The "fetal origins" hypothesis: challenges and opportunities for maternal and child nutrition

The "fetal origins" hypothesis postulates that conditions, most likely nutritional, "program" the fetus for the development of chronic diseases in adulthood. Associations between the newborn's size at birth and various determinants or consequences of chronic diseases have been identified in many, but not all, of the available studies. It remains to be established whether these associations are causal. Remarkably little information is available on the specific role of maternal nutritional status. The role of birth weight remains difficult to interpret except as a proxy for events in intrauterine life. Unfortunately, birth weight does not make an important contribution to the population attributable risk of cardiovascular disease; lifestyle factors during adulthood make much greater contributions. Data from experimental species suggest possible mechanisms for the origin of chronic disease early in life. It is too soon to use this research as a basis for new interventions directed at pregnant women for the purpose of reducing chronic disease in their offspring.

Obesity may impair lactogenesis II

Data from livestock species and experimental animal models suggest that excess body fatness may impair lactogenesis. For example, it has long been known that overfed dairy cows are at risk of fat cow syndrome, a condition characterized by lactation failure in the early postpartum period. Obese rats often lose their litters in the early postpartum period to primary lactation failure. A negative association between high body mass index (BMI) before conception and the duration of lactation has been documented in studies from diverse human populations. Findings from our laboratory establish that among women who ever attempted to breastfeed their infants, high BMI before conception was also associated with failure to initiate breastfeeding successfully. In a more recent study, we found that high prepregnant BMI was specifically associated with later onset of lactogenesis II. This was mediated by parity but not by breastfeeding behavior. Psychosocial factors related to a woman's intention to breastfeed and her planned duration of breastfeeding did not modify this association. Taken together, these findings in animals and women strongly suggest that maternal obesity in the perinatal period is a cause of delayed lactogenesis.

Impact of lactation on maternal body weight and body composition

Women worldwide generally lose weight and body fat during lactation. This loss, although increased by longer, more intensive breastfeeding, is modest and may be reduced by increased food intake and decreased activity. Higher parity and older age are associated with greater weight loss postpartum among poorly nourished women. Well-nourished women or those who breastfeed only for a limited time may not return to their prepregnant weight or body composition by the end of the lactation period. Those who are overweight or obese may have difficulty initiating or maintaining lactation. For the majority of women in the world, lactation is unlikely to represent a threat to their health. To advise women on how to optimize their health and lactational performance, one must consider all of the changes in maternal nutritional status that occur during a reproductive cycle, which may or may not compensate for the modest decreases in body weight associated with lactation.

Impact of food supplementation during lactation on infant breast-milk intake and on the proportion of infants exclusively breast-fed

To evaluate whether milk production can be improved by increasing food intake, a randomized, double-blind, supplementation trial was completed among 102 lactating Guatemalan women. The subjects were undernourished, as indicated by their low values for calf circumference (CC) and the small size of their infants at birth. A high-energy (2.14 MJ/d, HES) and a low-energy (0.50 MJ/d, LES) supplement were distributed 6 d/wk from wk 5 to 25 of lactation. Data were evaluated using repeated-measures analysis of variance on the increments from initial values for each outcome variable with one-tailed tests of statistical significance. The maternal energy intake increased 1.18 MJ/d (P < 0.01) more among the HES than the LES women. Benefit from supplementation was more evident among the more undernourished (CC </= median value, 29.5 cm) women. Among these 53 lower-CC women, infant milk and milk energy intakes were 10% higher (64 g/d and 14 MJ/d, respectively, at wk 25) in the HES than the LES group. After controlling for other determinants of infant milk and energy intakes in regression analyses, the significance of these differences increased to P < 0.04. However, there was no detectable effect on infant growth. Logistic regression analysis was used to show that HES women were significantly (P < 0.05) more likely than LES women to be exclusively breast-feeding their infants at wk 20, the time when the effect of supplementation was most evident. These findings establish that milk production and the duration of exclusive breast-feeding of undernourished women can be improved with the provision of supplemental food.

Linking maternal and infant benefits of a nutritional supplement during pregnancy and lactation

To evaluate the effect of a nutritional supplement on change in women's weight during a reproductive cycle and on the difference in birth weight between one infant and the previous one, we analyzed data on 176 complete reproductive cycles from an experiment that was conducted in rural Guatemala. Women with an initial weight <50 kg were classified as marginally nourished or malnourished. Women whose intake of the supplement was in the top 2 tertiles were distinguished from those whose intake was in the lowest tertile. Linear regression modeling was used to estimate the effect of supplementation on these outcomes and to control for confounding factors. Malnourished women gained weight during the reproductive cycle, but their second (study) infant tended to weigh less at birth than their prior-born infant. Higher intakes of supplement were associated with a less negative difference in birth weight. Marginally nourished women lost weight during the reproductive cycle and their second (study) infant tended to weigh more at birth than their prior-born infant. Higher intakes of supplement were associated with a less negative weight [corrected] trend for the women themselves. Well-nourished women and their infants did not show any of these benefits from supplementation. These findings help explain past contradictory findings on maternal depletion as well as on the benefits of nutritional supplementation for mothers and their infants.

Recognizing the reversible nature of child-feeding decisions: breastfeeding, weaning, and relactation patterns in a shanty town community of Lima, Peru

Researchers have normally considered weaning to be a non-reversible event. To determine the validity of this assumption, we interviewed 36 mothers of toddlers who were living in a poor shanty town of Lima, Peru. Data from 32 women were complete and used in this analysis. Mothers described their beliefs, practices, and decisions about breastfeeding, weaning, and relactation (the reintroduction of breastfeeding after weaning). We recorded attempted weaning events if the mother reported (1) purposefully not breastfeeding with the intention to wean, or (2) carrying out an action that was believed to cause the child to stop breastfeeding. Using a constant comparative approach, references to child-feeding decisions were coded, categorized, and analyzed. All mothers breastfed for at least 12 months; the median duration of breastfeeding was 25 months. There were several different patterns of child-feeding. Thirteen women never attempted to wean their children or had weaned on the first attempt. The majority (n = 19) of women, however, attempted to wean their children - some as early as 3 months of age but relactated between less than 1 day and 3 months later. Factors that influenced feeding decisions were primarily related to maternal and child health, and maternal time commitments. Children were weaned when there was a perceived problem of maternal health or time commitments and child health was not at risk of deterioration. Mothers postponed weaning because of poor child health. The primary reason for relactation was a child's negative reaction to weaning (e.g., incessant crying or refusal to eat). Personalities of the mother and child were important determinants of feeding decisions. These results demonstrate that maternal and child factors jointly influence child-feeding decisions and that these decisions are easily reversed. As relactation is culturally acceptable, health practitioners should consider recommending relactation when children have been prematurely weaned and human milk would improve their nutritional and health status.

Effects of under- and overnutrition on lactation in laboratory rats

To study the effects of maternal nutritional status on lactational performance, the diets of laboratory rats were manipulated with food restriction or increases in fat concentration. Compared with rats fed control diets ad libitum, conception rate, milk production and litter growth decreased and milk fat concentration increased in both chronically food restricted and obese animals. Chronically food restricted rats mobilized body fat and reduced their energy expenditure for maintenance and activity. Differences in suckling pattern between control and food-restricted rats affected hormone concentrations important for successful lactation. Obese rats experienced greater difficulty than controls in delivering their pups and more of their pups died in the first days of life. Milk production among obese rats may be constrained by poor appetite and the high heat production that characterizes lactation in litter-bearing species. There are many parallels as well as important differences between results obtained from these models and findings in nursing women. Nevertheless, these models provide useful information about the possible mechanisms by which maternal nutritional status affects lactational performance.

[A combined methodology for understanding the duration of breast feeding the poor neighborhoods of Managua, Nicaragua]

This study examined the relationship of several maternal variables to the duration of exclusive breast-feeding and the total duration of breast-feeding, along with attitudes, perceptions, and beliefs about breast-feeding among women living in poor neighborhoods of Managua, Nicaragua. The field work was carried out in December 1992 and January 1993 using qualitative and quantitative methods. A structured questionnaire was administered in interviews with 556 mothers of children under 12 months of age, and meetings of four directed discussion groups were held, in which a total of 20 women participated. At one week of age, almost all the children of the mothers who were surveyed had been breast-fed, but only 45% had been exclusively breast-fed. At 12 weeks old, 30% were already completely weaned. The discussion groups revealed the coexistence of positive opinions about both breast-feeding and bottle-feeding. However, exclusive breast-feeding was considered harmful for the mother, and breast milk was not thought to be sufficient nourishment for the child. Previous experience was strongly related to the duration of exclusive breast-feeding and to total breast-feeding duration. Attitudes, social support, and work situation were important factors influencing the total length of time women breast-fed a child. In general, the results obtained through the interviews and in the discussion groups were in agreement and showed that the elements needed to promote exclusive breast-feeding were social support, a favorable community environment, and policies that dealt with problems faced by working mothers. The complementary research methods were useful for obtaining information about the relative importance of different factors that determine the duration of breast-feeding and for understanding that practice in greater depth from the mother's point of view.

Maternal obesity and breast-feeding success in a rural population of white women

Maternal obesity interferes with the initiation and maintenance of lactation in animal models but it has not been investigated widely in women. We reviewed medical records from a white population to examine the relation between prepregnant overweight [body mass index (BMI; in kg/m2) 26.1-29.0] and obesity (BMI > 29.0) on initiation and duration of breast-feeding. Logistic regression revealed that of those who ever put their infants to the breast (n = 810), women who were overweight [odds ratio (OR) = 2.54, P < 0.05] or obese (OR = 3.65, P < 0.0008) had less success initiating breast-feeding than did their normal-weight counterparts (BMI < 26.1). Proportional-hazards regression revealed higher rates of discontinuation of exclusive breast-feeding in overweight (RR = 1.42, P < 0.04) and obese (RR = 1.43, P < 0.02) women and higher discontinuation of breast-feeding to any extent in overweight (RR = 1.68, P < 0.006) and obese (RR = 1.73, P = 0.001) women. Controlling for parity, socioeconomic status, maternal education, and other factors that often covary with maternal obesity and breast-feeding did not change these results. These results suggest that excessive fatness in the reproductive period may inhibit lactational performance in women.

Breast milk or animal-product foods improve linear growth of Peruvian toddlers consuming marginal diets

Although breast-feeding is widely accepted as important for infant health, its benefits during the second year of life have been questioned. We analyzed data from 107 breast-fed and weaned Peruvian children living in a periurban community to determine whether breast milk contributed to improved linear growth between 12 and 15 mo of age. Breast-feeding frequency was self-reported; intakes of complementary foods and animal products were estimated from a food-frequency survey. Multivariate-linear-regression analysis was used to predict the length of the children at 15 mo of age. Determinants of length included length and weight-for-length at 12 mo of age (US National Center for Health Statistics standards), interval between 12- and 15-mo measurements, breast-feeding frequency, incidence of diarrhea, and intakes of complementary and animal-product foods. Complementary foods, animal-product foods, and breast milk all promoted toddlers' linear growth. In subjects with low intakes of animal-product foods, breast-feeding was positively associated (P < 0.05) with linear growth. There was a 0.5-cm/3 mo difference in linear growth between weaned toddlers and children who consumed the average number of feedings of breast milk. Linear growth was also positively associated with intake of animal-product foods in children with low intakes of complementary foods. The negative association between diarrhea and linear growth did not occur in subjects with high complementary-food intakes. When the family's diet is low in quality, breast milk is an especially important source of energy, protein, and accompanying micronutrients in young children. Thus, continued breast-feeding after 1 y of age, in conjunction with feeding of complementary foods, should be encouraged in toddlers living in poor circumstances.

Duration of breastfeeding associated with obesity during adolescence

The relationship between duration of breastfeeding and obesity (body mass index > or = 85 percentile) at adolescence was investigated in a white, rural population (n = 136) in which confounding by race was absent and confounding by socioeconomic status was expected to be minimal. Relevant data were abstracted from hospital charts. When examined independently, minimal (< or = 2 months) or no breastfeeding was positively associated with adolescent obesity (p < 0.03). This association was present in the lower but not the higher socioeconomic status group. However, when sex, birthweight, and socioeconomic status were included in a multiple regression model, duration of breastfeeding was no longer significantly associated with obesity during adolescence.

Food supplementation during lactation shortens anestrus and elevates gonadotropins in rats

Breastfeeding delays the resumption of ovulation in women, a phenomenon particularly important in less developed areas. Although human and animal studies indicate that undernutrition extends the period of lactational anestrus, the effect of improving nutritional status during lactation on this time of infecundability, however, is less clear. To assess the effects of food supplementation on duration of lactational anestrus, Sprague-Dawley rats were assigned to one of three dietary groups: 1) control (C), given unrestricted access to diet AIN-76A; 2) food-restricted (FR), fed 50% of the control intake; and 3) food-supplemented (FS), food-restricted until d 0 of lactation and thereafter given unrestricted access to diet AIN-76A. Time to first detectable proestrus was monitored starting on d 10 of lactation. Nursing behaviors and gonadotropin and prolactin concentrations were measured in both intact and ovariectomized dams on d 10, 15 and 20 of lactation; we report these data only on the ovariectomized group, which represents the more appropriate animal model of human reproductive physiology during lactation. Proestrus returned significantly (P < 0.0001) sooner in both FS (18.1 +/- 2.4 d) and C (18.0 +/- 2.9 d) than in FR (28.8 +/- 2.8 d) intact dams. FS rats had higher luteinizing hormone and follicle stimulating hormone concentrations than FR rats (P < 0.0001 for each). Prolactin concentrations were lower on d 20 than on d 10 of lactation for all groups (P < 0.02), but we found no effect of dietary treatment. FS rats spent more time away from their pups (P < 0.05) and experienced less suckling (P < 0.05) than FR rats on d 15 of lactation. These results indicate that food supplementation of previously underfed rats hastens the return of ovulation and is accompanied by alterations in nursing behaviors.

Association of breastfeeding and stunting in Peruvian toddlers: an example of reverse causality

BACKGROUND

Child feeding recommendations include breastfeeding beyond 12 months, however, some researchers have reported increased rates of malnutrition in breastfed toddlers. A negative association between growth and breast-feeding may reflect reverse causality; that is, the outcome (growth) is a determinant of the predictor (breastfeeding), and not vice versa. We examined this question with data from 134 Peruvian toddlers.

METHODS

A linear regression analysis predicted length at the age of 15 months by length at 12 months, study interval, and 12-14.9-month breastfeeding, complementary food intake, and diarrhoeal incidence. This analysis defined the association between breastfeeding and linear growth. To elucidate the direction of the effect between breastfeeding and linear growth, logistic regression was used to predict the probability of weaning by the end of 14 months. Determinants included weight-for-age (W/A) at 12 months, complementary food intake at 9-11.9 months, and change in diarrhoeal incidence between 9 and 14.9 months.

RESULTS

There was a significant (P < 0.01) interaction of breastfeeding, diarrhoeal incidence, and complementary food intake on length at 15 months. Increased breastfeeding was associated with a 1.0 cm decrease in length gain when dietary intake was low and diarrhoeal morbidity was high, implying that breastfeeding is harmful. The logistic analysis, however, demonstrated that the risk of weaning decreased only when W/A and dietary intake were low and diarrhoeal morbidity was high.

CONCLUSIONS

The negative association between breastfeeding and linear growth reflected reverse causality. Increased breastfeeding did not lead to poor growth; children's poor growth and health led to increased breastfeeding. Children's health must be considered when evaluating the association of breastfeeding with anthropometric outcomes.

Documentation of second-by-second breastfeeding behaviors using a novel method

The specific way nursing patterns influence the duration of postpartum amenorrhea is unknown. This may result from the shortcomings of available methods: the daily log and recall. We tested these against a novel method, an event monitor (EM), consisting of a wrist-worn stopwatch that stores events. Exclusively breastfeeding women (n = 11) were assigned randomly to use each of the three methods twice during a 2-week period surrounding Weeks 4, 8, and 12 postpartum. More nursing episodes were recorded with the EM than log during Week 4 (p < 0.03) and Week 8 (p < 0.02). EM captured more episodes than recall during all study periods (p < 0.004). The EM was considered as acceptable and accurate to mothers as the other methods and, therefore, is a useful option for documenting breastfeeding patterns.

Consumption of a high fat diet impairs reproductive performance in Sprague-Dawley rats

Rats made obese by cafeteria feeding have poor reproductive outcomes. To investigate this phenomenon in animals fed a more nutritionally adequate diet, female rats were fed either a high fat (HF) (modified AIN-76A, 35 g fat/100 g diet) or a control (C) (AIN-76A, 5 g fat/100 g diet), diet, beginning at 27 d of age. To assess reproductive performance, rats were studied at d 0, 5 and 18 of pregnancy and on d 3 of lactation. Pregnancy rates were significantly (P < 0.001) lower in the high fat-fed rats than in the control-fed rats (56.4 and 89.1%, respectively). There was no difference between groups in total pregnancy weight gain or the proportion of weight gained during pregnancy that was retained by the dam. High fat-fed dams tended to gain weight more rapidly early in gestation than control-fed dams and then less rapidly than control-fed dams during the last week of gestation. Litter number and pup weight at birth did not differ between groups, but of high fat-fed pups had significantly higher (P < 0.04) mortality rates than pups of control-fed dams (16.5 and 7.7%, respectively) over the first 3 d of life. Control-fed dams experienced the expected reduction (P < 0.05) in plasma insulin concentrations between the end of pregnancy and early lactation, but high fat-fed dams did not. Thus, physiological mechanisms controlling distribution of metabolic fuels may not be functioning properly in high fat-fed dams. Therefore, consuming a high fat diet reduces a rat's capacity to conceive and ability to maintain her litter during the perinatal period.

Adherence to iron supplementation during pregnancy in Tanzania: determinants and hematologic consequences

Limited adherence to iron supplementation is thought to be a major reason for the low effectiveness of anemia-prevention programs. In rural Tanzania, women at 21-26 wk of gestation were randomly given either 120 mg of a conventional (Con) iron supplement or 50 mg of a gastric-delivery-system (GDS) iron supplement for 12 wk. Adherence was assessed by using a pill bottle equipped with an electronic counting device. Adherence in the GDS group was 61% compared with 42% for the Con group. In both groups, women experiencing side effects had about one-third lower adherence. Fewer side effects were observed in the GDS group. In a subgroup of women with a low initial hemoglobin concentration (< or = 120 g/L), the response to the iron supplements suggested that both of the applied doses were unnecessarily high for adequate hematologic response in a population with a marginal hemoglobin concentration. The GDS group appeared to require a dose one-fourth as high as that of the Con group for an equal effect on improving hemoglobin to normal concentrations.

Naloxone administration does not relieve the inhibition of gonadotropin release in food-restricted, lactating rats

Lactational anovulation is an important factor in determining birth spacing in women living in developing countries. Therefore, a more comprehensive understanding of the mechanisms involved in the relationships among lactation, nutrition and ovulation is important. This study was designed using the food-restricted, lactating rat to examine whether endogenous opioids might be involved in depressing gonadotropin release. Females were mated after 65 d of age and, beginning on d 42 of life, offered food in unrestricted amounts (control) or were food restricted to 50% of what the controls consumed. On d 15 of lactation, dams were injected with either naloxone hydrochloride (3 mg/kg body weight) or saline and killed 0, 15, 30 or 60 min later. Plasma was analyzed for luteinizing hormone, follicle-stimulating hormone and prolactin. Food restriction decreased plasma concentrations of luteinizing hormone and follicle-stimulating hormone (P < 0.005). Naloxone administration marginally influenced follicle stimulating hormone (P < 0.1), but not luteinizing hormone concentration regardless of diet group. The interaction among diet group, drug group and time of killing was significant for plasma prolactin concentration (P < 0.05). Food restriction lowered prolactin concentrations, but this effect was diminished with increasing time after injection of naloxone. Furthermore, the magnitude of the effect of food restriction was lessened and even reversed with treatment of naloxone. These results indicate that endogenous opioids are not the primary mechanism suppressing luteinizing hormone release in food-restricted lactating rats.

Screening for nutrition interventions: the risk or the differential-benefit approach?

The risk approach has been promoted to improve screening for nutrition interventions on the premise that indicators of risk also predict greater response to interventions. This study tested whether the determinants of the risk of poor growth (eg, low length-for-age) at 36 mo of age were the same as the determinants of differential benefit from food supplementation. The sample included 460 Guatemalan children who were exposed to either a high-energy, high-protein drink (atole) or a low-energy, no-protein drink (fresco) during their first 36 mo of life [INCAP (Institute of Nutrition of Central America and Panama) supplementation trial]. Low maternal stature, poor socioeconomic status, inadequate home diet, high diarrhea rates, and low anthropometry scores at 3 or 6 mo were all determinants of the risk of poor growth. Only indicators of child's thinness at 3 or 6 mo of age (low weight-for-age, weight-for-length, or midupper arm circumference) were determinants of differential benefit from supplementation. Thus, the development of screening indicators should be based on analyses of the predictors of differential benefit, not on conventional risk-factor analysis.

Food restriction, gonadotropins, and behavior in the lactating rat

This study sought to quantify effects of undernutrition on behaviors and to relate these to gonadotropin and prolactin concentrations in the lactating dam. Dams were studied in a 2 x 3 factorial design with litter size and food intake as the two factors. Behavioral data were collected from each dam and her litter on day 9, day 14, and day 19 of lactation, and maternal blood samples collected. Plasma was analyzed for luteinizing hormone, follicle stimulating hormone and prolactin. On day 15 of lactation, percent time nursing, number of pups actively nursing, total number of pups nursing and dam location acted as mediating factors of the effect of diet group on plasma luteinizing hormone concentration. No such relationships were seen for plasma follicle stimulating hormone, and only nest condition score appeared to be a mediator for plasma prolactin concentration. In conclusion, this analysis suggests that food restriction indirectly influences plasma concentration of luteinizing hormone, but not follicle stimulating hormone, by changing maternal and pup behaviors. The relationship among diet, behavior and circulating prolactin was less clear.

Pre- and postweaning food restrictions interact to determine reproductive success and milk volume in rats

This study was designed to determine if nutrient availability during gestation and early life modifies the effects of subsequent dietary intake on reproductive and lactation performance. Rat pups, whose mothers had been allowed free access to food or were food-restricted to 50% of ad libitum consumption were assigned to free access or food restricted groups after weaning, creating 4 groups (pre- and postweaning diet). Pre- and postweaning diets interacted significantly to influence age at conception, number of pups born, and milk yield on d 14 of lactation. Early undernutrition deterred conception in dams later allowed free access to food and resulted in fewer pups born to dams later allowed free access to food, but not those in the food-restricted group. By d 15 of lactation, only dietary treatment after weaning influenced litter weight. Milk yield per gram dam weight was not impaired in the food restricted-ad libitum group but was lowered in dams in the ad libitum-food restricted group. Milk yield per gram litter weight was not impaired in ad libitum-food restricted dams but was reduced in food restricted-ad libitum dams. These results extend to the preweaning period our previous finding that past or current food restriction impairs reproductive success and decreases milk yield in rats.

Nutritional status and behavior during lactation

Effects of chronic maternal food restriction and time of day on maternal and pup behaviors were examined in ovariectomized Sprague-Dawley rats (n = 26). Dams were fed ad lib (AL) or were restricted to 85% (85 AL) or 70% (70 AL) of ad lib intake. Dams and their 5-pup litters were observed for 45 min at night on days 9, 14, and 19 of lactation and during the day on day 14. A novel behavioral instrument was used to observe maternal and pup behaviors. At night, food-restricted animals engaged in more nursing behaviors than AL animals. Differential pup stimuli may account for this difference. AL animals engaged in more nursing behaviors during the day than night, whereas 70 AL animals demonstrated the opposite diurnal pattern. Time of feeding may explain this difference. On the other hand, 85 AL animals behaved similarly during the day and at night. Therefore, alterations in circadian behavior patterns are less pronounced in rats mildly restricted (85 AL) than in rats more food restricted (70 AL).

Evaluation of indicators for use in vitamin A intervention trials targeted at women

This paper examines the ability of three indicators to detect changes in women's vitamin A status. Serum retinol concentration, milk vitamin A concentration, and milk vitamin A per gram milk fat were used to assess the vitamin A status of mildly deficient Indonesian women before and after supplementation in a randomized intervention trial. Choice of indicator made a fourfold difference in the sample size required to measure a statistically significant change in vitamin A status. Milk vitamin A per gram milk fat was the best indicator of response, milk vitamin A concentration was intermediate, and serum retinol concentration performed most poorly. Serum retinol concentration was equally responsive across the range of vitamin A status in this population. The milk indicators were more responsive among women of lower status than women of higher status. Milk vitamin A is an efficient indicator for monitoring the effects of vitamin A interventions in women.