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Nkhoma M, Ashorn P, Ashorn U, Dewey KG, Gondwe A, Maleta K. Lipid based nutrient supplements during pregnancy may improve foetal growth in HIV infected women - A cohort study. PLoS One 2019; 14:e0215760. [PMID: 31048878 PMCID: PMC6497372 DOI: 10.1371/journal.pone.0215760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 04/07/2019] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES Both maternal HIV infection and antiretroviral therapy are associated with adverse birth outcomes. The role of antenatal nutrient supplements with regard to adverse birth outcomes in HIV infected women exposed to antiretroviral therapy is not well known. We assessed the association between HIV and birth outcomes and explored whether antenatal lipid-based nutrient supplements (LNS) modulated this association. METHODS We analysed a nested cohort of pregnant Malawian women who received daily LNS, multiple micronutrients (MMN) or iron and folic acid (IFA). Birth weight, length-for-age z-score (LAZ) and weight-for-age z-score (WAZ) were analysed as continuous outcomes and proportion of stunting and small-for-gestational age (SGA) as dichotomous outcomes. RESULTS 134 HIV infected (46 LNS, 39 MMN, 49 IFA) and 833 HIV uninfected (271 LNS, 287 MMN, 275 IFA) women were included. Maternal HIV infection was associated with a lower mean birth weight (-129g (-209, -48), P = 0.002); LAZ (-0.34 (-0.54, -0.13), P = 0.002) and WAZ (-0.21 (-0.40, -0.02), P = 0.041) and a higher risk of stunting (RR (95% confidence interval), 1.87 (1.24, 2.83), P = 0.003) and SGA (1.66 (1.21, 2.26), P = 0.001) in the newborn. If the women received LNS, HIV was not associated with LAZ (mean difference (95%); -0.02 (-0.35, 0.31), P = 0.918) or newborn stunting (RR (95% CI), 0.84 (0.34, 2.03), P = 0.691). However HIV tended to be associated with LAZ if the women received MMN (-0.42 (-0.80, -0.03), P = 0.053); and was significantly associated with LAZ if the women received IFA (-0.52 (-0.89, -0.14), P = 0.021) and with newborn stunting if they received MMN (2.40 (1.15, 4.98), P = 0.029) or IFA (2.40 (1.26, 4.59), P = 0.024). CONCLUSIONS Further research to investigate the impact of LNS on various aspects of foetal growth in HIV infected women is warranted.
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Affiliation(s)
- Minyanga Nkhoma
- Centre for Child Health Research, Faculty of Medicine and Health Technology, Tampere, University, Tampere, Finland
| | - Per Ashorn
- Centre for Child Health Research, Faculty of Medicine and Health Technology, Tampere, University, Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Ulla Ashorn
- Centre for Child Health Research, Faculty of Medicine and Health Technology, Tampere, University, Tampere, Finland
| | - Kathryn G. Dewey
- Department of Nutrition, University of California Davis, Davis, California, United States of America
| | - Austrida Gondwe
- Centre for Child Health Research, Faculty of Medicine and Health Technology, Tampere, University, Tampere, Finland
| | - Kenneth Maleta
- School of Public Health and Family Medicine, University of Malawi College of Medicine, Blantyre, Malawi
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Das JK, Salam RA, Hadi YB, Sadiq Sheikh S, Bhutta AZ, Weise Prinzo Z, Bhutta ZA. Preventive lipid-based nutrient supplements given with complementary foods to infants and young children 6 to 23 months of age for health, nutrition, and developmental outcomes. Cochrane Database Syst Rev 2019; 5:CD012611. [PMID: 31046132 PMCID: PMC6497129 DOI: 10.1002/14651858.cd012611.pub3] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND One nutritional intervention advocated to prevent malnutrition among children is lipid-based nutrient supplements (LNS). LNS provide a range of vitamins and minerals, but unlike most other micronutrient supplements, LNS also provide energy, protein and essential fatty acids. Alternative recipes and formulations to LNS include fortified blended foods (FBF), which are foods fortified with vitamins and minerals, and micronutrient powders (MNP), which are a combination of vitamins and minerals, OBJECTIVES: To assess the effects and safety of preventive LNS given with complementary foods on health, nutrition and developmental outcomes of non-hospitalised infants and children six to 23 months of age, and whether or not they are more effective than other foods (including FBF or MNP).This review did not assess the effects of LNS as supplementary foods or therapeutic foods in the management of moderate and severe acute malnutrition. SEARCH METHODS In October 2018, we searched CENTRAL, MEDLINE, Embase, 21 other databases and two trials registers for relevant studies. We also checked the reference lists of included studies and relevant reviews and contacted the authors of studies and other experts in the area for any ongoing and unpublished studies. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs that evaluated the impact of LNS plus complementary foods given at point-of-use (for any dose, frequency, duration) to non-hospitalised infants and young children aged six to 23 months in stable or emergency settings and compared to no intervention, other supplementary foods (i.e. FBF), nutrition counselling or multiple micronutrient supplements or powders for point-of-use fortification of complementary foods. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies for relevance and, for those studies included in the review, extracted data, assessed risk of bias and rated the quality of the evidence using the GRADE approach. We carried out statistical analysis using Review Manager software. We used a random-effects meta-analysis for combining data as the interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables,. MAIN RESULTS Our search identified a total of 8124 records, from which we included 17 studies (54 papers) with 23,200 children in the review. The included studies reported on one or more of the pre-specified primary outcomes, and five studies included multiple comparison groups.Overall, the majority of trials were at low risk of bias for random sequence generation, allocation concealment, blinding of outcome assessment, incomplete outcome data, selective reporting and other sources of bias, but at high risk of bias for blinding of participants and personnel due to the nature of the intervention. Using the GRADE approach, we judged the quality of the evidence for most outcomes as low or moderate.LNS+complementary feeding compared with no intervention Thirteen studies compared LNS plus complementary feeding with no intervention. LNS plus complementary feeding reduced the prevalence of moderate stunting by 7% (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.88 to 0.98; nine studies, 13,372 participants; moderate-quality evidence), severe stunting by 15% (RR 0.85, 95% CI 0.74 to 0.98; five studies, 6151 participants; moderate-quality evidence), moderate wasting by 18% (RR 0.82, 95% CI 0.74 to 0.91; eight studies; 13,172 participants; moderate-quality evidence), moderate underweight by 15% (RR 0.85, 95% CI 0.80 to 0.91; eight studies, 13,073 participants; moderate-quality evidence), and anaemia by 21% (RR 0.79, 95% CI 0.69 to 0.90; five studies, 2332 participants; low-quality evidence). There was no impact of LNS plus complementary feeding on severe wasting (RR 1.27, 95% CI 0.66 to 2.46; three studies, 2329 participants) and severe underweight (RR 0.78, 95%CI 0.54 to 1.13; two studies, 1729 participants). Adverse effects did not differ between the groups (RR 0.86, 95% CI 0.74 to 1.01; three studies, 3382 participants).LNS+complementary feeding compared with FBF Five studies compared LNS plus complementary feeding with other FBF, including corn soy blend and UNIMIX. We pooled four of the five studies in meta-analyses and found that, when compared to other FBF, LNS plus complementary feeding significantly reduced the prevalence of moderate stunting (RR 0.89, 95% CI 0.82 to 0.97; three studies, 2828 participants; moderate-quality evidence), moderate wasting (RR 0.79, 95% CI 0.65 to 0.97; two studies, 2290 participants; moderate-quality evidence), and moderate underweight (RR 0.81, 95% CI 0.73 to 0.91; two studies, 2280 participants; moderate-quality evidence). We found no difference between LNS plus complementary feeding and FBF for severe stunting (RR 0.41, 95% CI 0.12 to 1.42; two studies, 729 participants; low-quality evidence), severe wasting (RR 0.64, 95% CI 0.19 to 2.81; two studies, 735 participants; moderate-quality evidence), and severe underweight (RR 1.23, 95% CI 0.67 to 2.25; one study, 173 participants; low-quality evidence).LNS+complementary feeding compared with MNP Four studies compared LNS plus complementary feeding with MNP. We pooled data from three of the four studies in meta-analyses and found that compared to MNP, LNS plus complementary feeding significantly reduced the prevalence of moderate underweight (RR 0.88, 95% CI 0.78 to 0.99; two studies, 2004 participants; moderate-quality evidence) and anaemia (RR 0.38, 95% CI 0.21 to 0.68; two studies, 557 participants; low-quality evidence). There was no difference between LNS plus complementary feeding and MNP for moderate stunting (RR 0.92, 95% CI 0.82 to 1.02; three studies, 2365 participants) and moderate wasting (RR 0.97, 95% CI 0.77 to 1.23; two studies, 2004 participants). AUTHORS' CONCLUSIONS The findings of this review suggest that LNS plus complementary feeding compared to no intervention is effective at improving growth outcomes and anaemia without adverse effects among children aged six to 23 months in low- and middle-income countries (LMIC) in Asia and Africa, and more effective if provided over a longer duration of time (over 12 months). Limited evidence also suggests that LNS plus complementary feeding is more effective than FBF and MNP at improving growth outcomes.
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Affiliation(s)
- Jai K Das
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiSindPakistan
| | - Rehana A Salam
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiSindPakistan
| | - Yousaf Bashir Hadi
- West Virginia UniversityDepartment of Internal Medicine1 Medical Center DriveMorgantownWest VirginiaUSA26506
| | - Sana Sadiq Sheikh
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiSindPakistan
| | - Afsah Z Bhutta
- Dow University of Health SciencesKarachiSindhPakistan75500
| | - Zita Weise Prinzo
- World Health OrganizationDepartment of Nutrition for Health and DevelopmentAvenue Appia 20GenevaGESwitzerland1211
| | - Zulfiqar A Bhutta
- The Hospital for Sick ChildrenCentre for Global Child HealthTorontoCanada
- Aga Khan University HospitalCenter for Excellence in Women and Child HealthKarachiPakistan
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Bourassa MW, Osendarp SJ, Adu‐Afarwuah S, Ahmed S, Ajello C, Bergeron G, Black R, Christian P, Cousens S, de Pee S, Dewey KG, Arifeen SE, Engle‐Stone R, Fleet A, Gernand AD, Hoddinott J, Klemm R, Kraemer K, Kupka R, McLean E, Moore SE, Neufeld LM, Persson L, Rasmussen KM, Shankar AH, Smith E, Sudfeld CR, Udomkesmalee E, Vosti SA. Review of the evidence regarding the use of antenatal multiple micronutrient supplementation in low- and middle-income countries. Ann N Y Acad Sci 2019; 1444:6-21. [PMID: 31134643 PMCID: PMC6852202 DOI: 10.1111/nyas.14121] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/26/2019] [Accepted: 04/26/2019] [Indexed: 12/22/2022]
Abstract
Inadequate micronutrient intakes are relatively common in low- and middle-income countries (LMICs), especially among pregnant women, who have increased micronutrient requirements. This can lead to an increase in adverse pregnancy and birth outcomes. This review presents the conclusions of a task force that set out to assess the prevalence of inadequate micronutrient intakes and adverse birth outcomes in LMICs; the data from trials comparing multiple micronutrient supplements (MMS) that contain iron and folic acid (IFA) with IFA supplements alone; the risks of reaching the upper intake levels with MMS; and the cost-effectiveness of MMS compared with IFA. Recent meta-analyses demonstrate that MMS can reduce the risks of preterm birth, low birth weight, and small for gestational age in comparison with IFA alone. An individual-participant data meta-analysis also revealed even greater benefits for anemic and underweight women and female infants. Importantly, there was no increased risk of harm for the pregnant women or their infants with MMS. These data suggest that countries with inadequate micronutrient intakes should consider supplementing pregnant women with MMS as a cost-effective method to reduce the risk of adverse birth outcomes.
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Affiliation(s)
| | - Saskia J.M. Osendarp
- Osendarp NutritionBerkel & Rodenrijsthe Netherlands
- Division of Human Nutrition and HealthWageningen UniversityWageningenthe Netherlands
| | - Seth Adu‐Afarwuah
- Department of Nutrition and Food ScienceUniversity of GhanaLegonAccraGhana
| | - Saima Ahmed
- The New York Academy of SciencesNew YorkNew York
| | - Clayton Ajello
- The Vitamin Angels Alliance, Inc.Santa BarbaraCalifornia
| | | | - Robert Black
- Johns Hopkins Bloomberg School of Public HealthBaltimoreMaryland
| | - Parul Christian
- Johns Hopkins Bloomberg School of Public HealthBaltimoreMaryland
- Bill & Melinda Gates FoundationSeattleWashington
| | - Simon Cousens
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Saskia de Pee
- Division of Human Nutrition and HealthWageningen UniversityWageningenthe Netherlands
- UN World Food ProgrammeRomeItaly
- Friedman School of Nutrition Science and PolicyTufts UniversityBostonMassachusetts
| | - Kathryn G. Dewey
- Department of NutritionUniversity of CaliforniaDavisDavisCalifornia
| | - Shams El Arifeen
- International Centre for Diarrhoeal Disease ResearchDhakaBangladesh
| | | | | | | | - John Hoddinott
- Division of Nutritional SciencesCornell UniversityIthacaNew York
| | - Rolf Klemm
- The Vitamin Angels Alliance, Inc.Santa BarbaraCalifornia
- Helen Keller InternationalBaltimoreMaryland
| | | | | | | | - Sophie E. Moore
- Department of Women and Children's HealthKing's College LondonLondonUnited Kingdom
| | | | - Lars‐Åke Persson
- London School of Hygiene and Tropical MedicineAddis AbabaEthiopia
| | | | - Anuraj H. Shankar
- Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMassachusetts
- Summit Institute of DevelopmentMataramIndonesia
| | - Emily Smith
- Bill & Melinda Gates FoundationSeattleWashington
- Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMassachusetts
| | - Christopher R. Sudfeld
- Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMassachusetts
| | | | - Stephen A. Vosti
- Department of NutritionUniversity of CaliforniaDavisDavisCalifornia
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54
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Townsend R, Sileo F, Stocker L, Kumbay H, Healy P, Gordijn S, Ganzevoort W, Beune I, Baschat A, Kenny L, Bloomfield F, Daly M, Devane D, Papageorghiou A, Khalil A. Variation in outcome reporting in randomized controlled trials of interventions for prevention and treatment of fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:598-608. [PMID: 30523658 DOI: 10.1002/uog.20189] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/13/2018] [Accepted: 11/22/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Although fetal growth restriction (FGR) is well known to be associated with adverse outcomes for the mother and offspring, effective interventions for the management of FGR are yet to be established. Trials reporting interventions for the prevention and treatment of FGR may be limited by heterogeneity in the underlying pathophysiology. The aim of this study was to conduct a systematic review of outcomes reported in randomized controlled trials (RCTs) assessing interventions for the prevention or treatment of FGR, in order to identify and categorize the variation in outcome reporting. METHODS MEDLINE, EMBASE and The Cochrane Library were searched from inception until August 2018 for RCTs investigating therapies for the prevention and treatment of FGR. Studies were assessed systematically and data on outcomes that were reported in the included studies were extracted and categorized. The methodological quality of the included studies was assessed using the Jadad score. RESULTS The search identified 2609 citations, of which 153 were selected for full-text review and 72 studies (68 trials) were included in the final analysis. There were 44 trials relating to the prevention of FGR and 24 trials investigating interventions for the treatment of FGR. The mean Jadad score of all studies was 3.07, and only nine of them received a score of 5. We identified 238 outcomes across the included studies. The most commonly reported were birth weight (88.2%), gestational age at birth (72.1%) and small-for-gestational age (67.6%). Few studies reported on any measure of neonatal morbidity (27.9%), while adverse effects of the interventions were reported in only 17.6% of trials. CONCLUSIONS There is significant variation in outcome reporting across RCTs of therapies for the prevention and treatment of FGR. The clinical applicability of future research would be enhanced by the development of a core outcome set for use in future trials. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Townsend
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - F Sileo
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - L Stocker
- Women and Children Division, University Hospital Southampton NHS Foundation Trust, Princess Anne Hospital, Southampton, UK
| | - H Kumbay
- GKT School of Medicine, King's College, London, UK
| | - P Healy
- Health Research Board - Trials Methodology Research Network, Galway, Ireland
- School of Nursing and Midwifery, NUI Galway, Galway, Ireland
| | - S Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - W Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - I Beune
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A Baschat
- Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - L Kenny
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - F Bloomfield
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - M Daly
- Advocacy and Policymaking, Irish Neonatal Health Alliance, Wicklow, Ireland
| | - D Devane
- Health Research Board - Trials Methodology Research Network, Galway, Ireland
- School of Nursing and Midwifery, NUI Galway, Galway, Ireland
| | - A Papageorghiou
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Nuffield Department of Women's & Reproductive Health, University of Oxford, John Radcliffe Hospital Women's Centre, Oxford, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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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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56
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Oaks BM, Jorgensen JM, Baldiviez LM, Adu-Afarwuah S, Maleta K, Okronipa H, Sadalaki J, Lartey A, Ashorn P, Ashorn U, Vosti S, Allen LH, Dewey KG. Prenatal Iron Deficiency and Replete Iron Status Are Associated with Adverse Birth Outcomes, but Associations Differ in Ghana and Malawi. J Nutr 2019; 149:513-521. [PMID: 30629202 PMCID: PMC6398386 DOI: 10.1093/jn/nxy278] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 05/29/2018] [Accepted: 10/08/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Previous literature suggests a U-shaped relation between hemoglobin concentration and adverse birth outcomes. There is less evidence on associations between iron status and birth outcomes. OBJECTIVE Our objective was to determine the associations of maternal hemoglobin concentration and iron status with birth outcomes. METHODS We conducted a secondary data analysis of data from 2 cohorts of pregnant women receiving iron-containing nutritional supplements (20-60 mg ferrous sulfate) in Ghana (n = 1137) and Malawi (n = 1243). Hemoglobin concentration and 2 markers of iron status [zinc protoporphyrin and soluble transferrin receptor (sTfR)] were measured at ≤20 weeks and 36 weeks of gestation. We used linear and Poisson regression models and birth outcomes included preterm birth (PTB), newborn stunting, low birth weight (LBW), and small-for-gestational-age. RESULTS Prevalence of iron deficiency (sTfR >6.0 mg/L) at enrollment was 9% in Ghana and 20% in Malawi. In early pregnancy, iron deficiency was associated with PTB (9% compared with 17%, adjusted RR: 1.63; 95% CI: 1.14, 2.33) and stunting (15% compared with 23%, adjusted RR: 1.44; 95% CI: 1.09, 1.94) in Malawi but not Ghana, and was not associated with LBW in either country; replete iron status (sTfR <10th percentile) was associated with stunting (9% compared with 15%, adjusted RR: 1.71; 95% CI: 1.06, 2.77) in Ghana, but not PTB or LBW, and was not associated with any birth outcomes in Malawi. In late pregnancy, iron deficiency was not related to birth outcomes in either country and iron-replete status was associated with higher risk of LBW (8% compared with 16%, adjusted RR: 1.90; 95% CI: 1.17, 3.09) and stunting (6% compared with 13%, adjusted RR: 2.14; 95% CI: 1.21, 3.77) in Ghana, but was not associated with birth outcomes in Malawi. CONCLUSIONS The associations of low or replete iron status with birth outcomes are population specific. Research to replicate and extend these findings would be beneficial. These trials were registered at clinicaltrials.gov as NCT00970866 (Ghana) and NCT01239693 (Malawi).
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Affiliation(s)
- Brietta M Oaks
- Department of Nutrition and Food Sciences, University of Rhode Island, Kingston, RI,Address correspondence to BMO (e-mail: )
| | - Josh M Jorgensen
- Program in International and Community Nutrition, Department of Nutrition
| | - Lacey M Baldiviez
- USDA, Agricultural Research Service Western Human Nutrition Research Center, Davis, CA
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Ghana
| | - Ken Maleta
- Department of Community Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Harriet Okronipa
- Program in International and Community Nutrition, Department of Nutrition,Department of Nutrition and Food Science, University of Ghana, Legon, Ghana
| | - John Sadalaki
- Department of Community Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Anna Lartey
- Department of Nutrition and Food Science, University of Ghana, Legon, Ghana
| | - Per Ashorn
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Ulla Ashorn
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland,Center for Child Health Research, University of Tampere Faculty of Medicine and Life Sciences and Tampere University Hospital, Tampere, Finland
| | - Stephen Vosti
- Department of Agricultural and Resource Economics, University of California, Davis, CA
| | - Lindsay H Allen
- USDA, Agricultural Research Service Western Human Nutrition Research Center, Davis, CA
| | - Kathryn G Dewey
- Program in International and Community Nutrition, Department of Nutrition
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57
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Sudfeld CR, Smith ER. New Evidence Should Inform WHO Guidelines on Multiple Micronutrient Supplementation in Pregnancy. J Nutr 2019; 149:359-361. [PMID: 30773589 PMCID: PMC6398379 DOI: 10.1093/jn/nxy279] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/21/2018] [Accepted: 10/10/2018] [Indexed: 11/28/2022] Open
Abstract
Recent data from an individual patient data (IPD) meta-analysis of 17 randomized control trials including >100,000 women living in low- and middle-income countries found that multiple micronutrient supplementation (MMS) in pregnancy reduced the risk of low birth weight, preterm birth, and being born small for gestational age. Further, MMS reduced the risk of neonatal and infant mortality for females, and there was no evidence of increased risk among the 26 subgroups examined. The 2016 WHO antenatal care guidelines, which were released before the IPD meta-analysis, did not universally recommend MMS, noting: "There is some evidence of additional benefit … but there is also some evidence of risk." The guidelines suggest that MMS may increase the risk of neonatal mortality based on an exploratory subgroup analysis of 6 randomized trials. However, we identified several issues with this subgroup analysis. In this report we correct and update the subgroup analysis and show that there is no evidence that MMS increases the risk of neonatal mortality. There is growing scientific consensus that MMS containing iron and folic acid (IFA) is superior to IFA alone. The WHO guidelines currently state that "policy-makers in populations with a high prevalence of nutritional deficiencies might consider the benefits of MMN [multiple micronutrient] supplements on maternal health to outweigh the disadvantages, and may choose to give MMN supplements that include iron and folic acid." This equivocal guidance has created confusion about the best course of action for public health programs in low- and middle-income countries. Given the new evidence, WHO should review their statements regarding the potential neonatal mortality risks and re-evaluate the overall potential benefits of implementing MMS as a public health program.
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Affiliation(s)
- Christopher R Sudfeld
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA
| | - Emily R Smith
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA,Bill & Melinda Gates Foundation, Seattle, WA,Address correspondence to ERS (e-mail: )
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58
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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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59
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Caiafa K, Dewey KG, Michaelsen KF, de Pee S, Collins S, Rogers BL, El-Kour T, Walton S, Webb P. Food Aid for Nutrition: Narrative Review of Major Research Topics Presented at a Scientific Symposium Held October 21, 2017, at the 21st International Congress of Nutrition in Buenos Aires, Argentina. Food Nutr Bull 2019; 40:111-123. [DOI: 10.1177/0379572118817951] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Kristine Caiafa
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Kathryn G. Dewey
- Department of Nutrition, Program in International and Community Nutrition, University of California, Davis, Davis, CA, USA
| | - Kim F. Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark
| | - Saskia de Pee
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
- World Food Programme, Rome, Italy
- Human Nutrition, Wageningen University, Wageningen, The Netherlands
| | - Steve Collins
- Valid International, Oxford, UK
- Valid Nutrition, Cork, Republic of Ireland
| | | | | | - Shelley Walton
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
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60
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Barua P, Beeson JG, Maleta K, Ashorn P, Rogerson SJ. The impact of early life exposure to Plasmodium falciparum on the development of naturally acquired immunity to malaria in young Malawian children. Malar J 2019; 18:11. [PMID: 30658632 PMCID: PMC6339377 DOI: 10.1186/s12936-019-2647-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 01/12/2019] [Indexed: 11/23/2022] Open
Abstract
Background Antibodies targeting malaria blood-stage antigens are important targets of naturally acquired immunity, and may act as valuable biomarkers of malaria exposure. Methods Six-hundred and one young Malawian children from a randomized trial of prenatal nutrient supplementation with iron and folic acid or pre- and postnatal multiple micronutrients or lipid-based nutrient supplements were followed up weekly at home and febrile episodes were investigated for malaria from birth to 18 months of age. Antibodies were measured for 601 children against merozoite surface proteins (MSP1 19kD, MSP2), erythrocyte binding antigen 175 (EBA175), reticulocyte binding protein homologue 2 (Rh2A9), schizont extract and variant surface antigens expressed by Plasmodium falciparum-infected erythrocytes (IE) at 18 months of age. The antibody measurement data was related to concurrent malaria infection and to documented episodes of clinical malaria. Results At 18 months of age, antibodies were significantly higher among parasitaemic than aparasitaemic children. Antibody levels against MSP1 19kD, MSP2, schizont extract, and IE variant surface antigens were significantly higher in children who had documented episodes of malaria than in children who did not. Antibody levels did not differ between children with single or multiple malaria episodes before 18 months, nor between children who had malaria before 6 months of age or between 6 and 18 months. Conclusions Antibodies to merozoite and IE surface antigens increased following infection in early childhood, but neither age at first infection nor number of malaria episodes substantially affected antibody acquisition. These findings have implications for malaria surveillance during early childhood in the context of elimination. Trials registration Clinical Trials Registration: NCT01239693 (Date of registration: 11-10-2010). URL: http://www.ilins.org
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Affiliation(s)
- Priyanka Barua
- The Department of Medicine (RMH), Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, 3000, Australia.,Department of Zoology, University of Dhaka, Dhaka, 1000, Bangladesh
| | - James G Beeson
- The Department of Medicine (RMH), Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, 3000, Australia.,Burnet Institute, Melbourne, VIC, 3004, Australia.,Department of Microbiology and Central Clinical School, Monash University, Melbourne, VIC, 3800, Australia
| | - Kenneth Maleta
- School of Public Health and Family Medicine, University of Malawi, Blantyre 3, Malawi
| | - Per Ashorn
- Faculty of Medicine and Life Sciences, University of Tampere and Tampere University Hospital, 33100, Tampere, Finland.,Research and Development, Maternal, Newborn and Adolescent Health, World Health Organization, Geneva 27, 1211, Switzerland
| | - Stephen J Rogerson
- The Department of Medicine (RMH), Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, 3000, Australia.
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61
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Stewart RC, Ashorn P, Umar E, Dewey KG, Ashorn U, Creed F, Rahman A, Tomenson B, Prado EL, Maleta K. Associations between antenatal depression and neonatal outcomes in Malawi. MATERNAL AND CHILD NUTRITION 2018; 15:e12709. [PMID: 30426668 DOI: 10.1111/mcn.12709] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 09/17/2018] [Accepted: 09/20/2018] [Indexed: 01/05/2023]
Abstract
Studies from several low- and middle-income countries have shown that antenatal depression may be a risk factor for poor neonatal outcomes. However, those studies conducted in sub-Saharan Africa have not consistently demonstrated this association. We set out to investigate whether antenatal depression is associated with shorter duration of pregnancy and reduced newborn size in rural Malawi. Pregnant women recruited from four antenatal clinics to the International Lipid-Based Nutrient Supplements Project-DYAD-Malawi (iLiNS-DYAD-M) randomised controlled trial of nutrient supplementation were screened for antenatal depression in the second or third trimester using a locally validated version of the Self Reporting Questionnaire (SRQ). Outcomes were duration of pregnancy, birthweight, newborn length for age z-score (LAZ), head circumference z-score, and mid-upper arm circumference (MUAC). Other potential confounding factors and predictors of birth outcome were measured and adjusted for in the analysis. 1,391 women were enrolled to the trial. 1,006/1,391 (72.3%) of these women completed an SRQ and gave birth to a singleton infant whose weight was measured within 2 weeks of birth. 143/1,006 (14.2%) scored SRQ ≥ 8, indicating likely depression. Antenatal depression was not associated with birth weight, duration of pregnancy, newborn LAZ, or head-circumference Z-score. There was an inverse association with newborn MUAC (adjusted mean difference - 0.2 cm (95% CI -0.4 to 0, p = 0.021) the significance of which is unclear. The study was conducted within a randomised controlled trial of nutritional supplementation and there was a high proportion of missing data in some enrolment sites; this may have affected the validity of our findings.
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Affiliation(s)
- Robert C Stewart
- Department of Mental Health, College of Medicine, University of Malawi and Division of Psychiatry, University of Edinburgh, Edinburgh, UK
| | - Per Ashorn
- Centre for Child Health Research, University of Tampere Faculty of Medicine and Life Sciences, Tampere, Finland.,Department of Pediatrics, Tampere University Hospital, Tampere, Finland
| | - Eric Umar
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kathryn G Dewey
- Department of Nutrition, University of California, Davis, California, USA
| | - Ulla Ashorn
- Centre for Child Health Research, University of Tampere Faculty of Medicine and Life Sciences, Tampere, Finland
| | - Francis Creed
- Neuroscience and Mental Health, University of Manchester, UK
| | - Atif Rahman
- Institute of Psychology, Health and Society, University of Liverpool, UK
| | | | - Elizabeth L Prado
- Department of Nutrition, University of California, Davis, California, USA
| | - Ken Maleta
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
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62
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Gondwe A, Ashorn P, Ashorn U, Dewey KG, Maleta K, Nkhoma M, Mbotwa J, Jorgensen JM. Pre-pregnancy body mass index (BMI) and maternal gestational weight gain are positively associated with birth outcomes in rural Malawi. PLoS One 2018; 13:e0206035. [PMID: 30352100 PMCID: PMC6198955 DOI: 10.1371/journal.pone.0206035] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 10/03/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Whereas poor maternal nutritional status before and during pregnancy is widely associated with adverse birth outcomes, studies quantifying this association in low income countries are scarce. We examined whether maternal pre-pregnancy body mass index (BMI) and weight gain during pregnancy are associated with birth outcomes in rural Malawi. METHODS We analyzed the associations between pre-pregnancy BMI and average weekly gestational weight gain (WWG) and birth outcomes [duration of gestation, birth weight, length-for-age z-score (LAZ), and head circumference-for-age z-score (HCZ)]. We also determined whether women with low or high pre-pregnancy BMI or women with inadequate or excessive WWG were at increased risk of adverse birth outcomes. RESULTS The analyses included 1287 women with a mean BMI of 21.8 kg/m2, of whom 5.9% were underweight (< 18.5 kg/m2), 10.9% were overweight (≥ 25 kg/m2), 71.8% had low WWG [below the lower limit of the Institute of Medicine (IOM) recommendation], and 5.2% had high WWG (above IOM recommendation). In adjusted models, pre-pregnancy BMI was not associated with duration of pregnancy (p = 0.926), but was positively associated with birth weight and HCZ (<0.001 and p = 0.003, respectively). WWG was positively associated with duration of gestation (p = 0.031), birth weight (p<0.001), LAZ (p<0.001), and HCZ (p<0.001). Compared to normal weight women, underweight women were at increased risk of having stunted infants (p = 0.029). Women with low WWG were at increased risk of having infants with low birth weight (p = 0.006) and small head circumference (p = 0.024) compared to those with normal weight gain. Those with high BMI or high WWG were not at increased risk of adverse birth outcomes. CONCLUSIONS WWG is an important predictor of birth outcomes in rural Malawi. The high prevalence of inadequate WWG compared to low pre-pregnancy BMI highlights the need to investigate causes of inadequate weight gain in this region.
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Affiliation(s)
- Austrida Gondwe
- University of Tampere, Faculty of Medicine and Life Sciences, Centre for Child Health Research, Tampere, Finland
| | - Per Ashorn
- University of Tampere, Faculty of Medicine and Life Sciences, Centre for Child Health Research, Tampere, Finland
- Tampere University Hospital, Department of Paediatrics, Tampere, Finland
| | - Ulla Ashorn
- University of Tampere, Faculty of Medicine and Life Sciences, Centre for Child Health Research, Tampere, Finland
| | - Kathryn G. Dewey
- Department of Nutrition, University of California Davis, Davis, California, United States of America
| | - Kenneth Maleta
- University of Malawi College of Medicine, School of Public Health and Family Medicine, Blantyre, Malawi
| | - Minyanga Nkhoma
- University of Tampere, Faculty of Medicine and Life Sciences, Centre for Child Health Research, Tampere, Finland
| | - John Mbotwa
- University of Malawi College of Medicine, School of Public Health and Family Medicine, Blantyre, Malawi
| | - Josh M. Jorgensen
- Department of Nutrition, University of California Davis, Davis, California, United States of America
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63
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Jorgensen JM, Ashorn P, Ashorn U, Baldiviez LM, Gondwe A, Maleta K, Nkhoma M, Dewey KG. Effects of lipid-based nutrient supplements or multiple micronutrient supplements compared with iron and folic acid supplements during pregnancy on maternal haemoglobin and iron status. MATERNAL & CHILD NUTRITION 2018; 14:e12640. [PMID: 30047245 PMCID: PMC6175407 DOI: 10.1111/mcn.12640] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 05/17/2018] [Accepted: 05/22/2018] [Indexed: 12/20/2022]
Abstract
We examined the effect of three types of prenatal supplements containing different amounts of iron on haemoglobin (Hb) and iron status (zinc protoporphyrin [ZPP] and soluble transferrin receptor [sTfR]) in late pregnancy among 1,379 women in rural Malawi. Participants were recruited at ≤20 gestational weeks (gw) and randomly assigned to consume daily (1) 60-mg iron and folic acid (IFA); (2) 20-mg iron plus 17 micronutrients in a capsule (MMN); or (3) lipid-based nutrient supplement (LNS; 118 kcal) with 20-mg iron plus 21 micronutrients, protein, and fat. We analysed differences between intervention groups in mean Hb, ZPP, and sTfR at 36 gw, and the proportion with anaemia (Hb < 100 g L-1 ) and iron deficiency (ZPP > 60 μmol mol-1 haem or sTfR > 6 mg L-1 ) at 36 gw. Women in the IFA group had higher Hb at 36 gw than women in the LNS group (P = 0.030) and higher iron status (lower ZPP and sTfR) than women in both the LNS (P < 0.001 for both ZPP and sTfR) and MMN (P = 0.025 and P = 0.046) groups. Results for anaemia and iron deficiency showed similar trends. Further research is needed to elucidate the appropriate amount of iron to improve Hb and iron status, while improving birth outcomes.
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Affiliation(s)
- Josh M. Jorgensen
- Program in International and Community Nutrition, Department of NutritionUniversity of CaliforniaDavisCaliforniaUSA
| | - Per Ashorn
- Department of PaediatricsTampere University HospitalTampereFinland
- Faculty of Medicine and Life SciencesUniversity of TampereTampereFinland
| | - Ulla Ashorn
- Center for Child Health ResearchUniversity of Tampere School of Medicine and Tampere University HospitalTampereFinland
| | - Lacey M. Baldiviez
- Program in International and Community Nutrition, Department of NutritionUniversity of CaliforniaDavisCaliforniaUSA
| | - Austrida Gondwe
- Department of Community HealthUniversity of Malawi College of MedicineBlantyreMalawi
| | - Ken Maleta
- Department of Community HealthUniversity of Malawi College of MedicineBlantyreMalawi
| | - Minyanga Nkhoma
- Department of Community HealthUniversity of Malawi College of MedicineBlantyreMalawi
| | - Kathryn G. Dewey
- Program in International and Community Nutrition, Department of NutritionUniversity of CaliforniaDavisCaliforniaUSA
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64
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Preconception Micronutrient Supplementation Reduced Circulating Branched Chain Amino Acids at 12 Weeks Gestation in an Open Trial of Guatemalan Women Who Are Overweight or Obese. Nutrients 2018; 10:nu10091282. [PMID: 30208589 PMCID: PMC6165402 DOI: 10.3390/nu10091282] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/04/2018] [Accepted: 09/06/2018] [Indexed: 12/13/2022] Open
Abstract
Elevated branched chain amino acids (BCAAs: valine, leucine, and isoleucine) are well-established biomarkers of obesity-associated insulin resistance (IR). Mounting evidence suggests that low- and middle-income countries are suffering from a "double burden" of both undernutrition (growth stunting) and overnutrition (obesity) as these countries undergo a "nutrition transition". The purpose of this study was to examine if pre-pregnancy body mass index (BMI, kg/m²) and a daily lipid-based micronutrient supplement (LNS, Nutriset) would lead to cross-sectional differences in circulating levels of branched chain amino acids (BCAAs) in Guatemalan women experiencing short stature during early pregnancy. Using data from an ongoing randomized controlled trial, Women First, we studied women who were normal weight (NW, BMI range for this cohort = 20.1⁻24.1 kg/m²) or overweight/obese (OW/OB, BMI range for this cohort = 25.6⁻31.9 kg/m²), and divided into two groups: those who received daily LNS ≥ 3 months prior to conception through 12 weeks gestation (+LNS), or no LNS (-LNS) (n = 9⁻10/group). BCAAs levels were obtained from dried blood spot card samples (DBS) assessed at 12 weeks gestation. DBS cards provide a stable, efficient, and reliable means of collecting, transporting, and storing blood samples in low resource or field settings. Circulating maternal leptin, adiponectin, and insulin were determined by immunoassays from serum samples collected at 12 weeks gestation. We found maternal pre-pregnancy body mass index (ppBMI) was associated with higher circulating BCAAs (r² = 0.433, p = 0.002) and higher leptin/adiponectin ratio (r = 0.466, p = 0.044) in -LNS mothers at 12 weeks gestation. +LNS mothers demonstrated no correlations between BCAAs or leptin/adiponectin ratio across ppBMI suggesting LNS may be effective at improving metabolic status in OW/OB mothers during early pregnancy.
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65
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Olney DK, Leroy J, Bliznashka L, Ruel MT. PROCOMIDA, a Food-Assisted Maternal and Child Health and Nutrition Program, Reduces Child Stunting in Guatemala: A Cluster-Randomized Controlled Intervention Trial. J Nutr 2018; 148:1493-1505. [PMID: 30184223 PMCID: PMC6118165 DOI: 10.1093/jn/nxy138] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/13/2018] [Accepted: 06/20/2018] [Indexed: 01/14/2023] Open
Abstract
Background Food-assisted maternal and child health and nutrition (FA-MCHN) programs may foster child growth during the first 1000 d (pregnancy and the first 2 y of a child's life), but evidence is scant. Objective We evaluated the impact of an FA-MCHN program, PROCOMIDA, on linear growth (stunting [length-for-age z score (LAZ) < -2] and length-for-age difference [LAD]) among children aged 1-24 mo. PROCOMIDA was implemented in Guatemala by Mercy Corps and was available to beneficiaries throughout the first 1000 d. Methods We used a longitudinal, cluster-randomized controlled trial with groups varying in family ration sizes [full (FFR), reduced (RFR), and none (NFR)] and individual ration types provided to mothers (pregnancy to 6 mo postpartum) and children (6-24 mo of age) [corn-soy blend (CSB), lipid-based nutrient supplement (LNS), micronutrient powder (MNP)]: 1) FFR + CSB (n = 576); 2) RFR + CSB (n = 575); 3) NFR + CSB (n = 542); 4) FFR + LNS (n = 550); 5) FFR + MNP (n = 587); 6) control (n = 574). Program impacts compared with control, and differential impacts between groups varying family ration size or individual ration type, were assessed through the use of linear mixed-effects models and post hoc simple effect tests (significant if P < 0.05). Results PROCOMIDA significantly reduced stunting at age 1 mo in FFR + CSB, RFR + CSB, and FFR + MNP groups compared with control [5.05, 4.06, and 3.82 percentage points (pp), respectively]. Stunting impact increased by age 24 mo in FFR + CSB and FFR + MNP relative to control (impact = 11.1 and 6.5 pp at age 24 mo, respectively). For CSB recipients, the FFR compared with RFR or NFR significantly reduced stunting (6.47-9.68 pp). CSB reduced stunting significantly more than LNS at age 24 mo (8.12 pp). Conclusions FA-MCHN programs can reduce stunting during the first 1000 d, even in relatively energy/food-secure populations. Large family rations with individual rations of CSB or MNP were most effective. The widening of impact as children age highlights the importance of intervening throughout the full first 1000 d. This trial was registered at clinicaltrials.gov as NCT01072279.
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Affiliation(s)
- Deanna K Olney
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington DC
| | - Jef Leroy
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington DC
| | - Lilia Bliznashka
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington DC
| | - Marie T Ruel
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington DC
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66
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Das JK, Hoodbhoy Z, Salam RA, Bhutta AZ, Valenzuela‐Rubio NG, Weise Prinzo Z, Bhutta ZA. Lipid-based nutrient supplements for maternal, birth, and infant developmental outcomes. Cochrane Database Syst Rev 2018; 8:CD012610. [PMID: 30168868 PMCID: PMC6513224 DOI: 10.1002/14651858.cd012610.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Ready-to-use lipid-based nutrient supplements (LNS) are a highly nutrient-dense supplement, which could be a good source of macro- and micronutrients for pregnant women who need to supplement their nutrient intake. OBJECTIVES To assess the effects of LNS for maternal, birth and infant outcomes in pregnant women. Secondary objectives were to explore the most appropriate composition, frequency and duration of LNS administration. SEARCH METHODS In May 2018, we searched CENTRAL, MEDLINE, Embase, 22 other databases and two trials registers for any published and ongoing studies. We also checked the reference lists of included studies and relevant reviews, and we contacted the authors of included studies and other experts in the field to identify any studies we may have missed, including any unpublished studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs that compared LNS given in pregnancy to no intervention, placebo, iron folic acid (IFA), multiple micronutrients (MMN) or nutritional counselling. DATA COLLECTION AND ANALYSIS We used standard Cochrane procedures. MAIN RESULTS We included four studies in 8018 pregnant women. All four studies took place in stable community settings in low- and middle-income countries: Bangladesh, Burkina Faso, Ghana and Malawi. None were in emergency settings. The oldest trial was published in 2009. Of the four included studies, one compared LNS to IFA, one compared LNS to MMN, and two compared LNS to both IFA and MMN.We considered the included studies to be of medium to high quality, and we rated the quality of the evidence as moderate using the GRADE approach.LNS versus IFAMaternal outcomes: there was no difference between the LNS and IFA groups as regards maternal gestational weight gain per week (standard mean difference (SMD) 0.46, 95% confidence interval (CI) -0.44 to 1.36; 2 studies, 3539 participants). One study (536 participants) showed a two-fold increase in the prevalence of maternal anaemia in the LNS group compared to the IFA group, but no difference between the groups as regards adverse effects. There was no difference between the two groups for maternal mortality (risk ratio (RR) 0.53, 95% CI 0.12 to 2.41; 3 studies, 5628 participants).Birth and infant outcomes: there was no difference between the LNS and IFA groups for low birth weight (LBW) (RR 0.87, 95% CI 0.72 to 1.05; 3 studies, 4826 participants), though newborns in the LNS group had a slightly higher mean birth weight (mean difference (MD) 53.28 g, 95% CI 28.22 to 78.33; 3 studies, 5077 participants) and birth length (cm) (MD 0.24 cm, 95% CI 0.11 to 0.36; 3 studies, 4986 participants). There was a reduction in the proportion of infants who were small for gestational age (SGA) (RR 0.94, 95% CI 0.89 to 0.99; 3 studies, 4823 participants) and had newborn stunting (RR 0.82, 95% CI 0.71 to 0.94; 2 studies, 4166 participants) in the LNS group, but no difference between the LNS and IFA groups for preterm delivery (RR 0.94, 95% CI 0.80 to 1.11; 4 studies, 4924 participants), stillbirth (RR 1.14; 95% CI 0.52 to 2.48; 3 studies, 5575 participants) or neonatal death (RR 0.96, 95% CI 0.14 to 6.51). The current evidence for child developmental outcomes is not sufficient to draw any firm conclusions.LNS versus MMNMaternal outcomes: one study (662 participants) showed no difference between the LNS and MMN groups as regards gestational weight gain per week or adverse effects. Another study (557 participants) showed an increased risk of maternal anaemia in the LNS group compared to the MMN group.Birth and infant outcomes: there was no difference between the LNS and MMN groups for LBW (RR 0.92, 95% CI 0.74 to 1.14; 3 studies, 2404 participants), birth weight (MD 23.67 g, 95% CI -10.53 to 57.86; 3 studies, 2573 participants), birth length (MD 0.20 cm, 95% CI -0.02 to 0.42; 3 studies, 2567 participants), SGA (RR 0.95, 95% CI 0.84 to 1.07; 3 studies, 2393 participants), preterm delivery (RR 1.15, 95% CI 0.93 to 1.42; 3 studies, 2630 participants), head circumference z score (MD 0.10, 95% CI -0.01 to 0.21; 2 studies, 1549 participants) or neonatal death (RR 0.88, 95% CI 0.36 to 2.15; 1 study, 1175 participants). AUTHORS' CONCLUSIONS Findings from this review suggest that LNS supplementation has a slight, positive effect on weight at birth, length at birth, SGA and newborn stunting compared to IFA. LNS and MMN were comparable for all maternal, birth and infant outcomes. Both IFA and MMN were better at reducing maternal anaemia when compared to LNS. We did not find any trials for LNS given to pregnant women in emergency settings.Readers should interpret the beneficial findings of the review with caution since the evidence comes from a small number of trials, with one-large scale study (conducted in community settings in Bangladesh) driving most of the impact. In addition, effect sizes are too small to propose any concrete recommendation for practice.
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Affiliation(s)
- Jai K Das
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiSindPakistan
| | - Zahra Hoodbhoy
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiSindPakistan
| | - Rehana A Salam
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiSindPakistan
| | | | - Nancy G Valenzuela‐Rubio
- Autonomous University of SinaloaSchool of Nutrition and GastronomyPuerto Ensenada Ave. 1783Nuevo CuliacanCuliacanSinaloaMexico80170
- Mexican Association for Nutrition and Health ResearchCuliacanMexico
| | - Zita Weise Prinzo
- World Health OrganizationDepartment of Nutrition for Health and DevelopmentAvenue Appia 20GenevaGESwitzerland1211
| | - Zulfiqar A Bhutta
- The Hospital for Sick ChildrenCentre for Global Child HealthTorontoONCanadaM5G A04
- Aga Khan University HospitalCentre for Excellence in Women and Child HealthStadium RoadPO Box 3500KarachiPakistan74800
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Glosz CM, Schaffner AA, Reaves SK, Manary MJ, Papathakis PC. Effect of Nutritional Interventions on Micronutrient Status in Pregnant Malawian Women with Moderate Malnutrition: A Randomized, Controlled Trial. Nutrients 2018; 10:nu10070879. [PMID: 29986492 PMCID: PMC6073606 DOI: 10.3390/nu10070879] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 07/02/2018] [Accepted: 07/05/2018] [Indexed: 01/12/2023] Open
Abstract
Micronutrient deficiencies during pregnancy are common in Africa and can cause adverse outcomes. The objective was to measure micronutrient status and change in moderately malnourished pregnant Malawian women randomized to one of three nutritional interventions. Serum vitamin B12, 25-hydroxyvitamin D, folate, retinol, ferritin, zinc, albumin and C-reactive protein were measured in pregnant women with MUAC ≥20.6 cm and ≤23.0 cm at enrollment (n = 343) and after 10 weeks (n = 229) of receiving: (1) ready-to-use supplementary food (RUSF); (2) fortified corn-soy blend (CSB+) with multiple-micronutrient supplement (CSB+UNIMMAP); or (3) CSB+ with iron and folic acid (CSB+IFA). Each provided 100⁻300% Recommended Dietary Allowance of most micronutrients and 900 kcal/day. Birth length was measured in 272 infants. Enrollment measurements indicated deficiencies in vitamin B12 (20.9%) and zinc (22.3%), low values of ferritin (25.1%) and albumin (33.7%), and elevated CRP (46.0%). Vitamin B12 is known to decrease in the third trimester; the RUSF group had the smallest decrease from enrollment to week 10 (3%), compared to 20% decrease in the CSB+IFA group and 8% decrease in the CSB+UNIMMAP group (p = 0.001). Mean serum 25-hydroxyvitamin D increased most in the RUSF group (+6.4 ng/mL), compared to CSB+IFA (+1.7 ng/mL) and CSB+UNIMMAP (+2.7 ng/mL) (p < 0.001). Micronutrient deficiencies and inflammation are common among moderately malnourished pregnant women and had little improvement despite supplementation above the RDA, with the exception of vitamins B12 and D.
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Affiliation(s)
- Cambria M Glosz
- Department of Food Science and Nutrition, California Polytechnic State University, San Luis Obispo, CA 93407, USA.
| | - Andrew A Schaffner
- Department of Food Science and Nutrition, California Polytechnic State University, San Luis Obispo, CA 93407, USA.
| | - Scott K Reaves
- Department of Food Science and Nutrition, California Polytechnic State University, San Luis Obispo, CA 93407, USA.
| | - Mark J Manary
- Washington University School of Medicine, Washington University, St. Louis, MO 63110, USA.
| | - Peggy C Papathakis
- Department of Food Science and Nutrition, California Polytechnic State University, San Luis Obispo, CA 93407, USA.
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Hanjahanja-Phiri T. Intergenerational Effects of Maternal Exposure to Drought in Utero on Newborn Size in Rural Malawi. ANNALS OF NUTRITION AND METABOLISM 2018; 73:74-75. [PMID: 29945123 DOI: 10.1159/000490671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 06/06/2018] [Indexed: 11/19/2022]
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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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Prado EL, Phuka J, Ocansey E, Maleta K, Ashorn P, Ashorn U, Adu-Afarwuah S, Oaks BM, Lartey A, Dewey KG. A method to develop vocabulary checklists in new languages and their validity to assess early language development. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2018; 37:13. [PMID: 29751834 PMCID: PMC5948920 DOI: 10.1186/s41043-018-0145-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 05/01/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Since the adoption of United Nations' Sustainable Goal 4.2 to ensure that all children have access to quality early child development (ECD) so that they are ready for primary education, the demand for valid ECD assessments has increased in contexts where they do not yet exist. The development of early language ability is important for school readiness. Our objective was to evaluate the validity of a method to develop vocabulary checklists in new languages to assess early language development, based on the MacArthur-Bates Communicative Development Inventories. METHODS Through asking mothers of young children what words their children say and through pilot testing, we developed 100-word vocabulary checklists in multilingual contexts in Malawi and Ghana. In Malawi, we evaluated the validity of the vocabulary checklist among 29 children age 17-25 months compared to three language measures assessed concurrently: Developmental Milestones Checklist-II (DMC-II) language scale, Malawi Developmental Assessment Tool (MDAT) language scale, and the number of different words (NDW) in 30-min recordings of spontaneous speech. In Ghana, we assessed the predictive validity of the vocabulary checklist at age 18 months to forecast language, pre-academic, and other skills at age 4-6 years among 869 children. We also compared the predictive validity of the vocabulary checklist scores to that of other developmental assessments administered at age 18 months. RESULTS In Malawi, the Spearman's correlation of the vocabulary checklist score with DMC-II language was 0.46 (p = 0.049), with MDAT language was 0.66 (p = 0.016) and with NDW was 0.50 (p = 0.033). In Ghana, the 18-month vocabulary checklist score showed the strongest (rho = 0.12-0.26) and most consistent (8/12) associations with preschool scores, compared to the other 18-month assessments. The largest coefficients were the correlations of the 18-month vocabulary score with the preschool cognitive factor score (rho = 0.26), language score (0.25), and pre-academic score (0.24). CONCLUSIONS We have demonstrated the validity of a method to develop vocabulary checklists in new languages, which can be used in multilingual contexts, using a feasible adaptation process requiring about 2 weeks. This is a promising method to assess early language development, which is associated with later preschool language, cognitive, and pre-academic skills.
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Affiliation(s)
- Elizabeth L. Prado
- Department of Nutrition, University of California Davis, 3253 Meyer Hall, One Shields Ave, Davis, CA 95616 USA
| | - John Phuka
- School of Public Health and Family Medicine, University of Malawi College of Medicine, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Eugenia Ocansey
- Department of Nutrition, University of California Davis, 3253 Meyer Hall, One Shields Ave, Davis, CA 95616 USA
- Department of Nutrition and Food Science, University of Ghana, Legon, Box LG 134, Legon, Accra, Ghana
| | - Kenneth Maleta
- School of Public Health and Family Medicine, University of Malawi College of Medicine, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Per Ashorn
- Center for Child Health Research, University of Tampere Faculty of Medicine and Life Sciences and Tampere University Hospital, Arvo building, FIN 33014 Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, POB 2000, FIN 33521 Tampere, Finland
| | - Ulla Ashorn
- Center for Child Health Research, University of Tampere Faculty of Medicine and Life Sciences and Tampere University Hospital, Arvo building, FIN 33014 Tampere, Finland
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Box LG 134, Legon, Accra, Ghana
| | - Brietta M. Oaks
- Department of Nutrition and Food Sciences, University of Rhode Island, 131 Fogarty Hall, Kingston, RI 02881 USA
| | - Anna Lartey
- Department of Nutrition and Food Science, University of Ghana, Legon, Box LG 134, Legon, Accra, Ghana
| | - Kathryn G. Dewey
- Department of Nutrition, University of California Davis, 3253 Meyer Hall, One Shields Ave, Davis, CA 95616 USA
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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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Adu-Afarwuah S. From the Field: Improving Fetal and Infant Growth in Vulnerable Populations. Food Nutr Bull 2018; 39:S60-S68. [PMID: 29734823 DOI: 10.1177/0379572118773035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND This article summarizes a presentation given at the 2017 Dairy for Global Nutrition Conference in Boise, Idaho. OBJECTIVE To give an overview of the pattern of early growth faltering in developing countries and examine the implications of the iLiNS-DYAD randomized trial in Ghana. METHODS The pattern of growth faltering in developing countries was outlined. In Ghana, 1320 women ≤ 20 weeks of pregnancy were assigned to 20 g/d small-quantity lipid-based nutrient supplement (SQ-LNS; LNS group) or multiple micronutrients (MMNs) containing 22 and 18 vitamins and minerals, respectively, until 6 months postpartum, or iron and folic acid (IFA) until delivery, and thereafter placebo until 6 months postpartum. Infants in the LNS group were assigned to SQ-LNS from 6 to 18 months of age. RESULTS Mean anthropometric z-scores for infants in developing countries start below the World Health Organization standard at 1 month of age, and generally decline until about age of 24 months. In the Ghana trial, mean (SD) birth weight (g) was greater ( P = .044) for the LNS group (3030 [414]) than the IFA group (2945 [442]) but not the MMN group (3005 [435]). Among primiparous mothers, the LNS group had significantly greater mean birth length, weight, and head circumference than the IFA or MMN group. By 18 months of age, the mean length (95% confidence interval) for the LNS group was +0.6 (0.1-1.1) cm greater than for the IFA group and +0.6 (0.1-1.2) cm greater than for the MMN group. CONCLUSION Pre- and post-natal SQ-LNS consumption may improve fetal and infant growth in similar populations.
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Affiliation(s)
- Seth Adu-Afarwuah
- 1 Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
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Adams KP, Okronipa H, Adu-Afarwuah S, Arimond M, Kumordzie S, Oaks BM, Ocansey ME, Young RR, Vosti SA, Dewey KG. Ghanaian parents' perceptions of pre and postnatal nutrient supplements and their effects. MATERNAL AND CHILD NUTRITION 2018; 14:e12608. [PMID: 29656569 PMCID: PMC6866179 DOI: 10.1111/mcn.12608] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 02/12/2018] [Accepted: 02/28/2018] [Indexed: 12/31/2022]
Abstract
Small-quantity lipid-based nutrient supplements (SQ-LNS) have been studied in efficacy and effectiveness trials, but little is known about how parents perceive the products and their effects. In a randomised trial in Ghana, efficacy of SQ-LNS provided to women during pregnancy and the first 6 months postpartum and to their children from 6 to 18 months of age was assessed by comparison with iron-folic acid (IFA) capsules and multiple micronutrient (MMN) capsules provided to women. In a follow-up study conducted when the index children from the original trial were between 4 and 6 years of age, we used survey-based methods to assess retrospective and current parental perceptions of nutrient supplements generally and of SQ-LNS and their effects compared with perceptions IFA and MMN capsules. Most parents perceived that the assigned supplements (SQ-LNS, IFA, or MMN) positively impacted the mother during pregnancy (approximately 89% of both mothers and fathers) and during lactation (84% of mothers and 86% of fathers). Almost all (≥90%) of mothers and fathers perceived that the assigned supplement positively impacted the index child and expected continued positive impacts on the child's health and human capital into the future. A smaller percentage of parents perceived negative impacts of the supplements (7%-17% of mothers and 4%-12% of fathers). Perceptions of positive impacts and of negative impacts did not differ by intervention group. The results suggest that similar populations would likely be receptive to programs to deliver SQ-LNS or micronutrient capsules.
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Affiliation(s)
- Katherine P Adams
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, California, USA
| | - Harriet Okronipa
- Department of Nutrition, University of California, Davis, Davis, California, USA
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Accra, Ghana
| | - Mary Arimond
- Intake-Center for Dietary Assessment, FHI 360, Washington, District of Columbia, USA
| | - Sika Kumordzie
- Department of Nutrition, University of California, Davis, Davis, California, USA
| | - Brietta M Oaks
- Department of Nutrition and Food Sciences, University of Rhode Island, Kingston, Rhode Island, USA
| | - Maku E Ocansey
- Department of Nutrition, University of California, Davis, Davis, California, USA
| | - Rebecca R Young
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, California, USA
| | - Stephen A Vosti
- Department of Agricultural and Resource Economics, University of California, Davis, Davis, California, USA
| | - Kathryn G Dewey
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, California, USA
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Hendrixson DT, Koroma AS, Callaghan-Gillespie M, Weber J, Papathakis P, Manary MJ. Use of a novel supplementary food and measures to control inflammation in malnourished pregnant women in Sierra Leone to improve birth outcomes: study protocol for a prospective, randomized, controlled clinical effectiveness trial. BMC Nutr 2018; 4:15. [PMID: 32153879 PMCID: PMC7050866 DOI: 10.1186/s40795-018-0218-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 03/07/2018] [Indexed: 12/11/2022] Open
Abstract
Background The negative synergy between poor nutritional status and infectious diseases is doubly detrimental in pregnancy. In Sierra Leone, maternal malnutrition is amongst the highest in the world, while maternal mortality is high at 1320/100,000 live births and stunting in under-five is 37.9%, ranked 110/132 worldwide. Maternal malnutrition has been associated with preterm birth, small-for-gestational age infants, and poor maternal outcomes. Infants born prematurely or small-for-gestational age experience higher mortality and are at risk for stunting and decreased cognitive performance. Nutritional interventions alone during pregnancy may not be as effective in the setting of increased inflammation from repeated infections. Interventions are needed to improve maternal outcomes and reduce stunting in this population. Methods/design This will be a prospective, randomized, controlled clinical effectiveness trial of an improved supplementary food plus anti-infective therapies compared to standard therapy in malnourished pregnant women. Pregnant women will be randomized to receive a low water activity, ready-to-use supplementary food plus five anti-infective interventions or the standard of care which is 3.5 kg corn/ soy blended flour with 350 mL vegetable oil every two weeks. The five anti-infective interventions are 1) insecticide-treated mosquito net at the time of enrollment into the study, 2) sulfadoxine-pyrimethamine given every 4 weeks, beginning at enrollment or at 13 weeks’ gestation, whichever is later, 3)azithromycin at a dose of 1 g given once at enrollment (after first trimester)and again during 28–34 weeks of gestation, 4)single dose 400 mg albendazole given in second trimester, and 5) testing and treatment for bacterial vaginosis at enrollment and again at 28–34 weeks of gestation. Treatment will be provided for the duration of the pregnancy. The primary outcome measure will be birth length. Secondary outcomes in the mothers will include rates of maternal weight gain and increase in mid-upper arm circumference, and time to maternal anthropometric recovery. Secondary outcomes in the infants will include birth weight, birth head circumference, and linear and ponderal growth. Discussion Malnutrition remains a major problem in the developing world with lasting maternal and infant consequences. Maternal malnutrition has been associated with intrauterine growth retardation, low birth weight (LBW), pre-term delivery and poor cognitive development. Nutritional interventions alone have not been successful in reducing stunting. By bundling nutritional and anti-infective interventions, we aim to reduce intrauterine growth restriction and low birth weight in moderately malnourished pregnant women in Sierra Leone. If successful, this bundle can easily be implemented by governments or non-governmental organizations. Trial registration Clinicaltrials.govNCT03079388; Date: March 5, 2017.
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Affiliation(s)
- D Taylor Hendrixson
- 1Department of Pediatrics, One Children's Place, Washington University in St. Louis, Campus Box 8116, Saint Louis, MO 63110 USA
| | - Aminata Shamit Koroma
- 2Ministry of Health and Sanitation, The Republic of Sierra Leone, 4th Floor Youyi Building, Freetown, Sierra Leone
| | - Meghan Callaghan-Gillespie
- 1Department of Pediatrics, One Children's Place, Washington University in St. Louis, Campus Box 8116, Saint Louis, MO 63110 USA
| | - Jacklyn Weber
- 1Department of Pediatrics, One Children's Place, Washington University in St. Louis, Campus Box 8116, Saint Louis, MO 63110 USA
| | - Peggy Papathakis
- 3Department of Food Science and Nutrition, California Polytechnic State University, San Luis Obispo, CA 93407 USA
| | - Mark J Manary
- 1Department of Pediatrics, One Children's Place, Washington University in St. Louis, Campus Box 8116, Saint Louis, MO 63110 USA
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75
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Adams KP, Vosti SA, Ayifah E, Phiri TE, Adu‐Afarwuah S, Maleta K, Ashorn U, Arimond M, Dewey KG. Willingness to pay for small-quantity lipid-based nutrient supplements for women and children: Evidence from Ghana and Malawi. MATERNAL & CHILD NUTRITION 2018; 14:e12518. [PMID: 28960913 PMCID: PMC6088232 DOI: 10.1111/mcn.12518] [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] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 07/18/2017] [Accepted: 08/30/2017] [Indexed: 01/22/2023]
Abstract
Small-quantity lipid-based nutrient supplements (SQ-LNS) are designed to enrich maternal and child diets with the objective of preventing undernutrition during the first 1,000 days. Scaling up the delivery of supplements such as SQ-LNS hinges on understanding private demand and creatively leveraging policy-relevant factors that might influence demand. We used longitudinal stated willingness-to-pay (WTP) data from contingent valuation studies that were integrated into randomized controlled nutrition trials in Ghana and Malawi to estimate private valuation of SQ-LNS during pregnancy, postpartum, and early childhood. We found that average stated WTP for a day's supply of SQ-LNS was more than twice as high in Ghana than Malawi, indicating that demand for SQ-LNS (and by extension, the options for effective delivery of SQ-LNS) may be very context specific. We also examined factors associated with WTP, including intervention group, household socioeconomic status, birth outcomes, child growth, and maternal and child morbidity. In both sites, WTP was consistently negatively associated with household food insecurity, indicating that subsidization might be needed to permit food insecure households to acquire SQ-LNS if it is made available for purchase. In Ghana, WTP was higher among heads of household than among mothers, which may be related to control over household resources. Personal experience using SQ-LNS was not associated with WTP in either site.
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Affiliation(s)
- Katherine P. Adams
- Program in International and Community Nutrition, Department of NutritionUniversity of California, DavisDavisCaliforniaUSA
| | - Stephen A. Vosti
- Department of Agricultural and Resource EconomicsUniversity of California, DavisDavisCaliforniaUSA
| | - Emmanuel Ayifah
- Department of Economics, School of Economic and Business SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Thokozani E. Phiri
- School of Public Health and Health SystemsUniversity of WaterlooOntarioCanada
| | - Seth Adu‐Afarwuah
- Department of Nutrition and Food ScienceUniversity of GhanaAccraGhana
| | - Kenneth Maleta
- School of Public Health and Family MedicineUniversity of Malawi College of MedicineBlantyreMalawi
| | - Ulla Ashorn
- Department of International HealthUniversity of Tampere School of MedicineTampereFinland
| | - Mary Arimond
- Program in International and Community Nutrition, Department of NutritionUniversity of California, DavisDavisCaliforniaUSA
| | - Kathryn G. Dewey
- Program in International and Community Nutrition, Department of NutritionUniversity of California, DavisDavisCaliforniaUSA
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76
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Harjunmaa U, Doyle R, Järnstedt J, Kamiza S, Jorgensen JM, Stewart CP, Shaw L, Hallamaa L, Ashorn U, Klein N, Dewey KG, Maleta K, Ashorn P. Periapical infection may affect birth outcomes via systemic inflammation. Oral Dis 2018; 24:847-855. [PMID: 29230915 DOI: 10.1111/odi.12817] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 11/26/2017] [Accepted: 12/03/2017] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Maternal dental periapical infections are associated with preterm birth and intrauterine growth restriction. This study investigates whether the association is mediated through bacterial spread from periapical lesions to placenta (direct pathway) or systemic inflammatory reaction (indirect pathway). MATERIALS AND METHODS We compared birth outcomes in Malawian mothers with and without periapical infection. As markers of a direct pathway, we identified placental bacteria using a 16S rDNA approach and assessed histological evidence of inflammation in the placenta and amniotic membranes. We measured C-reactive protein, alpha-1-acid glycoprotein, and salivary cortisol as markers of an indirect pathway. We used regression models to associate the predictor variables with duration of pregnancy and newborn size. RESULTS Of 1,024 women, 23.5% had periapical infection. There was no association of periapical infection with either bacterial DNA or histological inflammation in placenta or membranes. Periapical infection was associated with C-reactive protein, alpha-1-acid glycoprotein, and cortisol concentrations in a dose-dependent manner at 36 weeks. Addition of alpha-1-acid glycoprotein or cortisol concentration into regression models attenuated the association between periapical infection and pregnancy outcomes. CONCLUSION There was no evidence of direct spread of periapical bacteria to the placenta. Periapical infections and adverse pregnancy outcomes are in part mediated through systemic inflammation.
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Affiliation(s)
- U Harjunmaa
- Center for Child Health Research, University of Tampere Faculty of Medicine and Life Sciences and Tampere University Hospital, Tampere, Finland
| | - R Doyle
- Microbiology, Virology & Infection Control, Great Ormond Street Hospital NHS Foundation Trust, London, UK.,Institute of Child Health, University College London, London, UK
| | - J Järnstedt
- Department of Radiology, Medical Imaging Center, Tampere University Hospital, Tampere, Finland
| | - S Kamiza
- Department of Pathology, University of Malawi College of Medicine, Blantyre, Malawi
| | - J M Jorgensen
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - C P Stewart
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - L Shaw
- Institute of Child Health, University College London, London, UK
| | - L Hallamaa
- Center for Child Health Research, University of Tampere Faculty of Medicine and Life Sciences and Tampere University Hospital, Tampere, Finland
| | - U Ashorn
- Center for Child Health Research, University of Tampere Faculty of Medicine and Life Sciences and Tampere University Hospital, Tampere, Finland
| | - N Klein
- Institute of Child Health, University College London, London, UK
| | - K G Dewey
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - K Maleta
- Department of Community Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - P Ashorn
- Center for Child Health Research, University of Tampere Faculty of Medicine and Life Sciences and Tampere University Hospital, Tampere, Finland
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77
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A Lactobacillus-Deficient Vaginal Microbiota Dominates Postpartum Women in Rural Malawi. Appl Environ Microbiol 2018; 84:AEM.02150-17. [PMID: 29305501 PMCID: PMC5835753 DOI: 10.1128/aem.02150-17] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 12/29/2017] [Indexed: 01/09/2023] Open
Abstract
The bacterial community found in the vagina is an important determinant of a woman's health and disease status. A healthy vaginal microbiota is associated with low species richness and a high proportion of one of a number of different Lactobacillus spp. When disrupted, the resulting abnormal vaginal microbiota is associated with a number of disease states and poor pregnancy outcomes. Studies up until now have concentrated on relatively small numbers of American and European populations that may not capture the full complexity of the community or adequately predict what constitutes a healthy microbiota in all populations. In this study, we sampled and characterized the vaginal microbiota found on vaginal swabs taken postpartum from a cohort of 1,107 women in rural Malawi. We found a population dominated by Gardnerella vaginalis and devoid of the most common vaginal Lactobacillus species, even if the vagina was sampled over a year postpartum. This Lactobacillus-deficient anaerobic community, commonly labeled community state type (CST) 4, could be subdivided into four further communities. A Lactobacillus iners-dominated vaginal microbiota became more common the longer after delivery the vagina was sampled, but G. vaginalis remained the dominant organism. These results outline the difficulty in all-encompassing definitions of what a healthy or abnormal postpartum vaginal microbiota is. Previous identification of community state types and associations among bacterial species, bacterial vaginosis, and adverse birth outcomes may not represent the complex heterogeneity of the microbiota present. (This study has been registered at ClinicalTrials.gov as NCT01239693.) IMPORTANCE A bacterial community in the vaginal tract is dominated by a small number of Lactobacillus species, and when not present there is an increased incidence of inflammatory conditions and adverse birth outcomes. A switch to a vaginal bacterial community lacking in Lactobacillus species is common after pregnancy. In this study, we characterized the postpartum vaginal bacterial community of a large group of women from a resource-poor, undersampled population in rural Malawi. The majority of women were found to have a Lactobacillus-deficient community, and even when sampled a year after delivery the majority of women still did not have Lactobacillus present in their vaginal microbiota. The effect of becoming pregnant again for those who do not revert to a Lactobacillus-dominant community is unknown, and this could suggest that not all Lactobacillus-deficient community structures are adverse. A better understanding of this complex community state type is needed.
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78
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Barua P, Chandrasiri UP, Beeson JG, Dewey KG, Maleta K, Ashorn P, Rogerson SJ. Effect of nutrient supplementation on the acquisition of humoral immunity to Plasmodium falciparum in young Malawian children. Malar J 2018; 17:74. [PMID: 29415730 PMCID: PMC5804088 DOI: 10.1186/s12936-018-2224-6] [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] [Received: 09/28/2017] [Accepted: 01/31/2018] [Indexed: 11/17/2022] Open
Abstract
Background There is evidence that suggests that undernutrition has a detrimental effect on malarial immunity in children. The aim of the study was to discover whether nutrient supplementation improved development of malarial antibody immunity in children up to 18 months of age. Methods The study was conducted with a subset of 432 Malawian children from a randomized controlled trial of nutritional supplements. The arms included pre- and postnatal small-quantity lipid-based nutrient supplements for both mother and child; prenatal supplementation with iron and folic acid; and pre- and postnatal supplementation with multiple micronutrients. Paired plasma samples were collected at 6 and 18 months of age. The levels of antibodies against merozoite surface protein 1 (MSP1 19kD) and MSP2, erythrocyte binding antigen 175 (EBA175), reticulocyte binding protein homologue 2A (Rh2A9), schizont extract and variant antigens expressed on the surface of infected erythrocytes were measured. Results At 18 months of age, 5.4% of children were parasitaemic by microscopy and 49.1% were anaemic. Antibodies to the tested merozoite antigens and schizont extract increased between 6 and 18 months and this increase was statistically significant for MSP1, MSP2 and EBA175 (p < 0.0001) whereas IgG to variant surface antigens decreased with increasing age (p < 0.0001). However, the supplementation type did not have any impact on the prevalence or levels of antibodies at either 6 or 18 months of age to any of the tested malaria antigens in either univariate analysis or multivariate analysis after adjusting for covariates. Conclusions Pre- and postnatal lipid-based nutrient supplementation did not alter malaria antibody acquisition during infancy, compared to prenatal supplementation with iron and folic acid or pre- and postnatal supplementation with multiple micronutrients. Trail registeration Clinicaltrials.gov registration number NCT01239693
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Affiliation(s)
- Priyanka Barua
- Department of Medicine (RMH), Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
| | - Upeksha P Chandrasiri
- Department of Medicine (RMH), Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
| | - James G Beeson
- Department of Medicine (RMH), Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia.,Burnet Institute for Medical Research and Public Health, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | | | | | - Per Ashorn
- University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Stephen J Rogerson
- Department of Medicine (RMH), Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia.
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79
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Ashorn P, Hallamaa L, Allen LH, Ashorn U, Chandrasiri U, Deitchler M, Doyle R, Harjunmaa U, Jorgensen JM, Kamiza S, Klein N, Maleta K, Nkhoma M, Oaks BM, Poelman B, Rogerson SJ, Stewart CP, Zeilani M, Dewey KG. Co-causation of reduced newborn size by maternal undernutrition, infections, and inflammation. MATERNAL AND CHILD NUTRITION 2018; 14:e12585. [PMID: 29316198 PMCID: PMC6055652 DOI: 10.1111/mcn.12585] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 11/24/2017] [Accepted: 12/05/2017] [Indexed: 01/21/2023]
Abstract
More than 20 million babies are born with low birthweight annually. Small newborns have an increased risk for mortality, growth failure, and other adverse outcomes. Numerous antenatal risk factors for small newborn size have been identified, but individual interventions addressing them have not markedly improved the health outcomes of interest. We tested a hypothesis that in low‐income settings, newborn size is influenced jointly by multiple maternal exposures and characterized pathways associating these exposures with newborn size. This was a prospective cohort study of pregnant women and their offspring nested in an intervention trial in rural Malawi. We collected information on maternal and placental characteristics and used regression analyses, structural equation modelling, and random forest models to build pathway maps for direct and indirect associations between these characteristics and newborn weight‐for‐age Z‐score and length‐for‐age Z‐score. We used multiple imputation to infer values for any missing data. Among 1,179 pregnant women and their babies, newborn weight‐for‐age Z‐score was directly predicted by maternal primiparity, body mass index, and plasma alpha‐1‐acid glycoprotein concentration before 20 weeks of gestation, gestational weight gain, duration of pregnancy, placental weight, and newborn length‐for‐age Z‐score (p < .05). The latter 5 variables were interconnected and were predicted by several more distal determinants. In low‐income conditions like rural Malawi, maternal infections, inflammation, nutrition, and certain constitutional factors jointly influence newborn size. Because of this complex network, comprehensive interventions that concurrently address multiple adverse exposures are more likely to increase mean newborn size than focused interventions targeting only maternal nutrition or specific infections.
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Affiliation(s)
- Per Ashorn
- Centre for Child Health Research, Faculty of Medicine and Life Sciences, University of Tampere and Tampere University Hospital, Tampere, Finland.,Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Lotta Hallamaa
- Centre for Child Health Research, Faculty of Medicine and Life Sciences, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Lindsay H Allen
- USDA Agricultural Research Service Western Human Nutrition Research Center, Davis, California, USA.,Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, California, USA
| | - Ulla Ashorn
- Centre for Child Health Research, Faculty of Medicine and Life Sciences, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Upeksha Chandrasiri
- Department of Medicine at Peter Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Megan Deitchler
- Food and Nutrition Technical Assistance III Project, Washington DC, District of Columbia, USA
| | - Ronan Doyle
- Institute of Child Health, University College London, London, UK
| | - Ulla Harjunmaa
- Centre for Child Health Research, Faculty of Medicine and Life Sciences, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Josh M Jorgensen
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, California, USA
| | - Steve Kamiza
- Faculty of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Nigel Klein
- Institute of Child Health, University College London, London, UK
| | - Kenneth Maleta
- Faculty of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Minyanga Nkhoma
- Faculty of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Brietta M Oaks
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, California, USA
| | - Basho Poelman
- Centre for Child Health Research, Faculty of Medicine and Life Sciences, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Stephen J Rogerson
- Department of Medicine at Peter Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Christine P Stewart
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, California, USA
| | - Mamane Zeilani
- External Research and Nutrition, Nutriset S.A.S, Malaunay, France
| | - Kathryn G Dewey
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, California, USA
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80
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Adams KP, Ayifah E, Phiri TE, Mridha MK, Adu-Afarwuah S, Arimond M, Arnold CD, Cummins J, Hussain S, Kumwenda C, Matias SL, Ashorn U, Lartey A, Maleta KM, Vosti SA, Dewey KG. Maternal and Child Supplementation with Lipid-Based Nutrient Supplements, but Not Child Supplementation Alone, Decreases Self-Reported Household Food Insecurity in Some Settings. J Nutr 2017; 147:2309-2318. [PMID: 28978680 PMCID: PMC5697970 DOI: 10.3945/jn.117.257386] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 08/15/2017] [Accepted: 09/12/2017] [Indexed: 12/02/2022] Open
Abstract
Background: It is unknown whether self-reported measures of household food insecurity change in response to food-based nutrient supplementation.Objective: We assessed the impacts of providing lipid-based nutrient supplements (LNSs) to women during pregnancy and postpartum and/or to their children on self-reported household food insecurity in Malawi [DOSE and DYAD trial in Malawi (DYAD-M)], Ghana [DYAD trial in Ghana (DYAD-G)], and Bangladesh [Rang-Din Nutrition Study (RDNS) trial].Methods: Longitudinal household food-insecurity data were collected during 3 individually randomized trials and 1 cluster-randomized trial testing the efficacy or effectiveness of LNSs (generally 118 kcal/d). Seasonally adjusted Household Food Insecurity Access Scale (HFIAS) scores were constructed for 1127 DOSE households, 732 DYAD-M households, 1109 DYAD-G households, and 3671 RDNS households. The impact of providing LNSs to women during pregnancy and the first 6 mo postpartum and/or to their children from 6 to 18-24 mo on seasonally adjusted HFIAS scores was assessed by using negative binomial models (DOSE, DYAD-M, and DYAD-G trials) and mixed-effect negative binomial models (RDNS trial).Results: In the DOSE and DYAD-G trials, seasonally adjusted HFIAS scores were not different between the LNS and non-LNS groups. In the DYAD-M trial, the average household food-insecurity scores were 14% lower (P = 0.01) in LNS households than in non-LNS households. In the RDNS trial, compared with non-LNS households, food-insecurity scores were 17% lower (P = 0.02) during pregnancy and the first 6 mo postpartum and 15% lower (P = 0.02) at 6-24 mo postpartum in LNS households.Conclusions: The daily provision of LNSs to mothers and their children throughout much of the "first 1000 d" may improve household food security in some settings, which could be viewed as an additional benefit that may accrue in households should policy makers choose to invest in LNSs to promote child growth and development. These trials were registered at clinicaltrials.gov as NCT00945698 (DOSE) NCT01239693 (DYAD-M), NCT00970866 (DYAD-G) and NCT01715038 (RDNS).
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Affiliation(s)
| | - Emmanuel Ayifah
- Department of Economics, School of Economic and Business Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Thokozani E Phiri
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Malay K Mridha
- Departments of Nutrition and,James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | | | | | - Joseph Cummins
- Department of Economics, University of California, Riverside, Riverside, CA
| | - Sohrab Hussain
- Saving Newborn Lives Program, Save the Children International, Dhaka, Bangladesh
| | | | | | - Ulla Ashorn
- Center for Child Health Research, University of Tampere Faculty of Medicine and Life Sciences and Tampere University Hospital, Tampere, Finland
| | - Anna Lartey
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Kenneth M Maleta
- School of Public Health and Family Medicine, University of Malawi College of Medicine, Blantyre, Malawi; and
| | - Stephen A Vosti
- Agricultural and Resource Economics, University of California, Davis, Davis, CA
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81
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Dewey KG, Oaks BM. U-shaped curve for risk associated with maternal hemoglobin, iron status, or iron supplementation. Am J Clin Nutr 2017; 106:1694S-1702S. [PMID: 29070565 PMCID: PMC5701708 DOI: 10.3945/ajcn.117.156075] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Both iron deficiency (ID) and excess can lead to impaired health status. There is substantial evidence of a U-shaped curve between the risk of adverse birth outcomes and maternal hemoglobin concentrations during pregnancy; however, it is unclear whether those relations are attributable to conditions of low and high iron status or to other mechanisms. We summarized current evidence from human studies regarding the association between birth outcomes and maternal hemoglobin concentrations or iron status. We also reviewed effects of iron supplementation on birth outcomes among women at low risk of ID and the potential mechanisms for adverse effects of high iron status during pregnancy. Overall, we confirmed a U-shaped curve for the risk of adverse birth outcomes with maternal hemoglobin concentrations, but the relations differ by trimester. For low hemoglobin concentrations, the link with adverse outcomes is more evident when hemoglobin concentrations are measured in early pregnancy. These relations generally became weaker or nonexistent when hemoglobin concentrations are measured in the second or third trimesters. Associations between high hemoglobin concentration and adverse birth outcomes are evident in all 3 trimesters but evidence is mixed. There is less evidence for the associations between maternal iron status and adverse birth outcomes. Most studies used serum ferritin (SF) concentrations as the indicator of iron status, which makes the interpretation of results challenging because SF concentrations increase in response to inflammation or infection. The effect of iron supplementation during pregnancy may depend on initial iron status. There are several mechanisms through which high iron status during pregnancy may have adverse effects on birth outcomes, including oxidative stress, increased blood viscosity, and impaired systemic response to inflammation and infection. Research is needed to understand the biological processes that underlie the U-shaped curves seen in observational studies. Reevaluation of cutoffs for hemoglobin concentrations and indicators of iron status during pregnancy is also needed.
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Affiliation(s)
- Kathryn G Dewey
- Program in International and Community Nutrition and Department of Nutrition, University of California, Davis, CA
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82
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Prado EL, Ashorn U, Phuka J, Maleta K, Sadalaki J, Oaks BM, Haskell M, Allen LH, Vosti SA, Ashorn P, Dewey KG. Associations of maternal nutrition during pregnancy and post-partum with maternal cognition and caregiving. MATERNAL AND CHILD NUTRITION 2017; 14:e12546. [PMID: 29098783 PMCID: PMC5901033 DOI: 10.1111/mcn.12546] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 08/16/2017] [Accepted: 09/19/2017] [Indexed: 11/30/2022]
Abstract
Pregnant and post-partum women require increased nutrient intake and optimal cognition, which depends on adequate nutrition, to enable reasoning and learning for caregiving. We aimed to assess (a) differences in maternal cognition and caregiving between women in Malawi who received different nutritional supplements, (b) 14 effect modifiers, and (c) associations of cognition and caregiving with biomarkers of iron, Vitamin A, B-vitamin, and fatty acid status. In a randomized controlled trial (n = 869), pregnant women daily received either multiple micronutrients (MMN), 20 g/day lipid-based nutrient supplements (LNS), or a control iron/folic acid (IFA) tablet. After delivery, supplementation continued in the MMN and LNS arms, and the IFA control group received placebo until 6 months post-partum, when cognition (n = 712), caregiving behaviour (n = 669), and biomarkers of nutritional status (n = 283) were assessed. In the full group, only one difference was significant: the IFA arm scored 0.22 SD (95% CI [0.01, 0.39], p = .03) higher than the LNS arm in mental rotation. Among subgroups of women with baseline low hemoglobin, poor iron status, or malaria, those who received LNS scored 0.4 to 0.7 SD higher than the IFA arm in verbal fluency. Breastmilk docosahexaenoic acid and Vitamin B12 concentrations were positively associated with verbal fluency and digit span forward (adjusting for covariates ps < .05). In this population in Malawi, maternal supplementation with MMN or LNS did not positively affect maternal cognition or caregiving. Maternal docosahexaenoic acid and B12 status may be important for post-partum attention and executive function.
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Affiliation(s)
- Elizabeth L Prado
- Department of Nutrition, University of California Davis, Davis, California, USA
| | - Ulla Ashorn
- Center for Child Health Research, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland
| | - John Phuka
- School of Public Health and Family Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Kenneth Maleta
- School of Public Health and Family Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - John Sadalaki
- School of Public Health and Family Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Brietta M Oaks
- Department of Nutrition, University of California Davis, Davis, California, USA
| | - Marjorie Haskell
- Department of Nutrition, University of California Davis, Davis, California, USA
| | - Lindsay H Allen
- Department of Nutrition, University of California Davis, Davis, California, USA.,USDA, ARS Western Human Nutrition Research Center, University of California Davis, Davis, California, USA
| | - Steve A Vosti
- Department of Agricultural and Resource Economics, University of California Davis, Davis, California, USA
| | - Per Ashorn
- Center for Child Health Research, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland.,Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Kathryn G Dewey
- Department of Nutrition, University of California Davis, Davis, California, USA
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Smith ER, Shankar AH, Wu LSF, Aboud S, Adu-Afarwuah S, Ali H, Agustina R, Arifeen S, Ashorn P, Bhutta ZA, Christian P, Devakumar D, Dewey KG, Friis H, Gomo E, Gupta P, Kæstel P, Kolsteren P, Lanou H, Maleta K, Mamadoultaibou A, Msamanga G, Osrin D, Persson LÅ, Ramakrishnan U, Rivera JA, Rizvi A, Sachdev HPS, Urassa W, West KP, Zagre N, Zeng L, Zhu Z, Fawzi WW, Sudfeld CR. Modifiers of the effect of maternal multiple micronutrient supplementation on stillbirth, birth outcomes, and infant mortality: a meta-analysis of individual patient data from 17 randomised trials in low-income and middle-income countries. Lancet Glob Health 2017; 5:e1090-e1100. [PMID: 29025632 DOI: 10.1016/s2214-109x(17)30371-6] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/24/2017] [Accepted: 08/18/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Micronutrient deficiencies are common among women in low-income and middle-income countries. Data from randomised trials suggest that maternal multiple micronutrient supplementation decreases the risk of low birthweight and potentially improves other infant health outcomes. However, heterogeneity across studies suggests influence from effect modifiers. We aimed to identify individual-level modifiers of the effect of multiple micronutrient supplements on stillbirth, birth outcomes, and infant mortality in low-income and middle-income countries. METHODS This two-stage meta-analysis of individual patient included data from 17 randomised controlled trials done in 14 low-income and middle-income countries, which compared multiple micronutrient supplements containing iron-folic acid versus iron-folic acid alone in 112 953 pregnant women. We generated study-specific estimates and pooled subgroup estimates using fixed-effects models and assessed heterogeneity between subgroups with the χ2 test for heterogeneity. We did sensitivity analyses using random-effects models, stratifying by iron-folic acid dose, and exploring individual study effect. FINDINGS Multiple micronutrient supplements containing iron-folic acid provided significantly greater reductions in neonatal mortality for female neonates compared with male neonates than did iron-folic acid supplementation alone (RR 0·85, 95% CI 0·75-0·96 vs 1·06, 0·95-1·17; p value for interaction 0·007). Multiple micronutrient supplements resulted in greater reductions in low birthweight (RR 0·81, 95% CI 0·74-0·89; p value for interaction 0·049), small-for-gestational-age births (0·92, 0·87-0·97; p=0·03), and 6-month mortality (0·71, 0·60-0·86; p=0·04) in anaemic pregnant women (haemoglobin <110g/L) as compared with non-anaemic pregnant women. Multiple micronutrient supplements also had a greater effect on preterm births among underweight pregnant women (BMI <18·5 kg/m2; RR 0·84, 95% CI 0·78-0·91; p=0·01). Initiation of multiple micronutrient supplements before 20 weeks gestation provided greater reductions in preterm birth (RR 0·89, 95% CI 0·85-0·93; p=0·03). Generally, the survival and birth outcome effects of multiple micronutrient supplementation were greater with high adherence (≥95%) to supplementation. Multiple micronutrient supplements did not significantly increase the risk of stillbirth or neonatal, 6-month, or infant mortality, neither overall or in any of the 26 examined subgroups. INTERPRETATION Antenatal multiple micronutrient supplements improved survival for female neonates and provided greater birth-outcome benefits for infants born to undernourished and anaemic pregnant women. Early initiation in pregnancy and high adherence to multiple micronutrient supplements also provided greater overall benefits. Studies should now aim to elucidate the mechanisms accounting for differences in the effect of antenatal multiple micronutrient supplements on infant health by maternal nutrition status and sex. FUNDING None.
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Affiliation(s)
- Emily R Smith
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Anuraj H Shankar
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Summit Institute of Development, Mataram, Indonesia
| | - Lee S-F Wu
- The JiVitA Project, Johns Hopkins University in Bangladesh, Gaibandha, Bangladesh; Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Said Aboud
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Hasmot Ali
- The JiVitA Project, Johns Hopkins University in Bangladesh, Gaibandha, Bangladesh; Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Rina Agustina
- Summit Institute of Development, Mataram, Indonesia; Department of Nutrition, Faculty of Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Shams Arifeen
- International Centre for Diarrhoeal Diseases Research Bangladesh (ICDDR,B), Dhaka, Bangladesh
| | - Per Ashorn
- Centre for Child Health Research and Department of Paediatrics, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland
| | - Zulfiqar A Bhutta
- Center for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Parul Christian
- The JiVitA Project, Johns Hopkins University in Bangladesh, Gaibandha, Bangladesh; Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Kathryn G Dewey
- Department of Nutrition and Program in International and Community Nutrition, University of California-Davis, Davis, CA, USA
| | - Henrik Friis
- Department of Nutrition Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Exnevia Gomo
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Piyush Gupta
- Department of Pediatrics, University College of Medical Sciences, Delhi, India
| | - Pernille Kæstel
- Department of Nutrition Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Patrick Kolsteren
- Nutrition and Child Health Unit, Department of Public Health, Prince Leopold Institute of Tropical Medicine, Antwerp, Belgium; Faculty of Bio-science engineering, Ghent University, Belgium
| | - Hermann Lanou
- Institut de Recherche en Sciences de la Santé, Ministry of Scientific Research and Innovation, Ouagadougou, Burkina Faso
| | - Kenneth Maleta
- School of Public Health and Family Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | | | - Gernard Msamanga
- Department of Community Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Lars-Åke Persson
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden
| | - Usha Ramakrishnan
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, USA
| | - Juan A Rivera
- Instituto Nacional de Salud Publica, Cuernavaca, Mexico
| | - Arjumand Rizvi
- Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan
| | - H P S Sachdev
- Pediatric and Clinical Epidemiology Unit, Sitar am Bhartia Institute of Science and Research, New Delhi, India
| | - Willy Urassa
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Keith P West
- The JiVitA Project, Johns Hopkins University in Bangladesh, Gaibandha, Bangladesh; Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Noel Zagre
- UNICEF Regional Office for West and Central Africa, Dakar, Senegal
| | - Lingxia Zeng
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, China
| | - Zhonghai Zhu
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi Province, China
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
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84
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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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85
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Jorgensen JM, Arnold C, Ashorn P, Ashorn U, Chaima D, Cheung YB, Davis JCC, Fan YM, Goonatilleke E, Kortekangas E, Kumwenda C, Lebrilla CB, Maleta K, Totten SM, Wu LD, Dewey KG. Lipid-Based Nutrient Supplements During Pregnancy and Lactation Did Not Affect Human Milk Oligosaccharides and Bioactive Proteins in a Randomized Trial. J Nutr 2017; 147:1867-1874. [PMID: 28794206 PMCID: PMC5610548 DOI: 10.3945/jn.117.252981] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 05/12/2017] [Accepted: 07/10/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Human milk oligosaccharides (HMOs) and bioactive proteins are beneficial to infant health. Recent evidence suggests that maternal nutrition may affect the amount of HMOs and proteins in breast milk; however, the effect of nutrient supplementation on HMOs and bioactive proteins has not yet been well studied. OBJECTIVE We aimed to determine whether lipid-based nutrient supplements (LNSs) affect milk bioactive protein and HMO concentrations at 6 mo postpartum in women in rural Malawi. These are secondary outcomes of a previously published randomized controlled trial. METHODS Women were randomly assigned to consume either an iron and folic acid capsule (IFA) daily from ≤20 wk gestation until delivery, followed by placebo daily from delivery to 6 mo postpartum, or a multiple micronutrient (MMN) capsule or LNS daily from ≤20 wk gestation to 6 mo postpartum. Breast milk concentrations of total HMOs, sialylated HMOs, fucosylated HMOs, lactoferrin, lactalbumin, lysozymes, antitrypsin, immunoglobulin A, and osteopontin were analyzed at 6 mo postpartum (n = 647). Between-group differences in concentrations and in proportions of women classified as having low concentrations were tested. RESULTS HMO and bioactive protein concentrations did not differ between groups (P > 0.10 for all comparisons). At 6 mo postpartum, the proportions of women with low HMOs or bioactive proteins were not different between groups except for osteopontin. A lower proportion of women in the IFA group had low osteopontin compared with the LNS group after adjusting for covariates (OR: 0.5; 95% CI: 0.3, 0.9; P = 0.016). CONCLUSION The study findings do not support the hypothesis that supplementation with an LNS or MMN capsule during pregnancy and postpartum would increase HMO or bioactive milk proteins at 6 mo postpartum among Malawian women. This trial was registered at clinicaltrials.gov as NCT01239693.
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Affiliation(s)
| | | | - Per Ashorn
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland;,Department of Pediatrics, Tampere University Hospital, Tampere, Finland
| | - Ulla Ashorn
- Biochemistry and Molecular Medicine, University of California, Davis, Davis, CA
| | - David Chaima
- Department of Community Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Yin Bun Cheung
- Centre for Quantitative Medicine, Duke-National University of Singapore Graduate Medical School, Singapore, Singapore; and,Department of Biostatistics, Singapore Clinical Research Institute, Singapore, Singapore
| | | | - Yue-Mei Fan
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | | | - Emma Kortekangas
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Chiza Kumwenda
- Department of Community Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Carlito B Lebrilla
- Chemistry, and,Biochemistry and Molecular Medicine, University of California, Davis, Davis, CA
| | - Kenneth Maleta
- Department of Community Health, University of Malawi College of Medicine, Blantyre, Malawi
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86
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Callaghan-Gillespie M, Schaffner AA, Garcia P, Fry J, Eckert R, Malek S, Trehan I, Thakwalakwa C, Maleta KM, Manary MJ, Papathakis PC. Trial of ready-to-use supplemental food and corn-soy blend in pregnant Malawian women with moderate malnutrition: a randomized controlled clinical trial. Am J Clin Nutr 2017; 106:1062-1069. [PMID: 28793991 PMCID: PMC6483045 DOI: 10.3945/ajcn.117.157198] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 06/14/2017] [Indexed: 01/16/2023] Open
Abstract
Background Malnutrition during pregnancy in sub-Saharan Africa is associated with poor birth outcomes. Objective This study compared maternal and offspring anthropometry for moderately malnourished pregnant women receiving ready-to-use supplemental food (RUSF), a fortified corn-soy blend (CSB+) with a daily multiple micronutrient antenatal supplement [United Nations International Multiple Micronutrient Preparation (UNIMMAP)], or standard of care comprising CSB+ and iron and folic acid (IFA). Design A single-blind randomized controlled clinical trial was conducted in southern Malawi among 1828 pregnant women with moderate malnutrition, defined as a midupper arm circumference (MUAC) ≥20.6 and ≤23.0 cm. Women received 1 of 3 dietary treatment regimens that provided ∼900 kcal/d and 33-36 g protein/d. Maternal and infant anthropometry were followed until the child was 3 mo old. Results Newborns had a mean length-for-age z score of -1.3 ± 1.2 and 22% were stunted at birth. Mothers receiving RUSF had the highest weight gain during supplementation (3.4 ± 2.6, 3.0 ± 2.2, and 3.2 ± 2.4 kg for the RUSF, CSB+ with UNIMMAP, and CSB+ with IFA groups, respectively; P = 0.03). Newborn birth weights and lengths were similar across intervention groups, but the incidence of newborns with a birth weight <2.4 kg (weight-for-age z score <-2) was higher in the CSB+ with UNIMMAP group than the other groups (17%, 18%, and 24% for the CSB+ with IFA, RUSF, and CSB+ with UNIMMAP groups, respectively; P = 0.02). At birth, HIV-exposed newborns had a similar length and weight as newborns without HIV exposure, but their head circumference was smaller (34.0 ± 1.5 and 34.3 ± 1.6 cm, respectively; P = 0.02). At 3 mo of age, HIV-exposed infants had smaller weights, lengths, and head and arm circumferences than infants without HIV exposure. Conclusions RUSF improved maternal weight gain compared with CSB+ with UNIMMAP. The large amount of food given and the modest effect on linear growth in newborns suggests that stunting in utero is unlikely to be reduced by supplemental food alone. This trial was registered at clinicaltrials.gov as NCT02120599.
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Affiliation(s)
| | - Andrew A Schaffner
- Department of Statistics, California Polytechnic State University, San Luis Obispo, CA
| | - Patsy Garcia
- Department of Statistics, California Polytechnic State University, San Luis Obispo, CA
| | - Jocelyn Fry
- Department of Nutrition and Food Science, California Polytechnic State University, San Luis Obispo, CA
| | - Rachael Eckert
- Department of Nutrition and Food Science, California Polytechnic State University, San Luis Obispo, CA
| | - Shirin Malek
- Department of Nutrition and Food Science, California Polytechnic State University, San Luis Obispo, CA
| | - Indi Trehan
- Department of Pediatrics, Washington University, St. Louis, MO
- School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Chrissie Thakwalakwa
- School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Kenneth M Maleta
- School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Mark J Manary
- Department of Pediatrics, Washington University, St. Louis, MO
- School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Peggy C Papathakis
- Department of Nutrition and Food Science, California Polytechnic State University, San Luis Obispo, CA
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87
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Adu-Afarwuah S, Lartey A, Dewey KG. Meeting nutritional needs in the first 1000 days: a place for small-quantity lipid-based nutrient supplements. Ann N Y Acad Sci 2017; 1392:18-29. [PMID: 28319655 DOI: 10.1111/nyas.13328] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 01/28/2017] [Accepted: 02/06/2017] [Indexed: 02/06/2023]
Abstract
The first 1000 days of life is marked by intense metabolic activity and tissue deposition. The increased nutritional needs during this period, and the challenges to meeting them, are often not understood or appreciated. Here, we describe the nutritional needs during the first 1000 days, highlight the challenges to meeting these needs in developing countries, outline intervention strategies, and examine the consumption of small-quantity lipid-based nutrient supplements (SQ-LNS) as a promising strategy. In low-income settings, the challenge to meeting nutritional needs during the first 1000 days is worsened by overreliance on cereal-based diets of low nutrient density and high prevalence of infections and infestations. Dietary diversification is the ideal long-term solution to nutritional deficiencies, but difficulties with obtaining adequate amounts of iron, zinc, and certain vitamins may still remain. Several other interventions are available, but applying them is often fraught with challenges, including cost and contextual factors limiting efficacy. Evidence suggests that SQ-LNS supplementation may help reduce inadequate gestational weight gain and promote fetal and child growth and development in some populations. More research is needed to evaluate the effectiveness of SQ-LNS and other fortified products in different contexts and within integrated programs that address other determinants of maternal and child undernutrition.
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Affiliation(s)
- Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Anna Lartey
- Food and Agriculture Organization of the United Nations, Rome, Italy
| | - Kathryn G Dewey
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, California
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88
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Cates JE, Unger HW, Briand V, Fievet N, Valea I, Tinto H, D’Alessandro U, Landis SH, Adu-Afarwuah S, Dewey KG, ter Kuile FO, Desai M, Dellicour S, Ouma P, Gutman J, Oneko M, Slutsker L, Terlouw DJ, Kariuki S, Ayisi J, Madanitsa M, Mwapasa V, Ashorn P, Maleta K, Mueller I, Stanisic D, Schmiegelow C, Lusingu JPA, van Eijk AM, Bauserman M, Adair L, Cole SR, Westreich D, Meshnick S, Rogerson S. Malaria, malnutrition, and birthweight: A meta-analysis using individual participant data. PLoS Med 2017; 14:e1002373. [PMID: 28792500 PMCID: PMC5549702 DOI: 10.1371/journal.pmed.1002373] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 07/11/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Four studies previously indicated that the effect of malaria infection during pregnancy on the risk of low birthweight (LBW; <2,500 g) may depend upon maternal nutritional status. We investigated this dependence further using a large, diverse study population. METHODS AND FINDINGS We evaluated the interaction between maternal malaria infection and maternal anthropometric status on the risk of LBW using pooled data from 14,633 pregnancies from 13 studies (6 cohort studies and 7 randomized controlled trials) conducted in Africa and the Western Pacific from 1996-2015. Studies were identified by the Maternal Malaria and Malnutrition (M3) initiative using a convenience sampling approach and were eligible for pooling given adequate ethical approval and availability of essential variables. Study-specific adjusted effect estimates were calculated using inverse probability of treatment-weighted linear and log-binomial regression models and pooled using a random-effects model. The adjusted risk of delivering a baby with LBW was 8.8% among women with malaria infection at antenatal enrollment compared to 7.7% among uninfected women (adjusted risk ratio [aRR] 1.14 [95% confidence interval (CI): 0.91, 1.42]; N = 13,613), 10.5% among women with malaria infection at delivery compared to 7.9% among uninfected women (aRR 1.32 [95% CI: 1.08, 1.62]; N = 11,826), and 15.3% among women with low mid-upper arm circumference (MUAC <23 cm) at enrollment compared to 9.5% among women with MUAC ≥ 23 cm (aRR 1.60 [95% CI: 1.36, 1.87]; N = 9,008). The risk of delivering a baby with LBW was 17.8% among women with both malaria infection and low MUAC at enrollment compared to 8.4% among uninfected women with MUAC ≥ 23 cm (joint aRR 2.13 [95% CI: 1.21, 3.73]; N = 8,152). There was no evidence of synergism (i.e., excess risk due to interaction) between malaria infection and MUAC on the multiplicative (p = 0.5) or additive scale (p = 0.9). Results were similar using body mass index (BMI) as an anthropometric indicator of nutritional status. Meta-regression results indicated that there may be multiplicative interaction between malaria infection at enrollment and low MUAC within studies conducted in Africa; however, this finding was not consistent on the additive scale, when accounting for multiple comparisons, or when using other definitions of malaria and malnutrition. The major limitations of the study included availability of only 2 cross-sectional measurements of malaria and the limited availability of ultrasound-based pregnancy dating to assess impacts on preterm birth and fetal growth in all studies. CONCLUSIONS Pregnant women with malnutrition and malaria infection are at increased risk of LBW compared to women with only 1 risk factor or none, but malaria and malnutrition do not act synergistically.
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Affiliation(s)
- Jordan E. Cates
- Department of Epidemiology, UNC-Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Holger W. Unger
- Department of Obstetrics and Gynaecology, Edinburgh Royal Infirmary, Edinburgh, United Kingdom
- Department of Medicine at the Doherty Institute, The University of Melbourne, Parkville, Victoria, Australia
| | - Valerie Briand
- UMR216-MERIT, French National Research Institute for Sustainable Development (IRD), Paris Descartes University, Paris, France
| | - Nadine Fievet
- UMR216-MERIT, French National Research Institute for Sustainable Development (IRD), Paris Descartes University, Paris, France
| | - Innocent Valea
- Unite de Recherche Clinique de Nanoro, Institut de Recherche en Sciences de la Santé-DRO, Bobo-Dioulasso, Burkina Faso
- Departement de Recherche Clinique, Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Halidou Tinto
- Unite de Recherche Clinique de Nanoro, Institut de Recherche en Sciences de la Santé-DRO, Bobo-Dioulasso, Burkina Faso
- Departement de Recherche Clinique, Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Umberto D’Alessandro
- Medical Research Council Unit, The Gambia; London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sarah H. Landis
- Worldwide Epidemiology, GlaxoSmithKline, Uxbridge, United Kingdom
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Kathryn G. Dewey
- Department of Nutrition, University of California, Davis, California, United States of America
| | - Feiko O. ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Meghna Desai
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Stephanie Dellicour
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Peter Ouma
- Kenya Medical Research Institute (KEMRI)/ Centre for Global Health Research, Kisumu, Kenya
| | - Julie Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Martina Oneko
- Kenya Medical Research Institute (KEMRI)/ Centre for Global Health Research, Kisumu, Kenya
| | - Laurence Slutsker
- Malaria and Neglected Tropical Diseases, Center for Malaria Control and Elimination, PATH, Seattle, Washington, United States of America
| | - Dianne J. Terlouw
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Simon Kariuki
- Kenya Medical Research Institute (KEMRI)/ Centre for Global Health Research, Kisumu, Kenya
| | - John Ayisi
- Kenya Medical Research Institute (KEMRI)/ Centre for Global Health Research, Kisumu, Kenya
| | - Mwayiwawo Madanitsa
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Victor Mwapasa
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Per Ashorn
- Center for Child Health Research University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland
| | - Kenneth Maleta
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Ivo Mueller
- Walter and Eliza Hall Institute, Parkville, Victoria, Australia
| | - Danielle Stanisic
- Institute for Glycomics, Griffith University, Gold Coast, Queensland, Australia
| | - Christentze Schmiegelow
- Centre for Medical Parasitology, Depart. Of Immunology and Microbiology, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark
| | - John P. A. Lusingu
- Centre for Medical Parasitology, Depart. Of Immunology and Microbiology, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Melissa Bauserman
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, School of Medicine, UNC-Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Nutrition, UNC-Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Linda Adair
- Department of Nutrition, UNC-Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Stephen R. Cole
- Department of Epidemiology, UNC-Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Daniel Westreich
- Department of Epidemiology, UNC-Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Steven Meshnick
- Department of Epidemiology, UNC-Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Stephen Rogerson
- Department of Medicine at the Doherty Institute, The University of Melbourne, Parkville, Victoria, Australia
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Doyle RM, Harris K, Kamiza S, Harjunmaa U, Ashorn U, Nkhoma M, Dewey KG, Maleta K, Ashorn P, Klein N. Bacterial communities found in placental tissues are associated with severe chorioamnionitis and adverse birth outcomes. PLoS One 2017; 12:e0180167. [PMID: 28700642 PMCID: PMC5507499 DOI: 10.1371/journal.pone.0180167] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 06/12/2017] [Indexed: 01/12/2023] Open
Abstract
Preterm birth is a major cause of neonatal mortality and morbidity worldwide. Bacterial infection and the subsequent inflammatory response are recognised as an important cause of preterm birth. It is hypothesised that these organisms ascend the cervical canal, colonise placental tissues, cause chorioamnionitis and in severe cases infect amniotic fluid and the foetus. However, the presence of bacteria within the intrauterine cavity does not always precede chorioamnionitis or preterm birth. Whereas previous studies observing the types of bacteria present have been limited in size and the specificity of a few predetermined organisms, in this study we characterised bacteria found in placental tissues from a cohort of 1391 women in rural Malawi using 16S ribosomal RNA gene sequencing. We found that specific bacteria found concurrently on placental tissues associate with chorioamnionitis and delivery of a smaller newborn. Severe chorioamnionitis was associated with a distinct difference in community members, a higher bacterial load and lower species richness. Furthermore, Sneathia sanguinengens and Peptostreptococcus anaerobius found in both matched participant vaginal and placental samples were associated with a lower newborn length-for-age Z-score. This is the largest study to date to examine the placental microbiome and its impact of birth outcomes. Our results provide data on the role of the vaginal microbiome as a source of placental infection as well as the possibility of therapeutic interventions against targeted organisms during pregnancy.
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Affiliation(s)
- Ronan M. Doyle
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Department of Microbiology, Virology and Infection Control, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
- * E-mail:
| | - Kathryn Harris
- Department of Microbiology, Virology and Infection Control, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - Steve Kamiza
- Department of Pathology, University of Malawi College of Medicine, Blantyre, Malawi
| | - Ulla Harjunmaa
- Center for Child Health Research, University of Tampere Faculty of Medicine and Life Sciences, and Tampere University Hospital, Tampere, Finland
| | - Ulla Ashorn
- Department for International Health, University of Tampere School of Medicine, Tampere, Finland
| | - Minyanga Nkhoma
- Department for International Health, University of Tampere School of Medicine, Tampere, Finland
| | - Kathryn G. Dewey
- Department of Nutrition, University of California Davis, Davis, California, United States of America
| | - Kenneth Maleta
- Department of Community Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Per Ashorn
- Department for International Health, University of Tampere School of Medicine, Tampere, Finland
- Department of Paediatrics, University of Tampere School of Medicine, Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Nigel Klein
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
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90
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Effect of 12-month intervention with lipid-based nutrient supplement on the physical activity of Malawian toddlers: a randomised, controlled trial. Br J Nutr 2017; 117:511-518. [PMID: 28382892 PMCID: PMC5426340 DOI: 10.1017/s0007114517000290] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Physical activity is beneficial for children’s well-being. The effect of dietary
supplementation on children’s physical activity in food-insecure areas remains little
studied. We examined the effects of a lipid-based nutrient supplement (LNS) on children’s
objectively measured physical activity in a randomised, controlled,
outcome-assessor-blinded trial. Mothers of the children received one capsule daily of
Fe-folic acid (IFA), one capsule containing eighteen micronutrients (MMN) or one 20 g
sachet of LNS (containing twenty-two MMN, protein, carbohydrates, essential fatty acids
and 494 kJ (118 kcal)) during pregnancy and for 6 months thereafter. Children in the IFA
and MMN groups received no supplementation, and these groups were collapsed into a single
control group; children in the LNS group received 20 g LNS from 6 to 18 months. We
measured physical activity with accelerometers over 1 week at 18 months. The main outcome
was mean vector magnitude counts/15 s. Of the 728 children at the beginning of child
intervention at 6 months, 570 (78 %) provided sufficient data for analysis. The mean
accelerometer counts for the 190 children in the LNS group and for the 380 children in the
control group were 303 (sd 59) and 301 (sd 56), respectively (Pfor difference=0·65). LNS, given to mothers during pregnancy and 6 months
postpartum and to their infants from 6 to 18 months of age, did not increase physical
activity among 18-month-old children.
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91
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Jobarteh ML, McArdle HJ, Holtrop G, Sise EA, Prentice AM, Moore SE. mRNA Levels of Placental Iron and Zinc Transporter Genes Are Upregulated in Gambian Women with Low Iron and Zinc Status. J Nutr 2017; 147:1401-1409. [PMID: 28515164 PMCID: PMC5483961 DOI: 10.3945/jn.116.244780] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 01/12/2017] [Accepted: 03/30/2017] [Indexed: 12/22/2022] Open
Abstract
Background: The role of the placenta in regulating micronutrient transport in response to maternal status is poorly understood. Objective: We investigated the effect of prenatal nutritional supplementation on the regulation of placental iron and zinc transport. Methods: In a randomized trial in rural Gambia [ENID (Early Nutrition and Immune Development)], pregnant women were allocated to 1 of 4 nutritional intervention arms: 1) iron and folic acid (FeFol) tablets (FeFol group); 2) multiple micronutrient (MMN) tablets (MMN group); 3) protein energy (PE) as a lipid-based nutrient supplement (LNS; PE group); and 4) PE and MMN (PE+MMN group) as LNS. All arms included iron (60 mg/d) and folic acid (400 μg/d). The MMN and PE+MMN arms included 30 mg supplemental Zn/d. In a subgroup of ∼300 mother-infant pairs, we measured maternal iron status, mRNA levels of genes encoding for placental iron and zinc transport proteins, and cord blood iron levels. Results: Maternal plasma iron concentration in late pregnancy was 45% and 78% lower in the PE and PE+MMN groups compared to the FeFol and MMN groups, respectively (P < 0.001). The mRNA levels of the placental iron uptake protein transferrin receptor 1 were 30–49% higher in the PE and PE+MMN arms than in the FeFol arm (P < 0.031), and also higher in the PE+MMN arm (29%; P = 0.042) than in the MMN arm. Ferritin in infant cord blood was 18–22% lower in the LNS groups (P < 0.024). Zinc supplementation in the MMN arm was associated with higher maternal plasma zinc concentrations (10% increase; P < 0.001) than in other intervention arms. mRNA levels for intracellular zinc-uptake proteins, in this case zrt, irt-like protein (ZIP) 4 and ZIP8, were 96–205% lower in the PE+MMN arm than in the intervention arms without added zinc (P < 0.025). Furthermore, mRNA expression of ZIP1 was 85% lower in the PE+MMN group than in the PE group (P = 0.003). Conclusion: In conditions of low maternal iron and in the absence of supplemental zinc, the placenta upregulates the gene expression of iron and zinc uptake proteins, presumably in order to meet fetal demands in the face of low maternal supply. The ENID trial was registered at www.controlled-trials.com as ISRCTN49285450.
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Affiliation(s)
- Modou Lamin Jobarteh
- Medical Research Council Unit The Gambia, Banjul, The Gambia.,Rowett Institute of Nutrition and Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Harry J McArdle
- Rowett Institute of Nutrition and Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Grietje Holtrop
- Biomathematics and Statistics Scotland (BioSS), Aberdeen, United Kingdom; and
| | - Ebrima A Sise
- Medical Research Council Unit The Gambia, Banjul, The Gambia
| | | | - Sophie E Moore
- Medical Research Council Unit The Gambia, Banjul, The Gambia; .,Division of Women's Health, King's College London, London, United Kingdom
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92
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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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93
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Lipid-based Nutrient Supplements Do Not Affect Gut Bifidobacterium Microbiota in Malawian Infants: A Randomized Trial. J Pediatr Gastroenterol Nutr 2017; 64:610-615. [PMID: 27403608 DOI: 10.1097/mpg.0000000000001333] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The aim of the study was to assess the effect of nutritional supplementation with lipid-based nutrient supplements (LNS) and corn-soy blend flour on Bifidobacterium and Staphylococcus aureus gut microbiota composition in Malawian infants. In addition, the microbiota changes over time were characterized in the study infants. METHODS Healthy 6-month-old Malawian infants were randomly assigned to 1 of 4 intervention schemes for a 6-month period. Infants in the control group were not provided with any supplementary food. Infants in other 3 groups received either micronutrient-fortified corn-soy blend, micronutrient-fortified LNS with milk protein base, or micronutrient-fortified LNS with soy protein base between 6 and 12 months of age. Fecal bifidobacteria and S aureus gut microbiota at 6 and 12 months of age were analyzed by quantitative real-time polymerase chain reaction method. RESULTS There was no difference in change in bacterial prevalence or counts between the intervention groups during the 6-month study period. When looking at the total study population, higher counts of total bacteria (P = 0.028), Bifidobacterium genus (P = 0.027), B catenulatum (P = 0.031), and lower counts of B infantis (P < 0.001), B lactis (P < 0.001), B longum (P < 0.001), and S aureus (P < 0.001) were detected in the children's stools at 12 months rather than at 6 months of age. CONCLUSIONS The dietary supplementation did not have an effect on the Bifidobacterium and S aureus microbiota composition of the study infants. The fecal bifidobacterial diversity of the infants, however, changed toward a more adult-like microbiota profile within the observed time.
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94
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Stewart RC, Ashorn P, Umar E, Dewey KG, Ashorn U, Creed F, Rahman A, Tomenson B, Prado EL, Maleta K. The impact of maternal diet fortification with lipid-based nutrient supplements on postpartum depression in rural Malawi: a randomised-controlled trial. MATERNAL & CHILD NUTRITION 2017; 13:e12299. [PMID: 27060705 PMCID: PMC6866218 DOI: 10.1111/mcn.12299] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 12/18/2015] [Accepted: 01/04/2016] [Indexed: 01/31/2023]
Abstract
Perinatal depression is highly prevalent in low-and-middle-income countries and has been linked to poor child health. Suboptimal maternal nutrition may be a risk factor for perinatal depression. In this randomised-controlled trial conducted in rural Malawi, we set out to test the hypothesis that women taking a fatty acid-rich lipid-based nutrient supplement (LNS) would have fewer depressive symptoms postpartum than those taking iron-folate (IFA) or multiple-micronutrient (MMN) capsules. Women were recruited from antenatal clinics and randomised to receive LNS or MMN during pregnancy and for 6 months postpartum, or IFA during pregnancy only. Maternal depressive symptoms were measured using validated translations of the Self Reporting Questionnaire (SRQ) and Edinburgh Postnatal Depression Scale (EPDS), antenatally (SRQ only) and at 6 months postpartum (SRQ and EPDS). Analysis was by modified intention to treat. One thousand three hundred and ninety one women were randomised (LNS = 462, MMN = 466, IFA = 463). The groups were similar across a range of baseline variables. At 6 months postpartum, 1078 (77.5%) had SRQ completed; mean (SD) scores were LNS 1.76(2.73), MMN 1.92(2.75), IFA 1.71(2.66), P = 0.541. One thousand and fifty seven (76.0%) had EPDS completed; mean (SD) scores were LNS 5.77(5.53), MMN 5.43(4.97), IFA 5.52(5.18), P = 0.676. There were no statistically significant differences between the groups on SRQ or EPDS scores (continuous or dichotomised) in unadjusted or adjusted models. In conclusion, fortification of maternal diet with LNS compared with MMN or IFA did not reduce postnatal depressive symptoms in this study.
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Affiliation(s)
- Robert C. Stewart
- Manchester Mental Health and Social Care NHS Trust, ManchesterUK and Institute of Brain, Behaviour and Mental Health, University of ManchesterUK
| | - Per Ashorn
- Department for International HealthUniversity of Tampere School of Medicine, Finland and Department of Pediatrics, Tampere University HospitalFinland
| | - Eric Umar
- Department of Community Health, College of MedicineUniversity of MalawiMalawi
| | | | - Ulla Ashorn
- Department for International HealthUniversity of Tampere School of MedicineFinland
| | - Francis Creed
- Institute of Brain, Behaviour and Mental HealthUniversity of ManchesterUK
| | - Atif Rahman
- Institute of Psychology, Health and SocietyUniversity of LiverpoolUK
| | - Barbara Tomenson
- Biostatistics Unit, Institute of Population HealthUniversity of ManchesterUK
| | | | - Ken Maleta
- Department of Community Health, College of MedicineUniversity of MalawiMalawi
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95
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Oaks BM, Young RR, Adu-Afarwuah S, Ashorn U, Jackson KH, Lartey A, Maleta K, Okronipa H, Sadalaki J, Baldiviez LM, Shahab-Ferdows S, Ashorn P, Dewey KG. Effects of a lipid-based nutrient supplement during pregnancy and lactation on maternal plasma fatty acid status and lipid profile: Results of two randomized controlled trials. Prostaglandins Leukot Essent Fatty Acids 2017; 117:28-35. [PMID: 28237085 PMCID: PMC5338685 DOI: 10.1016/j.plefa.2017.01.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 01/10/2017] [Accepted: 01/24/2017] [Indexed: 11/29/2022]
Abstract
It is unknown whether a novel small-quantity lipid-based nutrient supplement (SQ-LNS) containing alpha-linolenic (ALA) and linoleic acids impacts maternal plasma lipids and fatty acid status. We measured plasma fatty acids (wt%) and lipid concentrations at 36 wk gestation and breast milk fatty acids (wt%) at 6 months postpartum in a subsample of women enrolled in a randomized controlled trial studying the effects of SQ-LNS on birth outcomes and child growth. Women≤20 wk gestation in Ghana (n=1,320) and Malawi (n=1,391) were assigned to receive daily either: 1) iron-folic acid (pregnancy); 2) multiple micronutrients (pregnancy and lactation); or 3) SQ-LNS (pregnancy and lactation). At 36 wk, plasma ALA levels were higher in those receiving SQ-LNS. SQ-LNS increased breast milk ALA in Ghana but not Malawi. There was no effect on plasma lipids or other selected fatty acids. SQ-LNS may impact plasma and breast milk ALA levels depending on the population.
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Affiliation(s)
- Brietta M Oaks
- Program in International and Community Nutrition, Department of Nutrition, University of California, 3135 Meyer Hall, One Shields Avenue, Davis, CA 95616, USA.
| | - Rebecca R Young
- Program in International and Community Nutrition, Department of Nutrition, University of California, 3135 Meyer Hall, One Shields Avenue, Davis, CA 95616, USA
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Ghana
| | - Ulla Ashorn
- Center for Child Health Research, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland
| | | | - Anna Lartey
- Department of Nutrition and Food Science, University of Ghana, Legon, Ghana
| | - Kenneth Maleta
- University of Malawi College of Medicine, Department of Community Health, Blantyre, Malawi
| | - Harriet Okronipa
- Program in International and Community Nutrition, Department of Nutrition, University of California, 3135 Meyer Hall, One Shields Avenue, Davis, CA 95616, USA
| | - John Sadalaki
- University of Malawi College of Medicine, Department of Community Health, Blantyre, Malawi
| | | | | | - Per Ashorn
- Center for Child Health Research, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland; Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Kathryn G Dewey
- Program in International and Community Nutrition, Department of Nutrition, University of California, 3135 Meyer Hall, One Shields Avenue, Davis, CA 95616, USA
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Ndounga Diakou LA, Ntoumi F, Ravaud P, Boutron I. Published randomized trials performed in Sub-Saharan Africa focus on high-burden diseases but are frequently funded and led by high-income countries. J Clin Epidemiol 2017; 82:29-36.e6. [DOI: 10.1016/j.jclinepi.2016.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 10/10/2016] [Accepted: 10/26/2016] [Indexed: 01/05/2023]
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97
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Nkhoma M, Ashorn P, Ashorn U, Dewey KG, Gondwe A, Mbotwa J, Rogerson S, Taylor SM, Maleta K. Providing lipid-based nutrient supplement during pregnancy does not reduce the risk of maternal P falciparum parasitaemia and reproductive tract infections: a randomised controlled trial. BMC Pregnancy Childbirth 2017; 17:35. [PMID: 28095801 PMCID: PMC5240436 DOI: 10.1186/s12884-016-1215-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 12/29/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Maternal infections are associated with maternal and foetal adverse outcomes. Nutrient supplementation during pregnancy may reduce the occurrence of infections by improving maternal immunity. We aimed to investigate the impact of small-quantity lipid-based nutrient supplement (SQ-LNS) on the occurrence of Plasmodium falciparum parasitaemia during pregnancy and trichomoniasis, vaginal candidiasis and urinary tract infection (UTI) after delivery. METHODS Pregnant Malawian women enrolled in the iLiNS-DYAD trial receiving daily supplementation with SQ-LNS, multiple micronutrients (MMN) or iron & folic acid (IFA) from <20 gestation weeks (gw) were assessed for P. falciparum parasitaemia at 32 gw using rapid diagnostic testing (RDT), at 36 gw using polymerase chain reaction (PCR) and at delivery using both RDT and PCR; and at one week after delivery for trichomoniasis and vaginal candidiasis using wet mount microscopy and for UTI using urine dipstick analysis. The prevalence of each infection by intervention group was estimated at the prescribed time points and the global null hypothesis was tested using logistic regression. Adjusted analyses were performed using preselected covariates. RESULTS The prevalence of P. falciparum parasitaemia was 10.7% at 32 gw, 9% at 36 gw, and 8.3% by RDT and 20.2% by PCR at delivery. After delivery the prevalence of trichomoniasis was 10.5%, vaginal candidiasis was 0.5%, and UTI was 3.1%. There were no differences between intervention groups in the prevalence of any of the infections. CONCLUSION In this population, SQ-LNS did not influence the occurrence of maternal P. falciparum parasitaemia, trichomoniasis, vaginal candidiasis or UTI. TRIAL REGISTRATION Identifier: NCT01239693 (10 November 2010).
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Affiliation(s)
- Minyanga Nkhoma
- University of Tampere School of Medicine, University of Tampere, Arvo building, FI-33014 Tampere, Finland
| | - Per Ashorn
- University of Tampere School of Medicine, University of Tampere, Arvo building, FI-33014 Tampere, Finland
- Department of Pediatrics, Tampere University Hospital, FI-33521 Tampere, Finland
| | - Ulla Ashorn
- University of Tampere School of Medicine, University of Tampere, Arvo building, FI-33014 Tampere, Finland
| | - Kathryn G. Dewey
- Department of Nutrition, University of California, One Shields Ave., Davis, CA 95616-8669 USA
| | - Austrida Gondwe
- University of Tampere School of Medicine, University of Tampere, Arvo building, FI-33014 Tampere, Finland
| | - John Mbotwa
- School of Public Health and Family Medicine, College of Medicine, Mahatma Gandhi Road, Blantyre, Malawi
| | - Stephen Rogerson
- Department of Medicine at the Peter Doherty Institute, 792 Elizabeth Street, Melbourne, VIC 3000 Australia
| | - Steve M. Taylor
- Division of Infectious Diseases and International Health, Duke University Medical Center, Box 102359 DUMC, Durham, NC 27705 USA
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC 27599-7435 USA
| | - Kenneth Maleta
- School of Public Health and Family Medicine, College of Medicine, Mahatma Gandhi Road, Blantyre, Malawi
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98
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Arimond M, Abbeddou S, Kumwenda C, Okronipa H, Hemsworth J, Jimenez EY, Ocansey E, Lartey A, Ashorn U, Adu-Afarwuah S, Vosti SA, Hess SY, Dewey KG. Impact of small quantity lipid-based nutrient supplements on infant and young child feeding practices at 18 months of age: results from four randomized controlled trials in Africa. MATERNAL AND CHILD NUTRITION 2016; 13. [PMID: 27910260 PMCID: PMC5516197 DOI: 10.1111/mcn.12377] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/24/2016] [Accepted: 08/10/2016] [Indexed: 01/19/2023]
Abstract
Optimal infant and young child feeding (IYCF) practices can help ensure nutrient adequacy and support healthy growth and development. Small‐quantity lipid‐based nutrient supplements (SQ‐LNS) have been proposed to help fill nutrient gaps, but little is known about the impact of provision of SQ‐LNS on breastfeeding or complementary feeding practices. In the context of four coordinated randomized controlled nutrient supplementation trials in diverse sites in Africa, we compared IYCF practices at infant age 18 months (after 9–12 months of supplementation) between those receiving and not receiving SQ‐LNS. Practices were assessed by caregiver recall. Continued breastfeeding ranged from 74% (Ghana site) to 97% (Burkina Faso site) and did not differ between groups in any site; prevalence of frequent breastfeeding also did not differ. In two sites (Burkina Faso and Malawi), infants receiving SQ‐LNS were more likely to meet the World Health Organization recommendations for frequency of feeding (percentage point differences of 12–14%, P < 0.0001 and P = 0.005, respectively; the remaining two sites did not have data for this indicator). Most indicators of infant dietary diversity did not differ between groups in any site, but in the same two sites where frequency of feeding differed, infants receiving SQ‐LNS were less likely to have low frequency of consumption of animal‐source foods in the previous week (percentage point differences of 9–19% for lowest tertile, P = .02 and P = 0.04, respectively). We conclude that provision of SQ‐LNS did not negatively impact self‐reported IYCF practices and may have positively impacted frequency of feeding.
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Affiliation(s)
- Mary Arimond
- Department of Nutrition, University of California Davis, Davis, California, USA
| | - Souheila Abbeddou
- Department of Nutrition, University of California Davis, Davis, California, USA
| | - Chiza Kumwenda
- Department for International Health, University of Tampere School of Medicine, Tampere, Finland
| | - Harriet Okronipa
- Department of Nutrition, University of California Davis, Davis, California, USA
| | - Jaimie Hemsworth
- Nutrition Group, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Elizabeth Yakes Jimenez
- Department of Individual, Family, and Community Education, University of New Mexico, Albuquerque, New Mexico, USA.,Department of Family and Community Medicine, University of New Mexico, Albuquerque, New Mexico, USA.,Center for Education Policy Research, University of New Mexico, Albuquerque, New Mexico, USA.,Pacific Institute for Research and Evaluation, Albuquerque, New Mexico, USA
| | - Eugenia Ocansey
- Department of Nutrition, University of California Davis, Davis, California, USA
| | - Anna Lartey
- Department of Nutrition and Food Science, University of Ghana, Legon, Ghana
| | - Ulla Ashorn
- Department for International Health, University of Tampere School of Medicine, Tampere, Finland
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Ghana
| | - Stephen A Vosti
- Department of Agricultural and Resource Economics, University of California Davis, Davis, California, USA
| | - Sonja Y Hess
- Department of Nutrition, University of California Davis, Davis, California, USA
| | - Kathryn G Dewey
- Department of Nutrition, University of California Davis, Davis, California, USA
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99
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Chandrasiri UP, Fowkes FJI, Beeson JG, Richards JS, Kamiza S, Maleta K, Ashorn P, Rogerson SJ. Association between malaria immunity and pregnancy outcomes among Malawian pregnant women receiving nutrient supplementation. Malar J 2016; 15:547. [PMID: 27829430 PMCID: PMC5103486 DOI: 10.1186/s12936-016-1597-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 10/31/2016] [Indexed: 11/24/2022] Open
Abstract
Background Malaria antibody responses measured at delivery have been associated with protection from maternal anaemia and low birth weight deliveries. Whether malarial antibodies present in the first half of pregnancy may protect from these or other poor birth outcomes is unclear. To determine whether malaria antibodies in the first half of pregnancy predict pregnancy outcomes, antibodies were measured to a range of merozoite antigens and to antigens expressed on the surface of parasitized red blood cells (pRBCs) in plasma samples collected at 14–20 weeks of gestation from Malawian women. The latter antibodies were measured as total IgG to pRBCs, and antibodies promoting opsonic phagocytosis of pRBCs. Associations between antibodies and maternal haemoglobin in late pregnancy or newborn size were investigated, after adjusting for potential covariates. Results Antibodies to pRBC surface antigens were associated with higher haemoglobin concentration at 36 weeks. Total IgG to pRBCs was associated with 0.4 g/l [(95% confidence interval (0.04, 0.8)] increase in haemoglobin, and opsonizing antibody with 0.5 (0.05, 0.9) increase in haemoglobin for each 10% increase in antibody. These antibodies were not associated with birthweight, placental malaria, or newborn anthropometrics. Antibodies to merozoite antigens and non-placental-binding IEs were not associated with decreased risk of any of these outcomes. In some instances, they were negatively associated with outcomes of interest. Conclusion Antibodies to placental-binding infected erythrocytes may be associated with higher haemoglobin levels in pregnancy, whereas antibodies to other malaria antigens may instead be markers of malaria exposure. Trial registration clinicaltrials.gov NCT01239693. Registered Nov 10, 2010.
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Affiliation(s)
- Upeksha P Chandrasiri
- Department of Medicine at the Doherty Institute of Infection and Immunity, University of Melbourne, 792 Elizabeth Street, Melbourne, VIC, Australia
| | - Freya J I Fowkes
- Macfarlane Burnet Institute of Medical Research, 85 Commercial Road, Prahran, VIC, Australia.,Department of Epidemiology, Centre for Epidemiology and Biostatistics, University of Melbourne, Melbourne, VIC, Australia.,Department of Preventive Medicine and Infectious Diseases, Monash University, Clayton, VIC, Australia
| | - James G Beeson
- Department of Medicine at the Doherty Institute of Infection and Immunity, University of Melbourne, 792 Elizabeth Street, Melbourne, VIC, Australia.,Macfarlane Burnet Institute of Medical Research, 85 Commercial Road, Prahran, VIC, Australia.,Department of Microbiology, Monash University, Clayton, VIC, Australia
| | - Jack S Richards
- Macfarlane Burnet Institute of Medical Research, 85 Commercial Road, Prahran, VIC, Australia.,Department of Microbiology, Monash University, Clayton, VIC, Australia
| | - Steve Kamiza
- University of Malawi College of Medicine, Blantyre, Malawi
| | - Kenneth Maleta
- Faculty of Public Health and Family Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Per Ashorn
- Centre for Child Health Research, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland.,Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Stephen J Rogerson
- Department of Medicine at the Doherty Institute of Infection and Immunity, University of Melbourne, 792 Elizabeth Street, Melbourne, VIC, Australia.
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100
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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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