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Maternal and infant nutrition attitudes and practices of physicians in British Columbia Johnston, Elizabeth MacLeod 1975

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MATERNAL AND  INFANT NUTRITION ATTITUDES  PRACTICES OF PHYSICIANS  AND  IN BRITISH COLUMBIA  ELIZABETH MACLEOD JOHNSTON  B.Sc,  Acadia University,  M.S.,  Nova S c o t i a ,  Cornell University,  New  York,  1968 1970  A DISSERTATION SUBMITTED IN PARTIAL FULFILMENT  OF  THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY  in  the D i v i s i o n of  '  Human N u t r i t i o n S c h o o l o f Home E c o n o m i c s  We  accept  required  this  d i s s e r t a t i o n as c o n f o r m i n g  standard  THE UNIVERSITY OF BRITISH COLUMBIA AUGUST, 1975  to the  In presenting  t h i s thesis in p a r t i a l f u l f i l m e n t of the requirements f o r  an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y a v a i l a b l e for reference and study. I further agree that permission for extensive  copying of t h i s thesis  for scholarly purposes may be granted by the Head of my Department or by his representatives.  I t i s understood that copying or p u b l i c a t i o n  of t h i s thesis f o r f i n a n c i a l gain s h a l l not be allowed without my w r i t t e n permission.  Department of  Home E c o n o m i c s  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 P l a c e Vancouver, Canada V6T 1W5  August  19,  1975  ABSTRACT  Periods of ability the  first  stage at  to  nutritional injury. two  i n the  years life  t h i s time.  als  r a p i d growth are  tion  i n the  information  o f m a t e r n a l and A t u d e s and  tion  mothers of  p r o v i d e d by  practices  of  years of  sex  i n the  and  province  new  than at  the  of was  the  vital  profession-  q u a l i t y of  to are  nutri-  i n t h i s important  of  to  investigate  the  of  British  area  nutrition  was  criterion assessed.  professional  respondent, number o f  atti-  patients  influ-  variables,  nutri-  Variates  studied  country  type of  of  medical  practice,  seen weekly, sources  attendance at  n u t r i t i o n i n medical  school  and  The  d a t a on  l o c a t i o n and  consulted,  Columbia.  of  continuing  specialization,  education.  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  also  other  primary  assess the  physicians  in  However, t h e r e  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 of  any  n u t r i t i o n advice  infants.  upon t h e  practices,  information  inclusion  p r e g n a n c y and  general practitioners, pediatricians  variates  practice,  nutrition  frequently  l i t e r a t u r e that  d e m o g r a p h i c and  training,  vulner-  infant nutrition.  selected  included  special  h e n c e , optimum n u t r i t i o n i s  dissemination of  designed  attitudes  of  Growth d u r i n g  i s more r a p i d  are  s t u d y was  obstetricians ence o f  and  Physicians  concerned with the  studies  life  cycle  p r e g n a n t women and no  of  periods  and  The  and  nature  practices  assessed. I n M a r c h 1975,  practising  questionnaires  were m a i l e d  general p r a c t i t i o n e r s , pediatricians  ii  to  and  all  1981  obstetri-  cians i n the province of B r i t i s h r e t u r n e d b y 724 pediatricians  Columbia.  Questionnaires  were  ( 4 1 . 3 % ) g e n e r a l p r a c t i t i o n e r s , 69 ( 6 2 . 7 % )  a n d 51 ( 4 3 . 2 %  ) obstetricians.  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 conducted  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  reported at the highest l e v e l of significance. 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 titioners,  pediatricians  f o r general  prac-  and o b s t e t r i c i a n s were 72%, 8 1 %  and  64% r e s p e c t i v e l y .  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  obstetricians  practice  analysis  indicated  that n u t r i t i o n attitude  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 nutritionist-dietitian ded  s c o r e s were 60%,  respectively.  Regression and  Nutrition practices'  (a) were f e m a l e  (b) c o n s u l t e d w i t h  (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 -  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 n d (e) h a d n u t r i t i o n i n  t h e i r medical  school education.  i n p r a c t i c e m o r e t h a n 10 y e a r s the a t t i t u d e  and p r a c t i c e  trained  scored  p r a c t i t i o n e r s who w e r e  s i g n i f i c a n t l y lower  on  tests.  Nutrition practice for pediatricians  General  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 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 w e r e h i g h e r f o r p e d i a t r i c i a n s who w e r e i n p r a c t i c e more than  f i v e but fewer than  10 y e a r s .  s c o r e s were s i g n i f i c a n t l y lower p r a c t i c e more t h a n non-human s o u r c e s sional  journals  10 y e a r s .  Obstetricians'  attitude  f o r p h y s i c i a n s who w e r e i n  Obstetricians  who c o n s u l t e d w i t h  o f n u t r i t i o n information other than  a n d human s o u r c e s  i i i  of information other  profesthan  nutritionist-dietitians nutrition  practice  scored  s i g n i f i c a n t l y h i g h e r on t h e  test.  Correlation  analysis  showed t h a t  were s i g n i f i c a n t l y c o r r e l a t e d  nutrition  to nutrition practices  practitioners  ( r = 0.370 ) , p e d i a t r i c i a n s  obstetricians  ( r = 0.424 ) .  Student t - t e s t and  obstetricians'  analysis  practice  indicated  test  the  differences  three  that  for nutrition  need  pediatricians'  s c o r e s were s i g n i f i c a n t l y T h e r e were no  among t h e n u t r i t i o n a t t i t u d e  sig-  scores f o r  groups.  Implications  ation  f o r general  ( r = 0.259 ) a n d  higher than those o f general p r a c t i t i o n e r s . nificant  attitudes  f o r n u t r i t i o n educators  i n the medical  of nutrition  into  included  school curriculum,  continuing  the incorpor-  e d u c a t i o n programs and t h e  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  iv  t h e need  physicians.  TABLE OF CONTENTS  ABSTRACT  .............  i i  L I S T OF TABLES  v i i  L I S T OF FIGURES  x i i  ACKNOWLEDGEMENTS  ..  •  xiii  Chapter I.  INTRODUCTION  .............  B a c k g r o u n d a n d Need Statement o f t h e Problem Hypotheses D e f i n i t i o n s o f terms Assumptions . .. II.  .  REVIEW OF THE LITERATURE  DESIGN OF THE STUDY Research Design Population Data C o l l e c t i o n Data c o l l e c t i o n Procedure Data A n a l y s i s  •••r?••r  •••i n s t r u m e n t s . ...............  v  1 7 9 11 13 15  N u t r i t i o n i n Pregnancy E f f e c t o f n u t r i t i o n o n t h e outcome of pregnancy . Weight g a i n i n pregnancy . Sodium r e s t r i c t i o n .. . Iron intake D i e t a r y P r a c t i c e s o f P r e g n a n t Women ......... N u t r i t i o n E d u c a t i o n f o r Pregnancy .. N u t r i t i o n i n Infancy Importance o f n u t r i t i o n i n i n f a n c y ........ Iron d e f i c i e n c y Breast-feeding ,, Introduction of solids Infant Dietary Practices .................... N u t r i t i o n Education f o r Infancy ............. Role o f P h y s i c i a n i n N u t r i t i o n Education A t t i t u d e s and P r a c t i c e s S u r v e y R e s e a r c h by M a i l Q u e s t i o n n a i r e ....... T e c h n i q u e s , advantages and disadvantages Response r a t e Non r e s p o n s e Summary III.  1  15 15 20 23 25 27 31 36 36 38 41 43 45 48 50 54 58 58 60 63 65 67 68 68 69 69 73 75  IV.  FINDINGS AND  INTERPRETATIONS  ,  78  Rates of Response C o m p a r i s o n o f E a r l y and L a t e R e s p o n d e n t s General P r a c t i t i o n e r s D e s c r i p t i o n of respondents 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 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 Summary o f g e n e r a l p r a c t i t i o n e r s ' results 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 of respondents 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 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 Summary o f p e d i a t r i c i a n s ' and obstetricians' results Comparison of N u t r i t i o n A t t i t u d e s 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 O b s t e t r i c i a n s V.  SUMMARY AND  108 109 109 116 124 133  134  IMPLICATIONS  137 137  Implications  147  ..  .  APPENDICES A. 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 and Postcards Validation Questionnaire  and  150  Follow-Up 165  Correspondence  with Validators  189  C.  Pretest  D. E.  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 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  F.  97  Summary  LITERATURE CITED  B.  78 79 81 81 89  Questionnaire  196  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 Practice Tests  vi  198 201  and 208  LIST OF TABLES I. II.  III.  Percentage o f pregnant women w i t h "inadequate" and "less-than-adequate" i n t a k e s o f n u t r i e n t s  29  Percentage o f pregnant women i n B r i t i s h Columbia w i t h l e s s than t w o - t h i r d s o f t h e recommended d i e t a r y intake  30  Percentage o f c h i l d r e n zero t o f o u r y e a r s o f age w i t h "inadequate" and " l e s s - t h a n - a d e q u a t e " i n t a k e s of n u t r i e n t s . . . .  47  IV.  S c o r i n g system  fornutrition attitude  test  70  V.  S c o r i n g system  fornutrition practice  test  72  VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV. XVI. XVII.  Summary o f response r a t e s from p h y s i c i a n s Number and percentage o f p h y s i c i a n s d e s i g n a t e d as e a r l y and l a t e respondents Comparison o f e a r l y and l a t e respondents on b a s i s of mean percentage t e s t s c o r e s  79 80 81  D i s t r i b u t i o n o f g e n e r a l 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  D i s t r i b u t i o n o f g e n e r a l 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  D i s t r i b u t i o n o f g e n e r a l p r a c t i t i o n e r s by y e a r s o f practice  83  D i s t r i b u t i o n o f g e n e r a l p r a c t i t i o n e r s by type o f practice  84  D i s t r i b u t i o n o f g e n e r a l p r a c t i t i o n e r s by number of p a t i e n t s seen weekly  84  Number and percentage o f 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 i n g sources o f n u t r i t i o n i n f o r m a t i o n  85  Number and percentage o f g e n e r a l 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 f o r s p e c i a l i z a t i o n  86  Number and percentage o f 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 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...  87  Number and percentage o f 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 i n g type 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 schools  88  vii  XVIII. XIX.  XX.  XXI. XXII.  XXIII.  XXIV.  XXV.  XXVI.  XXVII.  XXVIII.  XXIX.  XXX.  XXXI.  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 a n d practice tests f o rgeneral practitioners  90  Statements measuring n u t r i t i o n a t t i t u d e s f o r which general p r a c t i t i o n e r s received lowest mean s c o r e s  91  Statements measuring 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 which general p r a c t i t i o n e r s received l o w e s t mean s c o r e s  92  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 concerning breast-feeding..  95  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 general p r a c t i t i o n e r s concerning early introduction of solids  96  of  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  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 s e x o f r e s p o n d e n t  98  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  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  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  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 s e e n w e e k l y  100  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 s e e n w e e k l y  101  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  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 b a s e d 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 p r o g r a m s . . .  102  viii  XXXII.  XXXIII.  XXXIV.  XXXV.  XXXVI. XXXVII. XXXVIII. XXXIX. XL. XLI. XLII.  XLIII.  XLIV.  XLV.  XLVI.  Mean percentage 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 c o n t i n u i n g e d u c a t i o n programs attended...  103  Mean percentage 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 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  103  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 g e n e r a l 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 test  105  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 a c h i e v e d by 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 test  107  D i s t r i b u t i o n 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 by country of medical t r a i n i n g  109  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 sex  110  and o b s t e t r i c i a n s by  D i s t r i b u t i o n 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 by l o c a t i o n of p r a c t i c e Distribution of pediatricians years o f p r a c t i c e  110  and o b s t e t r i c i a n s by I l l  D i s t r i b u t i o n 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 by type o f p r a c t i c e  I l l  D i s t r i b u t i o n 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 by number o f p a t i e n t s seen weekly  112  Number and percentage 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 i n d i c a t i n g sources o f n u t r i t i o n information  113  Number and percentage o f p e d i a t r i c i a n s and o b s t e tricians indicating additional training for specialization  114  Number and percentage 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 i n d i c a t 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  115  Number and percentage 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 i n d i c a t i n g type o f n u t r i t i o n e d u c a t i o n i n medical school  115  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 and p r a c t i c e t e s t 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 .  117  ix  XLVII. XLVIII.  XLIX.  L.  LI.  LII.  LIII.  LIV.  LV.  LVI.  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 l o w e s t mean s c o r e s  118  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 l o w e s t mean s c o r e s  119  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 l o w e s t mean s c o r e s ,  120  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 a c h i e v e d l o w e s t mean s c o r e s  121  Comparison o f a t t i t u d e s and p r a c t i c e s f o r pediatricians concerning n u t r i t i o n a l advice  122  Comparison o f a t t i t u d e s and p r a c t i c e s f o r obstetricians concerning n u t r i t i o n a l advice..,,.,,,  123  Mean p e r c e n t a g e s c o r e s o f p e d i a t r i c i a n s a n d 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 b a s e d on 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  124  Mean p e r c e n t a g e s c o r e s o f p e d i a t r i c i a n s a n d 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 b a s e d on s e x o f r e s p o n d e n t  125  Mean p e r c e n t a g e s c o r e s o f p e d i a t r i c i a n s a n d 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 b a s e d on l o c a t i o n o f p r a c t i c e  126  Mean p e r c e n t a g e s c o r e s o f p e d i a t r i c i a n s a n d 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 tests  LVII.  LVIII.  LIX.  LX.  LXI.  based  on y e a r s o f p r a c t i c e  126  Mean p e r c e n t a g e s c o r e s o f p e d i a t r i c i a n s a n d 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 b a s e d on t y p e o f p r a c t i c e  127  Mean p e r c e n t a g e s c o r e s o f p e d i a t r i c i a n s a n d 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 b a s e d on number o f p a t i e n t s s e e n w e e k l y . , . . . ,  127  Mean p e r c e n t a g e s c o r e s o f p e d i a t r i c i a n s a n d 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 b a s e d on a d d i t i o n a l t r a i n i n g f o r specialization  128  Mean p e r c e n t a g e s c o r e s o f p e d i a t r i c i a n s a n d 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 b a s e d 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  129  Mean p e r c e n t a g e s c o r e s o f 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 a n d p r a c t i c e t e s t s b a s e d on number 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 . , , - 129  x  LXII.  LXIII.  LXIV.  LXV.  LXVI.  Mean p e r c e n t a g e s c o r e s o f p e d i a t r i c i a n s a n d 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 b a s e d 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 school  130  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 p e r c e n t a g e scores a c h i e v e d by p e d i a t r i c i a n s on t h e 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  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 p e r c e n t a g e scores a c h i e v e d by o b s t e t r i c i a n s on t h e 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  C o m p a r i s o n o f 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 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  C o m p a r i s o n o f 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 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  xi  L I S T OF  The v i c i o u s c i r c l e medical schools  FIGURES  of n u t r i t i o n  xii  teaching  in  ACKNOWLEDGEMENTS  The a u t h o r major  advisor,  couragement expertise  Dr.  during  in  Molly  assistance  C.  L.  A.  of  is  .for  for  throughout pated  in  the  the Above  thanks  to her  encouragement  this  support study  to  this  her  and e n -  and f o r  Eleanor  acknowledged  Dr.  her  D.  B.  Vaines  for  this  their  report.  Jelliffe  of  examiner.  study  Association, the graduate in pretesting  and to  to  thesis.  extended to Drs.  authorizing  study  graduate  external  are  assistance  her  the p r e p a r a t i o n o f  as  computer programming,  for  committee, Dr.  expressed  thanks  her a p p r e c i a t i o n  gratefully  in  serving  for  of  thesis  Columbia M e d i c a l  Nutrition  were  the  also  Sincere  British  Schwartz,  T o w e l l , are  for  and W i l f o r d  express  the p e r i o d of  and s u p p o r t  Appreciation U.  Nancy  to  the development  Members and D r .  wishes  Glass,  on b e h a l f Mr.  Patterson  of  the  Christopher  students and  in  Webber  Human  encouragement  t h e many p h y s i c i a n s  who  partici-  survey. all,  the  author  son, Mark,  would  like  and h u s b a n d ,  and e x t e n s i v e  David,  contributions  invaluable.  xiii  to  to  give  special  whose this  continual thesis  CHAPTER I  INTRODUCTION  Background  Nutrition is  o f the utmost  the  infant.  The  general physical  In  his nutritional  of h i s mental  Gussow, 1970  pregnancy  Need  and  the f i r s t  importance t o the h e a l t h  and p a r t i c u l a r l y fulfilment  during  and  and w e l l - b e i n g  condition status,  and p h y s i c a l  are central  capacities  attitude  recent years,  attention  has b e e n  One  of great  significance  regarding maternal weight  gain  f o c u s e d on  (1970) has  Food  of  a p p r o x i m a t e l y 24 p o u n d s , w h i l e p r o m i n e n t  E n g l a n d recommend  27.5  for primigravidae Columbia  established  t o fewer  and  t h e U.S.A.  the  and  the  t o t h e outcome o f  longer  in  paper  ( Birch  i n pregnancy.  weight gain  Committee o f M a t e r n a l N u t r i t i o n ,  British  t o the  i s t h e g e n e r a l change i n  pounds f o r t h e n o r m a l p r e g n a n t woman i s no  gain  child,  ).  popular p r a c t i c e o f r e s t r i c t i n g  The  life of  o f t h e young  r e l a t i o n s h i p o f a number o f m a t e r n a l f a c t o r s pregnancy.  years of  The than  once 20  recommended.  Nutrition  Board  suggested a t o t a l maternal weight researchers i n  pounds a s a r e a s o n a b l e a v e r a g e ( H y t t e n and  Leitch,  Medical Association by t h e N u t r i t i o n  recommends an a v e r a g e w e i g h t  gain  19 71  i n Pregnancy Columbia  o f 24 p o u n d s . 1  ).  weight Indeed,  has e n d o r s e d t h e  Health Planning Council of B r i t i s h  gain  position  Committee (1973)  the  of  that  However, t h e  2 results  from N u t r i t i o n Canada showing  the s p e c i f i c  British  Columbia  caloric  (1975) i n d i c a t e t h a t  n a n t women i n t h i s levels  in  limiting  fast,  weight gain Felig  restriction  should  at this  i n pregnancy  state.  This  f o r preg-  gain.  t h o u g h t t o be a n reduction  t i m e may h a v e a d v e r s e e f f e c t s  (1973) h a s d e m o n s t r a t e d  ketonemia  the non-gravid  reduction  optimum w e i g h t  t i m e f o r o b e s e women t o p r a c t i s e w e i g h t  the fetus.  night  intakes  below t h e a c c e p t a b l e  a d d i t i o n , p r e g n a n c y i s no l o n g e r  appropriate  on  are generally  t h a t would promote t h i s In  since  province  findings i n  i s three  suggests  n o t be u n d e r t a k e n  that  a f t e r an o v e r -  times greater  that  severe  than  caloric  i n pregnancy and weight  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 intake o f  c a r b o h y d r a t e s must b e a v o i d e d . Similarly, of and  indiscriminant Leitch  recent salt  information  restriction  (1971) o b s e r v e d t h a t  lower i n c i d e n c e  during  They c o n c l u d e d  t o regard  pathologic  s i g n i f i c a n c e i n pregnancy.  edema a s h a v i n g p h y s i o l o g i c  f o r the general  women s h o u l d  to salt  Katz,  their  that  i t was  rather  than  population  food  and p r e g n a n t  to taste  ( Lindheimer  1974 ) .  The gaining  Hytten  Thus, r e s t r i c t i o n o f  sodium i s n o t w a r r a n t e d  and  pregnancy.  i n f a n t s and a s l i g h t l y r e -  reasonable  be a l l o w e d  re-evaluation  p r e g n a n t women w i t h edema h a d a  o f low b i r t h w e i g h t  duced r a t e o f i n f a n t m o r t a l i t y .  demands a  i m p o r t a n c e o f optimum n u t r i t i o n d u r i n g  new i m p e t u s a s e v i d e n c e  i s mounting t h a t  infancy i s  malnutrition  3  during  t h i s stage of  intelligence 1965;  ( S t o c h and  Cravioto  1973  ).  the  first  total  et  life  brain  cells  Martin,  1970;  ( W i n i c k and  ).  entails hydrate,  i n t o the  switch and  The  the  practice  feeding  i n an  concern.  of  reserves to  b a c k on  i n the  linoleic  inadequate  supply of  i n the  event of the  which infant  solids  generally high  Mayer,  in  carbo-  least, this is  consi-  infants  and  four  imagined  (1974) s u g g e s t e d  t h e i r fat stores  an  foods  Dwyer and  t r e a t r e a l or  deplete  receive  early  Early  1973;  skim m i l k to  e f f o r t to Fomon  of  of  ).  infants probably fall  practice  i n f a t t o one  ( Hahn, 1973  causing  the  Oates,  introduction  detrimental  age  the  undernutrition  f a t accumulation  from a d i e t h i g h  of  in  Rosso  infant's diet.  i n experimental animals, at  months o f  1969;  encourage overconsumption  S h u k l a e t a l . , 1972;  addition,  t o be  also  also questioning  foods  Winick,  clear.  result i n excessive  In a  solid  s o l i d s may  t u r n may  that  obesity  such  hence have  illness.  to  no  They may  essential fatty  also  acid,  acid. Iron  another  Rosso,  less  of  Robales,  cause permanent r e d u c t i o n - i n  are  are  and  severe undernutrition  this period  ( T a i t z , 1971;  is  will  that  and  consequences of m i l d  weaning t o  six  C h a s e and  Cravioto  the  introduction  dered  affect learning  ) but  Nutritionists  1973  adversely  Smythe, 1963;  a l . , 1966;  years of  e t a l . , 1970  in  may  S t u d i e s have i n d i c a t e d  number o f  during  life  deficiency  f a c t o r of  a n e m i a among  increasing  infants  importance  and  ( Fuerth,  toddlers 1971;  is  Owen  4  et  a l . , 1971;  Lanzkowsky,  are  recommending u s e  the  i n f a n t i s not  enriched is  also being  our  during  iron-fortified  being  breast-fed.  formulas  academies  from b i r t h i f  Supplementation with six to  18 months o f  ironage  advocated. recent  information  has  for nutrition  the  of  first  years  information  American C o l l e g e  state  Some p e d i a t r i c  recommendations  mine i f t h i s The  )'.  c e r e a l s from approximately  Since in  of  1974  life,  brought during  i t appears  i s reaching  significant pregnancy  important  the maternal  o f O b s t e t r i c i a n s and  changes  and to  deter-  population.  Gynecologists  (1974)  that: . . . t h e 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 e x t e n d i n g f a r beyond her p r e s e n t p r e g n a n c y ( p. 1 ) . Various  is  the  tion  i n v e s t i g a t o r s have p o i n t e d  t h a t the  p r i m a r y p r o f e s s i o n a l upon whom homemakers r e l y  information  Gifft  out  ( Young e t aT. , 1956;  Fox  for  e t al_. , 1970  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  physician nutri-  ).  ares  . . . t r u s t e d and l o o k e d up t o a s a u t h o r i t i e s i n m a t t e r s p e r t a i n i n g t o h e a l t h (and) a r e h i g h l y respected l e g i t i m i z e r s of n u t r i t i o n information ( P- 355 ).. However, p h y s i c i a n s Phillips not  (1971) showed t h a t  familiar  nutrition. nutrition  with  many o f  Kjellman  second year  the  (19 74)  among m e d i c a l  g e n e r a l l y are  not  nutrition  medical  b a s i c c o n c e p t s and  demonstrated  students  was  students  were  principles  t h a t knowledge  poor but  experts.  results  of  of  from  fifth  5 year third  s t u d e n t s were year  these  ) investigated  studies  ( Phillips,  College  1971; K j e l l m a n ,  t h e n u t r i t i o n knowledge o f m e d i c a l  t h e r e do n o t a p p e a r t o be any s t u d i e s nutrition  from  students.  Although 1974  s i g n i f i c a n t l y worse than t h o s e  that  investigated the  knowledge o f p r a c t i s i n g p h y s i c i a n s .  of Obstetricians  and G y n e c o l o g i s t s  students,  Y e t , t h e American  (1974) s t a t e  that:  . . . the ultimate r e s p o n s i b i l i t y f o r ensuring a h i g h q u a l i t y n u t r i t i o n component o f m a t e r n i t y c a r e s e r v i c e s r e s t s w i t h t h e p h y s i c i a n as t h e l e a d e r o f t h e m a t e r n a l 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 p o s s e s s k n o w l e d g e a n d s k i l l s i n n u t r i t i o n a l a s s e s s m e n t a n d management ( p . 9 ) . Nutrition indicator a  of nutrition attitudes  s t u d y b y Emmons a n d Hayes  ship of  k n o w l e d g e , however,  and n u t r i t i o n p r a c t i c e s .  who h a d s t u d i e d  positive their  e t al_. (1970),  and p r a c t i c e s  (1975)  school  community  organizations  graduates On t h e  i n a study o f the n u t r i t i o n  o f 340 s u b j e c t s  who were members o f  i n New Y o r k S t a t e ,  found a high  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  nutrition practices.  related  o f Ohio high  n u t r i t i o n i n Home E c o n o m i c s c o u r s e s .  o t h e r hand, J a l s o  various  S i m i l a r l y , Schwartz  t h e r e was no c o r r e l a t i o n b e t w e e n t h e n u t r i t i o n know-  l e d g e and t h e n u t r i t i o n p r a c t i c e s  attitudes  practices  no r e l a t i o n s h i p was f o u n d b e t w e e n 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 . that  In  (1973) i n v e s t i g a t i n g t h e r e l a t i o n -  o f mothers' n u t r i t i o n knowledge t o t h e f e e d i n g  their children,  found  i s n o t a l w a y s a good  to practices.  Thus, a t t i t u d e s  were d i r e c t l y  6  Physicians generally provide survey  research  considered 1953;  e v e n when t h e s u b j e c t o f t h e r e s e a r c h i s  t o be o f a n o n - t h r e a t e n i n g  G u l l e n and G a r r i s o n ,  Research d e a l i n g with attitudes  ing  area  19 73;  the less  research  of nutrition  changing. source  Since  ( Deutscher,  a n d V i v i a n , 197 4 ) .  threatening  attempting  area  maternal  a greater response t o assess  than  t h e more t h r e a t e n -  literature  and i n f a n t  indicates that  nutrition  the p h y s i c i a n i s the primary  of nutrition  of nutrition  knowledge.  Review o f t h e e x i s t i n g mation concerning  nature  Schiller  and p r a c t i c e s may e l i c i t  would s i m i l a r  a low r e s p o n s e r a t e t o  advice  f o r many m o t h e r s ,  infor-  i s rapidly  professional an  investigation  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 kind of n u t r i t i o n  to the maternal  population.  information being  disseminated  7 Statement of  A s u r v e y was practitioners Columbia  to  and  obstetricians  and  This approval of The gating  the 1.  criterion  attitudes  variables,  following  and  practices  professional  Columbia M e d i c a l  objectives  British  Comparisons  conducted w i t h the  British  general  were  nutrition attitudes  v a r i o u s d e m o g r a p h i c and  and  variates.  co-operation  and  Association.  were e s t a b l i s h e d  for  investi-  problem: To  a s s e s s the  nutrition  quality  o f m a t e r n a l and  information being  m a t e r n a l p o p u l a t i o n by pediatricians 2.  province of  infant nutrition.  s t u d y was the  i n the  t h e i r current  r e g a r d i n g m a t e r n a l and  practices,  Problem  c o n d u c t e d among p e d i a t r i c i a n s ,  ascertain  made between t h e  the  To  i n the  general  pediatricians,  related  the  obstetricians. differences  obstetricians  i n the  and and  province of  to:  (a)  location  (b)  sex  (c)  location  of  (d)  years of  practice  (e)  type of  of  to  practitioners,  nutrition attitudes  practitioners as  disseminated  determine whether s i g n i f i c a n t  exist of  and  infant  of medical  respondent practice  practice  training  practices general  British  Columbia  8  (f)  number o f seen  prenatal patients  sources  of  nutrition  (h)  additional  (i)  number and t y p e o f  attended  school  training  continuing  a nutrition  i n the l a s t  extent of  information  s p e c i a l i z a t i o n or  programs w i t h  two  education  component years  n u t r i t i o n education in  medical  training  To d e t e r m i n e among p e d i a t r i c i a n s ,  3.  infants  weekly  (g)  (j)  and/or  and g e n e r a l  practitioners  relationship  of  obstetricians  the nature of  nutrition attitudes  to  the nutrition  practices. To d e t e r m i n e w h e t h e r  4.  to modify for  this  differences  exist  between t h e n u t r i t i o n a t t i t u d e s  tices  of  general  pediatricians This  significant  s t u d y was  and  practitioners  as  compared  designed  assessment.  practo  obstetricians. t o meet t h e s e  objectives  and d e v e l o p 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 type of  and  and  instruments  Hypothese:  The  following  There w i l l  be  null  on  tests  be  o b s t e t r i c i a n s and  sex  of the  There w i l l tests  be  a t t i t u d e s and  a t t i t u d e s and  on  practice.  on  years  of  There w i l l  of  There w i l l tests  based  of  pediatricians  in  general based  achieved  practices  of  pediatricians  general based  achieved  practices  of  pediatricians  in  in  general based  practice. be  practitioners, type  a t t i t u d e s and  o b s t e t r i c i a n s and  no s i g n i f i c a n t d i f f e r e n c e s  tests of n u t r i t i o n  on  general  achieved  practices  no s i g n i f i c a n t d i f f e r e n c e s  tests of n u t r i t i o n practitioners,  of  pediatricians  no s i g n i f i c a n t d i f f e r e n c e s  o b s t e t r i c i a n s and  be  practices  in  respondent.  practitioners,  There w i l l  achieved  medical t r a i n i n g .  o b s t e t r i c i a n s and  of n u t r i t i o n  location of  tested:  no s i g n i f i c a n t d i f f e r e n c e s  of n u t r i t i o n  practitioners, on  a t t i t u d e s and  location of t h e i r  There w i l l  were  no s i g n i f i c a n t d i f f e r e n c e s  tests of n u t r i t i o n practitioners,  hypothese;  a t t i t u d e s and  o b s t e t r i c i a n s and  achieved  practices  of  pediatricians  in  general based  practice. be  no s i g n i f i c a n t d i f f e r e n c e s  of n u t r i t i o n  a t t i t u d e s and  achieved  practices  of  in  general  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 o f p r e n a t a l  patients  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 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 , 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 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.  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 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 , 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 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.  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 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 , 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 t h e number and 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 programs a t t e n d e d i n t h e l a s t two y e a r s . 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 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 , 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 b a s e d on 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 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 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 and 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 by 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  11 and 12.  pediatricians.  There w i l l scores  for nutrition  between  There w i l l  the scores  tices  d i f f e r e n c e i n the  a t t i t u d e s and p r a c t i c e s  the general p r a c t i t i o n e r s  tricians. in  be no s i g n i f i c a n t  and t h e p e d i a -  be no s i g n i f i c a n t d i f f e r e n c e  for nutrition  between t h e g e n e r a l  a t t i t u d e s and  practitioners  prac-  and  obstetricians.  Definitions  o f Terms  The f o l l o w i n g t e r m s a r e d e f i n e d f o r t h e p u r p o s e o f  this  -.1  study: General  P r a c t i t i o n e r - C o n d u c t s m e d i c a l e x a m i n a t i o n s , makes d i a g n o s i s , p r e s c r i b e s m e d i c i n e s and g i v e s o t h e r m e d i c a l t r e a t m e n t s 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 t h e human b o d y . E x a m i n e s p a t i e n t and o r d e r s o r p e r f o r m s v a r i o u s t e s t s , a n a l y s e s , and X - r a y s t o p r o v i d e i n f o r m a t i o n on t h e p a t i e n t ' s c o n d i t i o n . Anal y z e s r e p o r t s a n d f i n d i n g s o f t e s t s and e x a m i n a t i o n and d i a g n o s e s 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 t r e a t m e n t s and d r u g s . 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 f r o m c o m m u n i c a b l e d i s e a s e s . Prov 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 , h y g i e n e , and methods o f p r e v e n t i o n o f d i s e a s e . Makes h o u s e and emergency c a l l s t o a t t e n d t o p a t i e n t u n a b l e t o v i s i t o f f i c e or c l i n i c . R e p o r t s b i r t h s , d e a t h s , and o u t break o f contagious diseases t o governmental authorities. 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 at s u r g i c a l procedures. May c o n d u c t p h y s i c a l exami n a t i o n s of a p p l i c a n t s f o r insurance to determine h e a l t h and r i s k i n v o l v e d . May c o n d u c t p r e - e m p l o y m e n t e x a m i n a t i o n s f o r company o r o r g a n i z a t i o n s u c h a s p o l i c e f o r c e , a n d examine s t a f f t o d e t e r m i n e e l i g i b i l i t y f o r sick leave or d i s a b i l i t y claims. May p r o v i d e c a r e f o r p a s s e n g e r s and c r e w a b o a r d s h i p . Physician, 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 o f O c c u p a t i o n s , 1971 )  12  P e d i a t r i c i a n - C a r r i e s o u t m e d i c a l care f o r c h i l d r e n from b i r t h through a d o l e s c e n c e t o a i d i n p h y s i c a l and m e n t a l 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 e x t e n t o f a i l m e n t , d i s e a s e o r 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 , i m m u n i z a t i o n s , and o t h e r m e d i c a l t r e a t m e n t s ; and a d v i s e s c l i e n t s . A c t s as consultant t o other medical 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 d i a g n o s e a n d 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 m a l f o r m a t i o n s . Child Specialist. ( C a n a d i a n 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 d i a g n o s e s and t r e a t s d i s e a s e s o f t h e female r e p r o d u c t i v e t r a c t . Examines patient to ascertain condition, u t i l i z i n g physical 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 . D e t e r m i n e s need f o r m o d i f i e d d i e t a n d p h y s i c a l a c t i v i t i e s , a n d recommends plan. 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 medication o r surgery, 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 m o t h e r , f o r p r e s c r i b e d p e r i o d o f t i m e , following childbirth. Diagnoses and t r e a t s female patients for diseases o f the reproductive tract, using s u r g i c a l procedures as required. 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 t h e f e m a l e 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 , a n d p o s t n a t a l p e r i o d s a n d be d e s i g n a t e d accordingly. ( 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 ) . Nutrition  Attitudes - Physicians'  ance o f v a r i o u s  aspects  n a t a l p e r i o d and d u r i n g "learned,  emotionally  of n u t r i t i o n during infancy.  Nutrition  the pre-  An a t t i t u d e i s a  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 t o w a r d p.  a t t i t u d e s towards t h e import-  something"  ( Redman, 1968,  67 ) . Practices - Physicians'  techniques  and i n f o r m a t i o n  practices including the p e r t a i n i n g t o m a t e r n a l and  13  infant  nutrition  used  in counselling  expectant  and m o t h e r s o r g u a r d i a n s o f i n f a n t s . counselling Clinic  Practice for  Private  - An  by a g r o u p  together.  Practice  - An  treatment  includes  sources of  by  - The  admitted  of physicians p r a c t i s i n g  a single  city  nutrients.  are  e s t a b l i s h m e n t where p a t i e n t s  - A baby r a n g i n g i n age  surrounding  and  e s t a b l i s h m e n t where p a t i e n t s  treatment  Metropolitan Area  City  food s e l e c t i o n  medicine  for Infant  on  This  mothers  are  admitted  physician.  from  birth  t o two  o f V a n c o u v e r and  years.  immediately  area.  - Settlement of over  Town - S e t t l e m e n t o f n o t  5,000. less  than  2,500 and  n o t more  than  5,000. Village  - Settlement of l e s s  than  2,500.  Assumptions  The of t h i s 1.  following  assumptions  h a v e b e e n made f o r t h e  purpose  study: The of  p o p u l a t i o n s t u d i e d , which accounts a l l practising  pediatricians,  general practitioners  in British  r e p r e s e n t a t i v e of the e n t i r e tising  pediatricians,  for  97%  obstetricians Columbia,  and  is  population of prac-  obstetricians  and  general  14  p r a c t i t i o n e r s i n the p r o v i n c e 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 expect a n t mothers and/or mothers o f i n f a n t s on m a t t e r s o f nutrition.  3.  The p h y s i c i a n s c o m p l e t e d t h e q u e s t i o n n a i r e i n good f a i t h and w i t h o u t any h e l p from books, or other  resources.  colleagues  CHAPTER  REVIEW OF  Good h e a l t h every  individual  health.  I t has  throughout  and  nutrition  LITERATURE  the  life  periods of  Two  such p e r i o d s of  special  is a vital  vulnerability  rapid  infancy.  Hence, s p e c i a l  nutrition  for  the  I t i s the  to  c a r e must be  p r e g n a n t woman and responsibility  of  infant  tance of  stages of  nutrition  at  these  e n c o u r a g e , c o u n s e l and  direct  the  proper n u t r i t i o n a l  Nutrition Effect  effects Formerly  component o f  of  Nutrition  in  On  nutritional  taken to fetus  the  health  the  life  thought that  the  the  Outcome o f  of  i s a p p a r e n t now,  m o t h e r and  the  It  fetus  are  of  the  f e t u s was  point of  mother.  15  for  the  professionals  cycle  impor-  and  to  in  the  Pregnancy have  far-reaching  m o t h e r and a  total  view, growing normally  affected  optimum  Pregnancy  well-being  i t was  and  in  habits.  on  and  injury.  r e c o g n i z e the  d u r i n g pregnancy can  health  good growth  ensure  her  care to  for  p r e g n a n c y and  Optimum n u t r i t i o n the  rapid  maternal population  from a n u t r i t i o n a l the  i s important  growth occur d u r i n g  c o n c e r n e d w i t h m a t e r n a l and  attainment of  cycle  l o n g b e e n known t h a t p e r i o d s o f  are  infant.  THE  II  parasite at  however, t h a t b o t h by  the  quantity  infant.  and  the  expense  the quality  of  16 the  maternal d i e t . The  e f f e c t s of  p r e g n a n c y on  the  extreme n u t r i t i o n a l  mortality  and  have b e e n amply d e m o n s t r a t e d obvious e t h i c a l on  humans.  of  n u t r i t i o n on  reasons,  Many s t u d i e s the  Susser,  1970;  Osofsky,  relationship  i s so  evidence that  the  the  that  have attempted outcome o f  For  to assess the  effect.  M a t e r n a l N u t r i t i o n , 1970; ).  consistent prenatal  Nevertheless, that  performed  human p r e g n a n c y  than a causative  1975  during  offspring  i n animal experiments.  c o u r s e and  C o m m i t t e e on  of  s u c h e x p e r i m e n t s c a n n o t be  shown a c o r r e l a t i v e r a t h e r r e v i e w s see  morbidity  deprivation  impact have  ( For Bergner  and  this correlative  i t provides  convincing  d i e t does a f f e c t the  health  of  the  offspring. A number o f relationship  the  Antonov  from  the  deprivation  European p o p u l a t i o n .  (1947) i n L e n i n g r a d  the  and  Smith  (1947) i n  impact o f wartime  lation.  The  r e s u l t s i n d i c a t e d a marked d e c r e a s e  birth period  significant  rates of  and  an  increases  increase  deprivation.  of  s t a r v a t i o n on  i n the  the  studies,  Holland, maternal  prematurity  i n neonatal mortality  During  for certain  In r e t r o s p e c t i v e  the  rate,  outcome  occurred  assessed  ity  a definite  large-scale observations.  II severe n u t r i t i o n a l  segments o f  suggest  between m a t e r n a l n u t r i t i o n and  p r e g n a n c y were o b t a i n e d W o r l d War  e a r l y works t h a t  i n the and during  popu-  fertilstillthe  17  In G r e a t  Britain  Leningrad  and H o l l a n d  nutrition  i s important  time,  t h e wartime s i t u a t i o n  but strengthens  rationing  the hypothesis  t o reproductive  t h e B r i t i s h government  efficiency.  introduced  a policy  i n w h i c h p r e g n a n t women were g i v e n  ( B a i r d , 1965 ) .  The q u a l i t y  especially  those  enhanced.  Subsequently,  25%  this  during  Other  contrasts  of the diet  with  that At this  o f food  special  priority  o f p r e g n a n t women,  i n t h e l o w i n c o m e g r o u p s , was s i g n i f i c a n t l y the s t i l l b i r t h  p e r i o d o f improved  studies of nutrition  rate  fell  nutritional during  a  notable  intake.  p r e g n a n c y have been  c o n d u c t e d when d i e t a r y i n t a k e was n o t r e g i m e n t e d  ( Ebbs e t a_l. ,  1942;  B u r k e e t ajL. , 1943; B a l f o u r , 1944; Cameron a n d Graham,  1944;  D i e c k m a n e t a l . , 1951; J e a n s e t a l . , 1955 ) .  the  f i n d i n g s o f these  diets than the  s t u d i e s support  have a more f a v o u r a b l e do " p o o r " d i e t s .  effect  a favourable  outcome o f p r e g n a n c y was c o n s i d e r e d stillbirths  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 mother a t t h e t e r m i n a t i o n Not relationship and  the thesis that  Fralin,  "good"  o n t h e outcome o f p r e g n a n c y  I n most c a s e s  incidence of prematurity,  In general,  e f f e c t on  t o be a r e d u c t i o n i n t h e  and n e o n a t a l  mortality.  to the status of the  o f pregnancy.  a l l s t u d i e s , however, h a v e shown s u c h a d i r e c t between n u t r i t i o n  and i n f a n t  viability  ( Williams  1942; M c G a n i t y e t a l . , 1953; Macy e t a l . ,  1954;  18 Tompkins e t a l . , 1955; Crump e t al., 1959 ) . comprehensive o f these co-workers on over University the  minations  2,000 p r e g n a n t women a t V a n d e r b i l t A complete n u t r i t i o n a l  i n c l u d i n g p h y s i c a l examination,  o f body  conducted during  fluids  study  and  o b s t e t r i c and f e t a l  study  abnormalities.  low  The a u t h o r s  causative  were a b o v e a n y s u c h  should  be n o t e d  level  i n this  i n t a k e s were g i v e n  of nutrition  study  the incidence of  women were c o n s i d e r e d  vitamin  or mineral  s u p p l e m e n t s were n o t i n c l u d e d  required  not at risk.  i n g l y v a r i e d " a n d 27% o f t h e women w i t h  there  r e l a t i o n s h i p between  below t h e n a t i o n a l average,  g r o u p was c e r t a i n l y  more, t h e d i e t s o f t h e s e  thus,  concluded  effect.  that  b i r t h w e i g h t was s l i g h t l y  suggests that t h i s  and  nutrition  a n d t h e outcome o f p r e g n a n c y o r t h a t t h e s u b j e c t s  to p r e c i p i t a t e a detrimental It  The f i n d i n g s o f  r e l a t i o n s h i p between  e i t h e r t h e r e was no d i r e c t  of t h i s  t o be  the lowest  supplements.  i n calculating  "gratify-  nutritional These  nutrient  d e f i c i e n c i e s may h a v e b e e n r e c o r d e d  when  which  Further-  intakes  i n fact  were n o n e . Because o f t h e i n c o n s i s t e n c i e s i n t h e r e s u l t s ,  in  deter-  a n d a s e v e n d a y d i e t a r y r e c o r d , was  i n d i c a t e d no d i r e c t  malnutrition  evaluation of  biochemical  each t r i m e s t e r o f pregnancy.  the  that  s t u d i e s was c o n d u c t e d b y M c G a n i t y a n d  i n Tennessee.  gravida,  One o f t h e most  this  reported  area  was c u r t a i l e d  the results  until  recently.  of a nutritional  Habicht  research  e t al.  supplementation  (1974)  program i n  19 Guatemala.  The  data  differences  i n b i r t h weight  i n t a k e o f mother. 20,000 c a l o r i e s entire  of  protein weight  The  of the  patients  Patients'  had  i n g e s t e d fewer  the l i m i t i n g  (1972) i n M o n t r e a l seen a t the Montreal  M o t h e r s on  than  that  factor  Diet  20,000  calories  calories  rather  in influencing  Dispensary  low  results  than birth  over  from  indicated  p r e m a t u r i t y were s i m i l a r lower  that  than  1963-71. the  improving  i n c o m e s were p r o v i d e d w i t h  mortality  significantly  on  i n t a k e and  c o u n s e l l e d on m e t h o d s o f  The  and  the  significantly  reported results  supplements. and  protein  of a supplement throughout  authors concluded  t o be  on  i n g e s t e d g r e a t e r than  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  diets.  patients  had  babies with b i r t h weights  p a t i e n t s were i n d i v i d u a l l y their  based  significant  offspring.  Higgins 1,500  had  appeared  t h e r e were no  However, women who  t h o s e who  supplement.  that  of o f f s p r i n g  i n the form  pregnancy  g r e a t e r than  indicated  the r a t e s of  food  perinatal  t o those of the f o r other public  private clinic  patients. Although conflicting  the  results,  findings these  i n c o n s i s t e n c i e s may  t o p r o b l e m s i n m e t h o d o l o g y and indicative and  o f a l a c k o f an  outcome o f p r e g n a n c y .  noted  that:  o f t h e above s t u d i e s be  design rather than  association  show some related being  between m a t e r n a l  Additionally,  Calloway  (1974)  diet has  20  . . . most s t u d i e s have b a s e d a s s e s s m e n t o f e f f i c i e n c y of treatments during pregnancy s o l e l y on t h e s i z e and c o n d i t i o n o f t h e n e w l y b o r n c h i l d and h a v e shown a s u r p r i s i n g l a c k o f 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 o f the mother ( P . 91 ) . Women c a n optimal  and  nutritional  do  intakes  of maternal d e p l e t i o n  or  considerable.  This  adolescent  requires  who  g r o w t h as w e l l are  as  bear v i a b l e o f f s p r i n g at but  delayed  19 63;  is particularly a high  for that  1970  Bennett,  Claman and ) and  1961;  Bell,  anemia  of  the  buting Bell,  care  t o the 1964;  are  b e e n c o n s i s t e n t l y r e l a t e d t o an  b i r t h weight of al^. , 1968;  In  during  the  infant  Higgins,  1972  As  Woutersz,  1963;  Committee as  on  inadequate  factors  contri-  ( Claman  and  ).  Pregnancy s u p p l e m e n t a t i o n has outcome o f  is strongly  ( E a s t m a n and ).  toxemia  Maternal N u t r i t i o n ,  important  improved  pregnancy  own  adolescents  of  young mothers  "good" n u t r i t i o n o r  t o t a l weight gain  f o r her  M a t e r n a l N u t r i t i o n , 1970  Weight Gain  i n terms  pregnant  I s r a e l and  P o o r d i e t s as w e l l  i n these very  C o m m i t t e e on  Although  Woutersz,  than  be  Pregnant  incidence  1962;  o f t e n m e n t i o n e d as  toxemia  intake  fetus. high  r a t e may f o r the  C o m m i t t e e on  ( I s r a e l and ).  t o the mother  true  nutrient  Mussio,  19 64;  M a t e r n a l N u t r i t i o n , 1970 prenatal  cost  recovery  known t o h a v e a p a r t i c u l a r l y  ( A z n a r and  et  the  less  weight gain  pregnancy,  related  Jackson,  not  1968;  during  to Singer pregnancy  increases  so does b i r t h w e i g h t .  established and  Low b i r t h  ( Bergner and S u s s e r ,  is  (1971) c o n c l u d e d  consistent with  authors  reproductive  The  appetites  average weight g a i n  kilograms.  was in  conclu-  eating 1957 ) .  women was 27.5 p o u n d s o r 12.5 for multigravidae  was  review o f the l i t e r a t u r e , t h e  N u t r i t i o n (1970) r e p o r t e d  a s a n optimum w e i g h t g a i n  during  24 p o u n d s o r 10.9  pregnancy.  This  a l s o a d o p t e d b y t h e N u t r i t i o n i n P r e g n a n c y Committee British  Columbia.  average weight gain be  These  fewer.  an e x t e n s i v e  Committee o n M a t e r n a l kilograms  ( Thomson a n d B i l l e w i c z ,  f o r these  two p o u n d s  After  Hytten  efficiency.  o f normal p r i m i g r a v i d a e  The a v e r a g e w e i g h t g a i n  approximately  pregnancy,  w o r k s a n d b a s e d many o f t h e i r  s i o n s on a l a r g e - s c a l e s t u d y to their  during  t h a t a w e i g h t g a i n o f 25-30 p o u n d s  improved  reviewed e a r l i e r  according  neurological disorders  1970; S i m p s o n e t aJL. , 1975 ) .  In a r e v i e w o f w e i g h t g a i n Leitch  i s well  a s an a n t e c e d e n t 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 ,  o f m e n t a l r e t a r d a t i o n and o t h e r  and  weight  any harm w i t h  Although  this  (1973)  f i g u r e i s taken as t h e  f o r a n o r m a l woman, t h e r e  intakes  value  somewhat g r e a t e r  d o e s n o t seem t o  than t h i s .  Recent  work d o e s n o t b e a r o u t t h e c l a i m t h a t a d d i t i o n a l f a t a c c u m u l a tion  during  pregnancy p r e d i s p o s e s  obstetrical  difficulties  on  N u t r i t i o n , 1970 ) .  Maternal  have shown t h a t e x c e s s i v e  t o toxemia o r increased  i n t h e n o r m a l p r e g n a n t woman Moreover, S i n g e r  weight gain  ( Committee  e t _al.  i n pregnancy  (1968)  i s associated  22 with  increased  tual  ability  infant  of the child  A deterrent amount o f w e i g h t relationship subsequent  1971  weight  i n later  and w i t h improved  ( greater  t h a n 35 p o u n d s  an e x c e s s i v e  ) i s the possible  f a t a c c u m u l a t i o n i n pregnancy and  obesity.  Some f a t a c c u m u l a t i o n i s a n a t u r a l  consequence  o f pregnancy  ( H y t t e n and L e i t c h ,  ) t h a t one s h o u l d n o t a t t e m p t t o a v o i d .  i d e a l weight  after  parturition  t h e Food  In returning t o  and N u t r i t i o n  t h e 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 ded a l l o w a n c e s , h a v e a d v o c a t e d a r e d u c t i o n during  lactation  milk production.  so t h a t  intellec-  life.  t o p r e g n a n t women g a i n i n g  of excessive  later  physiological  birth  this  stored  i ntotal  energy might  I n t a k e s o f o t h e r n u t r i e n t s must  Board o f recommen-  caloric  intake  be u s e d f o r remain  adequate. F o r women who e n t e r p r e g n a n c y no a t t e m p t restrict 1970; with  t h e i r weight gain  Pitkin adequate  protein and  s h o u l d be i n i t i a t e d  et al.,  f o r energy,  repair.  intake,  produced by t h e c a t a b o l i s m  can r e s u l t  1970 ) .  Nutrition,  restriction,  for tissue  suggested that  of maternal f a t stores, impairment  even  i n utilization of  i t unavailable  i t h a s been  associated with i n t e l l e c t u a l ( Churchill,  Marked c a l o r i c  thus making  In a d d i t i o n ,  t o reduce weight o r t o  ( Committee on M a t e r n a l  1972 ) .  protein  either  i n a state of obesity,  growth  acetonuria,  may be  i n the offspring  23  Sodium  Restriction  Toxemia o f pregnancy and  i sgenerally associated with  abnormal sodium r e t e n t i o n .  during  pregnancy  The r o u t i n e r e s t r i c t i o n  toxemia  the relationship remains  acceptance  unclear, the dietary  ( Committee on M a t e r n a l and Katz,  restriction  The  evidence  practice.  of salt  Pitkin  e t a l . , 1972;  ).  for utilizing  sodium r e s t r i c t i o n  i sc o n f l i c t i n g .  o f toxemia  involving  h i g h and low sodium i n t a k e s f o r t h e t r e a t m e n t no d i f f e r e n c e s  In a t least  i n the  treatment  toxemia,  intake  i s ineffective  1970;  Nutrition,  1974  i nmedical  o f sodium i n t a k e t o t h e t r e a t m e n t o f  w i t h t h e aim o f p r e v e n t i n g pre-eclampsia  Lindheimer  of salt  i n t h e hope o f a v o i d i n g o r r e d u c i n g edema  formation has gained widespread Although  edema  i n the c l i n i c a l  one s t u d y  c o u r s e s were  o f acute  apparent  ( M e n g e r t a n d T a c c h i , 1961 ).  "Abnormal" weight  considered  d i s e a s e , may n o t o c c u r , a n d  overt  thehallmark  of this  edema may n o t be p r e s e n t  of pre-eclampsia  a r e severe  Rhodes ( 1962 ) d e m o n s t r a t e d  On  e v e n when o t h e r m a n i f e s t a t i o n s  ( Lindheimer  t h a t the  a s s o c i a t e d w i t h an abnormally  and Katz,  a retrospective  o f over  that  study  1974  were  g a i n i n pregnancy. a r e accom-  Thomson e t a l . (1967)  24,000  ).  forms o f toxemia  t h e o t h e r hand, many n o r m a l p r e g n a n c i e s o f edema.  found  severe  low weight  p a n i e d b y some d e g r e e  and  gain, previously  single  legitimate  n e a r l y 40% o f t h e m o t h e r s o f t h e s e  conducted births  infants  24  experienced had  some e v i d e n c e o f edema.  M o r e o v e r , women w i t h  babies with g r e a t e r b i r t h weights  perinatal mortality. statistically reviewing  and reduced  These d i f f e r e n c e s ,  significant.  rates of  however, were n o t  H y t t e n and L e i t c h  t h e d a t a on t o t a l  edema  (1971),  body w a t e r c o n c l u d e d  after  that:  . . . i t seems r e a s o n a b l e t o r e g a r d edema a s h a v i n g p h y s i o l o g i c a l rather 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  to eliminate  edema i s  unwarranted. Sodium, l i k e pregnancy  f o r normal  s t u d i e s on p r e g n a n t indicated  that  other essential fetal rats  nutrients,  i s needed d u r i n g  growth and development.  Data  ( P i k e , 1964; P i k e a n d G u r s k y ,  sodium r e s t r i c t i o n  of  expanding  t h e muscle,  dent  and l e a d i n g  t o hyponatremia.  bone and b r a i n  i n the r e s t r i c t e d  r a t s had an i n c r e a s e d m o i s t u r e fetal of ly,  immaturity  i t appears  Lindheimer  volume  was e v i -  pregnant  indicating  Although  the results  a n i m a l s must be i n t e r p r e t e d j u d i c i o u s -  reasonable t o suspect that  t i o n may h a v e d e l e t e r i o u s  pregnant  content, possibly  me-  depletion  organism  and f e t u s e s o f these  ( K i r k s e y e t a_l. 1962 ) .  studies with laboratory  Sodium  of the maternal  animals  1970 )  may t a x t h e p h y s i o l o g i c a l  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 from  from  effects  and K a t z  women who t o l e r a t e  (19 74)  severe  sodium  restric-  i n t h e human. state  that  sodium r e s t r i c t i o n  t h e r e a r e some p o o r l y and t h a t  routine  salt  restriction  hence, weight g a i n restriction these  a s a means o f l i m i t i n g  i s unnecessary.  reduces the incidence  authors  conclude  Since  claims  iodization,  salt  iodine t o residents of regions restriction an  source  Pregnancy only  be n o t e d  that  provides  a significant  low i n t h i s  to salt  i n Canada,  amount o f  nutrient.  Routine  p r e g n a n t women o f  Intake  imposes a c o n s i d e r a b l e  for the increased  burden on i r o n  Red c e l l  blood  volume.  while  plasma volume i n c r e a s e s i n hemoglobin  volume i n c r e a s e s  levels  workers have s p e c u l a t e d to  facilitate  placenta gators  blood  ( Hytten  disagree,  flow  about  value  This  30%  results  ina  because o f hemodilution.  that this  d i l u t i o n m i g h t be  Some  necessary  t h r o u g h t h e m a t e r n a l o r g a n i s m and  a n d L e i t c h , 1971; H a l l , however, a n d s u g g e s t  o f pregnancy.  maternal  approximately  50%.  Maintaining  1974 ) .  Most  t h a t a hemoglobin  above 12 g p e r 100 m l i s a n a p p r o p r i a t e part  needs,  requirements o f the fetus but also  t o compensate f o r t h e a d d i t i o n a l needs f o r i n c r e a s e d  decrease  because  o f an e s s e n t i a l n u t r i e n t . Iron  not  be a l l o w e d  o f s a l t may, t h e r e f o r e , d e p r i v e  important  salt  that:  In a d d i t i o n , i t s h o u l d compulsory  that  o f toxemia a r e unconvincing,  . • . . t h e p r e g n a n t woman s h o u l d h e r f o o d t o t a s t e ( p. 4 38 ) .  of  edema a n d  level  during  hemoglobin l e v e l s  r e q u i r e s an a d d i t i o n a l 700 mg o f i r o n  level  the latter  above  ( Council  investi-  this  on Food  26  and  N u t r i t i o n , 1968 ) , most o f i t i n t h e l a t t e r  h a l f of preg-  nancy. Iron to supply studied  stores  this  i n healthy  additional iron.  s t o r e s were  "scant  o f t h e sample.  high  t h a t by t h e t h i r d  i n the majority  84% h a d no m e a s u r a b l e Since  body r e s e r v e s  o f women.  while  substantially.  intake  t h e Food and N u t r i t i o n Board  somewhat d i f f i c u l t  greater  approximately  to obtain  i n t a k e must be i n Standard  18 mg.  These  alone  Rothman, 1971; P i t k i n  pregnancy  foods  6 mg o f i r o n States  p e r day from d i e t a r y iron  (19 74)  intakes can  since  approximately  Consequently,  p r e g n a n c y a p p e a r t o be n e c e s s a r y  (1974) h a s  States  P r e g n a n t women i n t h e U n i t e d  ( P r i t c h a r d , 1970 ) .  iron  At the time o f  o f 15 mg d u r i n g  from d i e t  13 o r 14 mg o f i r o n  S i n c e most o f t h i s  trimester  i n the United  than  commonly consumed by women c o n t a i n 1,000 c a l o r i e s .  iron  The C a n a d i a n D i e t a r y  intake  reserves  o f i r o n may n o t b e a d e q u a t e t o meet  a recommended d a i l y  suggests a d a i l y  per  ) i n two-thirds  reserves.  a d d i t i o n a l demands o f p r e g n a n c y ,  established  be  ( 350 mg o r l e s s  Iron  De Leeuw e t a l . (1966) s t u d i e d t h e i r o n  s t o r e s were a b s e n t  creased  (19 67)  socio-economic background.  o r absent"  o f p r e g n a n t women a n d f o u n d  the  S c o t t and P r i t c h a r d  114 c o l l e g e women who h a d n e v e r b e e n p r e g n a n t a n d who  were f r o m a r e l a t i v e l y  delivery  y o u n g women may be i n s u f f i c i e n t  supplements  ingest sources  during  ( P r i t c h a r d , 1970; C h a n a r i n a n d  e t a l . , 1972; S c o t t e t a l . , 1975 ) .  iron  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 o f t h e r e c e n t warning about the t e r a t o g e n i c e f f e c t of i r o n given and  i n the f i r s t  56 days o f pregnancy  F o r f a r , 1971 ), i t would seem a p p r o p r i a t e  ( Nelson  to restrict  supplements t o t h e l a s t h a l f o f pregnancy. D i e t a r y P r a c t i c e s o f Pregnant Women The  n u t r i t i o n a l requirements o f t h e pregnant woman a r e  g r e a t l y i n c r e a s e d over those o f the non-gravid  state.  In order  t o meet the i n c r e a s e d n u t r i e n t allowances s e t by the Canadian D i e t a r y Standard i n the U n i t e d  (1974) o r t h e Food and N u t r i t i o n Board  (1974)  S t a t e s , i t i s necessary t o choose foods c a r e f u l l y  so as not t o exceed t h e optimum c a l o r i c i n t a k e but s t i l l the necessary p r o t e i n , v i t a m i n s  obtain  and m i n e r a l s .  S e v e r a l o l d e r s t u d i e s have r e p o r t e d  on t h e n u t r i e n t  i n t a k e s o f pregnant women ( Ebbs e t a l . , 1941; Burke e t a l . , 1943;  Jeans e t a l . , 1952; Murphy and Wertz, 1954; Stevens and  Ohlson, 1967 ).  The major f i n d i n g s o f these s t u d i e s i n d i c a t e d  t h a t d i e t s f o r expectant mothers were f r e q u e n t l y inadequate i n calcium,  p r o t e i n and i r o n .  Vitamin  and m i n e r a l  supplementation  i n c r e a s e d the i r o n i n t a k e but d i d not a l l e v i a t e the l a c k o f c a l c i u m and p r o t e i n i n the d i e t s o f these women. studies 1970;  More r e c e n t  ( Bartholomew and Poston, 1970; Nobmann and Adams,  H a r r i l l e t a l . , 1973; N u t r i t i o n Canada, 1973; Thompson  e t a l . , 1974 ) have demonstrated t h a t n u t r i e n t i n t a k e s pregnancy remain below d e s i r a b l e l e v e l s .  during  This i s p a r t i c u l a r l y  28 true  f o r the pregnant adolescent B a r t h o l o m e w and P o s t o n  protein, dietary  iron,  standards  prenatal c l i n i c attributed specific food  A and v i t a m i n  f o rvarious  customs p l a y e d  ignorance,  A and r i b o f l a v i n  preparations levels  The  increased  except  nutritive  the dietary  the intakes  f o r p r o t e i n and c a l c i u m .  value  o f f o o d s s e l e c t e d by a g r o u p o f 30  C o m p a r i s o n o f mean d i e t a r y i n t a k e w i t h  preparations  by H a r r i l l  showed t h a t c a l c i u m ,  iron  and co-workers  supplements but t h e content  was n o t i n c l u d e d  t h e recommended  and t h i a m i n  s u p p l i e d by t h e f o o d s e a t e n .  took v i t a m i n - m i n e r a l  Vitamin-  of a l l nutrients to  (1973).  the n u t r i e n t s l e a s t  calcium,  o f t h e recom-  20% o f t h e s a m p l e . the intakes  intake  of iron,  i n C o l o r a d o was a s s e s s e d  allowances  to  role.  t o be b e l o w t w o - t h i r d s  f o r over  was  and s e c o n d l y ,  patients  dietary  recommended  S u p e r s t i t i o n s and b i z a r r e  1970, Nobmann a n d Adams r e c o r d e d  acceptable  intakes of  The p o o r n u t r i t i o n  a s m a l l e r y e t important  mended d i e t a r y i n t a k e mineral  C were b e l o w  foods.  46 p r e n a t a l p a t i e n t s a n d f o u n d  vitamin  that  i n a g r o u p o f 200 p a t i e n t s r e g i s t e r e d i n a  i n South C a r o l i n a .  dislikes  1975 ) .  (1970) r e p o r t e d  primarily to nutrition  In of  vitamin  ( Weigley,  i n the calculation  Most  were  patients  o f these of nutrient  intake. The al are  report  from N u t r i t i o n Canada  (1973) on t h e n u t r i t i o n -  s t a t u s o f p r e g n a n t women i n d i c a t e s t h a t n u t r i e n t still  inadequate  in a significant  intakes  p o r t i o n o f the maternal  population. on  a total  Nutrition  The  data  on d i e t a r y  sample o f 894 C a n a d a by  intake  pregnant  local  health  ( Table  women who  I ) is  based  were r e f e r r e d  to  units.  TABLE I PERCENTAGE OF PREGNANT WOMEN WITH INADEQUATE AND LESS-THAN-ADEQUATE INTAKES OF NUTRIENTS  General  Less-than-Adequate  Inadequate  Nutrient  Population  3.3  8.5  Iron  24.8  22.6  Calcium  19.9  18.6  28.9  28.6  Protein  Potential  Vitamin  D  Vitamin  A  10.9  14.9  Vitamin  C  2.0  8.2  Thiamin  3.9  21.5  Riboflavin  5.0  17.0  Niacin  0.8  3.9  of  Source: N u t r i t i o n Canada, N a t i o n a l Survey, Department 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 , C a n a d a . 1973, p . 110. Biochemical  ted  the d i e t a r y  e v a l u a t i o n f o r a number o f n u t r i e n t s  findings.  Thirty  percent  in  t h e 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  of  low  in  serum p r o t e i n  values  for total levels  serum p r o t e i n .  of the pregnant as  "at r i s k "  However, t h e  i s a normal occurrence  during  supporwomen  because  decrease pregnancy  30  so the s i g n i f i c a n c e o f t h i s values  f i n d i n g remains  showed a m o d e r a t e r i s k  o f anemia  unclear.  ( values  Hemoglobin  b e t w e e n 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 The s p e c i f i c f i n d i n g s  intakes of vitamin  D.  f o r B r i t i s h Columbia  ( Table II  )  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 w e r e b e l o w adequate 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 However,  excessive  population.  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  a s m a l l number o f p r e g n a n t  in  women. TABLE  II  PERCENTAGE OF PREGNANT WOMEN I N B R I T I S H COLUMBIA WITH LESS THAN TWO-THIRDS OF THE RECOMMENDED D A I L Y INTAKE OF NUTRIENTS  Nutrient  Recommended Daily Intake  Calories  61 g r a m s  Potential Vitamin D  400  12%  I.U.  40%  15 mg  Iron  Than  21%  2,400  Protein  Report, Canada,  % With Less 2/3 R . D . I .  15%  Source: N u t r i t i o n C a n a d a , The B r i t i s h C o l u m b i a S u r v e y Department 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 , 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  B a s e d on C a n a d i a n D i e t a r y  Standard,  May be h i g h e r  intake.  than a c t u a l  1974.  31 It  s h o u l d be  constitute  noted  t h a t p r e g n a n t women i n t h i s  a probability  sample and  may  survey  did  not  therefore:  . . . 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 c o m p a r e d 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 C a n a d a , 1973, p. 103 ) .  Nutrition  Effective to  nutrition  nutritional  start  s t u d i e s t h a t the  are  than  less this  adequate.  Pregnancy  i s necessary  f o r t h e mother and  f o r the  previous  For  education  e n s u r e optimum n u t r i t i o n  ble  to  Education  infant.  the  It i s evident  use  In r e c e n t years  o f v i t a m i n and  1972;  P i t k i n e t a l . , 1972;  cases  the  vitamin-mineral  Harrill  mineral  the  approach  supplement alone  i n the d i e t  ), w h i l e exceeded  ( Thompson e t a l . , 1974  ( King ).  et a l . ,  In  some  c o n t a i n the  nu-  ( Jeans et a l . ,  i n others the c o n t r i b u t i o n the  recommended a l l o w a n c e  by  ).  e t a_l. (1973) commented on  p r e g n a n t women on  the  s u p p l e m e n t s by a l l  preparations d i d not  e t a l . , 1973  Harrill by  from  t h e m o s t common  Thompson e t a l . , 1974  t r i e n t s w h i c h were m o s t d e f i c i e n t  500%  possi-  d i e t a r y h a b i t s o f many p r e g n a n t women  pregnant p a t i e n t s regardless of n u t r i e n t intake  from the  best  problem o f d i e t a r y i n a d e q u a c y a p p e a r s t o have been  indiscriminant  1952;  i n order  vitamin-mineral  the o v e r - r e l i a n c e  supplementation  and  stated  that: . . . i t has l o n g b e e n 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 o f one o r more n u t r i e n t s may i n c r e a s e t h e n e e d o f o t h e r n u t r i e n t s w h i c h may o r may not be p r o v i d e d by t h e s u p p l e m e n t a t i o n ( p. 165 ) .  32 Excessive tially are et  intakes  of  dangerous.  some v i t a m i n s  High  levels  and  of vitamin  p o s s i b l y r e l a t e d to hypercalcemia a l . , 1972  ); e x c e s s i v e  intakes  f o r a s c o r b i c a c i d i n the  19 6 5 ); and  high  preparations  i n the  Pitkin the  i n the  fetus  poten-  pregnancy  infant C may  ( Pitkin induce  s u p p l e m e n t s as w e l l increased  ( N e l s o n and  e t a l . (1972) s u g g e s t e d  avoidance of routine  be  a  high  o f f s p r i n g ( Cochrane,  h a v e b e e n r e l a t e d t o an  abnormalities  for  of v i t a m i n  may  D during  of vitamin  requirement  levels  minerals  incidence  F o r f a r , 1971  t h a t an  supplementation  as  of  ).  additional is  iron  reason  the:  . . . f a l s e s e n s e o f s e c u r i t y i t may c o n v e y t o e i t h e r p a t i e n t or p h y s i c i a n regarding d e f i c i e n c i e s of e s s e n t i a l n u t r i t i o n a l elements other than vitamins. 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 p o o r f o o d h a b i t s ( p. 775 ) . Since  r o u t i n e s u p p l e m e n t a t i o n does not  nutrition ledge  by  education  can  food  habits during  although  affect  education  of  the  during  earliest  a dietary interview,  "good",  "fair"  for  experimental  the  periods  or  throughout  "poor".  have a b e n e f i c i a l  suggests  s t u d i e s on  literature  effects Berry  d i e t s were c l a s s i f i e d  p r e g n a n c y on  effect  on  on  this  way.  the  P a t i e n t s who  know-  that diet instruction  c o n d u c t e d by  g r o u p were g i v e n  the  The  in a positive  p r e g n a n c y was  appropriate,  increasing nutrition  pregnancy.  somewhat l i m i t e d ,  nutrient intake  One  During  form of  d i e t a r y i n s t r u c t i o n may  improving topic,  i n the  a p p e a r t o be  of  e_t a l . (19 52) . as  were r a n d o m l y  i n s t r u c t i o n s at  specific  diet  ways t o  either selected three improve  their  diets.  At  'instructed'  the  g r o u p had  'control'  group but  ever,  increase  the  end  of  p r e g n a n c y , more p a t i e n t s  'good' d i e t s  than d i d  this difference i n the  was  percentage of  percentage at  the  f i r s t i n t e r v i e w was  ted'  but  not  patients  'instructed' vitamin  A,  t h i a m i n and  In  a  attending dietary Multiple  patients  s t u d y by  a prenatal  regression  i n s t r u c t i o n made a ascorbic  'controls'.  was  found  ascorbic Mason and  clinic  acid.  A  also  contributed  acid  levels.  Rivers  natal  clinics.  listened  to  importance At  of  a and  On 20  the  subsequent v i s i t s ,  offered  little  patients  intake.  dietary  iron,  relationship l e v e l s was  Adams  the by  (19 70) by  studied  experimental the  f o r the  physician  The  test  the at  results  pre-  group on  the  pregnancy.  to maintain  control  of  ascorbic  physicians  were, e n c o u r a g e d  instruction.  dietary  i n plasma l e v e l s  adequate d i e t during  Physicians  between  assessed.  that  adequate plasma  minute p r e s e n t a t i o n an  by  patients  n u t r i t i o n knowledge  initial visit  of  'instruc-  calcium,  indicated  instruction offered  essentials  adequate d i e t a r y  acid  data  the  to maintenance of  diet  the  improvement  (1970) on  York, the  the  I n C a l i f o r n i a , Nobmann and effectiveness  of  How-  acid.  plasma a s c o r b i c  s c o r e on  significant.  Greater  significant difference high  the  the  good d i e t s o v e r  for intakes  i n New  analyses of  in  significant for  for  i n s t r u c t i o n and  not  those  in  an  group  indicated  that  34 for  t h e p a t i e n t s who r e c e i v e d  the  intakes  in  more c o n s i s t e n t  o f t h e major n u t r i e n t s  dietary  increased.  advice,  Even s o , changes  t h e d i e t s were n o t l a r g e enough f o r many o f t h e women t o  meet t h e recommended d i e t a r y a l l o w a n c e s . that  increased  food  intake.  physicians health  appetite  were more i m p o r t a n t  Similar Dietary their  attending  r e s u l t s are reported  classes  results of this  additional and  change.  by H a r r i l l  t o 28 p r e n a t a l  In a d d i t i o n ,  et a l .  third  study  o r formal  14 o f t h e s e  28 p a t i e n t s atten-  instruction i n nutrition.  i n d i c a t e d t h a t t h e 14 women who h a d  i n s t r u c t i o n had a b e t t e r trimesters  (1973).  p a t i e n t s by  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  dance a t p r e n a t a l  their  dietary instruction,  i n influencing dietary  physicians.  for increasing  t h a n f a m i l y members o r o t h e r  i n s t r u c t i o n s were g i v e n  received  The  was t h e m a j o r r e a s o n  F o r t h e women who r e c e i v e d  professionals  T h e women i n d i c a t e d  nutrient  intake  i n t h e second  o f p r e g n a n c y t h a n t h o s e who h a d n o t h a d  such i n s t r u c t i o n . Results tion  studies  suggest that  c a n be e f f e c t i v e i n p r o d u c i n g  habits small  o f these  during  pregnancy.  a desirable  d i dlead  nutrients  - calcium  and p r o t e i n .  difficult  to obtain  from r o u t i n e  quently  change i n d i e t a r y  A l t h o u g h t h e c h a n g e i n many c a s e s was  i t was i n a p o s i t i v e d i r e c t i o n .  ment i n d i e t a r y h a b i t s  n u t r i t i o n educa-  I n most c a s e s t h e i m p r o v e -  t o an i n c r e a s e  i n two i m p o r t a n t  These n u t r i e n t s supplementation  lacking i n the maternal d i e t .  are usually and a r e f r e -  35  P r e g n a n t women, p a r t i c u l a r l y to  be more r e c e p t i v e  group  ( Stearns,  mother  to nutrition  1958; G i f f t  i s not motivated  education than  e t a l . , 1972 ) .  she w i l l  fare  A positive  sound n u t r i t i o n a l applying this ous  benefits  Nutrition positive  advice,  advice  and l a s t i n g  effect  time  health.  nutritional  habits  i n a state  nutrition,  can y i e l d  cycle  and numer-  practices. may h a v e a  f o r both the pregnant  I t w o u l d t h e n be h o p e d t h a t  t h e next pregnancy  f o r the  i n interpreting  i n the l i f e  on food  intake  toward  lifestyles  i n promotion o f p o s i t i v e  woman a n d h e r f a m i l y .  tional  to individual  i f the  do i t f o r t h e w e l -  attitude  and a s s i s t a n c e  education a t t h i s  would s t a r t  frequently  are thought  any o t h e r  Even  t o improve h e r d i e t a r y  s a k e o f h e r own h e a l t h , of her offspring.  primigravidae,  this  o f improved  mother  nutri-  36 Nutrition  in  Infancy  Importance o f N u t r i t i o n One is  o f t h e most c r i t i c a l  d u r i n g the  first  ment a r e p r o c e e d i n g reports of  i n the  two  years  literature  pace.  concerning  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)  g r o w t h , m e n t a l d e v e l o p m e n t and C h a s e and Kallen,  M a r t i n , 1970;  1973  one  plasia is  (1968) d e m o n s t r a t e d  o f t h r e e main phases: a c c o m p a n i e d by  d u r i n g the  first  that n u t r i t i o n a l tion  mental a b i l i t y 1970  normal i n f a n t s  two  and  severe  develop-  numerous consequences  i t s effects  on  ( Monckeberg,  Robales,  t h a t organ  1965;  1968;  Winick,  growth  (3) h y p e r t r o p h y  p e r i o d s when c e l l  time,  1973;  i n f a n t s was Monckeberg  hyperIt  i s occurring  impairment  of  ( Chase  and  showed t h a t i n f a n t s who  f r o m marasmus i n e a r l y i n v e r b a l performance.  either  (2)  When m a l n u t r i -  apparently evident (19 68)  occurs  alone.  division  irreversible  s u p p o r t i n g the h y p o t h e s i s  ciated with  the  d e p r i v a t i o n i s most c r i t i c a l .  of  ).  rehabilitated  studies  There are  (1) h y p e r p l a s i a a l o n e  hypertrophy  occurred during this  Martin,  when g r o w t h and  behaviour  C r a v i o t o and  nutrition  ).  Winick in  Infancy  p e r i o d s f o r optimum  of l i f e  at a rapid  in  life  still  lagged  were  behind  However, many o f  the  that m a l n u t r i t i o n i s asso-  a lag or a d e f i c i t  in intellectual  develop-  37 ment a r e c o m p l i c a t e d by u n f a v o u r a b l e Thus,  socio-economic  variables.  i t i s i m p o s s i b l e t o s a y how much m a l n u t r i t i o n  contributes  to the depressed  much may be a r e s u l t  cognitive  of unfortunate  p e r se  d e v e l o p m e n t and how  social  and  environmental  conditions. In Nutrition  Western c o u n t r i e s , Canada  ( body w e i g h t s a total to  s e v e r e PCM i s r e l a t i v e l y  (1973) r e p o r t e d o n l y 2 c a s e s o f s e v e r e  less  than  60% o f t h e m e d i a n f o r t h e i r  s a m p l e o f 1,331.  For infants  PCM.  The f i n d i n g s  ( Nutrition  f o r the province of B r i t i s h  C a n a d a , The B r i t i s h  showed no e v i d e n c e  o f PCM.  i n g e s t e d two t o t h r e e t i m e s Nutritional deficits tations  do o c c u r  vitamin  generally  their  Survey  protein  Report,  1975 )  age c a t e g o r y  requirements.  although  I n most c a s e s  i n 38 ' f u l l  o f Canada  adequate  Columbia  clinical  manifes-  i t i s extremely  t h e consequences o f these m i l d e r forms o f  Canada r e p o r t e d t h a t than  o f moderate  subjects i n this  Nevertheless, nutrient  D resulted  major c i t y  Most  i n North America  to assess  malnutrition.  Columbia  birth  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  a r e seldom e v i d e n t .  difficult  evidence  PCM  age ) i n  and t o d d l e r s f r o m  f o u r y e a r s o f a g e , 3.6% h a d c l i n i c a l  rare.  ( Barsky,  blown  1  deficiencies cases  1968 ) .  of rickets  and t o d d l e r s had l e s s  Exposure  c o n s i d e r e d t o be an u n r e l i a b l e  in a  I n 1974, N u t r i t i o n  42.5% o f t h e i n f a n t s  i n t a k e s o f v i t a m i n D.  such as  to sunlight i s  source o f vitamin D  38 ( Kodicek, certain  1973  parts  limited.  ).  of  This  may  be  particularly pertinent  C a n a d a where e x p o s u r e t o  O t h e r d e f i c i e n c i e s s u c h as  sunlight  i r o n deserve  to  may  be  special  attention. Iron  The to  last  over The  normal f u l l  from t h r e e to  s i x months o f incidence  year of Iron  life  of  s i x months o f  age  occurs but  The the  10  Using  100  n i n e month o l d  et  al.  12  to  of  ml  months o f  iron  deficiency. second  l a t e r pre-school  group a t  r e v i e w s see  years.  a l l l e v e l s of  among c h i l d r e n  sociofrom  L a n z k o w s k y , 1974  was  anemia i n i n f a n t s  Fuerth  infants  age  More r e c e n t l y , ml  i n the  anemia.  were p r e v i o u s l y  (1971) o b s e r v e d  100  to  infants  r e a c h e s a peak i n t h e  i n t h i s age  to describe  t h i s standard,  in  per  stores  Consequently,  more v u l n e r a b l e  ( For  incidence  g per  23  age.  iron  and  ).  s t a n d a r d used  than  sufficient  i t i s most p r e v a l e n t  low-income f a m i l i e s . 1974  are  then drops o f f  economic s t a t u s ,  Theuer,  t e r m i n f a n t has  iron deficiency  and  deficiency  Deficiency  an  seen  used t o  in private  a hemoglobin to  be  assess an  of  5%  and in  of  Owen infants  States. level  of  i n d i c a t i v e of  less  anemia.  incidence  practice  o v e r a l l incidence United  d i r e c t l y with  Hemoglobin l e v e l s of  (1971) r e p o r t e d  i n the  considered  varies  l e s s than anemia.  11 The  g  3%  39 results of  o f a study u t i l i z i n g  16% i n i n f a n t s  families  four  defined ml  i n this  1974 ) .  deficiency  as a hemoglobin l e v e l  o r above b u t a t r a n s f e r r i n In  An a d d i t i o n a l  t o have i r o n  survey  indicated  saturation  a sample o f C a n a d i a n  infants  six  g p e r 100 m l a n d 57% h a d h e m o g l o b i n l e v e l s  that  population Utilization only  ml  1975  Nutrition  of less  than  ( Nutrition  (1973)  i n the general 10 g p e r 100 m l .  standard demonstrated  a g e g r o u p were c o n s i d e r e d  C a n a d a , The B r i t i s h  below  t h a n 11  Canada  that  anemic i n B r i t i s h  However, 23.2% h a d h e m o g l o b i n l e v e l s Columbia  b e l o w 11 g p e r Survey  Report,  ). The  are  clinical  controversial.  deficiency in  levels  levels  less  and t o d d l e r s  o f t h e same h e m o g l o b i n  1.7% o f t h i s  Columbia. 100  4.4% o f t h e i n f a n t s  had hemoglobin  b e l o w 17%.  29% h a d h e m o g l o b i n  ( M i l n e e t a l . 1971 ) .  anemia,  t o 18 months o f age  10  reported  without  level  a l l socio-economic classes,  p e r 100 m l  51% o f t h e  o f 11 g p e r 100  of  g  an i n c i d e n c e  t o 2 4 months o f age f r o m l o w income  ( Haddy e t aJ..  sample was c o n s i d e r e d  t h i s value  consequences o f i r o n  Owen e t a_l. (1971) r e p o r t e d  may be a s s o c i a t e d w i t h m e a s u r a b l e  somatic growth. deficiency  Pre-school children  had  iron  and  lacked motivation  Oski  deficiency that  (1973) have f o u n d  i n Philadelphia  and H o w e l l ,  a correlation  iron  underachievement  anemia had poor a t t e n t i v e n e s s ( Beller  anemia  i n school  1971 ) .  between i r o n  who  Webb and deficiency  40  anemia  and poor  scholastic  (19 72)  indicated  performance  t h a t mothers  of infants  ment h a d f e w e r c o m p l a i n t s a b o u t irritability that  deficient.  appetite  i s commonly  relationship,  r e a s o n a b l e and r e a l i s t i c The Pediatrics  s e e n i n i n f a n t s who  iron-enriched  1958  foods or i r o n  demonstrated  that  cereals.  iron  that  t o recommend  drops  proves a levels  t o be a  Academy o f  formulas  food  i n this  infants form.  i n the United  from  feeding  the i n c l u s i o n of  i n the infant's diet frequently  a n d e a r l y work  R e c e n t work  that healthy  cereals  are iron  i s not being breast-fed.  Many o f t h e s e c e r e a l s  i n the pyrophosphate  some i n f a n t iron  cereals.  i r o n pyrophosphate  from i n f a n t  iron  o f t h e American iron-fortified  An i r o n - f o r t i f i e d  ) indicated  appear  i s t h e optimum f o r m o f i n f a n t  i s p o s s i b l y more a p p r o p r i a t e  months o f a g e .  actually  does  t o 12> months o f age i f t h e i n f a n t  sodium  e t a l . (1966) o b s e r v e d  goal.  (1971) h a s recommended  iron-fortified  daytime  attainment o f hemoglobin  Committee o f N u t r i t i o n  Since breast-feeding it  Judisch  Fuerth  an i r o n s u p p l e -  infant's  11 g p e r 100 m l o r a b o v e f o r i n f a n t s  birth  given  A l t h o u g h none o f t h e s e s t u d i e s  c a u s e and e f f e c t of  their  and s l e e p p a t t e r n s .  abnormal  i n adolescents.  until  18  recommended i s  have i r o n  ( Schultz  f o r m was r e a d i l y  added  as  and S m i t h , absorbed  ( R i o s e t a l . 1975 ) , h o w e v e r , absorbed only Fomon  (19 74)  reported  States contain  i s reasonably well-absorbed.  about  1% o f that  electrolytic  The u s e o f c e r e a l s w i t h  41 t h i s new f o r m o f i r o n tially. the  should  Unfortunately,  market  increase  many o f t h e s e  iron  absorption  substan-  c e r e a l s a r e n o t y e t on  i n Canada. Breast-Feeding  The food  milk  o f each s p e c i e s  i s considered  t o be t h e optimum  f o r i t s newborn and t h e human i s no e x c e p t i o n .  cline  i n breast-feeding  despair cline  throughout the world  by n u t r i t i o n i s t s .  frequently parallels  i s viewed  In underdeveloped an i n c r e a s e  i n infant mortality countries  advantages o f b r e a s t - f e e d i n g 1969; D a v i e s ,  1971;  Jelliffe  tages  f o r developed  making  and  1975 ) .  important  (1) e a s y  incidence of allergies  availability,  the possible  exception ( Jelliffe  interaction  to infantile and J e l l i f f e ,  (Gerrard,  advan-  f o r mother and c h i l d  1975 ) (4) i m p r o v e d m o t h e r - c h i l d  S h u k l a e t a l . , 1972; J e l l i f f e  reduced  ( with  1968;  and J e l l i f f e ,  expensive than b o t t l e - f e e d i n g  ( Newton, 1971 ) (5) a s a d e t e r r e n t 1971;  The m o s t  method o f f e e d i n g  n u t r i e n t content  D ) (3) l e s s  Jelliffe,  1963; J e l l i f f e ,  c o u n t r i e s a p p e a r t o be  i t a convenient  of vitamin  ( Gunther,  the considerable  1969; Baum, 1971; J e l l i f f e  and J e l l i f f e ,  (2) w e l l b a l a n c e d  the con-  severe.  T h e r e h a v e b e e n numerous r e v i e w s c i t i n g  MacKeith,  with  countries the de-  ( P l a n k a n d M i l a n e s i , 1973 ) b u t i n d e v e l o p e d sequences a r e l e s s  The d e -  1974 ) .  obesity  ( Taitz,  1975 ) (6) In a d d i t i o n ,  breast milk provides infant  infections  considerable protection against  ( M a t a and  i s considered  Wyatt,  Generally  this  developed  c o u n t r i e s where s t a n d a r d s  Gerrard  (1974) c a u t i o n e d  Canada,  such  Schaefer  as  the  f a n t s who  mg  cholesterol  ( 300  mg  per  100  50 mg  cholesterol  readily  a higher  are  ).  i n under-  low  but  applied to parts  of  i n Saskatchewan.  incidence of middle were b o t t l e - f e d  i s also relatively per  per  i s an  during  development.  100  g f a t ) and 100  important  the  Reiser  vegetable  in  ear  than  in in-  months o f  - Savoie,  speculated life  may  o f a d u l t m a l e r a t s were i n v e r s e l y i n the  t o cow  f a t formulas  breast milk  milk  ( approx-  1973  ).  Since  b r a i n and  that  blood  abnormal cholesterol  p r o p o r t i o n a l to on  challenge during  which they  raised.  Hence, c h o l e s t e r o l  required  f o r the development of the c h o l e s t e r o l  ner-  hypocholester-  lead to  (1973) showed t h a t t h e  amount o f c h o l e s t e r o l  cholesterol  compared  c o n s t i t u e n t of the  (1973) h a s  first  high  g f a t ) as  g f a t ) Kuzdzai  vous system, Schubert  levels  1974  were b r e a s t - f e d .  ( 500  olemia  of hygiene  Reservations  i n C a n a d i a n E s k i m o s who  Breast milk  imately  Indian  Gerrard,  f a r more i m p o r t a n t  that this  (1971) a l s o f o u n d  infections  t o be  1971,  early  the  were  i n f a n c y may  be  degradation  mechanisms. Despite bottle-feeding  the  apparent  a p p e a r s t o be  1940's, a p p r o x i m a t e l y  65%  of  advantages of b r e a s t - f e e d i n g , increasing in popularity. infants  i n the  United  In  the  S t a t e s were  43  breast-fed only in  10%  the  New  to  15%  health  Dublin,  of  Only  6.3%  breast milk  17%  "the  among t h e  of  beyond  their  a t any  at the  )  in  attended  one 11%  time of  time. of  In  mothers  discharge  i n f a n t s i n England  weeks o f age  (1975) n o t e d ,  This  increase  upper s o c i a l  ( L a d a s , 1972  the  cussed  ( Shukla et a l .  physician  success  or  in a later  breast"  ( Rivera,  physicians  failure  as  the  fruits,  e a r l y as  e a r l y consumption of  i n t a k e and  subsequent  19 71  trend  prevalent  )., c o l l e g e  ( H a r r i s and  gradu-  Chan, 1969  important This w i l l  ).  role be  dis-  review.  Solids  h a v e shown t h a t  f o r m o f c e r e a l s and intake  i s more  of breast-feeding.  s e c t i o n of  is a  industrialized  i s thought to play a very  Recent surveys  dietary  i n the  in breast-feeding  classes  ) , and  however, t h a t t h e r e  Introduction of  This  child  1972  1974  i n a study  o f m o t h e r s who  a group of 12  By  ( Martinez,  (1974) i n d i c a t e d t h a t  b o t t l e back to the  The  the  ).  ).  countries.  in  that only  Kevany  1948  e t a l . (19 74)  breast-fed  and  Applebaum  ates  Maslansky  sample were b r e a s t - f e e d i n g  received  ( Bain,  i n f a n t s were b r e a s t - f e d  clinics  from h o s p i t a l .  from  newborn p e r i o d  reported  Kalapesi  their  1972  the  same c o u n t r y .  York C i t y ,  child  in  during  solid  foods,  become a p a r t o f  one  week o f  age  solid  foods  leads  f a t accumulation  mainly  the  ( Taitz,  infant's 1974  to a high  ( Taitz,  1971;  in  ).  caloric Shukla  44  et  a l . , 1972; Dwyer a n d Mayer, A number o f s t u d i e s  1970  ) have d e m o n s t r a t e d  throughout childhood. "multiple obesity in  ( Lloyd,  that  f a t babies generally  Although obesity  ( Hirsh  are believed  and K n i t t l e , to increase  and t h e f i r s t  Brook  (1972) f o u n d t h a t  first  year of l i f e  after  one y e a r o f a g e .  that  The  of  the degree o f  overweight  in cell  c h i l d r e n who  size  during  1968 ) ; f u r t h e r (hypertrophy).  i n early  infancy  obese may  effects.  showed t h a t obesity  ( S h u k l a e t a T . 1972  Oates  I n humans,  t h a n t h o s e becoming  r e s u l t s o f a s u r v e y o f 300 n o r m a l  of these  ).  present  became o b e s e a f t e r t h e  Thus, o v e r f e e d i n g  from i n f a n t i l e  1972  (hyperplasia)  ( Winick,  h a d more f a t c e l l s  y e a r o f age i n E n g l a n d suffering  1970; B r o o k ,  year of l i f e  have l o n g - t e r m d e t r i m e n t a l  infants before  i n f a n t s up t o one  16.7% o f t h e s e  i n f a n t s were  a n d a f u r t h e r 27.7% were ).  Solid  f o o d s were g i v e n  to  t h e y were f o u r weeks o l d .  (1973) , i n a s t u d y o f 100 i n f a n t s u n d e r s i x months  of  age, d e m o n s t r a t e d  to  the infant at three  that  solid  f o o d s were g e n e r a l l y  t o f o u r weeks o f a g e .  were more p r e v a l e n t  infants  remain f a t  i s a disease  i n number  g r o w t h r e s u l t s f r o m an i n c r e a s e  gains  1966; E i d ,  i s l a r g e l y d e p e n d e n t on t h e number o f f a t c e l l s  gestation  39.7%  1961; A s h e r ,  o r i g i n s " , i t h a s been s u g g e s t e d  t h e body  cells  1973 ) .  in artificially-fed  introduced  Excessive than  i n a s t u d y o f s i x week o l d i n f a n t s r e p o r t e d  weight  breast-fed by T a i t z  45  (1971). first  In  this  week o f  s t u d y , most  excessive  o f more s e r i o u s  renal  solute  solids  to very  Davies  (1973) s t u d i e d  age  and  ity  greater  t o be that the  young  found the  formula-fed  than  infants  11.1%  this  high  the  age  300  very  liter  the  the  general  comitant  increase  teristic  of  the  Dietary  decline  i n the  body  be  an  benefit  for  incidence  hyperosmolarity introduced  of  fluids.  i n the  in  until  the  four  Mayer,  industrialized  1973  ).  Practices  i n breast-feeding,  early  s u m p t i o n o f many n u t r i e n t s Dwyer and  not  emphasized  capacity  nutritional  increase  osmolar-  age. Infant  The  of  of  solid' foods  author the  ).  infants,  infant's d i e t at  dangers of  young i n f a n t , s o l i d s s h o u l d  s i x months o f  stressed  normal t o n i c i t y  In view o f and  The  is  of  months  ( plasma  formulas plus  a p p e a r t o h a v e any  obesity  to three  ) in breast-fed  fed  greatly  feeding  T a i t z , 1974  hyperosmolarity  respectively.  load  the  1973;  of s o l i d s i n t o the  infant.  infantile  of  infants  40.5%  solute  p r o d u c e d by  ( Davies,  mOsm p e r  and  does not  healthy  the  p h y s i o l o g i c a l consequence  i n f a n t s f r o m one  incidence  Introduction  of  60  i n f a n t s and  0%,  load  kidney t o m a i n t a i n the  early  solids in  life.  Possibly the  infants received  i n t r o d u c t i o n of nations,  i n infancy The  one  has  with the  con-  s o l i d s charac-  led to  over-con-  ( Shukla et a l . ,  major e x c e p t i o n  1972;  i s iron  to  46  ( Filer  and M a r t i n e z , Filer  1964; M a s l a n s k y ,  and M a r t i n e z  (1964) s t u d i e d  months o f age i n t h e U n i t e d than h a l f  of the infants  Apparently Purvis  1  the s o l i d  States  foods  findings.  a t t r i b u t e d mainly  4,146  infants  and c o n c l u d e d  d i d not receive ingested  (1973) d a t a on i n f a n t s  these e a r l i e r  1974 ) .  that  adequate  at s i x  more  iron  intakes.  were p o o r i n i r o n  content.  one t o 13 months o f age  The l a c k  support  of i r o n i n the d i e t s  was  to the discontinuance of iron-enriched  products at approximately  s i x months o f a g e .  Vitamin  cereal  supple-  ments a p p e a r e d t o be an e c o n o m i c and n u t r i t i o n a l w a s t e  since  they elevated  levels.  nutrient  I n New age  indicated  iron  York C i t y , that  and n i a c i n  particularly sented  only  intakes  well  b e y o n d recommended  a survey of i n f a n t s  dietary  nutrients  were a d e q u a t e e x c e p t f o r  ( M a s l a n s k y e t a_l. 1974  l o w among g i r l s  ).  aged n i n e  37% o f t h e recommended  Iron  of  supplements c o n t a i n e d  interesting findings  iron.  regarding  More t h a n h a l f o f t h e i n f a n t s  dietary  month o f l i f e .  This infant  more t h a n  given  s o l i d s added t o t h e b o t t l e s .  was repre-  allowances. but only  Vitamin 47% o f  survey revealed feeding  a  within  50% o f t h e c h i l d r e n  proportion  the were  By 11 months o f a g e , s w e e t s  t h e 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  greater  number  practices.  had s o l i d s i n t r o d u c e d  first  in  Also,  intake  t o 12 months a n d  s u p p l e m e n t s were t a k e n by 80% o f t h e i n f a n t s these  u n d e r one y e a r o f  o f the c a l o r i e s t o the i n f a n t ' s  a  d i e t than d i d  47 vegetables.  The a u t h o r s  state  that:  . . . i n t o o many i n s t a n c e s f o o d s 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 t h e d i e t i n t h e v e r y y o u n g and i n c r e a s e i n c o n s u m p t i o n w i t h e a c h month ( p . 785 ) . Nutrition and olds  vitamin ( Table  Canada  (1973) r e p o r t e d  D i n the general  population  low i n t a k e s o f zero  of iron  to four  year  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  General Inadequate  Nutrient  Population Less-than-Adequate  1.1  1.6  Iron  23.5  20.7  Calcium  13.1  13.0  17.9  42.5  Protein  Potential Vitamin  D  Vitamin  A  3.2  6.3  Vitamin  C  3.9  6.6  Thiamin  1.4  15.0  Riboflavin  0.7  4.6  Niacin  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 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 , C a n a d a , 1973, p . 66.  Transferrin  saturation levels  revealed  t h a t 12.7%  48 of t h i s  population  Serum v i t a m i n  g r o u p were a t h i g h  A v a l u e s c l a s s i f i e d 22.8%  a t moderate r i s k .  The  specific  were somewhat s i m i l a r Survey Report,  for vitamin  one  of  of the  the  had  excessive  proper  ously  age  Although  D  intakes,  of vitamin  young  Columbia  British  13.2%  of the  Columbia the  i n f a n t s under  I . U. p e r  day  supplements.  as  a  result  Education  preparations  Hence, t h e  o f the mother i s c r u c i a l of the  date advice  infant. and  Education  in  is obvi-  to the  nutritional  from the  them s e l e c t  cerning  infant feeding practices.  provided  Evidence that  feeding  p r o d u c e d a 23%  totally  breast-fed.  s e m i n a r s on  increase  This  i n the  information  i n c r e a s e was  t h e many  These  advanbe  workers  infants  statistically  con-  would  advantages of  number o f  well-  feeding  such education  the  part  up-to-  infant  by S l o p e r e t a l . ( 1 9 7 5 ) .  t h a t h o l d i n g ward  the  accurate  regarding  preponderance of  on  for  emotional  i s needed f o r mothers r e g a r d i n g  of breast-feeding.  reported  others  and  Mothers need g u i d a n c e ,  to help  o f b e n e f i t was  Infancy  feeding behavior  e n t h u s i a s t i c support  Education  for  i n f a n t d e p e n d s e x c l u s i v e l y on  nutrient intake.  tages  toddlers  needed.  The  being  i n f a n t s and  some i n f a n t s were b e l o w  management o f v i t a m i n - m i n e r a l  Nutrition  his  iron deficiency.  findings for British  more t h a n 1, 000  use  of  of  ( N u t r i t i o n C a n a d a , The  197 5 ) .  standard year  risk  breastbeing  significant.  49  For in  m o t h e r s who the  do  not  preparation  reported  of  e l e c t to breast-feed, formulas.  hypernatremia  and  et  ( T a i t z and  a l . , 1971;  the  fact  phasized this  Smith,  that  nutrition.  Byers,  even d e a t h because of  a  1974  ).  " f a t " baby  i s not  in industrialized  to  life.  and  of  timing  o f good e a t i n g  Stern,  desired  of v i t a m i n  countries  their  1971;  goal  in-  Coodin  educated of  to  infant  supplements i s over-em-  and  although  i n many  i n some c a s e s  cases  i t constitutes  life.  shaping of  early years of  formulas to  and  the  i n economic waste,  a p o t e n t i a l hazard The  Roloff  over-anxious  M o t h e r s must a l s o be  F u r t h e r m o r e , use  r e s u l t s only  the  1972;  i s needed  Numerous i n v e s t i g a t o r s h a v e  o r unknowing mothers g i v i n g c o n c e n t r a t e d fants  education  food The  this  habits  way  i s thought  i n w h i c h new  foods are  procedure contribute  habits.  Gifft  to begin  to the  e t a l . (1972) p o i n t  in  the  introduced  development out  that:  . . . 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 k n o w l e d g e o f t h e p a r e n t s f o r m t h e framework w i t h i n which the c h i l d d e v e l o p s h i s own f o o d h a b i t s . This 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 ) . Specific  food  certainly solid her  be  foods.  preference basis  and  conveyed  dislikes  to  the  of  child  the as  parents w i l l  the  child  Even i f a mother o f f e r s a f o o d  feelings will  a m o t h e r who  the  likes  likely  i s fond  of  be  communicated  s w e e t s may  f o r sweet f o o d s . for lifetime  eating  By  the  time the  patterns  begins  that  t o the  condition  she  baby.  her  child  child  i s well  almost eating dislikes, Thus, to  enters  established  a school  50  ( Gifft  e t a l . , 1972; W a l k e r e t a l . , 1973  ).  It i s therefore:  . . . v i t a l to the future n u t r i t i o n a l health o f 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 t h e y a r e s h a p i n g a l i f e t i m e f o o d p a t t e r n by t h e way t h e y i n f l u e n c e e a t i n g experiences during 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  The p h y s i c i a n the  dietary  intake,  in Nutrition  i s i n an i m p o r t a n t  Education  position to  and hence, t h e n u t r i t i o n a l  p r e g n a n t and l a c t a t i n g woman and t h e y o u n g  status  infant.  r e g a r d e d b y much o f s o c i e t y a s t h e l e g i t i m i z e r o f on a l l a s p e c t s o f h e a l t h leader  i n these  and i s g e n e r a l l y  looked  information up t o a s a  matters.  i s e i t h e r t h e p r i m a r y o r one o f t h e most  professionals nutrition Gifft  f r o m whom homemakers and o t h e r s  information  e t a l . , 1972;  (19 75) r e p o r t e d al  along  of  y o u n g women.  ( Young  Cho  that  e t a l . , 1956;  e t a l . , 1974  the physician  with the n u t r i t i o n i s t Fox e t a l .  was  (1970),  c h i l d r e n , observed that  accepting  advice  child's life.  important  derive  their  Fox e t a l . , 1970;  C o s p e r and  an i m p o r t a n t  Wakerfield professionchoices  i n a survey of the d i e t s of  70% o f t h e m o t h e r s  from the p h y s i c i a n Gifft  ).  the  i n i n f l u e n c i n g the food  preschool  the  of the  He i s  Numerous i n v e s t i g a t i o n s h a v e i n d i c a t e d t h a t physician  influence  during  the f i r s t  e t a l . (1972) e m p h a s i z e  reported year of  that:  51 . . . the p h y s i c i a n i s i n a c r u c i a l p o s i t i o n t o i n f l u e n c e the b e h a v i o r of p a r e n t s i n r e l a t i o n to f e e d i n g t h e i r c h i l d r e n , f o r he i s one o f the primary sources t h a t most p a r e n t s have f o r i n formation and guidance about what and how t o feed t h e i r c h i l d r e n ( p. 351 ). Members o f the American C o l l e g e of O b s t e t r i c i a n s and Gynecologists  (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 p h y s i c i a n i n p r e n a t a l n u t r i t i o n c a r e .  The  p h y s i c i a n must possess knowledge o f n u t r i t i o n management and e i t h e r provide  these necessary s e r v i c e s o r d e l e g a t e  some o t h e r q u a l i f i e d p r o f e s s i o n a l .  them t o  I t i s , however:  . . . v i t a l f o r the p h y s i c i a n t o demonstrate to the p a t i e n t h i s or her concern w i t h t h i s important aspect o f care ( p. 11 ). Baric sibility  (1970), i n an a n a l y s i s o f the p h y s i c i a n ' s  i n health education,  i n d i c a t e d t h a t the p h y s i c i a n 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 o f optimum h e a l t h and t o g i v e i t a s t a t u s to  ' c u r a t i v e ' medicine.  respon-  In order  relative  t o do t h i s , the p h y s i c i a n needs  t o be r e l a t i v e l y c e r t a i n of the b e n e f i t of any p r e v e n t i v e sures t h a t he recommends j u s t as he must be w i t h measures.  He must a l s o take the i n i t i a t i v e  h e a l t h matters such as b r e a s t - f e e d i n g . quently  i s not done.  therapeutic  in certain beneficial  Unfortunately,  this  fants.  fre-  Shukla e t a l . (1972), i n a study o f i n f a n t  f e e d i n g p r a c t i c e s , noted t h a t 81% o f the mothers r e p o r t e d neither doctor  mea-  nor nurse advised  them t o b r e a s t - f e e d  A f u r t h e r 16% s a i d t h a t b r e a s t - f e e d i n g  that  their i n -  was mentioned by  52  the  doctor  only  casually.  Applebaum  (1975) n o t e d  that:  . . . many m o t h e r s who w i s h t o n u r s e a r e d i s couraged because o f t h e p h y s i c i a n ' s i n d i f f e r e n c e t o o r i g n o r a n c e o f t h e m a t t e r ( p . 98 ) . It  a p p e a r s , however, t h a t t h e p h y s i c i a n does  t o p l a y an a c t i v e r o l e  i n the dissemination  ledge  The L a y A d v i s o r y  to the p u b l i c .  Chapter o f the C o l l e g e on  the role  ( Larsen, doctors  1974 ) .  surveyed  physician other  This report  o f Canada  in British  know-  indicated that  reported  Columbia 93% o f t h e m e d i c a l  b e l i e v e d that the p a t i e n t should  f o r help with  resource  of nutrition  C o m m i t t e e o f t h e B. C.  of Family Physicians  of the family physician  desire  see t h e  non-medical problems before  approaching  personnel.  . . . i t appears . . . that the m a j o r i t y o f both consumers and d o c t o r s e x p e c t 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 t o . . . n u t r i t i o n a l m a t t e r s ( p . 103 ) . . Paradoxically, medical a minor r o l e , medical  197 0;  Facilities, al.,  ( Mueller,  1971; C o u n c i l  it  19 67;  Nutritional  i n a curriculum  that  i nthe  Sciences  Training  i n Medical  1974; Dwyer a n d S t a r e ,  1974 ) .  i n c l u d e d as p a r t o f o t h e r  o r i f a f a c u l t y member h a s a  i n the subject.  places  on F o o d s and N u t r i t i o n , 1973; Wen e t  i s frequently only  such as b i o c h e m i s t r y , interest  generally  C o m m i t t e e on N u t r i t i o n E d u c a t i o n  1973; D u t r a d e O l i v e i r a ,  Nutrition  training  i f a n y , on t h e i m p o r t a n c e o f n u t r i t i o n  curriculum  Committee,  school  Many a r g u e t h a t t h e r e i s already  filled  with  courses,  particular  i s no room f o r e s s e n t i a l medical  53 courses, with the world  the  result  a p p e a r t o be  Surveys  that  medical  students  was  poor  and  a desire this in  an  adequate  indicated  ( Phillips,  1971;  that  ( Dutra  de  ( Dutra  de  their  nutrition  increasingly  ( Gifft  1974  to learn nutrition  ).  matter  19 74  knowledge  ).  of  nutrition  ). concerned and  with  the  f r e q u e n t l y show  e t a l . 1972  ).  a p p a r e n t l y has  i n c r e a s e d knowledge o f n u t r i t i o n 1974  Oliveira,  knowledge o f  preventive aspects of medicine  willingness  schools i n  Oliveira,  the n u t r i t i o n  K j e l l m a n , 1974  students are  to learn  Oliveira,  medical  information with other subject  have i n v e s t i g a t e d  Medical social  o n l y a few  are teaching n u t r i t i o n  Integration of n u t r i t i o n does not  that  As not  ( F i g u r e 1,  yet, resulted  Dutra  de  ). Medical Students Are W i l l i n g to Learn N u t r i t i o n  N u t r i t i o n S h o u l d Be Taught i n M e d i c a l Schools  M e d i c a l S c h o o l s Say They Are, T e a c h i n g N u t r i t i o n  S t u d e n t s and P h y s i c i a n s Have P o o r Knowledge o f N u t r i t i o n Figure  Dutra  de  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 teaching i n medical schools.  Oliveira  recognized dently,  1  (1974) commented t h a t  as a s u b j e c t i m p o r t a n t  i t will  not  until  enough t o be  nutrition taught  r e c e i v e adequate emphasis o r  is  indepen-  justice  i n the  54  medical  school curriculum. A t t i t u d e s and P r a c t i c e s Attitudes are acquired p r e d i s p o s i t i o n s to react 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 f a v o u r a b l y o r u n f a v o u r a b l y , a given type o f person, 19 68 ) .  P r a c t i c e s are overt gestures  preference 1 9 7 3 ).  s i t u a t i o n , object or ideal indicating  and commitment i n some o b s e r v a b l e  toward  ( Kilander, an i n d i v i d u a l ' s  activity  ( Rogers,  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  practice i s overt. According  t o D i l l e h a y ( 1 9 6 5 ) , a t t i t u d e s have t h r e e  major components: 1.  b e l i e f s o r c o g n i t i o n about t h e o b j e c t  2.  a f f e c t o r f e e l i n g s toward the o b j e c t  3.  behavioral tendencies  to act  S i n c e a t t i t u d e s a r e c o m p r i s e d o f these t h r e e components a r e o f t e n t h o u g h t o f as systems.  they  A change i n any one p a r t o f  t h e 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 t h e o t h e r 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 d e g r e e s o f 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 , t h e  degree o f c o n s i s t e n c y among t h e t h r e e components w i l l be g r e a t e r than i f t h e t o p i c i s considered unimportant o r 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 , 1969 ).  i s considered  t o be i m p o r t a n t  Thus, i f n u t r i t i o n  by a p h y s i c i a n he may have beha-  55  vioral  tendencies Attitudes  supports:  to p r a c t i c e n u t r i t i o n are  b a s e d on  ( D i l l e h a y , 1965  one  education.  of three  motivational  ):  1.  knowledge, e i t h e r f a c t u a l  or gained  from  2.  ego-defence, p r o t e c t i o n o f one's sense  experience  of  adequacy 3. All  social  adjustment  t h r e e m o t i v a t i o n a l b a s e s may  O n l y when an acquired  a t t i t u d e i s b a s e d on  information  t o c h a n g e and  throughinformation Attitudes ceptible are  1973 der  ).  The  s i n c e he  ( Gifft in  defence of  or knowledge about the formed t h r o u g h  an  This  or education  i s perceived ).  unique p o s i t i o n to is particularly  social  practices.  relationship  object  The  credibility  ( Gifft  as As  being an  i n f l u e n c e the  true with  the  Newton and  of maternal  be  because of  as  an  susleaders addi-  Rogers, opinion  lea-  knowledgeable  leader,  the  a t t i t u d e s of  p r a c t i c e of  Newton  the a t t i t u d e .  opinion  e t a l . , 1972;  extremely  opinion  of  solely  a d j u s t m e n t may  leaders.  where a t t i t u d e s t o w a r d b r e a s t - f e e d i n g to overt  newly  attitude is  altered  p h y s i c i a n i s f r e q u e n t l y regarded  e t a l . , 1972  will  t h e ego t h e  g e n e r a l l y c a n n o t be  t o change t h r o u g h o p i n i o n  experience  simultaneously.  knowledge a l o n e  g e n e r a l l y i n d i v i d u a l s of high  tional  acting  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 a r e b a s e d on difficult  be  physician i s others.  breast-feeding  seem t o be  directly  related  (1950) i n v e s t i g a t e d  a t t i t u d e s toward b r e a s t - f e e d i n g  to  the  56  success of breast-feeding. of  an  interview  B e h a v i o r was infant  usually  held  a s s e s s e d by  received.  Attitudes within  attitudes.  successful  tudes and  Success of  "nutrition cantly who  26%  breast-fed  d i d not  amount o f  feel  were r e l a t e d  to  that  or  ), c a u t i o n  In molding  on  or  t h o s e who  had  their infants.  m o t h e r s who  held  c h i l d r e n who  nega-  related  positive attitudes  to  were  negative  atti-  S i m i l a r l y , Emmons the  attitude,  consumed a  " n u t r i t i o n i s important".  m u s t be  behavior  behavior  contrast,  attitudes  of  cognitive  is  discrepant  be  more c o n s i s t e n t  do  used  social influences,  a bearing  also  feeding  signifi-  of  mothers  Thus,  attitudes  practices.  in forecasting  s u c h as  was  each  toward  calcium than d i d c h i l d r e n  Although a t t i t u d e s 1973  had  of  i s i m p o r t a n t " , had  greater  delivery.  amount o f m i l k t h a t  breast-feeding  (1974) n o t e d t h a t  means  than mothers w i t h d o u b t f u l  M o t h e r s who  while only  successfully  Hayes  hours of  Mothers w i t h p o s i t i v e a t t i t u d e s  mothers' a t t i t u d e s . 74%  24  measuring the  g a v e s i g n i f i c a n t l y more m i l k tive  were d e t e r m i n e d by  a f f e c t overt  in inferring attitudes  from a t t i t u d e s . education  ( Dillehay, b e h a v i o r may  ( Festinger,  dissonance,  i f an  and  1965 be  19 64  actions.  from  behavior  factors  p e r s o n a l n e e d s may  have  ).  the ).  ( Rogers,  Many o t h e r  motivating According  i n d i v i d u a l behaves  w i t h h i s b e l i e f s , the with his  behavior  b e l i e f s may The  force  to  the  i n a way  c h a n g e so  discrepancy  is  in theory that as  to  believed  57  t o be u n c o m f o r t a b l e attitudes. brought  and c o n s e q u e n t l y m o t i v a t e s a c h a n g e i n  The d i s s o n a n c e  into  l i n e with  i s r e d u c e d when a t t i t u d e s  actions.  T h e r e a r e no s t u d i e s physicians' could  attitudes  be s p e c u l a t e d  viduals,  19 69  ).  that  physicians,  ( Wicker,  being  consistent  intelligent  with t h e i r  ).  It indi-  practices  questions of  n o t be r e f l e c t e d i n s p e c i f i c 1969  relate  practices.  On t h e o t h e r h a n d , a t t i t u d e  a g e n e r a l n a t u r e may practices  i n the l i t e r a t u r e that  to t h e i r counselling  would have a t t i t u d e s  ( Wicker,  are  behavioral  58  S u r v e y R e s e a r c h by  The that  mail questionnaire  i s c o m p l e t e d by  and  collected  the  r e s p o n d e n t and  for  the use  is  a need  in  another  are  the  Questionnaire  i s a data  respondent  t h r o u g h the m a i l w i t h the  researcher.  way  ( Clarke,  collected  wide g e o g r a p h i c a l  ).  the  encompass a l l t h e easily that  answered  i s , yield  an  to Scott  This author  between  justification  i s that  Such i s the  be  there  obtained  case  when  individuals  data over  a  Disadvantages  of t h i s  information, ).  to  be  of  research  and  be  is  s t a t e m e n t s must unambiguous  I t must a l s o be  (1969) t h e method o r a  concluded  interest  type  and  reliable,  accurate,  or  valid,  measure.  i s t h a t they  onto the dimension of the  contact  reasonably  questionnaire  consistent results  of closed questions  limiting  The  necessary  'open-question'  technique.  aspect  itself.  m e a s u r i n g what i t p u r p o r t s  either  researcher,  area.  ( H a r r i s , 1960  According  instrument  the  primary  from a l a r g e sample o f  most i m p o r t a n t  questionnaire  direct  collection  T e c h n i q u e s , A d v a n t a g e s and The  no  t h a t cannot 1970  collection  r a t h e r than  The  o f t h i s method o f d a t a  for information  being  Mail  questionnaire  utilize  'closed-question'  t h a t the f o r c e the  of the  can  strongest  advantage  respondents'  researcher,  p r o p o r t i o n o f uncodable answers.  The  replies  thereby strongest  59 d i s a d v a n t a g e a p p e a r s t o be t h e t h r e a t t o r a p p o r t respondents  find  even i n s u l t i n g . reactions  long  lists  Deutscher  to a mailed  of closed questions (1953),  i n a study  questionnaire,  noted  s i n c e many t e d i o u s and  of physicians'  that:  . . . men w i t h a b o v e a v e r a g e i n t e l l i g e n c e a n d e d u c a t i o n t e n d t o r e b e l i f a s k e d t o make s t e r e o t y p i c a l judgements (p. 6 0 1 ) . A d v a n t a g e s and d i s a d v a n t a g e s are  discussed  by W a l l a c e  advantage t o u s i n g er t o survey period other  this  (1954) a n d M i l l e r technique  methods o f s u r v e y  research  often e a s i e r to reach  them p e r s o n a l l y . so  t h a t they  are  the  ( Colombotos, questionnaires are  i t permits  a  i n a relatively  a n d may be e v e n  technique  ( Jackson,  research-  short  feasible  60 t i m e s  than  less  1961 ) . I t  than t o i n t e r v i e w  I t a l s o ensures anonymity t o t h e respondents t o answer c a n d i d l y .  This prevents  interpretation  respondent  The p r i m a r y  With  the mail  t h e problem o f i n t e r v i e w e r and respondent  eliminated.  a biased  (1970).  b u s y p e o p l e by m a i l  a r e more l i k e l y  questionnaire  questionnaires  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  expensive than t h e i n t e r v i e w is  i s that  a l a r g e group o f p e o p l e  o f time.  of mail  the interviewer  recording  o f t h e r e s p o n s e and g e n e r a l l y  f r o m g i v i n g more s o c i a l l y 1970 ) .  from  Wallace  are particularly  acceptable  biases  curtails  responses  (1954) p o i n t s o u t t h a t suited f o rpopulations  mail that  somewhat homogeneous. T h e r e a r e a l s o a number o f w e a k n e s s e s o r d i s a d v a n t a g e s  to using mail  questionnaires.  The r e s p o n d e n t may n o t answer  60 honestly  o r may  properly.  disregard  Assurances of  encourage honesty disadvantage o v e r who  r e s p o n d may  be  f r o m t h o s e who  i n s t r u c t i o n s and  good i n t e n t and  ( Rummel, 1964  i s that  will  the  the  reply.  mail  The  ).  The  not  anonymity  answer usually  s i n g l e major  questionnaire  i n d i v i d u a l s who  o f f e r s no  do  not  control  choose  to  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 do.  non-response b i a s  This  can  introduce  t h a t must be  a very  significant  c o n t r o l l e d i n the  analysis  of  the r e s u l t s . Response Response t o m a i l Longsworth as  7%.  tions 25% on  Many s t u d i e s or  questionnaires that  that  the  are  a small  physicians  c o n d u c t e d by  ( L e v i n e and  to mail  returned  Gordon,  towards a d m i n i s t r a t i v e  private  Garrison 45.1%  practices  on  be  reporting  low  organiza10%  to  professionals yielded  the  response  i n d i c a t e values  on  as  ).  (1953) n o t e d  questionnaires  response r a t e of  could  respondents  1958  studies  Deutscher  and  widely.  s u r v e y s c o n d u c t e d by  questionnaires  Gullen  vary  a response rate of  highly motivated  extremes.  Occupations'. physician  Other  l i m i t e d number o f  physicians  t h e s e two  ).  number o f  response A  1970  can  response rate  u n s k i l l e d personnel y i e l d  ( Miller,  100%  of  (1953) n o t e d  Rate  that  'Public  57%  an  medical doctors'  in continuing  between of  Images o f  (1973) r e p o r t e d  rate  379 Female  overall attitudes  education.  In  a s u r v e y on care,  physicians' receptivity  an o v e r a l l  reminders  response  rate  and  returned  q u e s t i o n n a i r e s on  health care  Vivian  survey  a response  i n , or f a m i l i a r i t y  1953;  i n the  social  can  be  D i l l m a n , 1972; of these  response  of postage  four  ).  2,000 p h y s i c i a n s i n the  to respond  increased  subject  factors  1954;  educated  o r who  H a c k l e r and  are  ( Miller,  matter  in  Miller,  eliciting 1970  ).  profession1970  ).  numerous ways i n  ( Longsworth, Bourgette,  1953;  1973  ).  Miller, The  most  are:  inclusion  2.  e n d o r s e m e n t by  a  3.  objective  type  questions  4.  inclusion  o f a stamped,  5.  printed  6.  follow-up  adhesive  of a cover  sponsor  s e l f - a d d r e s s e d envelope attractive  format  reminders i n a study of the g e n e r a l p o p u l a t i o n ,  postage  of college  letter  q u e s t i o n n a i r e w i t h an  (1969),  produced  the  sciences suggests  that bulk postage.  a survey  with,  1.  Champion showed t h a t  1974  of the d i e t i t i a n  Wallace,  a r e more h i g h l y  which responses  important  of  o f t h e most i m p o r t a n t  ( Longsworth,  Literature  in  the r o l e  a r e a l s o much more l i k e l y  1970;  obtained after  (1974) r e p o r t e d 36.4%  i s one  I n d i v i d u a l s who als  was  team.  Interest the  66%  to r e t u r n the q u e s t i o n n a i r e ( Mechanic,  Schiller  of  of  to innovations to health  stamps p r o d u c e d G u l l a h o r n and  graduates,  Gullahorn  showed t h a t  a higher y i e l d ,  a slightly  although  higher the  better  (1963), classes  differences  62 were s m a l l . When q u e s t i o n n a i r e s  a r e long o f n e c e s s i t y , they  be made t o look as s h o r t as p o s s i b l e 1958;  Dillman,  1972 ).  ( Levine  should  and Gordon,  T h i s can be accomplished  through  p r i n t i n g r a t h e r than mimeographing and use o f both s i d e s o f the page.  Kelsey  and Acheson  (1971) found no s i g n i f i c a n t  differ-  ence i n the response r a t e from surgeons t o e i t h e r mimeographed or typed  questionnaires.  A personalized  i n c r e a s e t h e response r a t e i n t h i s Follow-up i s v e r y  cover l e t t e r d i d n o t  survey.  important, and a c c o r d i n g  to M i l l e r  (1970), can i n c r e a s e response r a t e by as much as 40%. (1965) i n c r e a s e d h i s r e t u r n s follow-up.  Eckland  from 67% t o 94% by p e r s i s t e n t  Inducements such as a promise o f t h e summary o f t h e  f i n d i n g s o r t h e i n c l u s i o n o f money may i n c r e a s e t h e r e t u r n s . Hackler  and Bourgette  (1973) demonstrated t h a t t h e i n c l u s i o n  o f one d o l l a r s i g n i f i c a n t l y i n c r e a s e d t h e response r a t e o f a questionnaire  sent t o t h e mothers o f s c h o o l c h i l d r e n .  G u l l e n and G a r r i s o n encing  (1973) i n v e s t i g a t e d f a c t o r s  the r a t e s o f response t o m a i l q u e s t i o n n a i r e s  t i s i n g physicians.  by p r a c -  The purpose was t o determine whether t h e  assumptions made i n the consumer and s o c i a l s c i e n c e s  litera-  t u r e on i n c r e a s i n g response r a t e t o m a i l q u e s t i o n n a i r e s be a p p l i e d t o p h y s i c i a n s . of p h y s i c i a n s  influ-  T h i s survey assessed  i n p r i v a t e p r a c t i c e regarding  could  the a t t i t u d e s ,  c e r t a i n common  administrative p r a c t i c e s i n continuing education.  The two  main treatment v a r i a b l e s were format  ( i n c l u d i n g both d e s i g n  and r e p r o d u c t i o n p r o c e s s ) and postage with t h i r d c l a s s  ).  ( first  c l a s s compared  There were a t o t a l of seven sub-treatments.  The r e s u l t s showed t h a t the response r a t e ranged from a low of 34.2%  f o r a mimeographed two-part t e a r - o f f p o s t c a r d  sent by b u l k m a i l , t o a h i g h o f 57.1% l e t t e r sent by metered  first  for a business-style  class mail.  Use of adhesive pos-  tage stamps d i d not produce an i n c r e a s e i n response r a t e over metered postage.  I t was  concluded by the authors t h a t assump-  t i o n s u s u a l l y made by e p i d e m i o l o g i s t s i n d e s i g n i n g m a i l surveys may  be a p p l i e d t o the p h y s i c i a n i n p r i v a t e  practice.  Non-Response Non-response t o m a i l q u e s t i o n n a i r e s can e x i s t i n one of  two forms:  complete non-response  Complete non-response may the  or p a r t i a l  non-response.  r e s u l t from e i t h e r f a i l u r e t o r e c e i v e  q u e s t i o n n a i r e o r f a i l u r e t o complete i t .  Partial  non-  response r e f e r s t o a r e t u r n e d q u e s t i o n n a i r e w i t h one o r more r e l e v a n t q u e s t i o n s unanswered. Pratt  Donald  (1966) i n d i c a t e t h a t people who  (1960) and Mayer and a r e not i n t e r e s t e d o r  p e r s o n a l l y i n v o l v e d i n the s u b j e c t matter o f the survey are u n l i k e l y t o respond. Gannon e t a l . (1971) s t u d i e d response r a t e s i n a survey of  food s t o r e workers and found a lower response r a t e from  those workers who  were l e s s educated, s i n g l e and male.  This  confirmed higher  the  educational  e t a l . 1970 1975  earlier  ).  A  report  that  f e m a l e s and  l e v e l s have h i g h e r survey  of  those  response r a t e s  smoking h a b i t s  when 87%  smokers t h a n non-smokers. of  The attitudes that  the  questionnaires  results  toward  were  of a survey  innovations  non-respondents  by  This  Mechanic  (1974) on  i n medical-care  included a higher  proportion  earlier,  those  who  were l i c e n s e d t o p r a c t i c e i n 1940  also  less  tion.  likely  time  to belong  None o f t h e s e  school  of  graduated  were o n . f u l l  from medical  salaries.  to at  least  physicians'  d e l i v e r y showed  who  who  be  returned.  those  those  to  t r e n d p e r s i s t e d even  doctors,  and  ( Ellis  ( S e l t z e r et a l .  ) showed t h a t n o n - r e s p o n d e n t s were more l i k e l y  cigarette  with  older  i n 19 35 or  or before,  N o n - r e s p o n d e n t s were  one  specialty organiza-  d i f f e r e n c e s , however, was  statistically  significant. Since to the  questionnaire  original If  the  they the 1953  c e r t a i n segments o f  population.  the  data  possibilities  not  be r e p r e s e n t a t i v e o f  is relatively  level  of  s a m p l e may  Hence, a n o n - r e s p o n s e b i a s  sample p o p u l a t i o n  have a s i m i l a r  may  the  of  education  non-response b i a s  not  is  respond the  introduced.  homogeneous, t h a t i s , and  the  same  occupation,  are decreased  ( Wallace,  ). Mayer and adjusted  by  Pratt  may  be  the  e n t i r e sample o r by  (1966) s u g g e s t e d  weighing  the  t h a t non-response  a c t u a l responses to  extrapolating trends  across  bias  represent response  65  waves.  Both of these methods assume t h a t non-respondents  the same as respondents. 1959  Other workers  ( Larson and Catton,-  ) have noted t h a t l a t e responders may  non-responders.  returns.  be i n d i c a t i v e  A c c o r d i n g t o t h e s e workers,  check f o r a non-response  are  b i a s by comparing  of  i t i s possible to  the e a r l y and  late  I f 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 the s c o r e s are  e v i d e n t then one can assume t h a t t h e r e i s no non-response Harris  (19 60) noted t h a t an 80% response r a t e i s n e c e s s a r y  b e f o r e the e f f e c t s  of non-response  b i a s can be negated.  t h i s r a t e of response the s t a t i s t i c a l if  bias.  results  At  are the same as  100% of the survey p o p u l a t i o n responded. Summary T h i s 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 d u r i n g the p r e n a t a l and p o s t n a t a l p e r i o d s on the l a t e r growth and development of the infant.  Pregnant women and mothers must be made aware of  the importance  of n u t r i t i o n a t t h i s time i n the l i f e  cycle  and take measures t o ensure the b e s t p o s s i b l e n u t r i t i o n a l for their  start  infant.  I t i s the r e s p o n s i b i l i t y o f h e a l t h p r o f e s s i o n a l s i n the areas o f maternal and i n f a n t pregnant women and new  n u t r i t i o n t o a d v i s e and  mothers i n the attainment of these  direct  66  goals.  P h y s i c i a n s as l e a d e r s o f the h e a l t h care teams  be c o g n i z a n t  should  o f the c u r r e n t i n f o r m a t i o n a v a i l a b l e on n u t r i -  t i o n and promote the acceptance o f good n u t r i t i o n a l h a b i t s i n these p a t i e n t s . of those  o f the a t t i t u d e s and p r a c t i c e s  p h y s i c i a n s most i n v o l v e d w i t h maternal and i n f a n t  nutrition will disseminated nutrition  Determination  e l u c i d a t e the k i n d of n u t r i t i o n  information  being  t o the maternal p o p u l a t i o n and assess the need f o r  services i n this v i t a l  area.  CHAPTER I I I DESIGN OF THE STUDY  This attitudes  s t u d y was d e s i g n e d  and c o u n s e l l i n g  pediatricians Columbia. variables and  and o b s t e t r i c i a n s  being  to ascertain  attitudes  The  non-manipulable  the kind  i n maternal  and p r a c t i c e s  s u r v e y was c o n d u c t e d  A status,  Medical  s t u d y was d e s i g n e d  as  of n u t r i t i o n information  and i n f a n t n u t r i t i o n o n t h e  with the co-operation of the  Association.  was c o n d u c t e d  ( B a k e r and S c h u t z ,  study  variables  utilizing  survey  to establish the r e l a and t h e research  non-manipulable techniques  1972 ) .  criterion  toward  Design  non-experimental  t i o n s h i p between t h e c r i t e r i o n  attitudes  upon t h e  of general practitioners,  Research  The  variates  assessed  and o b s t e t r i c i a n s .  Columbia  variates  This  ) was  t o mothers and hence, t o e x p l o r e t h e impact  r e c e n t developments  pediatricians  and p r a c t i c e s  was d e t e r m i n e d .  disseminated  British  of general practitioners,  i n the province of B r i t i s h  ( nutrition attitudes  project  nutrition  the n u t r i t i o n  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  criterion.variates  of  practices  the e f f e c t of selected,  a pilot  to investigate  ( dependent  ) variables  were:  (I)  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  67  prac-  68 tices.  The n o n - m a n i p u l a b l e  categorized as:  (1)  of medical t r a i n i n g , d e n t and  (2)  ( independent  demographic  ) variables  data which included  l o c a t i o n o f p r a c t i c e and sex o f  professional  were country respon-  d a t a w h i c h i n c l u d e d y e a r s and  o f p r a c t i c e , number o f p a t i e n t s tion information consulted,  seen weekly,  sources of  s p e c i a l i z a t i o n of t r a i n i n g ,  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 n u t r i t i o n i n medical school  type nutricon-  of  training.  The n a t u r e o f t h e r e l a t i o n s h i p b e t w e e n t h e c r i t e r i o n variables  a n d t h e v a r i a t e s was a s s e s s e d .  In  addition,  the  n a t u r e of the 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 s e l v e s was  them-  determined. Population  For 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  population of p r a c t i s i n g 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 Association  pediatricians,  r e g i s t e r e d w i t h the B r i t i s h Columbia  and p r a c t i s i n g  i n B r i t i s h Columbia.  This  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 , tricians  and o b s t e t r i c i a n s  i n the province.  sample o f  1,981  physicians.  Medical repre-  pedia-  There were  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 a n d 118 for a total  entire  1,753  obstetricians  69 Data  Collection  Data C o l l e c t i o n  D a t a were c o l l e c t e d questionnaires signed  b y means o f s e l f - a d m i n i s t e r e d  ( Appendix A ).  t o measure s e p a r a t e l y ,  practices  data.  The q u e s t i o n n a i r e s  nutrition  as w e l l as t o c o l l e c t  professional  Instruments  attitudes  and p r a c t i c e s c o n c e r n i n g  completed  by o b s t e t r i c i a n s w h i l e  the  nutrition  completed and  by p e d i a t r i c i a n s .  toward  The  by a d a t a  area  maternal n u t r i t i o n  a questionnaire  Both q u e s t i o n n a i r e s  instrument  developed  throughout pregnancy.  by a g r o u p o f n u t r i t i o n of prenatal nutrition.  experts  measured  were  was  combined  were mea-  for this  system  ( Table  study.  test  was  who had e x p e r i e n c e  experts.  IV ) v a l i d a t e d by S c h w a r t z  This system provided  This  The q u e s t i o n n a i r e  by a g r o u p o f a d u l t n u t r i t i o n  response  that  practitioners.  tested  first  was  c o n s i s t e d o f 10 s t a t e m e n t s r e f l e c t i n g t h e  importance o f n u t r i t i o n  the  nutrition  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  collection  questionnaire  validated  t h a t measured  nutrition  Attitudes sured  i n f o r m a t i o n and  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  completed by t h e g e n e r a l  Attitudes  a t t i t u d e s and n u t r i t i o n  demographic  A questionnaire  were d e -  was  in  pre-  The s c o r i n g  (1973) was  utilized.  f o r two r e s p o n s e s t o e a c h s t a t e m e n t ; t h e  i n d i c a t e d whether t h e respondent  agreed o r d i s a -  70 greed and the second response w i t h which the respondent was  i n d i c a t e d the degree  agreed or d i s a g r e e d .  of c o n f i d e n c e  Each statement ,  scored from 0 t o 7 w i t h a p o s s i b l e a t t i t u d e score between  0 and  70. TABLE IV SCORING SYSTEM FOR  Scale  NUTRITION ATTITUDE TEST  Degree o f C e r t a i n t y  Response  Very Moderately Doubtful Doubtful 1 2  Moderately Confident 3  Very Confident 4  Agree Agree Disagree  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 a t t i t u d e s were measured 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.  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 tance of n u t r i t i o n throughout t e s t was  the f i r s t  r e f l e c t i n g the impor2 y e a r s of l i f e .  v a l i d a t e d by a group of n u t r i t i o n e x p e r t s who  experience i n i n f a n t n u t r i t i o n .  The  This  had  The p r e t e s t and s c o r i n g  system  71 were a n a l o g o u s tricians'  to that  utilized  f o r the  assessment of  attitudes.  Attitudes  o f g e n e r a l p r a c t i t i o n e r s were m e a s u r e d  combining  the data c o l l e c t i o n  attitudes  with the t e s t f o r p e d i a t r i c i a n s '  ( Appendix A  Nutrition  practices  counselling validated  tice or  20  a group o f n u t r i t i o n  ( Table V took  time;  95%  of  of the time;  assumed t h a t  total  experts.  was  experience  The  pre-  scoring  of a s p e c i f i c  prac-  ' f r e q u e n t l y ' , 'sometimes',  'always'  was  designated  ' f r e q u e n t l y ' meant 50%  indicated  The  q u e s t i o n n a i r e was  frequency  'always',  research,  'sometimes'  of the time.  a possible  form  For t h i s  than  'never'  the  the  had  by  nutrition  This test  e x p e r t s who The  study.  regarding  women.  nutrition  ) indicated  for this  statements  f o r pregnant  a group o f a d u l t  'never'.  of the  5%  by  by  and  greater  and  practices  developed  area of prenatal n u t r i t i o n .  system,  attitudes  o f o b s t e t r i c i a n s were a s s e s s e d  instrument  questionnaire c o n s i s t e d of  tested  for obstetricians'  practices  a data c o l l e c t i o n  the  instrument  by  ).  Nutrition  in  obste-  5%  t o 49%  of the  to  was  s c o r e between  0 and  s c o r e d from 60.  95%  time;  t h e p r a c t i c e was c o n d u c t e d l e s s  Each statement  as  0 t o 3,  than with  72  TABLE V SCORING SYSTEM FOR NUTRITION PRACTICE TEST  Score  Response  Scale  Always  Never  Always  4  3  Frequently  3  2  Sometimes  2  1  Never  1  0  Never  1  3  Sometimes  2  2  Frequently Always  3  1  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 a s s e s s e d by a data c o l l e c t i o n instrument developed f o r t h i s study. questionnaire  The  c o n s i s t e d o f 20 s t a t e m e n t s r e g a r d i n g n u t r i t i o n  counselling practices for infants.  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 t h e a r e a 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 t o t h a t u t i l i z e d f o r t h e assessment o f o b s t e t r i c i a n s ' nutrition practices. 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 c o m b i n i n g t h e 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 with 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 d a t a  Demographic and p r o f e s s i o n a l d a t a v a r i a t e s ) were o b t a i n e d  ( non-manipulable  i n a s e p a r a t e s e c t i o n o f t h e ques-  73 tionnaire.  T h i s s e c t i o n was  physician's country type  of p r a c t i c e ,  patients mation,  of medical  years  training,  additional specialization education  the medical  on t h e  sex, l o c a t i o n  i n p r a c t i c e and number  and i n f a n t s s e e n w e e k l y .  continuing in  composed o f 11 q u e s t i o n s  of prenatal  Sources of n u t r i t i o n or t r a i n i n g ,  programs and t h e i n c l u s i o n  s c h o o l p r o g r a m were a l s o  and  infor-  attendance a t of nutrition  studied.  Procedure  The nutrition  data  experts  A validation  were v a l i d a t e d by States  ( Appendix B ).  ( A p p e n d i x B ) was d e s i g n e d  i n f o r m a t i o n on c l a r i t y ,  collection  ( 80% ) r e t u r n e d  instruments  i n Canada and t h e U n i t e d  questionnaire  used t o c o l l e c t the data  collection  instruments.  the v a l i d a t i o n  and  p r e c i s i o n and c o n t e n t  Sixteen  o f t h e 20 v a l i d a t o r s  questionnaires.  Fourteen  these  were r e c e i v e d i n t i m e f o r i n c o r p o r a t i o n o f t h e i r  tions  into  the f i n a l  questionnaire.  more v a l i d a t o r s d i s a g r e e d naire.  with  of  of  sugges-  S t a t e m e n t s t h a t two o r  were d e l e t e d  from the q u e s t i o n -  O t h e r s t a t e m e n t s were r e v i s e d i n o r d e r  to eliminate  ambiguities. The 197 5, tion  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  by g r a d u a t e s t u d e n t s  a n d f a c u l t y members i n Human N u t r i -  at the U n i v e r s i t y of B r i t i s h  students  and f a c u l t y  i n March,  Columbia.  Sixteen  graduate  members c o m p l e t e d t h e q u e s t i o n n a i r e  along  74 with a pretest were  questionnaire  again revised to  and t o  i n c l u d e the Packages  eliciting  suggestions  s u p p o r t and s t a t i n g  of t h i s  questionnaires first  improve the  stamped, study  of  the  by A p r i l  15,  r e m i n d e r was m a i l e d t o  d a t e was  set  c o d e d and t h e of  Columbia. tests,  all  May 27,  of  the m a i l  all  the  Computing Center  S c o r i n g of  the  study,  subjects  After  60  the  a new A second  i n May.  w h i c h was  the  the  stating  questionnaires submitted to  at  the  The  days  final  from  Package  U n i v e r s i t y of  for  A time  for  the  the Key-punching  and  British  practices  analyses  i n the  statistical  1974  S o c i a l Sciences  s c h e d u l e was d e s i g n e d  )  designed  analyses  the  ( N i e e_t a_l.  1975  to  well  Regresas  i n order  as  were  computing  B r i t i s h Columbia T r i a n g u l a r  ( B j e r r i n g and S e a g r a v e s , Package  responses  u s i n g programmes  by p e r s o n n e l  selected  the  U n i v e r s i t y of  nutrition attitudes  study,  The programmes  Statistical  the  Return of  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  i n c l u d e d the sion  for  letter  ( Appendix A ).  1975,  questionnaires  furnished for this  Center.  a cover  reminder,  p e r f o r m e d b y an IBM 3 7 0 / 1 6 8 c o m p u t e r , or  subjects.  was r e q u e s t e d .  subjects  at  questions  mailing.  Upon r e c e i p t  Service  pretest  1975.  a post-card  post-card  were  the  questionnaires  e n v e l o p e were m a i l e d t o  1975,  was m a i l e d t o  initial  of  authorization  return  deadline,  the  the  i n M a r c h 27,  deadline elapsed,  cut-off  clarity  The  containing a questionnaire,  and an a d d r e s s e d , subjects  ( Appendix C ).  facilitate  ) .  75  completion  of t h i s  study. Schedule  Stage 1 - P l a n n i n g and  Preparation  1.  D e s i g n Study  December  2.  Develop q u e s t i o n n a i r e  January  1  75  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 n u t r i t i o n experts  February  1  75  4.  W r i t e and p r i n t c o v e r and r e m i n d e r c a r d s  5.  by  letters  '74  February  '75  Pretest validated questionnaires  March  '75  6.  R e v i s e and p r i n t  March  ' 75  7.  Develop c o d i n g  March  '75  questionnaires  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  March  •75  2.  Mail questionnaires to physicians  March  '75  3.  M a i l reminders  AprilMay  '75  AprilMay  •75  Stage 3 - Data A n a l y s e s  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 check c o d i n g  2.  Key-punch from coded q u e s t i o n n a i r e s  May  •75  3.  Data a n a l y s i s by computer  June  •75  4.  R e s u l t s and  JuneJuly  •75  final  responses,  report  Data A n a l y s i s Data c o l l e c t e d were coded, key-punched o n t o c a r d s ,  and  treated s t a t i s t i c a l l y ing  by computer a n a l y s i s , t o t e s t t h e  follow-  hypotheses: 1.  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 counselling practices  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 was 2.  determined  ( h y p o t h e s i s 11 )  by c o r r e l a t i o n a n a l y s i s .  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  o f 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 was  con-  d u c t e d 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 t h e group means.  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 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 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 ( h y p o t h e s i s 12 3.  ).  S t e p w i s e r e g r e s s i o n a n a l y s e s were c a r r i e d out on t h e 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 p r a c t i c e s , t o d e t e r m i n e whether t h e  variables  and  non-manipulable  v a r i a t e s were f a c t o r s w h i c h r e l a t e d t o t h e  4.  and  criterion  ( o b j e c t i v e 2 ).  The r e l a t i o n s h i p o f each o f 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 and t y p e o f p r a c t i c e , y e a r s o f p r a c t i c e , sex o f r e s p o n d e n t , weekly,  number o f p a t i e n t s seen  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 , number  and 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 programs a t t e n d e d and i n c l u s i o n 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  77 school t r a i n i n g to n u t r i t i o n attitudes  and 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 obstetricians  ( hypotheses 1, 2, 3, 4, 5, 6, 7,  8, 9, 10 ) was t e s t e d  by a one-way a n a l y s i s o f  variance f o r s i g n i f i c a n t differences  i n group means  f o r each o f the c r i t e r i o n v a r i a b l e s . 5.  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  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 who attended one c o n t i n u i n g programme  education  t o those who attended more than one  programme was determined by t - t e s t f o r s i g n i f i c a n t differences In a d d i t i o n , was a d i f f e r e n c e  i n group s c o r e s . a t - t e s t was used t o determine i f t h e r e  between e a r l y and l a t e respondents 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 . A l l r e s u l t s were reported a t the highest l e v e l of s i g n i f i c a n c e .  CHAPTER  FINDINGS AND  In t h i s and  tion  of the  INTERPRETATIONS  of general  o b s t e t r i c i a n s i n the  nature  was  study  practitioners, pediatricians  province  of B r i t i s h  r e l a t i o n s h i p of 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 explored.  variables  IV  The  a t t i t u d e s and  the nutri-  selected environmental v a r i a t e s  r e l a t i o n s h i p between t h e  ( nutrition  Columbia,  a t t i t u d e s and  two  criterion  p r a c t i c e s ) was  also  investigated. Rates of  Questionnaires registered with total  of  overall  844  returned engaged  British  response rate of  literature ).  were s e n t  questionnaires  s p o n s e compares  1974  the  Of  the  to  1,9 81  were r e t u r n e d , ( Table  with  others  Garrison,  questionnaires  VI  1973;  received,  questionnaires tabulation  p r a c t i c e of o b s t e t r i c s or were i n c o m p l e t e l y  impossible.  78  physicians  Association.  representing ).  This  reported  unanswered, m a i n l y because t h e i n the  practising  Columbia M e d i c a l  42.5%  favourably  ( G u l l e n and  Response  Schiller 60  an  r a t e of  i n the and  ( 3.0%  A  re-  recent  Vivian,  ) were  p h y s i c i a n was pediatrics.  answered, thus making  no  longer  Twenty their  79 TABLE V I SUMMARY OF RESPONSE RATES FROM PHYSICIANS  Number Sent  Number Received  % Received  1,753  724  41.3  Pediatricians  110  69  62.7  Obstetricians  118  51  43.2  1,981  844  42.6  Physician  General Practitioners  Total  C o m p a r i s o n o f E a r l y and L a t e  The survey over  major disadvantage  research  instrument  who r e s p o n d s .  of the mail  I f non-respondents d i f f e r  b i a s may be i n t r o d u c e d w h i c h c o u l d  duals  Results  who r e s p o n d  who do n o t r e s p o n d 1963  late  lack of control significantly  s t u d i e d , a non-response  invalidate  the interpretation  o f s t u d i e s have i n d i c a t e d t h a t to questionnaires  at a l l ( Larson  as a  are similar  and C a t t o n ,  indivi-  t o those  1959; R o e h e r ,  ) . Of  ted  questionnaire  i s the researcher's  f r o m r e s p o n d e n t s on t h e i s s u e s b e i n g  of the survey.  Respondents  t h e 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  q u e s t i o n n a i r e , 467 d i d s o by t h e f i r s t  deadline  a comple-  d a t e and  80 hence, were d e s i g n a t e d as e a r l y respondents. ( 28% ) g e n e r a l p r a c t i t i o n e r s t o r e t u r n  The f i n a l  180  questionnaires before  the f i n a l c u t - o f f date were c o n s i d e r e d t o be l a t e  respondents.  Q u e s t i o n n a i r e s 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 f o r e a r l y and l a t e  respondents  ( Table V I I ). TABLE V I I NUMBER AND PERCENTAGE OF PHYSICIANS DESIGNATED AS EARLY AND LATE RESPONDENTS  Physician  Early  General Practitioner  467  Late  ( 72% )  180  ( 28% )  Pediatrician  59 ( 87% )  9  ( 13% )  Obstetrician  37 ( 77% )  11 ( 23%')  Results of t - t e s t analyses f o r s i g n i f i c a n t i n group means o f t e s t s c o r e s f o r e a r l y and l a t e showed no s i g n i f i c a n t d i f f e r e n c e s  if  l a t e respondents  scores f o r general p r a c t i -  and o b s t e t r i c i a n s  ( Table V I I I ).  Thus,  may be c o n s i d e r e d s i m i l a r t o non-respondents  the non-response i n t h i s study of the r e s u l t s .  respondents  a t the 1% l e v e l f o r n u t r i t i o n  a t t i t u d e scores or n u t r i t i o n p r a c t i c e tioners, pediatricians  differences  should not b i a s  the i n t e r p r e t a t i o n  81 TABLE V I I I COMPARISON OF EARLY AND LATE RESPONDENTS ON BASIS OF MEAN PERCENTAGE TEST SCORES  Mean Test Scores Physician General  Early  Late  Significance  Practitioners'  Nutrition  Attitudes  72.75  72. 32  / N.S.  Nutrition  Practices  60.11  59.87  N.S.  Pediatricians' Nutrition  Attitudes  81.58  81.10  N.S.  Nutrition  Practices  65.75  64.46  N.S.  Obstetricians' Nutrition  Attitudes  62.43  69.99  N.S .  Nutrition  Practices  64.15  66.52  N.S.  General Description Univariate the  Practitioners o f Respondents  frequency t a b l e s  demographic and p r o f e s s i o n a l  were designed t o d e s c r i b e  c h a r a c t e r i s t i c s o f the g e n e r a l  p r a c t i t i o n e r s who responded t o t h i s  survey.  Country o f m e d i c a l t r a i n i n g Most g e n e r a l p r a c t i t i o n e r s who r e p l i e d t o the q u e s t i o n -  82 naire  received  Canada  the m a j o r i t y of t h e i r medical t r a i n i n g i n  ( T a b l e IX ) .  TABLE IX DISTRIBUTION  OF GENERAL PRACTITIONERS OF MEDICAL TRAINING  Country o f M e d i c a l Training  BY COUNTRY  Number  Canada  %  449  70.0  121  18.8  14  2.2  9  1.4  Australia  7  1.1  Germany  5  0.8  India  3  0.5  33  5.2  641  100.0  Great  Britain.  United States Ireland  1  Others Total  Sex Distribution that  593  were  female.  of respondents  a c c o r d i n g t o s e x showed  ( 91.9% ) o f t h e r e s p o n d e n t s were m a l e w h i l e 52  ( .8.1% )  Location of practice The  highest percentage  ( e x c l u d i n g Vancouver ( T a b l e X ).  o f r e s p o n d e n t s were f r o m  ) with p o p u l a t i o n s g r e a t e r than  cities  5000  83 TABLE X DISTRIBUTION OF GENERAL PRACTITIONERS LOCATION OF PRACTICE  BY  %  Number  Location Vancouver  228  35.3  Other  300  46.4  Town  66  10.2  Village  52  8.1  City  Years  of  100.0  646-  Total practice The  majority of the general practitioners  t h e q u e s t i o n n a i r e were i n p r a c t i c e ( Table  f o r more  responding  than  10  DISTRIBUTION OF GENERAL PRACTITIONERS YEARS OF PRACTICE  BY  to  years  XI ) . TABLE X I  Years <5  of  years but <  >10  10  years Total  Type o f  181  28.0  131  20.2  335  51.8  647  100. 0  practice More t h a n  practice  %  Number  Practice  ( Table  50% o f t h e r e s p o n d e n t s XII ).  were i n c l i n i c  o r group  84 TABLE X I I DISTRIBUTION OF GENERAL PRACTITIONERS TYPE OF PRACTICE  Type  BY  %  Number  Private  305  47.6  Clinic  336  52.4  641  100.0  Total  Patients  seen weekly The  fewer than more t h a n  m a j o r i t y of general  practitioners  ( 79.1% ) s e e  10 p r e g n a n t women w e e k l y b u t most p h y s i c i a n s 10 i n f a n t s p e r week  ( Table  TABLE  treat  XIII ).  XIII  DISTRIBUTION OF GENERAL PRACTITIONERS BY THE NUMBER OF PATIENTS SEEN WEEKLY  Number o f P r e n a t a l Patients  <10 > 10 b u t < 25 >25 Total Number o f I n f a n t s  Number  507  %  132  79.1 20.6  2  0.3  641  100.0  Number  %  <10  231  36.0  >10 b u t < 25  344 66  53.7 10.3  641  100.0  >25 Total  85 Sources  of nutrition information Of t h e r e s p o n d e n t s ,  that  they use r e s o u r c e m a t e r i a l  ( Table XIV ). other of  636 g e n e r a l p r a c t i t i o n e r s  source.  Professional  frequently  for nutrition information  j o u r n a l s were u t i l i z e d  Most p h y s i c i a n s r e f e r r e d  information. than  indicated  more t h a n any  t o more t h a n one s o u r c e  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 consultation with a n u t r i t i o n i s t - d i e t i t i a n . TABLE X I V  NUMBER AND PERCENTAGE OF GENERAL PRACTITIONERS INDICATING SOURCES OF NUTRITION INFORMATION  Source Professional  Number  %  journals  588  91.7  publications  399  62.2  379  58.6  356  55.5  349  54.4  284  44. 3  277  43.2  P h a r m a c e u t i c a l companies' brochures  227  35.4  Magazines  207  32.2  163  25.4  143  22.3  113  17.6  Radio  94  14.6  Television  86  13.4  Home  18  2.8  28  4.4  Government  Professional  bulletins  Books H e a l t h agency  publications  Colleague Nutritionist  Food  manufacturers' brochures  Audiovisual Public  Other  - Dietitian  aids  Health  Economist  Nurse  86  Specialization Table respondents that al  XV i n d i c a t e s  had a d d i t i o n a l  may be r e l a t e d  training  practiced  that  training  to nutrition.  i n pediatrics  as g e n e r a l p r a c t i t i o n e r s . under t h e heading  'other'  medicine  or i n t e r n a l medicine.  training  i n surgery  25% o f t h e  for specialization  i n areas  Some p h y s i c i a n s h a d  or obstetrics  together  Table  approximately  although  they  Specializations included training  General  practitioners  additionstill  grouped in tropical who h a d  o r a n e s t h e s i o l o g y were n o t i n c l u d e d i n  XV. TABLE XV  NUMBER AND  PERCENTAGE OF GENERAL PRACTITIONERS HAVING TRAINING FOR S P E C I A L I Z A T I O N  Training f o r Specialization  Number  ADDITIONAL  %  Obstetrics  38  5.9  Family  27  4.2  Neonatology  24  3.7  Pediatrics  19  2.9  13  2.0  50  7.7  161*  25.1*  Public  Practice  Health  Diploma  Other Total Ten  of these  Continuing The  p h y s i c i a n s h a d more t h a n  one s p e c i a l i z a t i o n .  education majority of physicians responding  d i d not attend  87 continuing the  education  respondents  registered education  programs  attended  these  f o r more t h a n  programs l i s t e d ,  the  i n the province  presented  i n other  Only  The two c o n t i n u i n g  and L a t e r L i f e " ,  attended  18.8% o f  20 p h y s i c i a n s  "Care o f t h e High R i s k  of British  general practitioners  XVI ) .  programs and j u s t  one p r o g r a m .  Newborn" a n d " E a r l y N u t r i t i o n offered  ( Table  Columbia.  Foetus  were  programs  However, many o f  continuing education  Canadian provinces  and  or i n the United  programs States.  TABLE XVI NUMBER AND  PERCENTAGE OF RESPONDENTS INDICATING ATTENDANCE AT CONTINUING EDUCATION PROGRAMS  Continuing Education Programs  Number  %  Care o f t h e High Risk F o e t u s a n d Newborn  43  6.6  E a r l y N u t r i t i o n and Later L i f e  14  2.2  Other  84  13.0  Total * Twenty o f t h e s e  Nutrition  121* physicians attended  i n medical  one p r o g r a m .  education  Most o f t h e r e s p o n d e n t s nutrition  more t h a n  18. 8*  ( T a b l e X V I I ).  had n e v e r t a k e n  a course  Some p h y s i c i a n s i n d i c a t e d  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  that  on nutri-  c o u r s e s and  88  had  little  practical  relevance.  comments t o q u e s t i o n n a i r e s had  no f o r m a l  nutrition  ).  ( See A p p e n d i x D f o r p h y s i c i a n s ' Forty percent  of the  respondents  education.  TABLE  XVII  NUMBER AND PERCENTAGE OF GENERAL PRACTITIONERS INDICATING TYPE OF NUTRITION EDUCATION IN MEDICAL SCHOOL  Format o f N u t r i t i o n Education  C o u r s e on  Nutrition  Number  %  14  2.1  Series of lectures  101  15.6  Integrated with other subject matter  338  52.2  No f o r m a l n u t r i t i o n education  262  40.5  it  89 Nutrition  Attitudes  and P r a c t i c e s  Method o f s c o r i n g  The  test  o f 20  sisted  of nutrition  statements  and by t h e d e g r e e ment was score  each  attitudes a n s w e r e d by  of certainty  f o r each  s c o r e d b e t w e e n 0 and 7  f o r the attitude  t e s t was  sents the t o t a l  number  one  o f p h y s i c i a n s who  talling number  statement  individual  or "Disagree Each  The mean  by a d d i n g  by 6 3 0 .  This  1  statetotal  respon-  figure repre-  completed  at least  Q u e s t i o n n a i r e s w i t h more  r e s p o n s e m i s s i n g were e l i m i n a t e d  s c o r e s f o r each  A ) con-  response.  calculated  s c o r e s and d i v i d i n g  statements.  'Agree'  ( T a b l e IV ).  dents' a t t i t u d e  o f t h e 20 o p i n i o n  ( Appendix  from t h e a n a l y s i s .  19  than Mean  on t h e t e s t were o b t a i n e d by t o -  statement  s c o r e s and d i v i d i n g  o f answered s t a t e m e n t s .  by t h e t o t a l  T h o s e q u e s t i o n n a i r e s w i t h one  u n a n s w e r e d s t a t e m e n t were a s s i g n e d t h e mean s c o r e s f o r t h a t particular  statement.  A separate section 40  statements  was  a n s w e r e d by i n d i c a t i n g  tice  was p e r f o r m e d .  'frequently , 1  to  on n u t r i t i o n  3  counselling  practices  The c a t e g o r i e s u t i l i z e d  A total  ( Appendix  the frequency w i t h which  'sometimes' and  ( Table V ).  least  of the questionnaire consisting of  'never*  o f 620  38 o f t h e 40 p r a c t i c e  scored  i n a manner a n a l o g o u s  test.  Scores  the prac'always',  and were s c o r e d f r o m  respondents  statements. to that  were  A )  completed  The p r a c t i c e  of the n u t r i t i o n  0  at  test  was  opinion  f r o m b o t h t e s t s were c o n v e r t e d t o p e r c e n t a g e s  so  90 that  the  Results  two  of  analyzed  f r o m a common  base.  tests  The practices  v a r i a b l e s c o u l d be  mean s c o r e s  for tests  are presented  considerably  higher  i n Table  than  of n u t r i t i o n XVIII.  attitudes  and  A t t i t u d e scores  p r a c t i c e scores  for general  were  practi-  tioners . TABLE  XVIII  MEAN PERCENTAGE SCORES FOR NUTRITION ATTITUDE PRACTICE TESTS FOR GENERAL PRACTITIONERS  Test  a  Mean S c o r e  Attitudes  72.64 +  8.75  Practices  60.05 +  7.49  Standard  Nutrition  Attitudes:  72.64% w i t h  practitioners  scored  few  trast of  daily tion  mean t e s t  physicians  on  items  feel  42.9%  3,  that  score  8,  lactation  N a t i o n a l Research C o u n c i l  to permit  ( Answer key  the  10  500  of maternal  f o r a l l statements  General  pregnancy  calories  i s i n Appendix  during  ).  con-  Board  stores. E  even  is in direct  Nutrition  body-fat  XIX ) .  appropriate  (1973) w h i c h recommended  intake of only  readjustment  nutrition  ( Table  i s an  This  F o o d and  for  92.1%.  f a t accumulated during  recommendations o f  i n c r e a s e d energy  to  9 and  n u t r i e n t i n t a k e remains adequate.  t o the  the  The  a range from  lowest  time t o e l i m i n a t e excess when t h e  a  Deviation  a t t i t u d e s was  Apparently,  AND  a lacta-  91 TABLE XIX STATEMENTS MEASURING NUTRITION ATTITUDES FOR WHICH GENERAL PRACTITIONERS RECEIVED LOWEST MEAN SCORES  Correct Response  Statement  10.  Mean Score  L a c t a t i o n i s a good t i m e to get r i d o f excess weight accumulated during pregnancy as l o n g as nut r i e n t i n t a k e remains adequate • •  Agree  7.0  3.2  I f e e l that pregnant women n e e d s o much f o l i c acid that i t i s d i f f i c u l t t o g e t i t from d i e t alone  Agree  7.0  3.2  Provided t h a t they enter pregnancy w i t h adequate h e m o g l o b i n l e v e l s , women need t o i n c r e a s e t h e i r iron intake only during the l a s t h a l f o f pregnancy  Agree  7.0  2.8  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 i n f o r m a t i o n on m a t e r n a l n u t r i t i o n i n the current s c i e n t i f i c j o u r n a l s and books  Disagree  7.0  2.9  t h a t there.was  little  Surprisingly, accurate, nals  Possible Score  practical  many p h y s i c i a n s  information  a n d b o o k s and y e t t h e y  t h e i r major source The  highest  felt  i n the current  s c i e n t i f i c jour-  l i s t e d t h e s c i e n t i f i c j o u r n a l s as  of nutrition  information  mean a t t i t u d e s c o r e  ( Table  XIV ) .  ( 6.6 ) was a c h i e v e d  on  statement  6 concerning  breast-feeding. been  listed  Average  scores  test  practices:  General  s c o r e o f 60.05% w i t h  L o w e s t mean s c o r e s were a c h i e v e d 30,  fora l l attitude  questions  have  i n A p p e n d i x F.  Nutrition practice  p h y s i c i a n s i n f o r m i n g p r e g n a n t women a b o u t  33, 34, a n d 38 ( T a b l e  practitioners  h a d a mean  a r a n g e f r o m 33.3% t o 88.3%.  on s t a t e m e n t s  4, 8, 15, 22, 28,  XX ) .  TABLE XX STATEMENTS MEASURING NUTRITION COUNSELLING PRACTICES FOR WHICH GENERAL PRACTITIONERS RECEIVED LOWEST MEAN SCORES  Statement 4.  8.  15.  22.  Correct Response  Possible Score  Mean Score  I a d v i s e h e a l t h y expect a n t women who do n o t d r i n k milk t o take a Never  3.0  0.9  Always  3.0  1.1  Never  3.0  0.9  Always  3.0  1.1  I encourage t h e average p r e g n a n t woman t o g a i n a p p r o x i m a t e l y 1 pound p e r week i n t h e l a s t 20  I prescribe a multiv 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 e v e n when t h e i r d i e t a r y i n t a k e appears adequate.. I a s k m o t h e r s f r o m what sources t h e i r 1 - 2 year olds obtain  93 T a b l e XX  (continued) Correct Response  .Statement  28.  30.  33.  34.  38.  Never  3.0  0.9  I recommend t h a t i r o n f o r t i f i e d foods o r i r o n d r o p s be a p a r t o f t h e infant's dietary regimen d u r i n g t h e 2nd y e a r of l i f e -  Always  3.0  1.2  I recommend t h a t by t h e time t h e c h i l d i s 5 months o f age he s h o u l d 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  Never  3.0  0.8  I recommend t h a t a multi-vitamin supplement be g i v e n t o h e a l t h y infants  Never  3.0  1.2  I encourage mothers t o i n c l u d e a b o u t 25 grams of p r o t e i n i n the d a i l y d i e t of a 1 - 2 year old  Always  3.0  1.1  i s evident  adequate.  vitamin  Yet i r o n - f o r t i f i e d  recommended  numerous s t u d i e s Nutrition it  that  34 ) a r e recommended w i d e l y  ally  Mean Score  I recommend t h a t human m i l k alone i s adequate in nutrient content f o r t h e f i r s t two months of l i f e  It and  Possible Score  for infants ( Filer  ( statements  e v e n when d i e t a r y  15  intake i s  foods or i r o n drops are not gener( statement  and M a r t i n e z ,  C a n a d a , 1973; M a s l a n s k y  i s iron rather  preparations  than vitamins  30 ) .  1964; P u r v i s ,  e t a l . , 1974  which  The r e s u l t s o f 1973;  ) h a v e shown  i s most l i k e l y  t o be  that  94  lacking  i n the infant's Few  one  physicians  diet. encourage a weight g a i n o f approximately  pound p e r week i n t h e l a s t  n o r m a l p r e g n a n t woman  20 weeks o f p r e g n a n c y  ( statement  recommendations o f s e v e r a l  8 ).  committees and  ( Committee on M a t e r n a l N u t r i t i o n , Nutrition  i n Pregnancy Committee,  weight gain to  eight  i n the v i c i n i t y  197 0;  leaving  latter  part.  Relationship A  highly  1973 ) who s u g g e s t a t o t a l  probability Jalso  This correlation  20 weeks o f p r e g -  correlation  ( r = 0.370 )  and p r a c t i c e s  of general  was s i g n i f i c a n t a t t h e 1%  These r e s u l t s  c o n f i r m t h e e a r l i e r work o f  e t a l . , (1965) who f o u n d a s t r o n g p o s i t i v e  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  correlation  ( r = 0.63 ) f o r  members o f community o r g a n i z a t i o n s  i n New Y o r k S t a t e .  workers  Schwartz,  a  ( Newton a n d Newton, 19 50;  similar positive  and  and  relationship  Other  197 5 ) h a v e  between n u t r i t i o n  adult  found  attitudes  practices. It  that  four  to practices  significant positive  level.  Generally,  20 pounds t o a c c u m u l a t e d u r i n g t h e  found between n u t r i t i o n a t t i t u d e s  practitioners.  to the  H y t t e n a n d L e i t c h , 1971;  o f 24 t o 2 8 p o u n d s .  approximately  of attitudes  i s contrary  investigators  pounds a r e g a i n e d d u r i n g t h e f i r s t  nancy,  was  This  for the  i s g r a t i f y i n g t o observe that  p r e g n a n t women s h o u l d  be i n f o r m e d  encourage b r e a s t - f e e d i n g  many p h y s i c i a n s  about  feel  breast-feeding  among t h e i r p r e g n a n t  patients  95 ( statements to  reports  did  6, 2 a n d 31 i n T a b l e  i n the recent  literature  breast milk Vitamin  This  i n some n u t r i e n t s  D ) a n d must be s u p p l e m e n t e d  apparently  ( Shukla e t a l . ,  However, few p h y s i c i a n s  i s inadequate  i s i n contrast  that physicians  l i t t l e t o encourage b r e a s t - f e e d i n g  Applebaum, 1975 ) .  1974;  XXI ) .  realized  1972;  that  ( particularly  ( Kodicek,  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 ,  1973; Fomon, 1975 ) .  TABLE XXI COMPARISON OF NUTRITION ATTITUDES AND PRACTICES OF GENERAL PRACTITIONERS CONCERNING BREAST-FEEDING  Statement  Correct Response  Possible Score  Mean Score  Attitude 6.  P r e g n a n t women s h o u l d b e informed about t h e p r o s and c o n s o f b r e a s t feeding  Agree  7.0  6. 6  I consider the p o s s i b i l ity of breast-feeding w i t h t h e p r e g n a n t women I s e e i n my p r a c t i c e  Always  3.0  2.8  I recommend t h a t human m i l k alone i s adequate in n u t r i e n t content f o r t h e f i r s t two months o f life  Never  3.0  0.9  I e n c o u r a g e h e a l t h y mothers of infants to breast-feed f o r the f i r s t s i x months  Always  3.0  2.1  Practices 2.  28.  31.  96 Attitudes  and p r a c t i c e s  on t h e i n t r o d u c t i o n  into  t h e 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  feel  p r e s s u r e d by m o t h e r s  to introduce  t h e y a p p e a r t o do s o on t h e i r own  of solids do n o t  s o l i d s a t an e a r l y a g e ;  initiative  ( Table XXII ).  TABLE X X I I COMPARISON OF NUTRITION ATTITUDES AND PRACTICES OF GENERAL PRACTITIONERS CONCERNING EARLY INTRODUCTION OF SOLIDS  Statement  Correct Response  Possible Score  Mean Score  Attitude 17.  Many m o t h e r s a r e a n x i o u s 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 b e s t t o go a l o n g  Disagree  7.0  5.1  Never  3.0  1.6  Never  3.0  1.6  Never  3.0  0.8  Practices 23.  25.  33.  I encourage mothers t o g i v e c e r e a l s added t o t h e b o t t l e f o r a healthy i n f a n t who i s n ' t s a t i s f i e d  I recommend t h e e a r l y ( w i t h i n 2 months o f birth ) introduction of s o l i d s such as c e r e a l s  I recommend t h a t by t h e time the c h i l d i s 5 months o f age he s h o u l d be e a t i n g c e r e a l s , f r u i t s ,  97 The R e l a t i o n s h i p  of Selected  Variates to  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 criterion variables  ( 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 n v e s t i g a t e d i n two ways: using  by one-way a n a l y s i s o f v a r i a n c e  S c h e f f e ' s t e s t and a n a l y s i s o f v a r i a n c e  multiple regression.  ) were  using  stepwise  Scheffe's t e s t allows multiple  comparisons  o f a number o f means t a k e n two a t a t i m e , even when t h e means are from groups o f u n e q u a l s i z e .  In order t o reduce t h e t o t a l  number o f v a r i a t e s , a number o f s i m i l a r v a r i a t e s were grouped under one h e a d i n g .  Stepwise regression  a n a l y s i s determined  w h i c h o f t h e 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 t h e criterion variables.  T h i s e f f e c t i s independent o f t h e 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 o f v a r i a n c e Location  of medical t r a i n i n g :  Table XXIII  indicates  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 s and p r a c t i c e s .  S i n c e 8 8.8%  of the  g e n e r a l 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 o r G r e a t Britain  ( T a b l e IX ), t h e r e m a i n i n g c o u n t r i e s were grouped  t o g e t h e r as one c a t e g o r y .  98  TABLE X X I I I MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR ATTITUDE AND PRACTICE TESTS BASED ON LOCATION OF MEDICAL TRAINING  Country  Test  NUTRITION  Significance  Canada  Great B r i t a i n  Other  Attitudes  73.01  72. 38  71.04  N.S.  Practices  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  significantly  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 e i r male c o u n t e r p a r t s  than d i d  ( T a b l e XXIV ) . TABLE X X I V  MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON SEX OF RESPONDENT  Sex  Test Male  Significance P < 0.01  Female  Attitudes  72.36  76.21  S.  Practices  59. 64  65.08  S.  Location of practice:  T h e r e 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 t e s t s b a s e d on l o c a t i o n o f p r a c t i c e  ( Table  XXV ) .  practices  99 TABLE XXV MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON LOCATION OF PRACTICE  Location of Practice Other Vancouver City Town  Test  Significance  Village  Attitudes  72. 85  73.04  70. 69  72.04  N.S.  Practices  60.28  59.79  60.82  59.60  N.S.  Years cated that  of practice:  10 y e a r s  tude  and p r a c t i c e fewer  XXVI  of variance  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  than  for  One way a n a l y s i s  scored s i g n i f i c a n t l y  than  tests  lower  than physicians  indi-  f o r more  on t h e n u t r i t i o n  atti-  who were i n p r a c t i c e  f i v e y e a r s and between f i v e  a n d 10 y e a r s  ( Table  ) . TABLE XXVI MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON YEARS OF PRACTICE  Years  Test <C.5 y e a r s  5  of Practice years-ClO  ^>10 y e a r s  Significance P<0.001  Attitudes  73.41  74. 81  71.32  S.  Practices  61.46  61.06  58.85  S.  Type o f p r a c t i c e :  T a b l e XXVII i n d i c a t e s  that  type o f  100 p r a c t i c e h a d 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 a n d practices  of general  practitioners. TABLE X X V I I  MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON TYPE OF PRACTICE  Type o f P r a c t i c e  Test  Private  Significance  Clinic  Attitudes  72. 31  72.87  N.S.  Practices  59.94  60.05  N.S.  Number o f p r e n a t a l difference  patients:  significant  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  b a s e d o n number o f p a t i e n t s though p h y s i c i a n s  seen weekly  ( Table XXVIII ). A l -  who s e e more t h a n 25 p a t i e n t s  have h i g h e r s c o r e s , group  T h e r e was no  t h e r e were o n l y  weekly appear t o  two p h y s i c i a n s  i n this  ( Table 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  Test  Number o f P r e n a t a l <10  > 10 b u t  Patients  <25  >  Significance 25  Attitudes  72.42  73.39  80.35  N.S.  Practices  59.60  61. 62  64.15  N.S.  101 Number had  of infants:  no s i g n i f i c a n t  ( Table  effect  The number o f i n f a n t s on t h e t e s t  scores of  seen  weekly  respondents  XXIX ) . TABLE XXIX  MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON NUMBER OF INFANTS SEEN WEEKLY  Number  Test <ClO  infants  of  Infants  infants  y>10  but<25  Significance >25  Attitudes  72.50  7 2 . 64  73.05  N.S.  Practices  59.59  60.14  60.56  N.S.  Additional had  additional  practitioners XXX  training  training without  for specialization:  scored  Physicians  s i g n i f i c a n t l y higher  any a d d i t i o n a l  specialization  than  who  general  ( Table  ) . TABLE  XXX  MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON ADDITIONAL TRAINING FOR S P E C I A L I Z A T I O N  Training  Test  for Specialization  Training  No  Training  Significance P < 0 . 05  Attitudes  74.00  72.26  S.  Practices  62.34  59.31  S.  Continuing  Education:  R e s p o n d e n t s who  had a t t e n d e d  one  102 o r more c o n t i n u i n g e d u c a t i o n heading  a n d compared t o r e s p o n d e n t s  continuing that  p r o g r a m s were g r o u p e d u n d e r o n e  education  programs.  t h e r e was a s i g n i f i c a n t  tude and p r a c t i c e  tests  who h a d n o t a t t e n d e d a n y  Analysis of variance  indicated  difference i n the n u t r i t i o n  based on these  two g r o u p s  atti-  ( Table  XXXI ) . TABLE XXXI MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON ATTENDANCE AT CONTINUING EDUCATION PROGRAMS ATTENDED  Continuing  Test  Education  Attendance  No  Programs  Significance P < 0.01  Attendance  Attitudes  75.04  72.16  S.  Practices  63.07  59.40  S.  Mean t e s t one  s c o r e s o f p h y s i c i a n s who a t t e n d e d  continuing education  titioners  who a t t e n d e d  p r o g r a m s were compared  o n l y one p r o g r a m .  t h a t t h e r e was no s i g n i f i c a n t these  two g r o u p s .  Table  more  than  to general  prac-  XXXII i n d i c a t e s  d i f f e r e n c e i n the t e s t  scores o f  103 TABLE X X X I I MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON NUMBER OF CONTINUING EDUCATION PROGRAMS ATTENDED  Number o f C o n t i n u i n g Programs  Test  1  Education  Significance  >1  Attitudes  74.73  76.78  N.S.  Practices  62. 60  65.93  N.S.  Nutrition had  no f o r m a l  those  i n medical  school:  n u t r i t i o n education  who h a d some t r a i n i n g  General  scored  i n nutrition  practitioners  significantly ( Table  less  who than  XXXIII ) .  TABLE X X X I I I MEAN PERCENTAGE SCORES OF GENERAL PRACTITIONERS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON NUTRITION EDUCATION IN MEDICAL SCHOOL  Test  Nutrition i n Medical Nutrition  No  School  Nutrition  Significance P < 0.05  Attitudes  73.46  71.61  S.  Practices  60.60  59.25  S.  104 Stepwise  regression The  relationship  two c r i t e r i o n regression. bases  were s e l e c t e d .  of medical t r a i n i n g  other variates;  number  training  - fewer  - fewer  no b a s e s  Nutrition analysis  T a b l e XXXIV. medical  patients  - fewer  test:  attitude  i n the countries  the t h i r d ficantly  regression category  f o r the -  Vancouver;  t h a n 10; number o f  The r e s u l t s  into  groups.  a second  consisted  listed  group  i n medical  school  information,  analysis  test  under  their  'demographic i n -  One g r o u p listed  regres-  are reported i n  d i d not receive  countries  showed t h a t  consisted of  medical doctors  attitude  and t h e O r i e n t .  respondents  ( from a l l o t h e r c o u n t r i e s  lower on t h e n u t r i t i o n  of stepwise  of a l l other general p r a c t i t i o n -  e r s , m o s t o f whom were f r o m E u r o p e a n Stepwise  and p r a c -  years; type of p r a c t i c e - p r i -  G e n e r a l p r a c t i t i o n e r s who  a third  of  f o r comparison.  attitude  from I r e l a n d ;  f r o m Germany;  f o r comparison  and 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  f o r m a t i o n ' were c a t e g o r i z e d physicians  multiple  of practice  Sources of n u t r i t i o n  f o r the n u t r i t i o n  training  t o the  but nominal,  attitudes  t h a n 10; and n u t r i t i o n  specialization  programs needed  The b a s e  location  than f i v e  - no n u t r i t i o n .  additional  by s t e p w i s e  to nutrition  - male;  of prenatal  patients  variates  I n a l i k e manner, b a s e s were c h o s e n  sex base  years of p r a c t i c e  infant  investigated  As most v a r i a t e s were n o t o r d i n a l ,  t i c e s was C a n a d a .  vate;  of the non-manipulable  v a r i a b l e s was  f o r comparison  country  sion  results  test  listed in  ) scored  signi-  when c o m p a r e d t o  105 p h y s i c i a n s t r a i n e d i n Canada..  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 more than 10 y e a r s scored s i g n i f i c a n t l y lower than those who were i n p r a c t i c e f o r l e s s than f i v e y e a r s .  TABLE XXXIV STEPWISE REGRESSION RESULTS FOR VARIATES SIGNIFICANTLY RELATED TO MEAN PERCENTAGE SCORES ACHIEVED BY GENERAL PRACTITIONERS ON THE NUTRITION ATTITUDE TEST  Variate Constant  70. 63  Location of medical t r a i n i n g : Other country  -6. 21  Sex:  3. 71  Female  Years o f p r a c t i c e :  J>10  Probability  Coefficient  ! < 0.001 :  < 0.01  -2. 35  ' < 0.001  14. 06  <0.05  Number o f p r e n a t a l p a t i e n t s : >25 Sources o f n u t r i t i o n i n f o r m a t i o n : Books Consultation with a nutritionist-dietitian 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 : Pediatrics Family P r a c t i c e  i  N u t r i t i o n education: Research o r e x t r a courses in nutrition  2. 75  < 0.001  3. 00  <: 0.001  4. 31 4. 84  <0.05 <0.01  11. 83  < 0.05  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  106 than t h e i r male c o u n t e r p a r t s as d i d those p h y s i c i a n s who had additional  training  i n pediatrics  or family practice.  d o c t o r s who had r e s e a r c h t r a i n i n g taken a d d i t i o n a l  Medical  i n n u t r i t i o n o r had under-  n u t r i t i o n courses a l s o had s i g n i f i c a n t l y  higher t e s t scores.  P h y s i c i a n s who c o n s u l t e d books o r 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 n u t r i t i o n attitude  tests. 2 The  c o e f f i c i e n t of determination  regression analysis Thus, the v a r i a t e s  o f the n u t r i t i o n a t t i t u d e  indicated  ) f o r the stepwise s c o r e s was 0.134.  s t u d i e d accounted f o r o n l y 13.4% o f the  variance i n n u t r i t i o n Nutrition  ( r  attitudes.  practice  test:  Stepwise r e g r e s s i o n  t h a t a number o f v a r i a t e s  to n u t r i t i o n p r a c t i c e  t e s t scores  were the same v a r i a t e s  were s i g n i f i c a n t l y ( Table XXXV ).  analysis related  Most o f these  t h a t were s i g n i f i c a n t l y r e l a t e d  to a t t i -  tude s c o r e s . P h y s i c i a n s who were from  '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 when compared t o g e n e r a l p r a c t i t i o n e r s received t h e i r training were a l s o  i n Canada.  who had  S i g n i f i c a n t l y lower s c o r e s  a c h i e v e d by 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 and those who c o n s u l t e d p h a r m a c e u t i c a l brochures f o r i n f o r m a t i o n 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  Variate  Coefficient  Constant Location  Sex: Years  57.20 of medical t r a i n i n g : Other c o u n t r i e s Female  of practice:  Sources  Probability  -4.10 5.04  >10  -2.11  of nutrition information: Government p u b l i c a t i o n s Pharmaceutical brochures Books Consultation with a nutritionist-dietitian  Additional specialization Pediatrics  1.54  <0.001 < 0.001 <0.05 <0.05 <0.001 <0.01  or training: 4.25  C o n t i n u i n g e d u c a t i o n programs: Care o f t h e High Risk Foetus - E a r l y N u t r i t i o n and L a t e r Development Other Nutrition education Research o r e x t r a in nutrition  1.48 •1.26 3.22  <0.01  3.44  <0.01  <0.01  4.19 2.33  <0.05 <0.01  10.58  <0.05  courses  108 S i g n i f i c a n t l y h i g h e r t e s t s c o r e s were o b t a i n e d female p h y s i c i a n s t i o n e r s who  when compared w i t h males.  General p r a c t i -  u t i l i z e d government p u b l i c a t i o n s , 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 f i c a n t l y higher.  a l s o scored  signi-  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 and  atten-  dance a t c o n t i n u i n g the  by  s c o r e s of  e d u c a t i o n programs s i g n i f i c a n t l y i n c r e a s e d  respondents. 2  The Hence, only was  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 19.2%  of the v a r i a n c e  a t t r i b u t e d t o the v a r i a t e s  ( r  studied. Results  f i n d i n g s from t h i s survey on g e n e r a l 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 and  p r a c t i c e s support h y p o t h e s i s 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 v a r i a b l e s and practice  ) and  hypothesis 5  ( type o f p r a c t i c e  ( l o c a t i o n of m e d i c a l t r a i n i n g ); 2 ( years of p r a c t i c e  ); 6  ( sex  ( attendance at c o n t i n u i n g  ); 8  between a t t i t u d e s and practitioners.  ).  Hypothesis 1  seen weekly ); 7  ( a d d i t i o n a l t r a i n i n g );  e d u c a t i o n programs ); 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 p a r t i a l l y rejected.  l o c a t i o n of  of respondent ); 4  ( number o f p a t i e n t s  ( sources of n u t r i t i o n i n f o r m a t i o n 9  0.192.  i n the n u t r i t i o n p r a c t i c e t e s t  Summary of General P r a c t i t i o n e r s ' The  ) was  t r a i n i n g ) were a l l  Furthermore, h y p o t h e s i s 11 practices  ) was  10  ( correlation  also rejected  for general  109 Pediatricians  and  Description  Univariate  frequency  o f Respondents  tables  t h e demographic and p r o f e s s i o n a l tricians Country  and o b s t e t r i c i a n s of medical The  ding  Obstetricians  who  were d e s i g n e d  c h a r a c t e r i s t i c s of the pedia-  responded t o t h i s  survey.  training  majority of pediatricians  and o b s t e t r i c i a n s  to the questionnaire obtained t h e i r medical  Canada  to describe  respon-  training i n  ( T a b l e XXXVI ) . TABLE  XXXVI  DISTRIBUTION OF PEDIATRICIANS AND OBSTETRICIANS BY COUNTRY OF MEDICAL TRAINING  Country  Pediatricians  Obstetricians  No.  No.  %  %  35  54.6  22  50.0  17  26.6  17  38.6  Australia  1  1.6  1  2.3  United  0  0  3  6.8  Canada Great  Britain  States  Other Total  Sex  of  11  17 .2  1  2.3  64  100.0  44  ioo. b  respondent Most p e d i a t r i c i a n s  tionnaires  were m a l e s  and o b s t e t r i c i a n s  ( T a b l e XXXVII ) .  who  r e t u r n e d ques-  110 TABLE XXXVII DISTRIBUTION OF PEDIATRICIANS AND BY SEX  Sex Male Female  Total  Location of Only represented  OBSTETRICIANS  Pediatricians  Obstetricians  No.  %  No.  63  92.6  45  93.8  5  7.4  3  6.2  68  100.0  48  100.0  Q. "O  practice two l o c a t i o n s  ( V a n c o u v e r and o t h e r c i t y  by t h e r e s p o n d e n t s TABLE  ) were  ( T a b l e XXXVIII ) . XXXVIII  DISTRIBUTION OF PEDIATRICIANS AND OBSTETRICIANS BY LOCATION OF PRACTICE  Pediatricians  Obstetricians  %  No.  %  Vancouver  42  62.7  29  60.4  Other  city  25  37.3  19  39.6  Total  67  100.0  48  100.0  Location  Years o f  practice D i s t r i b u t i o n of respondents  tice  No.  indicated  that  according  to years of  the majority of p e d i a t r i c i a n s  prac-  and o b s t e -  Ill  t r i c i a n s h a v e b e e n i n p r a c t i c e more t h a n 10 y e a r s TABLE DISTRIBUTION  Years o f p r a c t i c e <^5  years  >5  but <  ^>10  years  10  Total  ( T a b l e XXXIX ) .  XXXIX  OF P E D I A T R I C I A N S AND BY YEARS OF PRACTICE  OBSTETRICIANS  Pediatricians  Obstetricians  No.  No.  %  %  5  7.4  7  14.6  8  11.8  5  10.4  55  80.8  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 were engaged i n p r i v a t e p r a c t i c e TABLE DISTRIBUTION  responding t o t h i s  survey  ( T a b l e XL ) . XL  OF P E D I A T R I C I A N S AND BY TYPE OF PRACTICE  OBSTETRICIANS  Pediatricians  Obstetricians  Type of. p r a c t i c e  No.  %  No.  %  Private  49  73.1  35  74.5  Clinic  18  26.9  12  25.5  67  100.0  47  100.0  Total  112 Number o f As  patients expected,  pediatricians  t h a n do o b s t e t r i c i a n s obstetricians imately  s e e more p a t i e n t s  ( Table XLI ).  see fewer  than  Almost  10 p a t i e n t s  40% o f t h e p e d i a t r i c i a n s  weekly  50% o f t h e  weekly w h i l e  s e e more t h a n  25  approx-  infants  weekly. TABLE X L I DISTRIBUTION OF PEDIATRICIANS AND OBSTETRICIANS BY NUMBER OF PATIENTS SEEN WEEKLY  Number o f P a t i e n t s ( infant & prenatal  )  <^10 >10  b u t < C 25  >25 Total  Sources  of nutrition Of  Obstetricians  No.  No.  %  15  22.1  23  48.9  26  38.2  17  36.2  27  39.7  7  14.9  68  100.0  47  100.0  the respondents,  were u t i l i z e d  65  ( 95.6% ) p e d i a t r i c i a n s  indicated  f o r n u t r i t i o n information  journals  Q. "5  information  ( 97.9% ) o b s t e t r i c i a n s ial  Pediatricians  that  groups  of s p e c i a l i s t s .  they use r e s o u r c e mater-  ( Table XLII  ).  Professional  more t h a n any o t h e r s o u r c e and  tation with a n u t r i t i o n i s t - d i e t i t i a n  a n d 47  ranked  f i f t h with  consulboth  113 TABLE X L I I NUMBER AND PERCENTAGE OF P E D I A T R I C I A N S AND OBSTETRICIANS INDICATING SOURCES OF NUTRITION INFORMATION  Pediatricians  Obstetricians  No.  %  No.  %  64  98.4  44  93.6  Professional bulletins  51  78.4  34  72.3  Books  48  73.8  27  57.4  44  67.6  28  59.5  Nutritionist-Dietitian  43  66.1  19  42.5  Pharmaceutical brochures  companies'  32  49.2  16  34.0  H e a l t h agency  publications  31  47.6  15  31.9  30  46.1  27  41.5,  10  21.2  24  36.9  12  25.5  Magazines  21  32.3  16  34.0  Television  12  18.4  5  10.6  Radio  10  15.3  6  12.7  10  15.3  3  6.3  3  4.6  1  2.1  4  6.1  1  2.1  Sources o f N u t r i t i o n Information  Professional  Government  Food  journals  publications  manufacturers' brochures  Colleague Audiovisual  aids  Public Health Home Other  Economist  Nurse  4  8.5  114  Additional  training for specialization  Table pediatricians training. included, and  XLIII  indicates  that  approximately  a n d 20% o f t h e o b s t e t r i c i a n s  Specializations training  had  47% o f t h e additional  grouped under t h e t i t l e  i n cardiology,  'other'  allergies, internal  medicine  nephrology.  TABLE NUMBER AND  XLIII  PERCENTAGE OF PEDIATRICIANS AND OBSTETRICIANS INDICATING ADDITIONAL TRAINING FOR S P E C I A L I Z A T I O N  Pediatricians Training For Specialization  Neonatology Family Public  Practice Health  Diploma  Other Total  No.  %  No.  %  14  20.5  6  12.5  2  2.9  2  4.1  1  1.4  0  0.0  18  26.4  2  4.1  32*  47.0*  10  20.7  * T h r e e p h y s i c i a n s h a d more specialties. Continuing  than  one o f t h e a b o v e  education  Approximately least  Obstetricians  one-half  one c o n t i n u i n g e d u c a t i o n  o f the respondents program  ( Table  attended at  XLIV ) .  115 TABLE X L I V NUMBER AND PERCENTAGE OF P E D I A T R I C I A N S AND OBSTETRICIANS INDICATING ATTENDANCE AT CONTINUING EDUCATION PROGRAMS  Pediatricians  Obstetricians  No.  %  No.  Care o f t h e High R i s k F o e t u s a n d Newborn  17  25.0  18  E a r l y N u t r i t i o n and Later L i f e  13  19.1  1  2.1  Other  10  14.7  5  10.4  34*  50.0*  Continuing Education Programs  Total  * S i x p e d i a t r i c i a n s attended e d u c a t i o n program. Nutrition education  i n medical  Approximately obstetricians  37.5  47.9  more t h a n o n e c o n t i n u i n g  schools  30% o f t h e p e d i a t r i c i a n s  responding  23  Q. "6  and 56% o f t h e  t o t h e q u e s t i o n n a i r e h a d r e c e i v e d no  formal n u t r i t i o n education  ( Table  XLV ) .  TABLE X L V NUMBER AND PERCENTAGE OF P E D I A T R I C I A N S AND OBSTETRICIANS INDICATING TYPE OF NUTRITION EDUCATION I N MEDICAL SCHOOL  Format o f N u t r i t i o n Education Course on N u t r i t i o n  Pediatricians  Obstetricians  No.  No.  0  %  0.0  %  0  0.0  2  4.1  Series of lectures  13  19.1  Integrated with other subject matter  34  50.0  22  45.8  No f o r m a l n u t r i t i o n education  20  29.4  25  52.1  116 Nutrition Attitudes  Method o f  t e s t of n u t r i t i o n attitudes  ( Appendix  A  'Agree'  " D i s a g r e e ' and  or  response.  who  ) consisted  Each  ( T a b l e IV  ).  calculated  d i n g by  65.  by  by  naires score  The  ) was  48 obstetricians  s c o r e s and  the ob-  dividing  Those q u e s t i o n -  statement. for obstetricians  s c o r e d i n an a n a l o g o u s  completed  from  s t a t e m e n t w e r e a s s i g n e d t h e mean  test of n u t r i t i o n attitudes A  Questionnaires  on t h e t e s t were  i n d i v i d u a l statement  particular  divi-  pediatricians  statements.  statement  test  s c o r e s and  number o f  number o f a n s w e r e d s t a t e m e n t s .  for that  7  r e s p o n s e m i s s i n g were e l i m i n a t e d  w i t h an u n a n s w e r e d  ( Appendix  attitude  by  f o r the  score f o r the a t t i t u d e  a t l e a s t n i n e o f t h e 10  totalling  the t o t a l  answered  of c e r t a i n t y  i s the t o t a l  Mean s c o r e s f o r e a c h by  each  s c o r e d b e t w e e n 0 and  adding respondent figure  for pediatricians  statements,  the degree  The mean t o t a l  w i t h more t h a n one  tained  o f 10  s t a t e m e n t was  This  completed  study.  Practices  scoring  The  was  and  manner.  A total  a t l e a s t n i n e o f t h e 10  of  attitude  statements. Nutrition were a n s w e r e d  practice  tests  consisted  'always', ' f r e q u e n t l y ' ,  o f 20  'sometimes' and  Q u e s t i o n n a i r e s w i t h more t h a n one. u n a n s w e r e d inated  from  analysis.  46 o b s t e t r i c i a n s statements.  Thus, a t o t a l  completed  Again  statements  of  'never'.  statement  were  67 p e d i a t r i c i a n s  a t l e a s t 19 o f t h e 20  t h o s e q u e s t i o n n a i r e s w i t h one  that  and  practice unanswered  elim-  117 statement  were a s s i g n e d  Results of  t h e mean s c o r e  mean p e r c e n t a g e  scores  tricians  on t h e n u t r i t i o n a t t i t u d e  in  XLVI.  and ly  practices ).  test  Obstetricians' were v e r y  Pediatricians'  than  statement.  tests  The  Table  f o r that  for pediatricians and p r a c t i c e  scores  similar  test  tests  for nutrition  obste-  a r e shown  attitudes  ( 64.16% and 64.72%  s c o r e s were much h i g h e r  on t h e p r a c t i c e  and  respective-  on t h e a t t i t u d e  ( 81.51% and 65.57% r e s p e c t i v e l y ) .  TABLE X L V I MEAN PERCENTAGE SCORES FOR NUTRITION ATTITUDE AND PRACTICE TESTS FOR PEDIATRICIANS AND OBSTETRICIANS  Obstetricians  Pediatricians Test  Mean  Attitudes  81.51 +  11.88  Practices  65.57 +  6.67  a  standard  Nutrition  100.0%.  10  ( Table  attitudes:  impossible  Pediatricians XLVII  ).  are  sufficient  64.16 +  11.23  64.72 +  10.36  was  scores  81.5% w i t h lowest  f o r pedia-  a range from  on s t a t e m e n t s  of physicians f e l t  iron,  these  infants  may  that  have  45.7%  3, 6 and i t was  t o be a l a c t o - o v o v e g e t a r i a n and  Although  readily available.  The mean t e s t  scored  A number  f o r an i n f a n t  be w e l l - n o u r i s h e d . obtaining  a  Scores  deviation  tricians ' nutrition attitudes to  Mean  Scores  still  difficulty  i r o n drops or i r o n - f o r t i f i e d  foods  Some p h y s i c i a n s do n o t a p p e a r t o be aware  118 of  the  infant  high quantity of  salt  foods.  recent  Although  i n many c o m m e r c i a l l y  legislation  acceptable  substantially  foods,  comparable measures have been t a k e n  TABLE  salt  i n the  decreased no  the  found  level  prepared  United for  States  infant  i n Canada.  XLVII  STATEMENTS MEASURING NUTRITION ATTITUDES FOR WHICH PEDIATRICIANS ACHIEVED LOWEST MEAN SCORES  3.  6.  10.  I b e l i e v e t h a t many comm e r c i a l l y prepared infant 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 ,  Agree  7.0  4.5  I t i s important to invest 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 office visit  Agree  7.0  4.9  I n my o p i n i o n , i t i s imp 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 ( e a t s e g g s and m i l k p r o d u c t s b u t 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 ished •  Disagree  7.0  4.3  The  mean s c o r e  tricians  was  ments 3,  8,  allowances  for nutrition  64.16% w i t h 9 and  Some o b s t e t r i c i a n s  The  Mean Score  Possible Score  Correct Response  Statement  10  had  are  Nutrition  the  from  lowest  apparently  set for f o l i c  F o o d and  a range  acid  a t t i t u d e s achieved 34.3%  mean s c o r e s  90.0%.  the  obste-  State-  ( Table  unaware o f t h e h i g h  i n C a n a d a and  Board of  to  by  XLVIII  ).  recommended  the U n i t e d  N a t i o n a l Academy o f  States. Sciences  119 (1974) a n d t h e C a n a d i a n intakes o f approximately tremely al. on  difficult  Dietary 800  to obtain  1972 ) and a s u p p l e m e n t Maternal  Position  Nutrition,  Paper,  Standard daily.  (1974) have  suggested  This quantity  i s ex-  from d i e t a r y sources  ( Hoppner e t  i s f r e q u e n t l y recommended  1970; A m e r i c a n  Dietetic  ( Committee  Association  1975 ) . TABLE X L V I I I  STATEMENTS MEASURING NUTRITION ATTITUDES FOR WHICH OBSTETRICIANS ACHIEVED LOWEST MEAN SCORES • •  Statement  3.  8.  9.  10.  Correct Response  Possible Score  Mean Score  Agree  7.0  2.6  Agree  7.0  3.0  Agree  7.0  2.3  Disagree  7.0  2.9  L a c t a t i o n i s a good t i m e to g e t r i d o f excess weight accumulated i n pregnancy as l o n g a s nut r i e n t intake remains  I f e e l t h a t p r e g n a n t women n e e d s o much f o l i c acid that i t i s d i f f i c u l t t o g e t i t from d i e t Provided t h a t they enter pregnancy w i t h adequate h e m o g l o b i n l e v e l s , women need t o i n c r e a s e t h e i r iron intake only during the l a s t h a l f o f pregI f e e l that there i s l i t t l e p r a c t i c a l , accurate i n f o r m a t i o n on m a t e r n a l n u t r i t i o n i n the current s c i e n t i f i c j o u r n a l s and  120 Nutrition  practices:  on  the n u t r i t i o n p r a c t i c e  to  83.3%.  and  14  Pediatricians  ( T a b l e XLIX  troduction healthy not  t e s t was scored  65.6% w i t h  infants.  Many p e d i a t r i c i a n s  . I t appears t h a t  of the f a c t that  i s generally The  a range  prefer  f r o m 51.7% 8, 10, 13  the early i n -  supplements f o r  a number o f p e d i a t r i c i a n s a r e  i t i s iron rather  low i n i n f a n t s '  mean s c o r e  for pediatricians  l o w e s t on s t a t e m e n t s  o f s o l i d s and f a v o u r m u l t i v i t a m i n  cognizant  which  ).  The mean s c o r e  than  vitamins  diets.  f o r each p r a c t i c e  statement  i s listed  i n A p p e n d i x F. TABLE X L I X • STATEMENTS MEASURING NUTRITION PRACTICES FOR WHICH PEDIATRICIANS ACHIEVED LOWEST MEAN SCORES  Correct Response  Statement  8.  10.  13.  14.  I recommend t h a t human m i l k alone i s adequate i n nutrient content f o r the f i r s t two months o f l i f e . . 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 t h e i n f a n t ' s d i e t a r y regimen d u r i n g the I recommend t h a t time the c h i l d i o f age he s h o u l d cereals, fruits,  Never  3.0  0.9  Always  3.0  1.1  Never  3.0  0.7  Never  3.0  1.2  by t h e s 5 months be e a t i n g vege-  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 m e n t be given to healthy infants..  On t h e n u t r i t i o n p r a c t i c e mean t e s t  test obstetricians  s c o r e o f 64.7% w i t h a r a n g e f r o m  L o w e s t s c o r e s were a c h i e v e d on s t a t e m e n t s ( Table L ).  Mean Score  Possible Score  Some d e g r e e o f w e i g h t  obtained  a  36.7% t o 81.7%. 4, 8, 15 and 19  restriction  ( statement  8 )  121 appeared g daily spring  t o be e v i d e n t . ( statement ( Churchill,  Restricting  dietary  carbohydrates  t o 50  19 ) may i n d e e d be d e t r i m e n t a l t o t h e o f f 1970; F e l i g ,  1973 ) .  Again  there i s evidence  o f a n 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 s u p p l e m e n t s d u r i n g p r e g n a n c y . TABLE L STATEMENTS MEASURING NUTRITION PRACTICES FOR WHICH OBSTETRICIANS ACHIEVED LOWEST MEAN SCORES  Correct Response  Statement  4.  8.  15.  19.  Mean Score  I a d v i s e h e a l t h y expect a n t women who do n o t drink milk t o take a Never  3.0  1.0  Always  3.0  1.3  Never  3.0  0.9  Never  3.0  1.6  I encourage t h e average p r e g n a n t woman t o g a i n a p p r o x i m a t e l y 1 pound p e r week i n t h e l a s t 20 I prescribe a multivitamin supplement f o r my p r e n a t a l p a t i e n t s e v e n when t h e i r d i e t a r y i n t a k e appears adequate... When my p r e n a t a l p a tients are gaining too much w e i g h t I recommend that they r e s t r i c t d i etary carbohydrates t o a p p r o x i m a t e l y 50 grams  Comparison  of attitudes  A significant found  Possible Score  to practices  positive  between n u t r i t i o n  correlation  attitudes  ( r = 0.259 ) was  and p r a c t i c e s  for pediatricians.  122 This  c o r r e l a t i o n was  also  achieved  s i g n i f i c a n t a t t h e 5% l e v e l .  a highly  significant positive correlation  0.424 ) b e t w e e n a t t i t u d e s the  1%  physicians'  generally  counselling  pediatr icians  appeared  w h i c h was  s i g n i f i c a n t at  practices.  t o be r e f l e c t e d i n t h e One  important  ( T a b l e L I ) and o b s t e t r i c i a n s  the s u b s t i t u t i o n of multivitamin  advice. was  and p r a c t i c e s  ( r =  level. Attitudes  cerned  Obstetricians  exception f o r  ( Table L I I ) con-  supplements f o r d i e t a r y  Both groups o f s p e c i a l i s t s had t h e a t t i t u d e  important  t o give  centage o f p h y s i c i a n s  n u t r i t i o n a l advice-but  that i t  a much s m a l l e r  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  per-  patients.  TABLE L I COMPARISON OF ATTITUDES AND PRACTICES FOR PEDIATRICIANS CONCERNING NUTRITIONAL ADVICE  Statement  Correct Response  Possible Score  Mean Score  Attitude 2.  I f an i n f a n t i s r e c e i v i n g a multivitamin supplement, I f e e l t h a t I don't need t o be c o n c e r n e d a b o u t h i s  Disagree  7.0  6.4  I a s k m o t h e r s f r o m what sources t h e i r 1 - 2 year olds obtain vitamin C  Always  3.0  1.8  I encourage mothers t o include at least 2 glass e s (16 o z . ) o f m i l k i n a l - 2 year old's d i e t . . .  Always  3.0  1.9  Practices 2.  20.  123  TABLE L I I COMPARISON OF ATTITUDES AND PRACTICES FOR OBSTETRICIANS CONCERNING NUTRITIONAL ADVICE  Statement  Correct Response  Possible Score  Mean Score  Attitude As l o n g a s t h e e x p e c t a n t mother t a k e s a m u l t i v i t a m i n s u p p l e m e n t , 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  Disagree  7.0  6.3  I recommend t h a t e x p e c t a n t patients include a citrus f r u i t or juice i n their daily diet  Always  3.0  1.8  I recommend t h a t my p r e natal patients include an i r o n - r i c h f o o d ( i . e . o r g a n meats ) i n t h e i r weekly d i e t s  Always  3.0  1.8  I give pregnant adolescents 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 . . . .  Always  3.0  1.9  I e n c o u r a g e my p r e n a t a l p a t i e n t s t o have f o u r glasses of milk or the equivalent i n dairy products d a i l y  Always  3.0  1.7  Practices  10  12  14.  124 The R e l a t i o n s h i p  of Selected  Attitudes  and  Variates  to Nutrition  Practices  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 criterion variables investigated  ( 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  b y one-way a n a l y s i s  t e s t and b y s t e p w i s e m u l t i p l e One-way a n a l y s i s Location  of  of variance  using  t o the ) was  Scheffe's  regression.  variance  of medical t r a i n i n g :  Table L I I I i n d i c a t e s  that  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 tricians'  nutrition attitudes.  scored s i g n i f i c a n t l y  f o r o b s t e t r i c i a n s nor t o Pediatricians trained  h i g h e r on t h e p r a c t i c e  s i c i a n s t r a i n e d i n Great B r i t a i n .  trained  i n a l l other countries TABLE  i n Canada  t e s t t h a n d i d phy-  However, p e d i a t r i c i a n s  i n Great B r i t a i n scored s i g n i f i c a n t l y  pedia-  higher than  trained  pediatricians  combined. LIII  MEAN PERCENTAGE SCORES OF P E D I A T R I C I A N S AND OBSTETRICIANS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON LOCATION OF MEDICAL TRAINING  Country  Test Canada  Great B r i t a i n  Other  Significance P < 0.01  Pediatricians' Attitudes  83.98  79.46  79. 89  N.S.  Practices  67.75  64.01  61.66  S.  Attitudes  62.71  63.94  72. 83  N.S.  Practices  64.29  64.90  65 . 33  N.S.  Obstetricians'  I  125 Sex ences  of respondent:  T h e r e were no s i g n i f i c a n t d i f f e r -  i n t h e mean n u t r i t i o n a t t i t u d e  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 dents  and p r a c t i c e based  test scores  on s e x o f t h e r e s p o n -  ( Table LIV ). • TABLE L I V  MEAN PERCENTAGE SCORES OF PEDIATRICIANS AND OBSTETRICIANS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON SEX OF RESPONDENT  Sex o f R e s p o n d e n t Test  Male  Female  Significance  Attitudes  81. 68  79.45  N.S.  Practices  65.58  65.40  N.S.  Attitudes  63.77  70.00  N.S.  Practices  64.08  73.90  N.S.  Pediatricians'  Obstetricians'  Location of practice: Vancouver  P h y s i c i a n s who  d i d n o t have s c o r e s s i g n i f i c a n t l y  p h y s i c i a n s who  practised  tude o r p r a c t i c e  tests  i n other c i t i e s  ( T a b l e LV ) .  practice i n  different  on e i t h e r  from  the a t t i -  126 TABLE LV MEAN PERCENTAGE SCORES OF P E D I A T R I C I A N S AND OBSTETRICIANS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON LOCATION OF PRACTICE  Location Test  Vancouver  Pediatricians  Other  City  Significance  1  Attitudes  81.02  82.50  N.S.  Practices  65.65  65.40  N.S.  Attitudes  65.26  62.47  N.S.  Practices  66.32  62.23  N.S.  Obstetricians  1  Years o f p r a c t i c e :  One-way a n a l y s i s  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  of variance d i d not  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 b a s e d on y e a r s o f p r a c t i c e  ( Table LVI ) .  TABLE L V I MEAN PERCENTAGE SCORES OF P E D I A T R I C I A N S AND OBSTETRICIANS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON YEARS OF PRACTICE  Years Test  <i5 y e a r s  >5  of Practice b u t < 10 ^>10  years  Significance  Pediatricians' Attitudes  82.85  89.62  80.13  N.S.  Practices  69.02  65.00  65.33  N.S.  Attitudes  70.00  69.97  62.21  N.S.  Practices  67.15  57.02  65.35  N.S.  Obstetricians *  127  Type o f p r a c t i c e :  There were no s i g n i f i c a n t  differences  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 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 type o f p r a c t i c e  ( Table LVII ).  TABLE LVII MEAN PERCENTAGE SCORES OF PEDIATRICIANS AND OBSTETRICIANS . FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON TYPE OF PRACTICE  Type o f P r a c t i c e Test  Private  Clinic  Significance  Pediatricians * Attitudes  81.54  80.97  N.S.  Practices  64.86  67.59  N.S.  Attitudes  65.21  61.89  N.S.  Practices  65.64  62.28  N.S.  Obstetricians  1  Number o f p a t i e n t s :  Number o f p a t i e n t s 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 t e s t s c o r e s f o r a t t i tudes o r p r a c t i c 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  ( Table  LVIII ). TABLE L V I I I MEAN PERCENTAGE SCORES OF PEDIATRICIANS AND OBSTETRICIANS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON NUMBER OF PATIENTS SEEN WEEKLY  No. o f i n f a n t s o r p r e n a t a l p a t i e n t s Test  <10  >10  but < 2 5  >25  Significance  Pediatricians  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 S p e c i a l i z a t i o n or t r a i n i n g :  Physicians  who had a d d i -  t i o n a l t r a i n i n g were compared t o those p h y s i c i a n s training  ( Table LIX ).  w i t h no such  There was no s i g n i f i c a n t d i f f e r e n c e  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  S p e c i a l i z a t i o n or T r a i n i n g Test  Training  Pediatricians  No  Training  Significance  1  Attitudes  82.85  81.60  N.S.  Practices  65.75  65.86  N.S.  Attitudes  67.27  63.33  N.S.  Practices  64.68  64.73  N.S.  Obstetricians'  Continuing education:  Table LX i n d i c a t e s a s i g n i f i c a n t  d i f f e r e n c e between p r a c t i c e t e s t s c o r e s o f o b s t e t r i c i a n s attended c o n t i n u i n g not.  There were no  who  e d u c a t i o n programs compared t o those who d i d significant differences  tude s c o r e s f o r o b s t e t r i c i a n s .  in nutrition atti-  Attendance a t c o n t i n u i n g  educa-  t i o n programs 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 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 f o r 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  C o n t i n u i n g E d u c a t i o n Programs Attendance  Test  No A t t e n d a n c e  Significance P < 0.05  Pediatricians  1  Attitudes  81.46  83.04  N.S.  Practices  64.81  66.94  N.S.  Attitudes  65.71  62.73  N.S.  Practices  68.50  61.25  Obstetricians'  S.  P e d i a t r i c i a n s who 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 d i d n o t s c o r e s i g n i f i c a n t l y d i f f e r e n t l y p h y s i c i a n s who a t t e n d e d o n l y one program ( T a b l e L X I ) . a n a l y s i s c o u l d n o t be performed  from Similar  f o r o b s t e t r i c i a n s because t h e  sample group was t o o s m a l l . TABLE L X I MEAN PERCENTAGE SCORES OF PEDIATRICIANS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON NUMBER OF CONTINUING EDUCATION PROGRAMS ATTENDED  Test  Number o f C o n t i n u i n g E d u c a t i o n Programs 1  Significance  >1  Attitudes  82.95  73.14  N.S.  Practices  64.55  66.32  N.S.  130 N u t r i t i o n education i n medical t r a i n i n g :  On the a t t i -  tude and p r a c t i c e t e s t 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 who had some n u t r i t i o n e d u c a t i o n i n t h e i r m e d i c a l s c h o o l not  training did  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  no n u t r i t i o n e d u c a t i o n  who had  ( Table LXII ). TABLE LXII  MEAN PERCENTAGE SCORES OF PEDIATRICIANS AND OBSTETRICIANS FOR NUTRITION ATTITUDE AND PRACTICE TESTS BASED ON NUTRITION EDUCATION IN MEDICAL SCHOOL  Nutrition Nutrition  Test  Education No N u t r i t i o n  Significance  Pediatricians  1  Attitudes  82.21  81.18  N.S.  Practices  66.00  65.49  N.S.  Attitudes  65.64  62.79  N.S.  Practices  63.27  66.05  N.S.  Obstetricians'  Stepwise r e g r e s s i o n The  analysis  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 t h e  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 regression.  by stepwise  multiple  The number o f v a r i a t e s was reduced by combining a  number o f s i m i l a r v a r i a t e s  i n t o one group.  Countries of medical  131  training and  were r e d u c e d  others, with  Canada b e i n g  Sources of n u t r i t i o n Group 1 was other with  of  of  training  education  o r no  4  groups:  The are  p h y s i c i a n s who  fewer than  t r i c i a n s who  10  3 was  consultation  Group 4 c o n t a i n e d  a l l other  training;  attendance;  attendance and  at  as  years  results reported  continu-  nutrition  of  stepwise  in  i n Table  regression anal-  LXIII.  On  w e r e i n p r a c t i c e more t h a n scored  were i n p r a c t i c e  Pediatricians  trained  significantly  significantly fewer than i n Great  countries  scored  test  did physicians trained  lower  higher  five  the  atti-  five  years  than  pedia-  years.  Britain  on  the  and  i n other  nutrition  practice  i n Canada. 2  The tude t e s t variates the  coefficient  was  0.06  and  of determination f o r the  s t u d i e d accounted  variance.  to  nutrition.  for pediatricians  than  into  O t h e r v a r i a t e s were g r o u p e d  such  p r o g r a m s o r no  s c h o o l o r no  tude t e s t  and  information.  Pediatricians:  but  i n f o r m a t i o n ; Group  a nutritionist-dietitian;  medical  Britain  a base f o r comparison.  i n f o r m a t i o n were c o m b i n e d  non-human s o u r c e s  additional  ysis  used as  Canada, G r e a t  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 o f a l l  human s o u r c e s  ing  to three groups:  practice  f o r 6%  and  (.r test  14.4%  ) f o r the 0.144.  atti-  Thus,  respectively,  the of  132 TABLE  LXIII  STEPWISE REGRESSION RESULTS FOR VARIATES SIGNIFICANTLY RELATED TO MEAN PERCENTAGE SCORES ACHIEVED BY PEDIATRICIANS ON THE NUTRITION ATTITUDE AND PRACTICE TESTS  Variate  Attitude  .Coefficient  Test 80.373  Constant Years of p r a c t i c e > 5 b u t < 10 Practice  than  Test Constant  67.742  Country Great B r i t a i n Other c o u n t r i e s  -3.735 -6.086  Obstetricians:  were i n p r a c t i c e more  10 y e a r s  scored  O b s t e t r i c i a n s who  significantly  lower than  five  test  ( Table  :ians who  tion  information  LXIV  professional  ).  Phy.  from Group 2  years  journals ) scored  < 0.05 < 0.01  physicians  who  on t h e n u t r i t i o n a t t i t u d e  utilized  sources  ( non-human s o u r c e s significantly  of n u t r i -  other  higher  than  on t h e a t t i -  test. Stepwise r e g r e s s i o n r e s u l t s  t h a t o b s t e t r i c i a n s who Group 2 and G r o u p 4  consulted  other  consulted  ) scored  f o r the p r a c t i c e test  nutrition  ( human s o u r c e s  nutritionist-dietitian who  < 0.05  9.251  were i n p r a c t i c e f e w e r t h  tude  Probability  information  of information  significantly  showed  from  excluding  higher  than  those  resources. 2  The  coefficient  of determination  ( r  ) f o r the a t t i t u d e  133 tude t e s t was 0.204 and f o r the p r a c t i c e t e s t 0.260. variates studied  Thus, the  accounted f o r 20.4% and 26.0% r e s p e c t i v e l y ,  of the v a r i a n c e . TABLE LXIV STEPWISE REGRESSION RESULTS FOR VARIATES SIGNIFICANTLY RELATED TO MEAN PERCENTAGE SCORES ACHIEVED BY OBSTETRICIANS ON THE NUTRITION ATTITUDE AND PRACTICE TESTS  Coefficient  Variate Attitude  Probability  Test  Constant  58.55  Years o f P r a c t i c e >10  -9.30  < 0.01  13.72  <0.05  Sources o f n u t r i t i o n information Group 2 Practice  Test 53.34  Constant Sources o f n u t r i t i o n information Group 2 Group 4  9.88 8.98  Summary 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 ' The  <0.05 <0.01  Results  f i n d i n g s from t h i s survey on 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 support h y p o t h e s i s 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 v a r i a b l e s and sex o f respondent ); 3 ( l o c a t i o n o f p r a c t i c e ); 5 ( type o f p r a c t i c e  );. 6 ( number o f p a t i e n t s );  7 ( sources o f n u t r i t i o n i n f o r m a t i o n 9 ( attendance a t c o n t i n u i n g  ); 8 ( a d d i t i o n a l t r a i n i n g );  e d u c a t i o n 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 ) f o r pediatricians. thesis  Hypothesis 1 ( 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 ); hypo-  4 ( years o f p r a c t i c e  between a t t i t u d e  ) and h y p o t h e s i s 11 ( c o r r e l a t i o n  and p r a c t i c e s  ) were a l l r e j e c t e d  f o r pedia-  tricians . For  obstetricians,  the r e s u l t s o f t h i s study support  h y p o t h e s i s 1 ( no r e l a t i o n s h i p between c r i t e r i o n v a r i a b l e s and l o c a t i o n of medical t r a i n i n g ( location of practice  ); 2 ( sex o f respondent ); 3  ); 5 ( type o f p r a c t i c e  p a t i e n t s ); 8 ( a d d 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 o f n u t r i -  t i o n i n medical school t r a i n i n g practice  ); 6 ( number o f  ).  Hypothesis 4 ( y e a r s o f  ); 7 ( sources o f n u t r i t i o n i n f o r m a t i o n ); 9 ( a t t e n -  dance a t c o n t i n u i n g e d u c a t i o n programs ) and 11 ( c o r r e l a t i o n between a t t i t u d e s  and p r a c t i c e s  ) were a l l r e j e c t e d  f o r obste-  tricians . Comparison o f N u t r i t i o n A t t i t u d e s of General P r a c t i t i o n e r s ,  Pediatricians,  and P r a c t i c e s and  Obstetricians  Comparisons o f 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 practices  were made between g e n e r a l p r a c t i t i o n e r s  t r i c i a n s and between g e n e r a l p r a c t i t i o n e r s The a t t i t u d e  and o b s t e t r i c i a n s .  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  t e s t s o f 10 statements each. t i c a l t o the 10 a t t i t u d e the  and p e d i a -  The f i r s t  i n t o two  10 statements were  iden-  statements completed by o b s t e t r i c i a n s ;  l a s t 10 statements were the same as those completed by pe-  diatricians. cians'  Thus, comparisons were made between the o b s t e t r i -  t e s t and t h e f i r s t  tioners'  10 statements o f the g e n e r a l p r a c t i -  t e s t ; the p e d i a t r i c i a n s '  t e s t s was compared t o the f i n a l  135 10 s t a t e m e n t s  of  the general  The p r a c t i c e t e s t  practitioners'  for general  and c o m p a r e d t o t h e p e d i a t r i c i a n s analogous manner.  Analysis  for  t w e e n mean s c o r e s a r e r e p o r t e d  p r a c t i t i o n e r s was  and o b s t e t r i c i a n s '  significant i n Tables  TABLE  test.  test  differences  LXV and  divided in  an  be-  LXVI.  LXV  COMPARISON OF MEAN PERCENTAGE SCORES FOR NUTRITION ATTITUDES AND PRACTICES BETWEEN GENERAL PRACTITIONERS AND PEDIATRICIANS  Physician Test  General  Practitioner  Pediatrician  Significance P < 0.001  Attitudes  79.91  81.51  N.S.  Practices  60.02  65.57  S.  TABLE L X V I COMPARISON OF MEAN PERCENTAGE SCORES FOR NUTRITION ATTITUDES AND PRACTICES BETWEEN GENERAL PRACTITIONERS AND OBSTETRICIANS  Physician Test  General  Practitioner  Obstetrician  Significance P<0.01  Attitudes  65.38  64.16  N.S.  Practices  60.17  64.72  S.  Pediatricians higher  than general  and o b s t e t r i c i a n s  practitioners  scored  significantly  on t h e n u t r i t i o n  practice  136  tests.  However, 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  t h e 3 groups 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 s .  Attitude  among 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 h i g h e r than t h o s e f o r obstetricians  ( 81.5 and 64.1 r e s p e c t i v e l y  ) but these  a r e n o t d i r e c t l y comparable because d i f f e r e n t t e s t  scores  instruments  were used. P r a c t i c e t e s t s c o r e s o f 60.0%, 64.7% and 65.6% f o r 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 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, i m p o r t a n t t o r e a l i z e t h a t t h e s e low s c o r e s a r e n o t n e c e s s a r i l y  i n d i c a t i v e of i n -  a p p r o p r i a t e n u t r i t i o n p r a c t i c e s ; they may i n some cases represent the lack of n u t r i t i o n counselling  simply  by t h e p h y s i c i a n .  CHAPTER V SUMMARY AND IMPLICATIONS T h i s c h a p t e r i s a b r i e f review o f the o b j e c t i v e s , d e s i g n and major f i n d i n g s o f 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 o f the f i n d i n g s were also  discussed. Summary T h i s study was designed t o i n v e s t i g a t e the nature o f  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 the maternal and i n f a n t 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 i n the p r o v i n c e o f B r i t i s h Columbia.  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 p r a c t i c e s was a l s o a s s e s s e d . The gating  following  objectives  were e s t a b l i s h e d  for investi-  the problem: 1.  To assess the q u a l i t y o f maternal and i n f a n t n u t r i t i o n information maternal p o p u l a t i o n  being d i s s e m i n a t e d t o the  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.  Td determine whether s i g n i f i c a n t d i f f e r e n c e s exist  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  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 g e n e r a l p r a c t i t i o n e r s i n t h e province, o f B r i t i s h as r e l a t e d t o : 137  Columbia  138 (a)  l o c a t i o n of medical t r a i n i n g  (b)  sex  (c)  l o c a t i o n of  (d)  years  (e)  type  (f)  number o f  of  respondent  of of  practice  practice practice prenatal  patients  and/or  infants  seen weekly (g)  sources  of  nutrition information  (h)  additional training for  (i)  number and t y p e  of  specialization  continuing education  p r o g r a m s w i t h a n u t r i t i o n component attended (j)  extent of school  3..  i n the  two  years  n u t r i t i o n education  i n medical  training  To d e t e r m i n e and g e n e r a l  last  among p e d i a t r i c i a n s , practitioners  the  obstetricians  nature  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  of to  the nutrition  practices. 4.  To d e t e r m i n e w h e t h e r exist  between the  tices  of  general  pediatricians Data c o l l e c t i o n study to  assess  physicians. to  the  and  significant  nutrition attitudes practitioners  prac-  compared  were d e s i g n e d f o r  nutrition attitudes  a l l practicing general  as  and  to  obstetricians.  instruments  I n M a r c h 1975,  differences  and p r a c t i c e s  validated questionnaires practitioners,  this of were  pediatricians  and  sent  139  obstetricians  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  Association.  The sample c o n s i s t e d  110 p e d i a t r i c i a n s r e t u r n e d from  o f 1753 g e n e r a l p r a c t i t i o n e r s ,  and 118 o b s t e t r i c i a n s .  Q u e s t i o n n a i r e s were  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 ( 43.2% ) o b s t e 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 o f p e d i a t r i c i a n s were a s s e s s e d by a t e s t c o n s i s t i n g of 10 statements n u t r i t i o n during the f i r s t  two y e a r s o f l i f e .  a l s o c o n s i s t i n g o f 10 statements nutrition attitudes  r e l a t e d t o the importance  of  A similar test  was designed t o measure the  of o b s t e t r i c i a n s  toward p r e n a t a l  nutrition.  Both t e s t s were combined t o measure g e n e r a l p r a c t i t i o n e r s ' nutrition  attitudes.  Assessment o f n u t r i t i o n c o u n s e l l i n g conducted  by a t e s t of 20 statements  a d v i c e d i s s e m i n a t e d by p e d i a t r i c i a n s . practices  was  r e f l e c t i n g the n u t r i t i o n Nutrition  o f o b s t e t r i c i a n s were i n v e s t i g a t e d  of 2 0 statements  practices  counselling  by a s i m i l a r t e s t  on n u t r i t i o n a d v i c e g i v e n t o p r e n a t a l  patients.  Again both t e s t s were combined and a d m i n i s t e r e d t o g e n e r a l practitioners. Demographic and p r o f e s s i o n a l ted environmental of the  v a r i a t e s were c o l l e c t e d i n a s e p a r a t e  section  questionnaire. The d a t a were t r e a t e d  ing  data c o n c e r n i n g the s e l e c -  statistically  t o t e s t the f o l l o w -  hypotheses: The 1.  following  n u l l hypotheses  were  tested:  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  140  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 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 and p e d i a t r i c i a n s based on l o c a t i o n o f t h e i r m e d i c a l 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 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 , 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 o f t h e  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 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 , 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 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 d i f f e r e n c e s  achieved 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 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 , 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 y e a r s 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 d i f f e r e n c e s  achieved 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 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 , 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 t y p e 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 d i f f e r e n c e s  achieved 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 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 , 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 o f 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 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  practitioners, on 8.  sources  There  will  tests  of  obstetricians  of  nutrition information  be  no  9.  obstetricians  undertaking of  There  will  tests  of  be  no  the  number  attended 10.  obstetricians and type  i n the  There  will  tests  of  be  the  11.  There  12.  and p r a c t i c e s  of  differences,  in  general  and p e d i a t r i c i a n s  based  or  training.  achieved  and p r a c t i c e s  of  in  general  and p e d i a t r i c i a n s  based  education  programs  years. differences  achieved  and p r a c t i c e s  of  i n c l u s i o n of  nutrition in  in  general  and p e d i a t r i c i a n s  based  their  training. no s i g n i f i c a n t  correlation  nutrition attitudes  by  achieved  the  general  among  and n u t r i t i o n  practitioners,  the practices  obstetricians  pediatricians.  There for  be  for  achieved and  two  significant  of  differences  continuing  obstetricians  school  will  scores  of  nutrition attitudes  extent  medical  last  no  practitioners, on  significant  based  consulted.  additional specialization  nutrition attitudes  practitioners, on  significant  nutrition attitudes  practitioners, on  and p e d i a t r i c i a n s  will  be  no  significant  nutrition attitudes  general  practitioners  will  no  be  nutrition  significant attitudes  practitioners  and  difference  and p r a c t i c e s  and the  i n the  between  pediatricians.  difference  and p r a c t i c e s obstetricians.  i n the between  scores the There  scores the  for  general  142 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  two  criterion variables  was  determined by one-way a n a l y s i s o f v a r i a n c e  t e s t and was  ( n u t r i t i o n a t t i t u d e s and  stepwise r e g r e s s i o n  analysis.  employed t o determine the  t i o n e r s and  Scheffe's  Correlation  analysis  practices.  Comparison of  p r a c t i c e s c o r e s between g e n e r a l p r a c t i -  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 was  using  )  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 n u t r i t i o n a t t i t u d e and  practices  the  between g e n e r a l p r a c t i t i o n e r s  and  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 -  ences i n group means. l e v e l of s i g n i f i c a n c e .  A l l hypotheses were t e s t e d at the Results  were r e p o r t e d  a t the  5%  highest  l e v e l of s i g n i f i c a n c e . The  major f i n d i n g s of t h i s study f o r g e n e r a l p r a c t i -  t i o n e r s were: 1.  The  mean 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  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 were  2.  72.6%  and  60.0%  respectively.  The  lowest 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  practices related (a)  use  to:  of m u l t i v i t a m i n  pregnancy and  3.  and  supplements  during  infancy  (b)  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)  n u t r i t i o n advice f o r  (d)  weight g a i n d u r i n g  infancy  pregnancy  Female g e n e r a l 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 h i g h e r on  the  a t t i t u d e and  t h e i r male c o u n t e r p a r t s .  p r a c t i c e t e s t s than  143 4.  General  practitioners  more t h a n on b o t h  Medical tion  scored  p h y s i c i a n s who  less  than  10 y e a r s .  d o c t o r s who  scored  6.  with  P h y s i c i a n s who  attended  scored  no a d d i t i o n a l  continuing  than  training  education  s i g n i f i c a n t l y higher  d i d not attend  practitioners  who  than  any p r o g r a m s .  attended  more t h a n  physi-  General  one c o n t i n u i n g  education  program d i d not s c o r e s i g n i f i c a n t l y  different  from those  S i g n i f i c a n t l y higher attitude  tests  who  scored  school training  had  than  c o n s u l t e d books o r a  and p r a c t i c e  practitioners  countries  by p h y s i c i a n s who  scored  d i d not c o n s u l t these  General  on t h e  h a d no n u t r i t i o n .  practitioners  on t h e a t t i t u d e  one p r o g r a m .  s c o r e s were o b t a i n e d  nutritionist-dietitian  who  had a t t e n d e d  i n t h e i r medical  by p h y s i c i a n s who General  who  and p r a c t i c e  nutrition  9.  and p r a c t i c e s  on  specialization.  c i a n s who  8.  specializa-  s i g n i f i c a n t l y higher  of nutrition attitudes  programs  7.  lower  were i n  had a d d i t i o n a l  general practitioners for  significantly  than  or training  tests  were i n p r a c t i c e f o r  tests  practice 5.  10 y e a r s  who  s i g n i f i c a n t l y higher tests  sources  than  physicians  of n u t r i t i o n .  who were t r a i n e d  s i g n i f i c a n t l y lower  i n 'other'  on t h e a t t i -  144 tude and p r a c t i c e trained 10.  t e s t s than d i d physicians  i n Canada.  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 f o u n d  between l o c a t i o n o f p r a c t i c e , number o f p r e n a t a l and 11.  patients  t h e two c r i t e r i o n  type o f p r a c t i c e ,  a n d number o f i n f a n t s  variables.  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  correlated  ( 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  practices  for general p r a c t i t i o n e r s . The m a j o r f i n d i n g s  o f t h i s study 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 attitudes  and p r a c t i c e s  w e r e 81.5 a n d 65.5  respectively. 2.  The l o w e s t mean s c o r e s w e r e a c h i e v e d f o r n u t r i tion practices  related to:  (a)  early  introduction  of solids  (b)  supplementation of breast  (c)  use o f m u l t i v i t a m i n  milk  supplements  during  infancy 3.  P e d i a t r i c i a n s who w e r e t r a i n e d significantly  h i g h e r on t h e n u t r i t i o n  t e s t than physicians No c o n s i s t e n t  i n Canada  trained  scored  practice  i n a l l other  countries.  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 4.  test.  P e d i a t r i c i a n s who w e r e i n p r a c t i c e  f o r more  than  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 p h y s i c i a n s who w e r e i n p r a c t i c e No c o n s i s t e n t  than  l e s s than  5 years.  s i g n i f i c a n t r e l a t i o n s h i p was  between n u t r i t i o n p r a c t i c e s 5.  test  found  and years o f p r a c t i c e .  T h e r e 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 b e t w e e n s e x o f the respondent, l o c a t i o n of p r a c t i c e , p r a c t i c e , number o f p a t i e n t s , information,  type of  sources o f n u t r i t i o n  additional t r a i n i n g f o rs p e c i a l i z a -  tion^ attendance  a t continuing education  inclusion of n u t r i t i o n i n the medical  programs,  school  c u r r i c u l u m a n d 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  correlated  ( 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 The m a j o r f i n d i n g s  practices.  o f t h i s study 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 attitudes  t e s t scores f o rthe n u t r i t i o n  and p r a c t i c e  t e s t s w e r e 64.1 a n d 64.7  respectively. 2.  The l o w e s t mean s c o r e s w e r e a c h i e v e d practices (a)  f o rn u t r i t i o n  related t o :  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 weight  g a i n d u r i n g pregnancy  Obstetricians years  scored  who  were i n p r a c t i c e  test  than o b s t e t r i c i a n s  practice  less  than  of  f i v e years.  relationship  practice  than  10  s i g n i f i c a n t l y l o w e r on t h e n u t r i t i o n  attitude  consistent  more  was  who  were i n  No s i g n i f i c a n t  e v i d e n t between y e a r s  and s c o r e s o b t a i n e d  on t h e p r a c t i c e  test. Obstetricians of  who  consult  non-human  sources  n u t r i t i o n i n f o r m a t i o n other than  journals,  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  t u d e and p r a c t i c e sulted  professional  tests.  Obstetricians  who  w i t h human s o u r c e s o f n u t r i t i o n  other than a n u t r i t i o n i s t - d i e t i t i a n , significantly  con-  information  also  h i g h e r on t h e n u t r i t i o n  atti-  scored  practice  test. T h e r e was of  no s i g n i f i c a n t r e l a t i o n s h i p  the respondent,  location  the  of medical  or type o f p r a c t i c e ,  additional of  location  number  training,  of  patients,  specialization for training,  inclusion  n u t r i t i o n i n the medical  school  e d u c a t i o n and  two c r i t e r i o n v a r i a b l e s .  T h e r e was  no s i g n i f i c a n t c o n s i s t e n t  between a t t e n d a n c e a t c o n t i n u i n g and  between sex  the n u t r i t i o n a t t i t u d e  Nutrition  attitudes  relationship  e d u c a t i o n programs  and p r a c t i c e  were p o s i t i v e l y  scores.  correlated  ( r = 0.424 ) t o n u t r i t i o n c o u n s e l l i n g  practices.  147  Comparison o f the mean percentage s c o r e s f o r g e n e r a l practitioners, pediatricians practice  pediatricians  and o b s t e t r i c i a n s  indicated  that  scored 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  t e s t than d i d the g e n e r a l p r a c t i t i o n e r s .  Obstetricians  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 the g e n e r a l p r a c t i t i o n e r s the  nutrition practice  test.  There was no s i g n i f i c a n t  ence i n t h e n u t r i t i o n a t t i t u d e  on  differ-  s c o r e s . f o r t h e t h r e e groups.  Implications Some o f t h e f i n d i n g s  o f t h i s study should be g r a t i f y i n g  to 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 nutrition.  The r e l a t i v e l y h i g h response r a t e s ,  the encourage-  ment o f b r e a s t - f e e d i n g among the m a t e r n a l p o p u l a t i o n and the awareness o f the importance o f n u t r i t i o n y e a r s o f l i f e must be c o n s i d e r e d p o s i t i v e  i n the f i r s t attitudes  two  toward  n u t r i t i o n by many p h y s i c i a n s . The  results  o f t h i s survey, however, a l s o  indicate  p h y s i c i a n s need t o improve t h e i r n u t r i t i o n c o u n s e l l i n g t i c e s i n some important areas o f maternal and i n f a n t The  prac-  nutrition.  f o l l o w i n g recommendations a r e based on t h i s premise. R e l a t i v e t o the area o f u t i l i z i n g a c c e p t a b l e  of n u t r i t i o n are  that  i n f o r m a t i o n , the f o l l o w i n g s p e c i f i c  sources  implications  suggested: 1.  Physicians, especially  general  practitioners,  should u t i l i z e the e x p e r t i s e o f 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 f o r up-dating counselling 2.  their  nutrition  practices.  An assessment i s needed to determine whether t h e r e are s u f f i c i e n t n u t r i t i o n i s t s t o  supply  these c o n s u l t a n t s e r v i c e s t o the 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 3.  obstetricians.  N u t r i t i o n i n f o r m a t i o n s e r v i c e s should be e s t a b l i s h e d to p r o v i d e p h y s i c i a n s w i t h sources o f 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 i m p l i c a t i o n s c o n c e r n i n g the e s t a b l i s h m e n t  of  c o n t i n u i n g e d u c a t i o n programs a r e : 4.  C o n t i n u i n g e d u c a t i o n programs should be  designed  t o have g r e a t e r appeal t o p h y s i c i a n s , 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 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 should be implemented i n o r d e r to  im-  prove 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 n matern a l and  infant n u t r i t i o n f o r general  p e d i a t r i c i a n s and 6.  practitioners,  obstetricians.  C o n t i n u i n g e d u c a t i o n programs should i n c l u d e some emphasis on sources of r e l i a b l e n u t r i t i o n  infor-  mation, the use of m u l t i v i t a m i n supplements and the e f f e c t s of e a r l y n u t r i t i o n on l a t e r  life.  S p e c i f i c i m p l i c a t i o n s on the i n c l u s i o n o f n u t r i t i o n i n the m e d i c a l  school curriculum are:  149  7.  N u t r i t i o n s h o u l d be  included i n the  medical  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  correlates  with practical application. 8.  N u t r i t i o n i n medical  schools  should  emphasize  the r o l e of n u t r i t i o n i n p r e v e n t i v e and  medicine  hence, i t s importance i n maternal  and  infant nutrition. Recommendations f o r a d d i t i o n a l r e s e a r c h  in this  area  include: 9.  A survey  using a larger  c i a n s and  obstetricians  sample s i z e of p e d i a t r i s h o u l d be  undertaken  to  e s t a b l i s h r e l i a b l y t h e r e l a t i o n s h i p o f t h e demog r a p h i c and attitudes 10.  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A s s o c . 32:429, 1956.  APPENDIX A DATA COLLECTION AND FOLLOW-UP  165  INSTRUMENTS POSTCARDS  General P r a c t i t i o n e r s  No. Card NUTRITION OPINIONS  Some statements concerning maternal and i n f a n t n u t r i t i o n are made below. We a r e i n t e r e s t e d i n your judgement o f each statement, i n terms o f how i t r e f l e c t s your p e r s o n a l opinion or feelings. I f the statement d e s c r i b e s how you f e e l , c i r c l e 'A' f o r agree; i f the statement does not d e s c r i b e how you f e e l , c i r c l e 'D' f o r d i s a g r e e . A f t e r you have made your d e c i s i o n , i n d i c a t e how sure you are about your d e c i s i o n : C i r c l e 1. 2. 3. 4.  if if if if  you you you you  are are are are  VERY DOUBTFUL about your d e c i s i o n ( A or D MODERATELY DOUBTFUL about your d e c i s i o n MODERATELY CONFIDENT about your d e c i s i o n VERY CONFIDENT about your d e c i s i o n  PLEASE BE SURE TO RESPOND TWICE TO EACH STATEMENT. Sample:  N u t r i t i o n i s important t o good  health. D  This o p i n i o n i s agreement w i t h moderate confidence that n u t r i t i o n i s important to good h e a l t h .  Agree or Disagree  Degree of Confidence  Disregard this Column  Time devoted t o c o u n s e l l i n g p a t i e n t s on proper n u t r i t i o n i s time w e l l i n v e s t e d .  A D  12  3 4  2.  As long as the expectant mother takes a m u l t i - v i t a m i n supplement, I do not need to g i v e advice on n u t r i t i o n .  A D  12  3 4  8 9  3.  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 i n pregnancy as long as n u t r i e n t intake remains adequate.  A D  12  3 4  10 11  4.  R e s t r i c t i n g maternal weight gain t o l e s s than 20 pounds, decreases the l i k e l i h o o d o f severe toxemia.  A D  12  3 4  12 13  S a l t r e s t r i c t i o n i s necessary f o r a m a j o r i t y o f the pregnant, p o p u l a t i o n .  A  12  3 4  14 15  Pregnant women should be informed about the pros and cons o f b r e a s t feeding.  A D  12  3 4  16 17  C a l o r i c r e s t r i c t i o n may be i n d i c a t e d i n pregnancy because i t w i l l u s u a l l y r e s u l t i n a smaller i n f a n t and hence an easier delivery.  A D  12  3 4  18 19  D  168  Agree or Disagree  Disregard this Column  Degree of confidence  8.  I f e e l t h a t pregnant women need so much f o l i c a c i d that i t i s d i f f i c u l t to get i t from d i e t alone.  A D  1 2  3  4  20 21  9.  Provided t h a t they enter pregnancy with adequate hemoglobin l e v e l s , women need to i n c r e a s e t h e i r i r o n intake o n l y during the l a s t h a l f of pregnancy.  A D  1 2  3  4  22 23  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 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.  A D  1 2  3  4  24 25  11.  Mother's milk i s the optimum food f o r a healthy, newborn i n f a n t .  A D  1  3  4  26 27  12.  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 that I don't need t o be concerned about h i s diet.  A D  1 2  3  4  28 29  13.  I b e l i e v e t h a t many commercially"prepared i n f a n t foods c o n t a i n t o o high a quantity of s a l t .  A D  1 2  3  4  30 31  14.  Anemia i s r a r e l y , i f ever, seen i n i n f a n t s o f higher socioeconomic s t a t u s .  A D  1 2  3  4  32 33  15.  I f e e l t h a t as long as a c h i l d i s g a i n i n g weight, I don't have to worry about h i s n u t r i t i o n .  A D  1 2  3  4  34 35  16.  I t i s important to 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 intake a t each o f f i c e v i s i t .  A D  1 2  3  4  36 37  17.  Many mothers a r e 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 best t o go along with t h i s .  A D  1 2  3  4  38 39  18.  As long as the i n f a n t i s not s i c k he i s being f e d p r o p e r l y .  A D  1 2  3  4  40 41  19.  A very important p e r i o d f o r good n u t r i t i o n i s the f i r s t two years o f life.  A D  1 2  3  4  42 43  20.  In my o p i n i o n , i t i s impossible f o r an i n f a n t t o be a lacto-ovo v e g e t a r i a n ( eats eggs and milk products but no moat, f i s h o r p o u l t r y ) and s t i l l be well-nourished.  A  1 2  3  4  44 45  D  PLEASE CHECK TO BE SURE ALL STATEMENTS HAVE BEEN ANSWERED -  2 -  2  169 Demographic Information  Please check 1.  (y)  Disregard this Column  where a p p r o p r i a t e .  In what country d i d you o b t a i n the m a j o r i t y o f your medical Australia Canada France Great B r i t a i n India United States other ( please s p e c i f y )  2.  What i s your  sex? Male Female  3.  In which o f the f o l l o w i n g areas i s your p r a c t i c e l o c a t e d : m e t r o p o l i t a n 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) P r o f e s s i o n a l Data  4.  How many years have you been p r a c t i s i n g  medicine?  l e s s than 5 years more than 5 years but l e s s than 10 years more than 10 years 5.  What i s your type of p r a c t i c e ? private clinic  6.  (solo) (group)  What i s the number o f p r e n a t a l p a t i e n t s seen weekly? l e s s than 10 p r e n a t a l p a t i e n t s more than 10 but l e s s than 2 5 more than 25 p r e n a t a l p a t i e n t s  7.  What i s the number o f i n f a n t s seen weekly?  ( l e s s than two years o f age )  l e s s than 10 i n f a n t s more than 10 but l e s s than 25 more than 25 i n f a n t s  training?  170 Disregard this Column 8.  Please check a l l the sources on n u t r i t i o n i n f o r m a t i o n used i n your work. professional journals professional bulletins government p u b l i c a t i o n s h e a l t h agency p u b l i c a t i o n s (eg. Can. D i a b e t i c Assoc.) a u d i o v i s u a l a i d s ( f i l m s , tapes, e t c . ) magazines radio television food manufacturers' brochures or l a b e l s pharmaceutical companies' brochures o r l a b e l s books c o n s u l t a t i o n with a n u t r i t i o n i s t - d i e t i t i a n c o n s u l t a t i o n with a c o l l e a g u e c o n s u l t a t i o n with a p u b l i c h e a l t h nurse c o n s u l t a t i o n with a home economist other ( please s p e c i f y )  9.  Do you have 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 o r t r a i n i n g i n medicine? neonatology p u b l i c h e a l t h diploma other ( p l e a s e s p e c i f y )  10.  Please check i f you attended any o f the f o l l o w i n g c o n t i n u i n g education programs. Care o f the High Risk Foetus S Newborn - May '74 E a r l y N u t r i t i o n and Later L i f e - June '74 other ( please s p e c i f y )  11.  Please check which of the f o l l o w i n g p e r t a i n s t o your medical school t r a i n i n g . course on n u t r i t i o n l a s t i n g a t l e a s t 13 weeks s e r i e s of l e c t u r e s on n u t r i t i o n n u t r i t i o n i n t e g r a t e d with other course m a t e r i a l no formal n u t r i t i o n education other ( please s p e c i f y )  -  4,-  171 NUTRITION PRACTICES Some statements concerning maternal and i n f a n t n u t r i t i o n a r e made below. Please i n d i c a t e whether you conduct each p r a c t i c e - 'Always' 95% o f the time), 'Frequently' ( approximately 50 - 95% o f the time ), 'Sometimes' ( approximately 5 - 49% o f the time ), o r 'Never' ( < 5 % of the time), by c i r c l i n g the a p p r o p r i a t e number 1 - 4 . Always  Frequently  Sometimes  Never  Sample: I t e l l my p a t i e n t s that n u t r i t i o n i s important throughout pregnancy. T h i s answer would i n d i c a t e t h a t you f r e q u e n t l y t e l l p a t i e n t s t h a t n u t r i t i o n i s important throughout pregnancy.  Always (>95%)  Frequently (50 - 95%)  Sometimes (5 - 49%)  Never (<5%)  Disregard this  Colnmn  At the f i r s t p r e n a t a l v i s i t , I check the q u a l i t y of the p a t i e n t ' s diet.  46  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 feeding with the pregnant women I see i n my p r a c t i c e .  47  3.  I recommend that healthy pregnant women i n g e s t approximately 65 grams o f p r o t e i n d a i l y .  48  4.  I advise healthy expectant women who do not d r i n k m i l k t o take a calcium supplement.  49  5.  I recommend that 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 or j u i c e in t h e i r d a i l y d i e t .  50  6.  I a d v i s e my p r e n a t a l p a t i e n t s who smoke t o stop during pregnancy.  51  I recommend that healthy pregnant women i n c r e a s e t h e i r c a l o r i c intake 25% above the non-pregnant requirement.  52  I encourage the average pregnant woman t o gain approximately 1 pound p e r week i n the l a s t 20 weeks o f pregnancy.  53  -  5 -  172  Always (?95%)  Frequently (50 - 95%)  Sometimes (5 - 49%)  Never (< 5%)  Disregard this Column  I p r e s c r i b e megavitamin therapy f o r many pregnant women.  54  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 .  55  11.  I recommend to pregnant women who are obese t h a t they l i m i t t h e i r weight g a i n during pregnancy to 10 pounds o r l e s s .  56  12.  I g i v e pregnant adolescents 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 .  57  13.  I p r e s c r i b e an i r o n supplement i n the l a s t h a l f of pregnancy f o r my p r e n a t a l p a t i e n t s .  58  I encourage my p r e n a t a l p a t i e n t s to have four g l a s s e s of milk o r the e q u i v a l e n t i n d a i r y products daily.  59  9.  •14.  1  60  15.  I prescribe a multivitamin 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 intake appears adequate.  16.  I recommend that my p r e n a t a l p a t i e n t s eat a wide v a r i e t y of foods each day.  61  17.  Any p r e n a t a l p a t i e n t who gains over 15 pounds before term i s advised to l i m i t her s a l t intake.  62  18.  I g i v e pregnant women who are vegetarians 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 and iron.  63  19.  When my p r e n a t a l p a 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 to approximately 50 grams d a i l y .  64  -  6  -  173  Always (> 95%)  Frequently (50 - 95%)  Sometimes (5 - 49%)  Never «5%)  Disregard this Column  20.  I recommend t h a t a l l my p r e n a t a l p a t i e n t s take a f l u o r i d e supplement i f t h e i r water supply i s not f l u o r i d a t e d .  4  3  2  1  65  21.  I recommend w a i t i n g a t l e a s t 10 hours a f t e r b i r t h before g i v i n g the healthy newborn e i t h e r the b r e a s t or a formula.  4  3  2  1  66  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 v i t a m i n C.  4  3  2  1  67  23.  I encourage mothers to g i v e c e r e a l s added to the b o t t l e f o r a healthy i n f a n t who i s n ' t s a t i s f i e d with milk alone.  4  3  2  1  68  24.  I t e l l parents t h a t i t i s g e n e r a l l y l e s s expensive t o prepare sieved o r b l e n d e r i z e d foods than t o buy commercially prepared foods.  4  3  2  1  69  25.  I recommend the e a r l y ( w i t h i n 2 months o f b i r t h ) i n t r o d u c t i o n of s o l i d s such as c e r e a l s and fruits.  4  3  2  1  70  26.  I recommend the i n t r o d u c t i o n o f a source o f i r o n f o r healthy i n f a n t s between 3 - 6 months o f age.  4  3  2  1  71  27.  I p r e s c r i b e a f l u o r i d e supplement f o r my p e d i a t r i c p a t i e n t s i f the water supply i s not s u f f i c i e n t l y fluoridated.  4  3  2  1  72  28.  I recommend t h a t human milk 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 .  4  3  2  1  73  29.  I f a 3 - 4 month o l d i n f a n t i s overweight according to height and weight c h a r t s , I recommend the s u b s t i t u t i o n o f skim milk f o r formula.  4  3  2  1  74  30.  I recommend t h a t i r o n f o r t i f i e d foods o r 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 2nd year o f l i f e .  4  3  2  1  75  -  7 -  -  174  Always (> 95%) 31.  I encourage healthy mothers of i n f a n t s to breast feed f o r the f i r s t s i x months.  32.  I t e l l mothers who g i v e v i t a m i n supplements to g i v e o n l y the recommended dosage.  33.  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 , vegetables and meats.  34.  I recommend t h a t a m u l t i - v i t a m i n supplement be given to healthy infants.  35.  I advise mothers to introduce a wide v a r i e t y of foods i n t o t h e i r i n f a n t ' s d i e t before he i s two years of age.  Frequently (50 - 95%)  Sometimes (5 - 49%)  Never (<5%)  Disregard this Column 76  77  78  79  80  NO. Card 36.  I recommend sugar water (about 1 t s p . sugar/qt. H O) as a pacifier for children. z  37.  To decrease the l i k e l i h o o d o f a t h e r o s c l e r o t i c heart d i s e a s e i n l a t e r l i f e , I recommend a low c h o l e s t e r o l intake e a r l y in infancy.  38.  I encourage mothers to i n c l u d e about 25 grams o f p r o t e i n i n the d a i l y d i e t of a 1 - 2 year old.  39.  I t e l l mothers that megavitamin therapy should be used i n treating hyperactivity in infants.  40.  I encourage mothers to i n c l u d e at l e a s t 2 g l a s s e s (16 oz.) of milk i n a 1 - 2 year o l d ' s d i e t .  10  PLEASE CHECK TO BE SURE ALT, STATEMENTS HAVE BEEN ANSWERED Thank you  f o r t a k i n g the time to complete t h i s q u e s t i o n n a i r e . - 8 -  176 Obstetricians No. Card  NUTRITION OPINIONS  Some statements concerning maternal n u t r i t i o n are made below. we a r e i n t e r e s t e d i n your judgement o f each statement, i n terms o f how i t r e f l e c t s your personal o p i n i o n o r feelings. I f the statement d e s c r i b e s how you f e e l , c i r c l e A ' f o r agree; i f the statement does not d e s c r i b e how you f e e l , c i r c l e 'D' f o r d i s a g r e e . A f t e r you have made your d e c i s i o n , i n d i c a t e how sure you are about your d e c i s i o n : 1  C i r c l e 1. 2. 3. 4.  i i i i  f f f f  you you you you  are are are are  VERY DOUBTFUL about your d e c i s i o n ( A o r D ) MODERATELY DOUBTFUL about your d e c i s i o n MODERATELY CONFIDENT about your d e c i s i o n VERY CONFIDENT about your d e c i s i o n  PLEASE BE SURE TO RESPOND TWICE TO EACH STATEMENT. Sample:  N u t r i t i o n i s important t o good h e a l t h . T h i s o p i n i o n i s agreement with moderate confidence that n u t r i t i o n i s important to good h e a l t h .  Agree o r Disagree  Degree o f Confidence  Disregard this Column  1.  Time devoted t o c o u n s e l l i n g p a t i e n t s on proper n u t r i t i o n i s time w e l l i n v e s t e d .  A D  1 2  3  4  6 7  2.  As long as the expectant mother takes a m u l t i - v i t a m i n supplement, I do not need t o g i v e advice on n u t r i t i o n .  A D  1 2  3  4  8 9  3.  L a c t a t i o n i s a good time t o g e t r i d o f excess weight accumulated i n pregnancy as long as n u t r i e n t i n t a k e remains adequate.  A D  1 2  3  4  10 11  4.  R e s t r i c t i n g maternal weight g a i n t o l e s s than 20 pounds, decreases the l i k e l i h o o d o f severe toxemia.  A  1 2  3  4  12 13  S a l t r e s t r i c t i o n i s necessary f o r a m a j o r i t y o f the pregnant p o p u l a t i o n .  A  1 2  3  4  14 15  5.  D  D  177  Agree o r Disagree  Degree o f Confidence  Disregard this Column  6.  Pregnant women should be informed about the pros and cons o f b r e a s t feeding.  A D  7.  C a l o r i c r e s t r i c t i o n may be i n d i c a t e d i n pregnancy because i t w i l l u s u a l l y r e s u l t i n a smaller i n f a n t and hence an e a s i e r d e l i v e r y .  A D  1 2  3  4  18 19  8.  I f e e l that pregnant women need so much f o l i c a c i d that i t i s d i f f i c u l t to g e t i t from d i e t alone.  A D  1 2  3  4  20 21  9.  Provided t h a t they enter pregnancy w i t h adequate hemoglobin l e v e l s , women need to increase t h e i r iron intake only during the l a s t h a l f of pregnancy.  A D  1 2  3  4  22 23  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 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.  A D  1 2  3  4  24 25  10.  16 17  PLEASE CHECK TO BE SURE ALL STATEMENTS HAVE BEEN ANSWERED  - 2 -  178  Demographic Information  Please check  1.  (•) where a p p r o p r i a t e .  In what country d i d you o b t a i n the m a j o r i t y o f your medical t r a i n i n g ? •  2.  Disregard this Column  What i s your  Australia Canada France Great B r i t a i n India United S t a t e s other ( p l e a s e s p e c i f y )  sex? Male Female  3.  In which o f the f o l l o w i n g areas i s your p r a c t i c e l o c a t e d ? m e t r o p o l i t a n 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)  P r o f e s s i o n a l Data 4.  How many years have you been p r a c t i s i n g  i 5.  medicine?  l e s s than 5 years more than 5 years but l e s s than 10 years more than 10 years  What i s your type of p r a c t i c e ? p r i v a t e (solo) c l i n i c (group)  6.  What i s the number o f p r e n a t a l p a t i e n t s seen weekly? l e s s than 10 p r e n a t a l p a t i e n t s more than 10 but l e s s than 25 more than 25 p r e n a t a l p a t i e n t s  -  3 -  179  7.  Please check a l l the sources on n u t r i t i o n information your work.  Disregard this Column  used i n  professional journals professional bulletins government p u b l i c a t i o n s h e a l t h agency p u b l i c a t i o n s (eg. Can. D i a b e t i c Assoc.) a u d i o v i s u a l a i d s ( f i l m s , tapes, e t c . ) magazines radio television food manufacturers' brochures o r l a b e l s pharmaceutical companies' brochures o r l a b e l s books c o n s u l t a t i o n 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 c o n s u l t a t i o n w i t h a p u b l i c h e a l t h nurse c o n s u l t a t i o n with a home economist other ( p l e a s e s p e c i f y )  8.  Do  you  have 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 or t r a i n i n g i n medicine? neonatology p u b l i c h e a l t h diploma other ( p l e a s e s p e c i f y )  9.  Please check i f you programs.  attended any  of the f o l l o w i n g c o n t i n u i n g  Care of the High Risk Foetus & Newborn - May E a r l y N u t r i t i o n and L a t e r L i f e - June '74 other ( p l e a s e s p e c i f y )  10.  Please check which of the f o l l o w i n g p e r t a i n s training.  to your medical  education  '74  school  course on n u t r i t i o n l a s t i n g at l e a s t 13 weeks s e r i e s of l e c t u r e s on n u t r i t i o n n u t r i t i o n i n t e g r a t e d with other course m a t e r i a l no formal n u t r i t i o n education other ( p l e a s e s p e c i f y )  -  4  -  180 NUTRITION PRACTICES Some statements concerning maternal n u t r i t i o n are made below. Please i n d i c a t e whether you conduct each p r a c t i c e - 'Always' (> 95% o f the time), 'Frequently' ( approximately 50 - 95% o f the time ), 'Sometimes' ( approximately 5 - 49% o f the time ), o r 'Never' (< 5% of the time), by c i r c l i n g the a p p r o p r i a t e number 1 - 4 . Always Sample: I t e l l my p a t i e n t s that n u t r i t i o n i s important throughout pregnancy.  Frequently  4  (T)  Sometimes  Never  2  1  This answer would i n d i c a t e t h a t you f r e q u e n t l y t e l l p a t i e n t s 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 this Column  1.  At the f i r s t p r e n a t a l v i s i t , I check the q u a l i t y o f the p a t i e n t ' s diet.  4  3  2  1  26  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 feeding with t h e pregnant women I see i n my p r a c t i c e .  4  3  2  1  27  3.  I recommend t h a t healthy pregnant women i n g e s t approximately 65 grams of p r o t e i n d a i l y .  4  3  2  1  28  4.  I advise healthy expectant women who do not d r i n k m i l k t o take a calcium supplement.  4  3  2  1  29  5.  I recommend t h a t expectant p a t i e n t s include a c i t r u s f r u i t or juice i n their daily diet.  4  3  2  1  30  6.  I advise my p r e n a t a l p a t i e n t s who smoke t o stop during pregnancy.  4  3  2  1  31  7.  I recommend that healthy pregnant women i n c r e a s e t h e i r c a l o r i c i n t a k e 25% above the non-pregnant requirement.  4  3  2  1  32  8.  I encourage the average pregnant woman to gain approximately 1 pound p e r week i n the l a s t 20 weeks o f pregnancy.  4  3  2  1  33  9.  I p r e s c r i b e megavitamin therapy f o r many pregnant women.  4  3  2  1  34  I recommend that 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 .  4  3  2  1  35  10.  - 5-  181  - 6 -  183 Pediatricians  No. Card"  NUTRITION OPINIONS  Some statements concerning i n f a n t n u t r i t i o n are made below. We are i n t e r e s t e d i n your judgement o f each statement, i n terms of how i t r e f l e c t s your personal o p i n i o n or f e e l i n g s . If the statement d e s c r i b e s how you f e e l , c i r c l e 'A' f o r agree; i f the statement does not d e s c r i b e how you f e e l , c i r c l e 'D' f o r d i s a g r e e . A f t e r you have made your d e c i s i o n , i n d i c a t e how sure you are about your d e c i s i o n : C i r c l e 1. 2. 3. 4.  i f you i f you i f you i f you  are VERY DOUBTFUL about your d e c i s i o n ( A or D ) are.MODERATELY DOUBTFUL about your d e c i s i o n a r e MODERATELY CONFIDENT about your d e c i s i o n a r e VERY CONFIDENT about your d e c i s i o n  PLEASE BE SURE TO RESPOND TWICE TO EACH STATEMENT. Sample: N u t r i t i o n i s important  t o good h e a l t h .  T h i s o p i n i o n i s agreement with moderate confidence that n u t r i t i o n i s important to good h e a l t h .  O  Agree or Disagree  1  2  ©  Degree of Confidence  Disregard this Column 6 7  1.  Mother's milk i s the optimum food f o r a healthy, newborn i n f a n t .  A D  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 that I don't need t o be concerned about h i s d i e t .  A D  1 2  3  4  3.  I b e l i e v e that many commercially prepared i n f a n t foods contain too high a q u a n t i t y of s a l t .  A D  1 2  3  4  10 11  4.  Anemia i s r a r e l y , i f ever, seen i n i n f a n t s o f higher socioeconomic s t a t u s .  A D  1 2  3  4  12 13  5.  I f e e l that as long as a c h i l d i s g a i n i n g weight, I don't have t o worry about h i s nutrition.  A D  1 2  3  4  14 15  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 .  A D  1 2  3  4  16 17  7.  Many mothers a r e 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 best t o go along with t h i s .  A D  1 2  3  4  18 19  8.  As long as the i n f a n t i s not s i c k he i s being fed p r o p e r l y .  A  1 2  3  4  20 21  A very important p e r i o d f o r 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 .  A D  1 2  3  4  22 23  In my o p i n i o n , i t i s impossible f o r an i n f a n t to be a l a c t o - o v o vegetarian ( cats eggs and milk products but no moat, f i s h or p o u l t r y ) and s t i l l be well-nourished.  A D  1 2  3  4  24 25  9. 10.  D  PLEASE CHECK TO BE SURE ALL STATEMENTS HAVE BEEN ANSWERED  8 9  184  Demographic Information Please check 1.  I Disregard this Column  ) where a p p r o p r i a t e .  In what country d i d you o b t a i n the m a j o r i t y o f your medical  training?  Australia Canada France Great B r i t a i n India United S t a t e s other ( p l e a s e s p e c i f y )  2.  What i s your  sex? Male Female  3.  In which o f the f o l l o w i n g areas i s your p r a c t i c e l o c a t e d ? m e t r o p o l i t a n 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  4.  How many years have you been p r a c t i s i n g  Data  medicine?  l e s s than 5 years more than 5 years but l e s s than 10 years more than 10 years 5.  What i s your, type o f p r a c t i c e ? p r i v a t e (solo) c l i n i c (group)  6.  What i s the number o f i n f a n t s seen weekly?  ( l e s s than two years o f age)  l e s s than 10 i n f a n t s more than 10 but l e s s than 25 more than 25 i n f a n t s  -  2 o  18 5  7.  Disregard this Column Please check a l l the sources on n u t r i t i o n i n f o r m a t i o n used i n your work. professional journals professional bulletins government p u b l i c a t i o n s h e a l t h agency p u b l i c a t i o n s (eg. Can. D i a b e t i c Assoc.) a u d i o v i s u a l a i d s ( f i l m s , tapes, e t c . ) magazines radio television food manufacturers' brochures or l a b e l s pharmaceutical companies' brochures or l a b e l s books c o n s u l t a t i o n with a n u t r i t i o n i s t - d i e t i t i a n c o n s u l t a t i o n with a c o l l e a g u e c o n s u l t a t i o n with a p u b l i c h e a l t h nurse c o n s u l t a t i o n with a home economist other ( please s p e c i f y )  8.  Do you have 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 or t r a i n i n g i n medicine? neonatology p u b l i c h e a l t h diploma other ( please s p e c i f y )  9.  Please check i f you attended any o f the f o l l o w i n g c o n t i n u i n g education programs.  •  10.  Care o f the High Risk Foetus & Newborn - May '74 E a r l y N u t r i t i o n and L a t e r L i f e - June '74 other ( please s p e c i f y )  Please check which of the f o l l o w i n g p e r t a i n s to your medical school t r a i n i n g . course on n u t r i t i o n l a s t i n g a t l e a s t 13 weeks s c r i e s of l e c t u r e s on n u t r i t i o n n u t r i t i o n i n t e g r a t e d with other course m a t e r i a l no formal n u t r i t i o n education other ( please s p e c i f y )  -  3 -  186 NUTRITION PRACTICES Some statements concerning i n f a n t n u t r i t i o n are made below. Please i n d i c a t e whether you conduct each p r a c t i c e - 'Always' (> 95% o f the time), 'Frequently' ( approximately 50 - 95% of the time ), 'Sometimes' ( approximately 5 - 49% o f the time ), o r 'Never' (< 5% of the time), by c i r c l i n g the a p p r o p r i a t e number 1 - 4 . Always Sample: I t e l l my p a t i e n t s that n u t r i t i o n i s important throughout infancy.  4  Frequently ©  2  Sometimes  Never  1  T h i s answer would i n d i c a t e that you f r e q u e n t l y t e l l p a t i e n t s that n u t r i t i o n i s important throughout i n f a n c y .  Always (> 95%)  Frequently (50 - 95%)  Sometimes (5 - 49%)  Never (< 5%)  Disregard this Column  1.  I recommend w a i t i n g a t l e a s t 10 hours a f t e r b i r t h before g i v i n g the h e a l t h y newborn e i t h e r the b r e a s t or a formula.  26  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  27  3.  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 with m i l k alone.  28  4.  I t e l l parents that i t i s g e n e r a l l y l e s s expensive t o prepare s i e v e d o r b l e n d e r i z e d foods than to buy commercially prepared foods.  29  5.  I recommend the e a r l y ( w i t h i n 2 months o f 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 and f r u i t s .  30  6.  I recommend the i n t r o d u c t i o n o f a source o f i r o n f o r healthy i n f a n t s between 3 - 6 months o f age.  31  7.  I p r e s c r i b e a f l u o r i d e supplement for my p e d i a t r i c p a t i e n t s i f the water supply i s not s u f f i c i e n t l y fluoridated.  32  8.  I recommend that human milk 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 .  33  9.  I f a 3 - 4 month o l d overweight according and weight c h a r t s , I s u b s t i t u t i o n o f skim formula.  34  infant i s to h e i g h t recommend the milk for - 4 -  187 Disregard Always ( > 95%)  Frequently (50 - 95%)  Sometimes (5" - 49%)  Never (<5%)  this Column  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 of the i n f a n t ' s d i e t a r y regimen during the 2nd year of l i f e .  35  11.  I encourage healthy mothers o f i n f a n t s to b r e a s t feed f o r the f i r s t s i x months.  36  12.  I t e l l mothers who g i v e v i t a m i n supplements to g i v e 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 e a t i n g c e r e a l s , f r u i t s , vegetables and meats.  38  14.  I recommend that a m u l t i v i t a m i n supplement be given to h e a l t h y infants.  39  15.  I advise mothers to introduce a wide v a r i e t y of foods i n t o t h e i r i n f a n t ' s d i e t before he i s two years of age.  40  16.  I recommend sugar water (about 1 tsp. sugar/qt. H 0) 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 o f a t h e r o s c l e r o t i c heart d i s e a s e i n l a t e r l i f e , I recommend a low c h o l e s t e r o l intake e a r l y i n infancy.  42  18.  I encourage mothers to 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 of a 1 - 2 year o l d .  43  19.  I t e l l mothers that megavitamin therapy should be used i n t r e a t i n g hyperactivity in infants.  44  20.  I encourage mothers to i n c l u d e a t l e a s t 2 g l a s s e s (16 oz.) of milk i n a l - 2 year o l d ' s d i e t .  45  2  PLEASE CHECK TO BE SURE ALL STATEMENTS HAVE BEEN ANSWERED Thank you f o r t a k i n g the time to complete t h i s q u e s t i o n n a i r e .  -  5 -  APPENDIX B V A L I D A T I O N QUESTIONNAIRE AND CORRESPONDENCE WITH VALIDATORS  189  Validation  Questionnaire  Do the questions f o r p e d i a t r i c i a n s and general p r a c t i t i o n e r s an adequate v a r i e t y of t o p i c s on i n f a n t n u t r i t i o n ? Yes No I f . not, what i s missing?  represent  Do the questions f o r 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 an adequate v a r i e t y of t o p i c s on maternal n u t r i t o n ? Yes No I f not, what i s missing?  represent  Do you agree with our answers (answer sheet enclosed)? Yes No I f not, which statements and answers do query? S e c t i o n & Number Cou.rtent  Are any of the statements ambiguous? I f yes, which ones? S e c t i o n & Number  Yes  you  No Comment  Do the questions cover an adequate amount of information to o b t a i n a v a l i d estimate of 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 of o b s t e t r i c i a n s , p e d i a t r i c i a n s and general p r a c t i t i o n e r s ? Yes No Is the s c o r i n g system a p p r o p r i a t e f o r o b t a i n i n g an estimate 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 ? Yes No I f not, why not?  Is the order of the s e c t i o n s , appropriate? Yes No  i . e . , Opinions-Demographic Data-Practices, I f not, why not?  Do you wish to have a copy of the f i n a l q u e s t i o n n a i r e along with a synopsis of the f i n a l r e s u l t s ? Yes No I f yes, please complete the f o l l o w i n g : Name: Address: Additional  Comments:  THANK YOU  FOR  YOUR TIME AND  VALUABLE ASSISTANCE  NAME AND ADDRESSES OF VALIDATORS  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 A m h e r s t , M a s s a c h u s e t t s 01002 Dr. D o r i s C a l l o w a y Department o f N u t r i t i o n a l S c i e n c e s University of California B e r k e l e y , C a l i f o r n i a 94720 Ms. Rosemary C a l l o w a y Burrard Health Unit 1530 West 8 t h Avenue V a n c o u v e r , B.C. Dr. V i r g i n a C a m p b e l l Dean, S c h o o l o f Home E c o n o m i c s Acadia University W o l f v i l l e , Nova S c o t i a Dr. Samual Fomon Professor of Pediatrics U n i v e r s i t y o f Iowa Iowa C i t y , Iowa Dr. H e l e n 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 University 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 V a n c o u v e r , B.C. Mrs. A g n e s H i g g i n s Executive Director Montreal Diet Dispensary 2182 L i n c o l n Avenue M o n t r e a l , 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 S c h o o l D i s t r i c t 135 V a n N e s s Avenue San F r a n c i s c o , C a l i f o r n i a 94102  193  Dr. M a r g a r e t K i r k c a l d y Assistant Professor Home E c o n o m i c s D e p a r t m e n t 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 Assistant Professor D e p a r t m e n t o f Home E c o n o m i c s Mount S t . B e r n a r d C o l l e g e St. Francis Xavier 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 D r . K a t e Newman D e p a r t m e n t o f Human N u t r i t i o n & F o o d New Y o r k S t a t e C o l l e g e o f Human E c o l o g y Martha Van R e n s s e l a e r H a l l Cornell University I t h a c a , New Y o r k 14850 D r . G e o r g e 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 M e x i c o 8 7 1 3 1 Miss Margaret Phin c/o D r . & M r s . A.W. 1341 M a p l e S t r e e t W h i t e R o c k , B.C.  Phin  Dr. J e a n S a b r y Associate Professor C o l l e g e o f F a m i l y & Consumer U n i v e r s i t y o f Guelph Guelph, Ontario NIG 2W1  Studies  Mrs. Eva Lee Singh Associate Professor C o l l e g e o f Home E c o n o m i c s U n i v e r s i t y o f Saskatchewan Saskatoon, Saskatchewan S7N OWO M i s s A n n D. S u l l i v a n Assistant Professor D e p a r t m e n t o f Home E c o n o m i c s Mount S t . B e r n a r d C o l l e g e St. F r a n c i s Xavier College 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 Co-ordinator Maternal & I n f a n t Care P r o j e c t S e a t t l e , Washington  195  Dr. S h i r l e y Weber Professor U n i v e r s i t y o f Manitoba F a c u l t y o f Home Economics Winnipeg, Manitoba R3T 2N2 Dr. Myron Winick D i r e c t o r , I n s t i t u t e of N u t r i t i o n Columbia U n i v e r s i t y C o l l e g e o f P h y s i c i a n s 511 West 166*^ S t r e e t New York, N.Y. 10032  & Surgeons  APPENDIX C PRETEST QUESTIONNAIRE  196  Pretest Cover  Letter  1.  I s the purpose o f the q u e s t i o n n a i r e  clearly  stated?  Comment:  No  2.  Are the i n s t r u c t i o n s adequate? Comment:  3.  Does t h e l e t t e r Yes Comment:  General 1.  Yes  Yes  No  make y o u w a n t t o f i l l  i n the q u e s t i o n n a i r e ?  No  Layout Do y o u f e e l graphic  that the order  o f the sections i . e . , Opinions,  Data, P r a c t i c e s , i s a p p r o p r i a t e ?  Yes  Demo-  No  Comment:  Answering 1.  Scheme  Are the i n s t r u c t i o n s f o r answering  clear?  Yes  No  Comment: 2.  I s the answering Comment:  scheme e a s y t o f o l l o w ?  Yes  No  Statements 1.  A r e any s t a t e m e n t s :  Section  S Number  Comment  ambiguous  obviously  2.  biased  not  complete o r too long  too  easy o r t o o difficult  Do y o u t h i n k t h e s t a t e m e n t s a r e a d e q u a t e t o o b t a i 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 ? Yes  i n f o r m a t i o n on No  Comment:  Overall  Questionnaire  1.  Is t h e q u e s t i o n n a i r e  t o o long?  2.  Is t h e q u e s t i o n n a i r e  too time-consuming?  Yes  No  3.  Do t h e q u e s t i o n s a p p e a r r e p e t i t i o u s i . e . , a r e t h e ' p r a c t i c e ' q u e s tions too s i m i l a r t o the ' a t t i t u d e ' questions? Yes No  Yes.  No  APPENDIX D PHYSICIANS' COMMENTS TO  198  QUESTIONNAIRES  199  L i s t e d b e l o w a r e a number o f v o l u n t a r y comments accompanied the completed  which  questionnaires.  Favourable: " Congratulations " Interesting  on y o u r q u e s t i o n n a i r e !  study.  Good p o i n t s .  N u t r i t i o n i s my s e c o n d  interest.  " 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 excellent questionnaire. " " I o f f e r my p r a i s e study. "  of  " " your  to the people involved i n conducting  this  Unfavourable: " 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 s o o n 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 s o 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 the ignorance i n the answer. " " I s p e n t my l u n c h h o u r a n s w e r i n g t h i s body c a n w r i t e a P h . D. p a p e r . " Other  interesting  garbage j u s t so  some-  comments:  " I r e a l i z e that I should pregnant p a t i e n t s . "  s p e n d f a r more t i m e r e n u t r i t i o n w i t h  " 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've tried 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've been. "  200  Best of l u c k but I t h i n k the only way to improve b e t t e r n u t r i t i o n h a b i t s i s through a massive p u b l i c e d u c a t i o n program. A l s o , g i v e 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 m e d i c a l s t u d e n t s . " I wish you w e l l 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 f a m i l y d o c t o r s without r e a l l y knowing what we know about our p a t i e n t s and about n u t r i t i o n . Perhaps you c o u l d h e l p by sending pamphlets to our o f f i c e s f o r d i s t r i b u t i o n to our p a t i e n t s . " G e t t i n g mothers to remember the 4 food groups i s not Lectures school. clinical  easy.  i n n u t r i t i o n were timed too e a r l y i n . m e d i c a l They were not taken s e r i o u s l y s i n c e we had no correlation. "  N u t r i t i o n i n medical  s c h o o l was  p o o r l y done. "  U n i v e r s i t y t r a i n i n g i n n u t r i t i o n was  very poor. "  U n i v e r s i t y 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  s c h o o l had  l i t t l e practical  relevance.  I t i s no use i n f o r m i n g women about b r e a s t - f e e d i n g ; they what they want to anyway. "  do  Since many q u e s t i o n n a i r e s are sent to my o f f i c e I answer o n l y the ones where a p e r s o n a l c o n t a c t has been made. " I f a l a r g e number of d o c t o r s have not r e p l i e d I am not s u r p r i s e d 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 i n a c c u r a t e . " I f e e l a d i e t i t i a n o r n u t r i t i o n i s t must be c o n s i d e r e d a ' s p e c i a l i s t ' and t h a t having a f o r m a l l y t r a i n e d person to do r o u t i n e d i e t a r y c o u n s e l l i n g would not be an e f f e c t i v e way of u s i n g the d i e t i t i a n ' s t r a i n i n g . " I t was  fun. "  APPENDIX  E  ANSWER KEYS FOR NUTRITION ATTITUDE AND PRACTICE TESTS  201  202  ANSWER KEY FOR NUTRITION ATTITUDE TEST FOR GENERAL PRACTITIONERS  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  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 No.  Correct 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  Statement No.  Correct Response  204  ANSWER KEY FOR NUTRITION ATTITUDE TEST FOR PEDIATRICIANS  Statement  Number  Correct  Response  1  Agree  2  Disagree  3  Agree  4  Disagree  5  Disagree  6  Agree  7  Disagree  8  Disagree  9  Agree  10  Disagree  205 ANSWER KEY FOR NUTRITION PRACTICE TEST FOR PEDIATRICIANS  Statement No.  Correct 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  206  ANSWER KEY FOR NUTRITION ATTITUDE TEST FOR OBSTETRICIANS  S t a t e m e n t Number  Correct  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 FOR O B S T E T R I C I A N S  Statement No.  Correct Response  1  Always  2  Always  3  Always  4  Never  5  Always  6  Always  7  Never  8  Always  9  Never  10  Always  11  Never  12  Always  13  Always  14  Always  15  Never  16  Always  17  Never  18  Always  19  Never  20  Never  TEST  APPENDIX MEAN  SCORES  A T T I T U D E  AND  FOR  F NUTRITION  PRACTICE  208  TESTS  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 Number  Mean Score  Statement Number  Mean 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 P E D I A T R I C I A N S  Statement Number  Mean 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 Number  Mean 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  213  MEAN SCORES OF NUTRITION ATTITUDES ATTAINED BY OBSTETRICIANS  Statement Number  Mean 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 Number  Mean 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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