A maternal "mixed, high sugar" dietary pattern is associated with fetal growth

Circular RNAs mediate the regulation of maternal placental nutrient transport and fetal development by sugar-sweetened beverages

Epidemiological and experimental studies have demonstrated a strong association between maternal diet and fetal birth weight, obesity, and metabolic syndrome. We investigated the pathways and modes of action of circular RNAs (circRNAs) that mediate the regulation of maternal reproductive performance and fetal development by sugar-sweetened beverages (20 % sucrose water, SSBs) using C57BL/6J mice as a model. Results showed that SSBs significantly increased the reproductive performance (P<0.05), body weight (P<0.01), fetal birth weight (P<0.05), placental weight (P<0.01), and the expression of nutrient transporter genes in the placenta and fetal liver (P<0.05), mainly by accelerating the maternal energy metabolism during pregnancy. However, maternal serum biochemical indices, antioxidant indices, and pathological damage to the liver and placenta predicted that the mother would be at greater health risks during this period. Moreover, transcriptomics results indicated that the differentially expressed (DE) circRNAs in the placenta regulate the maternal multiple metabolic pathways and the placental nutrient transport efficiency by sponging miRNAs and forming growth factors and proteins, ultimately improving the maternal reproductive performance. In addition, we verified the reliability of the sequencing results using reverse transcription polymerase chain reaction and identified the possibility of DE circRNAs binding to nutrient transporter genes using targeting relationship prediction. Finally, we constructed a correlation network that regulates maternal placental nutrient transport based on DE circRNAs, targeted miRNAs and nutrient transport-related genes. This study will provide scientific dietary guidance for pregnant women and new research ideas for preventing and treating pregnancy complications.

Development, Implementation, and Process Evaluation of Bukhali: An Intervention from Preconception to Early Childhood

The Healthy Life Trajectories Initiative, an international consortium developed in partnership with the World Health Organization, is addressing childhood obesity from a life-course perspective. It hypothesises that an integrated complex intervention from preconception, through pregnancy, infancy and early childhood, will reduce childhood adiposity and non-communicable disease risk, and improve child development. As part of the Healthy Life Trajectories Initiative in South Africa, the Bukhali randomised controlled trial is being conducted with 18–28-year-old women in Soweto, where young women face numerous challenges to their physical and mental health. The aims of this paper were to describe the intervention development process (including adaptations), intervention components, and process evaluation; and to highlight key lessons learned. Intervention materials have been developed according to the life-course stages: preconception (Bukhali), pregnancy (Bukhali Baby), infancy (Bukhali Nana; birth—2 years), and early childhood (Bukhali Mntwana, 2–5 years). The intervention is delivered by community health workers, and includes the provision of health literacy resources, multi-micronutrient supplementation, in-person health screening, services and referral, nutrition risk support, SMS-reminders and telephonic contacts to assist with behaviour change goals. A key adaption is the incorporation of principles of trauma-information care, given the mental health challenges faced by participants. The Bukhali process evaluation is focussing on context, implementation and mechanisms of impact, using a mixed methods approach. Although the completion of the trial is still a number of years away, the documentation of the intervention development process and process evaluation of the trial can provide lessons for the development, implementation, and evaluation of such complex life-course trials.

Interactions between maternal health and placental morphology on neonate body composition

Background

We aimed to examine maternal metabolic correlates of neonate body composition, and the potential mediating effect of the placenta.

Methods

Data were collected throughout pregnancy and at delivery. An oral glucose tolerance test (OGTT) was conducted in order to diagnose or rule out gestational diabetes mellitus (GDM). Maternal weight and blood pressure were taken and hypertension and gestational weight gain (GWG) were defined. Gestational age, birth weight (BW) and weight to length ration (WLR) were recorded. Photographs were taken of the placenta, and the widths and lengths were measured digitally. Body composition was analysed via air displacement plethysmography or dual-energy x-ray absorptiometry. Mediation models were conducted to determine the mediation effect of the placental variables on the relationships between maternal health variables and neonate outcomes. Next, interaction terms were added to models to determine how maternal and placental variables interacted in their effect on neonate outcomes.

Results

A total of n = 280 women were included in the analysis. Majority were overweight or obese. Fourteen percent of women developed GDM during pregnancy, 5% had hypertension during pregnancy, 32% were HIV positive, and 32% had anemia. For the birth weight outcome, coefficients of BMI were attenuated by the addition of placental variables (Model 1 β=18.66 vs Model 2 β=16.40). Similar patterns were evident for GWG and hypertension, and for the WLR outcome. In all cases the addition of the placental variables attenuated associations between maternal exposures and neonatal outcomes, yet the level of significance did not change. Inclusion of interaction terms reversed the direction of the relationships between hypertension and BW and WLR, and between GWG and WLR.

Conclusion

The placenta buffers some harmful effects of obesity, GWG, and hypertension on neonate size, and placental efficiency interacted with most maternal risk factors to either counteract, or attenuate relationships with neonate size at birth. However the placenta was unable to completely counteract the negative effect of excess nutrient supply on in utero growth.

Associations of maternal dietary patterns during pregnancy and fetal intrauterine development

Dietary pattern is excellent in reflecting an individual's eating conditions. Longitudinal data on fetal growth can reflect the process of intrauterine growth. We aimed to evaluate the associations between maternal dietary patterns and intrauterine parameters in middle and late pregnancy. The present study was conducted within Jiangsu Birth Cohort (JBC) study. Dietary information was assessed with a food frequency questionnaire (FFQ) in the second and third trimester of gestation. B-ultrasound scans were performed to obtain fetal intrauterine parameters, including head circumference (HC), femur length (FL), abdominal circumference (AC), and estimated fetal weight (EFW). Exploratory factor analysis was used to extract dietary patterns. Multiple linear regression and linear mixed-effects model (LMM) were used to investigate the association between maternal dietary patterns and fetal growth. A total of 1,936 pregnant women were eligible for the study. We observed inverse associations of maternal “Vegetables and fish” and “Snack and less eggs” patterns during mid-pregnancy with fetal HC Z-score, respectively (“Vegetables and fish”: β = −0.09, 95% CI −0.12, −0.06; “Snack and less eggs”: β = −0.05, 95% CI −0.08, −0.02). On the contrary, “Animal internal organs, thallophyte and shellfish” pattern in the second trimester was associated with increased HC Z-scores (β = 0.04, 95% CI 0.02, 0.06). Consistently, score increase in “Vegetables and fish” pattern in the third trimester was inversely associated with the Z-scores of HC (β = −0.05, 95% CI −0.09, −0.02), while “Meat and less nuts” pattern was positively correlated with the Z-scores of HC (β = 0.04, 95% CI 0.02, 0.07). As compared to the fetus whose mothers at the lowest tertile of “Snack and less eggs” pattern in both trimesters, those whose mothers at the highest tertile demonstrated 1.08 fold (RR = 2.10, 95% CI 1.34–3.28) increased risk of small HC for gestational age (GA). No correlation was observed between maternal dietary patterns and other intrauterine parameters. Our results suggested the effects of maternal dietary patterns on fetal growth, particularly HC. These findings highlighted the adverse impact of unhealthy dietary pattern on fetal growth, might provide evidence for strategies to prevent intrauterine dysplasia and dietary guidelines during pregnancy.

Anti-inflammatory diets reduce the risk of excessive gestational weight gain in urban South Africans from the Soweto First 1000-Day Study (S1000)

Purpose

To (i): examine whether maternal dietary inflammation assessed using the dietary inflammatory index (DII) is associated with gestational weight gain (GWG) and delivery outcomes in urban South African women from the Soweto First 1000-Day Study (S1000); and (ii): explore whether serum high-sensitivity c-reactive protein (hs-CRP) levels mediate these associations.

Methods

Energy-adjusted-DII (E-DII™) scores were calculated for 478 pregnant women using a quantitative food frequency questionnaire. GWG (kg/week) was assessed via anthropometry and hs-CRP concentrations were assessed in a sub-sample at < 14 (n = 263) and at 24–28 (n = 270) weeks gestational age. Multivariable linear and logistic regression models were used to examine associations between maternal E-DII scores, GWG, hs-CRP concentrations, and delivery outcomes.

Results

Positive vs. negative E-DII scores were associated with an increased odds of excessive weight gain (OR (95% CI): 2.23 (1.20; 4.14); P = 0.01) during pregnancy. Higher hs-CRP concentrations in the first trimester were associated with lower weight-for-length z-score (β (95% CI): −0.06 (−0.11; −0.01) per 1 mg/l hs-CRP; P = 0.02) and a reduction in odds of a large-for-gestational age delivery (OR (95% CI): 0.66 (0.47; 0.94); P = 0.02). Higher hs-CRP concentrations in the second trimester were associated with an increased odds of delivering preterm (OR (95% CI): 1.16 (1.01; 1.32); P = 0.03).

Conclusions

Consumption of an anti-inflammatory diet during pregnancy reduced the risk of excessive GWG in a rapidly urbanising setting (Soweto, South Africa), where obesity prevalence rates are high. Further research is needed to better understand how maternal diet may ameliorate the effects of maternal adiposity on inflammatory milieu and fetal programming.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00394-022-02931-x.

Building knowledge, optimising physical and mental health and setting up healthier life trajectories in South African women (Bukhali): a preconception randomised control trial part of the Healthy Life Trajectories Initiative (HeLTI)

INTRODUCTION

South Africa's evolving burden of disease is challenging due to a persistent infectious disease, burgeoning obesity, most notably among women and rising rates of non-communicable diseases (NCDs). With two thirds of women presenting at their first antenatal visit either overweight or obese in urban South Africa (SA), the preconception period is an opportunity to optimise health and offset transgenerational risk of both obesity and NCDs.

METHODS AND ANALYSIS

Bukhali is the first individual randomised controlled trial in Africa to test the efficacy of a complex continuum of care intervention and forms part of the Healthy Life Trajectories Initiative (HeLTI) consortium implementing harmonised trials in Canada, China, India and SA. Starting preconception and continuing through pregnancy, infancy and childhood, the intervention is designed to improve nutrition, physical and mental health and health behaviours of South African women to offset obesity-risk (adiposity) in their offspring. Women aged 18-28 years (n=6800) will be recruited from Soweto, an urban-poor area of Johannesburg. The primary outcome is dual-energy X-ray absorptiometry derived fat mass index (fat mass divided by height2) in the offspring at age 5 years. Community health workers will deliver the intervention randomly to half the cohort by providing health literacy material, dispensing a multimicronutrient supplement, providing health services and feedback, and facilitating behaviour change support sessions to optimise: (1) nutrition, (2) physical and mental health and (3) lay the foundations for healthier pregnancies and early child development.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Human Ethics Research Committee University of the Witwatersrand, Johannesburg, South Africa (M1811111), the University of Toronto, Canada (19-0066-E) and the WHO Ethics Committee (ERC.0003328). Data and biological sample sharing policies are consistent with the governance policy of the HeLTI Consortium (https://helti.org) and South African government legislation (POPIA). The recruitment and research team will obtain informed consent.

TRIAL REGISTRATION

This trial is registered with the Pan African Clinical Trials Registry (https://pactr.samrc.ac.za) on 25 March 2019 (identifier: PACTR201903750173871).

PROTOCOL VERSION

20 March 2022 (version #4). Any protocol amendments will be communicated to investigators, Institutional Review Board (IRB)s, trial participants and trial registries.

Understanding Sex Differences in Childhood Undernutrition: A Narrative Review

Complementing a recent systematic review and meta-analysis which showed that boys are more likely to be wasted, stunted, and underweight than girls, we conducted a narrative review to explore which early life mechanisms might underlie these sex differences. We addressed different themes, including maternal and newborn characteristics, immunology and endocrinology, evolutionary biology, care practices, and anthropometric indices to explore potential sources of sex differences in child undernutrition. Our review found that the evidence on why sex differences occur is limited but that a complex interaction of social, environmental, and genetic factors likely underlies these differences throughout the life cycle. Despite their bigger size at birth and during infancy, in conditions of food deprivation, boys experience more undernutrition from as early as the foetal period. Differences appear to be more pronounced in more severe presentations of undernutrition and in more socioeconomically deprived contexts. Boys are more vulnerable to infectious disease, and differing immune and endocrine systems appear to explain some of this disadvantage. Limited evidence also suggests that different sociological factors and care practices might exert influence and have the potential to exacerbate or reverse observed differences. Further research is needed to better understand sex differences in undernutrition and the implications of these for child outcomes and prevention and treatment programming.

Relationships between adiposity distribution and metabolic health in preconception women in South Africa

Objective

Adipose tissue is a central regulator of metabolic health and a contributor to systemic inflammation. Patterns of adiposity deposition are important to understand for optimizing health. This study aimed to asses relationships between adiposity deposition and metabolic and inflammatory biomarkers in South African women prior to conception.

Methods

Non‐pregnant, healthy women (n = 298) were recruited for this cross‐sectional study via home visits. Body composition was measured by Dual X‐ray Absorptiometry. Inflammation markers C‐reactive protein (CRP), alpha1‐acid glycoprotein (AGP), hemoglobin A1c (HbA1c), and blood pressure were scored according to risk. A summative metabolic health risk score was created for women with obesity. Generalized regression models assessed relationships between adiposity deposition and outcomes with adjustment for potential confounders.

Results

Obesity was present in 22% of women (mean age = 20.93 years). Fat mass index was associated with inflammation and metabolic health risk (β = 0.58; p < 0.01). Visceral fat, trunk:limb ratio, android:gynoid ratio, body mass index, weight, and waist circumference were positively associated with CRP, AGP, and metabolic health risk (p < 0.01). Weight was associated with Hba1c (β < 0.01; p < 0.05). Participants with obesity and low metabolic health risk had lower fat mass index and visceral fat than participants with obesity and higher metabolic health risk.

Conclusions

Black South African women accumulated excess adipose tissue in abdominal regions. While fat mass and body mass were associated with inflammation and metabolic health risk, women with obesity and with lower fat mass index and lower visceral adipose tissue were metabolically protected. Identification of women at risk for metabolic disease preconception could help ensure future healthy pregnancies and prevent transference of risk to offspring.

The association between fetal growth and neonatal adiposity in urban South African infants

OBJECTIVE

To examine associations between maternal body mass index (BMI), gestational weight gain (GWG) and fetal growth and neonatal adiposity in urban South Africans.

METHODS

Maternal BMI was assessed at recruitment and GWG (kg/week) was calculated. Longitudinal fetal growth was measured via ultrasound and modelled using Superimposition by Translation and Rotation (SITAR). Neonatal adiposity was assessed using air displacement plethysmography or dual-energy X-ray absorptiometry. Multiple linear regression models were used to examine associations between maternal BMI, GWG and SITAR fetal growth parameters and neonatal fat mass index (FMI; kg/m³ ) in 304 mother-neonate pairs.

RESULTS

In pooled analyses, longitudinally modelled abdominal circumference size (β = 0.64 kg/m³ , P < .001) and velocity (β = 8.39 kg/m³ , P < .001) and biparietal diameter velocity (β = 4.55 kg/m³ , P = .020) were positively associated with neonatal FMI. GWG was positively associated with neonatal FMI in preliminary models (β = 1.07 kg/m³ per 1 kg/week; P = .040), with pooled models indicating mediation via fetal growth.

CONCLUSION

In utero abdominal growth is predictive of neonatal adiposity. Additionally, greater fetal growth - particularly of the abdominal circumference - mediates the effect of GWG on neonatal adiposity. In settings such as South Africa, strategies to ensure healthy pregnancy weight gain can contribute to prevention of intergenerational obesity risk.

Pilot implementation of Bukhali: A preconception health trial in South Africa

Objectives

This article describes the learnings from the pilot phase of the Healthy Life Trajectories Initiative, a preconception health trial for 18- to 25-year-old women in Soweto, South Africa.

Methods

The study compares two arms focussed on either physical and mental health (intervention; delivered by community health workers - 'Health Helpers') or standard of care plus (control; standard access to healthcare plus additional telephonic input on 'life skills'; delivered by call centre assistants). These are collectively referred to as Bukhali. Data on the pilot implementation of the Bukhali trial (n = 1655) were collected from (1) weekly team meetings, (2) two focus groups (one with the intervention team Health Helpers, n = 7; one with intervention participants, n = 8) and one paired interview with control call centre assistants (n = 2), (3) notes from eight debrief sessions with Health Helpers and (4) quantitative trial monitoring data. Qualitative data were thematically analysed.

Results

The findings clustered within three themes: (1) challenges for young women in Soweto, (2) priorities for young women in Soweto and (3) implementation challenges and perceptions of the intervention. Challenges were mostly related to tough socioeconomic circumstances and less prioritisation of living a healthier life. The priorities of employment and educational opportunities reflected the socioeconomic challenges, where health was not recognised as priority. The main challenge to participation and compliance with the trial was that young women in Soweto generally wanted a tangible and preferably financial and immediate benefit. Community peer sessions, despite being recommended by young women as part of the intervention development, were not successful. Many women also moved between multiple households within Soweto, which flagged concerns for a cluster trial and risk of contamination.

Conclusion

Preconception health trials should consider socioeconomic challenges present in urban poor contexts. Learnings from the pilot phase significantly affected the design and implementation of the main Bukhali trial.

A maternal "mixed, high sugar" dietary pattern is associated with fetal growth

This study examined associations between a maternal "mixed, high sugar" dietary pattern during pregnancy and ultrasound-determined fetal growth in 495 urban African women and explored whether these associations were independent of maternal baseline body mass index (BMI) and gestational weight gain (GWG). Linear mixed effects modelling (LMM) was used to test the associations between maternal mixed, high sugar dietary pattern score, baseline BMI (kg/m² ), and GWG (kg/week) and the following fetal growth outcomes: (a) biparietal diameter (cm), (b) head circumference (cm), (c) abdominal circumference (cm), and (d) femur length (cm). In the pooled LMM, a +1 standard deviation (SD) increase in the mixed, high sugar dietary pattern score was associated with higher biparietal diameter (0.03 cm/+1 SD; p = .007), head circumference (0.07 cm/+1 SD; p = .026), abdominal circumference (0.08 cm/+1 SD; p = .038), and femur length (0.02 cm/+1 SD; p = .015). Although these associations were independent of maternal BMI and GWG, higher baseline BMI was independently and positively associated with abdominal circumference (0.03 cm/+1 kg/m² ; p = .011) and femur length (0.01 cm/+1 kg/m² ; p = .007) and 1 kg/week greater GWG was associated with a 0.82 cm increase in abdominal circumference (p = .007). In urban African settings, where preconception maternal obesity prevalence is high and processed, high sugar diets are common, improving maternal dietary intake and BMI prior to conception should be prioritised for optimising pregnancy and birth outcomes as well as longer-term offspring health. In addition, dietary management strategies during pregnancy may be beneficial in facilitating healthy fetal growth.