Iron deficiency during the first 1000 days of life: are we doing enough to protect the developing brain?

Can micronutrient requirements be met by diets from sustainable sources: outcomes of dietary modelling studies using diet optimization

BACKGROUND

Consumption of diets from sustainable sources is required for planetary health, however, large sections of the population, including females of reproductive age and children, will be at risk of not meeting their micronutrient (MN) requirements in a complete transition to plant-based foods. Constrained diet optimization methods use mathematical programming to construct diets that meet predefined parameters and may contribute towards modelling dietary solutions that meet nutritional and planetary targets.

OBJECTIVE

Review the evidence from diet optimization studies proposing solutions to ensure MN availability in the context of a transition to diets from sustainable sources.

APPROACH

Narrative review focusing on literature published over the last five years.

RESULTS

Dietary modelling using diet optimization can design a range of omnivorous and plant-based diets that meet individual MN requirements, have reduced environmental impacts, and minimize deviation from culturally acceptable dietary practices. Using data from large-scale dietary surveys, diet optimization can support development of food-based dietary guidelines; identify limiting MNs in a particular context or a conflict between constraints e.g. nutrition and environment; explore food-based strategies to increase nutrient supply, such as fortification; and support trial design. Methods used and outcomes reported are sources of variability. Individual-level dietary data and MN requirements for population sub-groups such as females of reproductive age and children are important requirements. Although maintaining iron and zinc intakes are regularly reported to present challenges in diets from sustainable sources, few studies have considered bioavailability, which reduces with increased dietary phytate. These and other data gaps including acceptability and affordability must be addressed to improve the applicability of modelling outcomes in population recommendations.

CONCLUSIONS

Dietary modelling using diet optimization can be useful in the design of more sustainable diets that meet MN requirements, however, translation of outcomes into dietary intervention studies is required to test real-world application and adoption into dietary guidelines.

Iron deficiency anemia among infants: a retrospective cohort study

Postnatal iron deficiency, especially from ages 6 to 24 months, has long-term consequences lasting into adolescence and adulthood. We aimed to characterize iron deficiency anemia among infants from one central Israeli district by demographic and laboratory parameters. A retrospective chart review was performed on all infants from a single district who had undergone a complete blood count as part of a routine survey for iron deficiency anemia during 2010-2021. Data retrieved included hemoglobin levels, mean corpuscular volume, and demographic features: sex, sector (non-ultraorthodox Jew, ultraorthodox Jew, and Arab), socioeconomic status, and type of residence. The study group comprised 101,650 infants, aged 9 to 18 months. Iron deficiency anemia, defined as a hemoglobin level <11 g/dL and mean corpuscular volume <70 fl was observed in 4296 (4.2%) of the study infants. Iron deficiency anemia was more prevalent among Arab and ultraorthodox Jewish infants, than non-ultraorthodox Jewish infants (6.6% vs. 6% vs. 3%, respectively). It was also more prevalent among infants of low socioeconomic status, and relatively common among infants of rural residence. We identified two specific sub-populations at risk of developing iron deficiency anemia: Arab and ultraorthodox Jewish infants. We recommend enhancing the nationwide intervention program for both clinicians and parents, thereby treating iron deficiency anemia promptly to avoid short- and long-term deleterious health consequences.

Access to nutrition advice and knowledge, attitudes and practices of pregnant women in Ireland: A cross-sectional study

BACKGROUND

Healthy nutritional status, appropriate gestational weight gain and a balanced diet are important predictors of perinatal health outcomes. However, gaps exist in the translation of nutrition recommendations into dietary practices of women before and during pregnancy. The present study explored the relationship between access to nutrition advice, nutrition knowledge, attitudes and practices among pregnant women.

METHODS

Pregnant women aged > 18 years in Ireland were eligible to complete a self-administered survey consisting of four subsections (demographics, nutrition knowledge, attitudes and practices) delivered online through Qualtrics.

RESULTS

In this convenience sample (n = 334, median [interquartile range] gestation, 25.0 [16.0, 34.0] weeks), 85% had at least an honours bachelor degree and 88.9% planned their pregnancy. Two out of five women received nutrition advice during their pregnancy, mostly from a midwife. Based on the percentage of correct answers (of 15 questions), women with previous nutrition education (e.g., school home economics) had better median [interquartile range] nutrition knowledge than those with none (80.0% [66.7, 86.7%] vs. 73.3% [60.0, 80.0%], p < 0.001). Those who received nutrition advice during pregnancy did not score higher than those who did not (73.3% [66.7, 80.0%] vs. 73.3% [66.7, 80.0%], p = 0.6). Over three-quarters of participants considered nutritional supplement use to be very or extremely important. Although 73.6% and 92.4% took supplements prior to and during pregnancy, only 25.7% reported compliance with periconceptional folic acid supplementation guidelines. Half of respondents considered healthy eating during pregnancy as very or extremely important.

CONCLUSIONS

Access to nutrition advice during pregnancy was inadequate with poor nutrition knowledge, attitudes and practices observed. Accessible, evidence-based nutrition education for women prior to and during pregnancy is required.

Allostasis, health, and development in Latin America

The lifespan is influenced by adverse childhood experiences that create predispositions to poor health outcomes. Here we propose an allostatic framework of childhood experiences and their impact on health across the lifespan, focusing on Latin American and Caribbean countries. This region is marked by significant social and health inequalities nested in environmental and social stressors, such as exposure to pollution, violence, and nutritional deficiencies, which critically influence current and later-life health outcomes. We review several manifestations across cognition, behavior, and the body, observed at the psychological (e.g., cognitive, socioemotional, and behavioral dysfunctions), brain (e.g., alteration of the development, structure, and function of the brain), and physiological levels (e.g., dysregulation of the body systems and damage to organs). To address the complexity of the interactions between environmental and health-related factors, we present an allostatic framework regarding the cumulative burden of environmental stressors on physiological systems (e.g., cardiovascular, metabolic, immune, and neuroendocrine) related to health across the life course. Lastly, we explore the relevance of this allostatic integrative approach in informing regional interventions and public policy recommendations. We also propose a research agenda, potentially providing detailed profiling and personalized care by assessing the social and environmental conditions. This framework could facilitate the delivery of evidence-based interventions and informed childhood-centered policy-making.

Association between maternal hemoglobin concentration and educational attainment in mid-childhood in a high-resource obstetric setting: a prospective cohort study

BACKGROUND

Although maternal hemoglobin levels during pregnancy are commonly associated with perinatal outcomes, their link to childhood neurodevelopment remains uncertain.

OBJECTIVE

This study aimed to examine the associations between maternal hemoglobin in early and late pregnancy and the educational attainment of offspring mid-childhood in a high-resource obstetric setting.

STUDY DESIGN

Pregnancy data from a prospective birth cohort (Pregnancy Outcome Prediction Study, Cambridge, United Kingdom, 2008-2012, N=3285) were linked to mid-childhood educational outcomes (Department for Education, United Kingdom). Regression models adjusted for maternal, child, and socioeconomic factors were used to determine associations between maternal hemoglobin, pregnancy complications, and offspring educational outcomes (aged 5-7 years).

RESULTS

No association was observed between maternal hemoglobin at 12 weeks and the likelihood of either adverse pregnancy outcomes or children meeting expected educational standards between ages 5-7 years. Higher maternal hemoglobin at 28 weeks was associated with an increased risk of small-for-gestational-age infants (adjusted odds ratio, 1.26 [95% confidence interval, 1.11-1.59]; P=.002) and preterm birth (adjusted odds ratio, 1.38 [95% confidence interval, 1.11-1.81]; P=.005). There were no adverse birth outcomes associated with anemia. However, children of mothers who were anemic at 28 weeks had ∼40% increased risk of not attaining expected educational standards at age 5 (adjusted odds ratio, 1.42 [95% confidence interval, 1.03-1.95]; P=.03). There was no association between maternal anemia at 28 weeks and educational performance at ages 6-7. No associations were found between high maternal hemoglobin concentrations (top decile) or change in hemoglobin concentrations between 12 and 28 weeks and childhood educational attainment.

CONCLUSION

Maternal anemia at 28 weeks of pregnancy is associated with reduced educational attainment at 5 years old but not at older ages (6-7 years old). A proactive approach to increasing maternal hemoglobin in high-resource settings is unlikely to impact long-term childhood educational attainment.

Impact of consuming an environmentally protective diet on micronutrients: a systematic literature review

BACKGROUND

A global move toward consumption of diets from sustainable sources is required to protect planetary health. As this dietary transition will result in greater reliance on plant-based protein sources, the impact on micronutrient (MN) intakes and status is unknown.

OBJECTIVE

Evaluate the evidence of effects on intakes and status of selected MNs resulting from changes in dietary intakes to reduce environmental impact. Selected MNs of public health concern were vitamins A, D, and B12, folate, calcium, iron, iodine, and zinc.

METHODS

We systematically searched 7 databases from January 2011 to October 2022 and followed the PRISMA guidelines. Eligible studies had to report individual MN intake and/or status data collected in free-living individuals from the year 2000 onward and environmental outcomes.

RESULTS

From the 10,965 studies identified, 56 studies were included, mostly from high-income countries (n = 49). Iron (all 56) and iodine (n = 20) were the most and least reported MNs, respectively. There was one randomized controlled trial (RCT) that also provided the only biomarker data, 10 dietary intake studies, and 45 dietary modeling studies, including 29 diet optimization studies. Most studies sought to reduce greenhouse gas emissions or intake of animal-sourced foods. Most results suggested that intakes of zinc, calcium, iodine, and vitamins B12, A, and D would decrease, and total iron and folate would increase in a dietary transition to reduce environmental impacts. Risk of inadequate intakes of zinc, calcium, vitamins A, B12 and D were more likely to increase in the 10 studies that reported nutrient adequacy. Diet optimization (n = 29) demonstrated that meeting nutritional and environmental targets is technically feasible, although acceptability is not guaranteed.

CONCLUSIONS

Lower intakes and status of MNs of public health concern are a potential outcome of dietary changes to reduce environmental impacts. Adequate consideration of context and nutritional requirements is required to develop evidence-based recommendations. This study was registered prospectively with PROSPERO (CRD42021239713).

Sex-specific association between maternal mild anemia and children's behavioral development: a birth cohort study

There has been limited research on maternal anemia affecting children's behavioral development, with a lack of studies focusing on sex differences in this association. Based on the Ma'anshan Birth Cohort, 2132 mother-child pairs were included. Maternal anemia was evaluated based on the hemoglobin concentration and children's behavioral development was assessed by Achenbach Child Behavior Checklist 1.5-5. Binary logistic regression models indicated that compared with children born of mothers without anemia throughout pregnancy, maternal mild anemia during pregnancy or only anemia in the 3rd trimester was associated with increased risks of aggressive behaviors in boys. Maternal mild anemia only in the 2nd trimester was associated with increased risks of attention problems in boys. In girls, maternal mild anemia during pregnancy was associated with increased risks of withdrawn, internalizing problems and total problems. Girls born of mothers with mild anemia only in the 2nd trimester had higher risks of total problems. Maternal mild anemia in both 2nd and 3rd trimesters was associated with increased risks of internalizing problems in girls. Our study identified sex-specific effects of maternal mild anemia during pregnancy on children's behavioral development problems.

Determinants of iron-rich food deficiency among children under 5 years in sub-Saharan Africa: a comprehensive analysis of Demographic and Health Surveys

BACKGROUND

Iron deficiency is a major public health problem that affects the physical and cognitive development of children under 5 years of age (under-5 children) in sub-Saharan Africa (SSA). However, the factors associated with the limited consumption of iron-rich foods in the region are poorly understood.

OBJECTIVE

This study examined the prevalence and determinants of iron-rich food deficiency among under-5 children in 26 SSA countries.

DESIGN

This nationally representative quantitative study employed pooled data from Demographic and Health Surveys conducted between 2010 and 2019.

METHODS

Representative samples comprising 296 850 under-5 children from the various countries were used. Bivariate and multivariate logistic regression models were used to determine the associations between the lack of iron-rich food uptake and various sociodemographic factors.

RESULT

The overall prevalence of iron-rich food deficiency among the children in the entire sample was 56.75%. The prevalence of iron-rich food deficiency varied widely across the 26 countries, ranging from 42.76% in Congo Democratic Republic to 77.50% in Guinea. Maternal education, particularly primary education (OR 0.62, 95% CI 0.57 to 0.68) and higher education (OR 0.58, 95% CI 0.52 to 0.64), demonstrated a reduced likelihood of iron-rich food deficiency in the sample. Likewise, paternal education, with both primary education (OR 0.69, 95% CI 0.63 to 0.75) and higher education (OR 0.66, 95% CI 0.60 to 0.73) showed decreased odds of iron-rich food deficiency. Postnatal visits contributed significantly to reducing the odds of iron-rich food deficiency (OR 0.90, 95% CI 0.83 to 0.95), along with antenatal visits, which also had a positive impact (OR 0.84, 95% CI 0.74 to 0.95). Finally, residents in rural areas showed slightly higher odds of iron-rich food deficiency (OR 1.12, 95% CI 1.10 to 1.28).

CONCLUSION

Based on the findings, interventions targeting iron-food deficiency in the SSA region should take into strong consideration the key determinants highlighted in this study.

Iron metabolism and ferroptosis: A pathway for understanding preeclampsia

Preeclampsia (PE) is a serious medical condition that poses a significant health risk to women and children worldwide, particularly in the middle- and low-income countries. It is a complex syndrome that occurs as a result of abnormal pregnancy. Hypertension is the most common symptom of PE, with proteinuria and specific organ systems as detrimental targets. PE's pathogenesis is diverse, and its symptoms can overlap with other diseases. In early pregnancy, when the placenta takes over control, oxidative stress may be closely associated with ferroptosis, a type of cell death caused by intracellular iron accumulation. Ferroptosis in the placenta is defined by redox-active iron availability, loss of antioxidant capacity and phospholipids containing polyunsaturated fatty acids (PUFA) oxidation. Recent studies suggest a compelling potential link between ferroptosis and PE. In this article, we comprehensively review the current understanding of PE and discuss one of its emerging underlying mechanisms, the ferroptosis pathway. We also provide perspective and analysis on the implications of this process in the diagnosis, prevention, and treatment of preeclampsia. We aim to bridge the gap between clinicians and basic scientists in understanding this harmful disease and challenge the research community to put more effort into this exciting new area.

Awareness of Nutrition and Supplements Among Pregnant and Preconception Women: A Real-World Study in Vietnam

Background

Few studies have addressed relationships between health literacy (HL) and nutritional awareness in preconception/pregnancy populations, especially within Asia. We explored the rationale for nutrition-related education and/or HL interventions to improve nutritional intake among preconception/pregnant women.

Methods

A cross-sectional questionnaire-based real-world study was conducted among 100 preconception and 200 pregnant women in Vietnam in January/February 2022. The questionnaire included a validated screening tool for HL (Newest Vital Sign [NVS]), and questions on preconception/pregnancy-related nutritional knowledge and behavior, prenatal supplementation, sources of nutritional advice.

Results

Most respondents (62%) had limited HL and only 5% had adequate HL. Respondents with limited HL (NVS 0-1) showed less awareness of benefits of healthy eating before/during pregnancy, such as reduction in risk of birth defects. Most (94%) considered prenatal supplements beneficial, yet 64% were not convinced of supplement safety. The limited HL group reported the lowest use of supplements, including multivitamins, iron, and folic acid/folate.

Conclusion

The prevalence of limited HL and the low awareness of preconception/pregnancy-related nutrition suggest an urgent need to invest in nutrition-specific education and improving HL in maternal populations. This will help support adequate maternal nutrition and appropriate micronutrient supplementation before conception and throughout the "first 1000 days" of life.

Iron-Fortified Foods Are Needed To Meet the Estimated Average Requirement for Iron in Australian Infants Aged 6 to 12 Months

BACKGROUND

Meeting iron intake recommendations is challenging for infants 6-12 mo, especially breastfed infants. Three-quarters of Australian infants 6-12 mo have iron intakes below the estimated average requirement (7 mg), placing them at risk of iron deficiency. After 6 mo, breastmilk is no longer sufficient to meet the increased demand for iron, and iron-rich complementary foods are recommended. Iron-fortified foods may be a means of improving iron intake in infants, particularly those that are breastfed.

OBJECTIVES

The aims of the study were as follows: 1) to examine the effect of milk-type and fortified foods on iron intake and the prevalence of inadequacy in infants 6-12 mo; 2) to model the effect of fixed amounts of iron-fortified infant cereal (IFIC) at 6 levels of iron fortification on total iron intake and the prevalence of inadequacy; and 3) to assess the effect IFIC on the intake of other nutrients in the diet.

DESIGN

Secondary analysis of cross-sectional dietary intake data of infants 6-12 mo (n = 286) participating in the Australian Feeding Infants and Toddlers Study (OzFITS) 2021.

RESULTS

Median (interquartile range) iron intake was 8.9 (7.5, 10.3); 6.3 (4.5, 8.2); and 2.7 (1.5, 4.4) mg/d in formula-fed, combination-fed, and breastfed infants, respectively. The corresponding prevalence of inadequacy was 19%, 67%, and 96%. Infants who consumed fortified foods had higher median iron intakes than those who did not, 6.2 compared with 1.9 mg/d. Dietary modeling showed that consuming 18 g (300 kJ) of IFIC, fortified at 35 mg/100 g dry weight, reduces the prevalence of inadequacy for iron from 75% to 5% for all infants.

CONCLUSIONS

Iron intakes are low in Australian infants, especially for breastfed infants in the second half of infancy. Modeling shows that 300 kJ of IFIC, the current manufacturer-recommended serving, fortified at 35 mg/100 g dry weight, added to infant diets would be an effective means to reduce the prevalence of inadequacy for iron.

Long-term implications of fetal growth restriction

Fetal growth restriction (FGR), or intrauterine growth restriction (IUGR), is a complication of pregnancy where the fetus does not achieve its genetic growth potential. FGR is characterized by a pathological retardation of intrauterine growth velocity in the curve of intrauterine growth. However, the FGR definition is still debated, and there is a lack of a uniform definition in the literature. True IUGR, compared to constitutional smallness, is a pathological condition in which the placenta fails to deliver an adequate supply of oxygen and nutrients to the developing fetus. Infants with IUGR, compared to appropriately grown gestational age infants, have a significantly higher risk of mortality and neonatal complications with long-term consequences. Several studies have demonstrated how suboptimal fetal growth leads to long-lasting physiological alterations for the developing fetus as well as for the newborn and adult in the future. The long-term effects of fetal growth retardation may be adaptations to poor oxygen and nutrient supply that are effective in the fetal period but deleterious in the long term through structural or functional alterations. Epidemiologic studies showed that FGR could be a contributing factor for adult chronic diseases including cardiovascular disease, metabolic syndrome, diabetes, respiratory diseases and impaired lung function, and chronic kidney disease. In this review we discussed pathophysiologic mechanisms of FGR-related complications and potential preventive measures for FGR.

COVID-19-induced neurological symptoms: focus on the role of metal ions

Neurological symptoms are prevalent in both the acute and post-acute phases of coronavirus disease 2019 (COVID-19), and they are becoming a major concern for the prognosis of COVID-19 patients. Accumulation evidence has suggested that metal ion disorders occur in the central nervous system (CNS) of COVID-19 patients. Metal ions participate in the development, metabolism, redox and neurotransmitter transmission in the CNS and are tightly regulated by metal ion channels. COVID-19 infection causes neurological metal disorders and metal ion channels abnormal switching, subsequently resulting in neuroinflammation, oxidative stress, excitotoxicity, neuronal cell death, and eventually eliciting a series of COVID-19-induced neurological symptoms. Therefore, metal homeostasis-related signaling pathways are emerging as promising therapeutic targets for mitigating COVID-19-induced neurological symptoms. This review provides a summary for the latest advances in research related to the physiological and pathophysiological functions of metal ions and metal ion channels, as well as their role in COVID-19-induced neurological symptoms. In addition, currently available modulators of metal ions and their channels are also discussed. Collectively, the current work offers a few recommendations according to published reports and in-depth reflections to ameliorate COVID-19-induced neurological symptoms. Further studies need to focus on the crosstalk and interactions between different metal ions and their channels. Simultaneous pharmacological intervention of two or more metal signaling pathway disorders may provide clinical advantages in treating COVID-19-induced neurological symptoms.

A global perspective of delayed cord clamping in infants

Delayed umbilical cord clamping, DCC, a practice in which the umbilical cord is not clamped immediately after birth, promotes placental transfusion to preterm and term neonates. DCC may improve outcomes in preterm neonates by reducing mortality and blood transfusion requirements and increasing iron stores. Despite the recommendations from multiple governing bodies, including the World Health Organization, research on DCC in LMICs remains limited. Given that iron deficiency is prevalent, and most neonatal deaths occur in LMICs, DCC has the potential to improve outcomes in these settings. This article aims to provide a global perspective on DCC in LMICs and to identify knowledge gaps that offer future research opportunities.

Iron deficiency anemia in infants in Sousa (PB), Brazil: an association with nutritional status

OBJECTIVE

The aim of this study was to describe the prevalence of anemia and iron deficiency anemia (IDA) in infants and verify the association of iron deficiency with nutritional status.

METHODS

This cross-sectional and observational study included 104 infants aged between 7 and 9 months, assisted from August to September 2021 by the Family Health Strategy program in Sousa municipality (Paraíba, Brazil). Clinical and anthropometric data were collected, and a 24-h food recall questionnaire was applied using the DietPro software (version 5.0) in order to verify food consumption and assess iron intake. Variables associated with iron deficiency (p<0.05) were analyzed using multiple logistic regression.

RESULTS

Anemia and IDA were observed in 40.4% and 19.2% of infants, respectively. Only one infant was taking prophylactic supplementation (ferrous sulfate). Infants with IDA presented reduced hemoglobin (p<0.001) and ferritin (p<0.001) and increased Z-scores of body mass index-for-age (Z-BMI) (p=0.027), weight-for-height (p=0.007), and weight-for-age (p=0.032). All Z-scores were inversely correlated with ferritin (Z-BMI [rho: -0.37; p<0.001], weight-for-height [rho: -0.37; p<0.001], and weight-for-age [rho: -0.29; p=0.002]). Ferritin was also directly correlated with daily iron intake (rho: 0.22; p=0.018). Finally, multiple logistic regression showed a significant and direct association of iron deficiency with weight-for-height Z-score (odds ratio: 2.86; 95% confidence interval: 1.38-5.64; p=0.004).

CONCLUSION

About 60% of infants presented anemia or IDA. Iron deficiency was associated with the weight-for-height Z-score, showing the vulnerability of infants during the introduction of complementary feeding.

Iron Deficiency in the United States: Limitations in Guidelines, Data, and Monitoring of Disparities

Iron deficiency and the more severe sequela, iron deficiency anemia, are public health problems associated with morbidity and mortality, particularly among pregnant women and younger children. The 1998 Centers for Disease Control and Prevention recommendations for prevention and control of iron deficiency in the United States is old and does not reflect recent evidence but is a foundational reference for many federal, clinical, and program guidelines. Surveillance data for iron deficiency are sparse at all levels, with critical gaps for pregnant women and younger children. Anemia, iron deficiency, and iron deficiency anemia are often conflated but should not be. Clinical guidelines for anemia, iron deficiency, and iron deficiency anemia give inconsistent recommendations, causing nonsystematic assessment of iron deficiency. Screening for iron deficiency typically relies on identifying anemia, despite anemia's low sensitivity for iron deficiency. In the National Health and Nutrition Examination Survey, more than 70% of iron deficiency is missed among pregnant women and children by relying on hemoglobin for iron deficiency screening. To improve assessment and diagnosis and strengthen surveillance, better and more complete data and updated foundational guidance on iron deficiency and anemia are needed that consider new evidence for measuring and interpreting laboratory results. (Am J Public Health. 2022;112(S8):S826-S835. https://doi.org/10.2105/AJPH.2022.306998).

Perinatal Origins of Adult Disease and Opportunities for Health Promotion: A Narrative Review

The “developmental origins of health and disease” (DOHaD) hypothesis refers to the influence of early developmental exposures and fetal growth on the risk of chronic diseases in later periods. During fetal and early postnatal life, cell differentiation and tissue formation are influenced by several factors. The interaction between genes and environment in prenatal and early postnatal periods appears to be critical for the onset of multiple diseases in adulthood. Important factors influencing this interaction include genetic predisposition, regulation of gene expression, and changes in microbiota. Premature birth and intrauterine growth restriction (IUGR) are other important factors considered by the DOHaD hypothesis. Preterm birth is associated with impaired or arrested structural or functional development of key organs/systems, making preterm infants vulnerable to cardiovascular, respiratory, and chronic renal diseases during adulthood. Growth restriction, defined as impaired fetal growth compared to expected biological potential in utero, is an additional negative factor increasing the risk of subsequent diseases. Environmental factors implicated in the developmental programming of diseases include exposure to pollution, stress, drugs, toxic agents, nutrition, and exercise. The DOHaD may explain numerous conditions, including cardiovascular, metabolic, respiratory, neuropsychiatric, and renal diseases. Potential antenatal and postnatal preventive measures, interventions, and future directions are discussed.