Our study attempted to use 24 hours DDS which is a proxy measure of nutrition and whether it can correlate with MUAC in pregnant women attending the first antenatal visit among women. The majority of the women booking in the second trimester is similar to a study conducted by Nsibu and others in the Democratic Republic of Congo where the majority of antenatal women reported to the clinic after the first trimester (31). Reporting to the antenatal clinic in the first trimester is important as ailments can be detected in good time and treated before affecting the foetus (32). Women in this study might have shunned early antenatal booking as most of them feel that pregnancy is a natural phenomenon and does not require much intervention by the hospital authorities (33).
The number of women who had a low DDS in this study suggests undernutrition though this is higher than the magnitude of the problem reported in Ethiopia and Kenya respectively (34, 35) (28.6% and 31.7%). It is possible that the observed differences with the two studies could be due to different MUAC cut-off points that were used or Body mass index (BMI) difference among regions. However, in our study, we did not calculate the BMI of the women. This is because it is difficult to calculate the BMI in pregnancy unless the woman knows the pre-pregnancy weight.
In our study, the DDS was negatively correlated with the MUAC. Similarly, Ghosh and his colleagues in their study, found that having a high DDS did not have a positive increase on the MUAC (36). In this study, the DDS could have been negatively correlated with MUAC as the 24-hour dietary recall may not give a true reflection of the daily food intake of the participants. The positive correlation between age and MUAC is in keeping with a study among pregnant women conducted by Fakier et al., in the Metro West area of Cape Town (37). A cross-sectional study in Bangladesh in both male and female adults showed that there was a positive linear correlation between MUAC and the Body Mass Index (BMI) (38) which justifies the use of anthropometric measurements in nutritional assessment. The BMI is difficult to calculate in pregnancy as it requires calculation of the pre-pregnancy weight which very few women can remember (39).
Being single and poor were independently associated with lower MUAC at first antenatal visit. Other studies have shown that being poor, single and parity of more than three are associated with lower MUAC (40) in keeping with this study. However, one of the differences between the two studies was that we did not find associations between MUAC and lower education but in the other studies associations were reported. On the other hand, the United States Agency for International Development (USAID) reported that high fertility and unwanted pregnancy contributed to decreased nutritional status in women (35).
In this study, the median age was 27 years which is higher than what is reported in other studies (41). In our study we did not get information about age at first marriage but other studies have shown that women who were married or cohabiting were less likely to be under nourished (42). Although in our study there was no association between alcohol and lower MUAC, some studies have reported that alcohol consumption is associated with under nutrition and lower MUAC (43). This was probably due to the lower number of women who reported that they consumed alcohol (20%) compared to other studies where there is almost equal number of women who consume alcohol to those who do not (44, 45). We did not determine the association between MUAC and smoking because of the insufficient numbers (1%) of participants that smoked in this study. However others have reported that women who smoke during pregnancy were more likely to have lower MUAC and lower baby birth weight compared to non-smokers (46).
Other studies have reported that HIV positive status was independently associated with lower MUAC (47). One would speculate that it could be due to the independent effect of HIV on the immune system which is likely to be observed especially in immune compromised states. Surprisingly, in this study there was no association between HIV and lower MUAC suggesting that maybe it was not an immune compromised group although we did not check for CD4 or viral load to confirm our claims.
In our study, the majority of the women consumed starchy staples as part of their diet. This could be due to the fact that Zambia’s main staple food is maize (48). This is confirmed by the Science Brief on Bio fortification which explains that most of the African countries rely on maize as a staple food (49). Eating of dark green leafy vegetables was significant in the univariate analysis but not in the multivariate one. These findings have some similarities with the National Food and Nutrition Commission where it was discovered that most of the pregnant women took green leafy vegetables as part of their diet most of the time (50). Consumption of the vegetables in the Zambian diet is very common as they are cheap and most of the people cannot afford a varied diet. Eating vegetables however is an advantage as one is protected from cancer (51, 52). On the contrary, a study conducted in northern Ghana revealed that pregnant women who were of a low socio-economic status ate less vegetables compared to those who were of a higher socio-economic status. In the same study, there was a strong negative association between the consumption of animal products in the previous 24 hours and socio-economic status (53).
A cross-sectional descriptive study aimed at evaluating dietary habits among pregnant women in Turkey revealed that most of the foods consumed were fruits and vegetables with a decrease in the consumption of tea and red meat (22). Pregnant women from a low socio-economic class were two times more likely to be undernourished compared to pregnant women from food secure households (54). In the same study, pregnant women and their husbands who had low levels of education were more likely to be undernourished compared to those who had higher levels of education showing that the educational status can have a bearing on the nutritional status of individuals.
A study aimed at assessing the consumption pattern and dietary practices of women in Nigeria revealed high consumption of cereals and grains, in particular rice, the mostly consumed fruits were oranges and green leafy vegetables, whereas fish, meat and eggs were eaten on a daily basis (55). The study limitations include the fact that most of the participants were from a middle income background, however, non-adjusted and adjusted analysis was performed to factor in for the confounders. Additionally, it is possible that there was recall bias on the type of food consumed the previous day but women were given time to think about the activities that took place.