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48
Biochemical Changes Associated with Protein Energy
Malnutrition among Pregnant Women in Enugu Metropolis of
Nigeria

I(e)i *+a
,eart-ent of Science .a/orator) 0echnolog)
(1ioche-istr) %tion!
Institute of 2anage-ent Science' 3nugu' 3nugu State' Nigeria
3-ail4 a+ai(e)i5)ahoo.co-

Joshua Par(er 3li6ah
,eart-ent of 1ioche-istr)' 7ni8ersit) of Nigeria' Nsu((a' 3nugu State' Nigeria
3-ail4 ar(er.6oshua.unn.e+u.ng9 an+ ar(eselisco5)ahoo.co.u(

%+i/a *ro-e Solo-on (:orreson+ing author!
,eart-ent of 1ioche-istr)' 7ni8ersit) of Nigeria' Nsu((a' 3nugu State' Nigeria
3-ail4 aro-e.o+i/a5g-ail.co-

Abstract
Seru- total rotein' al/u-in' urea' total cholesterol' creatinine an+ calciu- were e8aluate+ in three grous of
fe-ale su/6ects as art of an in8estigation on the /ioche-ical changes associate+ with rotein energ)
-alnutrition (P32! in regnant wo-en. 0he first grou were "2 regnant wo-en with low total rotein (;"2g<l!'
the secon+ grou were "# regnant wo-en with nor-al total rotein (="2g<l! while the thir+ grou were "# non-
regnant' non-lactating' aarentl) health) wo-en with nor-al total rotein (=63(g!. *ll the su/6ects were
resi+ent in 3nugu -etroolis an+ age+ /etween 2# to 4# )ears. 0he regnant su/6ects were in +ifferent
gestational stages of regnanc)' ha8ing +ifferent arit) an+ atten+ing the antenatal clinic of Par(lane Secialist
>osital' 3nugu. 0he results show that there was no significant +ifference /etween the -ean seru- total rotein
of the +ifferent age grous (=#.#"!. Parit) (ie the nu-/er of chil+ren ha+ /) -other! correlate+ negati8el)
(;#.#"! with seru- total rotein' urea' total cholesterol' creatinine an+ calciu-. ?estational stage of regnanc)
in tri-esters correlate+ negati8el) an+ significantl) with seru- total rotein an+ seru- calciu- (;#.#"!. 0he
results also re8eale+ that seru- total cholesterol +i+ not correlate significantl) with seru- total rotein' urea'
total cholesterol' creatinine an+ calciu- (=#.#" in each case!. 7rea le8els correlate+ significantl) an+ ositi8el)
with seru- total rotein (r @ A #.246' ;#.#"!' an+ creatinine (r @ A#.2B"' ;#.#"!. creatinine correlate+
ositi8el) with seru- total rotein (r @ A#.4$B';#.#"!' urea (r @ A#. 2B"' ;#.#"! an+ calciu- ( r @ A #.3"6'
;#.#"!. :alciu- negati8el) an+ significantl) correlate+ with gestational stage of regnanc) in tri-esters (r @ -
#.288' ;#.#"! an+ correlate+ ositi8el) an+ significantl) with seru- total rotein (r @ A #.681' ;#.#"! an+
creatinine (r @ A #.#3"6' ;#.#"!.
Keywords: Protein energ) -alnutrition (P32!' Pregnanc)' 1ioche-ical' ?estation.

! "ntroduction
Protein 3nerg) 2alnutrition (P32! results when the /o+)Cs nee+ for rotein' energ) or /oth cannot /e satisfie+
/) the +iet. Dorl+wi+e' an esti-ate+ 8"2 -illion eole are un+ernourishe+ with -ost (81" -illion!' li8ing in
+e8eloing countries (D>%' 2##29 E*%' 2##4! Po8ert) is the -ain un+erl)ing cause of -alnutrition an+ its
+eter-inants (Sachs an+ 2c*rthur' 2##"!. 0he +egree an+ +istri/ution of Protein 3nerg) 2alnutrition (P32! in
a gi8en oulation +een+s on -an) factors F the olitical an+ econo-ic situation' le8el of e+ucation an+
sanitation' the season an+ cli-ate con+itions' foo+ ro+uction' cultural an+ religious foo+ custo-s' /reastfee+ing
ha/its' re8alence of infectious +iseases' the eGistence an+ effecti8eness of nutrition rogra--es an+ the
a8aila/ilit) an+ Hualit) of health ser8ices (E*%' 2##49 Sala-a et al.' 2##4!.
2alnutrition continues to /e a -a6or health /ur+en in +e8eloing countries. It is glo/all) the -ost i-ortant ris(
factor for illness an+ +eath with hun+re+s of -illions of regnant wo-en an+ )oung chil+ren articularl)
affecte+ (2uller an+ Irawin(el' 2##"!. Poor nutrition in regnanc) in co-/ination with infections is a co--on
cause of -aternal an+ infant -ortalit) an+ -or/i+it)' low /irth weight an+ intrauterine ?rowth Retar+ation
(I7?R! (Pena an+ 1acalao' 2##2!. In Nigeria' -aternal +eath er 1##'### /irths is ut at 8## while ercentage
low /irth weight stan+s at twent) (3nwonwu et al.' 2##4!.
0he nutritional status of a erson +een+s on foo+ consu-tion an+ not solel) the ro+uction an+ a8aila/ilit) of
foo+. ,ietar) energ) sul) -easure-ent assu-e that a8aila/le foo+ is +istri/ute+ an+ consu-e+ in relation to
reHuire-ent which is often not the case (D>%' 2##1!.
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.ow /irth weight /a/ies ha8e increase+ ris( of -ortalit)' -or/i+it) an+ +e8elo-ent of -alnutrition. :hil+ren
who suffer fro- -alnutrition are -ore li(el) to ha8e slowe+ growth' +ela)e+ +e8elo-ent' +ifficult) in school
an+ high rates of illness an+ the) -a) re-ain -alnourishe+ to a+ulthoo+ (Scri-shaw' 1$$89 */i+o)e an+ 3Je'
2###!. I7?R is associate+ with oor cogniti8e an+ neurological +e8elo-ent for the infant an+ in a+ulthoo+'
susceti/ilit) to car+io8ascular +isease' +ia/etes an+ renal +isease (,e %nis et al.' 1$$8!.
2alnutrition re-ains one of the worl+Cs highest riorit) health issues not onl) /ecause its effects are so
wi+esrea+ an+ long lasting /ut also /ecause it can /e era+icate+. 3ra+ication is /est carrie+ out at the re8enti8e
stage. >ence the nee+ to i+entif) grous of regnant wo-en at greater ris( of +e8eloing P32. Such high-ris(
grous can /e targete+ in an) lanne+ inter8ention rogra--e.
Pregnanc) is a nor-al h)siological rocess associate+ with -a6or alterations affecting e8er) -aternal organ'
s)ste- an+ -eta/olic athwa) (2c?anit) et al., 1$$4!. 0his h)siological rocess results in increase+ las-a
8olu-e an+ re+ /loo+ cells' +ecrease+ concentration of circulating nutrient-/in+ing roteins an+ other
-icronutrients (.a+io' 2###!.
0he ai- of this stu+) is to in8estigate so-e of the /ioche-ical changes associate+ with rotein energ)
-alnutrition (P32! in regnant wo-en in 3nugu -etroolis of Nigeria.

MA#E$"A%& AN' ME#()'&
*! &tudy &ub+ects
0hree grous of fe-ale 8olunteers were in8ol8e+ in this stu+). 0he first grou were "2 regnant wo-en with
low total rotein (;"2g<l!' the secon+ grou were "# regnant wo-en with nor-al total rotein (="2g<l!' while
the thir+ grou were "# non regnant' non lactating' aarentl) health) wo-en (="2g<l!. *ll the su/6ects were
/etween 2#-4# )ears of age. *ll the regnant su/6ects were atten+ing antenatal clinic of Par(lane Secialist
>osital' were in +ifferent gestational stages of regnanc) with +ifferent arit). Su/6ects with co-lications
such as h)ertension' +ia/etes' >I&<*I,S on a+-ission were eGclu+e+.
*!* Collection of Blood &amples and Preparation of &erum
1loo+ (2."-ls! was collecte+ fro- each 8olunteer /) 8eneuncture an+ +eli8ere+ into clean an+ +uel)
la/elle+ seci-en containers. 0he /loo+ was allowe+ to clot an+ then centrifuge+ at "### r- for 1# -inutes.
7sing a Pasteur iette seru- was searate+ fro- the cells an+ +eli8ere+ into a clean an+ +r) /ottle. It was
store+ froJen at F2#
#
: until it was use+.
*!, Preparation of $eagents
0he reagents use+ were high erfor-ance enJ)-atic colori-etric co--ercial anal)tical (its (1ios)ste-s
Reagents an+ Instru-ents' 1arcelona' Sain!. 0hese co--ercial (its were urchase+ an+ use+ accor+ing to the
-anufacturerCs +irection for all the ara-eters assa)e+.
*!- 'etermination of serum total protein
Princile4 0he seru- total rotein was +eter-ine+ using the 1iuret -etho+. 0he rotein in the sa-le reacte+
with coer II ion in al(aline -e+iun for-ing a coloure+ co-leG that was -easure+ sectrohoto-etricall)
,eter-ination of seru- rotein was carrie+ out accor+ing to the -etho+ of ?ornall et al. (1$4$! an+
1erg et al. (1$84!.
*!. 'etermination of &erum Albumin Concentration
0he -easure-ent of seru- al/u-in was /) the Huantitati8e -etho+ using (1.:.?! 1ro-ocresol green. 0his
-etho+ is /ase+ on the Huantitati8e /in+ing of al/u-in in the sa-le to the in+icator 3' 3C' "' "C F tetra /ro-o--
cresol sulhonehthalein (1:?! (1ro-ocresol ?reen!. 0his will for- a co-leG (nown as the *l/u-in F 1:?
co-leG. 0his co-leG a/sor/s -aGi-all) at "B8n-' the a/sor/ance (*! /eing +irectl) roortional to the
concentration of *l/u-in in the sa-le.
0he +eter-ination of seru- al/u-in concentration was +one accor+ing to the -etho+ of ,ou-as et al. (1$B1!.
*!/ 'etermination of &erum #otal Cholesterol
0he total cholesterol concentration of the test in+i8i+uals was +eter-ine+ using cholesterol enJ)-atic en+oint
-etho+. :holesterol is +eter-ine+ after enJ)-atic h)+rol)sis an+ oGi+ation. 0he in+icator Huinonei-ine is
for-e+ fro- h)+rogen eroGi+e an+ 4-a-inoanti)rine in the resence of henol an+ eroGi+e. 0he free an+
esterifie+ cholesterol in the sa-le originates /) -eans of the coule+ reactions +escri/e+ /elow' a coloure+
co-leG is for-e+ that can /e -easure+ sectrohoto-etricall).
0he concentration of seru- total cholesterol was +eter-ine+ accor+ing to the -etho+s of *llain et al.
(1$B4! an+ 2eiattini et al. (1$B8!.
*!0 'etermination of serum urea concentration
0he urea concentration of the test in+i8i+uals were +eter-ine+ /) the urease F salic)late enJ)-atic -etho+. 0his
uses the enJ)-e urease to h)+rol)Je urea. 0he a--onia ro+uce+ reacts with al(aline h)ochlorite an+ henol
in the resence of a catal)st to for- in+ohenol. 0he coloure+ co-leG is -easure+ sectrohoto-etricall). 0he
+eter-ination of seru- al/u-in concentration was +one accor+ing to the -etho+ of :heest/rough (1$$8!.

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*!1 'etermination of serum creatinine concentration
:reatinine in the sa-le reacte+ with icrate in al(aline -e+iu- to for- a coloure+ co-leG. 0he coloure+
co-leG is -easure+ sectrohoto-etricall). It is -easure+ within a short erio+ to a8oi+ interference fro- non
creatinine su/stances.
0he seru- concentration of seru- al/u-in concentration was +one accor+ing to the -etho+s of 1artels
an+ 1oh-er (1$B1! an+ Ea/in) an+ 3rtingshausen (1$B1!.
*!2 'etermination of serum calcium concentration
:alciu- in the sa-le reacte+ with -eth)lth)-ol /lue in al(aline -e+iu- to for- a coloure+ co-leG. 0he
coloure+ co-leG was -easure+ sectrohoto-etricall). >)+roG)Huinoline was inclu+e+ in the reagent to a8oi+
-agnesiu- interference.
0he +eter-ination of seru- al/u-in concentration was +one accor+ing to the -etho+s of ?in+ler an+ Iing
(1$B2! an+ 1arnett et al. (1$B3!.
&tatistical Analysis
0he +ata were anal)se+ using the SPSS ac(age of win+ows 8ersion 11.## (SPSS :ororation' I.!. ,ifferences
/etween the -eans were searate+ an+ anal)se+ for statistical +ifference using the one wa) *N%&* while
correlations /etween ara-eters were calculate+ using the Pearsons correlation coefficient. ,ifference in -eans
with 8alues ; #.#" were accete+ as significant. ,ata were resente+ as -eans stan+ar+ +e8iations.

,!3 $E&4%#&
0hree grous of fe-ale su/6ects were in8ol8e+ in this stu+). 0he first grou reresente+ "2 regnant wo-en
with low total rotein' the secon+ grou reresente+ "# regnant wo-en with nor-al total rotein while the thir+
grou reresente+ "# non regnant' non lactating aarentl) health) wo-en. *ll the su/6ects were age+ /etween
2# an+ 4# )ears. *ll the regnant su/6ects were in 8arious gestational stages of regnanc)' an+ +ifferent arit).
0he -ean age was 28.$# K ".31 for all the su/6ects stu+ie+.
,! 'istribution of Mean 5alues of Measured Parameters in the &ub+ects
Eig. 1 shows the -eans 8alues of seru- total rotein' al/u-in' glo/ulin' cholesterol' urea' creatinine an+ calciu-
of all the su/6ects stu+ie+.

,!* Effect of Age on the 'ifferent Parameters Measured
Eigs. 2 to " show the results of all ara-eters -easure+ for -others in +ifferent age grous +i8i+e+ accor+ing to
Fig. 1: Distribution of mean values of measured parameters in the
subjects
0
20
40
60
80
100
120
140
160
180
200
erum total
!rotein
"lbumin #lobulin erum
$holesterol
%rea $reatinine $alcium
#roup
&
e
a
n

$
o
n
c
.

'
m
g
(
d
l
)
Pregnant Low S.T.P
Pregnant Normal S.T.P
Non-pregnant Normal S.T.P
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&ol.4' No.14' 2#14

"1
their le8el of seru- total rotein. 0here was no significant +ifference in the -eans of the seru- total rotein of
-others of +ifferent age ranges an+ other ara-eters -easure+ (=#.#"!. 0herefore age -a) not affect the le8el
of seru- total rotein of a -other an+ also other ara-eters -easure+. * test of correlation showe+ that age of
-other +i+ not correlate significantl) with seru- total rotein. >owe8er age of -other correlate+ ositi8el) an+
significantl) with arit) onl) (r @ A #."4"! (;#.#"! an+ no other ara-eter -easure+ (=#.#" in each case!.




Fig. 2: $oncentration of serum total cholesterol of both pregnant
and non*pregnant subjects +ith different levels of serum total
protein
0
20
40
60
80
100
120
140
160
180
200
!regnant lo+ ,! !regnant normal ,! -on*pregnant -ormal
,!
#roup
&
e
a
n

$
h
o
l
e
s
t
e
r
o
l

$
o
n
c
.

'
m
g
(
d
l
)
< 25
25 - 33
> 33
Fig. .: $oncentration of serum urea of both pregnant and non*
pregnant subjects +ith different levels of serum total protein
0
/
10
1/
20
2/
.0
!regnant lo+ ,! !regnant normal ,! -on*pregnant -ormal
,!
#roup
&
e
a
n

e
r
u
m

%
r
e
a

$
o
n
c
.

'
m
g
(
d
l
)
< 25 Years
25 - 33 Years
> 33 Years
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Fig. 4: $oncentration of serum creatinine of both pregnant and non*
pregnant subjects +ith different levels of serum total protein
0
0.1
0.2
0..
0.4
0./
0.6
0.0
0.8
0.1
1
!regnant lo+ ,! !regnant normal ,! -on*pregnant -ormal
,!
#roup
&
e
a
n

e
r
u
m

$
r
e
a
t
i
n
i
n
e

$
o
n
c
.

'
m
g
(
d
l
)
< 25 Years
25 - 33 Years
> 33 Years
Fig. /: $oncentration of serum calcium of both pregnant and non*
pregnant subjects +ith ,!
0
2
4
6
8
10
12
!regnant lo+ ,! !regnant normal ,! -on*pregnant -ormal
,!
#roup
&
e
a
n

e
r
u
m

$
a

$
o
n
c
.

'
m
g
(
d
l
)
< 25 Years
25 - 33 Years
> 33 Years
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"3
'"&C4&&")N
Pregnanc) is a h)siological con+ition se8erel) aggra8ate+ /) rotein energ) -alnutrition. 0his -a(es rotein
energ) -alnutrition (P32! the -ost wi+esrea+ an+ +isa/ling u/lic health ro/le- a-ong wo-en eseciall)
in +e8eloing countries li(e Nigeria.
0he +e-an+ for /oth energ) an+ nutrient is increase+ +uring regnanc) an+ for well nourishe+ wo-en onl) a
s-all a-ount of a++itional energ) is reHuire+ (D>%' 1$$$!. Pregnanc) is also associate+ with -a6or alterations
in e8er) -aternal organ' s)ste- an+ -eta/olic athwa). &alues of /ioche-ical ara-eters -a) change as the
regnanc) a+8ances fro- first to thir+ tri-ester an+ to arturition an+ then return towar+s nor-al +uring ost
artu- erio+. 0he two -a6or h)siological forces +ri8ing these changes are4
(1! 0he increase in las-a 8olu-e' increase in re+ /loo+ cells an+ +ecrease+ concentrations of circulating
nutrient-/in+ing roteins an+ -icronutrients.
(2! 0he e8er increasing le8els of estrogen an+ rogesterone as well as other lacental relate+ hor-ones'
which ha8e articular i-act on -aternal lii+s (cholesterol! (2c?anit) et al., 1$$4!.
0hese two h)siological -o+ifications result in two +o-inant effects4 the first re+uces le8els of /ioche-ical
su/stances such as al/u-in an+ hae-oglo/in which return to nor-al 8F1# wee(s ost artu-. 0he secon+
causes lii+s to rise +uring regnanc) an+ return to nor-al at ost artu-. 0he -a6or conseHuences of rotein
energ) -alnutrition (P32! are -ainl) oor weight gain in regnanc)' anae-ia lea+ing to high ris( +eli8er) an+
low /irth-weight /a/ies that fail to thri8e.
0he result of this in8estigation showe+ that all the /ioche-ical ara-eters -easure+ 8iJ seru- total rotein'
*l/u-in' urea' total cholesterol' creatinine an+ calciu- were significantl) re+uce+ in regnant P32 in+i8i+ual
co-are+ with regnant an+ non-regnant controls.
0his agrees with the stu+ies of %n)ene(e et al. (2##3! which suggests that a/nor-alities in seru- le8els of
/ioche-ical ara-eters occur in an) for- of P32 an+ are relate+ to the se8erit) of the con+ition (Eig. 1!.
0he result of this in8estigation also showe+ there was no significant +ifference in the -ean seru- total rotein
in the +ifferent age grous (see Eigs. 2F"!. 0herefore age of -other -a) not /e a factor an+ -a) not affect the
le8el of seru- total rotein an+ other ara-eters -easure+. 0his agrees with the stu+) of %(wu et al. (2##B!'
which showe+ that the lower age grous (/elow 2# )ears an+ 2#F24 )ears! resente+ higher re8alence of P32
than other age grous' with the effect -ore ro-inent in rural areas than in ur/an areas.
In a++ition' .ai+o (2###! suggeste+ that -an) regnancies in +e8eloing countries are unlanne+' coule+ with
ina+eHuate +ietar) inta(e +ue to +ietar) ta/oos associate+ with regnanc)' gen+er an+ other cultural /eliefs.
0he results fro- assess-ent of /ioche-ical ara-eters showe+ that seru- total cholesterol +i+ not significantl)
correlate with seru- total rotein or an) other ara-eters -easure+ (= #.#" in each case!. Seru- total
cholesterol therefore -a) not /e a factor in changes associate+ with low seru- total rotein an+ rotein energ)
-alnutrition. 0hese fin+ings are in consonance with the 8iew of 0oigo et al. (2###! that low seru- cholesterol in
P32 -a) reflect energ) i-/alance. 0otal seru- cholesterol therefore is a useful -ar(er for energ) inta(e /ut
not for rotein inta(e.
0he seru- urea le8els were foun+ to correlate significantl) an+ ositi8el) with seru- total rotein (r @ A #.246'
; #.#"! an+ seru- creatinine le8el (r @ A #.2B"' ; #.#"! onl). Its correlation with other ara-eters were not
significant (=#.#" in each case!. 0his suggests that as the seru- total rotein increases' seru- urea an+
creatinine le8els increase with it an+ 8ice 8ersa.
* test of correlation further re8eale+ that seru- creatinine correlate+ ositi8el) an+ significantl) with seru-
total rotein le8el (r @ A #.4$B' ; #.#"!' seru- urea le8el (r @ A #.2B"' ; #.#"! an+ seru- calciu- le8els (r @
A #.3"6' ; #.#"!. 0his suggests that as seru- total rotein increases' seru- creatinine' seru- urea an+ seru-
calciu- le8els increase an+ 8ice 8ersa.
>owe8er' seru- calciu- was foun+ to ositi8el) an+ significantl) correlate with seru- total rotein le8el (r @ A
#.681' ;#.#"! an+ seru- creatinine le8el onl) (r @ A #.#3"6' ; #.#"!. 0his suggests that as seru- total rotein
increases' seru- calciu- le8els an+ seru- creatinine le8els increase with it an+ 8ice 8ersa.
0hese factors are ointers to Protein 3nerg) 2alnutrition (P32!. 0oigo et al. (2###! reorte+
that in in+i8i+uals with P32' there is low seru- concentration of creatinine' suggesting a +ecrease+ s(eletal
-uscle -ass or a low +ietar) rotein inta(e.

&ummary6Conclusion
In su--ar)' the seru- total rotein which is (nown to correlate ositi8el) an+ significantl) with rotein energ)
-alnutrition was foun+ to also correlate ositi8el) an+ significantl) with seru- le8els of urea' creatinine an+
calciu-. Seru- total cholesterol +i+ not correlate significantl) with seru- total rotein or an) other ara-eter
-easure+ (=#.#" in each case!.
0he seru- le8els of urea' creatinine' calciu- an+ cholesterol ha8e /een i-licate+ in this stu+) as 1ioche-ical
in+ices or 1ioche-ical 2ar(ers of P32 in regnant wo-en. Seru- total cholesterol -a) howe8er /e a useful
-ar(er for energ) inta(e an+ not for rotein inta(e. 0his agrees with the wor( of 0oigo et al. (2###! which liste+
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&ol.4' No.14' 2#14

"4
urea' creatinine' calciu- an+ cholesterol as seru- 1ioche-ical in+ices or seru- /ioche-ical -ar(ers of P32.

$E7E$ENCE&
*/i+o)e' R. %. an+ 3Je' ,. I. (2###!. :o-arati8e School Perfor-ance 0hrough 1etter >ealth an+ Nutrition in
Nsu((a' 3nugu' Nigeria. Nutrition Research, *3("!46#$-62#.
*llain' :. :.' Poon' .. S.' :han' :. S. ?.' Rich-on+' D. an+ Eu' P. :. (1$B4! 3nJ)-atic +eter-ination of total
seru- cholesterol. Clinical Chemistry, 2#44B#-4B".
*llen' .. an+ Doo+' R. J. (1$$4!. Calcium and Phosphorus. In' Shils' 2. 3.' %lson' J.*. an+ Shi(e' 2. (e+s.!
2o+ern Nutrition in >ealth an+ ,isease. 8
th
e+. &ol. I Dillia-s an+ Dil(ins' Phil. 7.S.*. 812-838.
*u+u' R. I.' *(an-u' *.S.' 2afe' *.?.' 3fiene-o(wu' :.' 2usa' *. L.' .e-oha' 3.' %+unai(e' 2. I.' EunsoF
*+e/a)o' 3. %.' 2eshac(' 3. an+ I+ig/e' 3. %. (2##4!. :hanges in seru- rotein an+ creatinine le8els in >I&
infecte+ Nigerians. Nigerian Journal of Health and Biomedical Science, 3(2!4 6$-B2.
1ar(er' >. 2. an+ .ees' R. (1$$6!. Nutrition and dietetics for Health Care. $
th
e+. :hurchill .i8ingstore 3-1#.
1arnett' R. N.' So(o+on' S. 1.' an+ ?ol+/erg' 2. >. (1$B3!. Perfor-ance (it use+ for clinical che-ical anal)sis
of calciu- in seru-. American Journal of Clinical Pathology, "$4 836-843.
1artels' >. an+ 1oh-er' 2. (1$B1!. 3ine -i(ro-etho+e Jur (reatinine /estin-ung.
Clinica Chimica Acta, 324 81-8".
1ehra-an' R. 3.' Ilieg-an' R. 2. an+ Jensen' >. 1. (2##4!. Nelsons e!t"oo# of Pediatrics, 1B
th
e+. D.1.
Saun+ers. P. 1B1.
1erg' 1.' Petersohn' ..' >el-' ?. an+ 0r)+ing' N. (1$84!. Reference 8alues for seru- co-onents in Pregnant
Do-en. Acta $"stetricia et %ynecologica Scandina&ica, 63(B!4 "83-"86.
1urtis' :. *. an+ *shwoo+' 3. R. (1$$6!. iet' (undamental of Clinical Chemistry. 4
th
e+. D.1. Saun+ers an+
:o. Phil. 7.S.*. 4"B-68$.
:hen' P. (2##1!. Reco--en+ation ,ail) *llowance chart. *8aila/le fro-4 http)**+++.penhealth.com*health,
inffo*pregrancy*stay healthy*articles*rda.html.
:hees/rough' 2. (1$$8!. -istrict .a"oratory Practice in ropical Countries. Part 1 :a-/ri+ge 7ni8. Press 7I.
PP 311-34#
,a8i+son' J. *.' >owar+' :. J.' Schiff' >. I.' an+ Eehsenfel+' E. :. (1$B$!. 7(1! as the 2ini-al >oriJontal ?auge
S)--etr). Journal of Chemical Physics' B#4 16$B.
,e %nis' 2.' 1lossner' 2. an+ &illar' J. (1$$8!. .e8els an+ Patterns of Intrauterine ?rowth Retar+ation in
,e8eloing :ountries. /uropean Journal of Clinical Nutrition9 "24"83-"$2.
,ou-as' 1.0.' Datson' D.*. an+ 1iggs' >.?. (1$B1!. *-ino aci+s an+ Proteins. Clinica Chimica Acta, 314 8B
3nc)cloe+ia *-ericana (1$$6!. Int 3+tn. 1)grolier Incoroate+ &ol. 1B $6-1#"
3nc)cloe+ia *-erican (1$$6!. International 3+. &ol. 1B 1)grolier Inc. . 136-13B
3nwonwu' :. %.' Phillis' R. S.' I/rahi-' :. ,. an+ ,anfillo' I. S. (2##4!. Nutrition an+ %ral >ealth in *frica.
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:reatinine with centrifiche-. Clinical Chemistry, 1B4 6$6-B##.
Eoo+ an+ *griculture %rganiJation (E*%! of the 7nite+ Nation (1$62!. :alciu- reHuire-ents4 Reort of a 6oint
E*%<D>% eGert consultation. Ro-e. E*%. Nutrition -eeting Reort No. 3#.
Eoo+ an+ *griculture %rganiJation of the 7nite+ Nations (2##4!. 7n+er Nourish-ent *roun+ the Dorl+. In 0he
State of Eoo+ Insecurit) in the Dorl+' Ro-e' 0he %rganiJation' 2##4.
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-eth)l-ol /lue. American Journal of Clinical Pathology, .14 3B6-382.
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an+ thir+ +egree -alnutrition. Journal of 0roical Pe+iatrics' 2' BB-83.
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1iuret Reaction. Journal of Biological Chemistry, 004 B"1-B66.
?rant' ?. >. (1$8B!. Amino Acids and Proteins. In' 0ietJ' N. D. e+s Eun+a-entals of :linical :he-istr). 3
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e+.
D.1. Saun+ers an+ :o. Phil. 7.S.*. 328-32$.
>ara-' I. (1$83!. Seru- Protein attern in nor-al regnanc) with secial reference to *cute hase reactants.
British Journal of $"stetrics and %ynaecology, 234 13$-14".
>aslett' :.' :hil8ers' 3. R.' 1oon' N. *. an+ :olle+ge' N. R. (2##2!. -a&idsons Principle and Practice of
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%lson' J.* an+ Shi(e' 2. (e+s! 2etho+ Nutrition in >ealth an+ ,isease 8
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7.S.*. 812-838.
Journal of Natural Sciences Research www.iiste.org
ISSN 2224-3186 (Paer! ISSN 222"-#$21 (%nline!
&ol.4' No.14' 2#14

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>i//ar+' 1. 2. (1$$2!. 2inerals an+ &ita-ins in Pregnanc). Practical Nutrition, (3!4 1-8.
>o+ges' 3. R. (1$8#!. Nutrition in 2e+ical Practice. 4
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1uttin .. e+s. Princiles of 2e+ical 0hera) in Pregnanc). 3
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e+. *leton an+ .ange'%l+ 0aan 'N.J. 311-
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7ni8. Press. ,ares Sala- . 1$.
Inight' 3. 2. (1$$4!. 1ioche-ical rofile of *frican *-erican Do-en +uring three tri-esters of regnanc)
an+ at +eli8er). Journal of Nutrition, *-4 $43-$"3.
.a+io' %. (2###!. Nutrition in Pregnanc)4 2ineral an+ &ita-in Sule-ents. American Journal of Clinical
Nutrition' 0*(1!4 28#-2$#.
.a+io' %. (1$$"!. $pportunities and constraints for reproducti&e health research in de&eloping countries. In'
&an .oo(' P.3. a+ PereJ-Palacias' ?. e+s' contraceti8e research an+ +e8elo-ent' 1$84-1$$44 the roa+ fro-
2eGico cit) to :airo an+ /e)on+ New ,elhi. %Gfor+ 7ni8. Press. P 48$-"##.
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2aine' ,. (2###!. Role of nutrition in re8ention of toGe-ia. American Journal of Clinical Nutrition, 0*4 2$8-
3##.
2a(ola' ,.' *sh' ,. 2.' 0otala' S. R.' .atha-' 2. :. an+ 2ehansho' >. (2##3!. * -icronutrient fortifie+
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Phil. 7.S.*. B#" F B26.
2eiattini' E.' Prencie' ..' 1ar+elli' E.' ?iannini' ?. an+ 0arli' P (1$B8!. 0he 4-h)+roG) /enJoate<4-
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Chemistry' *-4 2161 F 21 6".
2er8)n' .. (1$8"!. e+. ,ictionar) of 2inerals. 0horsons Pu/. Delling/orough N.N. 1B3 F 1BB.
2uller' %. an+ Irawin(el' 2. (2##"!. 2alnutrition an+ >ealth in ,e8eloing :ountries. C1AJ, 0(3!42B$-2$3.
National >eart' .ung an+ 1loo+ Institute (2##1! National :holesterol 3+ucation Progra--e 3Gert Panel. 0hir+
Reort of the National :holesterol 3+ucation Progra--e (N:3P! 3Gert Panel on ,etection' 38aluation an+
0reat-ent of >igh 1loo+ :holesterol in *+ults (*0P III!. NI> Pu/lications 1ethse+a
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status.a8aila/lefro-)**http)**+++.#idney.org*Professionals*#do5i*guidelines*updates*nut,ao6.html.
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&ol.4' No.14' 2#14

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$6 F $B
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e+. 3+war+ *rnol+' >o++er an+ Stoughton. .on+on 33" F 366.
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+eter-ination. Clinical Chemistry, *.4 336 F 33B.
0ietJ' N. D. (1$$$!. Clinical guide to .a"oratory tests) 3
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e+. Saun+ers an+ :o.
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insufficienc). Journal of Clinical Nutrition, 2(3!4 1$B F 2#B.
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2o+ern Nutrition in >ealth an+ ,iseases 8
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e+. &ol 1 Dillia-s an+ Dil(ins Phil. 7.S.*. $"# F $B4.
0rowell' >. :.' ,a8ies' J. N. P. an+ ,ean' R. E. *. (1$"4!. Iwashior(or. .on+on.
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Sus(in+' R.2. e+s. 0eGt/oo( of Pae+iatric Nutrition. Ra8en Press New Nor(.
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Dorl+ >ealth %rganiJation (D>%! (1$88!. 0echnical Reort Series' 0/14 1"
Dorl+ >ealth %rganiJation (D>%!. (1$$B!. 0he worl+ >ealth Reort 1$$B4 conHuering suffering' enriching
>u-anit). D>%. ?ene8a.
Dorl+ >ealth %rganiJation (D>%!. (1$$8!. Regional >ealth Reort 1$$84 Eocus on Do-en. New ,elhi' D>%
Regional %ffice for South 3ast *sia.
Dorl+ >ealth %rganiJation (D>%!. (1$$$!. >ealth Situation in the South 3ast *sia Region 1$$4-1$$B. New
,elhi' D>% Regional %ffice for South-3ast *sia
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th
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