g n i f i c a n t r e l a t i o n s h i p was found between n u t r i t i o n p r a c t i c e s and y e a r s o f p r a c t i c e . 5. There was no s i g n i f i c a n t r e l a t i o n s h i p between sex o f th e r e s p o n d e n t , l o c a t i o n o f p r a c t i c e , t y p e o f p r a c t i c e , number o f p a t i e n t s , s o u r c e s o f n u t r i t i o n i n f o r m a t i o n , a d d i t i o n a l t r a i n i n g f o r s p e c i a l i z a - t i o n ^ a t t e n d a n c e a t c o n t i n u i n g e d u c a t i o n programs, i n c l u s i o n o f n u t r i t i o n i n t h e m e d i c a l s c h o o l c u r r i c u l u m and t h e two c r i t e r i o n v a r i a b l e s . 6. N u t r i t i o n a t t i t u d e s were p o s i t i v e l y c o r r e l a t e d ( r = 0.259 ) t o n u t r i t i o n c o u n s e l l i n g p r a c t i c e s . The major f i n d i n g s o f t h i s s t u d y f o r o b s t e t r i c i a n s were: 1. The mean p e r c e n t a g e t e s t s c o r e s f o r t h e n u t r i t i o n a t t i t u d e s and p r a c t i c e t e s t s were 64.1 and 64.7 r e s p e c t i v e l y . 2. The l o w e s t mean s c o r e s were a c h i e v e d f o r n u t r i t i o n p r a c t i c e s r e l a t e d t o : (a) use o f m u l t i v i t a m i n supplements d u r i n g pregnancy (b) r e s t r i c t i o n o f w e i g h t g a i n d u r i n g pregnancy O b s t e t r i c i a n s who were i n p r a c t i c e more than 10 years sco r e d s i g n i f i c a n t l y lower on the n u t r i t i o n a t t i t u d e t e s t than o b s t e t r i c i a n s who were i n p r a c t i c e l e s s than f i v e y e a r s . No s i g n i f i c a n t c o n s i s t e n t r e l a t i o n s h i p was e v i d e n t between years of p r a c t i c e and s c o r e s o b t a i n e d on the p r a c t i c e t e s t . O b s t e t r i c i a n s who c o n s u l t non-human sources of n u t r i t i o n i n f o r m a t i o n o t h e r than p r o f e s s i o n a l j o u r n a l s , s c o r e d s i g n i f i c a n t l y h i g h e r on the a t t i - tude and p r a c t i c e t e s t s . O b s t e t r i c i a n s who con- s u l t e d w i t h human sources of n u t r i t i o n i n f o r m a t i o n o t h e r than a n u t r i t i o n i s t - d i e t i t i a n , a l s o s c o r e d s i g n i f i c a n t l y h i g h e r on the n u t r i t i o n p r a c t i c e t e s t . There was no s i g n i f i c a n t r e l a t i o n s h i p between sex of the respondent, l o c a t i o n o f m e d i c a l t r a i n i n g , l o c a t i o n o r type o f p r a c t i c e , number o f p a t i e n t s , a d d i t i o n a l s p e c i a l i z a t i o n f o r t r a i n i n g , i n c l u s i o n o f n u t r i t i o n i n the med i c a l s c h o o l e d u c a t i o n and the two c r i t e r i o n v a r i a b l e s . There was no s i g n i f i c a n t c o n s i s t e n t r e l a t i o n s h i p between attendance a t c o n t i n u i n g e d u c a t i o n programs and the n u t r i t i o n a t t i t u d e and p r a c t i c e s c o r e s . N u t r i t i o n a t t i t u d e s were p o s i t i v e l y c o r r e l a t e d ( r = 0.424 ) to n u t r i t i o n c o u n s e l l i n g p r a c t i c e s . 147 Comparison of the mean percentage scores for general p r a c t i t i o n e r s , p e d i a t r i c i a n s and obs t e t r i c i a n s indicated that p e d i a t r i c i a n s scored s i g n i f i c a n t l y higher on the n u t r i t i o n practice t e s t than did the general p r a c t i t i o n e r s . Obstetricians scored s i g n i f i c a n t l y higher than the general p r a c t i t i o n e r s on the n u t r i t i o n practice t e s t . There was no s i g n i f i c a n t d i f f e r - ence i n the n u t r i t i o n a t t i t u d e scores.for the three groups. Implications Some of the findings of t h i s study should be g r a t i f y i n g to health professionals concerned with maternal and infant n u t r i t i o n . The r e l a t i v e l y high response rates, the encourage- ment of breast-feeding among the maternal population and the awareness of the importance of n u t r i t i o n i n the f i r s t two years of l i f e must be considered p o s i t i v e attitudes toward n u t r i t i o n by many physicians. The r e s u l t s of t h i s survey, however, also indicate that physicians need to improve t h e i r n u t r i t i o n counselling prac- t i c e s i n some important areas of maternal and infant n u t r i t i o n . The following recommendations are based on t h i s premise. Relative to the area of u t i l i z i n g acceptable sources of n u t r i t i o n information, the following s p e c i f i c implications are suggested: 1. Physicians, e s p e c i a l l y general p r a c t i t i o n e r s , should u t i l i z e the expertise of n u t r i t i o n i s t s 148 and d i e t i t i a n s for up-dating t h e i r n u t r i t i o n counselling p r a c t i c e s . 2. An assessment i s needed to determine whether there are s u f f i c i e n t n u t r i t i o n i s t s to supply these consultant services to the general p r a c t i t i o n e r s , p e d i a t r i c i a n s and o b s t e t r i c i a n s . 3. N u t r i t i o n information services should be esta- blished to provide physicians with sources of r e l i a b l e n u t r i t i o n information. S p e c i f i c implications concerning the establishment of continuing education programs are: 4. Continuing education programs should be designed to have greater appeal to physicians, e s p e c i a l l y general p r a c t i t i o n e r s . 5. More continuing education programs with a n u t r i t i o n component should be implemented i n order to im- prove n u t r i t i o n a ttitudes and practices i n mater- nal and infant n u t r i t i o n for general p r a c t i t i o n e r s , p e d i a t r i c i a n s and o b s t e t r i c i a n s . 6. Continuing education programs should include some emphasis on sources of r e l i a b l e n u t r i t i o n i n f o r - mation, the use of multivitamin supplements and the e f f e c t s of early n u t r i t i o n on l a t e r l i f e . S p e c i f i c implications on the i n c l u s i o n of n u t r i t i o n i n the medical school curriculum are: 149 7. N u t r i t i o n s h o u l d be i n c l u d e d i n t h e m e d i c a l s c h o o l c u r r i c u l u m i n a manner w h i c h c o r r e l a t e s w i t h p r a c t i c a l a p p l i c a t i o n . 8. N u t r i t i o n i n m e d i c a l s c h o o l s s h o u l d emphasize t h e r o l e o f n u t r i t i o n i n p r e v e n t i v e m e d i c i n e and hence, i t s i m p o r t a n c e i n m a t e r n a l and i n f a n t n u t r i t i o n . Recommendations f o r a d d i t i o n a l r e s e a r c h i n t h i s a r e a i n c l u d e : 9. 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A t t i t u d e s versus a c t i o n s : the r e l a t i o n s h i p of v e r b a l and o v e r t b e h a v i o r a l responses t o a t t i t u d e o b j e c t s . J . Soc. Issues 25:41, 1969. W i l l i a m s , P. and F. F r a l i n . N u t r i t i o n study i n pregnancy. Amer. J . Obstet. Gynec. 43:1, 1942. Winick, M. N u t r i t i o n and c e l l growth. Nutr. Rev. 26:195, 1968. Winick, M. R e l a t i o n s h i p of n u t r i t i o n t o p h y s i c a l and mental development. B i b l . Nutr. D i e t . 18:114, 1973. Winick, M. and P. Rosso. The e f f e c t o f severe m a l n u t r i t i o n on c e l l u l a r growth of the human b r a i n . P e d i a t r . Res. 3: 181, 1969. Young, C. M., K. B e r r e s f o r d and B.G. Waldner. IV Her food problems, shopping h a b i t s , and sources of i n f o r m a t i o n . J . Amer. D i e t e t . Assoc. 32:429, 1956. APPENDIX A DATA COLLECTION INSTRUMENTS AND FOLLOW-UP POSTCARDS 165 General Practitioners NUTRITION OPINIONS No. Card Some statements concerning maternal and infant n u t r i t i o n are made below. We are i n - terested in your judgement of each statement, in terms of how i t r e f l e c t s your personal opinion or feelings. If the statement describes how you f e e l , c i r c l e 'A' for agree; i f the statement does not describe how you f e e l , c i r c l e 'D' for disagree. After you have made your decision, indicate how sure you are about your decision: C i r c l e 1. i f you are VERY DOUBTFUL about your decision ( A or D 2. i f you are MODERATELY DOUBTFUL about your decision 3. i f you are MODERATELY CONFIDENT about your decision 4. i f you are VERY CONFIDENT about your decision PLEASE BE SURE TO RESPOND TWICE TO EACH STATEMENT. Sample: Nutrition i s important to good health. This opinion i s agreement with moderate confidence that n u t r i t i o n i s important to good health. D Agree or Disagree Degree of Confidence Disregard this Column Time devoted to counselling patients on proper n u t r i t i o n i s time well invested. A D 1 2 3 4 2. As long as the expectant mother takes a multi-vitamin supplement, I do not need to give advice on n u t r i t i o n . 3. Lactation i s a good time to get r i d of excess weight accumulated in pregnancy as long as nutrient intake remains adequate. 4. Restricting maternal weight gain to less than 20 pounds, decreases the li k e l i h o o d of severe toxemia. A D A D A D 1 2 3 4 1 2 3 4 1 2 3 4 8 9 10 11 12 13 Salt r e s t r i c t i o n i s necessary for a majority of the pregnant, population. A D 1 2 3 4 14 15 Pregnant women should be informed about the pros and cons of breast feeding. A D 1 2 3 4 16 17 Caloric r e s t r i c t i o n may be indicated in pregnancy because i t w i l l usually re s u l t i n a smaller infant and hence an easier delivery. A D 1 2 3 4 18 19 168 8. I feel that pregnant women need so much f o l i c acid that i t i s d i f f i c u l t to get i t from d i e t alone. 9. Provided that they enter pregnancy with adequate hemoglobin le v e l s , women need to increase their iron intake only during the l a s t half of pregnancy. IC. I f e e l that there i s l i t t l e p r a c t i c a l , accurate information on maternal n u t r i t i o n i n the current s c i e n t i f i c journals and books. 11. Mother's milk i s the optimum food for a healthy, newborn infant. 12. If an infant i s receiving a multi- vitamin supplement, I f e e l that I don't need to be concerned about h i s diet. 13. I believe that many commercially"pre- pared infant foods contain too high a quantity of s a l t . 14. Anemia i s rarely, i f ever, seen i n infants of higher socioeconomic status. 15. I f e e l that as long as a c h i l d i s gaining weight, I don't have to worry about h i s n u t r i t i o n . 16. I t i s important to investigate the infant dietary intake at each o f f i c e v i s i t . 17. Many mothers are anxious to have the i r infants ingest solids as soon as possible and I f e e l that i t i s best to go along with t h i s . 18. As long as the infant i s not sick he i s being fed properly. 19. A very important period for good n u t r i t i o n i s the f i r s t two years of l i f e . 20. In my opinion, i t i s impossible for an infant to be a lacto-ovo vegetarian ( eats eggs and milk products but no moat, f i s h or poultry ) and s t i l l be well-nourished. 's Disregard Agree or Degree of this Disagree confidence Column A 1 2 3 4 20 D 21 A 1 2 3 4 22 D 23 A 1 2 3 4 24 D 25 A 1 2 3 4 26 D 27 A 1 2 3 4 28 D 29 A 1 2 3 4 30 D 31 A 1 2 3 4 32 D 33 A 1 2 3 4 34 D 35 A 1 2 3 4 36 D 37 A 1 2 3 4 38 D 39 A 1 2 3 4 40 D 41 A 1 2 3 4 42 D 43 A 1 2 3 4 44 D 45 PLEASE CHECK TO BE SURE ALL STATEMENTS HAVE BEEN ANSWERED - 2 - 169 Demographic Information Please check (y) where appropriate. 1. In what country did you obtain the majority of your medical training? Australia Canada Disregard this Column France Great B r i t a i n India United States other ( please specify ) 2. What i s your sex? Male Female 3. In which of the following areas i s your practice located: metropolitan area ( Vancouver ) other c i t y (population > 5,000) town (population 2,500 - 5,000) v i l l a g e (population < 2,500) Professional Data 4. How many years have you been practising medicine? less than 5 years more than 5 years but less than 10 years more than 10 years 5. What i s your type of practice? private (solo) c l i n i c (group) 6. What i s the number of prenatal patients seen weekly? less than 10 prenatal patients more than 10 but less than 2 5 more than 25 prenatal patients 7. What i s the number of infants ( less than two years of age ) seen weekly? less than 10 infants more than 10 but less than 25 more than 25 infants 170 8. Please check a l l the sources on n u t r i t i o n information used i n your work. professional journals professional b u l l e t i n s government publications health agency publications (eg. Can. Diabetic Assoc.) audiovisual aids ( films, tapes, etc. ) magazines radio t e l e v i s i o n food manufacturers' brochures or labels pharmaceutical companies' brochures or labels books consultation with a n u t r i t i o n i s t - d i e t i t i a n consultation with a colleague consultation with a public health nurse consultation with a home economist other ( please specify) 9. Do you have any additional s p e c i a l i z a t i o n or training i n medicine? neonatology public health diploma other ( please specify ) 10. Please check i f you attended any of the following continuing education programs. Care of the High Risk Foetus S Newborn - May '74 Early Nutrition and Later L i f e - June '74 other ( please specify ) 11. Please check which of the following pertains to your medical school training. course on n u t r i t i o n l a s t i n g at least 13 weeks series of lectures on nu t r i t i o n n u t r i t i o n integrated with other course material no formal n u t r i t i o n education other ( please specify ) Disregard t h i s Column - 4 , - 171 NUTRITION PRACTICES Some statements concerning maternal and infant n u t r i t i o n are made below. Please indicate whether you conduct each practice - 'Always' 95% of the time), 'Frequently' ( approx- imately 50 - 95% of the time ), 'Sometimes' ( approximately 5 - 49% of the time ), or 'Never' (<5% of the time), by c i r c l i n g the appropriate number 1 - 4 . Always Frequently Sometimes Never Sample: I t e l l my patients that n u t r i t i o n i s important throughout pregnancy. This answer would indicate that you frequently t e l l patients that n u t r i t i o n i s important throughout pregnancy. Always Frequently Sometimes Never (>95%) (50 - 95%) (5 - 49%) (<5%) Disregard t h i s Colnmn At the f i r s t prenatal v i s i t , I check the quality of the patient's d i e t . 46 2. I consider the p o s s i b i l i t y of breast feeding with the pregnant women I see in my practice. 3. I recommend that healthy pregnant women ingest approximately 65 grams of protein d a i l y . 4. I advise healthy expectant women who do not drink milk to take a calcium supplement. 5. I recommend that expectant patients include a ci t r u s f r u i t or juice in their d a i l y d i e t . 6. I advise my prenatal patients who smoke to stop during pregnancy. 47 48 49 50 51 I recommend that healthy pregnant women increase their c a l o r i c intake 25% above the non-pregnant requirement. I encourage the average pregnant woman to gain approximately 1 pound per week i n the l a s t 20 weeks of pregnancy. 52 53 - 5 - 172 Always Frequently Sometimes Never (?95%) (50 - 95%) (5 - 49%) (< 5%) 9. I prescribe megavitamin therapy for many pregnant women. 10. I recommend that my prenatal patients include an i r o n - r i c h food ( i . e . organ meats ) in their weekly d i e t s . 11. I recommend to pregnant women who are obese that they l i m i t their weight gain during pregnancy to 10 pounds or less. 12. I give pregnant adolescents s p e c i f i c instructions on food sources of protein. 13. I prescribe an iron supplement i n the l a s t half of pregnancy for my prenatal patients. •14. I encourage my prenatal patients to have four glasses of milk or the equivalent in dairy products d a i l y . 15. I prescribe a multivitamin supplement for my prenatal patients even when their dietary intake appears adequate. 16. I recommend that my prenatal patients eat a wide variety of foods each day. 17. Any prenatal patient who gains over 15 pounds before term i s advised to l i m i t her s a l t intake. 18. I give pregnant women who are vegetarians s p e c i f i c instructions on food sources of protein and iron. 19. When my prenatal patients are gaining too much weight I recommend that they r e s t r i c t dietary carbohydrates to approximately 50 grams d a i l y . Disregard this Column 54 55 56 57 58 59 1 60 61 62 63 64 - 6 - 173 20. I recommend that a l l my prenatal patients take a fluoride supplement i f their water supply i s not fluoridated. 21. I recommend waiting at least 10 hours after b i r t h before giving the healthy newborn either the breast or a formula. 22. I ask mothers from what sources their 1 - 2 year olds obtain vitamin C. 23. I encourage mothers to give cereals added to the bottle for a healthy infant who i s n ' t s a t i s f i e d with milk alone. 24. I t e l l parents that i t i s generally less expensive to prepare sieved or blenderized foods than to buy commercially prepared foods. 25. I recommend the early ( within 2 months of b i r t h ) introduction of solids such as cereals and f r u i t s . 26. I recommend the introduction of a source of iron for healthy infants between 3 - 6 months of age. 27. I prescribe a fluoride supplement for my pediatric patients i f the water supply i s not s u f f i c i e n t l y fluoridated. 28. I recommend that human milk alone i s adequate in nutrient content for the f i r s t two months of l i f e . 29. If a 3 - 4 month old infant i s overweight according to height and weight charts, I recommend the substitution of skim milk for formula. 30. I recommend that iron f o r t i f i e d foods or iron drops be a part of the infant's dietary regimen during the 2nd year of l i f e . Always (> 95%) Frequently (50 - 95%) Sometimes (5 - 49%) Never « 5 % ) Disregard t h i s Column 4 3 2 1 65 4 3 2 1 66 4 3 2 1 67 4 3 2 1 68 4 3 2 1 69 4 3 2 1 70 4 3 2 1 71 4 3 2 1 72 4 3 2 1 73 4 3 2 1 74 - 4 3 2 1 75 - 7 - 174 Always (> 95%) Frequently (50 - 95%) Sometimes (5 - 49%) Never (<5%) Disregard t h i s Column 31. I encourage healthy mothers of infants to breast feed for the f i r s t six months. 32. I t e l l mothers who give vitamin supplements to give only the recommended dosage. 33. I recommend that by the time the c h i l d i s 5 months of age he should be eating cereals, f r u i t s , vegetables and meats. 34. I recommend that a multi-vitamin supplement be given to healthy infants. 35. I advise mothers to introduce a wide variety of foods into t h e i r infant's d i e t before he i s two years of age. 76 77 78 79 80 NO. Card 36. I recommend sugar water (about 1 tsp. sugar/qt. HzO) as a p a c i f i e r for children. 37. To decrease the l i k e l i h o o d of atherosclerotic heart disease in l a t e r l i f e , I recommend a low cholesterol intake early in infancy. 38. I encourage mothers to include about 25 grams of protein i n the d a i l y diet of a 1 - 2 year old. 39. I t e l l mothers that megavitamin therapy should be used i n treating hyperactivity i n infants. 40. I encourage mothers to include at l e a s t 2 glasses (16 oz.) of milk i n a 1 - 2 year old's d i e t . PLEASE CHECK TO BE SURE ALT, STATEMENTS HAVE BEEN ANSWERED Thank you for taking the time to complete this questionnaire. - 8 - 10 176 Obstetricians No. Card NUTRITION OPINIONS Some statements concerning maternal n u t r i t i o n are made below. we are interested in your judgement of each statement, in terms of how i t r e f l e c t s your personal opinion or feelings. If the statement describes how you f e e l , c i r c l e 1 A ' for agree; i f the statement does not describe how you f e e l , c i r c l e 'D' for disagree. After you have made your decision, indicate how sure you are about your decision: C i r c l e 1. i f you are VERY DOUBTFUL about your decision ( A or D ) 2. i f you are MODERATELY DOUBTFUL about your decision 3. i f you are MODERATELY CONFIDENT about your decision 4. i f you are VERY CONFIDENT about your decision PLEASE BE SURE TO RESPOND TWICE TO EACH STATEMENT. Sample: Nutrition i s important to good health. This opinion i s agreement with moderate confidence that n u t r i t i o n i s important to good health. 1. Time devoted to counselling patients on proper n u t r i t i o n i s time well invested. 2. As long as the expectant mother takes a multi-vitamin supplement, I do not need to give advice on n u t r i t i o n . 3. Lactation i s a good time to get r i d of excess weight accumulated in pregnancy as long as nutrient intake remains adequate. 4. Restricting maternal weight gain to less than 20 pounds, decreases the lik e l i h o o d of severe toxemia. 5. Salt r e s t r i c t i o n i s necessary for a majority of the pregnant population. Agree or Disagree A D A D A D A D A D Degree of Confidence 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 Disregard t h i s Column 6 7 8 9 10 11 12 13 14 15 177 Agree or Disagree Degree of Confidence Disregard t h i s Column 6. Pregnant women should be informed about the pros and cons of breast feeding. 7. Caloric r e s t r i c t i o n may be indicated in pregnancy because i t w i l l usually r e s u l t i n a smaller infant and hence an easier delivery. 8. I f e e l that pregnant women need so much f o l i c acid that i t i s d i f f i c u l t to get i t from diet alone. 9. Provided that they enter pregnancy with adequate hemoglobin levels, women need to increase t h e i r iron intake only during the l a s t half of pregnancy. 10. I f e e l that there i s l i t t l e p r a c t i c a l , accurate information on maternal nu t r i t i o n i n the current s c i e n t i f i c journals and books. A D A D A D A D A D 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 16 17 18 19 20 21 22 23 24 25 PLEASE CHECK TO BE SURE ALL STATEMENTS HAVE BEEN ANSWERED - 2 - 178 Demographic Information Please check (•) where appropriate. Disregard this Column 1. In what country did you obtain the majority of your medical training? • Australia Canada France Great B r i t a i n India United States other ( please specify ) 2. What i s your sex? Male Female 3. In which of the following areas i s your practice located? metropolitan area ( Vancouver ) other c i t y (population > 5,000) town (population 2,500 - 5,000) v i l l a g e (population <2,500) Professional Data 4. How many years have you been pr a c t i s i n g medicine? less than 5 years more than 5 years but less than 10 years more than 10 years i 5. What i s your type of practice? private (solo) c l i n i c (group) 6. What i s the number of prenatal patients seen weekly? less than 10 prenatal patients more than 10 but less than 25 more than 25 prenatal patients - 3 - 179 7. Please check a l l the sources on n u t r i t i o n information used in your work. Disregard this Column professional journals professional b u l l e t i n s government publications health agency publications (eg. Can. Diabetic Assoc.) audiovisual aids ( films, tapes, etc. ) magazines radio t e l e v i s i o n food manufacturers' brochures or labels pharmaceutical companies' brochures or labels books consultation with a n u t r i t i o n i s t - d i e t i t i a n consultation wjth a colleague consultation with a public health nurse consultation with a home economist other ( please specify ) 8. Do you have any additional s p e c i a l i z a t i o n or training in medicine? neonatology public health diploma other ( please specify ) 9. Please check i f you attended any of the following continuing education programs. Care of the High Risk Foetus & Newborn - May '74 Early Nutrition and Later L i f e - June '74 other ( please specify ) 10. Please check which of the following pertains to your medical school trai n i n g . course on n u t r i t i o n l a s t i n g at least 13 weeks series of lectures on n u t r i t i o n nu t r i t i o n integrated with other course material no formal n u t r i t i o n education other ( please specify ) - 4 - 180 NUTRITION PRACTICES Some statements concerning maternal n u t r i t i o n are made below. Please indicate whether you conduct each practice - 'Always' (> 95% of the time), 'Frequently' ( approximately 50 - 95% of the time ), 'Sometimes' ( approximately 5 - 49% of the time ), or 'Never' (< 5% of the time), by c i r c l i n g the appropriate number 1 - 4 . Always Frequently Sometimes Never Sample: I t e l l my patients that 4 (T) 2 1 nut r i t i o n i s important throughout pregnancy. This answer would indicate that you frequently t e l l patients that n u t r i t i o n i s important throughout pregnancy. Always O 95%) Frequently (50 - 95%) Sometimes (5 - 49%) Never « 5 % ) Disregard t h i s Column 1. At the f i r s t prenatal v i s i t , I check the quality of the patient's d i e t . 4 3 2 1 26 2. I consider the p o s s i b i l i t y of breast feeding with the pregnant women I see i n my practice. 4 3 2 1 27 3. I recommend that healthy pregnant women ingest approximately 65 grams of protein d a i l y . 4 3 2 1 28 4. I advise healthy expectant women who do not drink milk to take a calcium supplement. 4 3 2 1 29 5. I recommend that expectant patients include a c i t r u s f r u i t or juice i n their d a i l y d i e t . 4 3 2 1 30 6. I advise my prenatal patients who smoke to stop during pregnancy. 4 3 2 1 31 7. I recommend that healthy pregnant women increase their c a l o r i c intake 25% above the non-pregnant requirement. 4 3 2 1 32 8. I encourage the average pregnant woman to gain approximately 1 pound per week in the l a s t 20 weeks of pregnancy. 4 3 2 1 33 9. I prescribe megavitamin therapy for many pregnant women. 4 3 2 1 34 10. I recommend that my prenatal patients include an iro n - r i c h food ( i . e . organ meats ) in their weekly die t s . 4 3 2 1 35 - 5 - 181 - 6 - 183 Pediatricians No. NUTRITION OPINIONS Card" Some statements concerning infant n u t r i t i o n are made below. We are interested in your judgement of each statement, i n terms of how i t r e f l e c t s your personal opinion or feelings. If the statement describes how you f e e l , c i r c l e 'A' for agree; i f the statement does not describe how you f e e l , c i r c l e 'D' for disagree. After you have made your decision, indicate how sure you are about your decision: C i r c l e 1. i f you are VERY DOUBTFUL about your decision ( A or D ) 2. i f you are.MODERATELY DOUBTFUL about your decision 3. i f you are MODERATELY CONFIDENT about your decision 4. i f you are VERY CONFIDENT about your decision PLEASE BE SURE TO RESPOND TWICE TO EACH STATEMENT. Sample: Nutrition i s important to good health. This opinion i s agreement with moderate confidence that n u t r i t i o n i s important to good health. O 1 2 © 1. Mother's milk i s the optimum food for a healthy, newborn infant. 2. If an infant i s receiving a multivitamin supplement, I f e e l that I don't need to be concerned about his d i e t . 3. I believe that many commercially prepared infant foods contain too high a quantity of s a l t . 4. Anemia i s rarely, i f ever, seen in infants of higher socioeconomic status. 5. I f e e l that as long as a c h i l d i s gaining weight, I don't have to worry about his n u t r i t i o n . 6. I t i s important to investigate the infant's dietary intake at each o f f i c e v i s i t . 7. Many mothers are anxious to have t h e i r infants ingest solids as soon as possible and I feel that i t i s best to go along with t h i s . 8. As long as the infant i s not sick he i s being fed properly. 9. A very important period for good n u t r i t i o n i s the f i r s t two years of l i f e . 10. In my opinion, i t i s impossible for an infant to be a lacto-ovo vegetarian ( cats eggs and milk products but no moat, f i s h or poultry ) and s t i l l be well-nourished. Agree or Disagree A D A D A D A D A D A D A D A D A D A D Degree of Confidence 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 Disregard t h i s Column 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 PLEASE CHECK TO BE SURE ALL STATEMENTS HAVE BEEN ANSWERED 184 Demographic Information Please check ) where appropriate. 1. In what country did you obtain the majority of your medical training? Australia Canada France Great B r i t a i n India United States other ( please specify ) I Disregard this Column 2. What i s your sex? Male Female 3. In which of the following areas i s your practice located? metropolitan area ( Vancouver ) other c i t y (population > 5,000) town (population 2,500 - 5,000) v i l l a g e (population• < 2,500) Professional Data 4. How many years have you been pra c t i s i n g medicine? less than 5 years more than 5 years but less than 10 years more than 10 years 5 . What i s your, type of practice? private (solo) c l i n i c (group) 6. What i s the number of infants ( less than two years of age) seen weekly? less than 10 infants more than 10 but less than 25 more than 25 infants - 2 - o 18 5 7. Please check a l l the sources on n u t r i t i o n information used i n your work. Disregard this Column professional journals professional b u l l e t i n s government publications health agency publications (eg. Can. Diabetic Assoc.) audiovisual aids ( films, tapes, etc. ) magazines radio t e l e v i s i o n food manufacturers' brochures or labels pharmaceutical companies' brochures or labels books consultation with a n u t r i t i o n i s t - d i e t i t i a n consultation with a colleague consultation with a public health nurse consultation with a home economist other ( please specify ) 8. Do you have any additional s p e c i a l i z a t i o n or training in medicine? neonatology public health diploma other ( please specify ) 9. Please check i f you attended any of the following continuing education programs. Care of the High Risk Foetus & Newborn - May '74 Early Nutrition and Later L i f e - June '74 • other ( please specify ) 10. Please check which of the following pertains to your medical school trai n i n g . course on nu t r i t i o n l a s t i n g at least 13 weeks scries of lectures on n u t r i t i o n nutrition integrated with other course material no formal n u t r i t i o n education other ( please specify ) - 3 - 1 8 6 NUTRITION PRACTICES Some statements concerning infant n u t r i t i o n are made below. Please indicate whether you conduct each practice - 'Always' (> 95% of the time), 'Frequently' ( approximately 50 - 95% of the time ), 'Sometimes' ( approximately 5 - 49% of the time ), or 'Never' (< 5% of the time), by c i r c l i n g the appropriate number 1 - 4 . Sample: I t e l l my patients that n u t r i t i o n i s important throughout infancy. Always Frequently Sometimes Never 4 © 2 1 This answer would indicate that you frequently t e l l patients that n u t r i t i o n i s important throughout infancy. Always (> 95%) Frequently (50 - 95%) Sometimes (5 - 49%) 1. I recommend waiting at least 10 hours after b i r t h before giving the healthy newborn either the breast or a formula. 2. I ask mothers from what sources t h e i r 1 - 2 year olds obtain vitamin C 3. I encourage mothers to give cereals added to the bottle for a healthy infant who i s n ' t s a t i s f i e d with milk alone. 4. I t e l l parents that i t i s generally less expensive to prepare sieved or blenderized foods than to buy commercially prepared foods. 5 . I recommend the early ( within 2 months of b i r t h ) introduction of solid s such as cereals and f r u i t s . 6. I recommend the introduction of a source of iron for healthy infants between 3 - 6 months of age. 7. I prescribe a fluoride supplement for my pediatric patients i f the water supply i s not s u f f i c i e n t l y fluoridated. 8. I recommend that human milk alone i s adequate in nutrient content for the f i r s t two months of l i f e . 9. If a 3 - 4 month old infant i s overweight according to height and weight charts, I recommend the substitution of skim milk for formula. Never (< 5%) Disregard t h i s Column 26 27 28 29 30 31 32 33 34 - 4 - 187 10. I recommend that iron f o r t i f i e d foods or iron drops be a part of the infant' sdietary regimen during the 2nd year of l i f e . Always ( > 95%) Frequently (50 - 95%) Sometimes (5" - 49%) Never (<5%) Disregard this Column 35 11. I encourage healthy mothers of infants to breast feed for the f i r s t six months. 36 12. I t e l l mothers who give vitamin supplements to give only the recommended dosage. 37 13. I recommend that by the time the c h i l d i s 5 months of age he should be eating cereals, f r u i t s , vegetables and meats. 38 14. I recommend that a multivitamin supplement be given to healthy infants. 39 15. I advise mothers to introduce a wide variety of foods into t h e i r infant's d i e t before he i s two years of age. 40 16. I recommend sugar water (about 1 tsp. sugar/qt. H20) as a p a c i f i e r for children. 41 17. To decrease the l i k e l i h o o d of atherosclerotic heart disease i n l a t e r l i f e , I recommend a low cholesterol intake early i n infancy. 42 18. I encourage mothers to include about 25 grams of protein i n the d a i l y d i e t of a 1 - 2 year o l d . 43 19. I t e l l mothers that megavitamin therapy should be used in treating hyperactivity in infants. 20. I encourage mothers to include at least 2 glasses (16 oz.) of milk i n a l - 2 year old's d i e t . 44 45 PLEASE CHECK TO BE SURE ALL STATEMENTS HAVE BEEN ANSWERED Thank you for taking the time to complete t h i s questionnaire. - 5 - APPENDIX B VALIDATION QUESTIONNAIRE AND CORRESPONDENCE WITH VALIDATORS 189 Validation Questionnaire Do the questions for pediatricians and general practitioners represent an adequate variety of topics on infant nutrition? Yes No If. not, what i s missing? Do the questions for obstetricians and general practitioners represent an adequate variety of topics on maternal nutriton? Yes No If not, what i s missing? Do you agree with our answers (answer sheet enclosed)? Yes No If not, which statements and answers do you query? Section & Number Cou.rtent Are any of the statements ambiguous? Yes No If yes, which ones? Section & Number Comment Do the questions cover an adequate amount of information to obtain a v a l i d estimate of the n u t r i t i o n attitudes and practices of obstetricians, pediatricians and general practitioners? Yes No Is the scoring system appropriate for obtaining an estimate of n u t r i t i o n attitudes and practices? Yes No If not, why not? Is the order of the sections, i . e . , Opinions-Demographic Data-Practices, appropriate? Yes No If not, why not? Do you wish to have a copy of the f i n a l questionnaire along with a synopsis of the f i n a l results? Yes No If yes, please complete the following: Name: Address: Additional Comments: THANK YOU FOR YOUR TIME AND VALUABLE ASSISTANCE NAME AND ADDRESSES OF VALIDATORS 193 Dr. V i r g i n a B e a l Department o f N u t r i t i o n & Food Skinner H a l l U n i v e r s i t y o f Massachusetts Amherst, Massachusetts 01002 Dr. D o r i s Calloway Department o f N u t r i t i o n a l S c i e n c e s U n i v e r s i t y o f C a l i f o r n i a B e r k e l e y , C a l i f o r n i a 94720 Ms. Rosemary Calloway B u r r a r d H e a l t h U n i t 1530 West 8th Avenue Vancouver, B.C. Dr. V i r g i n a Campbell Dean, School o f Home Economics A c a d i a U n i v e r s i t y W o l f v i l l e , Nova S c o t i a Dr. Samual Fomon P r o f e s s o r o f P e d i a t r i c s U n i v e r s i t y of Iowa Iowa C i t y , Iowa Dr. Helen G u t h r i e A s s o c i a t e P r o f e s s o r o f Foods & N u t r i t i o n The P e n n s y l v a n i a S t a t e U n i v e r s i t y U n i v e r s i t y Park, P e n n s y l v a n i a Dr. P e t e r Hahn Vancouver General H o s p i t a l Dept. O b s t e t r i c s & Gynecology Vancouver, B.C. Mrs. Agnes H i g g i n s E x e c u t i v e D i r e c t o r M o ntreal D i e t Dispensary 2182 L i n c o l n Avenue Montreal, Quebec Miss L o r e t t a Juhas S u p e r v i s o r o f Food S e r v i c e s San F r a n c i s c o U n i f i e d School D i s t r i c t 135 Van Ness Avenue San F r a n c i s c o , C a l i f o r n i a 94102 Dr. M a r g a r e t K i r k c a l d y A s s i s t a n t P r o f e s s o r Home Economics Department Mount S t . V i n c e n t U n i v e r s i t y H a l i f a x , Nova S c o t i a S i s t e r Leona M o r r i s s e y A s s i s t a n t P r o f e s s o r Department o f Home Economics Mount S t . B e r n a r d C o l l e g e S t . F r a n c i s X a v i e r U n i v e r s i t y A n t i g o n i s h , Nova S c o t i a Dr. Kate Newman Department o f Human N u t r i t i o n & Food New York S t a t e C o l l e g e o f Human E c o l o g y M a r t h a Van R e n s s e l a e r H a l l C o r n e l l U n i v e r s i t y I t h a c a , New York 14850 Dr. George Owen Department o f P e d i a t r i c s U n i v e r s i t y o f New M e x i c o A l b u q u e r q u e , New Mex i c o 87131 M i s s M a r g a r e t P h i n c/o Dr. & Mrs. A.W. P h i n 1341 Maple S t r e e t White Rock, B.C. Dr. J e a n Sabry A s s o c i a t e P r o f e s s o r C o l l e g e o f F a m i l y & Consumer S t u d i e s U n i v e r s i t y o f Guelph Guelph, O n t a r i o NIG 2W1 Mrs. Eva Lee S i n g h A s s o c i a t e P r o f e s s o r C o l l e g e o f Home Economics U n i v e r s i t y o f Saskatchewan S a s k a t o o n , Saskatchewan S7N OWO M i s s Ann D. S u l l i v a n A s s i s t a n t P r o f e s s o r Department o f Home Economics Mount S t . B e r n a r d C o l l e g e S t . F r a n c i s X a v i e r C o l l e g e A n t i g o n i s h , Nova S c o t i a M i s s B e r n a d i n e Tomasek N u t r i t i o n C o - o r d i n a t o r M a t e r n a l & I n f a n t Care P r o j e c t S e a t t l e , Washington 195 Dr. Shirley Weber Professor University of Manitoba Faculty of Home Economics Winnipeg, Manitoba R3T 2N2 Dr. Myron Winick Director, I n s t i t u t e of N u t r i t i o n Columbia University College of Physicians & Surgeons 511 West 166*̂  Street New York, N.Y. 10032 APPENDIX C PRETEST QUESTIONNAIRE 196 P r e t e s t Cover L e t t e r 1. I s the purpose o f the q u e s t i o n n a i r e c l e a r l y s t a t e d ? Yes Comment: No 2. Are the i n s t r u c t i o n s adequate? Yes No Comment: 3. Does the l e t t e r make you want t o f i l l i n the q u e s t i o n n a i r e ? Yes No Comment: General Layout 1. Do you f e e l t h a t the o r d e r o f the s e c t i o n s i . e . , O p i n i o n s , Demo- g r a p h i c Data, P r a c t i c e s , i s a p p r o p r i a t e ? Yes No Comment: Answering Scheme 1. Are the i n s t r u c t i o n s f o r answering c l e a r ? Yes No Comment: 2. I s the answering scheme easy t o f o l l o w ? Yes No Comment: Statements 1. Are any statements: S e c t i o n S Number Comment ambiguous o b v i o u s l y b i a s e d not complete o r too l o n g too easy o r too d i f f i c u l t 2. Do you t h i n k the statements a re adequate to o b t a i n i n f o r m a t i o n on a t t i t u d e s and p r a c t i c e s of p h y s i c i a n s ? Yes No Comment: O v e r a l l Q u e s t i o n n a i r e 1. Is the q u e s t i o n n a i r e too long? Yes No 2. Is the q u e s t i o n n a i r e too time-consuming? Yes. No 3. Do the q u e s t i o n s appear r e p e t i t i o u s i . e . , a r e the ' p r a c t i c e ' ques- t i o n s too s i m i l a r t o the ' a t t i t u d e ' q u e s t i o n s ? Yes No APPENDIX D PHYSICIANS' COMMENTS TO QUESTIONNAIRES 198 199 L i s t e d be l ow a r e a number o f v o l u n t a r y comments w h i c h accompan ied t h e c o m p l e t e d q u e s t i o n n a i r e s . F a v o u r a b l e : " C o n g r a t u l a t i o n s on y o u r q u e s t i o n n a i r e ! Good p o i n t s . " " I n t e r e s t i n g s t u d y . N u t r i t i o n i s my second i n t e r e s t . " " I 'm v e r y i n t e r e s t e d i n n u t r i t i o n and t h e r e s u l t s o f y o u r e x c e l l e n t q u e s t i o n n a i r e . " " I o f f e r my p r a i s e t o t h e p e o p l e i n v o l v e d i n c o n d u c t i n g t h i s s t u d y . " U n f a v o u r a b l e : " Dumb q u e s t i o n n a i r e . " " I hope I 'm n o t m i s t a k e n i n r e c o g n i z i n g t h e p r e s e n t k i c k i n n u t r i t i o n as a f a d t h a t w i l l soon o u t l i v e i t s a b s u r d i t y . " " Many o f t h e q u e s t i o n s a r e m i s l e a d i n g . They a r e so p h r a s e d t h a t t h e e x p e c t e d answer i s a l r e a d y i n c l u d e d ; o t h e r w i s e , i t r e v e a l s t h e i g n o r a n c e i n t h e answer . " " I s p en t my l u n c h hou r a n s w e r i n g t h i s ga rbage j u s t so some- body can w r i t e a Ph . D. p a p e r . " O t he r i n t e r e s t i n g comments: " I r e a l i z e t h a t I s h o u l d spend f a r more t i m e r e n u t r i t i o n w i t h p r e g n a n t p a t i e n t s . " " W i t h some c h a g r i n I r e t u r n y o u r q u e s t i o n n a i r e . I ' v e t r i e d t o f i n d n u t r i t i o n i n f o r m a t i o n f o r a number o f y e a r s now and t h i s q u e s t i o n n a i r e makes i t o b v i o u s how u n s u c c e s s f u l I ' v e been . " 200 Best of luck but I think the only way to improve better n u t r i t i o n habits i s through a massive public education program. Also, give more p r a c t i c a l t r a i n i n g i n n u t r i t i o n to medical students. " I wish you well i n improving n u t r i t i o n which i s the major world problem but ask you not to be too hard on us G. E's. Too many smart-alecs push t h e i r own d i e t programs and c r i t i c i z e family doctors without r e a l l y knowing what we know about our patients and about n u t r i t i o n . Perhaps you could help by sending pamphlets to our o f f i c e s for d i s t r i - bution to our patients. " Getting mothers to remember the 4 food groups i s not easy. Lectures i n n u t r i t i o n were timed too early in.medical school. They were not taken seriously since we had no c l i n i c a l c o r r e l a t i o n . " N u t r i t i o n i n medical school was poorly done. " University t r a i n i n g i n n u t r i t i o n was very poor. " University t r a i n i n g i n n u t r i t i o n was sadly lacking. " N u t r i t i o n i n medical school had l i t t l e p r a c t i c a l relevance. It i s no use informing women about breast-feeding; they do what they want to anyway. " Since many questionnaires are sent to my o f f i c e I answer only the ones where a personal contact has been made. " If a large number of doctors have not r e p l i e d I am not surprised as I thought i t was something of an examination i n u t r i t i o n , and most of us probably were a b i t inaccurate. " I f e e l a d i e t i t i a n or n u t r i t i o n i s t must be considered a ' s p e c i a l i s t ' and that having a formally trained person to do routine dietary counselling would not be an e f f e c t i v e way of using the d i e t i t i a n ' s t r a i n i n g . " It was fun. " APPENDIX E ANSWER KEYS FOR NUTRITION ATTITUDE AND PRACTICE TESTS 201 ANSWER KEY FOR NUTRITION ATTITUDE TEST FOR GENERAL PRACTITIONERS 202 Statement Number Corre c t Response 1 Agree 2 Disagree 3 Agree 4 Disagree 5 Disagree 6 Agree 7 Disagree 8 Agree 9 Agree 10 Disagree 11 Agree 12 Disagree 13 Agree 14 Disagree 15 Disagree 16 Agree 17 Disagree 18 Disagree 19 Agree 20 Disagree ANSWER KEY FOR NUTRITION PRACTICE TEST FOR GENERAL PRACTITIONERS 203 Statement Co r r e c t Statement Co r r e c t No. Response No. Response 1 Always 21 Never 2 Always 22 Always 3 Always 23 Never 4 Never 24 Always 5 Always 25 Never 6 Always 26 Always 7 Never 27 Always 8 Always 28 Never 9 Never 29 Never 10 Always 30 Always 11 Never 31 Always 12 Always 32 Always 13 Always 33 Never 14 Always 34 Never 15 Never 35 Always 16 Always 36 Never 17 Never 37 Never 18 Always 38 Always 19 Never 39 Never 20 Never 40 Always 204 ANSWER KEY FOR NUTRITION ATTITUDE TEST FOR PEDIATRICIANS Statement Number C o r r e c t Response 1 Agree 2 Disagree 3 Agree 4 Disagree 5 Di s a g r e e 6 Agree 7 Disagree 8 Disagree 9 Agree 10 Disagree ANSWER KEY FOR NUTRITION PRACTICE TEST FOR PEDIATRICIANS 205 Statement C o r r e c t No. Response 1 Never 2 Always 3 Never 4 Always 5 Never 6 Always 7 Always 8 Never 9 Never 10 Always 11 Always 12 Always 13 Never 14 Never 15 Always 16 Never 17 Never 18 Always 19 Never 20 Always 2 0 6 ANSWER KEY FOR NUTRITION ATTITUDE TEST FOR OBSTETRICIANS Statement Number C o r r e c t Response 1 Agree 2 Disagree 3 Agree 4 Disagree 5 Disagree 6 Agree 7 Disagree 8 Agree 9 Agree 10 Disagree 207 ANSWER K E Y FOR N U T R I T I O N P R A C T I C E T E S T FOR O B S T E T R I C I A N S S t a t e m e n t C o r r e c t N o . R e s p o n s e 1 A l w a y s 2 A l w a y s 3 A l w a y s 4 N e v e r 5 A l w a y s 6 A l w a y s 7 N e v e r 8 A l w a y s 9 N e v e r 10 A l w a y s 11 N e v e r 12 A l w a y s 13 A l w a y s 14 A l w a y s 15 N e v e r 16 A l w a y s 17 N e v e r 18 A l w a y s 19 N e v e r 20 N e v e r A P P E N D I X F M E A N S C O R E S F O R N U T R I T I O N A T T I T U D E A N D P R A C T I C E T E S T S 208 MEAN SCORES OF NUTRITION ATTITUDES ATTAINED BY GENERAL PRACTITIONERS Statement Number Mean Score 1 5.9 2 6.3 3 3.2 4 4.0 5 4.9 6 6.6 7 6.0 8 3.2 9 2.8 10 2.9 11 6.3 12 6.5 13 4.4 14 5.1 15 6.2 16 5.1 17 5.1 18 6.2 19 6.5 20 4.5 210 MEAN SCORES OF NUTRITION COUNSELLING PRACTICES ATTAINED BY GENERAL PRACTITIONERS Statement Mean Statement Mean Number Score Number Score 1 1.7 21 1.7 2 2.8 22 1.1 3 1.4 23 1.6 4 0.9 24 1.9 5 1.7 25 1.6 6 2.2 26 2.0 7 2.2 27 2.4 8 1.1 28 0.9 9 2.4 29 1.5 10 1.7 30 1.2 11 2.1 31 2.1 12 1.5 32 2.7 13 2.7 33 0.8 14 1.5 34 1.2 15 0.9 35 2.5 16 2.1 36 2.5 17 2.2 37 2.4 18 1.9 38 1.1 19 1.5 39 2.9 20 1.9 40 1.9 MEAN SCORES OF NUTRITION ATTITUDES ATTAINED BY PEDIATRICIANS Statement Mean Number Score 1 6.5 2 6.4 3 4.5 4 5.6 5 6.3 6 4.9 7 5.5 8 6.4 9 6.4 10 4.3 212 MEAN SCORES OF NUTRITION COUNSELLING PRACTICES ATTAINED BY PEDIATRICIANS Statement Mean Number Score 1 2.4 2 1.8 3 2.1 4 1.8 5 1.8 6 2.3 7 2.6 8 0.9 9 1.9 10 1.1 11 2.4 12 2.8 13 0.7 14 1.2 15 2.4 16 2.7 17 2.3 18 1.6 19 3.0 20 1.9 2 1 3 MEAN SCORES OF NUTRITION ATTITUDES ATTAINED BY OBSTETRICIANS Statement Mean Number Score 1 5 . 7 2 6 . 3 3 2 . 6 4 4 . 4 5 5 . 0 6 6 . 7 7 6 . 1 8 3 . 0 9 2 . 3 10 2 . 9 214 MEAN SCORES OF NUTRITION COUNSELLING PRACTICES ATTAINED BY OBSTETRICIANS Statement Mean Number Score 1 1.9 2 2.7 3 1.7 4 1.0 5 1.8 6 2.1 7 2.1 8 1.3 9 2.5 10 1.8 11 2.2 12 1.9 13 2.9 14 1.7 15 0.9 16 2.2 17 2.2 18 2.1 19 1.6 20 2.1

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