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InTable1, each of the stages of gestation at which measurements were made are shown, together with the relevant data. The difference in body weight between week 11 and week 16 is 1.6 kg. Using the measured value for body fat of the mother (from densitometry and skinfold thicknesses), this is converted into the appropriate mass of fat, i.e.,0.43 kg with an energy equivalent of 4,730 kcal ( the energy require for the deposition of 1 kg of fat, not adipose tissue, being taken as approximately 11,000 kcal). The energy equivalents for the relevant increases in the mass of the fetus, placenta and uterus, with values for the energy needed to deposit the protein and fat in these tissues, are 325 and 55kcal. Thus the overall total for the energy needed for these processes is 5,110 kcal. Similar calculations for the other gestational periods are shown in the other rows of the table, with an overall total for the whole pregnancy of 66,850 kcal.

Table 1 also shows the measured energy intakes (E1) and expenditures (EE) the differences between these in kcal/day, and the calculated total this energy difference for each period(EI-EE multiplied by number of days in the period) with also the total for the complete pregnancy in the bottom row, i.e., 49,840 kcal. The overall totals in columns 7 and 11 ought to be  approximately of minus 17,010 kcal, inTable 2 of + 32,212 kcal,inTable 3  of minus 47,588 kcal and in Table 4 of minus 105,372 kcal.Apart from  Table 1 most of these disagreements are considerable and would markedly influence the calculation of the supposed energy need of prehnancy. These 4 tables show result which are more or less proportionately typical of the group of 22 women measured in Glasgow.

There are various possible reasons for these large discrepancies, of which the most likely are errors in a) the measurement and estimated energy cost of the increased body mass, and b) the energy intake and energy expenditure measurements.

From a long experience of all these techniques in this laboratory, it seems unlikely that the measurements of the body mass, by repeated estimations using both body density and skinfold thicknesses, will have been in error by more than one to two kg at the most. The total amount of fat gained is, usually, of the order of 4-5kg so an error of 1-2kg represents+- 20-40% - a large and unlikely error indeed!

There seems little scope for error in the energy cost of laying down the fat mass.The energy value of fat is 9 kcal(38 kg)per g , depositing this in the body has been taken to be 11,000 kcal(46.0 MJ)/kg (which includes the energy cintent of the fat). It is almost impossible that than an error of more than about+-1,000kcal!(4.2MJ)can 0ccur here.

We are therefore almost compelled to assume that by far the largest source of error is either in the measurement of food intake or of energy expenditure.Food intake seems an improbable source of consistent or large bias in assessing energy intake, as has been briefly discussed above. Energy expenditure, on the other hand, because of the notorious difficulty in applying the rather primitive methodology in applying conditions, is the most likely source of a consistent and important error. For example, if energy expenditure were over or under extimated by as little as 200 kcal(840 KJ) per day – which is about a 10% error and would be acceptable normally, as a tolerable error- this is equivalent to 56,000 kcal (234 MJ) over the 280 days of pregnancy.

The conclusion would appear to be that energy expenditure measurements, as they are at present caeeied out, are incapable of being of much assistance to us in assessing energy balance in free-living conditions. This os not wide-ranging uses; they give information on the energy cost of single activities which may be of much help in determining the stress of work situations; they are of interest and perhaps of medical importance in sport; they are useful in giving advice  about the prevention or treatment of obesity; they can be utilized in measuring mechanical efficency of different body movements, or of differing designs of work tools. Valid assessment of physical activity can give us critically important information in marginally nourished or flagrantly malnourished populations. However, the errors are of such magnitude when these measurements are applied to the assessment of total energy expenditure over large parts of a day, or as the average over several complete days, that the interpreyation of such information must have very serious limitation.

There are several reasons for the potential errors, one of the largest being uncertainty about the validity of the measured value of energy expenditure in any activity when this is applied in real life situations where the actual energy expended could vary considerably. For example, the average of even several measurements of sitting or walking may not represent the average energy expended in such highly variable activities.

One the other hand, the estimate of total energy expenditure is hardly ever really essental in the context of energy balance. A general indication of the level of physical activity and of its fluctuations in normal everyday life is often useful in situations where energy balance is being investigated; e.g. in rural populations whose nutritional status may be marginally adequate. However, reasonably satisfactory information can usually be obtained by a few measurements of the energy expended in some specific activities coupled with an approximate breakdown of the duration of the varying activities for an average day. There is no need- and it is probable invalid in any case – to attempt an accurate estimation of the average total 24 – hour energy expenditure.

ABSTRACT  In many situations of marginal nutritional adequacy, attempts are made to assess energy balance in individual men or women. Several published papers have purported to describe this state by simultaneous measurements of energy intake and energy expenditure.  From results obtained by longitudinal studies, at 6- weekly intervals, on 22 pregnant women, it is argued that the methodology available at present for measuring 24 hours energy expenditure is inadequate for this purpose. The errors can be to large to permit sensible calculations of whether or not energy balance exists solely from energy intake and energy expenditure measures.

Introduction

In field situations it is often desirable to obtain information, derived from either measurements of food intake or of energy expenditure, or of both, which will then be used in an overall assessment of nutritional status.

It may appear necessary, in this context, to attempt to measure whether or not individuals are in energy balance, i.e. whether the intake of energy in the food equals the energy expended in the normal routine of daily life.

A problem of considerable magnitude in the precise analysis of energy balance in natural. Free-living situations relates to the methods used in its measurement. Unless energy balance is being assessed at a very superficial level solely on the basis of the maintenance of  constant body weight, which will be informative about will not us at what level it is occurring nor what adjustments in intake or expenditure may have occurred, measurement of both energy intake and energy expenditure are required. It is not intended to deal here with all of the details of the various methodologies, some of which have been described and analyzed elsewhere (1).However, some perhaps contentious conclusions can be drawn from some of our own recent data, not previously documented, which have become possible because of the unusual nature of the study – a series of repeated measures of all the various factors concerned in energy balance in a group of pregnant women studied longitudinally.

It has been long accepted that there may be considerable discrepancy in the agreement between energy intakes and expenditures of individuals, or even of groups, when these are measured during several consecutive days. Durnin (2) in 1961 showed that only 5% of a group of 69 men and women had intakes of energy which were closely related. On a day-to-day basis with expenditures. On a weekly basis about 60% of the individuals reached agreement between the two. The remainder demonstrated no relationship during 7 days between intake and expenditure of energy. There are also not notorious examples of marked discrepancy even in groups of people between their mean intakes and expenditures of energy without any obvious explanation.Norgan et al (3) in a study on 2 village populations in New Guinea, one being a coastal and the other a highland group, obtained very similar results for energy intake and expanditure in the highland group for both men and women, but there was a difference of about 500 kcal/d (2.1MJ)between the two sets of measurements in  both men and women in the coastal village village. The methodology was exactly the same in both situations and there seemed no  adequate explanation because of season, work, food availability, changing body weight, etc. These incompatabilities between intakes and expenditures have been a source of anxiety but have usually been shrugged off as being a reflection of the probability that measurements on an individual (or on groups of individuals), carried out during short period of time, might well not be expected to agree because of normal variability, from day or from week to week in both food intakes and physical activity. The resultant small alterations in body mass and body composition caused by these short-term energy imbalances, would be too fine to measure – the methodology in this field is too imprecise to detect small variations if this nature.However, studies which have been briefly described recently (4) give grounds for deeper concern about the used and limitations of measuring energy expenditure.

Sophisticated kinetic assays which measure the rate of enzyme reaction in NAD (P)(H) coupled systems have replaced the single point colorimetric assays. Former requires instrumentation and chemicals (auxilliary enzymes) which many laboratories in the developing countries may not afford . We have recently compared the colorimetric and kinetic assays for the erythrocyte enzymes ETK, EGR and EaspAT and their in vitro activation with the respective coenzymes (Jacob and Bamji unpublished). For ETK and EGR the two types of assays gave very comparable results the correlation coefficient for ETK-AC and EGR-AC being 0.8 and 0.92 respectively. The predictability coefficent  (percentage of subjects whose evaluation of nutrition status-normal or deficient, was comparable by the two assays) was over 92% in the case of these two enzymes (Table1). These results suggest that the laboratories that do not have a recording spectrophotometer with temperature control can use the colorimetric assays for ETK and EGR for assessing thiamin and riboflavin status, respectively.

In the case of EaspAT-AC the correlation coefficient was only 0.76 and predicability coefficient 85%. This was because the colorimetric assay gave lesser coenzyme stimulated activity and lower AC values (Table 1). This bizarre effect was traced to the inhibition of the regenerated but not the native holoenzyme by the product oxaloacetate (OA)which accumulates in the colorimetric assays, but is removed in the enzyme coupled kinetic assays(Table1). At higher concentrations of OA, even the basal activity was inhibited. Inhibition of the enzyme activity by the product is know to occur in ping-pong type of enzyme reactions, characteristic of transaminases. However, selective inhibition of the regenerated but not the native enzyme by OA is surprising.

Interpretation of biochemical tests: biochemical-clinical-functional correlations

Guidelines for the interpretation of biochemical tests have been evolved on the basis of controlled depletion repletion type of experiments and/ or comparison of healthy well nourished populations with malnourished populations (3,4).The questions that have been raised are: is tissue saturation with vitamin necessary for good health? What is the level of biochemical lesion that an individual can tolerate without being ill? In the absence of a proper definition of good health, and of sensitive functional parameters to identify and quantitate the impact of subclinical malnutrition, it is difficult to answer the above questions. Till such time, the object of nutritionists should be to achieve tissue saturation provided this is possible with modest intakes of vitamins.

Clear-cut correlations between biochemical and clinical lesions of vitamin deficiency are not always observed. The main reasons for these are: a) in the development of a deficiency disease, biochemical changes precede clinical lesions. During recovery, biochemistry is corrected before pathology. Therefore in(ตาราง)    cross-sectional surveys, individuals can be at different points in this spectrum; b) disease is a complex entity as indicated in the scheme; c) all biochemical tests do not change at the  same rate during development of deficiency. And d) diseases and drugs may confound the picture as mentioned earlier. Thus, in surveys one can encounter many individuals with biochemical but not the clinical lesions (subclinical deficiency) and a few individuals with normal biochemistry despite the presence of clinical lesions.

In Hyderabad we see a very high incidence (over 80%) of biochemical riboflavin deficiency among the low income group adults and children. The incidence of riboflavin responsive mucocutaneous lesions of the mouth (angular stomatric, glossitis) is also very high (15-25%). Table2 gives the EGR – AC values in subjects with and without oral lesions in some of our (ตาราง)  earlier studies (5-8).  When the control and patient populations were drawn from the same socioeconomic background, the difference between the two groups even if significant was marginal (studies 3 and 4) ( 7, 8). The marked difference observed in our earlier studies (5, 6), was perhaps more a reflection where is a very high incidence of biochemical deficiency, all can be regarded to be at risk. Further discrimination between individuals with and without lesions may not be marked.    After treatment with riboflavin there was significant biochemical and clinical improvement. Studies from Thailand and Yugoslavia reveal similar lack of clear-cut biochemical-clinical correlations in the case of oral lesions of B-vitamin deficiency (9, 10).

Vitamin deficiency can arise through inadequate intake, or malabsorption, or impaired utilization due to defective conversation of  vitamin to its coenzyme or tissue break-down and concomitant losses (Figure 1).Use of certain drugs such as oral contraceptives produces selective increaments in specific binding proteins or apoenzymes, thereby raising the cellular requirement for certain vitamins. These results in an abnormal redistribution of the vitamin between tissues and between various enzymes within a cell type, creating pockets of deficiency and excess- a state of relative deficiency(1,2). Interpretation of laboratory test under these circumstances becomes very difficult.

Absolute or relative vitamin deficiency would be expected to lead to specific biochemical lesions, molecular lesons( altered levels or structure of macromolecules) and disease in that order(Figure 1).Disease is however a complex entity. Very often subjects with biochemical or molecular lesions remain asymptomatic, unless there is some associated for only two vitamin deficiency diseases, viznigh blindness due to vitamin A deficiency and blood clotting defect due to vitamin K deficiency.

For the other vitamin deficiency diseases, the above mentioned cascade is not well defined. Subtle functional impairments such as reduced psychomotor performance and increased susceptbility to infections are suspected to occur even in the absence of clear cut mainifestaions of disease, but their importance in relation to human health is not fully recognized.

Problems usually encountered in the implementation of social and economic programs in the Philippined include red tape, reluctance of rural folks to adopt or adapt to new ideas, a strong dole-out mentality,failture of some beneficiaries to pay back laons, and politics.

Red tape, the scourge of any government system,has not spared the KKK movement. To minimize the problem, the Human Settlements Regulatory Commission(HSRC) in April 1983 relaxed the guidelines for processing of applications for HSRC locational clearnces for KKK-assisted projects.

Irregularities were reported in early 1983 in the borrowing of KKK project funds.Complants were aired on alleged malpractices which ranged from discrimination in the grant of loans to selling of application forms. One barangay official reportedly borrowed $ 90,000 from the KKK using fictitius names and projects, then lending the money at usurious interest rates. The Ministry of Human Settlements immediately ordered the suspension of KKK loans in areas where irrgular borrowings were reported, while dispatching investigation teams to these areas.

Complaints agains KKK loans disposal, however, have remained isolated cases that to not reflect the overall picture of the program.

E KKK success stories

Carito salvador of Davao City, who lost his left arm in a accident had lost his will to live became virtually a social parasite until he learned about the KKK.Skilled in nipa shingles production which he learned from hos father,he availed of a $ 928 loan to start the project.After only four months in operation,he has sterted paying back his loan, although he was actually given one year grace period to make his first payment.As of this report,Salvador was already earning at least$92 from an out put of 35,000 nipa shingles a month, and has employed 10 workers to whom he pays & 1.10 for every 100 shingles produced.He hopes to double his production employing 20 more workers and earning for himself an expected income of at 272.72 a month.

Teodoro and Sonny Labini,father and son, are indirect beneficiaries of a KKK-funded fishpond project in Jiabong,Western Samar. The Labinis were hired as fishpond workers at a daily rated of $1.36 and $.91 respectively. The new incime of $68 monthly was a big improvement from the $18- $ 27 a month that the family used to live on. Sonny,17,who had to quit schooling earlier for lack of funds,is now helping support his brothera and sisters through school.

These are only two of the thousanda of success stories of the KKK.