ࡱ> npmq` ;JbjbjqPqP .|::AEbbbbbbbv~~~8J,v?%pQ,}$$$$$$$$ 'hu)$b$bb$"""`bb$"$""bb"v p)~N |"$%0?%"* *"*b"'h"T $$f"X?%vvv dvvvvvvbbbbbb Food Cravings and Aversions in Human Pregnancy 1. Nutrition, Food Cravings and Aversions in Pregnancy In order to sustain a successful pregnancy, a mother experiences a number of physiological and behavioral adjustments; heightened food cravings and aversions are an example of such changes. Food cravings are generally described as a distinct state characterized by an intense urge to obtain a substance. In contrast, aversions are characterized by the repulsion and avoidance of particular foods. (Mercer, M and Holder, D 1997) Food aversions and cravings during human pregnancy have been documented for centuries, and are reported to occur ubiquitously around the world by between 50% and 90% of women. The most common cravings include fruit and fruit juices, sweets desserts and chocolates; whereas the most common aversions are nonalcoholic caffeinated beverages, meat, fish, poultry and eggs. (Bayley et al 2002) This behavior is particularly prominent during the first and third trimesters of pregnancy. However, not all craving and aversion behavior results in a nutritious diet. Pica; the craving for non-food substances such as detergent or soil, is a primary example of this. Additionally, women often report aversions for meats and eggs, which could lead to a dietary lack of protein; important for fetal growth and development. Food provides all organisms with the raw materials for growth, survival and reproduction. Therefore, it comes as no surprise that dietary consumption during pregnancy can have significant health implications for both a mother and fetus. There is substantial evidence to suggest it can affect a range of factors including the course of pregnancy, and the incidence of prematurity and congenital malformation in the infant. (Knox et al 1990) Therefore, understanding the etiology of food cravings and aversions during pregnancy is important in ensuring a mother and fetus attain adequate health and nutrition. There are several mechanisms suggested to explain craving and aversion experiences during human pregnancy. These involve perspectives from a range of disciplines, and include factors such as ensuring adequate nutrition, palatability changes, psychological impacts, hormonal effects and the influence of culture. This report will review these theories, while attempting to provide a holistic perspective and identify a broad common knowledge base on the issue. 2. Etiology 2.1 Culture A primary limitation in determining associations involved between pregnancy and food cravings is determining if the behavior is instigated by physiological or cultural influences. One of the first experimental studies to provide evidence for the influence of culture on food preferences during pregnancy was carried out in 1983 by Arthur Giles. This study involved 300 pregnant women in London, and found traditional cultural beliefs of nutrition in pregnancy to greatly influence the craving and aversion experience of pregnant women. (Knox et al 1990) In a review investigating food preferences during human pregnancy, Knox et al (1990) also suggested that these cravings and aversions for food may be influenced by socio-cultural factors and existing food habits. This was supported through reference to a number of studies and cross cultural analysis; involving research from the USA, UK, Italy and Africa, which provided evidence for regional differences in food preferences of pregnant women. Demissie et al (1998) conducted a cross sectional study involving 295 Southern Ethiopian women, and found 43% of the women craved milk and meat. However, this conflicts with reports based on western societies (particularly the USA), which indicate meat to be one of the most common aversions. (King, J 2000) Hence, this implies that culture may be a factor that influences craving and aversion behavior during pregnancy. Pica (the eating of non food substances) is a behavioral phenomenon most commonly observed in children and pregnant women. This behavior is reported to occur throughout the world; however cross-cultural analysis indicates the incidence and type of substances consumed seems to differ; implying a cultural influence. Corbett et al (2003) referred to a study in Kenya, which found that three quarters of all pregnant women who participated, ate soil on a regular basis. What was particularly interesting is that traditional belief in the region associated eating soil with improved outcomes in fertility and reproduction. In contrast, Knox et al (1990) referred to a study performed in Jamaica by Landman & Hall (1983), who found the prevalence for eating soil to be 14%. Hence, cultural beliefs are a likely factor in determining the types of foods pregnant women crave or avoid. However despite this evidence, there are numerous studies and data which contradict or question the extent of which culture influences this behavior. An example is noted by Knox et al (2000) who referred to research in Italy by Fidanza & Fidanza (1986), which found that although women reported meat to be an important nutritious food during pregnancy, it was also found to be the most frequently reported aversion. Similar findings were revealed in a longitudinal study involving calcium metabolism, which found pregnant women increased their intake of dairy products, despite being specifically told not to. (King, J 2000) Therefore, this indicates that factors other than culture may influence eating behavior in pregnancy. 2.2 Nutrition One principal theory to explain cravings and aversions in pregnancy indicates that it is a physiological mechanism, adapted to protect the mother and fetus from nutrient deficiencies or feto-toxic substances; and therefore ensure optimal growth and development of the fetus. This is supported by repeated study findings; that the most commonly avoided foods are alcoholic beverages, coffee, and cigarettes. Moreover, research indicates that in general, women crave foods that are lacking in their diets. (Demissie et al 1998) Therefore this supports the argument that cravings are triggered by a nutrient deficiency. There is also evidence to suggest that palatability; the acceptance and experienced reward from consuming a food, has an adaptive function which reflects a physical need for nutrients. For example, enhanced palatability for sweets may be a result of the increased demand for energy during pregnancy. (Yeomans et al 2004) This is supported by findings which indicate that the most commonly craved foods provide an increase in calcium and energy; whereas most food aversions involve reducing consumption of substances such as alcohol and caffeine, which are potentially harmful to the fetus. (King, J 2000) Cross-cultural studies have also provided evidence for this concept. Demissie et al (1998) conducted a cross sectional study involving 295 Southern Ethiopian women, which investigated the nutritional significance of food aversions and cravings during pregnancy. They discovered a strong association between the incidence of aversion and craving (x2 = 10.66, p <.001; odds ratio, 2.36). Subsequently, these results were attributed to the notion that food cravings and aversions are complementary processes to ensure optimal nutrition during pregnancy. Research into the behavior of Pica (the eating of non-food substances) in pregnancy has also provided evidence for this theory. Although the most commonly ingested pica substances involve non food substances such as soil, clay, starch, baking powder, soap, ashes, chalk, paint, burnt match heads, toilet paper, pebbles, and dust. (Corbett et al 2003) Research indicates that this behavior is associated with iron deficiency anemia, which can often be corrected with iron supplements. However, it is important to note that not all pregnant women who suffer from anemia practice Pica, and that the craved substances are not necessarily a source of iron. There are a number of studies which report evidence to reject this mechanism; Knox et al (1990) argued against the concept of a parasitic relationship between a mother and fetus, instead describing it as an anabolic process. They also identified that despite the maternal need for protein during pregnancy, reports of cravings for meat or eggs are rare, and among the most frequently reported aversions. Additionally, Rosso (1987) discovered that nutrient and energy needs of the fetus are unrelated to maternal appetite. This study found maternal appetite to be greatest between the twelfth and twentieth weeks of gestation; when nutrient demands of the fetus are at its minimum. Therefore, this suggests appetite and eating behavior in pregnancy may be influenced by factors other than simply maternal and fetal metabolic needs. 2.3 Psychological Factors Pregnancy is often associated with increased physical requirements from the mother, which often leads to heightened psychological and emotional demands. There is evidence to suggest that pregnant women who are more fatigued, stressed, and anxious consume more foods, and are more likely to experience food cravings and aversions. This is reflected by findings which indicate stress and anxiety are associated with higher intakes of breads, fats, oils, sweets, and snacks; and more likely to avoid the consumption of meat. (Hurley, K et al 2005) Another mechanism suggested to explain food cravings and aversions is taste aversion learning; where foods associated with illness are subsequently avoided. Bayley et al (2002) conducted a study investigating this concept, and found a significant relationship between experiencing morning sickness and incidence of food aversions. Therefore, this indicates that psychological factors may also play a role in influencing eating behaviors such as cravings and aversions during pregnancy. 2.4 Hormonal Influences Hormonal variation is a typical feature of pregnancy and is known to have multiple functions and effects concerning the health of both mother and fetus. There are several hormonal mechanisms reported to affect the incidence of cravings and aversions; these involve the influence of Endogenous Opioid Peptides, Estrogen and Progesterone, Prolactin, and the metabolism of glucose. 2.4.1 Endogenous Opioid Peptides Some people believe that these cravings are simply a consequence of an increase in the pleasure or reward value obtained from consuming certain foods. According to Mercer, M and Holder, D (1997) this change in palatability during pregnancy may reflect changes in endogenous opioid peptide (EOP) levels during pregnancy. Pregnancy and the accompanying stress is associated with changes in the opioid system. Experimental studies have found a strong relationship between endogenous opioid peptides (EOPs) and food intake. Mercer, M and Holder , D (1997) reviewed the evidence for this relationship, and discovered that EOPs and opioid agonists seem to increase food intake; whilst opioid antagonists were found to decrease food intake, through blocking the receptor binding of specific EOPs. More specifically, they concluded that altered EOP activity may elicit food cravings and subsequently increase short-term consumption. 2.4.2 Estrogen and Progesterone Progesterone and oestrogen are two primary hormones required to conceive and sustain a pregnancy; this explains the observed increase in circulation throughout the course of the process. Additionally, there is evidence to suggest that progesterone acts as an appetite stimulant while oestrogen acts as an appetite regulator. (Knox et al 1990) .A study conducted by Tepper, B and Seldner, A (1999) confirmed these findings, and added that they are also thought to play a role in taste changes during pregnancy. (Tepper, B and Seldner, A 1999) 2.4.3 Prolactin Prolactin is renowned for various regulatory functions of the brain. Evidence suggests that one of these functions is involved in influencing appetite. Therefore, it is argued that this hormone is responsible for the increase and changes in appetite during pregnancy; due to the observed increase in circulating levels of prolactin during this time. (Grattan et al 2001) 2.4.4 Gestational diabetes mellitus (GDM) Gestational diabetes mellitus (GDM) is a form glucose intolerance; similar to type 2 diabetes, which occurs in 1% to 14% of women during pregnancy. If left untreated, this disorder can lead to significant health implications for both mother and child. Women who suffer from GDM are also at greater risk of developing type II diabetes later in life. Treatment for this disorder typically requires monitoring a strict diet; however compliance to this advice is often limited. One theory to explain this suggests that women with GDM experience taste changes that could influence food preferences, and make dietary compliance difficult to adhere to. Previous studies involving other forms of diabetes indicate that sufferers have a reduced taste perception for sugars, leading to an increased preference for sweet foods. This change is taste perception is reported to reflect either direct or indirect effects of impaired glucose homeostasis or lipid metabolism. (Tepper, B and Seldner, A 1999) 3. Conclusion A review of the literature regarding food cravings and aversions in human pregnancy indicates that despite significant research in the field, there remains considerable deliberation concerning the etiology of this behavior. This is compounded by the observed variation of experience between cultural groups and individuals. Studies from a range of disciplines and perspectives have all reported significant evidence for their arguments. Therefore it is likely that this behavior is multi-factorial, involving a combination of biological, psychological and environmental determinants. Further research concerning this issue is considered crucial, due to the significant influence of nutrition in maternal and fetal health. In particular, improved understanding with respect to the interaction between different determining factors could have important clinical implications; such as improving the compliance of nutritional advice in women with gestational diabetes mellitus. References Bayley, T et al (2002) Food cravings and aversions during pregnancy: relationships with nausea and vomiting Appetite vol 38, pp. 45-51 (online) Available:  HYPERLINK "http://www.sciencedirect.com" www.sciencedirect.com (1st August 2005) Corbett, R et al (2003) Pica in Pregnancy: Does It Affect Pregnancy Outcomes? The American Journal of Maternal/Child Nursing vol 28: 3, pp. 183189 (online) Available:  HYPERLINK "http://nursingcenter.com/prodev/ce_article.asp?tid=412533" http://nursingcenter.com/prodev/ce_article.asp?tid=412533 (10th October 2005) Demissie, T et al (1998) Food aversions and cravings during pregnancy: Prevalence and significance for maternal nutrition in Ethiopia Food and Nutrition Bulletin vol 19: 1 (online) Available: http://www.unu.edu/unupress/food/V191e/begin.htm#Contents (10th October 2005) Grattan, D et al (2001) Prolactin Receptors in the Brain during Pregnancy and Lactation: Implications for Behavior Hormones and Behavior vol 40, 115124 (online) available: http://www.idealibrary.com Hurley, K et al (2005) Psychosocial Influences in Dietary Patterns During Pregnancy Journal of the American Dietetic Association vol 105: 6 (online) Available:  HYPERLINK "http://www.sciencedirect.com.au" www.sciencedirect.com.au (10th October 2005) King, J (2000) Physiology of pregnancy and nutrient metabolism American Journal of Clinical Nutrition, vol. 71: 5, pp. 1218-1225 (online) Available: http://www.ajcn.org/cgi/content/full/71/5/1218S (10th October 2005) Knox, B et al (1990) FOOD PREFERENCE DURING HUMAN PREGNANCY:A REVIEW Food Quality and Preference 2, pp.131-154 Mercer, M and Holder, D (1997) Food Cravings, Endogenous Opioid Peptides, and Food Intake: A Review Appetite, 29, 325352 (online) Available:  HYPERLINK "http://www.sciencedirect.com" www.sciencedirect.com (15th October 2005) Tepper, B and Seldner, A (1999) Sweet taste and intake of sweet foods in normal pregnancy and pregnancy complicated by gestational diabetes mellitus American Journal of Clinical Nutrition vol. 70: 2, pp. 277-284 (online) Available:  HYPERLINK "http://www.ajcn.org/cgi/content/full/70/2/277" http://www.ajcn.org/cgi/content/full/70/2/277 (10th October 2005) Rosso, P. (1987). Regulation of food intake during pregnancy and lactation Human obesity vol 499 pp. 191-196 Yeomans, M et al (2004) Palatability: response to nutritional need or need-free stimulation of appetite? British Journal of Nutrition vol 92, pp. 3-14 (online) Available:  HYPERLINK "http://www.ingentaconnect.com/content/cabi/bjn/2004/00000092/A00101s1/art00002" http://www.ingentaconnect.com/content/cabi/bjn/2004/00000092/A00101s1/art00002 (10th October 2005)     Tammy Knox Human Reproduction 316 Investigative Review /014>LZh ' 7     ) @   A B D 12abǮǮǦϛϛϛ h?RhN^h`h wh> h?RhSYhr h?RhD h?Rh>hSYhmhN^hhB% hZ5hZhZ5hZ h?Rh>h whA5CJ&aJ&=/01h  C D rsuvbdhgdb# dh7$8$H$gd>dhgd>gd<I:Jb7@_e] <HMdqrs~񻷰yqihZh=>*hZhZ>*hZh:q15hZh>5hZhZ5 hZ5 h hZhSYhyT( h?RhDkh` h?Rh=h  h?RhF h?RhDh B*phhrB*phhzWjB*phhSYB*phhN^B*phhrhN^ h?RhN^&'@!1M  &L`aLdrst$+HNST]^eԿƿʹh& h?RhKMU h?Rh-eh  h?Rh^ h?RhT h?RhDk h?Rhl h?Rh:-hUhh>y? h?Rh>y? h?RhBlhKMU h?Rh}(]>em!H`w7AWXqrWkʾΟξΓ h?Rh?R h0\hhSYh?RhSY\ hSY\ h\ h&\h?Rh\h1h& h?Rh h?RhT h?RhN- h?Rh5!h>y? h?Rh5S h?Rh-eh5S:   ;RSfk+NSk~abcgpq'./@PV},AHi~ޤ⫝⤫ޖޏޖ h<hI; h<he1$ h<hSY h<hV< h<hDk h<hNXehZh5!>*hZhDk>*hZhZ>* h>>*hkh?RhI;h1h-Joh>y?h0 h?Rh h?Rh?R8bcq9":"b$c$&&((3*4*5*O*p,q,Y.Z.[.s.//0P1 dh7$8$H$gd>dhgd>dhgdb#  f x !!!!L!N!O!u!v!!!!!!*"8"9":""""""">#@#E#O#Q#X###¾ɯɨܡɾɓ{v{v{ hT]h<hNXe]h<hS]h<h u] h<hS h<hp h<h> h<hTh<hNXeH* h+ h-Joh-Jo h<hNXehThI;hkNB h<h u h<hrww h<h5!h<hV<6 h<hV< h<he1$.#######$2$3$5$<$A$a$b$c$$$$$$$$:%%%%%%%& &&&#&&&&&&&&&&&&&&&&&&&&<'Ľĵh1h-Joh h<h< h<hSYhSYh<h5!\ h<h5!h/thG h<h-hT h<hV< h<h u h-Jo]h<hNXe] hT]h<h u]h<h uH*] hFv]5<'='P'''(P(Q(R(U(p(x(((((((c))))))))))***2*3*4*5*9*F*N*O*i****+yh9h>OJQJ^Jh*OJQJ^JhGOJQJ^Jh>OJQJ^JhZhe>* h">*hZh>>*hZhZ>*hb#hrww h<hrwwhGhSY h<h0Shh/thvc h<h u h<h- h<h<++ +.+M+Z+++++++,,,,$,X,Y,o,p,q,y,,,,, ---- -!-\-h-k-(.G.X.Y.Z.[.r.ͼͼͼ|wohZhZ>* hb#>* h6 hI$^hhG h,hhI$^h:VhhFvh#5 hh#h#B*OJQJ^Jph!hh#B*OJQJ^JphhFvB*OJQJ^JphhFvh>OJQJ^Jh9h>OJQJ^JhFvOJQJ^J)r.s.t....... //?/M/m////000)0/0;0<0D0S0y0z0}0001%101112181N1O1P1Q1Z1y1111ֵֵ֦֮yyh/HOJQJ^Jh7lh/HOJQJ^J hy6hc4hyOJQJ^Jh/HhyhV h7lhyh7lhyOJQJ^JhVOJQJ^JhFvOJQJ^JhyOJQJ^J hG6 hZ6h1h hGh* he>*-P1Q1333555r7s7788;;;;<<==_?j?k?\@]@ 7$8$H$gd<$ dh7$8$H$gd>dhgd>12292R2[2z222222222'3-3:3H3{3333334L4M4U4d4p44444444 5 55W5\5555󲭥|xs h"H*h" h%hZmhZm h-2^h\h\h){ h-2^hwxhGhwxhZhZ6 hZ6h h/HOJQJ^JhwxOJQJ^JhZOJQJ^Jh7lhVOJQJ^JhZhVhVOJQJ^Jh7lh OJQJ^J-555555556667 7 77A7[7]7s7y7777778881828C8D8R8S88888888%969N9Y9x9y999:$:);*;];_;y;;ͷhcJh hH*hY)hhh6hhJ6 h@hwx hhoN\ hG\ h\ h\h@hwx\ h\\h\h\6\h\hwx h%h"hZmh"7y;~;;;;;;;;;;; < < <e<m<o<<<<<<<r=====>>b>^?_?j??????@@1@2@3@H@I@L@N@Źzh<$h<$H*hV1h<$0Jjh<$Ujh<$Uh,h<$>*h,h<$6 h,h<$h<$h4=h<$>*CJ aJ h0Sh0ZhAhh>hh0Zh0She5 hb#5 h5 hh h%h0N@]@u@@@@@@AAAMAOAPAQAAAAAAAAA&B'BBBzBBBBBBBB#C$C9C:C>CBC]C^CxCyCzCѽ}uuh8Ph<$\h8Ph<$>*h8Ph<$6\h8Ph<$6 h8Ph<$hP#h<$>*hP#h<$6 hP#h<$h<$h<$H*hV1h<$0Jjh<$Ujh<$U h^h<$h^h<$>*\h^h<$6\h^h<$\h<$,]@AABByCzCxDyDSETEEEEFFFHHHHIIIIIgd0S 7$8$H$gdH"gdH" 7$8$H$gd<$gd<$zCCCCCCDDDHDIDJDbDcDgDiDwDxDyDDDDDDE>EBEDERESETEhEiEEEEEEᶮᘋ|qj h<$\]h h<$>*\]h h<$6 h h<$hBh<$OJQJ^J h?hH" hH"hH"hBh<$>*hBh<$6 hBh<$hH"hH"H*hV1hH"0Jj:hH"UjhH"UhH"h<$h?h<$>*h?h<$6 h?h<$%EEEEEEE(F)F1F2F3F5F>FSFTF~FFFFFFFFFFF@GAGgGrGsGGGǽ۪unfn^nnh%h<$>*h%h<$6 h%h<$h+ h<$OJQJ^JhH"hH"H*hV1hH"0Jj#hH"UjhH"UhH" h&Vh<$h<$h&Vh<$>*h&Vh<$>*]h&Vh<$6]h&Vh<$6\h&Vh<$] h<$] h h<$ h<$\]h h<$\]!GGGGGGGHHHH)HaHbHoHwHxHHHHHHH I I0I1I=IIIII󬤬qdPq'j-hV1h<$OJQJU^Jh<$h<$OJQJ^Jjh<$OJQJU^Jh<$OJQJ^Jh+ h<$OJQJ^Jh+ h<$>*OJQJ^Jh<$h<$6 h+ h<$hP#h<$KH \ h.Zh<$h.Zh<$0J6>*h.Zh<$6hV1h<$0Jjh<$U h h<$h<$jh<$UIIIIIIIIIIIIIIJ J7J9J:J;J»hPh-Gh%#jh%#U h0Sh<$hP#h<$KH \h<$h<$OJQJ^Jh<$OJQJ^Jjh<$OJQJU^JhV1h<$0JOJQJ^JIIIIIJJ J8J9J:J;Jgd0S ,1h/ =!"#$% DyK www.sciencedirect.comyK <http://www.sciencedirect.com/]DyK :http://nursingcenter.com/prodev/ce_article.asp?tid=412533yK thttp://nursingcenter.com/prodev/ce_article.asp?tid=412533DyK www.sciencedirect.com.auyK Bhttp://www.sciencedirect.com.au/DyK www.sciencedirect.comyK <http://www.sciencedirect.com/-DyK .http://www.ajcn.org/cgi/content/full/70/2/277yK \http://www.ajcn.org/cgi/content/full/70/2/277DyK Ohttp://www.ingentaconnect.com/content/cabi/bjn/2004/00000092/A00101s1/art00002yK http://www.ingentaconnect.com/content/cabi/bjn/2004/00000092/A00101s1/art00002@@@ NormalCJ_HaJmH sH tH Z`Z <$ Heading 1$<@&5CJ KH OJQJ\^JaJ N`"N <$ Heading 2dd@&[$\$5CJ$\aJ$DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k@(No List4U@4 l Hyperlink >*phB^@B l Normal (Web)dd[$\$.X@. -Emphasis6]4@"4 fHeader  !4 @24 fFooter  !;B|/01hCDr s u v bcq9:bc 3"4"5"O"p$q$Y&Z&[&s&''(P)Q)+++---r/s//0033334455_7j7k7\8]899::y;z;x<y<S=T====>>>@@@@AAAAAAAAABB B8B>>@@@@AA>>??@0AAA;BXXXXXX8@0(  B S  ?(Food%20aversions%20and%20cravings%20duriRFN2RFN3 references9@?@?@?@>>>>@@p@s@@@ AAAAAAAAAAAABB9B0y>A5!H"b#<$e1$B%yT(:-:q1>>y?#@kNB-GhoN0S5STKMU:VSY[Y0Z}(]I$^N^zc`-eNXef 0hzWjDkPkBly"o-Joz+q uFv w#wrwwwxm{){GVZk *Y)1^[PV<;DFvcN-!?>t-0SlZm>7m>Te=SrcJV "]~Y`#9/tTI;/H1PJ<\@AA VAA;B@UnknownGz Times New Roman5Symbol3& z ArialUNewCenturySchlbk-Roman;TimesNRMT;AdvPS6F0BITimesNRMT-Italic"1h{䌚&R ;8@ ;8@!4dAA2QHX ?A2.Food Cravings and Aversions in Human PregnancyTammyTammyOh+'0 (4 T ` lx0Food Cravings and Aversions in Human PregnancyTammy Normal.dotTammy82Microsoft Office Word@O@.Z@j ;8՜.+,D՜.+,\ hp|  @A /Food Cravings and Aversions in Human Pregnancy Title 8@ _PID_HLINKSAh$|*Ohttp://www.ingentaconnect.com/content/cabi/bjn/2004/00000092/A00101s1/art00002 _Q .http://www.ajcn.org/cgi/content/full/70/2/277 L http://www.sciencedirect.com/ Z!http://www.sciencedirect.com.au/ ~C:http://nursingcenter.com/prodev/ce_article.asp?tid=412533 Lhttp://www.sciencedirect.com/   !"#$%&'()*+,-./0123456789:;<=>@ABCDEFHIJKLMNOPQRSTUVWXYZ[\^_`abcdfghijkloRoot Entry FfqData ?1TableG*WordDocument.|SummaryInformation(]DocumentSummaryInformation8eCompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q