The mother of all nutrition labs
The mother of all nutrition labs
One of the perks of Kyly Whitfield’s job is holding lots of babies — as she does here in February 2019 in Cambodia’s Kampong Thom province — while their mothers provide data.
Image courtesy of Jelisa Gallant
Six years ago, while in Cambodia at the start of her PhD studies, University of British Columbia student Kyly Whitfield was enjoying a dinner of rice and fish with colleagues from Helen Keller International. Someone from the NGO, which battles malnutrition and blindness around the world, casually remarked how common infantile beriberi was throughout the Southeast Asian country.
Whitfield was stunned. This ancient disease, the result of a thiamine (vitamin B1)-poor diet, was still around?
Alarmed, yet intrigued at the same time, Whitfield refocused her PhD studies to uncover why this preventable and often-fatal disease still existed and what could be done to combat it.
A potentially deadly disease with an obvious cause
Beriberi diagnosis, treatment and prevention was first described by Chinese physician Sun Simiao about 1,500 years ago. It has plagued populations through the ages, especially those living in maritime Asia.
The symptoms differ in adults and infants, with the former developing paralysis of the lower limbs and edema (which is swelling caused by a build-up of fluid in tissue) and, in severe cases, death.
In babies, a host of symptoms: vomiting, edema, and rapid breathing, often lead to a misdiagnosis, exacerbating the likelihood of death, since beriberi must be treated quickly with intravenous thiamine diphosphate.
In Asia, the cause of beriberi in both adults and babies is well known: white polished rice, a carbohydrate-rich diet staple that is devoid of thiamine. Infants, of course, don’t eat rice. But their mothers do, thus depriving babies of the B1 that should be passed along in breast milk, as Whitfield discovered during her PhD research by analyzing blood- and milk-thiamine levels in Cambodian moms.
White rice is nutritionally deficient because, during the polishing process, the thiamine-rich bran husk is removed for improved taste and faster cooking. The by-product is fed to livestock.
[WHITFIELD] It’s funny because when I first arrived in Cambodia in 2012, I had this very naïve thought, “Okay, everyone just eat brown rice.”
But there’s lots of reasons why brown rice isn't consumed. A few are cultural or societal. Eating white rice is seen as high class or prestigious thing. And it also tastes better. But there’s also some pragmatic reasons. Brown rice still has fatty acids in the outer bran and husk so storing it, it spoils more easily. The fatty acids in the bran go rancid.
It also takes more fuel, more water and more time to cook brown than white rice. So it’s really not pragmatic. Those are the main reasons.
We weren’t seeing as much beriberi fifteen to twenty years ago because much of the rice in Cambodia was being hand polished, so people were pounding the rice themselves. There’s only so much you can do by hand so often, a bit of the bran was left behind, providing some thiamine.
But about fifteen, twenty years ago, mechanical milling became much more popular — I love these kinds of series of events to try to figure out what’s happening — people don’t actually charge people to mill their rice, they say instead, “We’ll mill it for free, but let us keep the rice polishings” and then they sell it as animal feed for pigs. So it’s actually in the best interest of the mill owner to mill the be-jesus out of that rice so they can get the most weight that they can of the polishings to sell as animal feed.
So as soon as mechanical milling came in, the rice became very polished and hardly any bran was ever left behind because it wouldn’t make sense. That’s when we really started seeing a bigger issue with beriberi in Cambodia.
Prevention can be as simple as fortified fish sauce and salt
There are cultural and practical barriers preventing Cambodians from switching to brown from white rice. It is considered low class while the fatty acids in the bran causes it to go rancid more easily. Thus, reasoned Whitfield, why not add thiamine to fish sauce, something that all Cambodians eat?
During her PhD project, Whitfield undertook randomized studies with three groups of breastfeeding mothers: two were given fish sauce containing different levels of thiamine while the third was given a placebo.
“The women who had the fortified fish sauce, their breast milk thiamine levels increased, their babies’ blood thiamine increased. It was an amazing success,” says Whitfield, who is now an assistant professor at Mount Saint Vincent University in Halifax, where she heads the CFI-funded Milk and Micronutrient Assessment Lab (MAMA Lab) in the Department of Applied Human Nutrition.
A Cambodian woman providing a breastmilk sample.
Image courtesy of Jelisa Gallant
Further investigation led Whitfield to discover that the neighbouring Southeast Asian countries of Myanmar and Laos had the same low-thiamine problem. However, fish sauce isn’t part of the diet in these two nations. So Whitfield came up with an alternative solution: thiamine-fortified salt. Currently she is undertaking study trials in Cambodia, assisted by two of her master’s students, to determine the exact amount of B1 that should be added to salt to optimize women’s milk-thiamine levels.
Breastfeeding “totally polarizing”
Whitfield’s research is groundbreaking and embraces a variety of research areas related to the “totally polarizing topic” of breastfeeding, from cultural norms to misinformation, milk quality and feeding practices.
In one study, for example, Whitfield began making inquiries after noticing that Halifax mothers generally eschewed breastfeeding, especially in public. She found that those mothers who fed breast milk tended to pump it first and store it for later. However, the process of refrigeration or freezing and then reheating, with multiple container changes, degrades and diminishes micronutrients and key nutrients like fat.
As well, bottle-feeding tends to prevent an infant from developing proper satiety cues, with bottle-fed babies typically being fed more and at faster rates, which can lead to becoming overweight. The long-term implications include obesity.
MAMA Lab provides needed precision
Using a wide range of high-tech equipment at the MAMA Lab, Whitfield is compiling vast amounts of highly detailed anthropometric (length and weight) data that will provide a foundational database to help establish optimum long-term health practices starting in infancy.
This includes a BOD POD, which is an egg-shaped chamber a person gets inside to measure their body composition to get percentage fat mass. It is a $100,000 piece of equipment and the only one in Atlantic Canada and is key to the accuracy of the data. It precisely measures body composition — replacing hydrostatic underwater weighing — even of very young children.
It also includes a High Performance Liquid Chromatography (HPLC) machine that measures such biomarkers as blood thiamine levels, and eight data processing stations for students, something Whitfield considers vital to train future scientists and researchers. As well, Whitfield bought a specialized chair to collect blood and milk from moms and two hospital-grade breast pumps.
The lab was awarded $192,986 from the CFI last May for new equipment, a critical investment for Whitfield’s research to continue. “I wouldn’t be able to do any research in Halifax without this grant.”
[WHITFIELD] The work that I’m doing at the Mount is all centred around responsive feeding, so how infants are fed.
I spent so much time in Cambodia where breastfeeding is the norm and in Vancouver breastfeeding is much more prevalent, not the same extent you see in Cambodia but you don’t see the same sort of stigma.
When I moved to Halifax in 2016, it was about five months before I saw a woman breastfeed. I was shocked at the lack of breastfeeding that I saw, just out and about. So I thought “This is really interesting.” I know the rates are low but to not see anyone breastfeeding is a bit shocking.
So I started thinking and asking around “Why? What’s happening?” And a lot of moms said they were pumping and some exclusively feeding their infant pumped milk. But when you think about milk, coming out of the breast, hot and steamy ready to go, is very different than pumping it, putting it into the freezer, putting it into the fridge, heating it up ideally in a water bath but sometimes I’m sure moms are microwaving it.
So there’s all those things about potential degradation of nutrients, loss of nutrients, when you’re changing from bottle to bottle. A lot of the fat in milk will stick to the sides of the plastic bottle so you’re losing that with every container change.
So that’s one piece. The other piece is you’re no longer feeding at the breast, you have much more control feeding out of the bottle. The caregiver that’s feeding, sometimes it’s mom, sometimes it’s a nanny or sometimes it’s the dad, the parent, whoever — they’re controlling it and gravity is controlling it.
So we talk about all the benefits of breast milk, of what’s in the milk, but then think about how it’s fed. When babies are fed at the breast, they start and stop when they want and often moms don’t question that. They don’t time. They don’t feel their breast to see how full it is. There’s nothing to that. But when you have a bottle you know you put six ounces in and you know that 20 minutes in there’s still one ounce left and why wouldn’t you try and prompt them to finish the end?
So there’s research out there showing babies are typically fed more and fed faster when they’re fed from a bottle, regardless of what’s in that bottle. Often it’s formula but sometimes it’s breast milk. And so all these questions started coming up. If moms aren’t feeding from the breast, how is this all going down?
The other piece to this is that there’s lots of information on breastfeeding but scant research and scant resources available to moms if they choose to bottle feed. If you go to the public health office and ask for instructions on how to properly reheat breast milk it’s a lot harder to find than the different positions you can use when you breastfeed.
So there’s a big gap to answer some of these questions I think would be really valuable to families in Nova Scotia and across Canada where breastfeeding isn’t as normalized as we see in low-income countries.
Kyly Whitfield visits a household in Prey Veng province in rural Cambodia in 2013 as part of as study to compare blood thiamine levels between women of reproductive age in Prey Veng, urban Phnom Penh and Vancouver.
Image courtesy of Soa Sovan Vannak
Nutrition of moms and older kids gives a complete picture
Accurate, precise anthropometric measurements of babies and milk-volume intake is only one part of Whitfield’s research oeuvre. She is planning to undertake anthropometric data collection beyond infanthood into toddlerhood via the BOD POD, ensuring she has a vast store of data for analysis and study.
And she is tracking body composition changes in new moms, looking at the difference in weight loss rates between those who breastfeed and those who don’t. “It will open up a whole new world of understanding of body composition changes in the mom and the baby through early life. It’s all going to be brand new. It’s really exciting stuff,” says Whitfield.
Independent research crucial
Jodine Chase of Edmonton, the co-lead for SafelyFed Canada, an organization that advocates for improved infant feeding policies by government, calls Whitfield’s research “critically important” as a way to provide families with improved information related to infant and maternal health.
Just as important, Chase adds, is that Whitfield’s research is independent. Today, much of the research into infant feeding is undertaken and funded by industry, which raises red flags about the objectivity of findings, says Chase. As well, Whitfield’s work will provide a counterpoint to the marketing that new moms are inundated with from breast-pump and bottle manufacturers. “They use feeding as a way to convince people they need a product,” Chase says.