Rural Gambian Women Research Articles

Vitamin D Status Increases During Pregnancy and in Response to Vitamin D Supplementation in Rural Gambian Women

Background:Vitamin D is important to maternal, fetal, and infant health, but quality data on vitamin D status in lowand middle-income countries and response to cholecalciferol supplementation in pregnancy are sparse. Objectives:We characterized vitamin D status and vitamin D metabolite change across pregnancy and in response to cholecalciferol supplementation in rural Gambia. Methods:This study was a secondary analysis of samples collected in a 4-arm trial of maternal nutritional supplementation [iron folic acid (FeFol); multiple micronutrients (MMN); protein energy (PE) as lipid-based supplement; PE + MMN]; MMN included 10 µg/d cholecalciferol. Plasma 25-hydroxycholecalciferol [25(OH)D3], 24,25-dihydroxycholecalciferol [24,25(OH)2D3], and C3-epimer-25-hydroxycholecalciferol [3-epi-25(OH)D3] were measured by LC-MS/MS in 863 women [aged 30 ± 7 y (mean ± SD)] in early pregnancy (presupplementation) and late pregnancy, (gestational age 14 ± 3 and 30 ± 1 wk). Changes in 25(OH)D3and vitamin D metabolite concentrations and associations with pregnancy stage and maternal age and anthropometry were tested. Results:Early pregnancy 25(OH)D3concentration was 70 ± 15 nmol/L and increased according to pregnancy stage (82 ± 18 and 87 ± 17 nmol/L in the FeFol and PE-arms) and to cholecalciferol supplementation (95 ± 19 and 90 ± 20 nmol/L in the MMN and PE + MMN-arms) P < 0.0001). There was no difference between supplemented groups. Early pregnancy 25(OH)D3was positively associated with maternal age and gestational age. Change in 25(OH)D3was negatively associated with late pregnancy, but not early pregnancy, triceps skinfold thickness. The pattern of change of 24,25(OH)2D3mirrored that of 25(OH)D3and appeared to flatten as pregnancy progressed, whereas 3-epi-25(OH)D3concentration increased across pregnancy. Conclusions:This study provides important data on the vitamin D status of a large cohort of healthy pregnant women in rural Africa. Without supplementation, vitamin D status increased during pregnancy, demonstrating that pregnancy stage should be considered when assessing vitamin D status. Nutritionally relevant cholecalciferol supplementation further increased vitamin D status. These data are relevant to the development of fortification and supplementation policies in pregnant women in West Africa.

Salt intakes of rural and urban Gambian women

Salt intakes of rural and urban Gambian women

Maternal bone mineral changes during pregnancy as measured by peripheral QCT in rural Gambian women with a habitually low calcium intake

Maternal bone mineral changes during pregnancy as measured by peripheral QCT in rural Gambian women with a habitually low calcium intake

Dietary potential renal acid load and net acid excretion in rural and urban pre-menopausal Gambian women

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Study of an Educational Hand Sorting Intervention for Reducing Aflatoxin B1 in Groundnuts in Rural Gambia

Aflatoxin, a human liver carcinogen, frequently contaminates groundnuts, maize, rice, and other grains, especially in Africa. The aim of this study was to evaluate the effectiveness of an educational intervention that involved training rural Gambian women on how to identify and remove moldy groundnuts to reduce aflatoxin B1 (AFB1) contamination. In total, 25 women, recruited from the West Kiang region of The Gambia, were trained on how to recognize and remove moldy groundnuts. Market-purchased groundnuts were hand sorted by the women. Groundnuts were sampled at baseline (n =5), after hand sorting ("clean," n =25 and "moldy," n =25), and after roasting (n =5). All samples were analyzed for AFB1 by enzyme-linked immunosorbent assay. A reduction of 42.9% was achieved based on the median AFB1 levels at baseline and after hand sorting (clean groundnuts), whereas an alternative estimate, based on the total AFB1 in moldy and clean groundnuts, indicated a reduction of 96.7%, with a loss of only 2% of the groundnuts. By roasting the already clean sorted groundnuts, the AFB1 reduction achieved (based on median levels) was 39.3%. This educational intervention on how to identify and remove moldy groundnuts was simple and effective in reducing AFB1 contamination.

Social and Cultural Factors Affecting Maternal Health in Rural Gambia: An Exploratory Qualitative Study.

BackgroundThe high rate of maternal mortality reported in The Gambia is influenced by many factors, such as difficulties in accessing quality healthcare and facilities. In addition, socio-cultural practices in rural areas may limit the resources available to pregnant women, resulting in adverse health consequences. The aim of this study is to depict the gender dynamics in a rural Gambian context by exploring the social and cultural factors affecting maternal health.Methods and FindingsFive focus group discussions that included 50 participants (aged 15–30 years, with at least one child) and six in-depth interviews with traditional birth attendants were conducted to explore perceptions of maternal health issues among rural women. The discussion was facilitated by guides focusing on issues such as how the women perceived their own physical health during pregnancy, difficulties in keeping themselves healthy, and health-related problems during pregnancy and delivery. The data resulting from the discussion was transcribed verbatim and investigated using a qualitative thematic analysis. In general, rural Gambian women did not enjoy privileges in their households when they were pregnant. The duties expected of them required pregnant women to endure heavy workloads, with limited opportunities for sick leave and almost nonexistent resources to access prenatal care. The division of labor between men and women in the household was such that women often engaged in non-remunerable field work with few economic resources, and their household duties during pregnancy were not alleviated by either their husbands or the other members of polygamous households. At the time of delivery, the decision to receive care by trained personnel was often beyond the women’s control, resulting in birth-related complications.ConclusionsOur findings suggest that despite women’s multiple roles in the household, their positions are quite unfavorable. The high maternal morbidity and mortality rate in The Gambia is related to practices associated with gender inequality.

Periconceptional multiple-micronutrient supplementation and placental function in rural Gambian women: a double-blind, randomized, placebo-controlled trial

Background: Maternal micronutrient deficiencies are commonly associated with clinical indicators of placental dysfunction.Objective: We tested the hypothesis that periconceptional multiple-micronutrient supplementation (MMS) affects placental function.Design: We conducted a double-blind, randomized, placebo-controlled trial of MMS in 17- to 45-y-old Gambian women who were menstruating regularly and within the previous 3 mo. Eligible subjects were pre–randomly assigned to supplementation with the UNICEF/WHO/United Nations University multiple micronutrient preparation (UNIMMAP) or placebo on recruitment and until they reached their first antenatal check-up or for 1 y if they failed to conceive. Primary outcome measures were midgestational indexes of utero-placental vascular-endothelial function [ratio of plasminogen-activator inhibitor (PAI) 1 to PAI-2 and mean uterine-artery resistance index (UtARI)] and placental active transport capacity at delivery [fetal to maternal measles antibody (MMA) ratio].Results: We recruited 1156 women who yielded 415 pregnancies, of which 376 met all of the inclusion criteria. With adjustment for gestational age at sampling, there were no differences in PAI-1 to PAI-2 or MMA ratios between trial arms, but there was a 0.02-unit reduction in UtARI between 18 and 32 wk of gestation (95% CI: −0.03, −0.00; P = 0.040) in women taking UNIMMAP.Conclusions: Placental vascular function was modifiable by periconceptional micronutrient supplementation. However, the effect was small and supplementation did not further affect other variables of placental function. This trial was registered at www.controlled-trials.com as ISRCTN 13687662.

Maternal nutrition at conception modulates DNA methylation of human metastable epialleles.

In experimental animals, maternal diet during the periconceptional period influences the establishment of DNA methylation at metastable epialleles in the offspring, with permanent phenotypic consequences. Pronounced naturally occurring seasonal differences in the diet of rural Gambian women allowed us to test this in humans. We show that significant seasonal variations in methyl-donor nutrient intake of mothers around the time of conception influence 13 relevant plasma biomarkers. The level of several of these maternal biomarkers predicts increased/decreased methylation at metastable epialleles in DNA extracted from lymphocytes and hair follicles in infants postnatally. Our results demonstrate that maternal nutritional status during early pregnancy causes persistent and systemic epigenetic changes at human metastable epialleles.

Randomized, placebo-controlled, calcium supplementation trial in pregnant Gambian women accustomed to a low calcium intake: effects on maternal blood pressure and infant growth

Background: Dietary calcium intake in rural Gambian women is very low (∼350 mg/d) compared with international recommendations. Studies have suggested that calcium supplementation of women receiving low-calcium diets significantly reduces risk of pregnancy hypertension.Objective: We tested the effects on blood pressure (BP) of calcium carbonate supplementation (1500 mg Ca/d) in pregnant, rural Gambian women.Design: The study was a randomized, double-blind, parallel, placebo-controlled supplementation trial from 20 wk of gestation (P20) until delivery (calcium: n = 330; placebo; n = 332). BP and anthropometric measures were taken at P20 and then 4 weekly until 36 wk of gestation (P36), and infant anthropometric measures were taken at 2, 13, and 52 wk postdelivery.Results: A total of 525 (calcium: n = 260; placebo: n = 265) women had BP measured at P36 and subsequently delivered a healthy term singleton infant. Mean compliance was 97%, and urinary calcium measures confirmed the group allocation. At P20, the mean (±SD) systolic blood pressure (SBP) was 101.2 ± 9.0 and 102.1 ± 9.3 mm Hg, and diastolic blood pressure (DBP) was 54.5 ± 7.3 and 55.8 ± 7.8 mm Hg, in the calcium and placebo groups, respectively. The intention-to-treat analysis that was adjusted for confounders showed no significant effect of calcium supplementation on the change between P20 and P36 (calcium compared with placebo; mean ± SEM) in SBP (−0.64 ± 0.65%; P = 0.3) or DBP (−0.22 ± 1.15%; P = 0.8). There was no significant effect of supplementation on BP, pregnancy weight gain, weight postpartum, or infant weight, length, and other measures of growth. However, the comparability of the original randomly assigned groups may have been compromised by the exclusion of 20.7% of women from the final analysis.Conclusions: Calcium supplementation did not affect BP in pregnancy. This result may have been because the Gambian women were adapted to a low dietary calcium intake, and/or obesity, high gestational weight gain, high underlying BP, tobacco use, alcohol consumption, and sedentary lifestyles were rare. This trial was registered at the International Standard Randomized Controlled Trial Register (www.controlled-trials.com/mrct/) as ISRCTN96502494.

Unexpected long-term effects of calcium supplementation in pregnancy on maternal bone outcomes in women with a low calcium intake: a follow-up study

Background: Calcium supplementation of pregnant Gambian women with a low calcium intake results in lower maternal bone mineral content in the subsequent lactation.Objective: The objective was to investigate whether the lower bone mineral content persists long term.Design: All women in the calcium supplementation trial (International Trial Registry ISRCTN96502494) who had been scanned with dual-energy X-ray absorptiometry at 52 wk of lactation (L52; n = 79) were invited for follow-up when neither pregnant nor lactating for ≥3 mo (NPNL) or at 52 wk postpartum in a future lactation (F52). Bone scans and anthropometric and dietary assessments were conducted.Results: Sixty-eight women participated (35 at both NPNL and F52 and 33 at only one time point): n = 59 NPNL (n = 31 calcium, n = 28 placebo) and n = 44 F52 (n = 24 calcium, n = 20 placebo). The mean (±SD) time from L52 was 4.9 ± 1.9 y for NPNL and 5.0 ± 1.3 y for F52. Size-adjusted bone mineral content (SA-BMC) was greater at NPNL than at L52 in the placebo group (P ≤ 0.001) but not in the calcium group (P for time-by-group interaction: lumbar spine, 0.002; total hip, 0.03; whole body, 0.03). No significant changes in SA-BMC from L52 to F52 were observed in either group. Consequently, the lower SA-BMC in the calcium group at L52 persisted at NPNL and F52 (P ≤ 0.001): NPNL (lumbar spine, −7.5 ± 0.7%; total hip, −10.5 ± 1.0%; whole body, −3.6 ± 0.5%) and F52 (lumbar spine, −6.2 ± 0.9%; total hip, −10.3 ± 1.4%; whole body, −3.2 ± 0.6%).Conclusion: In rural Gambian women with a low-calcium diet, a calcium supplement of 1500 mg/d during pregnancy resulted in lower maternal bone mineral content in the subsequent lactation that persisted long term. This trial was registered at www/controlled-trials.com/mrct/ as ISRCTN96502494.

DNA methylation potential: dietary intake and blood concentrations of one-carbon metabolites and cofactors in rural African women

Background: Animal models show that periconceptional supplementation with folic acid, vitamin B-12, choline, and betaine can induce differences in offspring phenotype mediated by epigenetic changes in DNA. In humans, altered DNA methylation patterns have been observed in offspring whose mothers were exposed to famine or who conceived in the Gambian rainy season.Objective: The objective was to understand the seasonality of DNA methylation patterns in rural Gambian women. We studied natural variations in dietary intake of nutrients involved in methyl-donor pathways and their effect on the respective metabolic biomarkers.Design: In 30 women of reproductive age (18–45 y), we monitored diets monthly for 1 y by using 48-h weighed records to measure intakes of choline, betaine, folate, methionine, riboflavin, and vitamins B-6 and B-12. Blood biomarkers of these nutrients, S-adenosylhomocysteine (SAH), S-adenosylmethionine (SAM), homocysteine, cysteine, and dimethylglycine were also assessed monthly.Results: Dietary intakes of riboflavin, folate, choline, and betaine varied significantly by season; the most dramatic variation was seen for betaine. All metabolic biomarkers showed significant seasonality, and vitamin B-6 and folate had the highest fluctuations. Correlations between dietary intakes and blood biomarkers were found for riboflavin, vitamin B-6, active vitamin B-12 (holotranscobalamin), and betaine. We observed a seasonal switch between the betaine and folate pathways and a probable limiting role of riboflavin in these processes and a higher SAM/SAH ratio during the rainy season.Conclusions: Naturally occurring seasonal variations in food-consumption patterns have a profound effect on methyl-donor biomarker status. The direction of these changes was consistent with previously reported differences in methylation of metastable epialleles. This trial was registered at www.clinicaltrials.gov as NCT01811641.

Breast milk sodium content in rural Gambian women: between‐ and within‐women variation in the first 6 months after delivery

It has been suggested that infancy is a particularly sensitive period with respect to the effect of dietary sodium on future risk of hypertension. One difficulty of researching the effects of early sodium intake on later health is accurately measuring sodium intake from breast milk. In observational studies, sodium content has been calculated by estimating breast milk volume consumed and assuming a fixed sodium concentration for all women at all times (a standardised measure). The objectives of this study were to investigate the variation in breast milk sodium concentration in the first 6 months postpartum within women and test whether the pattern of change in sodium concentration differs between women. The study population was 197 rural Gambian women. Multilevel models were used to investigate whether the sodium content of breast milk changed over time within and between women. Fractional polynomials were used to identify the best-fitting functions of age to be included in the within and between variance functions. Sodium levels decreased with time; the reduction was initially rapid (levels decreasing by 17.7% between 30 and 60 days after delivery). Immediately after birth, there was substantial variation in breast milk sodium content between women but this reduced with time. Our results suggest that it is not appropriate to use a standardised measure of breast milk sodium content when direct measurement is possible - particularly when there is a research interest in measuring sodium intake in very early infancy.

Haematological effects of multimicronutrient supplementation in non-pregnant Gambian women.

Background/Objectives:The use of multimicronutrient (MMN) supplementation to reduce the burden of anaemia in non-pregnant women of reproductive age has been little studied, particularly in Africa. The objective of the study was to evaluate haematological outcomes in non-pregnant, rural Gambian women of reproductive age, receiving daily MMN supplements for one-year.Subjects/Methods:The study in 293 women aged from 17 to 45 years old was nested within a double-blind, randomised placebo-controlled trial of periconceptional MMN supplementation [ISRCTN 13687662], using the United Nations International Multiple Micronutrient Preparation (UNIMMAP), received daily for one year or until conception. Red cell parameters and free erythrocyte protoporphyrin concentration were measured at baseline and after 12-months in those women who did not conceive.Results:Anaemic women (haemoglobin concentration <12g/dL) were more likely to be older and in economic deficit at baseline. Mean change in haemoglobin concentration was +0.6±1.4g/dL in the intervention arm and −0.2±1.2g/dL in the placebo arm (p<0.001). After supplementation with MMN the relative risk of anaemia (<12g/dL) was 0.59 (0.46, 0.76) compared to placebo. Anaemic subjects at baseline showed an increase in mean haemoglobin from 10.6g/dL to 11.8g/L (p<0.001) after MMN supplementation.Conclusion:MMN supplementation should be considered as a strategy for improving the micronutrient and haematological status of non-pregnant women of reproductive age.

Rural Gambian women's reliance on health workers to deliver sulphadoxine – pyrimethamine as recommended intermittent preventive treatment for malaria in pregnancy

BackgroundThe use of most anti-malarial medications is restricted during pregnancy, but two doses of sulphadoxine-pyrimethamine are recommended after the first trimester as intermittent preventive treatment in pregnancy (IPTp). In The Gambia, only 32% of women receive two doses and very little research has been conducted on women's awareness of drug safety during pregnancy. The objective of this paper was to assess whether rural Gambian women were aware of the importance of the timing of the two-dose IPT dose schedule and its relevance to drug safety.MethodsThis was a qualitative study in which 41 interviews and 16 focus group discussions with women, adolescents, men and traditional birth attendants were conducted. A generic qualitative approach was used to generate a theory as to why women might not participate in IPTp as recommended.ResultsAlthough most women used calendar months to count their stage of pregnancy, these months did not correlate with their concept of foetal development. Foetal growth was described following Islamic tradition as water, clot, piece of meat and human being, although there was little consensus about the order or timing in which these stages occurred. Common signs and conditions of malaria were known. Women were anxious about miscarriage and recognized that some medicines should not be taken in the first trimester, but were urged by men and traditional birth attendants to attend for antenatal care in the first trimester to "start treatment." General knowledge about the purpose of pregnancy medications and when they should be taken was poor among both men and women. One important result was that women relied entirely on health workers to provide safe drugs, at the correct time.ConclusionWomen did not have relevant information to judge the safety and appropriate timing of pregnancy drugs, which made them over-reliant on health workers. They should be encouraged to date their own pregnancies in culturally relevant terms and to anticipate when and which medications they should receive.

Maternal preconceptional weight and gestational length

Recent animal studies suggest that preconceptional undernutrition shortens gestation. We retested this idea among rural Gambian women who experience annual fluctuations in energy balance caused by the rains (with lowest weights in September to November) using records from 1918 infants. Pregnancies conceived in September to November were significantly shorter than those from better-fed months (38.6 vs 39.0 weeks; log-rank chi 2 = 17.4, P < .0001).

Parathyroid hormone and rates of bone formation are raised in perimenopausal rural Gambian women

To investigate rates of bone turnover and calcium homeostasis in Gambian women, we recruited 103 peri- and postmenopausal women, aged 45 to 80+ years and 11 women of reproductive age. Fasting blood was analyzed for plasma osteocalcin, PTH, 25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D [1,25(OH)2D], total- and bone-specific alkaline phosphatase. Plasma and urinary calcium, inorganic phosphate, sodium, potassium, creatinine, and albumin and urine free deoxypyridinoline (Dpd) was also measured. Samples from 20 premenopausal and 31 postmenopausal women from Cambridge, UK were analyzed, using the same methodology for comparison.For the Gambian women, peak calcium excretion occurred at around 50 years of age. For women aged ≥45 years, calcium excretion decreased by 3.0% per year of age (SE 1%; P < 0.005). In this age group, 25(OH)D also decreased with age (P < 0.005). Urinary sodium output, pH, and titratable acid output decreased (all P < 0.05) and total alkaline phosphatase (P < 0.005), osteocalcin (P < 0.005), and PTH (P < 0.05) increased with age.Comparisons were made between the following groups of Gambian and British women: premenopausal, early (age 55–64 years)- and late (age 65+ years)-postmenopausal. Gambian women of all ages were lighter (P < 0.001), shorter (P < 0.01), and had higher plasma bone-specific alkaline phosphatase activity (P < 0.05) and higher concentrations of osteocalcin (P < 0.05), PTH (P < 0.001), 1,25(OH)2D (P < 0.001), and 25(OH)D (P < 0.001). There were no consistent differences in calcitonin, while urinary free Dpd outputs were lower in the Gambians (P < 0.001). Plasma calcium, phosphate, and albumin (P < 0.01) were significantly lower. Urinary calcium, phosphate, sodium, and potassium excretion were lower, particularly in the postmenopausal group (P < 0.001). Although Gambian urine pH was more acidic, titratable acid output was lower (P < 0.01).These data show that Gambian women with low dietary calcium intakes and good vitamin D status have low urinary calcium excretion and that menopausal changes in calcium and bone metabolism among Gambian women are similar to those seen in other populations.In addition, they demonstrate that Gambian women of all ages have raised plasma PTH and 1,25(OH)2D concentrations and raised markers of osteoblast activity. We postulate that high endogenous PTH concentrations may be beneficial to bone health in Gambian women, removing fatigue damage and improving bone quality.

Plasma carotenoid and vitamin E concentrations in women living in a rural west African (Gambian) community.

Vitamin E and carotenoid pigments are important nutrients for the maintenance of health and protection of tissues against free radical damage. They also play a potential role in disease-risk-prediction and -protection, but little is known about their physiological and sociodemographic correlates and determinants, especially in a West African context. As part of a study of reproductive health in rural Gambian women, blood samples were obtained from 1286 women aged 15 to 54 years, living in the Farafenni area of The Gambia. Measurement of two forms of vitamin E and six carotenoids in plasma was performed by high performance liquid chromatography. All eight components, but especially the carotenoids: lycopene, alpha- and beta-carotene, exhibited a major seasonal variation, with maximum levels between May and July, corresponding to the end of the "mango" season and the beginning of the "rainy" season. Only the tocopherols varied significantly (increasing) with age. Several unexpected ethnic group differences were observed, and canthaxanthin was present at lower concentrations in women with manual occupations, compared to those with non-manual occupations. There were also significant differences associated with pregnancy and the postpartum period, especially for the tocopherols, but fewer differences associated with marital status. The observed patterns confirm that there are important seasonal, physiological, possibly genetic, and sociodemographic determinants of these nutrients in blood plasma, which may have significance for health and longevity.

Reproductive tract infection, symptoms and syndromic management in rural gambian women

International Journal of Gynecology & ObstetricsVolume 70, Issue S4 p. D22-D23 Free communication Chlamydia trachomatis Reproductive tract infection, symptoms and syndromic management in rural gambian women R. Bailey, R. BaileySearch for more papers by this authorR. Coleman, R. ColemanSearch for more papers by this authorB. West, B. WestSearch for more papers by this authorL. Morison, L. MorisonSearch for more papers by this authorG. Walraven, G. WalravenSearch for more papers by this author R. Bailey, R. BaileySearch for more papers by this authorR. Coleman, R. ColemanSearch for more papers by this authorB. West, B. WestSearch for more papers by this authorL. Morison, L. MorisonSearch for more papers by this authorG. Walraven, G. WalravenSearch for more papers by this author First published: 11 December 2003 https://doi.org/10.1016/S0020-7292(00)82565-5AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume70, IssueS42000Pages D22-D23 RelatedInformation

P5. Bone mineral changes in rural Gambian women during 18 months of lactation

1.(1) As a preliminary to operations intended to eliminate the major parasitic diseases, a health, nutrition and parasitological survey was made in Keneba, a village of 710 inhabitants in West Kiang, Gambia, during 1950-51.2.(2) The villagers depend for food very largely upon their cereals and foods of animal origin are rarely eaten. There is a marked seasonal variation in food supplies, giving rise to a regular “hungry season.”3.(3) Body weights of adults were below those of racially comparable groups and the growth pattern of children was considered to-be probably sub-optimal. Clinical signs attributable to deficiency of vitamin B complex factors were found to be common.4.(4) Malaria was found to be hyperendemic. P. falciparum predominated but P. malariae was seen in 8.5 per cent. of films. While some degree of immunity or tolerance is undoubtedly established, this appears to be a precarious one liable to break down under conditions of stress such as pregnancy. The inter-relationships of nutrition and malarial immunity are discussed.5.(5) Approximately one-third of the population was found to be infected with A. perstans and one-third with W. bancrofti. Possible reasons for the absence of evidence of filarial infection in infants and young children are discussed and its apparent inverse relationship to malaria noted.6.(6) Trypanosomal infection was found in 2.5 per cent. of the people.7.(7) Hookworm infestation was found to be common, rising to over 90 per cent. in the 6 to 10 years age-group, but loads were generally light. Ascaris and Taenia were found infrequently.8.(8) Anaemia was found to be almost universal, haemoglobin levels being lowest in the 2nd year of life. In males the levels were found to rise steadily with age well into middle life ; in females there was a marked fall during the child-bearing period.9.(9) Some degree of “auto-agglutination” of the blood was found in all subjects. The characteristics of this clumping of cells are described. It was not cold-agglutination, nor was it related to anaemia.10.(10) Hepatomegaly was observed very frequently in infants, often well below the age of weaning, and in children. Its incidence, associated clinical features and pathology appeared to differ from those of kwashiorkor (as defined). The possible aetiology of Gambian hepatomegaly is discussed and it is suggested that malaria, acting in conjunction with some other factor, probably nutritional and related to the constitution of breast-milk, may be the main cause of the condition.11.(11) Notes on the entomology of the area are added. It was not possible to make exhaustive investigations of disease vectors during the survey year.The overall impression gained from the survey and from observation at all seasons of a year is that the health of Keneba villagers is, at the best, marginal and that the reserves necessary to meet any unusual physiological or pathological stresses are small.Immunity to the effects of a variety of parasites is hardly won and precariously maintained.Although this population has maintained itself for many generations the level at which it has done so is very low and it is clear that the combined forces of malnutrition and parasitization are among the major factors limiting progress and development.

O5. Bone mineral content decreases with age in elderly rural Gambian women

O5. Bone mineral content decreases with age in elderly rural Gambian women