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Fall CHD, Kumaran K. Metabolic programming in early life in humans. Philos Trans R Soc Lond B Biol Sci 2019; 374:20180123. [PMID: 30966889 PMCID: PMC6460078 DOI: 10.1098/rstb.2018.0123] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2018] [Indexed: 12/25/2022] Open
Abstract
An association of low birth weight with an increased risk of adult cardiovascular disease and diabetes led to the developmental origins of health and disease (DOHaD) hypothesis, which proposes that undernutrition during early development permanently 'programmes' organ structure and metabolism, leading to vulnerability to later cardio-metabolic disease. High birth weight caused by maternal gestational diabetes is also associated with later diabetes, suggesting that fetal over-nutrition also has programming effects. Post-natal factors (excess weight gain/obesity, smoking, poor diets and physical inactivity) interact with fetal exposures to increase disease risk. Animal studies have shown permanent metabolic effects in offspring after alterations to maternal or early post-natal diets but evidence in humans is largely limited to observational and quasi-experimental situations such as maternal famine exposure. Randomized trials of maternal nutritional interventions during pregnancy have so far had limited follow-up of the offspring. Moreover, interventions usually started after the first trimester and therefore missed key peri-conceptional or early pregnancy events such as epigenetic changes, placentation and fetal organogenesis. Recent and ongoing trials intervening pre-conceptionally and powered for long-term offspring follow-up will address these issues. While current preventive strategies for cardio-metabolic disease focus on high-risk individuals in mid-life, DOHaD concepts offer a 'primordial' preventive strategy to reduce disease in future generations by improving fetal and infant development. This article is part of the theme issue 'Developing differences: early-life effects and evolutionary medicine'.
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Affiliation(s)
- Caroline H. D. Fall
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
| | - Kalyanaraman Kumaran
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
- Epidemiology Research Unit, CSI Holdsworth Memorial Hospital, Mysore, South India
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Abstract
BACKGROUND Multiple-micronutrient (MMN) deficiencies often coexist among women of reproductive age in low- and middle-income countries. They are exacerbated in pregnancy due to the increased demands of the developing fetus, leading to potentially adverse effects on the mother and baby. A consensus is yet to be reached regarding the replacement of iron and folic acid supplementation with MMNs. Since the last update of this Cochrane Review in 2017, evidence from several trials has become available. The findings of this review will be critical to inform policy on micronutrient supplementation in pregnancy. OBJECTIVES To evaluate the benefits of oral multiple-micronutrient supplementation during pregnancy on maternal, fetal and infant health outcomes. SEARCH METHODS For this 2018 update, on 23 February 2018 we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies. We also contacted experts in the field for additional and ongoing trials. SELECTION CRITERIA All prospective randomised controlled trials evaluating MMN supplementation with iron and folic acid during pregnancy and its effects on pregnancy outcomes were eligible, irrespective of language or the publication status of the trials. We included cluster-randomised trials, but excluded quasi-randomised trials. Trial reports that were published as abstracts were eligible. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We identified 21 trials (involving 142,496 women) as eligible for inclusion in this review, but only 20 trials (involving 141,849 women) contributed data. Of these 20 trials, 19 were conducted in low- and middle-income countries and compared MMN supplements with iron and folic acid to iron, with or without folic acid. One trial conducted in the UK compared MMN supplementation with placebo. In total, eight trials were cluster-randomised.MMN with iron and folic acid versus iron, with or without folic acid (19 trials)MMN supplementation probably led to a slight reduction in preterm births (average risk ratio (RR) 0.95, 95% confidence interval (CI) 0.90 to 1.01; 18 trials, 91,425 participants; moderate-quality evidence), and babies considered small-for-gestational age (SGA) (average RR 0.92, 95% CI 0.88 to 0.97; 17 trials; 57,348 participants; moderate-quality evidence), though the CI for the pooled effect for preterm births just crossed the line of no effect. MMN reduced the number of newborn infants identified as low birthweight (LBW) (average RR 0.88, 95% CI 0.85 to 0.91; 18 trials, 68,801 participants; high-quality evidence). We did not observe any differences between groups for perinatal mortality (average RR 1.00, 95% CI 0.90 to 1.11; 15 trials, 63,922 participants; high-quality evidence). MMN supplementation led to slightly fewer stillbirths (average RR 0.95, 95% CI 0.86 to 1.04; 17 trials, 97,927 participants; high-quality evidence) but, again, the CI for the pooled effect just crossed the line of no effect. MMN supplementation did not have an important effect on neonatal mortality (average RR 1.00, 95% CI 0.89 to 1.12; 14 trials, 80,964 participants; high-quality evidence). We observed little or no difference between groups for the other maternal and pregnancy outcomes: maternal anaemia in the third trimester (average RR 1.04, 95% CI 0.94 to 1.15; 9 trials, 5912 participants), maternal mortality (average RR 1.06, 95% CI 0.72 to 1.54; 6 trials, 106,275 participants), miscarriage (average RR 0.99, 95% CI 0.94 to 1.04; 12 trials, 100,565 participants), delivery via a caesarean section (average RR 1.13, 95% CI 0.99 to 1.29; 5 trials, 12,836 participants), and congenital anomalies (average RR 1.34, 95% CI 0.25 to 7.12; 2 trials, 1958 participants). However, MMN supplementation probably led to a reduction in very preterm births (average RR 0.81, 95% CI 0.71 to 0.93; 4 trials, 37,701 participants). We were unable to assess a number of prespecified, clinically important outcomes due to insufficient or non-available data.When we assessed primary outcomes according to GRADE criteria, the quality of evidence for the review overall was moderate to high. We graded the following outcomes as high quality: LBW, perinatal mortality, stillbirth, and neonatal mortality. The outcomes of preterm birth and SGA we graded as moderate quality; both were downgraded for funnel plot asymmetry, indicating possible publication bias.We carried out sensitivity analyses excluding trials with high levels of sample attrition (> 20%). We found that results were consistent with the main analyses for all outcomes. We explored heterogeneity through subgroup analyses by maternal height, maternal body mass index (BMI), timing of supplementation, dose of iron, and MMN supplement formulation (UNIMMAP versus non-UNIMMAP). There was a greater reduction in preterm births for women with low BMI and among those who took non-UNIMMAP supplements. We also observed subgroup differences for maternal BMI and maternal height for SGA, indicating greater impact among women with greater BMI and height. Though we found that MMN supplementation made little or no difference to perinatal mortality, the analysis demonstrated substantial statistical heterogeneity. We explored this heterogeneity using subgroup analysis and found differences for timing of supplementation, whereby higher impact was observed with later initiation of supplementation. For all other subgroup analyses, the findings were inconclusive.MMN versus placebo (1 trial)A single trial in the UK found little or no important effect of MMN supplementation on preterm births, SGA, or LBW but did find a reduction in maternal anaemia in the third trimester (RR 0.66, 95% CI 0.51 to 0.85), when compared to placebo. This trial did not measure our other outcomes. AUTHORS' CONCLUSIONS Our findings suggest a positive impact of MMN supplementation with iron and folic acid on several birth outcomes. MMN supplementation in pregnancy led to a reduction in babies considered LBW, and probably led to a reduction in babies considered SGA. In addition, MMN probably reduced preterm births. No important benefits or harms of MMN supplementation were found for mortality outcomes (stillbirths, perinatal and neonatal mortality). These findings may provide some basis to guide the replacement of iron and folic acid supplements with MMN supplements for pregnant women residing in low- and middle-income countries.
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Affiliation(s)
- Emily C Keats
- The Hospital for Sick ChildrenCentre for Global Child HealthTorontoCanada
| | - Batool A Haider
- Alkermes, Inc.Department of Health Economics and Outcomes Research852 Winter StreetWalthamMAUSA02451
| | - Emily Tam
- The Hospital for Sick ChildrenCentre for Global Child HealthTorontoCanada
| | - Zulfiqar A Bhutta
- The Hospital for Sick ChildrenCentre for Global Child HealthTorontoCanada
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Hambidge KM, Westcott JE, Garcés A, Figueroa L, Goudar SS, Dhaded SM, Pasha O, Ali SA, Tshefu A, Lokangaka A, Derman RJ, Goldenberg RL, Bose CL, Bauserman M, Koso-Thomas M, Thorsten VR, Sridhar A, Stolka K, Das A, McClure EM, Krebs NF. A multicountry randomized controlled trial of comprehensive maternal nutrition supplementation initiated before conception: the Women First trial. Am J Clin Nutr 2019; 109:457-469. [PMID: 30721941 PMCID: PMC6367966 DOI: 10.1093/ajcn/nqy228] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 08/07/2018] [Indexed: 12/28/2022] Open
Abstract
Background Reported benefits of maternal nutrition supplements commenced during pregnancy in low-resource populations have typically been quite limited. Objectives This study tested the effects on newborn size, especially length, of commencing nutrition supplements for women in low-resource populations ≥3 mo before conception (Arm 1), compared with the same supplement commenced late in the first trimester of pregnancy (Arm 2) or not at all (control Arm 3). Methods Women First was a 3-arm individualized randomized controlled trial (RCT). The intervention was a lipid-based micronutrient supplement; a protein-energy supplement was also provided if maternal body mass index (kg/m2) was <20 or gestational weight gain was less than recommendations. Study sites were in rural locations of the Democratic Republic of the Congo (DRC), Guatemala, India, and Pakistan. The primary outcome was length-for-age z score (LAZ), with all anthropometry obtained <48 h post delivery. Because gestational ages were unavailable in DRC, outcomes were determined for all 4 sites from WHO newborn standards (non-gestational-age-adjusted, NGAA) as well as INTERGROWTH-21st fetal standards (3 sites, gestational age-adjusted, GAA). Results A total of 7387 nonpregnant women were randomly assigned, yielding 2451 births with NGAA primary outcomes and 1465 with GAA outcomes. Mean LAZ and other outcomes did not differ between Arm 1 and Arm 2 using either NGAA or GAA. Mean LAZ (NGAA) for Arm 1 was greater than for Arm 3 (effect size: +0.19; 95% CI: 0.08, 0.30, P = 0.0008). For GAA outcomes, rates of stunting and small-for-gestational-age were lower in Arm 1 than in Arm 3 (RR: 0.69; 95% CI: 0.49, 0.98, P = 0.0361 and RR: 0.78; 95% CI: 0.70, 0.88, P < 0.001, respectively). Rates of preterm birth did not differ among arms. Conclusions In low-resource populations, benefits on fetal growth-related birth outcomes were derived from nutrition supplements commenced before conception or late in the first trimester. This trial was registered at clinicaltrials.gov as NCT01883193.
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Affiliation(s)
- K Michael Hambidge
- Department of Pediatrics, Section of Nutrition, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jamie E Westcott
- Department of Pediatrics, Section of Nutrition, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Ana Garcés
- INCAP (Instituto de Nutrición de Centro América y Panamá), Guatemala City, Guatemala
| | - Lester Figueroa
- INCAP (Instituto de Nutrición de Centro América y Panamá), Guatemala City, Guatemala
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belagavi, India
| | - Sangappa M Dhaded
- KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belagavi, India
| | - Omrana Pasha
- Aga Khan University, Karachi, Pakistan,Johns Hopkins University, Baltimore, MD
| | | | - Antoinette Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Adrien Lokangaka
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | | | | | - Carl L Bose
- University of North Carolina, Chapel Hill, NC
| | | | - Marion Koso-Thomas
- National Institute of Child Health and Human Development/NIH, Bethesda, MD
| | | | | | | | | | | | - Nancy F Krebs
- Department of Pediatrics, Section of Nutrition, University of Colorado Anschutz Medical Campus, Aurora, CO,Address correspondence to NFK (e-mail: )
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James P, Sajjadi S, Tomar AS, Saffari A, Fall CHD, Prentice AM, Shrestha S, Issarapu P, Yadav DK, Kaur L, Lillycrop K, Silver M, Chandak GR. Candidate genes linking maternal nutrient exposure to offspring health via DNA methylation: a review of existing evidence in humans with specific focus on one-carbon metabolism. Int J Epidemiol 2018; 47:1910-1937. [PMID: 30137462 PMCID: PMC6280938 DOI: 10.1093/ije/dyy153] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2018] [Indexed: 12/13/2022] Open
Abstract
Background Mounting evidence suggests that nutritional exposures during pregnancy influence the fetal epigenome, and that these epigenetic changes can persist postnatally, with implications for disease risk across the life course. Methods We review human intergenerational studies using a three-part search strategy. Search 1 investigates associations between preconceptional or pregnancy nutritional exposures, focusing on one-carbon metabolism, and offspring DNA methylation. Search 2 considers associations between offspring DNA methylation at genes found in the first search and growth-related, cardiometabolic and cognitive outcomes. Search 3 isolates those studies explicitly linking maternal nutritional exposure to offspring phenotype via DNA methylation. Finally, we compile all candidate genes and regions of interest identified in the searches and describe their genomic locations, annotations and coverage on the Illumina Infinium Methylation beadchip arrays. Results We summarize findings from the 34 studies found in the first search, the 31 studies found in the second search and the eight studies found in the third search. We provide details of all regions of interest within 45 genes captured by this review. Conclusions Many studies have investigated imprinted genes as priority loci, but with the adoption of microarray-based platforms other candidate genes and gene classes are now emerging. Despite a wealth of information, the current literature is characterized by heterogeneous exposures and outcomes, and mostly comprise observational associations that are frequently underpowered. The synthesis of current knowledge provided by this review identifies research needs on the pathway to developing possible early life interventions to optimize lifelong health.
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Affiliation(s)
- Philip James
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, UK
| | - Sara Sajjadi
- Genomic Research on Complex Diseases (GRC Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, India
| | - Ashutosh Singh Tomar
- Genomic Research on Complex Diseases (GRC Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, India
| | - Ayden Saffari
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, UK
| | - Caroline H D Fall
- MRC Life course Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Andrew M Prentice
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, UK
| | - Smeeta Shrestha
- Genomic Research on Complex Diseases (GRC Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, India
- School of Basic and Applied Sciences, Dayananda Sagar University, Bangalore, India
| | - Prachand Issarapu
- Genomic Research on Complex Diseases (GRC Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, India
| | - Dilip Kumar Yadav
- Genomic Research on Complex Diseases (GRC Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, India
| | - Lovejeet Kaur
- Genomic Research on Complex Diseases (GRC Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, India
| | - Karen Lillycrop
- Research Centre for Biological Sciences, Institute of Developmental Sciences, University of Southampton, Southampton, UK
| | - Matt Silver
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, UK
| | - Giriraj R Chandak
- Genomic Research on Complex Diseases (GRC Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, India
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Di Gravio C, Lawande A, Potdar RD, Sahariah SA, Gandhi M, Brown N, Chopra H, Sane H, Kehoe SH, Marley-Zagar E, Margetts BM, Jackson AA, Fall CHD. The Association of Maternal Age With Fetal Growth and Newborn Measures: The Mumbai Maternal Nutrition Project (MMNP). Reprod Sci 2018; 26:918-927. [PMID: 30419799 PMCID: PMC6637817 DOI: 10.1177/1933719118799202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Young maternal age is associated with poorer birth outcomes, but the mechanisms are incompletely understood. Using data from a prospective cohort of pregnant women living in Mumbai slums, India, we tested whether lower maternal age was associated with adverse fetal growth. Methods: Fetal crown-rump length (CRL) was recorded at a median (interquartile range, IQR) of 10 weeks’ gestation (9-10 weeks). Head circumference (HC), biparietal diameter (BPD), femur length (FL), and abdominal circumference (AC) were recorded at 19 (19-20) and 29 (28-30) weeks. Newborns were measured at a median (IQR) of 2 days (1-3 days) from delivery. Gestation was assessed using prospectively collected menstrual period dates. Results: The sample comprised 1653 singleton fetuses without major congenital abnormalities, of whom 1360 had newborn measurements. Fetuses of younger mothers had smaller CRL (0.01 standard deviation [SD] per year of maternal age; 95% confidence interval CI: 0.00-0.021; P = .04), and smaller HC, FL, and AC at subsequent visits. Fetal growth of HC (0.04 cm; 95% CI: 0.02-0.05; P < .001), BPD (0.01 cm; 95% CI: 0.00-0.01; P = .009), FL (0.04 cm; 95% CI: 0.02-0.06; P < .001), and AC (0.01 cm; 95% CI: 0.00-0.01; P = .003) up to the third trimester increased with maternal age. Skinfolds, head, and mid-upper arm circumferences were smaller in newborns of younger mothers. Adjusting for maternal prepregnancy socioeconomic status, body mass index, height, and parity attenuated the associations between maternal age and newborn size but did not change those with fetal biometry. Conclusion: Fetuses of younger mothers were smaller from the first trimester onward and grew slower, independently of known confounding factors.
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Affiliation(s)
- Chiara Di Gravio
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, United Kingdom.
| | | | | | | | - Meera Gandhi
- Centre for the Study of Social Change, Mumbai, India
| | - Nick Brown
- International Centre for Maternal and Child Health, Akademia Sjukhuset, University of Uppsala MTC-huset, Uppsala, Sweden
| | - Harsha Chopra
- Centre for the Study of Social Change, Mumbai, India
| | - Harshad Sane
- Centre for the Study of Social Change, Mumbai, India
| | - Sarah H Kehoe
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, United Kingdom
| | - Ella Marley-Zagar
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, United Kingdom
| | - Barrie M Margetts
- Public Health Nutrition, University of Southampton, Southampton, United Kingdom
| | - Alan A Jackson
- NIHR Southampton Biomedical Research Centre, Southampton, United Kingdom
| | - Caroline H D Fall
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, United Kingdom
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Ahmed S, Hassen K, Wakayo T. A health facility based case-control study on determinants of low birth weight in Dassie town, Northeast Ethiopia: the role of nutritional factors. Nutr J 2018; 17:103. [PMID: 30400909 PMCID: PMC6220456 DOI: 10.1186/s12937-018-0409-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 10/23/2018] [Indexed: 11/17/2022] Open
Abstract
Background Low birth weight remains a major public health problem affecting developing countries. Evidence shows that low birth weight has long lasting negative health consequences through its contribution to stunting, mental impairment and non-communicable chronic diseases in later life. Thus, it is worth investigating the role of nutritional factors as determinants of low birth weight to suggest nutritional interventions to curb its negative health outcomes. This study aimed to investigate the determinants of low birth weight with main focus on the role of nutritional factors in Ethiopia. Methods A facility-based case-control study was conducted from 3 February to 29 April, 2017. The data were collected using structured, pretested interviewer-administered questionnaire in all public health facilities of Dessie Town. Anthropometric measurements were made following standard procedures for both mothers and their newborns. Consecutive live births of < 2500 g and two succeeding normal weight babies were selected as cases and controls, respectively. Data were entered in to Epi-data software version 3.1, and exported to SPSS version 21, and analyzed using frequency, mean and percentage. Factors with p < 0.25 during bivariate analyses were entered into a multivariable logistic regression model to determine significant determinants of LBW. Statistical significance was considered at p < 0.05. Results were reported with odds ratio and 95% CI. Results Mean ± SD of birth weight (g) was 2138 ± 207 for cases and 3145 ± 415 for controls. After adjusting for potential confounders using multivariable logistic regression analysis, the absence of iron and folate supplementation, receiving no nutritional counseling and consuming no additional meal, maternal undernutrition, maternal anemia and inadequate dietary diversity during the current pregnancy were found to be significant determinants of low birth weight in our study. Conclusion Lack of nutritional counseling, absence of additional meal intake and iron and folate supplementation during pregnancy, and maternal undernutrition, maternal anemia and inadequate maternal dietary diversity were significant determinants of low birth weight. The importance of nutritional counseling, improving iron and folate supplementation during pregnancy, and nutritional status of pregnant women need to be strengthened to reduce the incidence of LBW in Ethiopia. In addition, behavioral change communications targeting pregnant women to improve women dietary diversity and their extra meal intake practice need to be enhanced in Ethiopia.
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Affiliation(s)
- Semira Ahmed
- Gambella Regional State Health Bureau, Gambella, Ethiopia
| | | | - Tolassa Wakayo
- Jimma University, Faculty of Public Health, Jimma, Ethiopia.
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Fox EL, Davis C, Downs SM, Schultink W, Fanzo J. Who is the Woman in Women's Nutrition? A Narrative Review of Evidence and Actions to Support Women's Nutrition throughout Life. Curr Dev Nutr 2018. [PMCID: PMC6349991 DOI: 10.1093/cdn/nzy076] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Nutrition interventions that target mothers alone inadequately address women's needs across their lives: during adolescence, preconception, and in later years of life. They also fail to capture nulliparous women. The extent to which nutrition interventions effectively reach women throughout the life course is not well documented. In this comprehensive narrative review, we summarized the impact and delivery platforms of nutrition-specific and nutrition-sensitive interventions targeting adolescent girls, women of reproductive age (nonpregnant, nonlactating), pregnant and lactating women, women with young children <5 y, and older women, with a focus on nutrition interventions delivered in low- and middle-income countries. We found that although there were many effective interventions that targeted women's nutrition, they largely targeted women who were pregnant and lactating or with young children. There were major gaps in the targeting of interventions to older women. For the delivery platforms, community-based settings, compared with facility-based settings, more equitably reached women across the life course, including adolescents, women of reproductive age, and older women. Nutrition-sensitive approaches were more often delivered in community-based settings; however, the evidence of their impact on women's nutritional outcomes was less clear. We also found major research and programming gaps relative to targeting overweight, obesity, and noncommunicable disease. We conclude that focused efforts on women during pregnancy and in the first couple of years postpartum fail to address the interrelation and compounding nature of nutritional disadvantages that are perpetuated across many women's lives. In order for policies and interventions to more effectively address inequities faced by women, and not only women as mothers, it is essential that they reflect on how, when, and where to engage with women across the life course.
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Affiliation(s)
- Elizabeth L Fox
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD
| | - Claire Davis
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD
| | - Shauna M Downs
- Department of Health Systems and Policy, School of Public Health, Rutgers University, New Brunswick, NJ
| | | | - Jessica Fanzo
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
- Nitze School of Advanced International Studies, Johns Hopkins University, Washington, DC
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Khan J, Mohanty SK. Spatial heterogeneity and correlates of child malnutrition in districts of India. BMC Public Health 2018; 18:1027. [PMID: 30119652 PMCID: PMC6098604 DOI: 10.1186/s12889-018-5873-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 07/23/2018] [Indexed: 12/13/2022] Open
Abstract
Background Despite sustained economic growth and reduction in money metric poverty in last two decades, prevalence of malnutrition remained high in India. During 1992–2016, the prevalence of underweight among children had declined from 53% to 36%, stunting had declined from 52% to 38% while that of wasting had increased from 17% to 21% in India. The national average in the level of malnutrition conceals large variation across districts of India. Using data from the recent round of National Family Health Survey (NFHS), 2015–16 this paper examined the spatial heterogeneity and meso-scale correlates of child malnutrition across 640 districts of India. Methods Moran’s I statistics and bivariate LISA maps were used to understand spatial dependence and clustering of child malnutrition. Multiple regression, spatial lag and error models were used to examine the correlates of malnutrition. Poverty, body mass index (BMI) of mother, breastfeeding practices, full immunization, institutional births, improved sanitation and electrification in the household were used as meso scale correlates of malnutrition. Results The univariate Moran’s I statistics was 0.65, 0.51 and 0.74 for stunting, wasting and underweight respectively suggesting spatial heterogeneity of malnutrition in India. Bivariate Moran’s I statistics of stunting with BMI of mother was 0.52, 0.46 with poverty and − 0.52 with sanitation. The pattern was similar with respect to wasting and underweight suggesting spatial clustering of malnutrition against the meso scale correlates in the geographical hotspots of India. Results of spatial error model suggested that the coefficient of BMI of mother and poverty of household were strong and significant predictors of stunting, wasting and underweight. The coefficient of BMI in spatial error model was largest found for underweight (β = 0.38, 95% CI: 0.29–0.48) followed by stunting (β = 0.23, 95% CI: 0.14–0.33) and wasting (β = 0.11, 95% CI: 0.01–0.22). Women’s educational attainment and breastfeeding practices were also found significant for stunting and underweight. Conclusion Malnutrition across the districts of India is spatially clustered. Reduction of poverty, improving women’s education and health, sanitation and child feeding knowledge can reduce the prevalence of malnutrition across India. Multisectoral and targeted intervention in the geographical hotspots of malnutrition can reduce malnutrition in India. Electronic supplementary material The online version of this article (10.1186/s12889-018-5873-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Junaid Khan
- International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai, 400088, India.
| | - Sanjay K Mohanty
- Department of Fertility Studies, International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai, 400088, India
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Abstract
BACKGROUND The growing appreciation of the multi-faceted importance of optimal maternal nutrition to the health and development of the infant and young child is tempered by incompletely resolved strategies for combatting challenges. OBJECTIVE To review the importance of maternal nutrition and strategies being employed to optimize outcomes. METHODS Selected data from recent literature with special focus on rationale for and currently published results of maternal nutrition supplements, including lipid based nutrition supplements. RESULTS 1) An impelling rationale for improving the maternal and in utero environment of low resource populations has emerged to achieve improved fetal and post-natal growth and development. 2) Based partly on population increases in adult height over one-two generations, much can be achieved by reducing poverty. 3) Maternal, newborn and infant characteristics associated with low resource environments include evidence of undernutrition, manifested by underweight and impaired linear growth. 4) Apart from broad public health and educational initiatives, to date, most specific efforts to improve fetal growth and development have included maternal nutrition interventions during gestation. 5) The relatively limited but real benefits of both iron/folic acid (IFA) and multiple micronutrient (MMN) maternal supplements during gestation have now been reasonably defined. 6) Recent investigations of a maternal lipid-based primarily micronutrient supplement (LNS) have not demonstrated a consistent benefit beyond MMN alone. 7) However, effects of both MMN and LNS appear to be enhanced by commencing early in gestation. CONCLUSIONS Poor maternal nutritional status is one of a very few specific factors in the human that not only contributes to impaired fetal and early post-natal growth but for which maternal interventions have demonstrated improved in utero development, documented primarily by both improvements in low birth weights and by partial corrections of impaired birth length. A clearer definition of the benefits achievable by interventions specifically focused on correcting maternal nutrition deficits should not be limited to improvements in the quality of maternal nutrition supplements, but on the cumulative quantity and timing of interventions (also recognizing the heterogeneity between populations). Finally, in an ideal world these steps are only a prelude to improvements in the total environment in which optimal nutrition and other health determinants can be achieved.
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Affiliation(s)
- K. Michael Hambidge
- Section of Nutrition, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, 12700 E 19th Ave, MS C-225, Aurora, CO 80045 USA
| | - Nancy F. Krebs
- Section of Nutrition, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, 12700 E 19th Ave, MS C-225, Aurora, CO 80045 USA
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60
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Singhal A. Early Life Origins of Obesity and Related Complications. Indian J Pediatr 2018; 85:472-477. [PMID: 29247430 DOI: 10.1007/s12098-017-2554-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 11/22/2017] [Indexed: 12/30/2022]
Abstract
The idea that nutrition in early life (such as before conception, during pregnancy and in infancy) can influence, or programme, long-term health, known as the 'Developmental Origins of Health and Disease Hypothesis', has generated great scientific interest. This concept is particularly relevant for the development of obesity and its complications, arguably the most important public health issue of the twenty-first century worldwide. The concept is strongly supported by evidence from animal studies, both observational and experimental (randomised) studies in humans, and is highly relevant for population health in both low-income and high-incomes countries. For instance, optimising nutrition in pregnancy (both in terms of under-nutrition and over-nutrition) and preventing too fast infant weight gain have been shown to reduce the risk of future obesity. Proposed mechanisms have included effects of early nutrition on the epigenome, hormones such as insulin, and regulation of appetite, that effect long-term risk of obesity. Although further data from experimental studies is required to support a causal link between early nutrition and future adiposity, the developmental origins hypothesis is already changing health policy and practice globally. The present review considers the evidence for the developmental origins of obesity, the mechanisms involved, and the implications for public health.
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Affiliation(s)
- Atul Singhal
- The Childhood Nutrition Research Centre; Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.
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Baxter JAB, Wasan Y, Soofi SB, Suhag Z, Bhutta ZA. Effect of life skills building education and micronutrient supplements provided from preconception versus the standard of care on low birth weight births among adolescent and young Pakistani women (15-24 years): a prospective, population-based cluster-randomized trial. Reprod Health 2018; 15:104. [PMID: 29855317 PMCID: PMC5984313 DOI: 10.1186/s12978-018-0545-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 05/24/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Risk factors known to impact maternal and newborn nutrition and health can exist from adolescence. If an undernourished adolescent girl becomes pregnant, her own health and pregnancy are at an increased risk for adverse outcomes. Offering preconception care from adolescence could provide an opportunity for health and nutrition promotion to improve one's own well-being, as well as future pregnancy outcomes and the health of the next generation. METHODS The Matiari emPowerment and Preconception Supplementation (MaPPS) Trial is a population-based two-arm, cluster-randomized, controlled trial of life skills building education and multiple micronutrient supplementation provided in a programmatic context to evaluate the impact on pre-identified nutrition and health outcomes among adolescent and young women (15-24 years) in Matiari district Pakistan, and the infants born to them within the context of the trial. The primary aim is to assess the effect of the intervention on the prevalence of low birth weight births (< 2500 g). The intervention includes bi-monthly life skills building education provided from preconception, and supplementation with multiple micronutrients during preconception (twice-weekly), pregnancy (daily), and post-partum (daily to 6 months). The standard of care includes non-regulated community-based health sessions and daily iron and folic acid supplementation during pregnancy. Additional outcome information will also be collected at set time periods. Among participants, these relate to nutrition (anthropometry, nutritional status), morbidity, and mortality. Among infants, these include birth outcomes (stillbirth, preterm birth, length of gestation, small for gestational age, birth defects), anthropometry, morbidity, and mortality. DISCUSSION Preconception care from adolescence that includes interventions targeting life skills development and nutrition is suggested to be important to improving the health and nutrition of adolescent and young women and their future offspring. This study is expected to offer insight into providing such an intervention both within a programmatic context and with an extended exposure period prior to conception. TRIAL REGISTRATION The MaPPS Trial was registered retrospectively on clinicaltrials.gov (Identifier: NCT03287882 ) on September 19, 2017.
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Affiliation(s)
- Jo-Anna B Baxter
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada
| | - Yaqub Wasan
- Centre of Excellence in Women and Child Health, Aga Khan University, Stadium Road, Karachi, Pakistan
| | - Sajid B Soofi
- Centre of Excellence in Women and Child Health, Aga Khan University, Stadium Road, Karachi, Pakistan
| | - Zamir Suhag
- Centre of Excellence in Women and Child Health, Aga Khan University, Stadium Road, Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada.
- Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada.
- Centre of Excellence in Women and Child Health, Aga Khan University, Stadium Road, Karachi, Pakistan.
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Krishnaveni GV, Kumaran K, Krishna M, Sahariah S, Chandak G, Kehoe S, Jones A, Bhat D, Danivas V, Srinivasan K, Suguna Shanthi J, Karat SC, Barker M, Osmond C, Yajnik C, Fall C. Life course programming of stress responses in adolescents and young adults in India: Protocol of the Stress Responses in Adolescence and Vulnerability to Adult Non-communicable disease (SRAVANA) Study. Wellcome Open Res 2018; 3:56. [PMID: 30027123 PMCID: PMC6039920 DOI: 10.12688/wellcomeopenres.14583.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2018] [Indexed: 01/04/2023] Open
Abstract
Background: Early life nutrition may affect individuals' susceptibility to adult non-communicable diseases (NCD). Psychological stress is a well-recognised NCD risk factor. Recent evidence suggests that impaired foetal nutrition alters neuro-endocrine pathways, and hypothalamic-pituitary-adrenal axis feedback systems, resulting in abnormal stress responses, and NCD risk. This study aims to examine adolescent cortisol and cardiovascular stress responses in relation to maternal nutrition and contemporaneous NCD risk markers. Methods: The study sample will be drawn from three well-established birth cohorts in India; the Parthenon cohort, Mysore (N=550, age~20y), the SARAS KIDS prenatal intervention cohort, Mumbai (N=300, age~10-12y) and the Pune Rural Intervention in Young Adults/ PRIYA cohort, Pune (N=100, age~22y). We will perform the 'Trier Social Stress Test (TSST)', a well-accepted stress-test module which involves participants performing 5-minutes each of public speaking and mental arithmetic tasks in front of unfamiliar 'judges' (stressor). Repeated measures of salivary cortisol and autonomic cardiovascular outcomes relative to the stressor will be assessed. Measures of psychological stress, cognitive function, blood pressure, glucose-insulin metabolism and depression will be carried out. Mechanistic studies including DNA methylation in gluco-corticoid receptor ( NR3C1) and 11β-HSD2 gene loci and neuroimaging will be carried out in a subsample. Qualitative interviews and focus group discussions in a subsample of the Parthenon cohort will explore the perception of stress and stressors among the youth. We will convert repeated measures into time-weighted averages before analysis. We will carry out multivariable regression analysis to test the associations. We will further refine the analyses using the mixed-model regression and conditional analyses for the association with repeated measures. Ethics and dissemination: This study has been approved by the research ethics committee of CSI Holdsworth Memorial Hospital, Mysore. The findings will be disseminated locally and at international meetings, and reports will be submitted to open access peer reviewed journals.
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Affiliation(s)
- GV Krishnaveni
- Epidemiology Research Unit, CSI Holdsworth Memorial Hospitol, Mysore, India
| | | | - Murali Krishna
- Epidemiology Research Unit, CSI Holdsworth Memorial Hospitol, Mysore, India
| | | | | | - Sarah Kehoe
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | | | - Dattatray Bhat
- Diabetes Unit, KEM Hospital Research Centre, Pune, India
| | - Vijay Danivas
- Mysore Medical College and Research Institute, Mysore, India
| | | | - J Suguna Shanthi
- Epidemiology Research Unit, CSI Holdsworth Memorial Hospitol, Mysore, India
| | - SC Karat
- Department of Pediatrics, Jerudong Park Medical Centre, Jerudong Park, Brunei
| | - Mary Barker
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Clive Osmond
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | | | - Caroline Fall
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
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Saville NM, Shrestha BP, Style S, Harris-Fry H, Beard BJ, Sen A, Jha S, Rai A, Paudel V, Sah R, Paudel P, Copas A, Bhandari B, Neupane R, Morrison J, Gram L, Pulkki-Brännström AM, Skordis-Worrall J, Basnet M, de Pee S, Hall A, Harthan J, Thondoo M, Klingberg S, Messick J, Manandhar DS, Osrin D, Costello A. Impact on birth weight and child growth of Participatory Learning and Action women's groups with and without transfers of food or cash during pregnancy: Findings of the low birth weight South Asia cluster-randomised controlled trial (LBWSAT) in Nepal. PLoS One 2018; 13:e0194064. [PMID: 29742136 PMCID: PMC5942768 DOI: 10.1371/journal.pone.0194064] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 02/20/2018] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Undernutrition during pregnancy leads to low birthweight, poor growth and inter-generational undernutrition. We did a non-blinded cluster-randomised controlled trial in the plains districts of Dhanusha and Mahottari, Nepal to assess the impact on birthweight and weight-for-age z-scores among children aged 0-16 months of community-based participatory learning and action (PLA) women's groups, with and without food or cash transfers to pregnant women. METHODS We randomly allocated 20 clusters per arm to four arms (average population/cluster = 6150). All consenting married women aged 10-49 years, who had not had tubal ligation and whose husbands had not had vasectomy, were monitored for missed menses. Between 29 Dec 2013 and 28 Feb 2015 we recruited 25,092 pregnant women to surveillance and interventions: PLA alone (n = 5626); PLA plus food (10 kg/month of fortified wheat-soya 'Super Cereal', n = 6884); PLA plus cash (NPR750≈US$7.5/month, n = 7272); control (existing government programmes, n = 5310). 539 PLA groups discussed and implemented strategies to improve low birthweight, nutrition in pregnancy and hand washing. Primary outcomes were birthweight within 72 hours of delivery and weight-for-age z-scores at endline (age 0-16 months). Only children born to permanent residents between 4 June 2014 and 20 June 2015 were eligible for intention to treat analyses (n = 10936), while in-migrating women and children born before interventions had been running for 16 weeks were excluded. Trial status: completed. RESULTS In PLA plus food/cash arms, 94-97% of pregnant women attended groups and received a mean of four transfers over their pregnancies. In the PLA only arm, 49% of pregnant women attended groups. Due to unrest, the response rate for birthweight was low at 22% (n = 2087), but response rate for endline nutritional and dietary measures exceeded 83% (n = 9242). Compared to the control arm (n = 464), mean birthweight was significantly higher in the PLA plus food arm by 78·0 g (95% CI 13·9, 142·0; n = 626) and not significantly higher in PLA only and PLA plus cash arms by 28·9 g (95% CI -37·7, 95·4; n = 488) and 50·5 g (95% CI -15·0, 116·1; n = 509) respectively. Mean weight-for-age z-scores of children aged 0-16 months (average age 9 months) sampled cross-sectionally at endpoint, were not significantly different from those in the control arm (n = 2091). Differences in weight for-age z-score were as follows: PLA only -0·026 (95% CI -0·117, 0·065; n = 2095); PLA plus cash -0·045 (95% CI -0·133, 0·044; n = 2545); PLA plus food -0·033 (95% CI -0·121, 0·056; n = 2507). Amongst many secondary outcomes tested, compared with control, more institutional deliveries (OR: 1.46 95% CI 1.03, 2.06; n = 2651) and less colostrum discarding (OR:0.71 95% CI 0.54, 0.93; n = 2548) were found in the PLA plus food arm but not in PLA alone or in PLA plus cash arms. INTERPRETATION Food supplements in pregnancy with PLA women's groups increased birthweight more than PLA plus cash or PLA alone but differences were not sustained. Nutrition interventions throughout the thousand-day period are recommended. TRIAL REGISTRATION ISRCTN75964374.
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Affiliation(s)
- Naomi M. Saville
- Institute for Global Health, University College London, London, United Kingdom
| | | | - Sarah Style
- Institute for Global Health, University College London, London, United Kingdom
| | - Helen Harris-Fry
- Institute for Global Health, University College London, London, United Kingdom
| | - B. James Beard
- Institute for Global Health, University College London, London, United Kingdom
| | - Aman Sen
- Mother and Infant Research Activities (MIRA), Kathmandu, Nepal
| | - Sonali Jha
- Mother and Infant Research Activities (MIRA), Kathmandu, Nepal
| | - Anjana Rai
- Mother and Infant Research Activities (MIRA), Kathmandu, Nepal
| | - Vikas Paudel
- Mother and Infant Research Activities (MIRA), Kathmandu, Nepal
| | - Raghbendra Sah
- Mother and Infant Research Activities (MIRA), Kathmandu, Nepal
| | - Puskar Paudel
- Mother and Infant Research Activities (MIRA), Kathmandu, Nepal
| | - Andrew Copas
- Institute for Global Health, University College London, London, United Kingdom
- MRC Clinical Trials Unit, University College London, London, United Kingdom
| | - Bishnu Bhandari
- Mother and Infant Research Activities (MIRA), Kathmandu, Nepal
| | - Rishi Neupane
- Mother and Infant Research Activities (MIRA), Kathmandu, Nepal
| | - Joanna Morrison
- Institute for Global Health, University College London, London, United Kingdom
| | - Lu Gram
- Institute for Global Health, University College London, London, United Kingdom
| | | | | | | | | | - Andrew Hall
- Save the Children UK, London, United Kingdom
| | - Jayne Harthan
- Institute for Global Health, University College London, London, United Kingdom
| | - Meelan Thondoo
- Institute for Global Health, University College London, London, United Kingdom
| | - Sonja Klingberg
- Institute for Global Health, University College London, London, United Kingdom
| | - Janice Messick
- Institute for Global Health, University College London, London, United Kingdom
| | | | - David Osrin
- Institute for Global Health, University College London, London, United Kingdom
| | - Anthony Costello
- Institute for Global Health, University College London, London, United Kingdom
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Stephenson J, Heslehurst N, Hall J, Schoenaker DAJM, Hutchinson J, Cade JE, Poston L, Barrett G, Crozier SR, Barker M, Kumaran K, Yajnik CS, Baird J, Mishra GD. Before the beginning: nutrition and lifestyle in the preconception period and its importance for future health. Lancet 2018; 391:1830-1841. [PMID: 29673873 PMCID: PMC6075697 DOI: 10.1016/s0140-6736(18)30311-8] [Citation(s) in RCA: 630] [Impact Index Per Article: 105.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 12/03/2017] [Accepted: 01/31/2018] [Indexed: 12/15/2022]
Abstract
A woman who is healthy at the time of conception is more likely to have a successful pregnancy and a healthy child. We reviewed published evidence and present new data from low-income, middle-income, and high-income countries on the timing and importance of preconception health for subsequent maternal and child health. We describe the extent to which pregnancy is planned, and whether planning is linked to preconception health behaviours. Observational studies show strong links between health before pregnancy and maternal and child health outcomes, with consequences that can extend across generations, but awareness of these links is not widespread. Poor nutrition and obesity are rife among women of reproductive age, and differences between high-income and low-income countries have become less distinct, with typical diets falling far short of nutritional recommendations in both settings and especially among adolescents. Several studies show that micronutrient supplementation starting in pregnancy can correct important maternal nutrient deficiencies, but effects on child health outcomes are disappointing. Other interventions to improve diet during pregnancy have had little effect on maternal and newborn health outcomes. Comparatively few interventions have been made for preconception diet and lifestyle. Improvements in the measurement of pregnancy planning have quantified the degree of pregnancy planning and suggest that it is more common than previously recognised. Planning for pregnancy is associated with a mixed pattern of health behaviours before conception. We propose novel definitions of the preconception period relating to embryo development and actions at individual or population level. A sharper focus on intervention before conception is needed to improve maternal and child health and reduce the growing burden of non-communicable diseases. Alongside continued efforts to reduce smoking, alcohol consumption, and obesity in the population, we call for heightened awareness of preconception health, particularly regarding diet and nutrition. Importantly, health professionals should be alerted to ways of identifying women who are planning a pregnancy.
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Affiliation(s)
- Judith Stephenson
- Institute for Women's Health, University College London, London, UK.
| | - Nicola Heslehurst
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Jennifer Hall
- Institute for Women's Health, University College London, London, UK
| | | | - Jayne Hutchinson
- Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Janet E Cade
- Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Lucilla Poston
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, London, UK
| | | | - Sarah R Crozier
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Mary Barker
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK; National Institute for Health Research Southampton Biomedical Research Centre, Southampton General Hospital, Southampton, UK
| | - Kalyanaraman Kumaran
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK; Epidemiology Research Unit, CSI Holdsworth Memorial Hospital, Mysore, Karnataka, India
| | - Chittaranjan S Yajnik
- Diabetes Unit, King Edward Memorial Hospital and Research Centre, Pune, Maharashtra, India
| | - Janis Baird
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK; National Institute for Health Research Southampton Biomedical Research Centre, Southampton General Hospital, Southampton, UK
| | - Gita D Mishra
- School of Public Health, University of Queensland, Herston, QLD, Australia
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Barker M, Dombrowski SU, Colbourn T, Fall CHD, Kriznik NM, Lawrence WT, Norris SA, Ngaiza G, Patel D, Skordis-Worrall J, Sniehotta FF, Steegers-Theunissen R, Vogel C, Woods-Townsend K, Stephenson J. Intervention strategies to improve nutrition and health behaviours before conception. Lancet 2018; 391:1853-1864. [PMID: 29673875 PMCID: PMC6075694 DOI: 10.1016/s0140-6736(18)30313-1] [Citation(s) in RCA: 217] [Impact Index Per Article: 36.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 12/03/2017] [Accepted: 01/31/2018] [Indexed: 12/11/2022]
Abstract
The nutritional status of both women and men before conception has profound implications for the growth, development, and long-term health of their offspring. Evidence of the effectiveness of preconception interventions for improving outcomes for mothers and babies is scarce. However, given the large potential health return, and relatively low costs and risk of harm, research into potential interventions is warranted. We identified three promising strategies for intervention that are likely to be scalable and have positive effects on a range of health outcomes: supplementation and fortification; cash transfers and incentives; and behaviour change interventions. On the basis of these strategies, we suggest a model specifying pathways to effect. Pathways are incorporated into a life-course framework using individual motivation and receptiveness at different preconception action phases, to guide design and targeting of preconception interventions. Interventions for individuals not planning immediate pregnancy take advantage of settings and implementation platforms outside the maternal and child health arena, since this group is unlikely to be engaged with maternal health services. Interventions to improve women's nutritional status and health behaviours at all preconception action phases should consider social and environmental determinants, to avoid exacerbating health and gender inequalities, and be underpinned by a social movement that touches the whole population. We propose a dual strategy that targets specific groups actively planning a pregnancy, while improving the health of the population more broadly. Modern marketing techniques could be used to promote a social movement based on an emotional and symbolic connection between improved preconception maternal health and nutrition, and offspring health. We suggest that speedy and scalable benefits to public health might be achieved through strategic engagement with the private sector. Political theory supports the development of an advocacy coalition of groups interested in preconception health, to harness the political will and leadership necessary to turn high-level policy into effective coordinated action.
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Affiliation(s)
- Mary Barker
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK; NIHR Southampton Biomedical Research Centre, Southampton General Hospital, Southampton, UK
| | - Stephan U Dombrowski
- Faculty of Natural Sciences, Division of Psychology, University of Stirling, Stirling, UK
| | - Tim Colbourn
- UCL Institute for Global Health, University College London, London, UK
| | - Caroline H D Fall
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Natasha M Kriznik
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | - Wendy T Lawrence
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK; NIHR Southampton Biomedical Research Centre, Southampton General Hospital, Southampton, UK
| | - Shane A Norris
- MRC Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gloria Ngaiza
- UCL Institute for Global Health, University College London, London, UK
| | - Dilisha Patel
- UCL EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | | | - Falko F Sniehotta
- Institute of Health and Society, Newcastle University and Fuse, the UK Clinical Research Collaboration Centre of Excellence for Translational Research in Public Health, Newcastle upon Tyne, UK
| | - Régine Steegers-Theunissen
- Department of Obstetrics and Gynaecology, and Department of Pediatrics, Division of Neonatology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Christina Vogel
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK; NIHR Southampton Biomedical Research Centre, Southampton General Hospital, Southampton, UK
| | - Kathryn Woods-Townsend
- NIHR Southampton Biomedical Research Centre, Southampton General Hospital, Southampton, UK; Southampton Education School, Faculty of Social and Human Sciences, University of Southampton, Southampton, UK
| | - Judith Stephenson
- UCL EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK.
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Mena KDR, Espitia OLP, Vergara JAD. Management of Ready-to-Use Parenteral Nutrition in Newborns: Systematic Review. JPEN J Parenter Enteral Nutr 2018; 42:1123-1132. [DOI: 10.1002/jpen.1165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 02/27/2018] [Indexed: 01/09/2023]
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Akgun N, Keskin HL, Ustuner I, Pekcan G, Avsar AF. Factors affecting pregnancy weight gain and relationships with maternal/fetal outcomes in Turkey. Saudi Med J 2018; 38:503-508. [PMID: 28439600 PMCID: PMC5447211 DOI: 10.15537/smj.2017.5.19378] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objectives: To determine the effects of pre-pregnancy body mass index (BMI) and gestational weight gain on maternal and fetal complications, and to examine whether Turkish women achieve the recommended gestational weight gain. We also investigated the relationship between pregnancy weight gain and mode of delivery, with an examination of maternal anthropometry. Methods: A retrospective cross-sectional study was conducted on a population of 986 pregnant women between November 2011 and November 2015 at Atatürk Education and Research Hospital, Ankara, Turkey. Maternal age, BMI, monthly weight gain during pregnancy, infant birth weight, gender, and maternal and fetal adverse outcomes were evaluated. Results: The frequency of maternal complications was positively associated with elevated pre-pregnancy BMI (p<0.05), and weight gain during pregnancy was associated with parity and increased infant birth weight (p<0.05). However, no correlations were observed between mean pregnancy weight gain and maternal complications (p>0.05). The percentage of women who gained the Institute of Medicine (IOM)-recommended amount of weight was the highest in the underweight BMI group (54.1%) and the lowest in the obese BMI group (24.3%). Pregnancy weight gain exceeded IOM recommendations in the overweight (56.3%) and obese (52.5%) groups. Conclusions: While maternal weight gain during pregnancy affects neonatal body weight, higher pre-pregnancy BMI has an adverse effect on recommended weight gain during pregnancy, with increased maternal complications.
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Affiliation(s)
- Nilufer Akgun
- Department of Gynecology and Obstetrics, Atatürk Education and Research Hospital, Ankara, Turkey. E-mail.
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Zulyniak MA, de Souza RJ, Shaikh M, Desai D, Lefebvre DL, Gupta M, Wilson J, Wahi G, Subbarao P, Becker AB, Mandhane P, Turvey SE, Beyene J, Atkinson S, Morrison KM, McDonald S, Teo KK, Sears MR, Anand SS. Does the impact of a plant-based diet during pregnancy on birth weight differ by ethnicity? A dietary pattern analysis from a prospective Canadian birth cohort alliance. BMJ Open 2017; 7:e017753. [PMID: 29138203 PMCID: PMC5695448 DOI: 10.1136/bmjopen-2017-017753] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Birth weight is an indicator of newborn health and a strong predictor of health outcomes in later life. Significant variation in diet during pregnancy between ethnic groups in high-income countries provides an ideal opportunity to investigate the influence of maternal diet on birth weight. SETTING Four multiethnic birth cohorts based in Canada (the NutriGen Alliance). PARTICIPANTS 3997 full-term mother-infant pairs of diverse ethnic groups who had principal component analysis-derived diet pattern scores-plant-based, Western and health-conscious-and birth weight data. RESULTS No associations were identified between the Western and health-conscious diet patterns and birth weight; however, the plant-based dietary pattern was inversely associated with birth weight (β=-67.6 g per 1-unit increase; P<0.001), and an interaction with non-white ethnicity and birth weight was observed. Ethnically stratified analyses demonstrated that among white Europeans, maternal consumption of a plant-based diet associated with lower birth weight (β=-65.9 g per 1-unit increase; P<0.001), increased risk of small-for-gestational age (SGA; OR=1.46; 95% CI 1.08 to 1.54;P=0.005) and reduced risk of large-for-gestational age (LGA; OR=0.71; 95% CI 0.53 to 0.95;P=0.02). Among South Asians, maternal consumption of a plant-based diet associated with a higher birth weight (β=+40.5 g per 1-unit increase; P=0.01), partially explained by cooked vegetable consumption. CONCLUSIONS Maternal consumption of a plant-based diet during pregnancy is associated with birth weight. Among white Europeans, a plant-based diet is associated with lower birth weight, reduced odds of an infant born LGA and increased odds of SGA, whereas among South Asians living in Canada, a plant-based diet is associated with increased birth weight.
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Affiliation(s)
- Michael A Zulyniak
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Russell J de Souza
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mateen Shaikh
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dipika Desai
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Diana L Lefebvre
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Milan Gupta
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Canadian Cardiovascular Research Network, Brampton, Ontario, Canada
| | - Julie Wilson
- Six Nations Health Services, Ohsweken, Ontario, Canada
| | - Gita Wahi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Padmaja Subbarao
- Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Allan B Becker
- Department of Immunology, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Piush Mandhane
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Stuart E Turvey
- Department of Paediatrics, Faculty of Medicine, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Joseph Beyene
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Stephanie Atkinson
- Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada
| | | | - Sarah McDonald
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Koon K Teo
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Malcolm R Sears
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sonia S Anand
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
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70
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Nongmaithem SS, Joglekar CV, Krishnaveni GV, Sahariah SA, Ahmad M, Ramachandran S, Gandhi M, Chopra H, Pandit A, Potdar RD, H D Fall C, Yajnik CS, Chandak GR. GWAS identifies population-specific new regulatory variants in FUT6 associated with plasma B12 concentrations in Indians. Hum Mol Genet 2017; 26:2551-2564. [PMID: 28334792 PMCID: PMC5886186 DOI: 10.1093/hmg/ddx071] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 02/20/2017] [Indexed: 01/26/2023] Open
Abstract
Vitamin B12 is an important cofactor in one-carbon metabolism whose dysregulation is associated with various clinical conditions. Indians have a high prevalence of B12 deficiency but little is known about the genetic determinants of circulating B12 concentrations in Indians. We performed a genome-wide association study in 1001 healthy participants in the Pune Maternal Nutrition Study (PMNS), replication studies in 3418 individuals from other Indian cohorts and by meta-analysis identified new variants, rs3760775 (P = 1.2 × 10−23) and rs78060698 (P = 8.3 × 10−17) in FUT6 to be associated with circulating B12 concentrations. Although in-silico analysis replicated both variants in Europeans, differences in the effect allele frequency, effect size and the linkage disequilibrium structure of credible set variants with the reported variants suggest population-specific characteristics in this region. We replicated previously reported variants rs602662, rs601338 in FUT2, rs3760776, rs708686 in FUT6, rs34324219 in TCN1 (all P < 5 × 10−8), rs1131603 in TCN2 (P = 3.4 × 10−5), rs12780845 in CUBN (P = 3.0 × 10−3) and rs2270655 in MMAA (P = 2.0 × 10−3). Circulating B12 concentrations in the PMNS and Parthenon study showed a significant decline with increasing age (P < 0.001), however, the genetic contribution to B12 concentrations remained constant. Luciferase reporter and electrophoretic-mobility shift assay for the FUT6 variant rs78060698 using HepG2 cell line demonstrated strong allele-specific promoter and enhancer activity and differential binding of HNF4α, a key regulator of expression of various fucosyltransferases. Hence, the rs78060698 variant, through regulation of fucosylation may control intestinal host-microbial interaction which could influence B12 concentrations. Our results suggest that in addition to established genetic variants, population-specific variants are important in determining plasma B12 concentrations.
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Affiliation(s)
- Suraj S Nongmaithem
- Genomic Research on Complex Diseases (GRC Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, Telangana 500 007, India
| | - Charudatta V Joglekar
- Diabetes Unit, King Edward Memorial Hospital and Research Centre, Rasta Peth, Pune, Maharashtra 411 011, India
| | - Ghattu V Krishnaveni
- Epidemiology Research Unit, CSI Holdsworth Memorial Hospital, Mysore, Karnataka 570 021, India
| | - Sirazul A Sahariah
- Research Department, Centre for the Study of Social Change, Mumbai, Maharashtra 400 051, India
| | - Meraj Ahmad
- Genomic Research on Complex Diseases (GRC Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, Telangana 500 007, India
| | - Swetha Ramachandran
- Genomic Research on Complex Diseases (GRC Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, Telangana 500 007, India
| | - Meera Gandhi
- Research Department, Centre for the Study of Social Change, Mumbai, Maharashtra 400 051, India
| | - Harsha Chopra
- Research Department, Centre for the Study of Social Change, Mumbai, Maharashtra 400 051, India
| | - Anand Pandit
- Department of Pediatrics, King Edward Memorial Hospital and Research Centre, Rasta Peth, Pune, Maharashtra 411 011, India
| | - Ramesh D Potdar
- Research Department, Centre for the Study of Social Change, Mumbai, Maharashtra 400 051, India
| | - Caroline H D Fall
- Research Department, Centre for the Study of Social Change, Mumbai, Maharashtra 400 051, India.,MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
| | - Chittaranjan S Yajnik
- Diabetes Unit, King Edward Memorial Hospital and Research Centre, Rasta Peth, Pune, Maharashtra 411 011, India
| | - Giriraj R Chandak
- Genomic Research on Complex Diseases (GRC Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, Telangana 500 007, India.,Human Genetics Unit, Genome Institute of Singapore, Biopolis, 138 672, Singapore
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71
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Chandak GR, Silver MJ, Saffari A, Lillycrop KA, Shrestha S, Sahariah SA, Di Gravio C, Goldberg G, Tomar AS, Betts M, Sajjadi S, Acolatse L, James P, Issarapu P, Kumaran K, Potdar RD, Prentice AM, Fall CH. Protocol for the EMPHASIS study; epigenetic mechanisms linking maternal pre-conceptional nutrition and children's health in India and Sub-Saharan Africa. BMC Nutr 2017; 3. [PMID: 30820326 PMCID: PMC6390934 DOI: 10.1186/s40795-017-0200-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Animal studies have shown that nutritional exposures during pregnancy can modify epigenetic marks regulating fetal development and susceptibility to later disease, providing a plausible mechanism to explain the developmental origins of health and disease. Human observational studies have shown that maternal peri-conceptional diet predicts DNA methylation in offspring. However, a causal pathway from maternal diet, through changes in DNA methylation, to later health outcomes has yet to be established. The EMPHASIS study (Epigenetic Mechanisms linking Pre-conceptional nutrition and Health Assessed in India and Sub-Saharan Africa, ISRCTN14266771) will investigate epigenetically mediated links between peri-conceptional nutrition and health-related outcomes in children whose mothers participated in two randomized controlled trials of micronutrient supplementation before and during pregnancy. Methods The original trials were the Mumbai Maternal Nutrition Project (MMNP, ISRCTN62811278) in which Indian women were offered a daily snack made from micronutrient-rich foods or low-micronutrient foods (controls), and the Peri-conceptional Multiple Micronutrient Supplementation Trial (PMMST, ISRCTN13687662) in rural Gambia, in which women were offered a daily multiple micronutrient (UNIMMAP) tablet or placebo. In the EMPHASIS study, DNA methylation will be analysed in the children of these women (~1100 children aged 5–7 y in MMNP and 298 children aged 7–9 y in PMMST). Cohort-specific and cross-cohort effects will be explored. Differences in DNA methylation between allocation groups will be identified using the Illumina Infinium MethylationEPIC array, and by pyrosequencing top hits and selected candidate loci. Associations will be analysed between DNA methylation and health-related phenotypic outcomes, including size at birth, and children’s post-natal growth, body composition, skeletal development, cardio-metabolic risk markers (blood pressure, serum lipids, plasma glucose and insulin) and cognitive function. Pathways analysis will be used to test for enrichment of nutrition-sensitive loci in biological pathways. Causal mechanisms for nutrition-methylation-phenotype associations will be explored using Mendelian Randomization. Associations between methylation unrelated to supplementation and phenotypes will also be analysed. Conclusion The study will increase understanding of the epigenetic mechanisms underpinning the long-term impact of maternal nutrition on offspring health. It will potentially lead to better nutritional interventions for mothers preparing for pregnancy, and to identification of early life biomarkers of later disease risk.
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Affiliation(s)
| | - Matt J Silver
- MRC Unit The Gambia and MRC International Nutrition Group, London School of Hygiene and Tropical Medicine, UK
| | - Ayden Saffari
- MRC Unit, The Gambia and MRC International Nutrition Group, London School of Hygiene and Tropical Medicine, UK
| | | | - Smeeta Shrestha
- CSIR-Centre for Cellular and Molecular Biology, Hyderabad, India
| | | | | | | | | | | | - Sara Sajjadi
- CSIR-Centre for Cellular and Molecular Biology, Hyderabad, India
| | | | - Philip James
- MRC Unit, The Gambia and MRC International Nutrition Group, London School of Hygiene and Tropical Medicine, UK
| | | | - Kalyanaraman Kumaran
- MRC Lifecourse Epidemiology Unit, University of Southampton, UK and CSI Holdsworth memorial Hospital, Mysore, India
| | | | - Andrew M Prentice
- MRC Unit, The Gambia and MRC International Nutrition Group, London School of Hygiene and Tropical Medicine, UK
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72
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Dewey KG. Reducing stunting by improving maternal, infant and young child nutrition in regions such as South Asia: evidence, challenges and opportunities. MATERNAL AND CHILD NUTRITION 2017; 12 Suppl 1:27-38. [PMID: 27187908 PMCID: PMC5084734 DOI: 10.1111/mcn.12282] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Meeting the high nutrient needs of pregnant and lactating women and their young children in regions such as South Asia is challenging because diets are dominated by staple foods with low nutrient density and poor mineral bioavailability. Gaps in nutritional adequacy in such populations probably date back to the agricultural revolution ~10 000 years ago. Options for improving diets during the first 1000 days include dietary diversification and increased intake of nutrient‐rich foods, improved complementary feeding practices, micronutrient supplements and fortified foods or products specifically designed for these target groups. Evidence from intervention trials indicates that several of these strategies, both prenatal and post‐natal, can have a positive impact on child growth, but results are mixed and a growth response is not always observed. Nutrition interventions, by themselves, may not result in the desired impact if the target population suffers from frequent infection, both clinical and subclinical. Further research is needed to understand the mechanisms underlying both prenatal and post‐natal growth restriction. In the meantime, implementation and rigorous evaluation of integrated interventions that address the multiple causes of stunting is a high priority. These intervention packages should ideally include improved nutrition during both pregnancy and the post‐natal period, prevention and control of prenatal and post‐natal infection and subclinical conditions that restrict growth, care for women and children and stimulation of early child development. In regions such as South Asia, such strategies hold great promise for reducing stunting and enhancing human capital formation.
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Affiliation(s)
- Kathryn G Dewey
- Department of Nutrition and Program in International and Community Nutrition, University of California, Davis, Davis, California, USA
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73
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Nguyen PH, Gonzalez-Casanova I, Young MF, Truong TV, Hoang H, Nguyen H, Nguyen S, DiGirolamo AM, Martorell R, Ramakrishnan U. Preconception Micronutrient Supplementation with Iron and Folic Acid Compared with Folic Acid Alone Affects Linear Growth and Fine Motor Development at 2 Years of Age: A Randomized Controlled Trial in Vietnam. J Nutr 2017; 147:1593-1601. [PMID: 28615372 DOI: 10.3945/jn.117.250597] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 04/13/2017] [Accepted: 05/24/2017] [Indexed: 11/14/2022] Open
Abstract
Background: Maternal health and nutrition play a crucial role in early child growth and development. However, little is known about the benefits of preconception micronutrient interventions beyond the role of folic acid (FA) and neural tube defects.Objective: We evaluated the impact of weekly preconception multiple micronutrient (MM) or iron and folic acid (IFA) supplementation on child growth and development through the age of 2 y compared with FA alone.Methods: We followed 1599 offspring born to women who participated in a randomized controlled trial of preconception supplementation in Vietnam. Women received weekly supplements that contained either 2800 μg FA, 60 mg Fe and 2800 μg FA, or 15 MMs including IFA, from baseline until conception followed by daily prenatal IFA supplements until delivery. Child anthropometry was measured at birth and at 3, 6, 12, 18, and 24 mo. Child development was measured with the use of the Bayley Scales for Infant Development III at 24 mo.Results: The groups were similar for baseline maternal and offspring birth characteristics. At 24 mo of age, the offspring in the IFA group had significantly higher length-for-age z scores (LAZs) (0.14; 95% CI: 0.03, 0.26), reduced risk of being stunted (0.87; 95% CI: 0.76, 0.99), and smaller yearly decline in LAZs (0.10; 95% CI: 0.04, 0.15) than the offspring in the FA group. Similar trends were found for the offspring in the MM group compared with the FA group for LAZs (0.10; 95% CI: -0.02, 0.22) and the risk of being stunted (0.88; 95% CI: 0.77, 1.01). Offspring in the IFA group had improved motor development (P = 0.03), especially fine motor development (0.41; 95% CI: 0.05, 0.77), at the age of 24 mo, but there were no differences for measures of cognition or language.Conclusions: Preconception supplementation with IFA improved linear growth and fine motor development at 2 y of age compared with FA. Future studies should examine whether these effects persist and improve child health and schooling. The trial was registered at clinicaltrials.gov as NCT01665378.
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Affiliation(s)
- Phuong H Nguyen
- International Food Policy Research Institute, Washington, DC; .,Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | | | | | | | - Hue Hoang
- Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | - Huong Nguyen
- Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | - Son Nguyen
- Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
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74
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Green R, Allen LH, Bjørke-Monsen AL, Brito A, Guéant JL, Miller JW, Molloy AM, Nexo E, Stabler S, Toh BH, Ueland PM, Yajnik C. Vitamin B 12 deficiency. Nat Rev Dis Primers 2017; 3:17040. [PMID: 28660890 DOI: 10.1038/nrdp.2017.40] [Citation(s) in RCA: 464] [Impact Index Per Article: 66.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Vitamin B12 (B12; also known as cobalamin) is a B vitamin that has an important role in cellular metabolism, especially in DNA synthesis, methylation and mitochondrial metabolism. Clinical B12 deficiency with classic haematological and neurological manifestations is relatively uncommon. However, subclinical deficiency affects between 2.5% and 26% of the general population depending on the definition used, although the clinical relevance is unclear. B12 deficiency can affect individuals at all ages, but most particularly elderly individuals. Infants, children, adolescents and women of reproductive age are also at high risk of deficiency in populations where dietary intake of B12-containing animal-derived foods is restricted. Deficiency is caused by either inadequate intake, inadequate bioavailability or malabsorption. Disruption of B12 transport in the blood, or impaired cellular uptake or metabolism causes an intracellular deficiency. Diagnostic biomarkers for B12 status include decreased levels of circulating total B12 and transcobalamin-bound B12, and abnormally increased levels of homocysteine and methylmalonic acid. However, the exact cut-offs to classify clinical and subclinical deficiency remain debated. Management depends on B12 supplementation, either via high-dose oral routes or via parenteral administration. This Primer describes the current knowledge surrounding B12 deficiency, and highlights improvements in diagnostic methods as well as shifting concepts about the prevalence, causes and manifestations of B12 deficiency.
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Affiliation(s)
- Ralph Green
- Department of Pathology and Laboratory Medicine, University of California Davis, 4400 V Street, PATH Building, Davis, California 95817, USA
| | - Lindsay H Allen
- USDA, ARS Western Human Nutrition Research Center, University of California Davis, Davis, California, USA
| | | | - Alex Brito
- USDA, ARS Western Human Nutrition Research Center, University of California Davis, Davis, California, USA
| | - Jean-Louis Guéant
- Inserm UMRS 954 N-GERE (Nutrition Génétique et Exposition aux Risques Environnementaux), University of Lorraine and INSERM, Nancy, France
| | - Joshua W Miller
- School of Environmental and Biological Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Anne M Molloy
- School of Medicine and School of Biochemistry and Immunology, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Ebba Nexo
- Department of Clinical Medicine, Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Sally Stabler
- Department of Medicine, University of Colorado Denver, Denver, Colorado, USA
| | - Ban-Hock Toh
- Centre for Inflammatory Diseases, Monash Institute of Medical Research, Clayton, Victoria, Australia
| | - Per Magne Ueland
- Laboratory of Clinical Biochemistry, Haukeland University Hospital, Bergen, Norway.,Section for Pharmacology, Department of Clinical Science, University of Bergen, Bergen, Norway
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75
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Johnson W, Elmrayed SA, Sosseh F, Prentice AM, Moore SE. Preconceptional and gestational weight trajectories and risk of delivering a small-for-gestational-age baby in rural Gambia. Am J Clin Nutr 2017; 105:1474-1482. [PMID: 28490512 PMCID: PMC5445671 DOI: 10.3945/ajcn.116.144196] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 03/29/2017] [Indexed: 12/18/2022] Open
Abstract
Background: Maternal nutritional status is a key determinant of small for gestational age (SGA), but some knowledge gaps remain, particularly regarding the role of the energy balance entering pregnancy.Objective: We investigated how preconceptional and gestational weight trajectories (summarized by individual-level traits) are associated with SGA risk in rural Gambia.Design: The sample comprised 670 women in a trial with serial weight data (7310 observations) that were available before and during pregnancy. Individual trajectories from 6 mo before conception to 30 wk of gestation were produced with the use of multilevel modeling. Summary traits were expressed as weight z scores [weight z score at 3 mo preconception (zwt-3 mo), weight z score at conception, weight z score at 3 mo postconception, weight z score at 7 mo postconception (zwt+7 mo), and conditional measures that represented the change from the preceding time] and were related to SGA risk with the use of Poisson regression with confounder adjustment; linear splines were used to account for nonlinearity.Results: Maternal weight at each time point had a consistent nonlinear relation with SGA risk. For example, the zwt-3 mo estimate was stronger in women with values ≤0.5 (RR: 0.736; 95% CI: 0.594, 0.910) than in women with values >0.5 (RR: 0.920; 95% CI: 0.682, 1.241). The former group had the highest observed SGA prevalence. Focusing on weight change, only conditional zwt+7 mo was associated with SGA and only in women with values >-0.5 (RR: 0.579; 95% CI: 0.463, 0.724).Conclusions: Protection against delivering an SGA neonate offered by greater preconceptional or gestational weight may be most pronounced in more undernourished and vulnerable women. Independent of this possibility, greater second- and third-trimester weight gain beyond a threshold may be protective. This trial was registered at http://www.isrctn.com/ as ISRCTN49285450.
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Affiliation(s)
- William Johnson
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom;
| | - Seham Aa Elmrayed
- Medical Research Council (MRC) Elsie Widdowson Laboratory, Cambridge, United Kingdom
| | - Fatou Sosseh
- Nutrition Theme, MRC Unit The Gambia, Banjul, Gambia
| | - Andrew M Prentice
- Nutrition Theme, MRC Unit The Gambia, Banjul, Gambia
- MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom; and
| | - Sophie E Moore
- Nutrition Theme, MRC Unit The Gambia, Banjul, Gambia
- Division of Women's Health, King's College London, London, United Kingdom
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76
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Carrara VI, Stuetz W, Lee SJ, Sriprawat K, Po B, Hanboonkunupakarn B, Nosten FH, McGready R. Longer exposure to a new refugee food ration is associated with reduced prevalence of small for gestational age: results from 2 cross-sectional surveys on the Thailand-Myanmar border. Am J Clin Nutr 2017; 105:1382-1390. [PMID: 28490508 PMCID: PMC5445675 DOI: 10.3945/ajcn.116.148262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 04/05/2017] [Indexed: 11/14/2022] Open
Abstract
Background: Despite the high risk of compromised nutrition, evidence of the effect of refugee rations on fetal growth is limited. A new ration containing micronutrient-fortified flour without increased caloric content of the general food basket was introduced to the Maela refugee camp in Thailand, July 2004.Objective: The effect of the length of gestational exposure of the new ration on fetal growth was compared with birth outcomes [small for gestational age (SGA), preterm birth (PTB)].Design: In an observational study in 987 newborns from 1048 prospectively followed antenatal clinic (ANC) attendees enrolled in 2 cross-sectional surveys, exposure was categorized in 2004 according to gestation at the time of commencing the new ration and in 2006 as comprehensive (preconception and pregnancy). In both surveys, the pregnancy-specific ration and vitamin supplements were routine.Results: In 2004, the proportions of SGA decreased with longer exposure to the new ration: no exposure during pregnancy (27.7%; n = 13 of 47) and exposure in the third (27.6%; n = 37 of 134), second (18.6%; n = 35 of 188), and first (19.4%; n = 6 of 31) trimesters, respectively (adjusted P-trend = 0.046). In 2006, the new ration was available to all women and there was no significant additional impact of the pregnancy-specific ration and vitamin supplements. Between 2004 and 2006, SGA decreased from 28.9% (13 of 45) to 17.3% (69 of 398) (adjusted P = 0.050), a reduction of 40.1% (95% CI: 34.7%, 45.9%); there was also a decrease in the percentage of underweight women on admission to the ANC (38.2%; 95% CI: 31.4%, 45.5%). PTB rates were low and not significantly different with exposure to the new ration.Conclusions: In 2004, the earlier in gestation in which the new ration was available the greater the effect on fetal growth as shown by a reduced prevalence of SGA. In 2006, additional benefits to fetal growth from the pregnancy-specific ration and vitamin supplements beyond those of the preconception ration were not observed. Good nutrition in pregnancy remains an important challenge for refugee populations. This trial was registered at http://drks-neu.uniklinik-freiburg.de/drks_web/ as DRKS00007736.
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Affiliation(s)
- Verena I Carrara
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand;
| | - Wolfgang Stuetz
- Institute of Biological Chemistry and Nutrition, University of Hohenheim, Stuttgart, Germany
| | - Sue J Lee
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; and,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Kanlaya Sriprawat
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Basi Po
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Borimas Hanboonkunupakarn
- Department of Clinical Tropical Medicine and,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; and
| | - François H Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand;,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Rose McGready
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand;,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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77
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Developmental origins of diabetes-an Indian perspective. Eur J Clin Nutr 2017; 71:865-869. [PMID: 28537579 DOI: 10.1038/ejcn.2017.87] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 04/19/2017] [Accepted: 04/23/2017] [Indexed: 02/07/2023]
Abstract
The developmental origins of health disease (DOHaD) hypothesis proposes that altered environmental influences (nutrition, metabolism, pollutants, stress and so on) during critical stages of fetal growth predisposes individuals to diabetes and other non-communicable disease in later life. This phenomenon is thought to reflect permanent effects ('programming') of unbalanced fetal development on physiological systems. Intrauterine programming may underlie the characteristic Indian 'thin-fat' phenotype and the current unprecedented epidemic of diabetes on the backdrop of multigenerational maternal undernutrition in the country. India has been at the forefront of the DOHaD research for over two decades. Both retrospective and prospective birth cohorts in India provide evidence for the role of impaired early-life nutrition on the later diabetes risk. These studies show that in a transitioning country such as India, maternal undernutrition (of micronutrients) and overnutrition (gestational diabetes) co-exist, and expose the offspring to disease risk through multiple pathways. Currently, the Indian scientists are embarking on complex mechanistic and intervention studies to find solutions for the diabetes susceptibility of this population. However, a few unresolved issues in this context warrant continued research and a cautious approach.
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Alemu T, Umeta M. Prevalence and Predictors of "Small Size" Babies in Ethiopia: In-depth Analysis of the Ethiopian Demographic and Health Survey, 2011. Ethiop J Health Sci 2017; 26:243-50. [PMID: 27358545 PMCID: PMC4913192 DOI: 10.4314/ejhs.v26i3.7] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Low Birth Weight (LBW) babies account for nearly 80% of neonatal deaths globally. In Ethiopia, only 5% of them are weighed at birth. This study analyzes the prevalence and key proximate determinants of reported infant size, and its validity to use as a proxy indicator for low birth weight inthe Ethiopian context. Methods In-depth analysis of the Ethiopian Demographic and Health Survey dataset was conducted using representative data collected from all regions in the country. Considering reported fetal size at birth as an outcome variable, key predicting variables from socio-demographic, household, child and obstetric characteristics were employed for analyses. Chi-square test and multivariate logistic regression model were used to determine predictors at p value < 0.05. Results An average of 29.1% of Ethiopian babies were reported “small” at birth in 2011. various variables from socio-demographic, household, child and maternal reproductive characteristics were identified as key predictors. Women who develop anemia and not attending antenatal care during pregnancy had 15% and 41% more risk of giving birth to the reported “small size” babies than their counterparts (AoR = 1.15, and 1.41, 95% CI (1.02, 1.64 and 1.06, 1.88) respectively. Maternal age at delivery, maternal literacy level, paternal educational status and presence of radio or television in the household and other factors were also other key predictors identified. Conclusion The prevalence of small size babies in Ethiopia is high but comparable to regional estimates of LBW. It is recommend that improving maternal nutritional and socio-economic status is a timely intervention to tackle the problem.
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Affiliation(s)
- Taddese Alemu
- Center of Food Science and Nutrition, College of Natural Sciences, Addis Ababa University, Ethiopia; Dilla University, College of Health and Medicine, and Referal Hospital. P.O.Box, 419, Dilla, Ethiopia
| | - Melaku Umeta
- Department of Medical Biochemistry, College of Health Sciences, Addis Ababa University, Ethiopia
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79
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Abstract
BACKGROUND Multiple-micronutrient (MMN) deficiencies often coexist among women of reproductive age in low- to middle-income countries. They are exacerbated in pregnancy due to the increased demands, leading to potentially adverse effects on the mother and developing fetus. Though supplementation with MMNs has been recommended earlier because of the evidence of impact on pregnancy outcomes, a consensus is yet to be reached regarding the replacement of iron and folic acid supplementation with MMNs. Since the last update of this Cochrane review, evidence from a few large trials has recently been made available, the inclusion of which is critical to inform policy. OBJECTIVES To evaluate the benefits of oral multiple-micronutrient supplementation during pregnancy on maternal, fetal and infant health outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (11 March 2015) and reference lists of retrieved articles and key reviews. We also contacted experts in the field for additional and ongoing trials. SELECTION CRITERIA All prospective randomised controlled trials evaluating MMN supplementation with iron and folic acid during pregnancy and its effects on the pregnancy outcome were eligible, irrespective of language or the publication status of the trials. We included cluster-randomised trials, but quasi-randomised trials were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach. MAIN RESULTS Nineteen trials (involving 138,538 women) were identified as eligible for inclusion in this review but only 17 trials (involving 137,791 women) contributed data to the review. Fifteen of these 17 trials were carried out in low and middle-income countries and compared MMN supplements with iron and folic acid versus iron with or without folic acid. Two trials carried out in the UK compared MMN with a placebo. MMN with iron and folic acid versus iron, with or without folic acid (15 trials): MMN resulted in a significant decrease in the number of newborn infants identified as low birthweight (LBW) (average risk ratio (RR) 0.88, 95% confidence interval (CI) 0.85 to 0.91; high-quality evidence) or small-for-gestational age (SGA) (average RR 0.92, 95% CI 0.86 to 0.98; moderate-quality evidence). No significant differences were shown for other maternal and pregnancy outcomes: preterm births (average RR 0.96, 95% CI 0.90 to 1.03; high-quality evidence), stillbirth (average RR 0.97, 95% CI 0.87, 1.09; high-quality evidence), maternal anaemia in the third trimester (average RR 1.03, 95% CI 0.85 to 1.24), miscarriage (average RR 0.91, 95% CI 0.80 to 1.03), maternal mortality (average RR 0.97, 95% CI 0.63 to 1.48), perinatal mortality (average RR 1.01, 95% CI 0.91 to 1.13; high-quality evidence), neonatal mortality (average RR 1.06, 95% CI 0.92 to 1.22; high-quality evidence), or risk of delivery via a caesarean section (average RR 1.04; 95% CI 0.74 to 1.46).A number of prespecified, clinically important outcomes could not be assessed due to insufficient or non-available data. Single trials reported results for: very preterm birth < 34 weeks, macrosomia, side-effects of supplements, nutritional status of children, and congenital anomalies including neural tube defects and neurodevelopmental outcome: Bayley Scales of Infant Development (BSID) scores. None of these trials reported pre-eclampsia, placental abruption, premature rupture of membranes, cost of supplementation, and maternal well-being or satisfaction.When assessed according to GRADE criteria, the quality of evidence for the review's primary outcomes overall was good. Pooled results for primary outcomes were based on multiple trials with large sample sizes and precise estimates. The following outcomes were graded to be as of high quality: preterm birth, LBW, perinatal mortality, stillbirth and neonatal mortality. The outcome of SGA was graded to be of moderate quality, with evidence downgraded by one for funnel plot asymmetry and potential publication bias.We carried out sensitivity analysis excluding trials with high levels of sample attrition (> 20%); results were consistent with the main analysis except for the findings for SGA (average RR 0.91, 95% CI 0.84 to 1.00). We explored heterogeneity through subgroup analyses by maternal height and body mass index (BMI), timing of supplementation and dose of iron. Subgroup differences were observed for maternal BMI for the outcome preterm birth, with significant findings among women with low BMI. Subgroup differences were also observed for maternal BMI and maternal height for the outcome SGA, indicating a significant impact among women with higher maternal BMI and height. The overall analysis of perinatal mortality, although showed a non-significant effect of MMN supplements versus iron with or without folic acid, was found to have substantial statistical heterogeneity. Subgroup differences were observed for timing of supplementation for this outcome, indicating a significantly higher impact with late initiation of supplementation. The findings between subgroups for other primary outcomes were inconclusive. MMN versus placebo (two trials): A single trial in the UK found no clear differences between groups for preterm birth, SGA, LBW or maternal anaemia in the third trimester. A second trial reported the number of women with pre-eclampsia; there was no evidence of a difference between groups. Other outcomes were not reported. AUTHORS' CONCLUSIONS Our findings support the effect of MMN supplements with iron and folic acid in improving some birth outcomes. Overall, pregnant women who received MMN supplementation had fewer low birthweight babies and small-for-gestational-age babies. The findings, consistently observed in several systematic evaluations of evidence, provide a basis to guide the replacement of iron and folic acid with MMN supplements containing iron and folic acid for pregnant women in low and middle-income countries where MMN deficiencies are common among women of reproductive age. Efforts could focus on the integration of this intervention in maternal nutrition and antenatal care programs in low and middle-income countries.
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Affiliation(s)
- Batool A Haider
- Harvard School of Public HealthDepartment of Global Health and Population677 Huntington AvenueBostonUSA02115
| | - Zulfiqar A Bhutta
- Hospital for Sick ChildrenCentre for Global Child HealthTorontoCanadaM5G A04
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80
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Baird J, Jacob C, Barker M, Fall CHD, Hanson M, Harvey NC, Inskip HM, Kumaran K, Cooper C. Developmental Origins of Health and Disease: A Lifecourse Approach to the Prevention of Non-Communicable Diseases. Healthcare (Basel) 2017; 5:E14. [PMID: 28282852 PMCID: PMC5371920 DOI: 10.3390/healthcare5010014] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/17/2017] [Accepted: 02/24/2017] [Indexed: 12/22/2022] Open
Abstract
Non-communicable diseases (NCDs), such as cardiovascular disease and osteoporosis, affect individuals in all countries worldwide. Given the very high worldwide prevalence of NCDs across a range of human pathology, it is clear that traditional approaches targeting those at most risk in older adulthood will not efficiently ameliorate this growing burden. It will thus be essential to robustly identify determinants of NCDs across the entire lifecourse and, subsequently, appropriate interventions at every stage to reduce an individual's risk of developing these conditions. A lifecourse approach has the potential to prevent NCDs, from before conception through fetal life, infancy, childhood, adolescence, adulthood and into older age. In this paper, we describe the origins of the lifecourse concept, the importance of early life influences, for example during pregnancy, examine potential underlying mechanisms in both cell biology and behavior change, and finally describe current efforts to develop interventions that take a lifecourse approach to NCD prevention. Two principal approaches to improving women's nutritional status are outlined: nutritional supplementation and behavior change.
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Affiliation(s)
- Janis Baird
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK.
| | - Chandni Jacob
- Institute of Developmental Sciences, University of Southampton, Southampton S016 5YA, UK.
| | - Mary Barker
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK.
- National Institute for Health Research Southampton Biomedical Research Centre, University Hospital Southampton, NHS Foundation Trust, Southampton SO16 6YD, UK.
| | - Caroline H D Fall
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK.
| | - Mark Hanson
- Institute of Developmental Sciences, University of Southampton, Southampton S016 5YA, UK.
- National Institute for Health Research Southampton Biomedical Research Centre, University Hospital Southampton, NHS Foundation Trust, Southampton SO16 6YD, UK.
| | - Nicholas C Harvey
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK.
- National Institute for Health Research Southampton Biomedical Research Centre, University Hospital Southampton, NHS Foundation Trust, Southampton SO16 6YD, UK.
| | - Hazel M Inskip
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK.
| | - Kalyanaraman Kumaran
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK.
| | - Cyrus Cooper
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK.
- National Institute for Health Research Southampton Biomedical Research Centre, University Hospital Southampton, NHS Foundation Trust, Southampton SO16 6YD, UK.
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81
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Lawande A, Di Gravio C, Potdar RD, Sahariah SA, Gandhi M, Chopra H, Sane H, Kehoe SH, Marley-Zagar E, Margetts BM, Jackson AA, Fall CHD. Effect of a micronutrient-rich snack taken preconceptionally and throughout pregnancy on ultrasound measures of fetal growth: The Mumbai Maternal Nutrition Project (MMNP). MATERNAL AND CHILD NUTRITION 2017; 14. [PMID: 28251804 PMCID: PMC5482394 DOI: 10.1111/mcn.12441] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 01/26/2017] [Accepted: 01/27/2017] [Indexed: 12/05/2022]
Abstract
Improving micronutrient intakes of under‐nourished mothers in low‐ and middle‐income countries increases birth weight, but there is little data on the nature and timing during gestation of any effects on fetal growth. Ultrasound measures of fetal size were used to determine whether and when a food‐based supplement affected fetal growth. Non‐pregnant women living in Mumbai slums, India (N = 6,513), were randomly assigned to receive either a daily micronutrient‐rich snack containing green leafy vegetables, fruit, and milk (treatment) or a snack made from lower‐micronutrient vegetables (control) in addition to their usual diet from before pregnancy until delivery. From 2,291 pregnancies, the analysis sample comprised 1,677 fetuses (1,335 fetuses of women supplemented for ≥3 months before conception). First‐trimester (median: 10 weeks, interquartile range: 9–12 weeks) fetal crown‐rump length was measured. Fetal head circumference, biparietal diameter, femur length, and abdominal circumference were measured during the second (19, 19–20 weeks) and third trimesters (29, 28–30 weeks). The intervention had no effect on fetal size or growth at any stage of pregnancy. In the second trimester, there were interactions between parity and allocation group for biparietal diameter (p = .02) and femur length (p = .04) with both being smaller among fetuses of primiparous women and larger among those of multiparous women, in the treatment group compared with the controls. Overall, a micronutrient‐rich supplement did not increase standard ultrasound measures of fetal size and growth at any stage of pregnancy. Additional ultrasound measures of fetal soft tissues (fat and muscle) may be informative.
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Affiliation(s)
| | - Chiara Di Gravio
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | | | | | - Meera Gandhi
- Centre for the Study of Social Change, Mumbai, India
| | - Harsha Chopra
- Centre for the Study of Social Change, Mumbai, India
| | - Harshad Sane
- Centre for the Study of Social Change, Mumbai, India
| | - Sarah H Kehoe
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Ella Marley-Zagar
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | | | - Alan A Jackson
- NIHR Southampton Biomedical Research Centre, Southampton, UK
| | - Caroline H D Fall
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
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82
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Birth weight and risk of ischemic heart disease: A Mendelian randomization study. Sci Rep 2016; 6:38420. [PMID: 27924921 PMCID: PMC5141503 DOI: 10.1038/srep38420] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 11/09/2016] [Indexed: 12/22/2022] Open
Abstract
Low birth weight is a risk factor for cardiovascular disease. However, the association could be confounded by many factors. We used Mendelian randomization to clarify the role of birth weight in ischemic heart disease (IHD) and lipids. We used all 7 single nucleotide polymorphisms (SNPs) independently contributing to birth weight at genome wide significance (p < 5 × 10−8) in separate sample instrumental variable analysis to estimate the effect of birth weight on IHD using the CARDIoGRAMplusC4D 1000 Genomes based GWAS case (n = 60,801)-control (n = 123,504) study and on lipids using GLGC (n = 188,577). Higher genetically predicted birth weight was associated with lower risk of IHD (odds ratio (OR) 0.96 per 100 grams, 95% confidence interval (CI) 0.93 to 0.99), but the association was not robust to sensitivity analyses excluding SNPs related to height or use of weighted median methods. Genetically predicted birth weight was not associated with low density lipoprotein cholesterol or triglycerides, but was associated with lower high density lipoprotein cholesterol (−0.014 standard deviation, 95% CI −0.027 to −0.0005) and the association was more robust to the sensitivity analyses. Our study does not show strong evidence for an effect of birth weight on IHD and lipids.
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83
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Karimbeiki R, Derakhshandeh Rishehri SM, Kelishadi R, Heidari-Beni M. Association of Milk and Dairy Products Consumption During Pregnancy with Fetal and Neonatal Head Circumferences: A Systematic Review. JOURNAL OF PEDIATRICS REVIEW 2016. [DOI: 10.17795/jpr-7690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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84
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Saville NM, Shrestha BP, Style S, Harris-Fry H, Beard BJ, Sengupta A, Jha S, Rai A, Paudel V, Pulkki-Brannstrom AM, Copas A, Skordis-Worrall J, Bhandari B, Neupane R, Morrison J, Gram L, Sah R, Basnet M, Harthan J, Manandhar DS, Osrin D, Costello A. Protocol of the Low Birth Weight South Asia Trial (LBWSAT), a cluster-randomised controlled trial testing impact on birth weight and infant nutrition of Participatory Learning and Action through women's groups, with and without unconditional transfers of fortified food or cash during pregnancy in Nepal. BMC Pregnancy Childbirth 2016; 16:320. [PMID: 27769191 PMCID: PMC5073870 DOI: 10.1186/s12884-016-1102-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 10/08/2016] [Indexed: 11/16/2022] Open
Abstract
Background Low birth weight (LBW, < 2500 g) affects one third of newborn infants in rural south Asia and compromises child survival, infant growth, educational performance and economic prospects. We aimed to assess the impact on birth weight and weight-for-age Z-score in children aged 0–16 months of a nutrition Participatory Learning and Action behaviour change strategy (PLA) for pregnant women through women’s groups, with or without unconditional transfers of food or cash to pregnant women in two districts of southern Nepal. Methods The study is a cluster randomised controlled trial (non-blinded). PLA comprises women’s groups that discuss, and form strategies about, nutrition in pregnancy, low birth weight and hygiene. Women receive up to 7 monthly transfers per pregnancy: cash is NPR 750 (~US$7) and food is 10 kg of fortified sweetened wheat-soya Super Cereal per month. The unit of randomisation is a rural village development committee (VDC) cluster (population 4000–9200, mean 6150) in southern Dhanusha or Mahottari districts. 80 VDCs are randomised to four arms using a participatory ‘tombola’ method. Twenty clusters each receive: PLA; PLA plus food; PLA plus cash; and standard care (control). Participants are (mostly Maithili-speaking) pregnant women identified from 8 weeks’ gestation onwards, and their infants (target sample size 8880 birth weights). After pregnancy verification, mothers may be followed up in early and late pregnancy, within 72 h, after 42 days and within 22 months of birth. Outcomes pertain to the individual level. Primary outcomes include birth weight within 72 h of birth and infant weight-for-age Z-score measured cross-sectionally on children born of the study. Secondary outcomes include prevalence of LBW, eating behaviour and weight during pregnancy, maternal and newborn illness, preterm delivery, miscarriage, stillbirth or neonatal mortality, infant Z-scores for length-for-age and weight-for-length, head circumference, and postnatal maternal BMI and mid-upper arm circumference. Exposure to women’s groups, food or cash transfers, home visits, and group interventions are measured. Discussion Determining the relative importance to birth weight and early childhood nutrition of adding food or cash transfers to PLA women’s groups will inform design of nutrition interventions in pregnancy. Trial registration ISRCTN75964374, 12 Jul 2013 Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-1102-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Naomi M Saville
- University College London, Institute for Global Health, London, UK.
| | - Bhim P Shrestha
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | - Sarah Style
- University College London, Institute for Global Health, London, UK
| | - Helen Harris-Fry
- University College London, Institute for Global Health, London, UK
| | - B James Beard
- University College London, Institute for Global Health, London, UK
| | - Aman Sengupta
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | - Sonali Jha
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | - Anjana Rai
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | - Vikas Paudel
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | | | - Andrew Copas
- University College London, Institute for Global Health, London, UK
| | | | - Bishnu Bhandari
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | - Rishi Neupane
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | - Joanna Morrison
- University College London, Institute for Global Health, London, UK
| | - Lu Gram
- University College London, Institute for Global Health, London, UK
| | - Raghbendra Sah
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | - Machhindra Basnet
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | - Jayne Harthan
- University College London, Institute for Global Health, London, UK
| | - Dharma S Manandhar
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | - David Osrin
- University College London, Institute for Global Health, London, UK
| | - Anthony Costello
- University College London, Institute for Global Health, London, UK
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85
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Baird J, Barker M, Harvey NC, Lawrence W, Vogel C, Jarman M, Begum R, Tinati T, Mahon P, Strommer S, Rose T, Inskip H, Cooper C. Southampton PRegnancy Intervention for the Next Generation (SPRING): protocol for a randomised controlled trial. Trials 2016; 17:493. [PMID: 27729061 PMCID: PMC5059927 DOI: 10.1186/s13063-016-1603-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 09/14/2016] [Indexed: 01/14/2023] Open
Abstract
Background The nutritional status and health of mothers influence the growth and development of infants during pregnancy and postnatal life. Interventions that focus on improving the nutritional status and lifestyle of mothers have the potential to optimise the development of the fetus as well as improve the health of mothers themselves. Improving the diets of women of childbearing age is likely to require complex interventions that are delivered in a socially and culturally appropriate context. In this study we aim to test the efficacy of two interventions: behaviour change (Healthy Conversation Skills) and vitamin D supplementation, and to explore the efficacy of an intervention that combines both, in improving the diet quality and nutritional status of pregnant women. Methods/design Women attending the maternity hospital in Southampton are recruited at between 8 and 12 weeks gestation. They are randomised to one of four groups following a factorial design: Healthy Conversation Skills support plus vitamin D supplementation (1000 IU cholecalciferol) (n = 150); Healthy Conversation Skills support plus placebo (n = 150); usual care plus vitamin D supplementation (n = 150); usual care plus placebo (n = 150). Questionnaire data include parity, sunlight exposure, diet assessment allowing assessment of diet quality, cigarette and alcohol consumption, well-being, self-efficacy and food involvement. At 19 and 34 weeks maternal anthropometry is assessed and blood samples taken to measure 25(OH) vitamin D. Maternal diet quality and 25(OH) vitamin D are the primary outcomes. Secondary outcomes are women’s level of self-efficacy at 34 weeks, pregnancy weight gain, women’s self-efficacy and breastfeeding status at one month after birth and neonatal bone mineral content, assessed by DXA within the first 14 days after birth. Discussion This trial is evaluating two approaches to improving maternal diet: a behaviour change intervention and vitamin D supplementation. The factorial design of this trial has the advantage of enabling each intervention to be tested separately as well as allowing exploration of the synergistic effect of both interventions on women’s diets and vitamin D levels. Trial registration ISRCTN07227232. Registered on 13 September 2013.
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Affiliation(s)
- Janis Baird
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK.
| | - Mary Barker
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK.,NIHR Nutrition Biomedical Research Centre, University of Southampton, Southampton, SO16 6YD, UK
| | - Wendy Lawrence
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
| | - Christina Vogel
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
| | - Megan Jarman
- Li Ka Shing Centre for Health Research Innovation, Department of Agriculture, Food and Nutritional Science, University of Alberta, Edmonton, T6G 2E1, Alberta, Canada
| | - Rufia Begum
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK.,NIHR Nutrition Biomedical Research Centre, University of Southampton, Southampton, SO16 6YD, UK
| | - Tannaze Tinati
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
| | - Pamela Mahon
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
| | - Sofia Strommer
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
| | - Taylor Rose
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
| | - Hazel Inskip
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK.,NIHR Nutrition Biomedical Research Centre, University of Southampton, Southampton, SO16 6YD, UK
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86
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Johnson W, Darboe MK, Sosseh F, Nshe P, Prentice AM, Moore SE. Association of prenatal lipid-based nutritional supplementation with fetal growth in rural Gambia. MATERNAL AND CHILD NUTRITION 2016; 13. [PMID: 27696720 PMCID: PMC5396370 DOI: 10.1111/mcn.12367] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 07/01/2016] [Accepted: 07/20/2016] [Indexed: 01/20/2023]
Abstract
Prenatal supplementation with protein-energy (PE) and/or multiple-micronutrients (MMNs) may improve fetal growth, but trials of lipid-based nutritional supplements (LNSs) have reported inconsistent results. We conducted a post-hoc analysis of non-primary outcomes in a trial in Gambia, with the aim to test the associations of LNS with fetal growth and explore how efficacy varies depending on nutritional status. The sample comprised 620 pregnant women in an individually randomized, partially blinded trial with four arms: (a) iron and folic acid (FeFol) tablet (usual care, referent group), (b) MMN tablet, (c) PE LNS, and (d) PE + MMN LNS. Analysis of variance examined unadjusted differences in fetal biometry z-scores at 20 and 30 weeks and neonatal anthropometry z-scores, while regression tested for modification of intervention-outcome associations by season and maternal height, body mass index, and weight gain. Despite evidence of between-arm differences in some fetal biometry, z-scores at birth were not greater in the intervention arms than the FeFol arm (e.g., birth weight z-scores: FeFol -0.71, MMN -0.63, PE -0.64, PE + MMN -0.62; group-wise p = .796). In regression analyses, intervention associations with birth weight and head circumference were modified by maternal weight gain between booking and 30 weeks gestation (e.g., PE + MMN associations with birth weight were +0.462 z-scores (95% CI [0.097, 0.826]) in the highest quartile of weight gain but -0.099 z-scores (-0.459, 0.260) in the lowest). In conclusion, we found no strong evidence that a prenatal LNS intervention was associated with better fetal growth in the whole sample.
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Affiliation(s)
| | - Momodou K Darboe
- MRC International Nutrition Group, MRC Unit The Gambia, Fajara, Banjul, The Gambia
| | - Fatou Sosseh
- MRC International Nutrition Group, MRC Unit The Gambia, Fajara, Banjul, The Gambia
| | - Patrick Nshe
- MRC International Nutrition Group, MRC Unit The Gambia, Fajara, Banjul, The Gambia
| | - Andrew M Prentice
- MRC International Nutrition Group, MRC Unit The Gambia, Fajara, Banjul, The Gambia
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87
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Association of parental body mass index before pregnancy on infant growth and body composition: Evidence from a pregnancy cohort study in Malaysia. Obes Res Clin Pract 2016; 10 Suppl 1:S35-S47. [DOI: 10.1016/j.orcp.2015.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 07/01/2015] [Accepted: 08/07/2015] [Indexed: 11/19/2022]
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88
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Relationship between dairy product intake during pregnancy and neonatal and maternal outcomes among Portuguese women. Obes Res Clin Pract 2016; 11:276-286. [PMID: 27473300 DOI: 10.1016/j.orcp.2016.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 06/28/2016] [Accepted: 07/04/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND The role played by dairy product intake during pregnancy on neonatal outcomes has raised interest in the last few years. However, studies on this association remain scarce. Thus, the aim of this study was to determine the association between dairy product consumption during pregnancy and neonatal and maternal outcomes. METHODS A prospective study was conducted with 98 pregnant women, aged 18-40, from the city of Porto, Portugal. Socio-demographic and lifestyle characteristics were assessed through a questionnaire. Dairy product consumption was assessed with a three-day food diary completed during the first and second trimesters. Postpartum medical records were examined for neonatal and maternal outcomes. Multivariate linear regression analyses were performed to assess the association between dairy intake and neonatal and maternal outcomes, adjusting for dietary variables and maternal characteristics. RESULTS Compared to the first trimester pregnant women had higher energy intake and lower calcium, iodine and yogurt intake in the second trimester (P<0.05). Total dairy and yogurt intake in the first trimester were positively associated with head circumference and placental weight (respectively β=0.002, P=0.014, β=0.333, P=0.012). Change in total dairy intake between the second and first trimester was negatively associated with maternal weight gain during pregnancy (β=-0.007, P=0.020). CONCLUSION The findings of this study suggest that dairy product intake during pregnancy may have an effect on neonatal head circumference, placental weight, and gestational weight gain.
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89
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Wells JCK, Pomeroy E, Walimbe SR, Popkin BM, Yajnik CS. The Elevated Susceptibility to Diabetes in India: An Evolutionary Perspective. Front Public Health 2016; 4:145. [PMID: 27458578 PMCID: PMC4935697 DOI: 10.3389/fpubh.2016.00145] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Accepted: 06/24/2016] [Indexed: 01/11/2023] Open
Abstract
India has rapidly become a "diabetes capital" of the world, despite maintaining high rates of under-nutrition. Indians develop diabetes at younger age and at lower body weights than other populations. Here, we interpret these characteristics in terms of a "capacity-load" model of glucose homeostasis. Specifically, we assume that glycemic control depends on whether the body's "metabolic capacity," referring to traits, such as pancreatic insulin production and muscle glucose clearance, is able to resolve the "metabolic load" generated by high levels of body fat, high dietary glycemic load, and sedentary behavior. We employ data from modern cohorts to support the model and the interpretation that elevated diabetic risk among Indian populations results from the high metabolic load imposed by westernized lifestyles acting on a baseline of low metabolic capacity. We attribute this low metabolic capacity to the low birth weight characteristic of Indian populations, which is associated with short stature and low lean mass in adult life. Using stature as a marker of metabolic capacity, we review archeological and historical evidence to highlight long-term declines in Indian stature associated with adaptation to several ecological stresses. Underlying causes may include increasing population density following the emergence of agriculture, the spread of vegetarian diets, regular famines induced by monsoon failure, and the undermining of agricultural security during the colonial period. The reduced growth and thin physique that characterize Indian populations elevate susceptibility to truncal obesity, and increase the metabolic penalties arising from sedentary behavior and high glycemic diets. Improving metabolic capacity may require multiple generations; in the meantime, efforts to reduce the metabolic load will help ameliorate the situation.
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Affiliation(s)
- Jonathan C K Wells
- Childhood Nutrition Research Centre, UCL Institute of Child Health , London , UK
| | - Emma Pomeroy
- McDonald Institute for Archaeological Research, University of Cambridge , Cambridge , UK
| | | | - Barry M Popkin
- Nutrition Department, Gillings Global School of Public Health, University of North Carolina School of Public Health , Chapel Hill, NC , USA
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90
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King JC. A Summary of Pathways or Mechanisms Linking Preconception Maternal Nutrition with Birth Outcomes. J Nutr 2016; 146:1437S-44S. [PMID: 27281808 PMCID: PMC4926847 DOI: 10.3945/jn.115.223479] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 01/05/2016] [Indexed: 11/14/2022] Open
Abstract
Population, human, animal, tissue, and molecular studies show collectively and consistently that maternal nutrition in the pre- or periconception period influences fetal growth and development, which subsequently affects the individual's long-term health. It is known that nutrition during pregnancy is an important determinant of the offspring's growth and health. However, now there is evidence that the mother's nutritional status at conception also influences pregnancy outcome and long-term health. For example, the mother's nutritional status at conception influences the way energy is partitioned between maternal and fetal needs. Furthermore, placental development during the first weeks of gestation reflects maternal nutrition and establishes mechanisms for balancing maternal and fetal nutritional needs. Also, maternal nutritional signals at fertilization influence epigenetic remodeling of fetal genes. These findings all indicate that maternal parenting begins before conception. The following papers from a symposium on preconception nutrition presented at the 2015 Scientific Sessions and Annual Meeting of the ASN emphasize the importance of maternal nutrition at conception on the growth and long-term health of the child.
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Affiliation(s)
- Janet C King
- Children's Hospital Oakland Research Institute, Oakland, CA
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91
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Sahariah SA, Potdar RD, Gandhi M, Kehoe SH, Brown N, Sane H, Coakley PJ, Marley-Zagar E, Chopra H, Shivshankaran D, Cox VA, Jackson AA, Margetts BM, Fall CHD. A Daily Snack Containing Leafy Green Vegetables, Fruit, and Milk before and during Pregnancy Prevents Gestational Diabetes in a Randomized, Controlled Trial in Mumbai, India. J Nutr 2016; 146:1453S-60S. [PMID: 27281802 PMCID: PMC4926846 DOI: 10.3945/jn.115.223461] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 01/04/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Prospective observational studies suggest that maternal diets rich in leafy green vegetables and fruit may help prevent gestational diabetes mellitus (GDM). OBJECTIVE Our objective was to test whether increasing women's dietary intake of leafy green vegetables, fruit, and milk before conception and throughout pregnancy reduced their risk of GDM. METHODS Project SARAS ("excellent") (2006-2012) was a nonblinded, individually randomized, controlled trial in women living in slums in the city of Mumbai, India. The interventions included a daily snack made from leafy green vegetables, fruit, and milk for the treatment group or low-micronutrient vegetables (e.g., potato and onion) for the control group, in addition to the usual diet. Results for the primary outcome, birth weight, have been reported. Women were invited to take an oral-glucose-tolerance test (OGTT) at 28-32 wk gestation to screen for GDM (WHO 1999 criteria). The prevalence of GDM was compared between the intervention and control groups, and Kernel density analysis was used to compare distributions of 120-min plasma glucose concentrations between groups. RESULTS Of 6513 women randomly assigned, 2291 became pregnant; of these, 2028 reached a gestation of 28 wk, 1008 (50%) attended for an OGTT, and 100 (9.9%) had GDM. In an intention-to-treat analysis, the prevalence of GDM was reduced in the treatment group (7.3% compared with 12.4% in controls; OR: 0.56; 95% CI: 0.36, 0.86; P = 0.008). The reduction in GDM remained significant after adjusting for prepregnancy adiposity and fat or weight gain during pregnancy. Kernel density analysis showed that this was explained by the fact that fewer women in the treatment group had a 2-h glucose concentration in the range 7.5-10.0 mmol/L. CONCLUSIONS In low-income settings, in which women have a low intake of micronutrient-rich foods, improving dietary micronutrient quality by increasing intake of leafy green vegetables, fruit, and/or milk may have an important protective effect against the development of GDM. This trial was registered at www.controlled-trials.com as ISRCTN62811278.
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Affiliation(s)
| | | | - Meera Gandhi
- Centre for the Study of Social Change, Mumbai, India; and
| | | | | | - Harshad Sane
- Centre for the Study of Social Change, Mumbai, India; and
| | | | | | - Harsha Chopra
- Centre for the Study of Social Change, Mumbai, India; and
| | | | | | | | - Barrie M Margetts
- Public Health Nutrition, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Caroline HD Fall
- MRC Lifecourse Epidemiology Unit,,To whom correspondence should be addressed. E-mail:
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Ramakrishnan U, Nguyen PH, Gonzalez-Casanova I, Pham H, Hao W, Nguyen H, Truong TV, Nguyen S, Harding KB, Reinhart GA, Neufeld LM, Martorell R. Neither Preconceptional Weekly Multiple Micronutrient nor Iron-Folic Acid Supplements Affect Birth Size and Gestational Age Compared with a Folic Acid Supplement Alone in Rural Vietnamese Women: A Randomized Controlled Trial. J Nutr 2016; 146:1445S-52S. [PMID: 27281806 DOI: 10.3945/jn.115.223420] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 01/26/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Maternal nutritional status before and during early pregnancy plays a critical role in fetal growth and development. The benefits of periconception folic acid (FA) supplementation in the prevention of neural tube defects is well recognized, but the evidence for preconception micronutrient interventions for improving pregnancy outcomes is limited. OBJECTIVE This study aimed to evaluate whether preconception supplementation with weekly iron and folic acid (IFA) or multiple micronutrients (MMs) improves birth outcomes compared with FA alone. METHODS We recruited 5011 women of reproductive age in a double-blind, randomized controlled trial in Vietnam and provided weekly supplements containing either 2800 μg FA, 60 mg Fe and 2800 μg FA (IFA), or the same amount of FA and iron plus other MMs until they conceived (n = 1813). All pregnant women received daily IFA through delivery, and were followed up for birth outcomes, including birth weight, gestational age, preterm delivery and small for gestational age (SGA). Group comparisons were done with the use of ANOVA or chi-square tests for both intention-to-treat (n = 1599) and per-protocol analyses (women consumed supplements ≥26 wk before conception; n = 824). Effect modification by baseline underweight or anemia status was tested with the use of generalized linear models. RESULTS The mean age of the women was 26 y, 30% were underweight, and <10% were nulliparous. The groups were similar for most baseline characteristics. The mean ± SD duration of the preconception intervention was 33 ± 25 wk and compliance was high (>90%). Infants born to the 3 groups of women did not differ (P ≥ 0.05) on mean ± SD birth weight (3076.8 ± 444.5 g) or gestational age (39.2 ± 2.0 wk), or prevalence of SGA (12%), low birth weight (5%) and preterm delivery (10%). There were no significant differences in women who consumed supplements ≥26 wk before conception or by baseline underweight or anemia. CONCLUSION Weekly supplementation with MMs or IFA before conception did not affect birth outcomes compared with FA in rural Vietnamese women. The trial was registered at clinicaltrials.gov as NCT01665378.
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Affiliation(s)
- Usha Ramakrishnan
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA;
| | - Phuong H Nguyen
- International Food Policy Research Institute, Hanoi, Vietnam; Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | - Ines Gonzalez-Casanova
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Hoa Pham
- Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | - Wei Hao
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Hieu Nguyen
- Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | - Truong V Truong
- Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | - Son Nguyen
- Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | | | - Gregory A Reinhart
- The Mathile Institute for the Advancement of Human Nutrition, Dayton, OH; and
| | | | - Reynaldo Martorell
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
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Zerfu TA, Umeta M, Baye K. Dietary diversity during pregnancy is associated with reduced risk of maternal anemia, preterm delivery, and low birth weight in a prospective cohort study in rural Ethiopia. Am J Clin Nutr 2016; 103:1482-8. [PMID: 27169832 DOI: 10.3945/ajcn.115.116798] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 04/08/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Anemia during pregnancy is a leading nutritional disorder with serious short- and long-term consequences for both the mother and the fetus. OBJECTIVE The objective was to investigate the association between dietary diversity during pregnancy and maternal anemia, low birth weight (LBW), preterm birth (PTB), and stillbirth in rural Ethiopia. DESIGN We conducted a prospective cohort study and enrolled 432 pregnant women in their first antenatal care visit (24-28 gestational weeks); 374 women completed the follow-up. By using the FAO Women's Dietary Diversity Scores (WDDSs), subjects were categorized into "inadequate" (WDDS <4) and "adequate" (WDDS ≥4) groups and were followed until delivery. Primary outcomes were maternal anemia, birth weight, term delivery, and stillbirth. RESULTS The attrition rate was 13.7% and was balanced across the 2 groups. The proportion of women consuming dairy, animal-source foods, fruits, and vegetables including vitamin A-rich ones was higher in the adequate than in the inadequate WDDS group (P < 0.05). The overall incidence of maternal anemia increased from 28.6% to 32.4% during the follow-up period. The overall proportion of LBW, PTB, and stillbirth were 9.1%, 13.6%, and 4.5%, respectively. After control for baseline differences, women in the inadequate group had a higher risk of anemia [adjusted RR (ARR: 2.29; 95% CI: 1.62, 3.24], LBW (ARR: 2.06; 95% CI: 1.03, 4.11), and PTB (ARR: 4.61; 95% CI: 2.31, 9.19) but not of stillbirth (ARR: 2.71; 95% CI: 0.88, 8.36) than women in the adequate group (P < 0.05). CONCLUSIONS A WDDS of ≥4 food groups during pregnancy was shown to be associated with lower risk of maternal anemia, LBW, and PTB. Population-based controlled trials of various options to improve dietary diversity are needed before conclusive recommendations can be made. This trial was registered at clinicaltrials.gov as NCT02620943.
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Affiliation(s)
- Taddese A Zerfu
- Center for Food Science and Nutrition, College of Natural Sciences and College of Medicine and Health Sciences and Referral Hospital, Dilla University, Gedeo, Ethiopia
| | - Melaku Umeta
- Department of Medical Biochemistry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia; and
| | - Kaleab Baye
- Center for Food Science and Nutrition, College of Natural Sciences and
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Balogun OO, da Silva Lopes K, Ota E, Takemoto Y, Rumbold A, Takegata M, Mori R. Vitamin supplementation for preventing miscarriage. Cochrane Database Syst Rev 2016; 2016:CD004073. [PMID: 27150280 PMCID: PMC7104220 DOI: 10.1002/14651858.cd004073.pub4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Miscarriage is a common complication of pregnancy that can be caused by a wide range of factors. Poor dietary intake of vitamins has been associated with an increased risk of miscarriage, therefore supplementing women with vitamins either prior to or in early pregnancy may help prevent miscarriage. OBJECTIVES The objectives of this review were to determine the effectiveness and safety of any vitamin supplementation, on the risk of spontaneous miscarriage. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group Trials Register (6 November 2015) and reference lists of retrieved studies. SELECTION CRITERIA All randomised and quasi-randomised trials comparing supplementation during pregnancy with one or more vitamins with either placebo, other vitamins, no vitamins or other interventions. We have included supplementation that started prior to conception, periconceptionally or in early pregnancy (less than 20 weeks' gestation). DATA COLLECTION AND ANALYSIS Three review authors independently assessed trials for inclusion, extracted data and assessed trial quality. We assessed the quality of the evidence using the GRADE approach. The quality of evidence is included for numerical results of outcomes included in the 'Summary of findings' tables. MAIN RESULTS We included a total of 40 trials (involving 276,820 women and 278,413 pregnancies) assessing supplementation with any vitamin(s) starting prior to 20 weeks' gestation and reporting at least one primary outcome that was eligible for the review. Eight trials were cluster-randomised and contributed data for 217,726 women and 219,267 pregnancies in total.Approximately half of the included trials were assessed to have a low risk of bias for both random sequence generation and adequate concealment of participants to treatment and control groups. Vitamin C supplementation There was no difference in the risk of total fetal loss (risk ratio (RR) 1.14, 95% confidence interval (CI) 0.92 to 1.40, seven trials, 18,949 women; high-quality evidence); early or late miscarriage (RR 0.90, 95% CI 0.65 to 1.26, four trials, 13,346 women; moderate-quality evidence); stillbirth (RR 1.31, 95% CI 0.97 to 1.76, seven trials, 21,442 women; moderate-quality evidence) or adverse effects of vitamin supplementation (RR 1.16, 95% CI 0.39 to 3.41, one trial, 739 women; moderate-quality evidence) between women receiving vitamin C with vitamin E compared with placebo or no vitamin C groups. No clear differences were seen in the risk of total fetal loss or miscarriage between women receiving any other combination of vitamin C compared with placebo or no vitamin C groups. Vitamin A supplementation No difference was found in the risk of total fetal loss (RR 1.01, 95% CI 0.61 to 1.66, three trials, 1640 women; low-quality evidence); early or late miscarriage (RR 0.86, 95% CI 0.46 to 1.62, two trials, 1397 women; low-quality evidence) or stillbirth (RR 1.29, 95% CI 0.57 to 2.91, three trials, 1640 women; low-quality evidence) between women receiving vitamin A plus iron and folate compared with placebo or no vitamin A groups. There was no evidence of differences in the risk of total fetal loss or miscarriage between women receiving any other combination of vitamin A compared with placebo or no vitamin A groups. Multivitamin supplementation There was evidence of a decrease in the risk for stillbirth among women receiving multivitamins plus iron and folic acid compared iron and folate only groups (RR 0.92, 95% CI 0.85 to 0.99, 10 trials, 79,851 women; high-quality evidence). Although total fetal loss was lower in women who were given multivitamins without folic acid (RR 0.49, 95% CI 0.34 to 0.70, one trial, 907 women); and multivitamins with or without vitamin A (RR 0.60, 95% CI 0.39 to 0.92, one trial, 1074 women), these findings included one trial each with small numbers of women involved. Also, they include studies where the comparison groups included women receiving either vitamin A or placebo, and thus require caution in interpretation.We found no difference in the risk of total fetal loss (RR 0.96, 95% CI 0.93 to 1.00, 10 trials, 94,948 women; high-quality evidence) or early or late miscarriage (RR 0.98, 95% CI 0.94 to 1.03, 10 trials, 94,948 women; moderate-quality evidence) between women receiving multivitamins plus iron and folic acid compared with iron and folate only groups.There was no evidence of differences in the risk of total fetal loss or miscarriage between women receiving any other combination of multivitamins compared with placebo, folic acid or vitamin A groups. Folic acid supplementation There was no evidence of any difference in the risk of total fetal loss, early or late miscarriage, stillbirth or congenital malformations between women supplemented with folic acid with or without multivitamins and/or iron compared with no folic acid groups. Antioxidant vitamins supplementation There was no evidence of differences in early or late miscarriage between women given antioxidant compared with the low antioxidant group (RR 1.12, 95% CI 0.24 to 5.29, one trial, 110 women). AUTHORS' CONCLUSIONS Taking any vitamin supplements prior to pregnancy or in early pregnancy does not prevent women experiencing miscarriage. However, evidence showed that women receiving multivitamins plus iron and folic acid had reduced risk for stillbirth. There is insufficient evidence to examine the effects of different combinations of vitamins on miscarriage and miscarriage-related outcomes.
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Affiliation(s)
- Olukunmi O Balogun
- National Center for Child Health and DevelopmentDepartment of Health PolicyMedical Building No. 2, Hongo Campus2‐10‐1 OkuraTokyoTokyoJapan157‐8535
| | - Katharina da Silva Lopes
- National Center for Child Health and DevelopmentDepartment of Health PolicyMedical Building No. 2, Hongo Campus2‐10‐1 OkuraTokyoTokyoJapan157‐8535
| | - Erika Ota
- St. Luke's International University, Graduate School of Nursing SciencesGlobal Health Nursing10‐1 Akashi‐choChuo‐KuTokyoJapan104‐0044
| | - Yo Takemoto
- National Research Institute for Child Health and Development2‐10‐1 Okura, Setagaya‐kuTokyo157‐8535Japan
| | - Alice Rumbold
- The University of AdelaideThe Robinson Research InstituteGround Floor, Norwich Centre55 King William RoadAdelaideNTAustraliaSA 5006
| | - Mizuki Takegata
- National Center for Child Health and DevelopmentDepartment of Health PolicyMedical Building No. 2, Hongo Campus2‐10‐1 OkuraTokyoTokyoJapan157‐8535
| | - Rintaro Mori
- National Center for Child Health and DevelopmentDepartment of Health PolicyMedical Building No. 2, Hongo Campus2‐10‐1 OkuraTokyoTokyoJapan157‐8535
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Gernand AD, Schulze KJ, Stewart CP, West KP, Christian P. Micronutrient deficiencies in pregnancy worldwide: health effects and prevention. Nat Rev Endocrinol 2016; 12:274-89. [PMID: 27032981 PMCID: PMC4927329 DOI: 10.1038/nrendo.2016.37] [Citation(s) in RCA: 323] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Micronutrients, vitamins and minerals accessible from the diet, are essential for biologic activity. Micronutrient status varies widely throughout pregnancy and across populations. Women in low-income countries often enter pregnancy malnourished, and the demands of gestation can exacerbate micronutrient deficiencies with health consequences for the fetus. Examples of efficacious single micronutrient interventions include folic acid to prevent neural tube defects, iodine to prevent cretinism, zinc to reduce risk of preterm birth, and iron to reduce the risk of low birth weight. Folic acid and vitamin D might also increase birth weight. While extensive mechanistic and association research links multiple antenatal micronutrients with plausible materno-fetal health advantages, hypothesized benefits have often been absent, minimal or unexpected in trials. These findings suggest a role for population context in determining health responses and filling extensive gaps in knowledge. Multiple micronutrient supplements reduce the risks of being born with low birth weight, small for gestational age or stillborn in undernourished settings, and justify micronutrient interventions with antenatal care. Measurable health effects of gestational micronutrient exposure might persist into childhood but few data exists on potential long-term benefits. In this Review, we discuss micronutrient intake recommendations, risks and consequences of deficiencies, and the effects of interventions with a particular emphasis on offspring.
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Affiliation(s)
- Alison D Gernand
- Department of Nutritional Sciences, The Pennsylvania State University, 110 Chandlee Laboratory, University Park, Pennsylvania 16802, USA
| | - Kerry J Schulze
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, Maryland 21205, USA
| | - Christine P Stewart
- Department of Nutrition, One Shields Avenue, University of California, Davis, California 95616, USA
| | - Keith P West
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, Maryland 21205, USA
| | - Parul Christian
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, Maryland 21205, USA
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Morton JS, Cooke CL, Davidge ST. In Utero Origins of Hypertension: Mechanisms and Targets for Therapy. Physiol Rev 2016; 96:549-603. [DOI: 10.1152/physrev.00015.2015] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The developmental origins of health and disease theory is based on evidence that a suboptimal environment during fetal and neonatal development can significantly impact the evolution of adult-onset disease. Abundant evidence exists that a compromised prenatal (and early postnatal) environment leads to an increased risk of hypertension later in life. Hypertension is a silent, chronic, and progressive disease defined by elevated blood pressure (>140/90 mmHg) and is strongly correlated with cardiovascular morbidity/mortality. The pathophysiological mechanisms, however, are complex and poorly understood, and hypertension continues to be one of the most resilient health problems in modern society. Research into the programming of hypertension has proposed pharmacological treatment strategies to reverse and/or prevent disease. In addition, modifications to the lifestyle of pregnant women might impart far-reaching benefits to the health of their children. As more information is discovered, more successful management of hypertension can be expected to follow; however, while pregnancy complications such as fetal growth restriction, preeclampsia, preterm birth, etc., continue to occur, their offspring will be at increased risk for hypertension. This article reviews the current knowledge surrounding the developmental origins of hypertension, with a focus on mechanistic pathways and targets for therapeutic and pharmacologic interventions.
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Affiliation(s)
- Jude S. Morton
- Departments of Obstetrics and Gynaecology and of Physiology, University of Alberta, Edmonton, Canada; Women and Children's Health Research Institute, Edmonton, Canada; and Cardiovascular Research Centre, Edmonton, Canada
| | - Christy-Lynn Cooke
- Departments of Obstetrics and Gynaecology and of Physiology, University of Alberta, Edmonton, Canada; Women and Children's Health Research Institute, Edmonton, Canada; and Cardiovascular Research Centre, Edmonton, Canada
| | - Sandra T. Davidge
- Departments of Obstetrics and Gynaecology and of Physiology, University of Alberta, Edmonton, Canada; Women and Children's Health Research Institute, Edmonton, Canada; and Cardiovascular Research Centre, Edmonton, Canada
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Dubey DK, Nath DC. An Epidemiological Model Investigating the Association between Mothers Nutritional Status and Low Birth Weight in India. Health (London) 2016. [DOI: 10.4236/health.2016.83027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
BACKGROUND Multiple-micronutrient (MMN) deficiencies often coexist among women of reproductive age in low- to middle-income countries. They are exacerbated in pregnancy due to the increased demands, leading to potentially adverse effects on the mother and developing fetus. Though supplementation with MMNs has been recommended earlier because of the evidence of impact on pregnancy outcomes, a consensus is yet to be reached regarding the replacement of iron and folic acid supplementation with MMNs. Since the last update of this Cochrane review, evidence from a few large trials has recently been made available, the inclusion of which is critical to inform policy. OBJECTIVES To evaluate the benefits of oral multiple-micronutrient supplementation during pregnancy on maternal, fetal and infant health outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (11 March 2015) and reference lists of retrieved articles and key reviews. We also contacted experts in the field for additional and ongoing trials. SELECTION CRITERIA All prospective randomised controlled trials evaluating MMN supplementation during pregnancy and its effects on the pregnancy outcome were eligible, irrespective of language or the publication status of the trials. We included cluster-randomised trials, but quasi-randomised trials were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach. MAIN RESULTS Nineteen trials (involving 138,538 women) were identified as eligible for inclusion in this review but only 17 trials (involving 137,791 women) contributed data to the review. Fifteen of these 17 trials were carried out in low and middle-income countries and compared MMN supplements with iron and folic acid versus iron with or without folic acid. Two trials carried out in the UK compared MMN with a placebo. MMN with iron and folic acid versus iron, with or without folic acid (15 trials): MMN resulted in a significant decrease in the number of newborn infants identified as low birthweight (LBW) (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.85 to 0.91; high-quality evidence) or small-for-gestational age (SGA) (average RR 0.90, 95% CI 0.83 to 0.97; moderate-quality evidence), and a reduced rate of stillbirth (RR 0.91, 95% CI 0.85 to 0.98; high-quality evidence). No significant differences were shown for other maternal and pregnancy outcomes: preterm births (RR 0.96, 95% CI 0.89 to 1.03; high-quality evidence), maternal anaemia in the third trimester (RR 0.97, 95% CI 0.86 to 1.10), miscarriage (RR 0.89, 95% CI 0.78 to 1.01), maternal mortality (RR 0.97, 95% CI 0.63 to 1.48), perinatal mortality (RR 0.97, 95% CI 0.84 to 1.12; high-quality evidence), neonatal mortality (RR 0.98, 95% CI 0.90 to 1.07; high -quality evidence), or risk of delivery via a caesarean section (RR 1.03; 95% CI 0.75 to 1.43).A number of prespecified, clinically important outcomes could not be assessed due to insufficient or non-available data. Single trials reported results for: very preterm birth < 34 weeks, macrosomia, side-effects of supplements, nutritional status of children, and congenital anomalies including neural tube defects and neurodevelopmental outcome: Bayley Scales of Infant Development (BSID) scores. None of these trials reported pre-eclampsia, placental abruption, premature rupture of membranes, cost of supplementation, and maternal well-being or satisfaction.When assessed according to GRADE criteria, the quality of evidence for the review's primary outcomes overall was good. Pooled results for primary outcomes were based on multiple trials with large sample sizes and precise estimates. The following outcomes were graded to be as of high quality: preterm birth, LBW, perinatal mortality, stillbirth and neonatal mortality. The outcome of SGA was graded to be of moderate quality, with evidence downgraded by one for funnel plot asymmetry and potential publication bias.We carried out sensitivity analysis excluding trials with high levels of sample attrition (> 20%); results were consistent with the main analysis. We explored heterogeneity through subgroup analysis by maternal height and body mass index (BMI), timing of supplementation and dose of iron. Subgroup differences were observed for maternal BMI and timing of supplementation for the outcome preterm birth, with significant findings among women with low BMI and with earlier initiation of supplementation in the prenatal period. Subgroup differences were also observed for maternal BMI, maternal height and dose of iron for the outcome SGA, indicating a significant impact among women with higher maternal BMI and height, and with MMN supplement containing 30 mg of iron versus control receiving 60 mg of iron. The findings between subgroups for other primary outcomes were inconclusive. MMN versus placebo (two trials): A single trial in the UK found no clear differences between groups for preterm birth, SGA, LBW or maternal anaemia in the third trimester. A second trial reported the number of women with pre-eclampsia; there was no evidence of a difference between groups. Other outcomes were not reported. AUTHORS' CONCLUSIONS Our findings support the effect of MMN supplements with iron and folic acid in improving birth outcomes. The findings, consistently observed in several systematic evaluations of evidence, provide a strong basis to guide the replacement of iron and folic acid with MMN supplements containing iron and folic acid for pregnant women in developing countries where MMN deficiencies are common among women of reproductive age. Efforts should be focused on the integration of this intervention in maternal nutrition and antenatal care programs in developing countries.
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Affiliation(s)
- Batool A Haider
- Harvard School of Public HealthDepartment of Global Health and Population677 Huntington AvenueBostonUSA02115
| | - Zulfiqar A Bhutta
- Hospital for Sick ChildrenCentre for Global Child HealthTorontoCanadaM5G A04
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Abstract
A developmental approach to public health focuses attention on better nourishing girls and young women, especially those of low socio-economic status, to improve mothers' nutrition and thereby the health of future generations. There have been significant advances in the behavioural sciences that may allow us to understand and support dietary change in young women and their children in ways that have not previously been possible. This paper describes some of these advances and aims to show how they inform this new approach to public health. The first of these has been to work out what is effective in supporting behaviour change, which has been achieved by careful and detailed analysis of behaviour change techniques used by practitioners in intervention, and of the effectiveness of these in supporting change. There is also a new understanding of the role that social and physical environments play in shaping our behaviours, and that behaviour is influenced by automatic processes and 'habits' as much as by reflective processes and rational decisions. To be maximally effective, interventions therefore have to address both influences on behaviour. An approach developed in Southampton aims to motivate, support and empower young women to make better food choices, but also to change the culture in which those choices are being made. Empowerment is the basis of the new public health. An empowered public demand for better access to better food can go a long way towards improving maternal, infant and family nutrition, and therefore the health of generations to come.
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Ota E, Hori H, Mori R, Tobe-Gai R, Farrar D. Antenatal dietary education and supplementation to increase energy and protein intake. Cochrane Database Syst Rev 2015:CD000032. [PMID: 26031211 DOI: 10.1002/14651858.cd000032.pub3] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Gestational weight gain is positively associated with fetal growth, and observational studies of food supplementation in pregnancy have reported increases in gestational weight gain and fetal growth. OBJECTIVES To assess the effects of education during pregnancy to increase energy and protein intake, or of actual energy and protein supplementation, on energy and protein intake, and the effect on maternal and infant health outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015), reference lists of retrieved studies and contacted researchers in the field. SELECTION CRITERIA Randomised controlled trials of dietary education to increase energy and protein intake, or of actual energy and protein supplementation, during pregnancy. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors independently extracted data and checked for accuracy. Extracted data were supplemented by additional information from the trialists we contacted. MAIN RESULTS We examined 149 reports corresponding to 65 trials. Of these trials, 17 were included, 46 were excluded, and two are ongoing. Overall, 17 trials involving 9030 women were included. For this update, we assessed methodological quality of the included trials using the standard Cochrane criteria (risk of bias) and the GRADE approach. The overall risk of bias was unclear. Nutritional education (five trials, 1090 women) Women given nutritional education had a lower relative risk of having a preterm birth (two trials, 449 women) (risk ratio (RR) 0.46, 95% CI 0.21 to 0.98, low-quality evidence), and low birthweight (one trial, 300 women) (RR 0.04, 95% CI 0.01 to 0.14). Head circumference at birth was increased in one trial (389 women) (mean difference (MD) 0.99 cm, 95% CI 0.43 to 1.55), while birthweight was significantly increased among undernourished women in two trials (320 women) (MD 489.76 g, 95% CI 427.93 to 551.59, low-quality evidence), but did not significantly increase for adequately nourished women (MD 15.00, 95% CI -76.30 to 106.30, one trial, 406 women). Protein intake increased significantly (three trials, 632 women) (protein intake: MD +6.99 g/day, 95% CI 3.02 to 10.97). No significant differences were observed on any other outcomes such as neonatal death (RR 1.28, 95% CI 0.35 to 4.72, one trial, 448 women, low-quality evidence), stillbirth (RR 0.37, 95% CI 0.07 to 1.90, one trial, 431 women, low-quality evidence), small-for-gestational age (RR 0.97, 95% CI 0.45 to 2.11, one trial, 404 women, low-quality evidence) and total gestational weight gain (MD -0.41, 95% CI -4.41 to 3.59, two trials, 233 women). There were no data on perinatal death. Balanced energy and protein supplementation (12 trials, 6705 women)Risk of stillbirth was significantly reduced for women given balanced energy and protein supplementation (RR 0.60, 95% CI 0.39 to 0.94, five trials, 3408 women, moderate-quality evidence), and the mean birthweight was significantly increased (random-effects MD +40.96 g, 95% CI 4.66 to 77.26, Tau² = 1744, I² = 44%, 11 trials, 5385 women, moderate-quality evidence). There was also a significant reduction in the risk of small-for-gestational age (RR 0.79, 95% CI 0.69 to 0.90, I² = 16%, seven trials, 4408 women, moderate-quality evidence). No significant effect was detected for preterm birth (RR 0.96, 95% CI 0.80 to 1.16, five trials, 3384 women, moderate-quality evidence) or neonatal death (RR 0.68, 95% CI 0.43 to 1.07, five trials, 3381 women, low-quality evidence). Weekly gestational weight gain was not significantly increased (MD 18.63, 95% CI -1.81 to 39.07, nine trials, 2391 women, very low quality evidence). There were no data reported on perinatal death and low birthweight. High-protein supplementation (one trial, 1051 women)High-protein supplementation (one trial, 505 women), was associated with a significantly increased risk of small-for-gestational age babies (RR 1.58, 95% CI 1.03 to 2.41, moderate-quality evidence). There was no significant effect for stillbirth (RR 0.81, 95% CI 0.31 to 2.15, one trial, 529 women), neonatal death (RR 2.78, 95% CI 0.75 to 10.36, one trial, 529 women), preterm birth (RR 1.14, 95% CI 0.83 to 1.56, one trial, 505 women), birthweight (MD -73.00, 95% CI -171.26 to 25.26, one trial, 504 women) and weekly gestational weight gain (MD 4.50, 95% CI -33.55 to 42.55, one trial, 486 women, low-quality evidence). No data were reported on perinatal death. Isocaloric protein supplementation (two trials, 184 women)Isocaloric protein supplementation (two trials, 184 women) had no significant effect on birthweight (MD 108.25, 95% CI -220.89 to 437.40) and weekly gestational weight gain (MD 110.45, 95% CI -82.87 to 303.76, very low-quality evidence). No data reported on perinatal mortality, stillbirth, neonatal death, small-for-gestational age, and preterm birth. AUTHORS' CONCLUSIONS This review provides encouraging evidence that antenatal nutritional education with the aim of increasing energy and protein intake in the general obstetric population appears to be effective in reducing the risk of preterm birth, low birthweight, increasing head circumference at birth, increasing birthweight among undernourished women, and increasing protein intake. There was no evidence of benefit or adverse effect for any other outcome reported.Balanced energy and protein supplementation seems to improve fetal growth, and may reduce the risk of stillbirth and infants born small-for-gestational age. High-protein supplementation does not seem to be beneficial and may be harmful to the fetus. Balanced-protein supplementation alone had no significant effects on perinatal outcomes.The results of this review should be interpreted with caution. The risk of bias was either unclear or high for at least one category examined in several of the included trials, and the quality of the evidence was low for several important outcomes. Also, as the anthropometric characteristics of the general obstetric population is changing, those developing interventions aimed at altering energy and protein intake should ensure that only those women likely to benefit are included. Large, well-designed randomised trials are needed to assess the effects of increasing energy and protein intake during pregnancy in women whose intake is below recommended levels.
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Affiliation(s)
- Erika Ota
- Department of Health Policy, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan, 157-8535
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