Postpartum Dietary Intakes and Food Taboos Among...

Mal J Nutr 11(1): 1-21, 2005

Postpartum Dietary Intakes and Food Taboos AmongChinese Women Attending Maternal and Child HealthClinics and Maternity Hospital, Kuala Lumpur

Poh Bee Koon, Wong Yuen Peng & Norimah A. Karim

Department of Nutrition & Dietetics, Faculty of Allied Health Sciences, Universiti KebangsaanMalaysia, Kuala Lumpur, Malaysia

ABSTRACT

Traditionally, Chinese women adhere to special dietary practices duringthe month following childbirth. This paper discusses the dietary practicesand food taboos practised by Chinese women in Kuala Lumpur. A totalof 134 Chinese mothers of children below one year were recruited fromthree Maternal and Child Health Clinics and Maternity Hospital, KualaLumpur. Questionnaires and in-depth interviews were used to obtaininformation on socioeconomic background, dietary practices, food taboosand cooking methods during the confinement period. Food intake wasassessed by multiple 24-hour dietary recall among 34 mothers duringtheir confinement month (zuo yuezi). Body weight and height weremeasured, and body mass index calculated. Majority of the respondentshad secondary school education (77.6%), household income betweenRM1001 and RM3000 (64%), and were homemakers (48.5%). The womenwere aged 18 – 39 years, and 68% were of normal weight. Most women(82%) practised 30 days of confinement, during which they adhered tospecial dietary practices. The diet was directed at attaining yin-yang(cold-hot) balance, whereby “hot” foods were most commonly used and“cold” foods were avoided. Ginger, rice wine and sesame seed oil,considered “hot” foods, were used in large amounts in the cooking. Rice,chicken and pork were also consumed in large amounts. Most vegetablesand fruits were considered “cold” and were prohibited during confine-ment. Most mothers drank specially-prepared teas boiled from Chineseherbs. Mean energy intake was 19% below RNI, while mean proteinintake was 93% above RNI (NCCFN, 2005). Mean intakes of thiamin,riboflavin and niacin were above 75% of RNI, while vitamins A and Cwere at half of RNI or less. Mean iron and calcium intakes were at 222%and 67% of RNI, respectively. It is concluded that most Chinese womenin Kuala Lumpur do conform to special dietary practices during zuoyuezi.

_________________Corresponding author: Assoc Prof Dr Poh Bee Koon, email: [email protected]

INTRODUCTION

According to Chinese beliefs, themother and child are extremely vulnerableto illness and potential death during themonth after birth. Traditionally, Chinesewomen follow a set of well-defined cultur-al practices designed to reduce this danger(Pillsbury, 1978). Women who follow thetraditions are said to be in confinement or“doing the month” (zuo yuezi).

Zuo yuezi serves as a physical conva-lescence, a preventative measure, a socialsanction to rest, a consolation, and aprompt for Chinese women to concentrateon their baby and their role of breastfeed-ing. It also serves as an occasion tostrengthen intra-family ties, especiallybetween the woman and her mother ormother-in-law (Cheung, 1997).

The mother must also restore thebalance of yin (cold) and yang (hot) in herbody. During the postpartum period, themother is in the period of strongest yin,and accordingly her diet should be basedupon yang foods, which are typically thosehigh in energy and protein (Hwu, Coates& Boore, 2001). Several foods, called galac-tagogues, are encouraged during lactationin the belief that their consumption willincrease the mother’s breast milk produc-tion (Pillsbury, 1978). These foods includechicken, pork, rice wine, fish, and wheatnoodles with egg. Strength-providingfoods and medicinal products, such aschicken, ginger and ginseng (Panax gin-seng) are also encouraged so that themother recovers quickly from the exertionof labour.

Zuo yuezi is embedded in the cultureof the Chinese and is practised not only inChina, but also by Chinese living in otherparts of the world. Studies in Hong Kong(Holroyd et al., 1997), Taiwan (Heh, Fu &Chin, 2001), Scotland (Cheung, 1997),California (Fishman, Evans & Jenks, 1988),Australia (Matthey, Panasetis & Barnett,2002), and Malaysia (Ngin, 1985) havefound that Chinese mothers practice zuo

yuezi to a certain extent after childbirth.In Malaysia, Chinese women do con-

form to some if not all zuo yuezi practices(Ngin, 1985). The Malaysian Chinesewomen are also known to have a pei yuewho keeps company with the mother for amonth after childbirth (Dixon, 1993). Thepei yue, sometimes the woman’s ownmother, mother-in-law, or a paid profes-sional, is an experienced woman whosejob is to cook and care for the the mother,baby and other children throughout theconfinement. The zuo yuezi practices, how-ever, are usually modified to suit themodern mother’s lifestyle, beliefs, andfinancial status. The dietary aspects of thezuo yuezi may also be modified but areusually followed.

A literature search of availableresources found very few studies specifi-cally relating to the dietary aspects ofconfinement after childbirth carried out inMalaysia in recent years. Several papersrelevant to this topic were published in the1950s to early 1980s: Millis (1958) reportedmodifications in food selection observedby Malays women during pregnancy andconfinement, Jensen (1967) discussedvarious aspects of Iban birth, Kuah (1972)studied Malay customs in relation to child-birth, Chen (1973) analysed customsrelated to childbirth in rural Malay cul-ture, and Manderson (1981a) reportedMalay confinement practices of roasting,smoking and dieting. Lee, Janet &Ravindran (1997) in a study on the inci-dence of postnatal depression amongwomen of Malay, Chinese and Indianethnicities in Seremban reported that64.3% followed “pantang larang” and85.7% took special diets, but did not elabo-rate on these aspects. Apart from Ngin’s(1985) study among Chinese women ofHokkien dialect in Selangor, there is noother known publication on confinementand its special dietary practices amongChinese women in Malaysia.

With this background in mind, thisstudy was carried out to determine the

2 Poh, Wong & Norimah

dietary practices of Chinese mothersduring confinement. This paper reportsthe dietary intakes and food taboos ofChinese mothers attending governmentclinics and hospitals in Kuala Lumpur.

METHODS

Respondents

A total of 134 Chinese mothers volun-teered to participate in this study. Amother was chosen if she had a childbelow 1 year old. If the mother had morethan one child, then the questionnaire wasdirected at the practices for the youngest.

A hundred respondents were motherswith a child below one year old whoattended three Maternal and Child HealthClinics in Kuala Lumpur, namely those atJalan Tun Ismail, Taman Sri Sinar, andJalan Cheras. These mothers were inter-viewed during their clinic visit.

Thirty-four mothers had given birthat the Maternity Hospital in KualaLumpur Hospital and were in confine-ment during the survey. These motherswere interviewed during their stay in thehospital after delivery and their socio-demographic data and contact numberswere obtained. The mothers also gavepermission to be interviewed by telephoneduring their confinement at home.

Questionnaire and interview

A set of questionnaires was used tocollect data on the socio-demographicbackground of the respondents, dietarypractices and food taboos observed duringconfinement after childbirth. The ques-tionnaire was interview-administered bytwo trained university students, whocould speak Mandarin, English andseveral Chinese dialects. Interviews wereconducted in Mandarin or English, andsupported by the use of Cantonese,Hokkien or Teochew dialects, depending

on the fluency of the respondents.A small proportion of the women

from each dialect group, namelyCantonese, Hakka, Hokkien, andTeochew, were also interviewed in detailas to the food taboos, dietary practices andcooking methods that they observedduring their confinement.

Food Intake

Food intake was assessed by multiple24-hour dietary recall method in 34mothers during their confinement month.The respondents were interviewed viatelephone for three days, namely twoweekdays and one weekend day. Theyhad been taught, when met during theirhospital stay, on how to estimate foodintake using common household measure-ments, such as plates, spoons and cups.

The food intake data was then con-verted to nutrient intake using a computerpackage based on the NutrientComposition of Malaysian Foods (Tee etal., 1997). Foods not found in theMalaysian database were obtained fromthe food composition tables of China,Singapore and ASEAN (PreventiveMedical Science Centre & Research Centreof Nutrition and Food Health, China, 1999;Ministry of Health, Singapore, 1993;Ministry of Health, Singapore, 1998;Puwastien et al., 2000).

Anthropometry

Body weight and height weremeasured in 100 women who attended theMaternal and Child Health Clinics. Bodyweight and height were measured in lightclothing and without shoes; using Tanitadigital scale to the nearest 0.2kg and SECAbodymeter 208 to the nearest 0.1cm,respectively. Body mass index (BMI) inkg/m2 was calculated for each subject.

The 34 respondents who weretelephone-interviewed during confine-ment were not measured. Self-reported

Postpartum dietary intakes and food taboos 3

weight and height at one month afterchildbirth were used. According toKuczmarski, Kuczmarski & Najjar (2001),self-reported heights and weights can beused with younger adults, but have limita-tions for older adults aged 60 years andabove. Since the respondents of this studywere women in their reproductive years,self-reported weight and height should beacceptable.

Data Analysis

Data analyses were performed usingSPSS Version 10.0 (Statistical Package forthe Social Sciences). A statistical descrip-tion of the population was made. Dietaryintake was analysed using the Diet 4program and compared with theRecommended Nutrient Intakes (RNI) forMalaysia (NCCFN, 2005).

RESULTS AND DISCUSSION

Sociodemographic Characteristics

Table 1 shows the demographic andsocio-economic characteristics of therespondents. The women were mostlyfrom Hokkien (36.6%), Cantonese (28.3%)and Hakka (24.6%) dialect groups.Teochew formed 6.0% of the pool and therest were from other dialect groups, suchas Hainan, Guangxi and Fuchow.

The majority of the women (77.6%)had secondary school education, 12.7%had tertiary education, 9% primary schooleducation, and only one (0.7%) had noformal education. A large proportion ofthe women (48.5%) were homemakers,with a similar proportion (44.0%) workingin the private sector. A minority were self-employed (5.2%) or worked in the govern-ment sector (2.3%).

The majority of the women who werehomemakers did not have a personalincome. Most of the women who wereemployed had a monthly personal income

of RM1500 and below (38.0%), 12.0%earned between RM1500 and RM3000,while only 1.5% had an income aboveRM3000. The women’s personal income,however, may not be reflective of theirfinancial situation. It would be more accu-rately represented by taking into accounttheir spouse’s income.

A majority of the respondents’spouses (79.1%) worked in the privatesector. Another 20.1% were self-employedand the remaining 0.8% worked in thegovernment sector. The majority of thespouses (76.9%) had an income of betweenRM1001 and RM3000. Of the remaining, asimilar percentage had incomes RM1000and below (11.9%), and above RM3000(11.2%).

The combined income of the respon-dents and their spouse is reported ashousehold income in Table 1. A majorityof the women (63.4%) had a householdincome of RM1001 – RM3000. Another28.4% had household income of betweenRM3001 – RM10,000; while only 1.5% hadhousehold income above RM10,000, and6.7% had household income RM1000 andbelow. This proportion reflects the lowerto middle income segment of patients whousually attend government clinics as themore affluent would usually seek treat-ment at private hospitals (Chan, 1996).

Physical Characteristics

Mean age of the women was 28.7 ± 5.0years, and ranged from 18 to 39 years atthe time of the interview (Table 2). Meanbody weight, height and BMI were 55.8 ±8.7 kg, 158.8 ± 5.6 cm, and 22.2 ± 3.7kg/m2, respectively.

Figure 1 shows that a majority of thewomen were of normal weight (68%).Another 15% were categorised as over-weight, 4% were obese Grade I, and nonewere categorised as obese Grades II or III.A smaller percentage suffered fromchronic energy deficiency (13%).



Table 1. Socio-demographic characteristics of mothers (n=134)

Number of subjects Characteristic No. Percentage

Dialect group Hokkien 49 36.6 Cantonese 38 28.3 Hakka 33 24.6 Teochew 8 6.0 Other dialects 6 4.5

Level of education No formal schooling 1 0.7 Primary 12 9.0 Secondary 104 77.6 Tertiary 17 12.7

Employment Government 3 2.3 Private 59 44.0 Homemaker 65 48.5 Self-employed 7 5.2

Personal income RM0 65 48.5 RM 1 – RM 1000 31 23.1 RM 1001 – RM 1500 20 14.9 RM 1501 – RM 2000 8 6.0 RM 2001 – RM 3000 8 6.0 > RM 3000 2 1.5

Spouse’s employment Government 1 0.8 Private 106 79.1 Self-employed 27 20.1

Spouse’s income RM 1000 and below 16 11.9 RM 1001 – RM 1500 45 33.6 RM 1501 – RM 2000 25 18.7 RM 2001 – RM 3000 33 24.6 > RM 3000 15 11.2

Household income RM 1000 and below 9 6.7 RM 1001 – RM 2000 48 35.8 RM 2001 – RM 3000 37 27.6 RM 3001 – RM 5000 24 17.9 RM 5001 – RM 10000 14 10.5 > RM 10000 2 1.5

Ismail et al. (1995) reported similar preva-lence in their study on 979 MalaysianChinese women, with 71% normal weight,12.9% overweight, 4.3% obese, and 11.8%CED. A more recent report from theNational Health and Morbidity Surveycompleted in 1996 also showed similartrends among Chinese women, that is62.7% normal weight, 18.7% overweight,and 5.3% obese, while 13.3% were under-weight (Lim et al., 2000).

As in the two nation-wide studies, thedual problems of under- and over-nutrition, which prevail in the Malaysianpopulation (Noor, 2002), were also evidentin the women who participated in thisstudy.

Dietary practices during confinement

Duration of confinement period

Figure 2 shows the duration of con-finement as practised by the respondentsafter their latest childbirth. The majority ofChinese women (82%) were in confine-ment for 30 days. Twelve percent practisedconfinement for 40 – 45 days, 5% were inconfinement for 60 days, and only 1%practised it for 90 days. The practice ofconfinement for 30 days is in accordancewith traditional Chinese custom, whichstipulates that a woman should be con-fined to the home for one full month ofconvalescence after giving birth (Pillsbury,1978). Reports from other countriesshowed that Chinese women who live inSydney, Australia (Matthey et al., 2002)


Figure 1. Distribution of respondents according to BMI categories

0

0

4

3

6

16

52

15

4

0 10 20 30 40 50 60

Obese III (BMI more than 40.0)

Obese II (35.1–40.0)

Obese I (BMI 30.1–35.0)

Pre-obes (BMI 25.1–30.0)

Normal (BMI 20.0–25.0)

Low Normal (BMI 18.6–19.9)

CED I (BMI 17.6–18.5)

CED II (BMI 16.1–17.5)

CED III (BMI 16.0 and below)

BM

Icat

egor

ies

Percent of cases (%)

and Scotland (Cheung, 1997) also prac-tised 30 days confinement.

It is also common for women of otherethnicities in Malaysia to practice confine-ment after childbirth. Malay women areconfined for 40 days (Laderman, 1982) to44 days (Chen, 1973), while Indian womenpractised 30 days of confinement (Colley,1978).

Women originating from otherSoutheast Asian countries are also report-ed to have special practices in the postpar-tum period. Rice (2000) reported thatHmong women originating from Laos andThailand practices nyo dua hli for 30 daysafter childbirth. Fishman et al. (1988) onthe other hand reported that Cambodian,Chinese and Vietnamese women living inCalifornia had special dietary practices for100 days postpartum.

Cooking methods and special ingredients

The cooking styles and special ingre-dients used in the diet of women in con-

finement were obtained from detailedinterviews with a small proportion of therespondents. Table 3 summarises thespecial ingredients commonly used andcooking methods adopted by the variousChinese dialect groups for mothers inconfinement.

The use of matured ginger as an ingre-dient for cooking foods for mothers inconfinement is common in all dialectgroups. Ginger is known as a “hot” orwarming food and is believed to enhanceblood circulation and have carminativeproperties (Lu, 1990).

The Cantonese and Hakka dialectgroups have very similar cooking styles,whereby chicken is simmered in rice wineand ginger without the addition of water.Another common dish is pig trotterssimmered in black vinegar and ginger.These dishes are alternately prepared andserved almost every day during confine-ment.

The Hokkien and Teochew dialectgroups also have many similarities,


Figure 2. Duration of confinement period

82%

5%1%1%

2%

9%

30 days40 days44 days45 days60 days90 days

whereby sesame seed oil is commonlyadded to stir-fried dishes, and water maybe added while cooking. Matured ginger,sesame oil and rice wine are believed toreinforce the warming elements of food.This is the reason the confinement dietuses an excessive amount of these threeingredients. Meat is served every day,usually rotating between chicken, pork,pig liver and kidney.

Chinese herbs were also frequentlyused in the foods and drinks prepared forthe mother in confinement. Red and blackdates, dried longans, kei zhi (boxthornfruits), tong kuei (angelica) and dang shen(Codonopsis pilosula) are commonly used.These herbs are reported to nourish blood,improve energy levels and revitalisehealth (Lu, 1990). Specially-prepared teasmade from various combinations of theabove-mentioned herbs were drunk forthe whole duration of the confinement.These teas are consumed in place of plainwater, which is believed to give a lot of“wind”.

In general, vegetables and fruits arenot encouraged. Depending on the peiyue’s beliefs, only certain types of vegeta-bles that are not considered “cold”, such asmushrooms, french beans, string beansand Chinese kale, were served. Somemothers were prohibited from all types ofvegetables and fruits during confinement.

Mothers were encouraged to eatplenty of rice and as much of the specially-prepared dishes as they possibly couldduring confinement, in order to recoverfrom the exhaustion of childbirth and toencourage breastmilk production. Themajority of the women were breastfeedingduring confinement (77%), while 23%were not.

Food taboos and food acceptance

Tables 4a – 4e show the acceptance ofvarious types of foods and beveragesduring confinement, and their propertiesaccording to the respondents’ beliefs.


Table 2. Physical characteristics of respondents (n=134)

Variable Mean ± SD Range

Age (years) 28.7 ± 5.0 18.0 – 39.0 Height (cm) 158.8 ± 5.6 142.0 – 175.0 Body weight (kg) 55.8 ± 8.7 38.0 – 80.0 BMI (kg/m2) 22.2 ± 3.7 14.8 – 32.0

Table 3. Cooking methods and ingredients commonly used by various Chinese dialects

Dialect Groups Ingredients Cooking methods

Cantonese, C Ginger (matured) C Chicken simmered with ginger inHakka C Rice wine wine, without adding water.

C Chinese tonic wine C Pig’s trotters simmered with gingerC Black vinegar in black vinegar

Hokkien, C Ginger (matured) C Chicken simmered with ginger in Teochew C Sesame seed oil wine and water mixture.

C Rice wine C Meat stir-fried with sesame seed oil.

The majority of Chinese women consid-ered most vegetables and fruits “cold” anddid not eat them during confinement(Tables 4a and 4b). Top of the list of pro-hibited vegetables were kangkung, beansprouts, cucumber, cabbage, watercress,brinjal, siew pak choy and lettuce – withmore than 70% of the respondents citingthat they were not allowed to eat thesevegetables during confinement. The list ofvegetables that were encouraged wasshorter – string beans, sawi, mushroom,french beans, Chinese kale, and carrot.Only 30 – 43% of the women reported thatthese vegetables were encouraged, while45 – 60% of the women cited these samevegetables as prohibited.

Many commonly eaten local andimported fruits were reported to be pro-hibited during confinement by 61 – 86% ofthe women, with watermelon, pineapple,nangka, cempedak, starfruit and papayatopping the list at above 80% prohibited. Amore acceptable fruit was apple with 42%citing it as encouraged or “must eat a lot”and 49% citing it as prohibited. Only 2 – 4% of the mothers cited all fruits as “musteat a lot”.

Table 4c shows that 58 - 96% of therespondents consider seafood (includingsquid, cockles, prawn and crab) and mostfish (including kembung, pari, tuna, sardineand bilis) as “poison” and were prohibitedfrom eating these foods. Ikan haruan werereported to be “encouraged” or “must eata lot” by about a quarter of the women.Ikan haruan is reported to enhance dermalwound healing (Baie & Sheikh, 2000), andis especially encouraged for women whounderwent caesarean section.

Table 4c also shows that sources ofprotein that were considered “hot” such aspork and chicken were most encouragedand were eaten every day by all thewomen (99 – 100%). Eggs and organ foodswere also encouraged (56 – 75%).Although mutton and beef were cate-gorised as “hot” food by more than halfthe women, the majority (42 – 48%) of

them were neutral on the acceptance ofthese two types of meat, and 27 – 32% saidthey were prohibited from eating them.These could be due to the cultural practiceof the Malaysian Chinese where the major-ity eats pork, chicken or fish daily, butmutton and beef are less commonly eaten.

Rice was categorised as a “hot” foodby 76% of the respondents, and was themost widely accepted food among the fivelisted under carbohydrate sources (Table4d). Potato appears to be more acceptedthan sweet potato and tapioca. Yam on theother hand, was listed as “poison” by 73%,and 90% were prohibited from eating yam.According to Lu (1990), Chinese yam andsweet potatoes are classified as yin foods.

Most spices were listed as “hot” foodsby more than 50% of the respondents(Table 4d). Ginger and sesame seed oil, themost commonly used items in Chinesecooking for women in confinement, werealso listed as “hot” by 84 – 86% of therespondents and more than 90% citedthem as encouraged or “must eat a lot”.

Most of the beverages listed wereclassified as “cold” by 59 – 88% of therespondents (Table 4e). Top of the list ofdrinks prohibited were carbonated water,ice, grass jelly, sugar cane and tea. Theonly drink that was classified as “hot” waschocolate and 90% said it was “encour-aged” or “must drink a lot”. Many of thewomen drank specially prepared teas inplace of plain water.

In a study reported by Noor Aini et al.(1994) among pregnant women of Malay,Chinese and Indian ethnicities in KualaSelangor, most vegetables and fruits werealso cited by the respondents to be “cold”,while most tubers were considered“windy”, with yam being cited also as“itchy”. Most protein foods were consid-ered “poison” except for chicken andmutton, while most spices were cited as“hot”. The traditional beliefs related to theproperties of food among the respondentsof the present study appear to be similar toto the report of Noor Aini et al. (1994).


10 Poh, Wong & NorimahTa

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864

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3115

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837

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130

711

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798

48

156

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933

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66

73

613

06

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Brin

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766

108

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45

626

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737

316

151

50

935

Lettu

ce(s

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36

182

526

08

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Pum

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687

1113

155

50

1723

Lady

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ger

606

1123

047

228

617

Spin

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593

626

646

80

541

Car

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577

630

045

120

1132

Chi

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532

736

251

175

1314

Fren

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(kac

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360

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586

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Postpartum dietary intakes and food taboos 11Ta

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132

630

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Pear

785

78

262

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136

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794

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1539

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113

1157

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860

881

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1816

Pota

to32

916

412

229

1410

45

Rice

10

36

901

760

023

Spic

esan

dot

hers

Cur

rypo

wde

r45

818

272

155

171

26

Chi

lli44

1021

232

154

190

27

Whi

tepe

pper

343

1141

111

507

141

Vin

egar

201

1233

340

621

037

Gin

ger

70

09

840

860

014

Sesa

me

seed

oil

32

318

740

840

016


Tabl

e4d

.Acc

epta

nce

ofbe

vera

ges

and

thei

rpro

pert

ies

acco

rdin

gto

resp

onde

nts’

belie

fs(n

=10

0)

Acc

epta

nce

Prop

ertie

s

Type

ofbe

vera

geN

otM

uste

atD

ono

tPr

ohib

ited

enco

urag

edN

eutr

alEn

cour

aged

alo

tCo

ldH

otPo

ison

Win

dykn

ow

Car

bona

ted

wat

er96

40

00

850

18

6

Ice

955

00

066

02

2012

Gra

ssje

lly(c

inca

u)93

50

20

880

05

7

Suga

rcan

ew

ater

867

52

080

00

515

Tea

8510

05

075

50

713

Frui

tjui

ce54

726

121

590

04

37

Suga

r47

1212

290

1810

425

43

Cof

fee

3514

1237

27

513

831

Cho

cola

tebe

vera

ge2

26

6723

079

00

21

Malay dietary practices during con-finement appear to be based on similarprinciples as Chinese practices, that is toavoid “cold” foods and favour “hot” foodsto restore the desired humoral balance(Laderman, 1983; Manderson, 1981a;Wilson, 1973). However, for Malays, thereare more categories of food than simply“hot” and “cold” foods, and there appearsto be disagreement in Malay society as towhich foods fit into which category(Dixon, 1993). The main agreementsappear to be the classification of pine-apples as “sharp” and prawns as “itchy”(Manderson, 1981b).

Among Malaysian Indians, the major-ity of whom are of South Indian descent,“cold” foods, such as tomatoes, cucum-bers, coconut milk and mutton, are avoid-ed during confinement. Foods consideredgood during confinement include veryspicy curries, shark and sting-ray, chickenand salted fish (Colley, 1978). Choudhry(1997) who studied Indian women inCanada also reported the balancing of“hot” versus “cold” foods during confine-ment after childbirth.

Another study carried out amongChinese mothers in Scotland also reportedsimilar findings, whereby “cold” foodssuch as fresh fruits were avoided. Similarto the findings of the present study, themost commonly consumed “hot” foodsreported by Cheung (1997) were chicken,wine, dried longan, brown sugar andsesame oil.

Women from many cultures through-out the world practise some sort of foodavoidance after childbirth for variousreasons (Sundararaj & Pereira, 1975;Manderson & Mathews, 1981; Fernandez& Guthrie, 1984; Fishman et al., 1988;Odebiyi, 1989; Harrison et al., 1993;Mahmood et al., 1997; Kaewsarn, Moyle &Creedy, 2003; Santos-Torres & Vasques-Garibay, 2003). The underlying explana-tion is that birth is a moment of extremevulnerability accompanied by excessiveloss of blood during delivery. The mother

should follow certain precautions whichprohibit or encourage the consumption ofcertain foods to restore the mother to goodhealth and to aid the flow of breastmilk.Although there are specific differences inthe types of foods avoided during confine-ment, vegetables and fruits are generallyavoided by many cultures, with the excep-tion of Thai practices (Kaewsarn et al.,2003).

Nutrient intakes during confinement

Table 5 shows the mean daily energyand nutrient intakes of the 34 women whowere in confinement during the study.Energy intake varies from 1390 kcal/dayto 2541 kcal/day. Mean energy intake was19% below RNI (Figure 3). Protein intake,on the other hand, was high and meanprotein intake was 93% above RNI. Meanintake of calcium was below RNI, at 67%of RNI, while mean intake of iron was222% of RNI at 15% iron bioavailability.Mean intakes of the B vitamins were above75% of RNI, whereas vitamins A and Cwere at half of RNI or less.

This is typical of a Chinese confine-ment diet, where mothers ate a high pro-tein diet, including pork and chicken, andintakes of vegetables and fruits were limit-ed. This is clearly shown in Figure 4,where carbohydrate, protein and fatcontributed 40%, 25% and 35% to totaldaily energy intake. This proportion dif-fers from the recommendation by theTechnical Subcommittee on RNI forEnergy and Macronutrients (NCCFN,2005), whereby total carbohydrate shouldcontribute 55 – 70%, protein 10 – 15%, andtotal fat 20 – 30% to total daily energyintake. The protein intake of the respon-dents was proportionally much higher dueto the high intake of meats, and the highintake of fats could be due to the relativelyhigh content of fat in pork.

Mean calcium intake (672 mg/day)reported in the present study is compara-tively higher than the 273 mg/day



Tabl

e5.

Dai

lyen

ergy

and

nutr

ient

inta

kes

ofC

hine

sew

omen

inco

nfin

emen

t(n

=34

)

Nut

rient

sRN

I1M

ean

±SD

Rang

e%

RNI2

%<R

NI3

Ener

gy(k

cal)

2500

2033

±24

613

90–

2541

8197

Prot

ein

(g)

62.5

121

±25

57–

176

193

3

Fat(

g)-

77±

1245

–10

4-

-

Car

bohy

drat

e(g

)-

209

±36

119

–27

6-

-

Cal

cium

(mg)

1000

672

±22

033

0–

1428

6797

Iron

(mg)

1022

±14

4–

7522

29

Vita

min

A(µ

gRE

)85

043

7±

249

135

–11

6051

94

Thia

min

(mg)

1.5

1.19

±0.

420.

20–

2.22

7979

Ribo

flavi

n(m

g)1.

61.

56±

0.48

0.53

–2.

5698

53

Nia

cin

(mg

NE)

1718

.6±

5.7

9.6

–32

.011

044

Vita

min

C(m

g)95

39±

348

–19

341

94

1RN

IMal

aysi

a(N

CC

FN,2

005)

,RN

Ival

uefo

riro

nis

base

don

15%

bioa

vaila

bilit

ydu

eto

high

inta

keof

mea

tin

conf

inem

entd

iet.

2M

ean

perc

enta

geof

RNIr

equi

rem

ent

3Pe

rcen

tage

ofre

spon

dent

sta

king

belo

wRN

I


110

41

9879

51

222

6781

193

0

50

100

150

200

250

Energy

Protein

Calcium Iro

n

Vitamin

A

Thiamin

Riboflavin

Niacin

Vitamin

C

Nutrients

Perc

entR

NI

Figure 3. Mean nutrient intakes of respondents as a percentage of RNI

Carbohydrate40%

Protein25%

Fat35%

Figure 4. Contribution of macronutrients to total daily energy intake

reported by Chee et al. (1996) for femaleestate workers, and 241 mg/day reportedby Zamaliah, Shamsul & Kandiah (1999)for university students. However, it is stillway below the RNI for lactation.

The mean iron intake (22 mg/day)reported in the present study is muchhigher than the 8.6 mg/day reported byChee et al. (1996) and 15.1 mg/day report-ed by Zamaliah et al. (1999). The compara-tively high intake of iron reflects the highintake of meat that in turn has a high ironcontent (specifically lean pork and pigliver and kidney) in Chinese confinementdiets. The high content of B vitamins inthese meats may also explain the relative-ly high intakes of thiamin, riboflavin, andniacin among the subjects of this study.

Mean Vitamin C intakes as reportedby Chee et al. (1996) and Zamaliah et al.(1999) were 25 mg/day and 30.1 mg/day,respectively. The mean vitamin C intakereported in the present study (39 mg/day)appears to be higher than the other twostudies, although the subjects of thepresent study tended to avoid fruits andvegetables in their diets. Nevertheless,mean Vitamin C intake does not meet RNI.

Other studies carried out amonglactating women during the postpartumperiod also reported low intakes of energyand various vitamins and minerals. Riveraet al. (2001) reported that the diets of nurs-ing mothers of low socioeconomic statusin Mexico are deficient in iron, zinc, andvitamins A and C. Another study carriedout among low-income women in Ontario,Canada who were breastfeeding, alsofound that intakes of energy, calcium, iron,thiamin, vitamin A and zinc were belowrecommended values for lactating women(Doran & Evers, 1997). Mackey et al. (1998)reported that lactating women at threemonths postpartum living in a universitycommunity in Pennsylvania, USA, hadmean energy, zinc, vitamins D and Eintakes that did not meet USRDA.

CONCLUSIONS

The results of this study revealed thatthe majority of Chinese mothers studieddo conform to some, if not all, traditionalzuo yuezi practices. The dietary aspects ofthese zuo yuezi practices were adhered tofor the most part, and this rather limitedthe food choices of the mothers. Of mostconcern is the lack of fruits and vegetables,which provides fiber as well as many vita-mins and minerals, in these women’sdiets. On the other hand, these womenconsume a lot of red meat and chicken,which ensures a high intake of iron.

A more balanced diet should berecommended for Chinese mothers in con-finement. Bearing in mind beneficial tradi-tional practices, especially the emphasison meats which helps to ensure that theconfinement diet consists of good qualityprotein and a high intake of iron and the Bvitamins, the mothers should also beencouraged to eat more fruits and vegeta-bles, in order to ensure adequate intake offiber, vitamins and minerals. In view of thelow intake of calcium amongst thesubjects, mothers in confinement, especial-ly those breastfeeding, should also beencouraged to consume milk as well asother milk products to enhance calciumintake.

ACKNOWLEDGEMENTS

The authors thank all participants fortheir support and cooperation. We aregrateful to Ms Wong Yuen Peng and MsLeong Huey Ling for conducting the inter-views with all respondents. The authorswould like to acknowledge the threeMaternal and Child Health Clinics and theMaternity Hospital Kuala Lumpur forgranting permission to conduct the study.


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