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Serrano Matos YA, Cano J, Shafiq H, Williams C, Sunny J, Cowardin CA. Colonization during a key developmental window reveals microbiota-dependent shifts in growth and immunity during undernutrition. MICROBIOME 2024; 12:71. [PMID: 38589975 PMCID: PMC11003143 DOI: 10.1186/s40168-024-01783-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 02/28/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Childhood undernutrition is a major global health challenge with devastating lifelong consequences. Linear growth stunting due to undernutrition has been linked to poor health outcomes, and mothers who experience growth stunting in childhood are more likely to give birth to stunted children later in life. Based on these findings, we hypothesized that intergenerational colonization of mice with microbiota from human donors with undernutrition may recapitulate certain immune and growth changes observed in this disorder. RESULTS To test this hypothesis, we developed a gnotobiotic murine model of undernutrition using microbiota from human infants with healthy or stunted growth trajectories. Intergenerational colonization with microbiota derived from children with growth stunting lead to less linear growth and the development of immune features of undernutrition and enteropathy, including intestinal villus blunting, lower liver IGF-1 and accumulation of intraepithelial lymphocytes and plasma cells in the small intestine. In contrast, colonization after weaning lead to fewer host phenotypic changes between these distinct microbial communities. CONCLUSIONS These results are broadly consistent with previous findings demonstrating that exposure of the immune system to microbial products during the weaning phase is a critical determinant of later life immune function. Overall, our results suggest intergenerational colonization with human microbiota samples is a useful approach with which to investigate microbiota-dependent changes in growth and immunity in early life. Murine models that capture the intergenerational and multifactorial nature of undernutrition are critical to understanding the underlying biology of this disorder. Video Abstract.
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Affiliation(s)
- Yadeliz A Serrano Matos
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
- Department of Microbiology, Immunology and Cancer Biology, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
| | - Jasmine Cano
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
| | - Hamna Shafiq
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
| | - Claire Williams
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
- Department of Microbiology, Immunology and Cancer Biology, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
| | - Julee Sunny
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
| | - Carrie A Cowardin
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA.
- Department of Microbiology, Immunology and Cancer Biology, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA.
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Hazel EA, Erchick DJ, Katz J, Lee ACC, Diaz M, Wu LSF, West KP, Shamim AA, Christian P, Ali H, Baqui AH, Saha SK, Ahmed S, Roy AD, Silveira MF, Buffarini R, Shapiro R, Zash R, Kolsteren P, Lachat C, Huybregts L, Roberfroid D, Zhu Z, Zeng L, Gebreyesus SH, Tesfamariam K, Adu-Afarwuah S, Dewey KG, Gyaase S, Poku-Asante K, Boamah Kaali E, Jack D, Ravilla T, Tielsch J, Taneja S, Chowdhury R, Ashorn P, Maleta K, Ashorn U, Mangani C, Mullany LC, Khatry SK, Ramokolo V, Zembe-Mkabile W, Fawzi WW, Wang D, Schmiegelow C, Minja D, Msemo OA, Lusingu JPA, Smith ER, Masanja H, Mongkolchati A, Keentupthai P, Kakuru A, Kajubi R, Semrau K, Hamer DH, Manasyan A, Pry JM, Chasekwa B, Humphrey J, Black RE. Neonatal mortality risk of vulnerable newborns by fine stratum of gestational age and birthweight for 230 679 live births in nine low- and middle-income countries, 2000-2017. BJOG 2024. [PMID: 38228570 DOI: 10.1111/1471-0528.17743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/29/2023] [Accepted: 12/13/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE To describe the mortality risks by fine strata of gestational age and birthweight among 230 679 live births in nine low- and middle-income countries (LMICs) from 2000 to 2017. DESIGN Descriptive multi-country secondary data analysis. SETTING Nine LMICs in sub-Saharan Africa, Southern and Eastern Asia, and Latin America. POPULATION Liveborn infants from 15 population-based cohorts. METHODS Subnational, population-based studies with high-quality birth outcome data were invited to join the Vulnerable Newborn Measurement Collaboration. All studies included birthweight, gestational age measured by ultrasound or last menstrual period, infant sex and neonatal survival. We defined adequate birthweight as 2500-3999 g (reference category), macrosomia as ≥4000 g, moderate low as 1500-2499 g and very low birthweight as <1500 g. We analysed fine strata classifications of preterm, term and post-term: ≥42+0 , 39+0 -41+6 (reference category), 37+0 -38+6 , 34+0 -36+6 ,34+0 -36+6 ,32+0 -33+6 , 30+0 -31+6 , 28+0 -29+6 and less than 28 weeks. MAIN OUTCOME MEASURES Median and interquartile ranges by study for neonatal mortality rates (NMR) and relative risks (RR). We also performed meta-analysis for the relative mortality risks with 95% confidence intervals (CIs) by the fine categories, stratified by regional study setting (sub-Saharan Africa and Southern Asia) and study-level NMR (≤25 versus >25 neonatal deaths per 1000 live births). RESULTS We found a dose-response relationship between lower gestational ages and birthweights with increasing neonatal mortality risks. The highest NMR and RR were among preterm babies born at <28 weeks (median NMR 359.2 per 1000 live births; RR 18.0, 95% CI 8.6-37.6) and very low birthweight (462.8 per 1000 live births; RR 43.4, 95% CI 29.5-63.9). We found no statistically significant neonatal mortality risk for macrosomia (RR 1.1, 95% CI 0.6-3.0) but a statistically significant risk for all preterm babies, post-term babies (RR 1.3, 95% CI 1.1-1.5) and babies born at 370 -386 weeks (RR 1.2, 95% CI 1.0-1.4). There were no statistically significant differences by region or underlying neonatal mortality. CONCLUSIONS In addition to tracking vulnerable newborn types, monitoring finer categories of birthweight and gestational age will allow for better understanding of the predictors, interventions and health outcomes for vulnerable newborns. It is imperative that all newborns from live births and stillbirths have an accurate recorded weight and gestational age to track maternal and neonatal health and optimise prevention and care of vulnerable newborns.
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Affiliation(s)
- Elizabeth A Hazel
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Daniel J Erchick
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Joanne Katz
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anne C C Lee
- Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Diaz
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lee S F Wu
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Keith P West
- Department of International Health, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Parul Christian
- Department of International Health, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Hasmot Ali
- JiVitA Maternal and Child Health Research Project, Rangpur, Bangladesh
| | - Abdullah H Baqui
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Samir K Saha
- Child Health Research Foundation, Dhaka, Bangladesh
| | | | | | - Mariângela F Silveira
- Post-Graduate Program in Epidemiology-Federal University of Pelotas, Pelotas, Brazil
| | - Romina Buffarini
- Post-Graduate Program in Epidemiology-Federal University of Pelotas, Pelotas, Brazil
| | - Roger Shapiro
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Rebecca Zash
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Patrick Kolsteren
- Department of Food Technology, Safety and Health, Ghent University, Ghent, Belgium
| | - Carl Lachat
- Department of Food Technology, Safety and Health, Ghent University, Ghent, Belgium
| | - Lieven Huybregts
- Department of Food Technology, Safety and Health, Ghent University, Ghent, Belgium
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, USA
| | - Dominique Roberfroid
- Namur University, Namur, Belgium
- Belgian Health Care Knowledge Centre, Brussels, Belgium
| | - Zhonghai Zhu
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, China
| | - Lingxia Zeng
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, China
| | - Seifu H Gebreyesus
- Department of Nutrition and Dietetics, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Kokeb Tesfamariam
- Department of Food Technology, Safety, and Health, Faculty of Bioscience Engineering, Ghent University, Ghent, Belgium
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Accra, Ghana
| | - Kathryn G Dewey
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, California, USA
| | | | | | - Ellen Boamah Kaali
- Kintampo Health Research Centre, Kintampo, Ghana
- Research and Development Division, Ghana Health Service, Accra, Ghana
| | - Darby Jack
- Columbia University's Mailman School of Public Health, New York, New York, USA
| | | | - James Tielsch
- George Washington University Milken Institute School of Public Health, Washington, District of Columbia, USA
| | - Sunita Taneja
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Ranadip Chowdhury
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Per Ashorn
- Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Kenneth Maleta
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Ulla Ashorn
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Charles Mangani
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Luke C Mullany
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Vundli Ramokolo
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Gertrude H Sergievsky Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York, USA
| | - Wanga Zembe-Mkabile
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- College Graduate of Studies, University of South Africa, Pretoria, South Africa
| | - Wafaie W Fawzi
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Dongqing Wang
- Department of Global and Community Health, College of Public Health, George Mason University, Fairfax, Virginia, USA
| | - Christentze Schmiegelow
- Department of Immunology and Microbiology, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark
| | - Daniel Minja
- National Institute of Medical Research, Tanga, Tanzania
| | | | | | - Emily R Smith
- Department of Global Health, Milken Institute School of Public Health, Washington, District of Columbia, USA
| | | | | | - Paniya Keentupthai
- College of Medicine and Public Health, Ubon Ratchathani University, Ubon Ratchathani, Thailand
| | - Abel Kakuru
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Richard Kajubi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Katherine Semrau
- Ariadne Labs, Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Albert Manasyan
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jake M Pry
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Bernard Chasekwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Jean Humphrey
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Robert E Black
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Perumal N, Wang D, Darling AM, Liu E, Wang M, Ahmed T, Christian P, Dewey KG, Kac G, Kennedy SH, Subramoney V, Briggs B, Fawzi WW. Suboptimal gestational weight gain and neonatal outcomes in low and middle income countries: individual participant data meta-analysis. BMJ 2023; 382:e072249. [PMID: 37734757 PMCID: PMC10512803 DOI: 10.1136/bmj-2022-072249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE To estimate the associations between gestational weight gain (GWG) during pregnancy and neonatal outcomes in low and middle income countries. DESIGN Individual participant data meta-analysis. SETTING Prospective pregnancy studies from 24 low and middle income countries. MAIN OUTCOME MEASURES Nine neonatal outcomes related to timing (preterm birth) and anthropometry (weight, length, and head circumference) at birth, stillbirths, and neonatal death. ANALYSIS METHODS A systematic search was conducted in PubMed, Embase, and Web of Science which identified 53 prospective pregnancy studies published after the year 2000 with data on GWG, timing and anthropometry at birth, and neonatal mortality. GWG adequacy was defined as the ratio of the observed maternal weight gain over the recommended weight gain based on the Institute of Medicine body mass index specific guidelines, which are derived from data in high income settings, and the INTERGROWTH-21st GWG standards. Study specific estimates, adjusted for confounders, were generated and then pooled using random effects meta-analysis models. Maternal age and body mass index before pregnancy were examined as potential modifiers of the associations between GWG adequacy and neonatal outcomes. RESULTS Overall, 55% of participants had severely inadequate (<70%) or moderately inadequate (70% to <90%) GWG, 22% had adequate GWG (90-125%), and 23% had excessive GWG (≥125%). Severely inadequate GWG was associated with a higher risk of low birthweight (adjusted relative risk 1.62, 95% confidence interval 1.51 to 1.72; 48 studies, 93 337 participants; τ2=0.006), small for gestational age (1.44, 1.36 to 1.54; 51 studies, 93 191 participants; τ2=0.016), short for gestational age (1.47, 1.29 to 1.69; 40 studies, 83 827 participants; τ2=0.074), and microcephaly (1.57, 1.31 to 1.88; 31 studies, 80 046 participants; τ2=0.145) compared with adequate GWG. Excessive GWG was associated with a higher risk of preterm birth (1.22, 1.13 to 1.31; 48 studies, 103 762 participants; τ2=0.008), large for gestational age (1.44, 1.33 to 1.57; 47 studies, 90 044 participants; τ2=0.009), and macrosomia (1.52, 1.33 to 1.73; 29 studies, 68 138 participants; τ2=0) compared with adequate GWG. The direction and magnitude of the associations between GWG adequacy and several neonatal outcomes were modified by maternal age and body mass index before pregnancy. CONCLUSIONS Inadequate and excessive GWG are associated with a higher risk of adverse neonatal outcomes across settings. Interventions to promote optimal GWG during pregnancy are likely to reduce the burden of adverse neonatal outcomes, however further research is needed to assess optimal ranges of GWG based on data from low and middle income countries.
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Affiliation(s)
- Nandita Perumal
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC, USA
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Dongqing Wang
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, VA, USA
| | - Anne Marie Darling
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Enju Liu
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Molin Wang
- Department of Epidemiology, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Biostatistics, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Tahmeed Ahmed
- Nutrition & Clinical Services, International Centre for Diarrheal Disease Research, Dhaka, Bangladesh
| | - Parul Christian
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kathryn G Dewey
- Department of Nutrition, University of California, Davis, CA, USA
| | - Gilberto Kac
- Nutritional Epidemiology Observatory, Josué de Castro Nutrition Institute, Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | - Stephen H Kennedy
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | | | - Brittany Briggs
- Certara USA, on behalf of the Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Epidemiology, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Nutrition, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
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Serrano Matos YA, Cano J, Shafiq H, Williams C, Sunny J, Cowardin CA. Colonization during a key developmental window reveals microbiota-dependent shifts in growth and immunity during undernutrition. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.07.07.547849. [PMID: 37461523 PMCID: PMC10350093 DOI: 10.1101/2023.07.07.547849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Childhood undernutrition is a major global health challenge with devastating lifelong consequences. Linear growth stunting due to undernutrition has been linked to poor outcomes, and mothers who experience stunting are more likely to give birth to stunted children. Murine models that capture the intergenerational and multifactorial nature of undernutrition are critical to understanding the underlying biology of this disorder. Here we report a gnotobiotic mouse model of undernutrition using microbiota from human infants with healthy or stunted growth trajectories. Intergenerational transmission of microbiota from parents to offspring leads to the development of growth and immune features of undernutrition and enteropathy, including reduced linear growth, intestinal villus blunting and accumulation of intraepithelial lymphocytes. In contrast, colonization after weaning reduces sensitivity to detect changes driven by distinct microbial communities. Overall, these results suggest intergenerational colonization is a useful approach with which to investigate microbiota-dependent growth and immunity in early life.
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Affiliation(s)
- Yadeliz A. Serrano Matos
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
- Department of Microbiology, Immunology and Cancer Biology, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
- These authors contributed equally
| | - Jasmine Cano
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
- These authors contributed equally
| | - Hamna Shafiq
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
| | - Claire Williams
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
- Department of Microbiology, Immunology and Cancer Biology, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
| | - Julee Sunny
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
| | - Carrie A. Cowardin
- Division of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
- Department of Microbiology, Immunology and Cancer Biology, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
- Senior author
- Lead contact
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Darling AM, Wang D, Perumal N, Liu E, Wang M, Ahmed T, Christian P, Dewey KG, Kac G, Kennedy SH, Subramoney V, Briggs B, Fawzi WW. Risk factors for inadequate and excessive gestational weight gain in 25 low- and middle-income countries: An individual-level participant meta-analysis. PLoS Med 2023; 20:e1004236. [PMID: 37486938 PMCID: PMC10406332 DOI: 10.1371/journal.pmed.1004236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/07/2023] [Accepted: 04/21/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Many women experience suboptimal gestational weight gain (GWG) in low- and middle-income countries (LMICs), but our understanding of risk factors associated with GWG in these settings is limited. We investigated the relationships between demographic, anthropometric, lifestyle, and clinical factors and GWG in prospectively collected data from LMICs. METHODS AND FINDINGS We conducted an individual participant-level meta-analysis of risk factors for GWG outcomes among 138,286 pregnant women with singleton pregnancies in 55 studies (27 randomized controlled trials and 28 prospective cohorts from 25 LMICs). Data sources were identified through PubMed, Embase, and Web of Science searches for articles published from January 2000 to March 2019. Titles and abstracts of articles identified in all databases were independently screened by 2 team members according to the following eligibility criteria: following inclusion criteria: (1) GWG data collection took place in an LMIC; (2) the study was a prospective cohort or randomized trial; (3) study participants were pregnant; and (4) the study was not conducted exclusively among human immunodeficiency virus (HIV)-infected women or women with other health conditions that could limit the generalizability of the results. The Institute of Medicine (IOM) body mass index (BMI)-specific guidelines were used to determine the adequacy of GWG, which we calculated as the ratio of the total observed weight gain over the mean recommended weight gain. Study outcomes included severely inadequate GWG (percent adequacy of GWG <70), inadequate GWG (percent adequacy of GWG <90, inclusive of severely inadequate), and excessive GWG (percent adequacy of GWG >125). Multivariable estimates from each study were pooled using fixed-effects meta-analysis. Study-specific regression models for each risk factor included all other demographic risk factors measured in a particular study as potential confounders, as well as BMI, maternal height, pre-pregnancy smoking, and chronic hypertension. Risk factors occurring during pregnancy were further adjusted for receipt of study intervention (if any) and 3-month calendar period. The INTERGROWTH-21st standard was used to define high and low GWG among normal weight women in a sensitivity analysis. The prevalence of inadequate GWG was 54%, while the prevalence of excessive weight gain was 22%. In multivariable models, factors that were associated with a higher risk of inadequate GWG included short maternal stature (<145 cm), tobacco smoking, and HIV infection. A mid-upper arm circumference (MUAC) of ≥28.1 cm was associated with the largest increase in risk for excessive GWG (risk ratio (RR) 3.02, 95% confidence interval (CI) [2.86, 3.19]). The estimated pooled difference in absolute risk between those with MUAC of ≥28.1 cm compared to those with a MUAC of 24 to 28.09 cm was 5.8% (95% CI 3.1% to 8.4%). Higher levels of education and age <20 years were also associated with an increased risk of excessive GWG. Results using the INTERGROWTH-21st standard among normal weight women were similar but attenuated compared to the results using the IOM guidelines among normal weight women. Limitations of the study's methodology include differences in the availability of risk factors and potential confounders measured in each individual dataset; not all risk factors or potential confounders of interest were available across datasets and data on potential confounders collected across studies. CONCLUSIONS Inadequate GWG is a significant public health concern in LMICs. We identified diverse nutritional, behavioral, and clinical risk factors for inadequate GWG, highlighting the need for integrated approaches to optimizing GWG in LMICs. The prevalence of excessive GWG suggests that attention to the emerging burden of excessive GWG in LMICs is also warranted.
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Affiliation(s)
- Anne Marie Darling
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Dongqing Wang
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, Virginia, United States of America
| | - Nandita Perumal
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Enju Liu
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Molin Wang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Tahmeed Ahmed
- Nutrition & Clinical Services, International Centre for Diarrheal Disease Research, Bangladesh
| | - Parul Christian
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Kathryn G. Dewey
- Department of Nutrition, University of California, Davis, Davis, California, United States of America
| | - Gilberto Kac
- Nutritional Epidemiology Observatory, Josué de Castro Nutrition Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Stephen H. Kennedy
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | | | - Brittany Briggs
- Certara USA, Inc. on behalf of the Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Wafaie W. Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
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Hunter PJ, Muthiani Y, Näsänen-Gilmore PK, Koivu AM, Pörtfors P, Bastola K, Vimpeli R, Luoma J, Ashorn U, Ashorn P. A modular systematic review of antenatal interventions to address undernutrition during pregnancy in the prevention of low birth weight. Am J Clin Nutr 2023; 117 Suppl 2:S134-S147. [PMID: 37331760 DOI: 10.1016/j.ajcnut.2023.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND Poor nutrition during pregnancy can lead to adverse birth outcomes including low birth weight (LBW). OBJECTIVE This modular systematic review aimed to provide evidence for the effects of seven antenatal nutritional interventions on the risks of LBW, preterm birth (PTB), small-for-gestational-age (SGA) and stillbirth (SB). METHODS We searched MEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials and CINAHL Complete between April and June 2020, with a further update in September 2022 (Embase only). We included randomized controlled trials (RCTs) and reviews of RCTs to estimate the effect sizes of the selected interventions on the four birth outcomes. RESULTS Evidence suggests that balanced protein and energy (BPE) supplementation for pregnant women with undernutrition can reduce the risk of LBW, SGA and SB. Evidence from low and lower middle-income countries (MIC) suggests that multiple micronutrient (MMN) supplementation can reduce the risk of LBW and SGA in comparison with iron or iron and folic acid supplementation and lipid-based nutrient supplements (LNS) with any quantity of energy can reduce the risk of LBW in comparison with MMN supplementation. Evidence from high and upper MIC suggests that supplementation with omega-3 fatty acids (O3FA) can reduce the risk and supplementation with high-dose calcium might possibly reduce the risk of LBW and PTB. Antenatal dietary education programs might possibly reduce the risk of LBW in comparison with standard-of-care. No RCTs were identified for monitoring weight gain followed by interventions to support weight gain in women who are underweight. CONCLUSIONS Provision of BPE, MMN and LNS to pregnant women in populations with undernutrition can reduce the risk of LBW and related outcomes. The benefits of O3FA and calcium supplementation to this population require further investigation. Targeting interventions to pregnant women who are not gaining weight has not been tested with RCTs.
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Affiliation(s)
- Patricia J Hunter
- University College London Great Ormond Street Institute of Child Health, London, UK.
| | - Yvonne Muthiani
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Pieta K Näsänen-Gilmore
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Finnish Institute for Health and Welfare, FI-00271, Helsinki, Finland
| | - Annariina M Koivu
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Pia Pörtfors
- Finnish Institute for Health and Welfare, FI-00271, Helsinki, Finland
| | - Kalpana Bastola
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Raija Vimpeli
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Juho Luoma
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Ulla Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Department of Pediatrics, Tampere University Hospital, Tampere, Finland
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7
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Koivu AM, Haapaniemi T, Askari S, Bhandari N, Black RE, Chico RM, Dewey KG, Duggan CP, Klein N, Kumar S, Lawn JE, Manji K, Näsänen-Gilmore PK, Salasibew M, Semrau KEA, Ashorn U, Ashorn P. What more can be done? Prioritizing the most promising antenatal interventions to improve birth weight. Am J Clin Nutr 2023; 117 Suppl 2:S107-S117. [PMID: 37331758 PMCID: PMC10447483 DOI: 10.1016/j.ajcnut.2022.10.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 10/13/2022] [Accepted: 10/28/2022] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND Low birth weight (LBW) is associated with neonatal mortality and sequelae of lifelong health problems; prioritizing the most promising antenatal interventions may guide resource allocation and improve health outcomes. OBJECTIVE We sought to identify the most promising interventions that are not yet included in the policy recommendations of the World Health Organization (WHO) but could complement antenatal care and reduce the prevalence of LBW and related adverse birth outcomes in low- and middle-income settings. METHODS We utilized an adapted Child Health and Nutrition Research Initiative (CHNRI) prioritization method. RESULTS In addition to procedures already recommended by WHO for the prevention of LBW, we identified six promising antenatal interventions that are not currently recommended by WHO with an indication for LBW prevention, namely: (1) provision of multiple micronutrients; (2) low-dose aspirin; (3) high-dose calcium; (4) prophylactic cervical cerclage; (5) psychosocial support for smoking cessation; and (6) other psychosocial support for targeted populations and settings. We also identified seven interventions for further implementation research and six interventions for efficacy research. CONCLUSION These promising interventions, coupled with increasing coverage of currently recommended antenatal care, could accelerate progress toward the global target of a 30% reduction in the number of LBW infants born in 2025 compared to 2006-10.
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Affiliation(s)
- Annariina M Koivu
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
| | - Tiia Haapaniemi
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sufia Askari
- Children's Investment Fund Foundation, London, United Kingdom
| | - Nita Bhandari
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Robert E Black
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - R Matthew Chico
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Kathryn G Dewey
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Christopher P Duggan
- Center for Nutrition, Boston Children's Hospital/Harvard Medical School; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Nigel Klein
- UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Joy E Lawn
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Karim Manji
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Pieta K Näsänen-Gilmore
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Katherine E A Semrau
- Ariadne Labs, Harvard T.H. Chan School of Public Health/Brigham and Women's Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Ulla Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Department of Paediatrics, Tampere University Hospital, Tampere, Finland
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8
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Ciulei MA, Smith ER, Perumal N, Jakazi CS, Sudfeld CR, Gernand AD. Nutritious Supplemental Foods for Pregnant Women from Food Insecure Settings: Types, Nutritional Composition, and Relationships to Health Outcomes. Curr Dev Nutr 2023; 7:100094. [PMID: 37250388 PMCID: PMC10209485 DOI: 10.1016/j.cdnut.2023.100094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/21/2023] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
There is growing evidence that the provision of nutritious supplemental foods to undernourished pregnant women can improve maternal and infant outcomes. However, comparing and synthesizing the evidence base is complicated by differences in interventions and products and the use of ambiguous terminology. We aimed to define 2 common types of nutritious supplemental foods used in pregnancy, balanced energy-protein (BEP) supplements and lipid-based nutrient supplements (LNS), and to review the evidence supporting each via a narrative review of systematic reviews and meta-analyses (SRMAs). Information about the nutritional composition of the food supplements and their effects on maternal and infant outcomes was abstracted. Five SRMAs (n = 20 trials) evaluated the effect of BEP compared with no BEP/control (comparison group commonly received iron and folic acid [IFA]). BEP foods/products ranged in calories (118-1017 kcals), protein (3-50 g), fat (6-57 g), and micronutrient content. Overall, maternal BEP improved birth weight and reduced the risk of stillbirth and small for gestational age when compared with no BEP/control in pregnancy. Three SRMAs (n = 5 trials) evaluated the effect of LNS compared with IFA or multiple micronutrients (MMNs). The LNS interventions comprised small- and large-quantity LNS that ranged in calories (118-746 kcals), protein (3-21 g), fat (10-53 g), and micronutrient content. LNS compared with IFA increased pregnancy duration, birth weight, and birth length and reduced the risk of small for gestational age and infant stunting; however, no beneficial effect of LNS was identified when compared with MMN. Despite heterogeneity in the nutritional composition of BEP supplements, the evidence suggests that in nutritionally at-risk populations, these products may improve birth outcomes in pregnant women. The evidence is limited but promising when LNS is compared with IFA in improving maternal and infant outcomes. Overall, BEP, compared with MMN or LNS, are key areas that have not been studied and deserve attention.
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Affiliation(s)
- Mihaela A. Ciulei
- Department of Nutritional Sciences, the Pennsylvania State University, University Park, PA, United States
| | - Emily R. Smith
- Department of Global Health, George Washington University Milken Institute School of Public Health, Washington, DC, United States
- Department of Exercise and Nutrition Sciences, George Washington University Milken Institute School of Public Health, Washington, DC, United States
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, United States
| | - Nandita Perumal
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, United States
| | - Chioniso S. Jakazi
- Department of Global Health, George Washington University Milken Institute School of Public Health, Washington, DC, United States
| | - Christopher R. Sudfeld
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, United States
- Department of Nutrition, Harvard School of Public Health, Boston, MA, United States
| | - Alison D. Gernand
- Department of Nutritional Sciences, the Pennsylvania State University, University Park, PA, United States
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9
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Hazel EA, Erchick DJ, Katz J, Lee ACC, Diaz M, Wu LSF, West KP, Shamim AA, Christian P, Ali H, Baqui AH, Saha SK, Ahmed S, Roy AD, Silveira MF, Buffarini R, Shapiro R, Zash R, Kolsteren P, Lachat C, Huybregts L, Roberfroid D, Zhu Z, Zeng L, Gebreyesus SH, Tesfamariam K, Adu-Afarwuah S, Dewey KG, Gyaase S, Poku-Asante K, Boamah Kaali E, Jack D, Ravilla T, Tielsch J, Taneja S, Chowdhury R, Ashorn P, Maleta K, Ashorn U, Mangani C, Mullany LC, Khatry SK, Ramokolo V, Zembe-Mkabile W, Fawzi WW, Wang D, Schmiegelow C, Minja D, Msemo OA, Lusingu JPA, Smith ER, Masanja H, Mongkolchati A, Keentupthai P, Kakuru A, Kajubi R, Semrau K, Hamer DH, Manasyan A, Pry JM, Chasekwa B, Humphrey J, Black RE. Neonatal mortality risk of vulnerable newborns: A descriptive analysis of subnational, population-based birth cohorts for 238 203 live births in low- and middle-income settings from 2000 to 2017. BJOG 2023. [PMID: 37156238 DOI: 10.1111/1471-0528.17518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 04/06/2023] [Accepted: 04/12/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVE We aimed to understand the mortality risks of vulnerable newborns (defined as preterm and/or born weighing smaller or larger compared to a standard population), in low- and middle-income countries (LMICs). DESIGN Descriptive multi-country, secondary analysis of individual-level study data of babies born since 2000. SETTING Sixteen subnational, population-based studies from nine LMICs in sub-Saharan Africa, Southern and Eastern Asia, and Latin America. POPULATION Live birth neonates. METHODS We categorically defined five vulnerable newborn types based on size (large- or appropriate- or small-for-gestational age [LGA, AGA, SGA]), and term (T) and preterm (PT): T + LGA, T + SGA, PT + LGA, PT + AGA, and PT + SGA, with T + AGA (reference). A 10-type definition included low birthweight (LBW) and non-LBW, and a four-type definition collapsed AGA/LGA into one category. We performed imputation for missing birthweights in 13 of the studies. MAIN OUTCOME MEASURES Median and interquartile ranges by study for the prevalence, mortality rates and relative mortality risks for the four, six and ten type classification. RESULTS There were 238 203 live births with known neonatal status. Four of the six types had higher mortality risk: T + SGA (median relative risk [RR] 2.6, interquartile range [IQR] 2.0-2.9), PT + LGA (median RR 7.3, IQR 2.3-10.4), PT + AGA (median RR 6.0, IQR 4.4-13.2) and PT + SGA (median RR 10.4, IQR 8.6-13.9). T + SGA, PT + LGA and PT + AGA babies who were LBW, had higher risk compared with non-LBW babies. CONCLUSIONS Small and/or preterm babies in LIMCs have a considerably increased mortality risk compared with babies born at term and larger. This classification system may advance the understanding of the social determinants and biomedical risk factors along with improved treatment that is critical for newborn health.
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Affiliation(s)
- Elizabeth A Hazel
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Daniel J Erchick
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Joanne Katz
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anne C C Lee
- Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Diaz
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lee S F Wu
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Keith P West
- Department of International Health, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Parul Christian
- Department of International Health, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Hasmot Ali
- JiVitA Maternal and Child Health Research Project, Rangpur, Bangladesh
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Samir K Saha
- Child Health Research Foundation, Dhaka, Bangladesh
| | | | | | - Mariângela F Silveira
- Post-Graduate Program in Epidemiology - Federal University of Pelotas, Pelotas, Brazil
| | - Romina Buffarini
- Post-Graduate Program in Epidemiology - Federal University of Pelotas, Pelotas, Brazil
| | - Roger Shapiro
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Rebecca Zash
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Patrick Kolsteren
- Department of Food Technology, Safety and Health, Ghent University, Ghent, Belgium
| | - Carl Lachat
- Department of Food Technology, Safety and Health, Ghent University, Ghent, Belgium
| | - Lieven Huybregts
- Department of Food Technology, Safety and Health, Ghent University, Ghent, Belgium
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, USA
| | - Dominique Roberfroid
- Namur University, Namur, Belgium
- Belgian Health Care Knowledge Centre, Brussels, Belgium
| | - Zhonghai Zhu
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, China
| | - Lingxia Zeng
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, China
| | - Seifu H Gebreyesus
- Department of Nutrition and Dietetics, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Kokeb Tesfamariam
- Department of Food Technology, Safety, and Health, Faculty of Bioscience Engineering, Ghent University, Ghent, Belgium
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Accra, Ghana
| | - Kathryn G Dewey
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, California, USA
| | | | | | - Ellen Boamah Kaali
- Kintampo Health Research Centre, Kintampo, Ghana
- Research and Development Division, Ghana Health Service, Accra, Ghana
| | - Darby Jack
- Columbia University's Mailman School of Public Health, New York, New York, USA
| | | | - James Tielsch
- George Washington University Milken Institute School of Public Health, Washington, District of Columbia, USA
| | - Sunita Taneja
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Ranadip Chowdhury
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Per Ashorn
- Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Kenneth Maleta
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Ulla Ashorn
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Charles Mangani
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Luke C Mullany
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Vundli Ramokolo
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Gertrude H Sergievsky Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York, USA
| | - Wanga Zembe-Mkabile
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- South African Research Chair in Social Policy at College Graduate of Studies, University of South Africa, Pretoria, South Africa
| | - Wafaie W Fawzi
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Dongqing Wang
- Department of Global and Community Health, College of Public Health, George Mason University, Fairfax, Virginia, USA
| | - Christentze Schmiegelow
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, and Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark
| | - Daniel Minja
- National Institute of Medical Research, Tanga, Tanzania
| | | | | | - Emily R Smith
- Department of Global Health, Milken Institute School of Public Health, Washington, District of Columbia, USA
| | | | | | - Paniya Keentupthai
- College of Medicine and Public Health, Ubon Ratchathani University, Ubon Ratchathani, Thailand
| | - Abel Kakuru
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Richard Kajubi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Katherine Semrau
- Ariadne Labs, Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Albert Manasyan
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jake M Pry
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Bernard Chasekwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Jean Humphrey
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Robert E Black
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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10
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Werner ER, Haskell MJ, Arnold CD, Caswell BL, Iannotti LL, Lutter CK, Maleta KM, Stewart CP. The Effects of One Egg Per Day on Vitamin A Status Among Young Malawian Children: A Secondary Analysis of a Randomized Controlled Trial. Curr Dev Nutr 2023; 7:100053. [PMID: 37181936 PMCID: PMC10111603 DOI: 10.1016/j.cdnut.2023.100053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/10/2023] [Accepted: 01/19/2023] [Indexed: 02/24/2023] Open
Abstract
Background Vitamin A deficiency (VAD) is common in populations with limited dietary diversity and access to vitamin A-rich foods. Objectives This analysis aimed to determine the impact of supplementing children's diets with 1 egg/d on the concentration of plasma retinol and RBP and the prevalence of VAD. Methods Children age 6-9 mo living in the Mangochi district of Malawi were individually randomly assigned to receive 1 egg/d for 6 mo (n = 331) or continue their usual diet (n = 329) in the Mazira trial (clinicaltrials.gov; NCT03385252). This secondary analysis measured plasma retinol by HPLC and RBP, CRP, and α-1-acid glycoprotein (AGP) by ELISA techniques at enrollment and 6 mo follow-up. Retinol and RBP were adjusted for inflammation, and mean concentrations were compared between groups using linear regression models. In addition, prevalence ratios of VAD (retinol <0.7 μmol/L) were compared between groups using log-binomial or modified Poisson regression models. Results After 6 mo of study participation, 489 were assessed for retinol (egg: n = 238; control: n = 251), and 575 (egg: n = 281; control: n = 294) were assessed for RBP. Prevalence of inflammation (CRP >5 mg/L or AGP >1 g/L: 62%) and inflammation-adjusted VAD (7%) at enrollment did not differ between groups. At follow-up, the egg intervention group did not differ from the control in inflammation-adjusted retinol [geometric mean (95% CI); egg: 1.10 μmol/L (1.07, 1.13); control: 1.08 (1.05, 1.12)], RBP [egg: 0.99 μmol/L (0.96, 1.02); control: 0.97 (0.94, 1.00)], or prevalence of VAD [egg: 6%; control: 3%; prevalence ratio: 1.87 (0.83, 4.24)]. Conclusions Provision of 1 egg/d did not impact VAD, plasma retinol, or RBP among young children in rural Malawi, where the prevalence of VAD was low. Curr Dev Nutr 2023;x:xx.This trial was registered at [clinicaltrials.gov] as [NCT03385252].
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Affiliation(s)
- E. Rochelle Werner
- Institute for Global Nutrition, University of California, Davis, Davis, CA, United States
| | - Marjorie J. Haskell
- Institute for Global Nutrition, University of California, Davis, Davis, CA, United States
| | - Charles D. Arnold
- Institute for Global Nutrition, University of California, Davis, Davis, CA, United States
| | - Bess L. Caswell
- Institute for Global Nutrition, University of California, Davis, Davis, CA, United States
- Western Human Nutrition Research Center, US Department of Agriculture, Davis, CA, United States
| | - Lora L. Iannotti
- E3 Nutrition Lab, Washington University in St Louis, St Louis, MO, United States
| | | | - Kenneth M. Maleta
- School of Public Health and Family Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Christine P. Stewart
- Institute for Global Nutrition, University of California, Davis, Davis, CA, United States
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11
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Luoma J, Adubra L, Ashorn P, Ashorn U, Bendabenda J, Dewey KG, Hallamaa L, Coghlan R, Horton WA, Hyöty H, Kortekangas E, Lehto KM, Maleta K, Matchado A, Nkhoma M, Oikarinen S, Parkkila S, Purmonen S, Fan YM. Association between asymptomatic infections and linear growth in 18-24-month-old Malawian children. MATERNAL & CHILD NUTRITION 2023; 19:e13417. [PMID: 36111423 DOI: 10.1111/mcn.13417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 06/22/2022] [Accepted: 07/13/2022] [Indexed: 12/15/2022]
Abstract
Inadequate diet and frequent symptomatic infections are considered major causes of growth stunting in low-income countries, but interventions targeting these risk factors have achieved limited success. Asymptomatic infections can restrict growth, but little is known about their role in global stunting prevalence. We investigated factors related to length-for-age Z-score (LAZ) at 24 months by constructing an interconnected network of various infections, biomarkers of inflammation (as assessed by alpha-1-acid glycoprotein [AGP]), and growth (insulin-like growth factor 1 [IGF-1] and collagen X biomarker [CXM]) at 18 months, as well as other children, maternal, and household level factors. Among 604 children, there was a continuous decline in mean LAZ and increased mean length deficit from birth to 24 months. At 18 months of age, the percentage of asymptomatic children who carried each pathogen was: 84.5% enterovirus, 15.5% parechovirus, 7.7% norovirus, 4.6% rhinovirus, 0.6% rotavirus, 69.6% Campylobacter, 53.8% Giardia lamblia, 11.9% malaria parasites, 10.2% Shigella, and 2.7% Cryptosporidium. The mean plasma IGF-1 concentration was 12.5 ng/ml and 68% of the children had systemic inflammation (plasma AGP concentration >1 g/L). Shigella infection was associated with lower LAZ at 24 months through both direct and indirect pathways, whereas enterovirus, norovirus, Campylobacter, Cryptosporidium, and malaria infections were associated with lower LAZ at 24 months indirectly, predominantly through increased systemic inflammation and reduced plasma IGF-1 and CXM concentration at 18 months.
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Affiliation(s)
- Juho Luoma
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Laura Adubra
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Ulla Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jaden Bendabenda
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kathryn G Dewey
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, California, USA
| | - Lotta Hallamaa
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Ryan Coghlan
- Research Center, Shriners Hospitals for Children, Portland, Oregon, USA.,Department of Molecular and Medical Genetics, Oregon Health and Science University, Portland, Oregon, USA
| | - William A Horton
- Research Center, Shriners Hospitals for Children, Portland, Oregon, USA.,Department of Molecular and Medical Genetics, Oregon Health and Science University, Portland, Oregon, USA
| | - Heikki Hyöty
- Department of Virology, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Fimlab Ltd., Tampere University Hospital, Tampere, Finland
| | - Emma Kortekangas
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Kirsi-Maarit Lehto
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Kenneth Maleta
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Andrew Matchado
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Minyanga Nkhoma
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sami Oikarinen
- Department of Virology, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Seppo Parkkila
- Fimlab Ltd., Tampere University Hospital, Tampere, Finland.,Clinical Medicine, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sami Purmonen
- Clinical Medicine, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Yue-Mei Fan
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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12
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Liu E, Wang D, Darling AM, Perumal N, Wang M, Ahmed T, Christian P, Dewey KG, Kac G, Kennedy S, Subramoney V, Briggs B, Fawzi WW. Effects of prenatal nutritional supplements on gestational weight gain in low- and middle-income countries: a meta-analysis of individual participant data. Am J Clin Nutr 2022; 116:1864-1876. [PMID: 36130877 PMCID: PMC10843965 DOI: 10.1093/ajcn/nqac259] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/29/2022] [Accepted: 09/13/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Gestational weight gain (GWG) below or above the Institute of Medicine (IOM) recommendations has been associated with adverse perinatal outcomes. Few studies have examined the effect of prenatal nutrient supplementations on GWG in low- and middle-income countries (LMICs). OBJECTIVES We aimed to investigate the effects of multiple micronutrient supplements (MMSs) and small-quantity lipid-based nutrient supplements (LNSs) on GWG in LMICs. METHODS A 2-stage meta-analysis of individual participant data was conducted to examine the effects of MMSs (45,507 women from 14 trials) and small-quantity LNSs (6237 women from 4 trials) on GWG compared with iron and folic acid supplements only. Percentage adequacy of GWG and total weight gain at delivery were calculated according to the IOM 2009 guidelines. Binary outcomes included severely inadequate (percentage adequacy <70%), inadequate (<90%), and excessive (>125%) GWG. Results from individual trials were pooled using fixed-effects inverse-variance models. Heterogeneity was examined using I2, stratified analysis, and meta-regression. RESULTS MMSs resulted in a greater percentage adequacy of GWG [weighted mean difference (WMD): 0.86%; 95% CI: 0.28%, 1.44%; P < 0.01] and higher GWG at delivery (WMD: 209 g; 95% CI: 139, 280 g; P < 0.01) than among those in the control arm. Women who received MMSs had a 2.9% reduced risk of severely inadequate GWG (RR: 0.971; 95% CI: 0.956, 0.987; P < 0.01). No association was found between small-quantity LNSs and GWG percentage adequacy (WMD: 1.51%; 95% CI: -0.38%, 3.40%; P = 0.21). Neither MMSs nor small-quantity LNSs were associated with excessive GWG. CONCLUSIONS Maternal MMSs were associated with greater GWG percentage adequacy and total GWG at delivery than was iron and folic acid only. This finding is consistent with previous results on birth outcomes and will inform policy development and local recommendations of switching routine prenatal iron and folic acid supplements to MMSs.
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Affiliation(s)
- Enju Liu
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Dongqing Wang
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, VA, USA
| | - Anne M Darling
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Nandita Perumal
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Molin Wang
- Department of Epidemiology, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Biostatistics, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Tahmeed Ahmed
- Nutrition & Clinical Services, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Parul Christian
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kathryn G Dewey
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Gilberto Kac
- Nutritional Epidemiology Observatory, Josué de Castro Nutrition Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Stephen Kennedy
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | | | - Brittany Briggs
- Certara USA, Inc. on behalf of the Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Nutrition, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - members of the GWG Pooling Project Consortium
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, VA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Biostatistics, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
- Nutrition & Clinical Services, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Nutrition, University of California, Davis, Davis, CA, USA
- Nutritional Epidemiology Observatory, Josué de Castro Nutrition Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford, United Kingdom
- Certara Canada, Montreal, Quebec, Canada
- DVPL Tech
- Certara USA, Inc. on behalf of the Bill & Melinda Gates Foundation, Seattle, WA, USA
- Department of Nutrition, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
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13
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Mtove G, Minja DTR, Abdul O, Gesase S, Maleta K, Divala TH, Patson N, Ashorn U, Laufer MK, Madanitsa M, Ashorn P, Mathanga D, Chinkhumba J, Gutman JR, Ter Kuile FO, Møller SL, Bygbjerg IC, Alifrangis M, Theander T, Lusingu JPA, Schmiegelow C. The choice of reference chart affects the strength of the association between malaria in pregnancy and small for gestational age: an individual participant data meta-analysis comparing the Intergrowth-21 with a Tanzanian birthweight chart. Malar J 2022; 21:292. [PMID: 36224585 PMCID: PMC9559842 DOI: 10.1186/s12936-022-04307-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The prevalence of small for gestational age (SGA) may vary depending on the chosen weight-for-gestational-age reference chart. An individual participant data meta-analysis was conducted to assess the implications of using a local reference (STOPPAM) instead of a universal reference (Intergrowth-21) on the association between malaria in pregnancy and SGA. METHODS Individual participant data of 6,236 newborns were pooled from seven conveniently identified studies conducted in Tanzania and Malawi from 2003-2018 with data on malaria in pregnancy, birthweight, and ultrasound estimated gestational age. Mixed-effects regression models were used to compare the association between malaria in pregnancy and SGA when using the STOPPAM and the Intergrowth-21 references, respectively. RESULTS The 10th percentile for birthweights-for-gestational age was lower for STOPPAM than for Intergrowth-21, leading to a prevalence of SGASTOPPAM of 14.2% and SGAIG21 of 18.0%, p < 0.001. The association between malaria in pregnancy and SGA was stronger for STOPPAM (adjusted odds ratio (aOR) 1.30 [1.09-1.56], p < 0.01) than for Intergrowth-21 (aOR 1.19 [1.00-1.40], p = 0.04), particularly among paucigravidae (SGASTOPPAM aOR 1.36 [1.09-1.71], p < 0.01 vs SGAIG21 aOR 1.21 [0.97-1.50], p = 0.08). CONCLUSIONS The prevalence of SGA may be overestimated and the impact of malaria in pregnancy underestimated when using Intergrowth-21. Comparing local reference charts to global references when assessing and interpreting the impact of malaria in pregnancy may be appropriate.
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Affiliation(s)
- George Mtove
- Tanga Medical Research Centre, National Institute for Medical Research, P. O. Box, 210, Tanga, Tanzania.
| | - Daniel T R Minja
- Tanga Medical Research Centre, National Institute for Medical Research, P. O. Box, 210, Tanga, Tanzania
| | - Omari Abdul
- Tanga Medical Research Centre, National Institute for Medical Research, P. O. Box, 210, Tanga, Tanzania
| | - Samwel Gesase
- Tanga Medical Research Centre, National Institute for Medical Research, P. O. Box, 210, Tanga, Tanzania
| | | | | | - Noel Patson
- Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Ulla Ashorn
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | | | | | - Per Ashorn
- Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research, Tampere University, Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Don Mathanga
- Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Diseases Control and Prevention, Atlanta, GA, USA
| | - Feiko O Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sofie Lykke Møller
- Section of Global Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Ib C Bygbjerg
- Section of Global Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Michael Alifrangis
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Thor Theander
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - John P A Lusingu
- Tanga Medical Research Centre, National Institute for Medical Research, P. O. Box, 210, Tanga, Tanzania
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Christentze Schmiegelow
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
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14
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Salenius M, Pyykkö J, Ashorn U, Dewey KG, Gondwe A, Harjunmaa U, Maleta K, Nkhoma M, Vosti SA, Ashorn P, Adubra L. Association between prenatal provision of lipid‐based nutrient supplements and caesarean delivery: Findings from a randomised controlled trial in Malawi. MATERNAL & CHILD NUTRITION 2022; 18:e13414. [PMID: 35909334 PMCID: PMC9480947 DOI: 10.1111/mcn.13414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/17/2022] [Accepted: 07/11/2022] [Indexed: 11/27/2022]
Abstract
In populations with a high prevalence of childhood and adolescent undernutrition, supplementation during pregnancy aiming at improving maternal nutritional status and preventing fetal growth restriction might theoretically lead to cephalopelvic disproportion and delivery complications. We investigated whether the prenatal provision of small‐quantity lipid‐based nutrient supplements (SQ‐LNS) was associated with an increased risk of caesarean section (CS) or other delivery complications. Pregnant Malawian women were randomised to receive daily i) iron–folic acid (IFA) capsule (control), ii) multiple micronutrient (MMN) capsule of 18 micronutrients (second control), or iii) SQ‐LNS with similar micronutrients as MMN, plus four minerals and macronutrients contributing 118 kcal. We analysed the associations of SQ‐LNS, CS, and other delivery complications using log‐binomial regressions. Among 1391 women enrolled, 1255 had delivery information available. The incidence of CS and delivery complications was 6.3% and 8.2%, respectively. The incidence of CS was 4.0%, 6.0%, and 8.9% (p = 0.017) in the IFA, MMN, and LNS groups, respectively. Compared to the IFA group, the relative risk (95% confidence interval) of CS was 2.2 (1.3–3.8) (p = 0.006) in the LNS group and 1.5 (0.8–2.7) (p = 0.200) in the MMN group. We found no significant differences for other delivery complications. Provision of SQ‐LNS to pregnant women may have increased the incidence of CS. The baseline rate was, however, lower than recommended. It is unclear if the higher CS incidence in the SQ‐LNS group resulted from increased obstetric needs or more active health seeking and a better supply of services. Trial registered at clinicaltrials.gov, NCT01239693. Provision of lipid‐based nutrient supplements (LNS) to pregnant Malawian women was associated with a higher incidence of caesarean delivery compared with iron–folic acid, which is the standard of care. The overall rate of caesarean section in this study was lower than recommended, and it remains unclear if the increased incidence in the LNS group resulted from increased obstetric needs or more active health seeking and a better supply of services. The association of LNS with higher caesarean delivery risk is a possible phenomenon in some settings and calls for monitoring obstetric complications in future prenatal nutritional supplementation studies and programs.
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Affiliation(s)
- Meeri Salenius
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Juha Pyykkö
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Ulla Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Kathryn G. Dewey
- Institute for Global Nutrition and Department of Nutrition University of California Davis Davis California USA
| | - Austrida Gondwe
- School of Public Health and Family Medicine, College of Medicine University of Malawi Blantyre Malawi
| | - Ulla Harjunmaa
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Kenneth Maleta
- School of Public Health and Family Medicine, College of Medicine University of Malawi Blantyre Malawi
| | - Minyanga Nkhoma
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Stephen A. Vosti
- Institute for Global Nutrition and Department of Nutrition University of California Davis Davis California USA
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology Tampere University Tampere Finland
- Department of Paediatrics Tampere University Hospital Tampere Finland
| | - Laura Adubra
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology Tampere University Tampere Finland
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15
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Liu Z, Fan YM, Ashorn P, Chingwanda C, Maleta K, Hallamaa L, Hyöty H, Chaima D, Ashorn U. Lack of Associations between Environmental Exposures and Environmental Enteric Dysfunction among 18-Month-Old Children in Rural Malawi. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10891. [PMID: 36078607 PMCID: PMC9517768 DOI: 10.3390/ijerph191710891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/25/2022] [Accepted: 08/28/2022] [Indexed: 06/15/2023]
Abstract
Environmental enteric dysfunction (EED) is common and contributes to linear growth faltering (stunting) and mortality among children in low-resource settings. A few studies on the environmental causes of EED have been conducted but the exact exposures that cause or predispose children to EED are context-specific and not clear. This study aimed to assess associations between selected environmental exposures and EED markers among 620 18-month-old children. This was a secondary analysis of data from Malawian children who participated in a randomized controlled trial (iLiNS-DYAD, registered at clinicaltrials.gov as NCT01239693) from birth to 18 months of age. Data on environmental exposures, including drinking water source, sanitation, exposure to animals, housing materials, season, residential area, and food insecurity were collected at enrolment. Biomarkers of EED included concentrations of calprotectin, regenerating 1B protein (REG1B), and alpha-1-antitrypsin from stool samples to assess intestinal inflammation, repair, and permeability, respectively. We performed bivariate and multivariable analyses to assess associations between environmental exposures and EED biomarkers. Adjusting for possible confounders, we did not find associations between the selected environmental exposures and the three biomarkers. These results do not provide support for our hypothesis that the studied adverse environmental exposures are associated with increased concentrations of children's EED markers in rural Malawi.
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Affiliation(s)
- Zhifei Liu
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, 33014 Tampere, Finland
| | - Yue-Mei Fan
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, 33014 Tampere, Finland
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, 33014 Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, 33521 Tampere, Finland
| | - Chilungamo Chingwanda
- School of Public Health & Family Medicine, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Kenneth Maleta
- School of Public Health & Family Medicine, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Lotta Hallamaa
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, 33014 Tampere, Finland
| | - Heikki Hyöty
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, 33014 Tampere, Finland
- Fimlab Laboratories, Pirkanmaa Hospital District, 33521 Tampere, Finland
| | - David Chaima
- School of Public Health & Family Medicine, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Ulla Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, 33014 Tampere, Finland
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16
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Liu Z, Ashorn U, Chingwanda C, Maleta K, Hallamaa L, Matchado A, Kortekangas E, Dewey KG, Ashorn P, Fan Y. Provision of small‐quantity lipid‐based nutrient supplements does not improve intestinal health among rural Malawian children. MATERNAL & CHILD NUTRITION 2022; 18:e13331. [PMID: 35128820 PMCID: PMC9218311 DOI: 10.1111/mcn.13331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 01/22/2022] [Accepted: 01/26/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Zhifei Liu
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Ulla Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | | | - Kenneth Maleta
- Department of Public Health University of Malawi Zomba Malawi
| | - Lotta Hallamaa
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Andrew Matchado
- Department of Public Health University of Malawi Zomba Malawi
| | - Emma Kortekangas
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Kathryn G Dewey
- Department of Nutrition University of California Davis CA USA
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology Tampere University Tampere Finland
- Department of Paediatrics Tampere University Hospital Tampere Finland
| | - Yue‐Mei Fan
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology Tampere University Tampere Finland
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17
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Prenatal fortified balanced energy-protein supplementation and birth outcomes in rural Burkina Faso: A randomized controlled efficacy trial. PLoS Med 2022; 19:e1004002. [PMID: 35560315 PMCID: PMC9140265 DOI: 10.1371/journal.pmed.1004002] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/27/2022] [Accepted: 04/27/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Providing balanced energy-protein (BEP) supplements is a promising intervention to improve birth outcomes in low- and middle-income countries (LMICs); however, evidence is limited. We aimed to assess the efficacy of fortified BEP supplementation during pregnancy to improve birth outcomes, as compared to iron-folic acid (IFA) tablets, the standard of care. METHODS AND FINDINGS We conducted an individually randomized controlled efficacy trial (MIcronutriments pour la SAnté de la Mère et de l'Enfant [MISAME]-III) in 6 health center catchment areas in rural Burkina Faso. Pregnant women, aged 15 to 40 years with gestational age (GA) <21 completed weeks, were randomly assigned to receive either fortified BEP supplements and IFA (intervention) or IFA (control). Supplements were provided during home visits, and intake was supervised on a daily basis by trained village-based project workers. The primary outcome was prevalence of small-for-gestational age (SGA) and secondary outcomes included large-for-gestational age (LGA), low birth weight (LBW), preterm birth (PTB), gestational duration, birth weight, birth length, Rohrer's ponderal index, head circumference, thoracic circumference, arm circumference, fetal loss, and stillbirth. Statistical analyses followed the intention-to-treat (ITT) principle. From October 2019 to December 2020, 1,897 pregnant women were randomized (960 control and 937 intervention). The last child was born in August 2021, and birth anthropometry was analyzed from 1,708 pregnancies (872 control and 836 intervention). A total of 22 women were lost to follow-up in the control group and 27 women in the intervention group. BEP supplementation led to a mean 3.1 percentage points (pp) reduction in SGA with a 95% confidence interval (CI) of -7.39 to 1.16 (P = 0.151), indicating a wide range of plausible true treatment efficacy. Adjusting for prognostic factors of SGA, and conducting complete cases (1,659/1,708, 97%) and per-protocol analysis among women with an observed BEP adherence ≥75% (1,481/1,708, 87%), did not change the results. The intervention significantly improved the duration of gestation (+0.20 weeks, 95% CI 0.05 to 0.36, P = 0.010), birth weight (50.1 g, 8.11 to 92.0, P = 0.019), birth length (0.20 cm, 0.01 to 0.40, P = 0.044), thoracic circumference (0.20 cm, 0.04 to 0.37, P = 0.016), arm circumference (0.86 mm, 0.11 to 1.62, P = 0.025), and decreased LBW prevalence (-3.95 pp, -6.83 to -1.06, P = 0.007) as secondary outcomes measures. No differences in serious adverse events [SAEs; fetal loss (21 control and 26 intervention) and stillbirth (16 control and 17 intervention)] between the study groups were found. Key limitations are the nonblinded administration of supplements and the lack of information on other prognostic factors (e.g., infection, inflammation, stress, and physical activity) to determine to which extent these might have influenced the effect on nutrient availability and birth outcomes. CONCLUSIONS The MISAME-III trial did not provide evidence that fortified BEP supplementation is efficacious in reducing SGA prevalence. However, the intervention had a small positive effect on other birth outcomes. Additional maternal and biochemical outcomes need to be investigated to provide further evidence on the overall clinical relevance of BEP supplementation. TRIAL REGISTRATION ClinicalTrials.gov NCT03533712.
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18
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Kuma MN, Tamiru D, Beressa G, Belachew T. Effect of Nutrition Interventions Before and/or During Early Pregnancy on Low Birth Weight in Sub-Saharan Africa: A Systematic Review and Meta-Analysis. Food Nutr Bull 2022; 43:351-363. [PMID: 35414279 DOI: 10.1177/03795721221078351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND This review aimed at synthesizing evidence on the effectiveness of nutritional interventions that were carried out before and/or during early pregnancy versus the control groups on reducing the risk of low weight at birth in sub-Saharan Africa. METHODS We have searched on MEDLINE, SCOPUS, CINAHL, HINARI, and Cochrane Library of systematic review databases for published articles in English language from 2010 to 2021 years. For unpublished studies, we searched on Google scholar. Randomized controlled trial studies of nutritional interventions carried out before/or during early pregnancy in sub-Saharan Africa to improve low birth weight were considered. The data were extracted and pooled using the Joanna Briggs Institute software. The effect size was calculated using fixed-effect models. Mantel-Haenszel method was used to calculate the relative risk with their respective 95% CI. Heterogeneity was assessed using the standard chi-square and I 2 tests. RESULTS Seven studies were included in the review with a total of 5934 participants. Three types of nutritional interventions were identified: iron supplementations, lipid-based supplementations, and nutritional education and counseling. We have identified only one intervention started during preconception. The meta-analysis showed that none of the identified nutrition interventions had a statistically significant effect on low birth weight. CONCLUSIONS Based on the review evidence, nutritional interventions before and/or during early pregnancy in sub-Saharan Africa had no significant effect on low birth weight. However, since our evidence was derived from a small number of trials and participants, a large-scale randomized controlled trials review might be required to elucidate the finding.
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Affiliation(s)
| | - Dessalegn Tamiru
- Department of Nutrition and Dietetics, Jimma University, Jimma, Ethiopia
| | - Girma Beressa
- Department of Nutrition and Dietetics, Jimma University, Jimma, Ethiopia
| | - Tefera Belachew
- Department of Nutrition and Dietetics, Jimma University, Jimma, Ethiopia.,School of Graduate Studies, Jimma University, Jimma, Ethiopia
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19
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Haskell MJ, Maleta K, Arnold CD, Jorgensen JM, Fan YM, Ashorn U, Matchado A, Monangi NK, Zhang G, Xu H, Belling E, Landero J, Chappell J, Muglia LJ, Hallman M, Ashorn P, Dewey KG. Provision of Small-Quantity Lipid-Based Nutrient Supplements Increases Plasma Selenium Concentration in Pregnant Women in Malawi: A Secondary Outcome of a Randomized Controlled Trial. Curr Dev Nutr 2022; 6:nzac013. [PMID: 35317414 PMCID: PMC8929992 DOI: 10.1093/cdn/nzac013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/05/2022] [Accepted: 01/25/2022] [Indexed: 11/14/2022] Open
Abstract
Background Pregnant women in Malawi are at risk of selenium deficiency, which can have adverse effects on pregnancy outcomes. Interventions for improving selenium status are needed. Objectives To assess the effect of provision of small-quantity lipid-based nutrient supplements (SQ-LNSs) to Malawian women during pregnancy on their plasma selenium concentrations at 36 wk of gestation. Methods Pregnant women (≤20 wk of gestation) were randomly assigned to receive daily either: 1) iron and folic acid (IFA); 2) multiple micronutrients (MMN; 130 µg selenium per capsule); or 3) SQ-LNS (130 µg selenium/20 g). Plasma selenium concentrations were measured by inductively coupled plasma mass spectrometry at baseline and after ≥16 wk of intervention (at 36 wk of gestation) and compared by intervention group. Results At 36 wk of gestation, median (quartile 1, quartile 3) plasma selenium concentrations (micromoles per liter) were 0.96 (0.73, 1.23), 0.94 (0.78, 1.18), and 1.01 (0.85, 1.28) in the IFA, MMN, and SQ-LNS groups, respectively. Geometric mean (GM) plasma selenium concentration was 5.4% (95% CI: 1.8%, 9.0%) higher in the SQ-LNS group than in the MMN group and tended to be higher than in the IFA group (+4.2%; 95% CI: 1.0%, 7.8%). The prevalence of adjusted plasma selenium concentrations <1 µmol/L was 55.1%, 57.8%, and 47.3% in the IFA, MMN, and SQ-LNS groups, respectively; it was lower in the SQ-LNS group than in the MMN group, OR = 0.44 (95% CI: 0.24, 0.83), and tended to be lower than in the IFA group, OR = 0.54 (95% CI: 0.29, 1.03). There was a significant interaction between baseline plasma selenium concentration and intervention group (P = 0.003). In the lowest tertile of baseline selenium concentrations, GM plasma selenium concentration was higher, and the prevalence of low values was lower in the SQ-LNS group compared with the MMN and IFA groups at 36 wk of gestation (P ≤ 0.007). Conclusions Provision of SQ-LNS containing selenium to pregnant women can be an effective strategy for improving their selenium status.This trial was registered at clinicaltrials.gov (identifier: NCT01239693).
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Affiliation(s)
- Marjorie J Haskell
- Institute for Global Nutrition, University of California, Davis, Davis, CA, USA
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Kenneth Maleta
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Charles D Arnold
- Institute for Global Nutrition, University of California, Davis, Davis, CA, USA
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Josh M Jorgensen
- Institute for Global Nutrition, University of California, Davis, Davis, CA, USA
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Yue-Mei Fan
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Ulla Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Andrew Matchado
- Institute for Global Nutrition, University of California, Davis, Davis, CA, USA
| | - Nagendra K Monangi
- Division of Neonatology, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ge Zhang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Center for Prevention of Preterm Birth, Perinatal Institute, Cincinnati Children's Hospital Medical Center and March of Dimes Prematurity Research Center Ohio Collaborative, Cincinnati, OH, USA
| | - Huan Xu
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Center for Prevention of Preterm Birth, Perinatal Institute, Cincinnati Children's Hospital Medical Center and March of Dimes Prematurity Research Center Ohio Collaborative, Cincinnati, OH, USA
| | - Elizabeth Belling
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Center for Prevention of Preterm Birth, Perinatal Institute, Cincinnati Children's Hospital Medical Center and March of Dimes Prematurity Research Center Ohio Collaborative, Cincinnati, OH, USA
| | - Julio Landero
- Department of Chemistry, University of Cincinnati, Cincinnati, OH, USA
| | - Joanne Chappell
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Center for Prevention of Preterm Birth, Perinatal Institute, Cincinnati Children's Hospital Medical Center and March of Dimes Prematurity Research Center Ohio Collaborative, Cincinnati, OH, USA
| | - Louis J Muglia
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Burroughs Wellcome Fund, Research Triangle Park, NC, USA
| | - Mikko Hallman
- Medical Research Centre Oulu, PEDEGO Research Unit, University of Oulu, Oulu, Pohjois-Pohjanmaa, Finland
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Kathryn G Dewey
- Institute for Global Nutrition, University of California, Davis, Davis, CA, USA
- Department of Nutrition, University of California, Davis, Davis, CA, USA
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20
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Kortekangas E, Fan YM, Chaima D, Lehto KM, Malamba-Banda C, Matchado A, Chingwanda C, Liu Z, Ashorn U, Cheung YB, Dewey KG, Maleta K, Ashorn P. Associations between Gut Microbiota and Intestinal Inflammation, Permeability and Damage in Young Malawian Children. J Trop Pediatr 2022; 68:6527323. [PMID: 35149871 PMCID: PMC8846364 DOI: 10.1093/tropej/fmac012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Environmental enteric dysfunction (EED) is common in low- and middle-income countries and associated with childhood undernutrition. The composition of gut microbiota has been implicated in the pathogenesis of EED. Our aim was to assess the associations between gut microbiota and EED biomarkers in rural Malawian children. We hypothesized that there would be an inverse association between microbiota maturity and diversity and fecal concentrations of EED biomarkers. METHODS We used data from fecal samples collected at 6, 18 and 30 months from 611 children who were followed up during a nutrition intervention trial. The primary time point for analysis was 18 months. Microbiota data were obtained through 16S rRNA sequencing and variables included microbiota maturity and diversity, phylogenetic dissimilarity and relative abundances of individual taxa. EED biomarkers included calprotectin (marker of inflammation), alpha-1 antitrypsin (intestinal permeability) and REG1B (intestinal damage). RESULTS There was an inverse association between microbiota maturity and diversity and fecal concentrations of all 3 EED biomarkers at 18 months (p≤0.001). The results were similar at 30 months, while at 6 months inverse associations were found only with calprotectin and alpha-1 antitrypsin concentrations. At 18 months, EED biomarkers were not associated with phylogenetic dissimilarity, but at 6 and 30 months several associations were observed. Individual taxa predicting EED biomarker concentrations at 18 months included several Bifidobacterium and Enterobacteriaceae taxa as well as potentially displaced oral taxa. CONCLUSIONS Our findings support the hypothesis of an inverse association between microbiota maturity and diversity and EED in rural Malawian children.
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Affiliation(s)
- Emma Kortekangas
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere 33014, Finland,Correspondence: Emma Kortekangas, Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Global Health, Tampere University, Arvo Ylpön katu 34, Arvo building, Tampere 33014, Finland. Tel: +358-3-355-111. Fax +358-3-213-4473. E-mail <>
| | - Yue-Mei Fan
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere 33014, Finland
| | - David Chaima
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kirsi-Maarit Lehto
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere 33014, Finland
| | - Chikondi Malamba-Banda
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Andrew Matchado
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi,Department of Nutrition and Institute for Global Nutrition, University of California Davis, Davis, CA 95616, USA
| | - Chilungamo Chingwanda
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Zhifei Liu
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere 33014, Finland
| | - Ulla Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere 33014, Finland
| | - Yin Bun Cheung
- Program in Health Services & Systems Research and Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore 169857, Singapore
| | - Kathryn G Dewey
- Department of Nutrition and Institute for Global Nutrition, University of California Davis, Davis, CA 95616, USA
| | - Kenneth Maleta
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere 33014, Finland,Department of Pediatrics, Tampere University Hospital, Tampere 33520, Finland
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21
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Smith JW, Matchado AJ, Wu LSF, Arnold CD, Burke SM, Maleta KM, Ashorn P, Stewart CP, Shaikh S, Ali H, Labrique AB, West KP, Christian P, Dewey KG, Groopman JD, Schulze KJ. Longitudinal Assessment of Prenatal, Perinatal, and Early-Life Aflatoxin B 1 Exposure in 828 Mother-Child Dyads from Bangladesh and Malawi. Curr Dev Nutr 2022; 6:nzab153. [PMID: 35155983 PMCID: PMC8829025 DOI: 10.1093/cdn/nzab153] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/14/2021] [Accepted: 12/22/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND In utero or early-life exposure to aflatoxin, which contaminates staple crops in disadvantaged settings, may compromise pregnancy and infant outcomes, but investigations into the extent, persistence, and determinants of aflatoxin exposure at these life stages have lacked longitudinal data collection and broad geographic representation. OBJECTIVES Aflatoxin exposure and selected determinants thereof were characterized in mother-child dyads with serial plasma/serum samples in prenatal, perinatal, and early life in Malawi and Bangladesh. METHODS Circulating aflatoxin B1 (AFB1)-lysine albumin adducts were measured in dyads from Bangladesh (n = 573; maternal first and third trimester, 3 mo postpartum, cord blood, infant 24 mo) and Malawi (n = 255; maternal second and third trimester, 6 mo postpartum, infant 6 and 18 mo) with isotope dilution mass spectrometry. We examined AFB1-lysine adduct magnitude, persistence, seasonality, and associations with infant feeding, and estimated daily AFB1 intake. RESULTS Maternal AFB1-lysine was higher in Malawi (98% detectable; median: 0.469, IQR: 0.225-1.027 pg/µL) than in Bangladesh (59%; 0.030, nondetectable [nd]-0.077 pg/µL). Although estimated dietary exposure in Malawi was temporally stable (648 ng AFB1/day), estimated intake in Bangladesh was reduced by 94% between rainy and winter seasons (98 to 6 ng/day). AFB1-lysine was low in cord blood from Bangladesh (15% detectable; 0.045, 0.031-0.088 pg/µL among detectable) and in Malawian infants at 6 mo of age (0.072, nd-0.236 pg/µL), but reached maternal concentrations by 18 or 24 mo (Bangladesh: 0.034, nd-0.063 pg/µL; Malawi: 0.370, 0.195-0.964 pg/µL). In Malawian infants, exclusive breastfeeding at 3 mo was associated with 58% lower AFB1-lysine concentrations at 6 mo compared with other feeding modes (P = 0.010). CONCLUSIONS Among pregnant women, aflatoxin exposure was persistently high in Malawi, while lower and seasonal in Bangladesh. Infants were partially protected from exposure in utero and with exclusive breastfeeding, but exposures reached adult levels by 18-24 mo of age. The Bangladesh and Malawi trials are registered at clinicaltrials.gov as NCT00860470 and NCT01239693.
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Affiliation(s)
- Joshua W Smith
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Andrew J Matchado
- Department of Nutrition and Institute for Global Nutrition, University of California, Davis, Davis, CA, USA
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Lee S-F Wu
- Center for Human Nutrition, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Charles D Arnold
- Department of Nutrition and Institute for Global Nutrition, University of California, Davis, Davis, CA, USA
| | - Sean M Burke
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Kenneth M Maleta
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Per Ashorn
- Tampere University, Faculty of Medicine and Health Technology, Center for Child, Adolescent and Maternal Health Research and Tampere University Hospital, Department of Pediatrics, Tampere, Finland
| | - Christine P Stewart
- Department of Nutrition and Institute for Global Nutrition, University of California, Davis, Davis, CA, USA
| | - Saijuddin Shaikh
- Center for Human Nutrition, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- The JiVitA Project of Johns Hopkins University, Bangladesh, Gaibandha, Bangladesh
| | - Hasmot Ali
- Center for Human Nutrition, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- The JiVitA Project of Johns Hopkins University, Bangladesh, Gaibandha, Bangladesh
| | - Alain B Labrique
- Center for Human Nutrition, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Keith P West
- Center for Human Nutrition, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Parul Christian
- Center for Human Nutrition, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Kathryn G Dewey
- Department of Nutrition and Institute for Global Nutrition, University of California, Davis, Davis, CA, USA
| | - John D Groopman
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Kerry J Schulze
- Center for Human Nutrition, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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22
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Adu-Afarwuah S, Arnold CD, Lartey A, Okronipa H, Maleta K, Ashorn P, Ashorn U, Fan YM, Matchado A, Kortekangas E, Oaks BM, Jackson KH, Dewey KG. Small-Quantity Lipid-Based Nutrient Supplements Increase Infants' Plasma Essential Fatty Acid Levels in Ghana and Malawi: A Secondary Outcome Analysis of the iLiNS-DYAD Randomized Trials. J Nutr 2022; 152:286-301. [PMID: 34543432 DOI: 10.1093/jn/nxab329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/07/2021] [Accepted: 09/13/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Small-quantity (SQ) lipid-based nutrient supplements (LNSs) may influence infants' plasma fatty acid (FA) profiles, which could be associated with short- and long-term outcomes. OBJECTIVES We aimed to determine the impact of SQ-LNS consumption on infants' plasma FA profiles in Ghana and Malawi. METHODS Ghanaian (n = 1320) and Malawian (n = 1391) women ≤20 weeks pregnant were assigned to consume 60 mg iron and 400 μg folic acid daily until delivery [iron and folic acid (IFA) group], multiple-micronutrient supplements (MMNs) until 6 months postpartum (MMN group), or SQ-LNSs (∼7.8 linoleic acid:α-linolenic acid ratio) until 6 months postpartum (LNS group). LNS group infants received SQ-LNS from 6 to 18 months of age. We compared infant plasma FAs by intervention group in subsamples (n = 379 in Ghana; n = 442 in Malawi) at 6 and 18 months using ANOVA and Poisson regression models. Main outcomes were mean percentage compositions (%Cs; percentage of FAs by weight) of α-linolenic acid (ALA), linoleic acid (LA), EPA, DHA, and arachidonic acid (AA). RESULTS At 6 months, LNS infants had greater mean ± SD ALA %Cs in Ghana (0.23 ± 0.08; IFA, 0.21 ± 0.06; MMN, 0.21 ± 0.07; P = 0.034) and Malawi (0.42 ± 0.16; IFA, 0.38 ± 0.15; MMN, 0.38 ± 0.14; P = 0.034) and greater AA values in Ghana (6.25 ± 1.24; IFA, 6.12 ± 1.13; MMN, 5.89 ± 1.24; P = 0.049). At 18 months, LNS infants had a tendency towards greater ALA (0.32 ± 0.16; IFA, 0.24 ± 0.08; MMN, 0.24 ± 0.10; P = 0.06) and LA (27.8 ± 3.6; IFA, 26.9 ± 2.9; MMN, 27.0 ± 3.1; P = 0.06) in Ghana, and greater ALA (0.45 ± 0.18; IFA, 0.39 ± 0.18; MMN, 0.39 ± 0.18; P < 0.001) and LA (29.7 ± 3.5; IFA, 28.7 ± 3.3; MMN, 28.6 ± 3.4; P = 0.011) in Malawi. The prevalence of ALA below the population-specific 10th percentile was lower in the LNS group compared to the MMN group, but not the IFA group. Groups did not differ significantly in plasma EPA or DHA levels. CONCLUSIONS SQ-LNS increased infants' plasma essential FA levels in Ghana and Malawi, which may have implications for health and developmental outcomes. These trials were registered at clinicaltrials.gov as NCT00970866 and NCT01239693.
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Affiliation(s)
- Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Charles D Arnold
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, CA, USA
| | - Anna Lartey
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Harriet Okronipa
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana.,Institute for Global Nutrition, Department of Nutrition, University of California, Davis, CA, USA
| | - Kenneth Maleta
- University of Malawi College of Medicine, School of Public Health and Family Medicine, Department of Public Health, Blantyre, Malawi
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Pediatrics, Tampere University Hospital, Tampere, Finland
| | - Ulla Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Yue-Mei Fan
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Andrew Matchado
- University of Malawi College of Medicine, School of Public Health and Family Medicine, Department of Public Health, Blantyre, Malawi
| | - Emma Kortekangas
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Brietta M Oaks
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, CA, USA
| | | | - Kathryn G Dewey
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, CA, USA
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23
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Katenga-Kaunda LZ, Kamudoni PR, Holmboe-Ottesen G, Fjeld HE, Mdala I, Shi Z, Iversen PO. Enhancing nutrition knowledge and dietary diversity among rural pregnant women in Malawi: a randomized controlled trial. BMC Pregnancy Childbirth 2021; 21:644. [PMID: 34551744 PMCID: PMC8456581 DOI: 10.1186/s12884-021-04117-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 09/10/2021] [Indexed: 12/02/2022] Open
Abstract
Background In many sub-Saharan African countries, such as Malawi, antenatal care (ANC) services do not deliver sufficient nutrition awareness to improve adequate dietary intake in pregnancy. We therefore compared the effects of supplementary nutrition education and dietary counselling with routine ANC service on nutrition knowledge and dietary intakes among Malawian pregnant women. Methods We used data from a two-armed cluster randomised controlled trial (RCT) of which the intervention group received supplementary nutrition education, dietary counselling and routine ANC services whereas the controls received only routine ANC services. The RCT was conducted in 10 control and 10 intervention villages in Mangochi, Southern Malawi and included pregnant women between their 9th and 16th gestational weeks. We examined the changes in nutrition knowledge and dietary diversity from enrolment (baseline) to study end-point of the RCT (two weeks before expected delivery). We used three linear multilevel regression models with random effects at village level (cluster) to examine the associations between indicators of nutrition knowledge and diet consumption adjusted for selected explanatory variables. Results Among 257 pregnant women enrolled to the RCT, 195 (76%) were available for the current study. The supplementary nutrition education and counselling led to significant improvements in nutrition knowledge, dietary diversity and nutrition behaviour in the intervention group compared with controls. Most women from both study groups had a moderate consumption of diversified foods at study end-point. A significant positive association between nutrition knowledge and consumption of a diversified diet was only observed in the intervention group. Conclusions Nutrition knowledge and dietary diversity improved in both study groups, but higher in the intervention group. Increased nutrition knowledge was associated with improved dietary diversity only in the intervention women, who also improved their nutrition perceptions and behaviour. Antenatal nutrition education needs strengthening to improve dietary intakes in pregnancy in this low resource-setting. Trial registration Clinical trials.gov ID: NCT03136393 (registered on 02/05/2017).
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Affiliation(s)
- Lillian Ziyenda Katenga-Kaunda
- Malawi Government, Health and Social Services, Mzuzu City Council, Mzuzu, Malawi.,Department of Nutrition, University of Oslo, Oslo, Norway
| | | | - Gerd Holmboe-Ottesen
- Department of Community Medicine and Global Health, University of Oslo, Oslo, Norway
| | - Heidi E Fjeld
- Department of Community Medicine and Global Health, University of Oslo, Oslo, Norway
| | - Ibrahimu Mdala
- Department of Community Medicine and Global Health, University of Oslo, Oslo, Norway
| | - Zumin Shi
- QU Health, Qatar University, Doha, Qatar
| | - Per Ole Iversen
- Department of Nutrition, University of Oslo, Oslo, Norway. .,Department of Haematology, Oslo University Hospital, Oslo, Norway. .,Division of Human Nutrition, Stellenbosch University, Tygerberg, South Africa.
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24
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Transparent reporting of recruitment and informed consent approaches in clinical trials recruiting children with minor parents in sub-Saharan Africa: a secondary analysis based on a systematic review. BMC Public Health 2021; 21:1473. [PMID: 34320934 PMCID: PMC8318049 DOI: 10.1186/s12889-021-11079-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 05/18/2021] [Indexed: 11/24/2022] Open
Abstract
Background Standardised checklists of items to be addressed in clinical study protocols and publications are promoting transparency in research. However, particular specifications for exceptional cases, such as children with minor parents are missing. This study aimed to examine the level of transparency regarding recruitment and informed consent approaches in publications of clinical trials recruiting children with minor parents in sub-Saharan Africa. We thereby focused particularly on the transparency about consenting persons (i.e. proxy decision-makers) and assessed the need to expand reporting guidelines for such exceptional cases. Methods We conducted a secondary analysis of clinical trial publications previously identified through a systematic review. Multiple scientific databases were searched up to March 2019. Clinical trial publications addressing consent and potentially recruiting children with minor parents in sub-Saharan Africa were included. 44 of the in total 4382 screened articles met our inclusion criteria. A descriptive analysis was performed. Results None of the included articles provided full evidence on whether any recruited children had minor parents and how consent was obtained for them. Four proxy decision-maker types were identified (parents; parents or guardians; guardians; or caregivers), with further descriptions provided rarely and mostly in referenced clinical trial registrations or protocols. Also, terminology describing proxy decision-makers was often used inconsistently. Conclusions Reporting the minimum maternal age alongside maternal data provided in baseline demographics can increase transparency on the recruitment of children with minor mothers. The CONSORT checklist should require clinical trial publications to state or reference exceptional informed consent procedures applied for special population groups. A standardized definition of proxy decision-maker types in international clinical trial guidelines would facilitate correct and transparent informed consent for children and children with minor parents. Study registration CRD42018074220. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11079-y.
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25
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Consumption of multiple micronutrients or small-quantity lipid-based nutrient supplements containing iodine at the recommended dose during pregnancy, compared with iron and folic acid, does not affect women's urinary iodine concentration in rural Malawi: a secondary outcome analysis of the iLiNS DYAD trial. Public Health Nutr 2021; 24:3049-3057. [PMID: 33054890 PMCID: PMC9884741 DOI: 10.1017/s1368980020003250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Inadequate iodine intake during pregnancy increases the risk of neonatal morbidity and mortality. We aimed to evaluate whether prenatal supplements containing iodine affect urinary iodine concentrations (UIC) of pregnant women in Malawi. DESIGN A randomised controlled trial. Pregnant women (n 1391) were assigned to consume 60 mg/d Fe and 400 µg/d folic acid (IFA) or 18 vitamins and minerals including 250 µg/d iodine (MMN) or 20 g/d small-quantity lipid-based nutrient supplements (SQ-LNS) with similar nutrient contents as MMN group, plus macronutrients (LNS) until childbirth. In a sub-study (n 317), we evaluated group geometric mean urinary iodine concentration (UIC) (µg/L) at 36 weeks of gestation controlling for baseline UIC and compared median (baseline) and geometric mean (36 weeks) UIC with WHO cut-offs: UIC < 150, 150-249, 250-499 and ≥500 reflecting insufficient, adequate, above requirements and excessive iodine intakes, respectively. SETTING Mangochi District, Malawi. PARTICIPANTS Women ≤20 weeks pregnant. RESULTS Groups had comparable background characteristics. At baseline, overall median (Q1, Q3) UIC (319 (167, 559)) suggested iodine intakes above requirements. At 36 weeks, the geometric mean (95 % CI) UIC of the IFA (197 (171, 226)), MMN (212 (185, 243)) and LNS (220 (192, 253)) groups did not differ (P = 0·53) and reflected adequate intakes. CONCLUSIONS In this setting, provision of supplements containing iodine at the recommended dose to pregnant women with relatively high iodine intakes at baseline, presumably from iodised salt, has no impact on the women's UIC. Regular monitoring of the iodine status of pregnant women in such settings is advisable. Clinicaltrials.gov identifier: NCT01239693.
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26
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Keats EC, Oh C, Chau T, Khalifa DS, Imdad A, Bhutta ZA. Effects of vitamin and mineral supplementation during pregnancy on maternal, birth, child health and development outcomes in low- and middle-income countries: A systematic review. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1127. [PMID: 37051178 PMCID: PMC8356361 DOI: 10.1002/cl2.1127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Almost two billion people who are deficient in vitamins and minerals are women and children in low- and middle-income countries (LMIC). These deficiencies are worsened during pregnancy due to increased energy and nutritional demands, causing adverse outcomes in mother and child. To reduce micronutrient deficiencies, several strategies have been implemented, including diet diversification, large-scale and targeted fortification, staple crop bio-fortification and micronutrient supplementation. Objectives To evaluate and summarize the available evidence on the effects of micronutrient supplementation during pregnancy in LMIC on maternal, fetal, child health and child development outcomes. This review will assess the impact of single micronutrient supplementation (calcium, vitamin A, iron, vitamin D, iodine, zinc, vitamin B12), iron-folic acid (IFA) supplementation, multiple micronutrient (MMN) supplementation, and lipid-based nutrient supplementation (LNS) during pregnancy. Search Methods We searched papers published from 1995 to 31 October 2019 (related programmes and good quality studies pre-1995 were limited) in CAB Abstracts, CINAHL, Cochrane Central Register of Controlled Trials, Embase, International Initiative for Impact Evaluations, LILACS, Medline, POPLINE, Web of Science, WHOLIS, ProQuest Dissertations & Theses Global, R4D, WHO International Clinical Trials Registry Platform. Non-indexed grey literature searches were conducted using Google, Google Scholar, and web pages of key international nutrition agencies. Selection Criteria We included randomized controlled trials (individual and cluster-randomized) and quasi-experimental studies that evaluated micronutrient supplementation in healthy, pregnant women of any age and parity living in a LMIC. LMIC were defined by the World Bank Group at the time of the search for this review. While the aim was to include healthy pregnant women, it is likely that these populations had one or more micronutrient deficiencies at baseline; women were not excluded on this basis. Data Collection and Analysis Two authors independently assessed studies for inclusion and risk of bias, and conducted data extraction. Data were matched to check for accuracy. Quality of evidence was assessed using the GRADE approach. Main Results A total of 314 papers across 72 studies (451,723 women) were eligible for inclusion, of which 64 studies (439,649 women) contributed to meta-analyses. Seven studies assessed iron-folic acid (IFA) supplementation versus folic acid; 34 studies assessed MMN vs. IFA; 4 studies assessed LNS vs. MMN; 13 evaluated iron; 13 assessed zinc; 9 evaluated vitamin A; 11 assessed vitamin D; and 6 assessed calcium. Several studies were eligible for inclusion in multiple types of supplementation. IFA compared to folic acid showed a large and significant (48%) reduction in the risk of maternal anaemia (average risk ratio (RR) 0.52, 95% CI 0.41 to 0.66; studies = 5; participants = 15,540; moderate-quality evidence). As well, IFA supplementation demonstrated a smaller but significant, 12% reduction in risk of low birthweight (LBW) babies (average RR 0.88, 95% CI 0.78 to 0.99; studies = 4; participants = 17,257; high-quality evidence). MMN supplementation was defined as any supplement that contained at least 3 micronutrients. Post-hoc analyses were conducted, where possible, comparing the differences in effect of MMN with 4+ components and MMN with 3 or 4 components. When compared to iron with or without FA, MMN supplementation reduced the risk of LBW by 15% (average RR 0.85, 95% CI 0.77 to 0.93; studies = 28; participants = 79,972); this effect was greater in MMN with >4 micronutrients (average RR 0.79, 95% CI 0.71 to 0.88; studies = 19; participants = 68,138 versus average RR 1.01, 95% CI 0.92 to 1.11; studies = 9; participants = 11,834). There was a small and significant reduction in the risk of stillbirths (average RR 0.91; 95% CI 0.86 to 0.98; studies = 22; participants = 96,772) and a small and significant effect on the risk of small-for-gestational age (SGA) (average RR 0.93; 95% CI 0.88 to 0.98; studies = 19; participants = 52,965). For stillbirths and SGA, the effects were greater among those provided MMN with 4+ micronutrients. Children whose mothers had been supplemented with MMN, compared to IFA, demonstrated a 16% reduced risk of diarrhea (average RR 0.84; 95% CI 0.76 to 0.92; studies = 4; participants = 3,142). LNS supplementation, compared to MMN, made no difference to any outcome; however, the evidence is limited. Iron supplementation, when compared to no iron or placebo, showed a large and significant effect on maternal anaemia, a reduction of 47% (average RR 0.53, 95% CI 0.43 to 0.65; studies = 6; participants = 15,737; moderate-quality evidence) and a small and significant effect on LBW (average RR 0.88, 95% CI 0.78 to 0.99; studies = 4; participants = 17,257; high-quality evidence). Zinc and vitamin A supplementation, each both compared to placebo, had no impact on any outcome examined with the exception of potentially improving serum/plasma zinc (mean difference (MD) 0.43 umol/L; 95% CI -0.04 to 0.89; studies = 5; participants = 1,202) and serum/plasma retinol (MD 0.13 umol/L; 95% CI -0.03 to 0.30; studies = 6; participants = 1,654), respectively. When compared to placebo, vitamin D supplementation may have reduced the risk of preterm births (average RR 0.64; 95% CI 0.40 to 1.04; studies = 7; participants = 1,262), though the upper CI just crosses the line of no effect. Similarly, calcium supplementation versus placebo may have improved rates of pre-eclampsia/eclampsia (average RR 0.45; 95% CI 0.19 to 1.06; studies = 4; participants = 9,616), though the upper CI just crosses 1. Authors' Conclusions The findings suggest that MMN and vitamin supplementation improve maternal and child health outcomes, including maternal anaemia, LBW, preterm birth, SGA, stillbirths, micronutrient deficiencies, and morbidities, including pre-eclampsia/eclampsia and diarrhea among children. MMN supplementation demonstrated a beneficial impact on the most number of outcomes. In addition, MMN with >4 micronutrients appeared to be more impactful than MMN with only 3 or 4 micronutrients included in the tablet. Very few studies conducted longitudinal analysis on longer-term health outcomes for the child, such as anthropometric measures and developmental outcomes; this may be an important area for future research. This review may provide some basis to guide continual discourse around replacing IFA supplementation with MMN along with the use of single micronutrient supplementation programs for specific outcomes.
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Affiliation(s)
- Emily C. Keats
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
| | - Christina Oh
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
| | - Tamara Chau
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
| | - Dina S. Khalifa
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
| | - Aamer Imdad
- PediatricsUpstate Medical University, SyracuseNew YorkUSA
| | - Zulfiqar A. Bhutta
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
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Lassi ZS, Padhani ZA, Rabbani A, Rind F, Salam RA, Bhutta ZA. Effects of nutritional interventions during pregnancy on birth, child health and development outcomes: A systematic review of evidence from low- and middle-income countries. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1150. [PMID: 37131924 PMCID: PMC8356342 DOI: 10.1002/cl2.1150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Optimal nutrition plays a crucial role in pregnancy. Poor maternal nutrition and maternal obesity has risk factors for serious fetal complications and neonatal outcomes, including intrauterine growth restriction, congenital abnormalities, stillbirth, low birth weight (LBW), preterm birth, fetal macrosomia, increased risk of neonatal infections, neonatal hypothermia, and neonatal death. The prevalence of maternal malnutrition is higher in low- and middle-income countries (LMICs) (10-19%) when compared with high-income countries, with variation by region and by country. Several behavioral interventions, including dietary control and exercise, have been found to reduce the risk of these adverse outcomes. However, none has reviewed dietary interventions to prevent maternal obesity in pregnant women. Objectives The review aims to assess the effectiveness of balanced energy protein (BEP) supplementation, food distribution programs (FDPs), and dietary interventions to prevent maternal obesity during pregnancy on birth, child health, and developmental outcomes. Search Methods We searched Cochrane Controlled Trials Register (CENTRAL), MEDLINE, Embase, CINAHL, and 12 other databases, and trials registers for ongoing studies up until April 2019. We also searched for gray literature from different sources and for citations on Google Scholar and Web of Sciences. We also checked the reference lists of included studies and relevant reviews and contacted the authors of studies for any ongoing and unpublished studies. The search was followed by title/abstract screening, full-text screening and data extraction. Selection Criteria We included randomized control trials, and quasi experimental trials to evaluate the impact of nutritional interventions (BEP, FDP, and dietary interventions to prevent maternal obesity) compared to control or standard of care, among healthy pregnant women of any age living in LMICs. Data Collection and Analysis Two review authors independently assessed and screened studies for eligibility, extracted data, and assessed quality of the studies included in the review. We conducted a meta-analysis of all reported primary and secondary outcomes. Subgroup analysis and GRADE assessment was performed for all reported primary outcomes. Main Results The review included 15 studies, of these, eight were on BEP supplementation, five on FDP, and two on interventions for obesity prevention. BEP supplementation may show a reduction in the rate of stillbirths by 61% (risk ratio [RR], 0.39; 95% CI, 0.19-0.80; three studies, n = 1913; low quality on GRADE), perinatal mortality by 50% (RR, 0.50; 95% CI, 0.30-0.84; one study, n = 1446; low quality on GRADE), LBW infants by 40% (RR, 0.60; 95% CI, 0.41-0.86; three studies, n = 1830; low quality of evidence on GRADE); small for gestational age (SGA) by 29% (RR, 0.71; 95% CI, 0.54-0.94; five studies, n = 1844) and increased birth weight by 107.28 g (mean difference [MD], 107.28 g; 95% CI, 68.51-146.04, eight studies, n = 2190). An increase of 107.28 g of birthweight is clinically significant in the countries where the intervention was provided. BEP supplementation had no effect on miscarriage, neonatal mortality, infant mortality, preterm birth, birth length, and head circumference. FDP may show improvement in mean birth weight by 46 g (MD, 46.00 g; 95% CI, 45.10-46.90, three studies, n = 5272), in birth length by 0.20 cm (MD, 0.20 cm; 95% CI, 0.20-0.20, three studies, n = 5272), and reduction in stunting by 18% (RR, 0.82; 95% CI, 0.71-0.94; two studies; n = 4166), and wasting by 13% (RR, 0.87; 95% CI, 0.78-0.97; two studies, n = 3883). There was no effect of FDP on miscarriage, maternal mortality, perinatal mortality, neonatal mortality, infant mortality, preterm birth, LBW, SGA, head circumference, and underweight babies. Studies on interventions for obesity prevention among pregnant women failed to report on the primary outcomes. The studies showed a 195.57 g reduction in mean birth weight (MD, -195.57 g, 95% CI, -349.46 to -41.68, two studies, n = 180), and had no effect on birth length, and macrosomia. Authors' Conclusions Our review highlights improvement in maternal, birth, and child outcomes through BEP supplementation and FDP during pregnancy. But, due to the small number of included studies and low quality of evidence, we are uncertain of the effect of BEP supplementation, FDP and dietary interventions for prevention of obesity on maternal, and child outcomes. Thus, further good quality research is recommended to assess the effect of these interventions on maternal, child and developmental outcomes.
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Affiliation(s)
- Zohra S. Lassi
- Robinson Research InstituteUniversity of AdelaideAdelaideSouth AustraliaSA 5005Australia
| | - Zahra A. Padhani
- Center of Excellence in Women and Child HealthAga Khan University HospitalKarachiPakistan
| | - Amna Rabbani
- Center of Excellence in Women and Child HealthAga Khan University HospitalKarachiPakistan
| | - Fahad Rind
- Center of Excellence in Women and Child HealthAga Khan University HospitalKarachiPakistan
| | - Rehana A. Salam
- Center of Excellence in Women and Child HealthAga Khan University HospitalKarachiPakistan
| | - Zulfiqar A. Bhutta
- Center of Excellence in Women and Child HealthAga Khan University HospitalKarachiPakistan
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
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Jorgensen JM, Young R, Ashorn P, Ashorn U, Chaima D, Davis JCC, Goonatilleke E, Kumwenda C, Lebrilla CB, Maleta K, Sadalaki J, Totten SM, Wu LD, Zivkovic AM, Dewey KG. Associations of Human Milk Oligosaccharides and Bioactive Proteins with Infant Morbidity and Inflammation in Malawian Mother-Infant Dyads. Curr Dev Nutr 2021; 5:nzab072. [PMID: 34084993 PMCID: PMC8163417 DOI: 10.1093/cdn/nzab072] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/21/2021] [Accepted: 04/23/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Human milk oligosaccharides (HMOs) and bioactive proteins likely benefit infant health, but information on these relations is sparse. OBJECTIVES We aimed to examine associations of milk content of HMOs and bioactive proteins with incidence and longitudinal prevalence of infant morbidity (any illness, fever, diarrhea, acute respiratory infection, and loss of appetite) and markers of inflammation [C-reactive protein (CRP) and α-1-acid glycoprotein (AGP)]. These are secondary analyses of a randomized controlled trial. METHODS Breast milk samples at 6 mo postpartum (n = 659) were analyzed to quantify absolute abundance of HMOs, relative abundance of fucosylated HMOs, sialylated HMOs, and 51 individual HMOs, and concentrations of 6 bioactive proteins (lactalbumin, lactoferrin, lysozyme, antitrypsin, IgA, and osteopontin). We examined associations of these constituents with infant morbidity from 6 to 7 and 6 to 12 mo, and CRP and AGP at 6 and 18 mo, considering maternal secretor status [presence or absence of the functional enzyme encoded by the fucosyltransferase 2 gene (FUT2) ] and adjusting for covariates and multiple hypothesis testing. RESULTS In secretors there were positive associations between total HMOs and longitudinal prevalence of fever (P = 0.032), between fucosylated HMOs and incidence of diarrhea (P = 0.026), and between lactoferrin and elevated CRP at 18 mo (P = 0.011). In nonsecretors, there were inverse associations between lactoferrin and incidence of fever (P = 0.007), between osteopontin and longitudinal prevalence of lost appetite (P = 0.038), and between fucosylated HMOs and incidence of diarrhea (P = 0.025), lost appetite (P = 0.019), and concentrations of AGP and CRP at 6 mo (P = 0.001 and 0.010); and positive associations between total HMOs and incidence of lost appetite (P = 0.024) and elevated CRP at 18 mo (P = 0.026), between lactalbumin and incidence of diarrhea (P = 0.006), and between lactoferrin and elevated CRP at 18 mo (P = 0.015). CONCLUSIONS Certain HMOs and bioactive proteins were associated with infant morbidity and inflammation, particularly in nonsecretors. Further research is needed to elucidate the causality of these relations.This trial was registered at clinicaltrials.gov as NCT01239693.
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Affiliation(s)
- Josh M Jorgensen
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Rebecca Young
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Per Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Tampere University Hospital, Department of Pediatrics, Tampere, Finland
| | - Ulla Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - David Chaima
- Department of Community Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Jasmine C C Davis
- Department of Chemistry, University of California, Davis, Davis, CA, USA
| | | | - Chiza Kumwenda
- Department of Community Health, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Food Science and Nutrition, School of Agricultural Sciences, University of Zambia, Lusaka, Zambia
| | - Carlito B Lebrilla
- Department of Chemistry, University of California, Davis, Davis, CA, USA
- Department of Biochemistry and Molecular Medicine, University of California, Davis, Davis, CA, USA
| | - Kenneth Maleta
- Department of Community Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - John Sadalaki
- Department of Community Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Sarah M Totten
- Department of Chemistry, University of California, Davis, Davis, CA, USA
| | - Lauren D Wu
- Department of Chemistry, University of California, Davis, Davis, CA, USA
| | - Angela M Zivkovic
- Department of Nutrition, University of California, Davis, Davis, CA, USA
- Foods for Health Institute, University of California, Davis, Davis, CA, USA
| | - Kathryn G Dewey
- Department of Nutrition, University of California, Davis, Davis, CA, USA
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Keats EC, Akseer N, Thurairajah P, Cousens S, Bhutta ZA. Multiple-micronutrient supplementation in pregnant adolescents in low- and middle-income countries: a systematic review and a meta-analysis of individual participant data. Nutr Rev 2021; 80:141-156. [PMID: 33846729 PMCID: PMC8754251 DOI: 10.1093/nutrit/nuab004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
CONTEXT Approximately 7.3 million births occur annually among adolescents in low- and middle-income countries. Pregnant adolescents constitute a nutritionally vulnerable group that could benefit from intervention to mitigate the mortality and adverse birth outcomes associated with adolescent pregnancy. OBJECTIVE The aim of this systematic review and meta-analysis was to assess the following: (1) the effect of multiple-micronutrient (MMN) supplementation vs iron and folic acid (IFA) supplementation among adolescents on maternal morbidity, birth outcomes, and mortality outcomes, (2) the effects of MMN supplementation in adolescents compared with the effects in adult women, and (3) the effect modification, if any, of MMN supplementation by baseline and geographic characteristics of adolescents. DATA SOURCES MEDLINE and Cochrane databases were searched, along with the reference lists of relevant reviews. STUDY SELECTION Multiple-micronutrient supplementation trials in pregnancy that were conducted in a low- or middle-income country and had included at least 100 adolescents (10-19 years of age) were eligible for inclusion. Two independent reviewers assessed study eligibility. DATA EXTRACTION Thirteen randomized controlled trials conducted in Africa and Asia were identified from 1792 reviews and 1578 original trials. Individual-level data was shared by study collaborators and was checked for completeness and extreme values. One- and two-stage individual participant data meta-analyses were conducted using data from randomized controlled trials of MMN supplementation. RESULTS A total of 15 283 adolescents and 44 499 adult women with singleton births were included in the individual participant data meta-analyses of MMN supplementation vs IFA supplementation. In adolescents, MMN supplementation reduced low birth weight (1-stage OR = 0.87, 95%CI 0.77-0.97; 2-stage OR = 0.81; 95%CI 0.74-0.88), preterm birth (1-stage OR = 0.88, 95%CI 0.80-0.98; 2-stage OR = 0.86, 95%CI 0.79-0.95), and small-for-gestational-age births (1-stage OR = 0.90, 95%CI 0.81-1.00; 2-stage OR = 0.86, 95%CI 0.79-0.95) when compared with IFA supplementation. The effects of MMN supplementation did not differ between adolescents and older women, although a potentially greater reduction in small-for-gestational-age births was observed among adolescents. Effect modification by baseline characteristics and geographic region was inconclusive. CONCLUSIONS Multiple-micronutrient supplementation can improve birth outcomes among pregnant adolescents in low- and middle-income countries. Policy related to antenatal care in these settings should prioritize MMN supplementation over the currently recommended IFA supplementation for all pregnant women, especially adolescents.
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Affiliation(s)
- Emily C Keats
- E.C. Keats, N. Akseer, P. Thurairajah, and Z.A. Bhutta are with the Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada. S. Cousens is with the London School of Hygiene & Tropical Medicine, London, United Kingdom. Z.A. Bhutta is with the Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. Z.A. Bhutta is with the Aga Khan University, Karachi, Pakistan. H. Ali is with the JiVitA Maternal and Child Nutrition and Health Research Project, Gaibandha, Bangladesh. S. El Arifeen is with the International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh. U. Ashorn is with the Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. J. Belizan is with the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. R.E. Black, P. Christian, A.B. Labrique, K. West, and L.S-F. Wu are with the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. L.M. De-Regil is with Nutrition International, Ottawa, Ontario, Canada. K. Dewey is with the University of California, Davis, Davis, California, USA. M.J. Dibley is with The University of Sydney, Sydney, New South Wales, Australia. W. Fawzi and C.R. Sudfeld are with the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA. H. Friis and P. Kaestel are with the University of Copenhagen, Copenhagen, Denmark. E. Gomo is with the University of Zimbabwe, Harare, Zimbabwe. L. Huybregts is with the International Food Policy Research Institute, Washington, DC, USA. R. Jayatissa is with the Medical Research Institute, Colombo, Sri Lanka. S.K. Khatry is with the Nepal Nutrition Intervention Project-Sarlahi, Kathmandu, Nepal. P.W. Kolsteren is with Ghent University, Ghent, Belgium. M. McCauley is with the Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom. B.M. Oaks is with the University of Rhode Island, Kingston, Rhode Island, USA. E. Piwoz is with the Bill & Melinda Gates Foundation, Seattle, Washington, USA. S. Shaikh is with the Society for Applied Studies, New Delhi, India. D.D. Soekarjo is with the Savica Consultancy, Jakarta, Indonesia. W. Urassa is with the Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. N. Zagre is with the UNICEF Regional Office for West and Central Africa, Dakar, Senegal. L. Zeng and Z. Zhu are with the School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, China
| | - Nadia Akseer
- E.C. Keats, N. Akseer, P. Thurairajah, and Z.A. Bhutta are with the Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada. S. Cousens is with the London School of Hygiene & Tropical Medicine, London, United Kingdom. Z.A. Bhutta is with the Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. Z.A. Bhutta is with the Aga Khan University, Karachi, Pakistan. H. Ali is with the JiVitA Maternal and Child Nutrition and Health Research Project, Gaibandha, Bangladesh. S. El Arifeen is with the International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh. U. Ashorn is with the Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. J. Belizan is with the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. R.E. Black, P. Christian, A.B. Labrique, K. West, and L.S-F. Wu are with the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. L.M. De-Regil is with Nutrition International, Ottawa, Ontario, Canada. K. Dewey is with the University of California, Davis, Davis, California, USA. M.J. Dibley is with The University of Sydney, Sydney, New South Wales, Australia. W. Fawzi and C.R. Sudfeld are with the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA. H. Friis and P. Kaestel are with the University of Copenhagen, Copenhagen, Denmark. E. Gomo is with the University of Zimbabwe, Harare, Zimbabwe. L. Huybregts is with the International Food Policy Research Institute, Washington, DC, USA. R. Jayatissa is with the Medical Research Institute, Colombo, Sri Lanka. S.K. Khatry is with the Nepal Nutrition Intervention Project-Sarlahi, Kathmandu, Nepal. P.W. Kolsteren is with Ghent University, Ghent, Belgium. M. McCauley is with the Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom. B.M. Oaks is with the University of Rhode Island, Kingston, Rhode Island, USA. E. Piwoz is with the Bill & Melinda Gates Foundation, Seattle, Washington, USA. S. Shaikh is with the Society for Applied Studies, New Delhi, India. D.D. Soekarjo is with the Savica Consultancy, Jakarta, Indonesia. W. Urassa is with the Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. N. Zagre is with the UNICEF Regional Office for West and Central Africa, Dakar, Senegal. L. Zeng and Z. Zhu are with the School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, China
| | - Pravheen Thurairajah
- E.C. Keats, N. Akseer, P. Thurairajah, and Z.A. Bhutta are with the Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada. S. Cousens is with the London School of Hygiene & Tropical Medicine, London, United Kingdom. Z.A. Bhutta is with the Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. Z.A. Bhutta is with the Aga Khan University, Karachi, Pakistan. H. Ali is with the JiVitA Maternal and Child Nutrition and Health Research Project, Gaibandha, Bangladesh. S. El Arifeen is with the International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh. U. Ashorn is with the Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. J. Belizan is with the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. R.E. Black, P. Christian, A.B. Labrique, K. West, and L.S-F. Wu are with the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. L.M. De-Regil is with Nutrition International, Ottawa, Ontario, Canada. K. Dewey is with the University of California, Davis, Davis, California, USA. M.J. Dibley is with The University of Sydney, Sydney, New South Wales, Australia. W. Fawzi and C.R. Sudfeld are with the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA. H. Friis and P. Kaestel are with the University of Copenhagen, Copenhagen, Denmark. E. Gomo is with the University of Zimbabwe, Harare, Zimbabwe. L. Huybregts is with the International Food Policy Research Institute, Washington, DC, USA. R. Jayatissa is with the Medical Research Institute, Colombo, Sri Lanka. S.K. Khatry is with the Nepal Nutrition Intervention Project-Sarlahi, Kathmandu, Nepal. P.W. Kolsteren is with Ghent University, Ghent, Belgium. M. McCauley is with the Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom. B.M. Oaks is with the University of Rhode Island, Kingston, Rhode Island, USA. E. Piwoz is with the Bill & Melinda Gates Foundation, Seattle, Washington, USA. S. Shaikh is with the Society for Applied Studies, New Delhi, India. D.D. Soekarjo is with the Savica Consultancy, Jakarta, Indonesia. W. Urassa is with the Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. N. Zagre is with the UNICEF Regional Office for West and Central Africa, Dakar, Senegal. L. Zeng and Z. Zhu are with the School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, China
| | - Simon Cousens
- E.C. Keats, N. Akseer, P. Thurairajah, and Z.A. Bhutta are with the Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada. S. Cousens is with the London School of Hygiene & Tropical Medicine, London, United Kingdom. Z.A. Bhutta is with the Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. Z.A. Bhutta is with the Aga Khan University, Karachi, Pakistan. H. Ali is with the JiVitA Maternal and Child Nutrition and Health Research Project, Gaibandha, Bangladesh. S. El Arifeen is with the International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh. U. Ashorn is with the Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. J. Belizan is with the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. R.E. Black, P. Christian, A.B. Labrique, K. West, and L.S-F. Wu are with the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. L.M. De-Regil is with Nutrition International, Ottawa, Ontario, Canada. K. Dewey is with the University of California, Davis, Davis, California, USA. M.J. Dibley is with The University of Sydney, Sydney, New South Wales, Australia. W. Fawzi and C.R. Sudfeld are with the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA. H. Friis and P. Kaestel are with the University of Copenhagen, Copenhagen, Denmark. E. Gomo is with the University of Zimbabwe, Harare, Zimbabwe. L. Huybregts is with the International Food Policy Research Institute, Washington, DC, USA. R. Jayatissa is with the Medical Research Institute, Colombo, Sri Lanka. S.K. Khatry is with the Nepal Nutrition Intervention Project-Sarlahi, Kathmandu, Nepal. P.W. Kolsteren is with Ghent University, Ghent, Belgium. M. McCauley is with the Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom. B.M. Oaks is with the University of Rhode Island, Kingston, Rhode Island, USA. E. Piwoz is with the Bill & Melinda Gates Foundation, Seattle, Washington, USA. S. Shaikh is with the Society for Applied Studies, New Delhi, India. D.D. Soekarjo is with the Savica Consultancy, Jakarta, Indonesia. W. Urassa is with the Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. N. Zagre is with the UNICEF Regional Office for West and Central Africa, Dakar, Senegal. L. Zeng and Z. Zhu are with the School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, China
| | - Zulfiqar A Bhutta
- E.C. Keats, N. Akseer, P. Thurairajah, and Z.A. Bhutta are with the Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada. S. Cousens is with the London School of Hygiene & Tropical Medicine, London, United Kingdom. Z.A. Bhutta is with the Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. Z.A. Bhutta is with the Aga Khan University, Karachi, Pakistan. H. Ali is with the JiVitA Maternal and Child Nutrition and Health Research Project, Gaibandha, Bangladesh. S. El Arifeen is with the International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh. U. Ashorn is with the Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. J. Belizan is with the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. R.E. Black, P. Christian, A.B. Labrique, K. West, and L.S-F. Wu are with the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. L.M. De-Regil is with Nutrition International, Ottawa, Ontario, Canada. K. Dewey is with the University of California, Davis, Davis, California, USA. M.J. Dibley is with The University of Sydney, Sydney, New South Wales, Australia. W. Fawzi and C.R. Sudfeld are with the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA. H. Friis and P. Kaestel are with the University of Copenhagen, Copenhagen, Denmark. E. Gomo is with the University of Zimbabwe, Harare, Zimbabwe. L. Huybregts is with the International Food Policy Research Institute, Washington, DC, USA. R. Jayatissa is with the Medical Research Institute, Colombo, Sri Lanka. S.K. Khatry is with the Nepal Nutrition Intervention Project-Sarlahi, Kathmandu, Nepal. P.W. Kolsteren is with Ghent University, Ghent, Belgium. M. McCauley is with the Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom. B.M. Oaks is with the University of Rhode Island, Kingston, Rhode Island, USA. E. Piwoz is with the Bill & Melinda Gates Foundation, Seattle, Washington, USA. S. Shaikh is with the Society for Applied Studies, New Delhi, India. D.D. Soekarjo is with the Savica Consultancy, Jakarta, Indonesia. W. Urassa is with the Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. N. Zagre is with the UNICEF Regional Office for West and Central Africa, Dakar, Senegal. L. Zeng and Z. Zhu are with the School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, China
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Castillo-Castrejon M, Yang IV, Davidson EJ, Borengasser SJ, Jambal P, Westcott J, Kemp JF, Garces A, Ali SA, Saleem S, Goldenberg RL, Figueroa L, Hambidge KM, Krebs NF, Powell TL. Preconceptional Lipid-Based Nutrient Supplementation in 2 Low-Resource Countries Results in Distinctly Different IGF-1/mTOR Placental Responses. J Nutr 2021; 151:556-569. [PMID: 33382407 PMCID: PMC7948206 DOI: 10.1093/jn/nxaa354] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/27/2020] [Accepted: 10/14/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Preconceptional maternal small-quantity lipid-based nutrient supplementation (SQLNS) improved intrauterine linear growth in low-resource countries as demonstrated by the Women First Preconception Maternal Nutrition Trial (WF). Fetal growth is dependent on nutrient availability and regulated by insulin-like growth factor 1 (IGF-1) through changes in placental transfer capacity, mediated by the mechanistic target of rapamycin (mTOR) pathway. OBJECTIVES Our objective was to evaluate the role of placental mTOR and IGF-1 signaling on fetal growth in women from 2 low-resource countries with high rates of stunting after they received preconceptional SQLNS. METHODS We studied 48 women from preconception through delivery who were from Guatemala and Pakistan and received SQLNS or not, as part of the WF study. Placental samples were obtained at delivery (control, n = 24; SQLNS, n = 24). Placental protein or mRNA expression of eukaryotic translation initiation factor binding protein-1 (4E-BP1), ribosomal protein S6 (rpS6), AMP-activated protein kinase α (AMPKA), IGF-1, insulin-like growth factor receptor (IGF-1R), and pregnancy associated plasma protein (PAPP)-A, and DNA methylation of the IGF1 promoter were determined. Maternal serum IGF-1, insulin-like growth factor binding protein (IGFBP)-3, IGFBP-4, IGFBP-5, PAPP-A, PAPP-A2, and zinc were measured. RESULTS Mean ± SEM maternal prepregnancy BMI differed between participants in Guatemala (26.5 ± 1.3) and Pakistan (19.8 ± 0.7) (P < 0.001). In Pakistani participants, SQLNS increased the placental rpS6(T37/46):rpS6 ratio (1.5-fold) and decreased the AMPKA(T172):AMPKA ratio. Placental IGF1 mRNA expression was positively correlated with birth length and birth weight z-scores. Placental PAPP-A (30-fold) and maternal serum zinc (1.2-fold) increased with SQLNS. In Guatemalan participants SQLNS did not influence placental mTOR signaling. Placental IGF-1R protein expression was positively associated with birth length and birth weight z-scores. SQLNS increased placental PAPP-A (40-fold) and maternal serum IGFBP-4 (1.6-fold). CONCLUSIONS In Pakistani pregnant women with poor nutritional status, preconceptional SQLNS activated placental mTOR and IGF-1 signaling and was associated with improved fetal growth. In contrast, in Guatemalan women SQLNS did not activate placental nutrient-sensing pathways. In populations experiencing childhood stunting, preconceptional SQLNS improves placental function and fetal growth only in the context of poor maternal nutrition. This trial was registered at clinicaltrials.gov as NCT01883193.
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Affiliation(s)
- Marisol Castillo-Castrejon
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ivana V Yang
- Biomedical Informatics & Personalized Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Elizabeth J Davidson
- Biomedical Informatics & Personalized Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sarah J Borengasser
- Section of Nutrition, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Purevsuren Jambal
- Section of Nutrition, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jamie Westcott
- Section of Nutrition, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jennifer F Kemp
- Section of Nutrition, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ana Garces
- Maternal and Infant Health Center, Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Sumera A Ali
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Lester Figueroa
- Maternal and Infant Health Center, Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - K Michael Hambidge
- Section of Nutrition, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nancy F Krebs
- Section of Nutrition, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Theresa L Powell
- Section of Neonatology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Liu Z, Fan Y, Ashorn P, Cheung YB, Hallamaa L, Hyöty H, Maleta K, Lehto K, Oikarinen S, Parkkila S, Ashorn U. Faecal regenerating 1B protein concentration is not associated with child growth in rural Malawi. J Paediatr Child Health 2021; 57:388-394. [PMID: 33112481 PMCID: PMC8048694 DOI: 10.1111/jpc.15231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/08/2020] [Accepted: 10/01/2020] [Indexed: 11/30/2022]
Abstract
AIM This study was designed to determine whether faecal regenerating 1B protein (REG1B) concentration is associated with physical growth among 6-30-month-old children in rural Malawi. METHODS This was a secondary analysis from a randomised controlled trial in rural Malawi in which we followed-up 790 live-born infants from birth to 30 months of age. We collected anthropometric data at the age of 6, 12, 18, 24 and 30 months. We measured faecal REG1B concentration by enzyme-linked immunosorbent assay (ELISA) technique using stool samples collected at 6, 18 and 30 months of age. We assessed the association between faecal REG1B concentration and children's physical growth using linear regression and longitudinal data analysis. RESULTS Of 790 live-born infants enrolled, 694 (87%) with at least one faecal REG1B concentration measurement were included in the analysis. Faecal REG1B concentration was not associated with the children's concurrent length-for-age z-score (LAZ), weight-for-age z-score (WAZ), weight-for-length z-score (WLZ) and mid-upper arm circumference-for-age z-score (MUACZ) at any time point (P > 0.05), nor with a change in their anthropometric indices in the subsequent 6-month period (P > 0.05). CONCLUSIONS Faecal REG1B concentration is not associated with LAZ, WAZ, WLZ and MUACZ among 6-30-month-old infants and children in rural Malawi.
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Affiliation(s)
- Zhifei Liu
- Center for Child Health Research, Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
| | - Yue‐Mei Fan
- Center for Child Health Research, Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
| | - Per Ashorn
- Center for Child Health Research, Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland,Department of PaediatricsTampere University HospitalTampereFinland
| | - Yin Bun Cheung
- Center for Child Health Research, Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland,Program in Health Services and Systems Research and Center for Quantitative MedicineDuke‐NUS Medical SchoolSingaporeSingapore
| | - Lotta Hallamaa
- Center for Child Health Research, Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
| | - Heikki Hyöty
- Center for Child Health Research, Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland,Fimlab LtdTampere University HospitalTampereFinland
| | - Kenneth Maleta
- Department of Public Health, School of Public Health & Family Medicine, College of MedicineUniversity of MalawiZombaMalawi
| | - Kirsi‐Maarit Lehto
- Center for Child Health Research, Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
| | - Sami Oikarinen
- Center for Child Health Research, Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
| | - Seppo Parkkila
- Center for Child Health Research, Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland,Fimlab LtdTampere University HospitalTampereFinland
| | - Ulla Ashorn
- Center for Child Health Research, Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
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Taneja S, Upadhyay RP, Chowdhury R, Kurpad AV, Bhardwaj H, Kumar T, Dwarkanath P, Bose B, Devi S, Kumar G, Kaur B, Bahl R, Bhandari N. Impact of nutritional interventions among lactating mothers on the growth of their infants in the first 6 months of life: a randomized controlled trial in Delhi, India. Am J Clin Nutr 2021; 113:884-894. [PMID: 33564825 PMCID: PMC8023824 DOI: 10.1093/ajcn/nqaa383] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 11/23/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND In lower-middle-income settings, growth faltering in the first 6 mo of life occurs despite exclusive breastfeeding. OBJECTIVE The aim was to test the efficacy of an approach to improve the dietary adequacy of mothers during lactation and thus improve the growth of their infants. METHODS Eligible mother-infant dyads (infants ≤7 d of age) were randomly assigned to either intervention or control groups. Mothers in the intervention group received snacks that were to be consumed daily, which provided 600 kcal of energy-with 25-30% of energy derived from fats (150-180 kcal) and 13% of energy from protein (80 kcal). Micronutrients were supplemented as daily tablets. We provided counseling on breastfeeding and infant-care practices to mothers in both groups. The primary outcome was attained infant length-for-age z scores (LAZ) at 6 mo of age. Secondary outcomes included exclusive breastfeeding proportion reported by the mother, maternal BMI and midupper arm circumference (MUAC), hemoglobin concentrations in mothers and infants, and the proportion of anemic infants at 6 mo of age. RESULTS We enrolled 816 mother-infant dyads. The intervention did not achieve a significant effect on LAZ at 6 mo (adjusted mean difference: 0.09; 95% CI: -0.03, 0.20). Exclusive breastfeeding at 5 mo was higher (45.1% vs. 34.5%; RR: 1.31; 95% CI: 1.04, 1.64) in the intervention group compared with the controls. There were no significant effects on mean hemoglobin concentration or the proportion of anemic infants at 6 mo of age compared with the control group. We noted significant effects on maternal nutritional status (BMI, MUAC, hemoglobin concentration, and proportion anemic). CONCLUSIONS Postnatal supplementation of 600 kcal energy, 20 g protein, and multiple micronutrients daily to lactating mothers did not affect infant LAZ at age 6 mo. Such supplementation may improve maternal nutritional status. This trial was registered at Clinical Trials Registry-India as CTRI/2018/04/013095.
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Affiliation(s)
- Sunita Taneja
- Center for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Ravi Prakash Upadhyay
- Center for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Ranadip Chowdhury
- Center for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Anura V Kurpad
- Department of Physiology, St John's Medical College, Bengaluru, India
| | - Himani Bhardwaj
- Center for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Tivendra Kumar
- Center for Health Research and Development, Society for Applied Studies, New Delhi, India
| | | | - Beena Bose
- Department of Physiology, St John's Medical College, Bengaluru, India
| | - Sarita Devi
- Department of Physiology, St John's Medical College, Bengaluru, India
| | - Gunjan Kumar
- Center for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Baljeet Kaur
- Center for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child, and Adolescent Health, World Health Organization, Geneva, Switzerland
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Maleta K, Fan YM, Luoma J, Ashorn U, Bendabenda J, Dewey KG, Hyöty H, Knip M, Kortekangas E, Lehto KM, Matchado A, Nkhoma M, Nurminen N, Parkkila S, Purmonen S, Veijola R, Oikarinen S, Ashorn P. Infections and systemic inflammation are associated with lower plasma concentration of insulin-like growth factor I among Malawian children. Am J Clin Nutr 2021; 113:380-390. [PMID: 33381802 PMCID: PMC7851819 DOI: 10.1093/ajcn/nqaa327] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 10/14/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Insulin-like growth factor I (IGF-I) is the most important hormonal promoter of linear growth in infants and young children. OBJECTIVES The objectives of this study were to compare plasma IGF-I concentration in a low- compared with a high-income country and characterize biological pathways leading to reduced IGF-I concentration in children in a low-income setting. METHODS We analyzed plasma IGF-I concentration from 716 Malawian and 80 Finnish children at 6-36 mo of age. In the Malawian children, we studied the association between IGF-I concentration and their environmental exposures; nutritional status; systemic and intestinal inflammation; malaria parasitemia and viral, bacterial, and parasitic enteric infections; as well as growth at 18 mo of age. We then conducted a pathway analysis to identify direct and indirect associations between these predictors and IGF-I concentration. RESULTS The mean IGF-I concentrations were similar in Malawi and Finland among 6-mo-old infants. At age 18 mo, the mean ± SD concentration was almost double among the Finns compared with the Malawians [24.2 ± 11.3 compared with 12.5 ± 7.7 ng/mL, age- and sex-adjusted difference in mean (95% CI): 11.8 (9.9, 13.7) ng/mL; P < 0.01]. Among 18-mo-old Malawians, plasma IGF-I concentration was inversely associated with systemic inflammation, malaria parasitemia, and intestinal Shigella, Campylobacter, and enterovirus infection and positively associated with the children's weight-for-length z score (WLZ), female sex, maternal height, mother's education, and dry season. Seasonally, mean plasma IGF-I concentration was highest in June and July and lowest in December and January, coinciding with changes in children's length gain and preceded by ∼2 mo by the changes in their WLZ. CONCLUSIONS The mean plasma IGF-I concentrations are similar in Malawi and Finland among 6-mo-old infants. Thereafter, mean concentrations rise markedly in Finland but not in Malawi. Systemic inflammation and clinically nonapparent infections are strongly associated with lower plasma IGF-I concentrations in Malawi through direct and indirect pathways.
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Affiliation(s)
- Kenneth Maleta
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Yue-Mei Fan
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Juho Luoma
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Ulla Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jaden Bendabenda
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kathryn G Dewey
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, CA, USA
| | - Heikki Hyöty
- Department of Virology, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Fimlab Ltd, Tampere University Hospital, Tampere, Finland
| | - Mikael Knip
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Paediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Programs for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Folkhälsan Research Centre, Helsinki, Finland
| | - Emma Kortekangas
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Kirsi-Maarit Lehto
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Andrew Matchado
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Minyanga Nkhoma
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Noora Nurminen
- Department of Virology, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Seppo Parkkila
- Fimlab Ltd, Tampere University Hospital, Tampere, Finland
- Clinical Medicine, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sami Purmonen
- Clinical Medicine, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Riitta Veijola
- Department of Paediatrics, PEDEGO Research Unit, Medical Research Centre, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Sami Oikarinen
- Department of Virology, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Per Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
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Kinshella MLW, Omar S, Scherbinsky K, Vidler M, Magee LA, von Dadelszen P, Moore SE, Elango R. Effects of Maternal Nutritional Supplements and Dietary Interventions on Placental Complications: An Umbrella Review, Meta-Analysis and Evidence Map. Nutrients 2021; 13:472. [PMID: 33573262 PMCID: PMC7912620 DOI: 10.3390/nu13020472] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 01/26/2021] [Indexed: 01/08/2023] Open
Abstract
The placenta is a vital, multi-functional organ that acts as an interface between maternal and fetal circulation during pregnancy. Nutritional deficiencies during pregnancy alter placental development and function, leading to adverse pregnancy outcomes, such as pre-eclampsia, infants with small for gestational age and low birthweight, preterm birth, stillbirths and maternal mortality. Maternal nutritional supplementation may help to mitigate the risks, but the evidence base is difficult to navigate. The primary purpose of this umbrella review is to map the evidence on the effects of maternal nutritional supplements and dietary interventions on pregnancy outcomes related to placental disorders and maternal mortality. A systematic search was performed on seven electronic databases, the PROSPERO register and references lists of identified papers. The results were screened in a three-stage process based on title, abstract and full-text by two independent reviewers. Randomized controlled trial meta-analyses on the efficacy of maternal nutritional supplements or dietary interventions were included. There were 91 meta-analyses included, covering 23 types of supplements and three types of dietary interventions. We found evidence that supports supplementary vitamin D and/or calcium, omega-3, multiple micronutrients, lipid-based nutrients, and balanced protein energy in reducing the risks of adverse maternal and fetal health outcomes. However, these findings are limited by poor quality of evidence. Nutrient combinations show promise and support a paradigm shift to maternal dietary balance, rather than single micronutrient deficiencies, to improve maternal and fetal health. The review is registered at PROSPERO (CRD42020160887).
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Affiliation(s)
- Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, BC V6Z 2K8, Canada; (M.-L.W.K.); (S.O.); (K.S.); (M.V.); (L.A.M.); (P.v.D.)
| | - Shazmeen Omar
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, BC V6Z 2K8, Canada; (M.-L.W.K.); (S.O.); (K.S.); (M.V.); (L.A.M.); (P.v.D.)
| | - Kerri Scherbinsky
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, BC V6Z 2K8, Canada; (M.-L.W.K.); (S.O.); (K.S.); (M.V.); (L.A.M.); (P.v.D.)
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 0B3, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, BC V6Z 2K8, Canada; (M.-L.W.K.); (S.O.); (K.S.); (M.V.); (L.A.M.); (P.v.D.)
| | - Laura A. Magee
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, BC V6Z 2K8, Canada; (M.-L.W.K.); (S.O.); (K.S.); (M.V.); (L.A.M.); (P.v.D.)
- Department of Women & Children’s Health, King’s College London, London WC2R 2LS, UK;
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, BC V6Z 2K8, Canada; (M.-L.W.K.); (S.O.); (K.S.); (M.V.); (L.A.M.); (P.v.D.)
- Department of Women & Children’s Health, King’s College London, London WC2R 2LS, UK;
| | - Sophie E. Moore
- Department of Women & Children’s Health, King’s College London, London WC2R 2LS, UK;
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, P.O. Box 273 Banjul, The Gambia
| | - Rajavel Elango
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 0B3, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
- Division of Neonatology, BC Women’s Hospital and Health Centre, Vancouver, BC V6H 3N1, Canada
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Jorgensen JM, Young R, Ashorn P, Ashorn U, Chaima D, Davis JCC, Goonatilleke E, Kumwenda C, Lebrilla CB, Maleta K, Prado EL, Sadalaki J, Totten SM, Wu LD, Zivkovic AM, Dewey KG. Associations of human milk oligosaccharides and bioactive proteins with infant growth and development among Malawian mother-infant dyads. Am J Clin Nutr 2021; 113:209-220. [PMID: 33096556 PMCID: PMC7779225 DOI: 10.1093/ajcn/nqaa272] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 09/01/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Human milk oligosaccharides (HMOs) and bioactive breast milk proteins have many beneficial properties. Information is sparse regarding associations between these milk constituents and infant growth and development in lower-income countries. OBJECTIVES We aimed to examine associations of milk content of HMOs and bioactive proteins at 6 mo postpartum with infant growth and motor and cognitive development. These are secondary analyses of a randomized controlled trial in rural Malawi. METHODS Breast milk samples were analyzed at 6 mo (n = 659) for general categories of HMOs (total HMOs, fucosylated HMOs, and sialylated HMOs), 51 individual HMOs, and 6 bioactive proteins (lactalbumin, lactoferrin, lysozyme, antitrypsin, IgA, and osteopontin). We examined associations of the relative abundances of HMOs and concentrations of bioactive proteins with infant growth from 6 to 12 mo [change in length-for-age (ΔLAZ), weight-for-age, weight-for-length, and head circumference z-scores] as well as ability to stand or walk alone at 12 mo, and motor and language skills, socioemotional development, executive function, and working memory at 18 mo. Analyses were adjusted for covariates and multiple hypothesis testing. RESULTS Among all participants, there were inverse associations of IgA and lactoferrin concentrations with motor skills (P = 0.018 and P = 0.044), and a positive association of lactalbumin concentration with motor skills (P = 0.038). Among secretors only [fucosyltransferase 2 gene (FUT2) positive], there were positive associations of absolute abundance of HMOs with ΔLAZ (P = 0.035), and relative abundance of fucosylated and sialylated HMOs with language at 18 mo (P < 0.001 and P = 0.033, respectively), and inverse associations of osteopontin with standing and walking at 12 mo (P = 0.007 and 0.002, respectively). Relative abundances of several individual HMOs were associated with growth and development, mostly among secretors. CONCLUSIONS Certain bioactive breast milk proteins and HMOs are associated with infant growth and motor and cognitive development. Further studies are needed to determine if a causal relation exists.This trial was registered at clinicaltrials.gov as NCT01239693.
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Affiliation(s)
- Josh M Jorgensen
- Department of Nutrition, University of California, Davis, CA, USA
| | - Rebecca Young
- Department of Nutrition, University of California, Davis, CA, USA
| | - Per Ashorn
- Faculty of Medicine and Life Sciences, Centre for Child Health Research, University of Tampere, Tampere, Finland
- Department of Pediatrics, Tampere University Hospital, Tampere, Finland
| | - Ulla Ashorn
- Faculty of Medicine and Life Sciences, Centre for Child Health Research, University of Tampere, Tampere, Finland
| | - David Chaima
- Department of Community Health, University of Malawi College of Medicine, Blantyre, Malawi
| | | | | | - Chiza Kumwenda
- Department of Community Health, University of Malawi College of Medicine, Blantyre, Malawi
- School of Agricultural Sciences, Department of Food Science and Nutrition, University of Zambia, Lusaka, Zambia
| | - Carlito B Lebrilla
- Department of Chemistry, University of California, Davis, CA, USA
- Department of Biochemistry and Molecular Medicine, University of California, Davis, CA, USA
| | - Kenneth Maleta
- Department of Community Health, University of Malawi College of Medicine, Blantyre, Malawi
| | | | - John Sadalaki
- Department of Community Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Sarah M Totten
- Department of Chemistry, University of California, Davis, CA, USA
| | - Lauren D Wu
- Department of Chemistry, University of California, Davis, CA, USA
| | - Angela M Zivkovic
- Department of Nutrition, University of California, Davis, CA, USA
- Foods for Health Institute, University of California, Davis, CA, USA
| | - Kathryn G Dewey
- Department of Nutrition, University of California, Davis, CA, USA
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36
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Adu‐Afarwuah S. Impact of nutrient supplementation on maternal nutrition and child growth and development in Sub-Saharan Africa: the case of small-quantity lipid-based nutrient supplements. MATERNAL & CHILD NUTRITION 2020; 16 Suppl 3:e12960. [PMID: 33347727 PMCID: PMC7752123 DOI: 10.1111/mcn.12960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 12/20/2019] [Accepted: 01/16/2020] [Indexed: 11/30/2022]
Abstract
Micronutrient deficiencies remain common among women and children in Sub-Saharan Africa (SSA); in pregnant/lactating women, the intakes of essential fatty acids may also be low. Enriching home-prepared foods with small-quantity lipid-based nutrient supplements (SQ-LNSs) is a promising new strategy of delivering additional micronutrients, essential fatty acids and good quality protein to women and children. This narrative review aimed to examine the impact of SQ-LNSs supplementation among women and infants and young children in SSA, and to discuss the differential impact of SQ-LNS consumption across different settings. Papers reporting randomized trials conducted in SSA in which apparently healthy women and/or ≥6-mo-old children received SQ-LNSs were identified through electronic and manual searches. Prenatal SQ-LNS consumption reduced the prevalence of low gestational weight gain in Ghana when compared with multiple micronutrients supplementation, and was associated with poorer iron/hemoglobin status when compared with iron-plus-folic acid supplementation. SQ-LNSs received alone or as intervention package improved infant/child growth in two trials in Ghana and one trial each in Burkina Faso, Kenya, Zimbabwe and South Africa, but had no impact on growth in two trials in Malawi. SQ-LNSs supplementation improved motor development in Ghana, Burkina Faso, Malawi, Kenya, and South Africa, but had no impact on language, socio-emotional, and executive functions in Ghana and Malawi and on Griffiths' developmental scores in Malawi. SQ-LNSs may contribute to improving child growth in SSA. More research is needed to determine the iron level in SQ-LNSs effective for improving both maternal hemoglobin/iron status and birth outcomes.
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Affiliation(s)
- Seth Adu‐Afarwuah
- Department of Nutrition and Food ScienceUniversity of GhanaAccraGhana
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Park JJH, Siden E, Harari O, Dron L, Mazoub R, Jeziorska V, Zannat NE, Gadalla H, Thorlund K, Mills EJ. Interventions to improve linear growth during exclusive breastfeeding life-stage for children aged 0-6 months living in low- and middle-income countries: a systematic review with network and pairwise meta-analyses. Gates Open Res 2020; 3:1720. [PMID: 33062941 PMCID: PMC7536351 DOI: 10.12688/gatesopenres.13082.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2020] [Indexed: 01/08/2023] Open
Abstract
Background: Exclusive breastfeeding (EBF) during the first six months of life is critical for child's linear growth. While there is strong evidence in favor of EBF, the evidence with regards to other interventions for linear growth is unclear. We evaluated intervention domains of micronutrients, food supplements, deworming, maternal education, water sanitation and hygiene (WASH), and kangaroo care, for their comparative effectiveness on linear growth. Methods: For this review, we searched for randomized clinical trials (RCTs) of the interventions provided to infants aged 0-6 months and/or their breastfeeding mothers in low- and middle-income countries reporting on length-for-age z-score (LAZ), stunting, length, and head circumference. We searched for reports published until September 17 th, 2019 and hand-searched bibliographies of existing reviews. For LAZ and stunting, we used network meta-analysis (NMA) to compare the effects of all interventions except for kangaroo care, where we used pairwise meta-analysis to compare its effects versus standard-of-care. For length and head circumference, we qualitatively summarized our findings. Results: We found 29 RCTs (40 papers) involving 35,119 mother and infant pairs reporting on the effects of aforementioned interventions on linear growth outcomes. Our NMA on LAZ found that compared to standard-of-care, multiple micronutrients administered to infants (MMN-C) improved LAZ (mean difference: 0.20; 95% credible interval [CrI]: 0.03,0.35), whereas supplementing breastfeeding mothers with MMN did not (MMN-M, mean difference: -0.02, 95%CrI: -0.18,0.13). No interventions including MMN-C (relative risk: 0.74; 95%CrI: 0.36,1.44) reduced risk for stunting compared to standard-of-care. Kangaroo care, on the other hand, improved head circumference (mean difference: 0.20 cm/week; 95% confidence intervals [CI]: 0.09,0.31 cm/week) and length (mean difference: 0.23 cm/week; 95%CI: 0.10,0.35 cm/week) compared to standard-of-care. Conclusion: Our study found important improvements for kangaroo care, but we did not find sufficient evidence for other interventions. Registration: PROSPERO CRD42018110450; registered on 17 October 2018.
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Affiliation(s)
- Jay J. H. Park
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z4, Canada
| | - Ellie Siden
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z4, Canada
| | - Ofir Harari
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Louis Dron
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Reham Mazoub
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S4K1, Canada
| | | | | | | | - Kristian Thorlund
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S4K1, Canada
| | - Edward J. Mills
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S4K1, Canada
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Hughes RL, Arnold CD, Young RR, Ashorn P, Maleta K, Fan YM, Ashorn U, Chaima D, Malamba-Banda C, Kable ME, Dewey KG. Infant gut microbiota characteristics generally do not modify effects of lipid-based nutrient supplementation on growth or inflammation: secondary analysis of a randomized controlled trial in Malawi. Sci Rep 2020; 10:14861. [PMID: 32908192 PMCID: PMC7481312 DOI: 10.1038/s41598-020-71922-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 08/21/2020] [Indexed: 12/22/2022] Open
Abstract
An unhealthy gut microbial community may act as a barrier to improvement in growth and health outcomes in response to nutritional interventions. The objective of this analysis was to determine whether the infant microbiota modified the effects of a randomized controlled trial of lipid-based nutrient supplements (LNS) in Malawi on growth and inflammation at 12 and 18 months, respectively. We characterized baseline microbiota composition of fecal samples at 6 months of age (n = 506, prior to infant supplementation, which extended to 18 months) using 16S rRNA gene sequencing of the V4 region. Features of the gut microbiota previously identified as being involved in fatty acid or micronutrient metabolism or in outcomes relating to growth and inflammation, especially in children, were investigated. Prior to correction for multiple hypothesis testing, the effects of LNS on growth appeared to be modified by Clostridium (p-for-interaction = 0.02), Ruminococcus (p-for-interaction = 0.007), and Firmicutes (p-for-interaction = 0.04) and effects on inflammation appeared to be modified by Faecalibacterium (p-for-interaction = 0.03) and Streptococcus (p-for-interaction = 0.004). However, after correction for multiple hypothesis testing these findings were not statistically significant, suggesting that the gut microbiota did not alter the effect of LNS on infant growth and inflammation in this cohort.
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Affiliation(s)
- Riley L Hughes
- Department of Nutrition, University of California, Davis, CA, USA
| | - Charles D Arnold
- Department of Nutrition, University of California, Davis, CA, USA
| | - Rebecca R Young
- Department of Nutrition, University of California, Davis, CA, USA
| | - Per Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Pediatrics, Tampere University Hospital, Tampere, Finland
| | - Ken Maleta
- College of Medicine, University of Malawi, Blantyre 3, Malawi
| | - Yue-Mei Fan
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Ulla Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - David Chaima
- School of Public Health and Family Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Chikondi Malamba-Banda
- School of Public Health and Family Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Mary E Kable
- Immunity and Disease Prevention, Western Human Nutrition Research Center, Agricultural Research Service, USDA, Davis, CA, USA
| | - Kathryn G Dewey
- Department of Nutrition, University of California, Davis, CA, USA.
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Kamng'ona AW, Young R, Arnold CD, Patson N, Jorgensen JM, Kortekangas E, Chaima D, Malamba C, Ashorn U, Cheung YB, Ashorn P, Maleta K, Dewey KG. Provision of Lipid-Based Nutrient Supplements to Mothers During Pregnancy and 6 Months Postpartum and to Their Infants from 6 to 18 Months Promotes Infant Gut Microbiota Diversity at 18 Months of Age but Not Microbiota Maturation in a Rural Malawian Setting: Secondary Outcomes of a Randomized Trial. J Nutr 2020; 150:918-928. [PMID: 31909811 PMCID: PMC7138685 DOI: 10.1093/jn/nxz298] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/26/2019] [Accepted: 11/18/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Diet may alter the configuration of gut microbiota, but the impact of prenatal and postnatal nutritional interventions on infant gut microbiota has not been investigated. OBJECTIVE We evaluated whether providing lipid-based nutrient supplements (LNSs) to mother-infant dyads promotes a more diverse and mature infant gut microbiota, compared to maternal supplementation with multiple micronutrients (MMN) or iron and folic acid (IFA). METHODS We enrolled 869 pregnant women in a randomized trial in Malawi. There were 3 study groups, with women receiving 1 MMN capsule daily during pregnancy and 6 mo postpartum, or 1 LNS sachet (20 g) daily during pregnancy and 6 mo postpartum, or 1 IFA capsule daily (during pregnancy) then a placebo daily (postpartum). Infants in the LNS group received LNS from 6 to 18 mo; infants in the other groups did not receive supplements. The infants' fecal microbiota were characterized by PCR amplification and sequencing of the bacterial 16S rRNA gene (variable region 4). The primary outcomes were microbiota α diversity and maturation [as microbiota-for-age z score (MAZ)]. Specific associations of taxa with intervention were established with indicator species analysis (ISA). RESULTS Primary outcomes did not differ between IFA and MMN groups, so these groups were combined (IFA + MMN). Mean ± SD α diversity was higher in the LNS group at 18 mo for Shannon index [3.01 ± 0.57 (LNS) compared with 2.91 ± 0.60 (IFA + MMN), P = 0.032] and Pielou's evenness index [0.61 ± 0.08 (LNS) compared with 0.60 ± 0.09 (IFA + MMN), P = 0.043]; no significant differences were observed at 1, 6, 12, or 30 mo. MAZ and β diversity did not differ at any age. We found 10 and 3 operational taxonomic units (OTUs) positively associated with LNS and IFA + MMN, respectively; however, these associations became nonsignificant following false discovery rate correction at 10%. CONCLUSIONS Prenatal and postnatal LNS intake promoted infant gut microbiota diversity at 18 mo, after 12 mo of child supplementation, but did not alter microbiota maturation. This trial was registered at clinicaltrials.gov as NCT01239693.
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Affiliation(s)
- Arox W Kamng'ona
- Department of Biomedical Sciences, University of Malawi, College of Medicine, Blantyre, Malawi,Address correspondence to AWK (e-mail: )
| | - Rebecca Young
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA 95616, USA
| | - Charles D Arnold
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA 95616, USA
| | - Noel Patson
- School of Public Health and Family Medicine, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Josh M Jorgensen
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA 95616, USA
| | - Emma Kortekangas
- Center for Child Health Research, University of Tampere Faculty of Medicine and Life Sciences, 33100 Tampere, Finland
| | - David Chaima
- School of Public Health and Family Medicine, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Chikondi Malamba
- School of Public Health and Family Medicine, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Ulla Ashorn
- Center for Child Health Research, University of Tampere Faculty of Medicine and Life Sciences, 33100 Tampere, Finland
| | - Yin B Cheung
- Program in Health Services & Systems Research and Center for Quantitative Medicine, Duke-NUS Medical School, Singapore 169857
| | - Per Ashorn
- Center for Child Health Research, University of Tampere Faculty of Medicine and Life Sciences, 33100 Tampere, Finland,Department of Pediatrics, Tampere University Hospital, 33520 Tampere, Finland
| | - Kenneth Maleta
- School of Public Health and Family Medicine, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Kathryn G Dewey
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, Davis, CA 95616, USA
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40
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Goto E. Effectiveness of Prenatal Lipid-Based Nutrient Supplementation to Improve Birth Outcomes: A Meta-analysis. Am J Trop Med Hyg 2020; 101:994-999. [PMID: 31516104 DOI: 10.4269/ajtmh.19-0287] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
This study was performed to examine whether prenatal lipid-based nutrient supplementation is an effective means of improving birth outcomes compared with other types of supplementation including iron folic acid (IFA), United Nations multiple micronutrient preparation (UNIMAP), other multiple micronutrients (MMN), and fortified corn-soy blend (CSB). A meta-analysis was performed to determine the relative risks and mean differences in birth outcomes between prenatal lipid-based nutrients versus prenatal IFA, UNIMAP, other MMN, and CSB in randomized controlled trials. Eleven databases, including PubMed (MEDLINE), were searched. Study quality was assessed using the Cochrane Collaboration's tool for assessing the risk of bias. Fifty-eight overall good-quality studies extracted from 11 eligible articles with 101,553 mother-baby pairs were included. Lipid-based nutrient supplementation significantly reduced the risks of low birthweight, small for gestational age, and stunting (n = 5, 5, and 4, respectively) and significantly increased the means of birthweight, birth length, arm circumference, and weight-for-age z-score (n = 5, 5, 4, and 3, respectively). Lipid-based nutrient supplementation did not significantly reduce the risk of preterm birth, stillbirth, abortion, perinatal death, or underweight (n = 5, 5, 5, 3, or 3, respectively) or significantly increase the mean of head circumference or height-for-age z-score (n = 4 or 2, respectively). In conclusion, the results supported the efficacy of prenatal lipid-based nutrient supplementation compared with IFA, UNIMAP, other MMN, and CSB for reducing the risk of small birth size.
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Affiliation(s)
- Eita Goto
- Department of Medicine and Public Health, Nagoya Medical Science Research Institute, Nagoya, Japan
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Kortekangas E, Kamng'ona AW, Fan Y, Cheung YB, Ashorn U, Matchado A, Poelman B, Maleta K, Dewey KG, Ashorn P. Environmental exposures and child and maternal gut microbiota in rural Malawi. Paediatr Perinat Epidemiol 2020; 34:161-170. [PMID: 32011017 PMCID: PMC7154550 DOI: 10.1111/ppe.12623] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 10/24/2019] [Accepted: 11/17/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gut microbiota composition is associated with child health, but the effect of the environment on microbiota composition is not well understood. Few studies have been conducted in low-income settings where childhood malnutrition is common and possibly related to microbiota composition. OBJECTIVES To investigate whether gut microbiota composition in young children and their mothers is associated with different environmental exposures in rural Malawi. We hypothesized that more adverse environmental exposures would be associated with lower levels of microbiota maturity and diversity. METHODS Faecal samples from up to 631 children and mothers participating in a nutrition intervention trial were collected at 1, 6, 12, 18, and 30 months (children) and at 1 month (mothers) after birth and analysed for microbiota composition with 16S rRNA sequencing. Bacterial OTU and genus abundances, measures of microbiota maturity and diversity, and UniFrac distances were compared between participants with different environmental exposures. The exposure variables included socio-economic status, water source, sanitary facility, domestic animals, maternal characteristics, season, antibiotic use, and delivery mode. RESULTS Measures of microbiota maturity and diversity in children were inversely associated with maternal education at 6, 18, and 30 months and did not otherwise differ consistently between participants with different environmental exposures. Phylogenetic distance was related to season of stool sample collection at all time points. At the level of individual OTUs and genera, season of stool sample collection, type of water source, and maternal education showed most associations with child gut microbiota, while HIV status was the most important predictor of relative OTU and genus abundances in mothers. CONCLUSION The results do not support the hypothesis that adverse environmental exposures are broadly associated with lower microbiota maturity and diversity but suggest that environmental exposures influence the abundance of several bacterial OTUs and genera and that low maternal education is associated with higher microbiota maturity and diversity.
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Affiliation(s)
- Emma Kortekangas
- Center for Child Health ResearchFaculty of Medicine and Health TechnologyTampere UniversityTampereFinland
| | - Arox W. Kamng'ona
- Department of Biomedical SciencesCollege of MedicineUniversity of MalawiBlantyreMalawi,Program in International and Community NutritionUniversity of California DavisDavisCAUSA
| | - Yue‐Mei Fan
- Center for Child Health ResearchFaculty of Medicine and Health TechnologyTampere UniversityTampereFinland
| | - Yin Bun Cheung
- Program in Health Services & Systems Research and Centre for Quantitative MedicineDuke‐NUS Medical SchoolSingaporeSingapore
| | - Ulla Ashorn
- Center for Child Health ResearchFaculty of Medicine and Health TechnologyTampere UniversityTampereFinland
| | - Andrew Matchado
- Program in International and Community NutritionUniversity of California DavisDavisCAUSA,School of Public Health and Family MedicineUniversity of Malawi College of MedicineBlantyreMalawi
| | - Basho Poelman
- Center for Child Health ResearchFaculty of Medicine and Health TechnologyTampere UniversityTampereFinland
| | - Kenneth Maleta
- School of Public Health and Family MedicineUniversity of Malawi College of MedicineBlantyreMalawi
| | | | - Per Ashorn
- Center for Child Health ResearchFaculty of Medicine and Health TechnologyTampere UniversityTampereFinland,Department of PaediatricsTampere University HospitalTampereFinland
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Lassi ZS, Padhani ZA, Rabbani A, Rind F, Salam RA, Das JK, Bhutta ZA. Impact of Dietary Interventions during Pregnancy on Maternal, Neonatal, and Child Outcomes in Low- and Middle-Income Countries. Nutrients 2020; 12:E531. [PMID: 32092933 PMCID: PMC7071393 DOI: 10.3390/nu12020531] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 01/20/2020] [Accepted: 02/11/2020] [Indexed: 01/08/2023] Open
Abstract
Optimal nutrition plays a crucial role in pregnancy. Maternal malnutrition is a risk factor for maternal, fetal, and neonatal complications and is more prevalent in low and middle-income countries (LMICs). This review aims to study the effectiveness of antenatal macronutrient nutritional interventions on maternal, neonatal, and child outcomes. We searched the CENTRAL, PubMed, Embase, and other databases for randomized controlled trials and quasi-experimental designs on healthy pregnant women in LMICs. We also searched grey literature and reports from Google Scholar, Web of Science, and websites of different organizations. Title/abstract screening, full-text screening, and data extraction filtered 15 studies for inclusion. Balanced energy protein (BEP) supplementation (n = 8) studies showed a reduced incidence of perinatal mortality, stillbirths, low birth weight (LBW) infants, small for gestational age (SGA) babies and increased birth weight. Food distribution programs (FDPs) (n =5) witnessed reduced rates of SGA, stunting, wasting, and increased birth weight and birth length. Studies on intervention for obesity prevention (n = 2) showed reductions in birth weight. Other findings were statistically insignificant. Subgroup analyses were conducted to study the effectiveness of supplementation between regions, location, the timing of supplementation and nutritional status; however, there were a limited number of studies in each subgroup. Data from our review supports the antenatal supplementation of BEP and FDP for the prevention of adverse maternal, neonatal, and child outcomes that can be utilized for future policymaking. However, more research is required before recommending obesity prevention programs.
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Affiliation(s)
- Zohra S Lassi
- Robinson Research Institute, University of Adelaide, Adelaide 5005, Australia
| | - Zahra A Padhani
- Department of Pediatrics, Aga Khan University, Karachi 74800, Pakistan; (Z.A.P.); (A.R.); (F.R.); (R.A.S.); (J.K.D.); (Z.A.B.)
| | - Amna Rabbani
- Department of Pediatrics, Aga Khan University, Karachi 74800, Pakistan; (Z.A.P.); (A.R.); (F.R.); (R.A.S.); (J.K.D.); (Z.A.B.)
| | - Fahad Rind
- Department of Pediatrics, Aga Khan University, Karachi 74800, Pakistan; (Z.A.P.); (A.R.); (F.R.); (R.A.S.); (J.K.D.); (Z.A.B.)
| | - Rehana A. Salam
- Department of Pediatrics, Aga Khan University, Karachi 74800, Pakistan; (Z.A.P.); (A.R.); (F.R.); (R.A.S.); (J.K.D.); (Z.A.B.)
| | - Jai K Das
- Department of Pediatrics, Aga Khan University, Karachi 74800, Pakistan; (Z.A.P.); (A.R.); (F.R.); (R.A.S.); (J.K.D.); (Z.A.B.)
| | - Zulfiqar A Bhutta
- Department of Pediatrics, Aga Khan University, Karachi 74800, Pakistan; (Z.A.P.); (A.R.); (F.R.); (R.A.S.); (J.K.D.); (Z.A.B.)
- Centre for Global Child Health, SickKids Hospital, Toronto, ON M5G 0A4, Canada
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43
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Park JJH, Siden E, Harari O, Dron L, Mazoub R, Jeziorska V, Zannat NE, Gadalla H, Thorlund K, Mills EJ. Interventions to improve linear growth during exclusive breastfeeding life-stage for children aged 0-6 months living in low- and middle-income countries: a systematic review and network and pairwise meta-analyses. Gates Open Res 2019; 3:1720. [PMID: 33062941 PMCID: PMC7536351 DOI: 10.12688/gatesopenres.13082.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2019] [Indexed: 11/13/2023] Open
Abstract
Background: Exclusive breastfeeding (EBF) during the first six months of life is critical for child's linear growth. While there is strong evidence in favor of EBF, the evidence with regards to other interventions for linear growth is unclear. We evaluated intervention domains of micronutrients, food supplements, deworming, maternal education, water sanitation and hygiene (WASH), and kangaroo care, for their comparative effectiveness on linear growth. Methods: For this review, we searched for randomized clinical trials (RCTs) of the interventions provided to infants aged 0-6 months and/or their breastfeeding mothers in low- and middle-income countries reporting on length-for-age z-score (LAZ), stunting, length, and head circumference. We searched for reports published until September 17 th, 2019 and hand-searched bibliographies of existing reviews. For LAZ and stunting, we used network meta-analysis (NMA) to compare the effects of all interventions except for kangaroo care, where we used pairwise meta-analysis to compare its effects versus standard-of-care. For length and head circumference, we qualitatively summarized our findings. Results: We found 29 RCTs (40 papers) involving 35,119 mother and infant pairs reporting on the effects of aforementioned interventions on linear growth outcomes. Our NMA on LAZ found that compared to standard-of-care, multiple micronutrients administered to infants (MMN-C) improved LAZ (mean difference: 0.20; 95% credible interval [CrI]: 0.03,0.35), whereas supplementing breastfeeding mothers with MMN did not (MMN-M, mean difference: -0.02, 95%CrI: -0.18,0.13). No interventions including MMN-C (relative risk: 0.74; 95%CrI: 0.36,1.44) reduced risk for stunting compared to standard-of-care. Kangaroo care, on the other hand, improved head circumference (mean difference: 0.20 cm/week; 95% confidence intervals [CI]: 0.09,0.31 cm/week) and length (mean difference: 0.23 cm/week; 95%CI: 0.10,0.35 cm/week) compared to standard-of-care. Conclusion: Our study found important improvements for kangaroo care, but we did not find sufficient evidence for other interventions. Registration: PROSPERO CRD42018110450; registered on 17 October 2018.
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Affiliation(s)
- Jay J. H. Park
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z4, Canada
| | - Ellie Siden
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z4, Canada
| | - Ofir Harari
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Louis Dron
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Reham Mazoub
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S4K1, Canada
| | | | | | | | - Kristian Thorlund
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S4K1, Canada
| | - Edward J. Mills
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S4K1, Canada
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Hambidge KM, Bann CM, McClure EM, Westcott JE, Garcés A, Figueroa L, Goudar SS, Dhaded SM, Pasha O, Ali SA, Derman RJ, Goldenberg RL, Koso-Thomas M, Somannavar MS, Herekar V, Khan U, Krebs NF. Maternal Characteristics Affect Fetal Growth Response in the Women First Preconception Nutrition Trial. Nutrients 2019; 11:E2534. [PMID: 31640153 PMCID: PMC6835723 DOI: 10.3390/nu11102534] [Citation(s) in RCA: 5] [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: 08/20/2019] [Revised: 09/28/2019] [Accepted: 10/15/2019] [Indexed: 02/02/2023] Open
Abstract
The objective of this secondary analysis was to identify maternal characteristics that modified the effect of maternal supplements on newborn size. Participants included 1465 maternal-newborn dyads in Guatemala, India, and Pakistan. Supplementation commenced before conception (Arm 1) or late 1st trimester (Arm 2); Arm 3 received usual care. Characteristics included body mass index (BMI), stature, anemia, age, education, socio-economic status (SES), parity, and newborn sex. Newborn outcomes were z-scores for length (LAZ), weight (WAZ), and weight to length ratio-for-age (WLRAZ). Mixed-effect regression models included treatment arm, effect modifier, and arm * effect modifier interaction as predictors, controlling for site, characteristics, and sex. Parity (para-0 vs. para ≥1), anemia (anemia/no anemia), and sex were significant effect modifiers. Effect size (95% CI) for Arm 1 vs. 3 was larger for para-0 vs. ≥1 for all outcomes (LAZ 0.56 (0.28, 0.84, p < 0.001); WAZ 0.45 (0.20, 0.07, p < 0.001); WLRAZ 0.52 (0.17, 0.88, p < 0.01) but only length for Arm 2 vs. 3. Corresponding effects for para ≥1 were >0.02. Arm 3 z-scores were all very low for para-0, but not para ≥1. Para-0 and anemia effect sizes for Arm 1 were > Arm 2 for WAZ and WLRAZ, but not LAZ. Arm 1 and 2 had higher WAZ for newborn boys vs. girls. Maternal nulliparity and anemia were associated with impaired fetal growth that was substantially improved by nutrition intervention, especially when commenced prior to conception.
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Affiliation(s)
- K Michael Hambidge
- Section of Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA.
| | | | | | - Jamie E Westcott
- Section of Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA.
| | - Ana Garcés
- INCAP (Instituto de Nutrición de Centro América y Panamá), Guatemala City 01011, Guatemala.
| | - Lester Figueroa
- INCAP (Instituto de Nutrición de Centro América y Panamá), Guatemala City 01011, Guatemala.
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belagavi, Karnataka 590010, India.
| | - Sangappa M Dhaded
- KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belagavi, Karnataka 590010, India.
| | - Omrana Pasha
- Department of Community Health Sciences, Aga Khan University, Karachi 74800, Pakistan.
| | - Sumera A Ali
- Department of Community Health Sciences, Aga Khan University, Karachi 74800, Pakistan.
| | - Richard J Derman
- Department of Global Affairs, Thomas Jefferson University, Philadelphia, PA 19107, USA.
| | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, NY 10032, USA.
| | | | - Manjunath S Somannavar
- KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belagavi, Karnataka 590010, India.
| | - Veena Herekar
- KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belagavi, Karnataka 590010, India.
| | - Umber Khan
- Department of Community Health Sciences, Aga Khan University, Karachi 74800, Pakistan.
| | - Nancy F Krebs
- Section of Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA.
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45
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Abstract
OBJECTIVES The determinants of gut microbiota composition and its effects on common childhood illnesses are only partly understood, especially in low-income settings. The aim of the present study was to investigate whether morbidity predicts gut microbiota composition in Malawian children and whether microbiota predicts subsequent morbidity. We tested the hypothesis that common infectious disease symptoms would be predictive of lower microbiota maturity and diversity. METHODS We used data from 631 participants in a randomized-controlled nutrition intervention trial, in which a small-quantity lipid-based nutrient supplement was provided to pregnant and lactating mothers and their children at 6 to 18 months of age. Fecal samples were collected from the children at 6, 12, 18, and 30 months of age and analyzed using 16S rRNA sequencing. Microbiota variables consisted of measures of microbiota diversity (Shannon Index), microbiota maturity (microbiota-for-age z score), and the relative abundances of taxa. Morbidity variables included gastrointestinal and respiratory symptoms and fever. RESULTS Diarrhea and respiratory symptoms from 11 to 12 months were predictive of lower microbiota-for-age z score and higher Shannon Index, respectively (P = 0.035 and P = 0.023). Morbidity preceding sample collection was predictive of the relative abundances of several bacterial taxa at all time points. Higher microbiota maturity and diversity at 6 months were predictive of a lower incidence rate of fever in the subsequent 6 months (P = 0.007 and P = 0.031). CONCLUSIONS Our findings generally do not support the hypothesis that morbidity prevalence predicts a subsequent decrease in gut microbiota maturity or diversity in rural Malawian children. Certain morbidity symptoms may be predictive of microbiota maturity and diversity and relative abundances of several bacterial taxa. Furthermore, microbiota diversity and maturity may be associated with the subsequent incidence of fever.
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46
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Kamng'ona AW, Young R, Arnold CD, Kortekangas E, Patson N, Jorgensen JM, Prado EL, Chaima D, Malamba C, Ashorn U, Fan YM, Cheung YB, Ashorn P, Maleta K, Dewey KG. The association of gut microbiota characteristics in Malawian infants with growth and inflammation. Sci Rep 2019; 9:12893. [PMID: 31501455 PMCID: PMC6733848 DOI: 10.1038/s41598-019-49274-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 08/22/2019] [Indexed: 01/01/2023] Open
Abstract
We tested the hypotheses that a more mature or diverse gut microbiota will be positively associated with infant growth and inversely associated with inflammation. We characterized gut microbiota from the stool samples of Malawian infants at 6 mo (n = 527), 12 mo (n = 632) and 18 mo (n = 629) of age. Microbiota diversity and maturity measurements were based on Shannon diversity index and microbiota for age Z-score (MAZ), respectively. Growth was calculated as change in Z-scores for weight-for-age (WAZ), length-for-age (LAZ) and head circumference-for-age (HCZ) from 6 to 12 mo and 12 to 18 mo. Biomarkers of inflammation (alpha-1-acid glycoprotein (AGP) and C-reactive protein (CRP)) were measured at 6 and 18 mo. Multivariable models were used to assess the association of each independent variable with each outcome. Microbiota diversity and maturity were related to growth in weight from 6 to 12 mo, but not to growth in length or head circumference or to growth from 12 to 18 mo. Microbiota diversity and maturity may also be linked to inflammation, but findings were inconsistent.
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Affiliation(s)
- Arox W Kamng'ona
- Department of Biomedical Sciences, University of Malawi, College of Medicine, Blantyre, Malawi.
| | - Rebecca Young
- Program in International and Community Nutrition and Department of Nutrition, University of California, Davis, CA, USA
| | - Charles D Arnold
- Program in International and Community Nutrition and Department of Nutrition, University of California, Davis, CA, USA
| | - Emma Kortekangas
- Center for Child Health Research, Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Noel Patson
- School of Public Health and Family Medicine, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Josh M Jorgensen
- Program in International and Community Nutrition and Department of Nutrition, University of California, Davis, CA, USA
| | - Elizabeth L Prado
- Program in International and Community Nutrition and Department of Nutrition, University of California, Davis, CA, USA
| | - David Chaima
- School of Public Health and Family Medicine, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Chikondi Malamba
- School of Public Health and Family Medicine, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Ulla Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Yue-Mei Fan
- Center for Child Health Research, Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Yin B Cheung
- Center for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Per Ashorn
- Center for Child Health Research, Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland.,Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Kenneth Maleta
- School of Public Health and Family Medicine, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Kathryn G Dewey
- Program in International and Community Nutrition and Department of Nutrition, University of California, Davis, CA, USA
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47
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Okala SG, Darboe MK, Sosseh F, Sonko B, Faye-Joof T, Prentice AM, Moore SE. Impact of nutritional supplementation during pregnancy on antibody responses to diphtheria-tetanus-pertussis vaccination in infants: A randomised trial in The Gambia. PLoS Med 2019; 16:e1002854. [PMID: 31386660 PMCID: PMC6684039 DOI: 10.1371/journal.pmed.1002854] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 06/27/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Exposure to a nutritionally deficient environment during fetal life and early infancy may adversely alter the ontogeny of the immune system and affect an infant's ability to mount an optimal immune response to vaccination. We examined the effects of maternal nutritional supplementation during pregnancy on infants' antibody responses to the diphtheria-tetanus-pertussis (DTP) vaccine included in the Expanded Programme on Immunisation (EPI). METHODS AND FINDINGS The Early Nutrition and Immune Development (ENID) trial was a randomised, partially blinded trial conducted between April 2010 and February 2015 in the rural West Kiang region of The Gambia, a resource-poor region affected by chronic undernutrition. Pregnant women (<20 weeks' gestation) with a singleton pregnancy (n = 875) were randomised to receive one of four supplements: iron-folic acid (FeFol; standard of care), multiple micronutrient (MMN), protein-energy (PE), or PE + MMN daily from enrolment (mean [SD] 13.7 [3.3] weeks' gestation) until delivery. Infants were administered the DTP vaccine at 8, 12, and 16 weeks of age according to the Gambian Government protocol. Results for the primary outcome of the trial (infant thymic size) were described previously; here, we report on a secondary outcome, infant antibody response to vaccination. The effects of supplementation on mean DTP antibody titres measured in blood samples collected from infants at 12 weeks (n = 710) and 24 weeks (n = 662) were analysed with adjustment for confounders including maternal age, compliance to supplement, and infant sex and season. At 12 weeks, following a single dose of the vaccine, compared with FeFol (mean 95% confidence interval [CI]; 0.11 IU/mL, 0.09-0.12), antenatal supplementation with MMN or MMN + PE resulted in 42.4% (95% CI 20.1-64.6; p < 0.001) and 29.4% (6.4-52.5; p = 0.012) higher mean anti-diphtheria titres, respectively. Mean anti-tetanus titres were higher by 9.0% (5.5-12.5), 7.8% (4.3-11.4), and 7.3% (4.0-10.7) in MMN, PE, and PE + MMN groups (all, p < 0.001), respectively, than in the FeFol group (0.55 IU/mL, 0.52-0.58). Mean anti-pertussis titres were not significantly different in the FeFol, MMN, and PE + MNN groups but were all higher than in the PE group (all, p < 0.001). At 24 weeks, following all three doses, no significant differences in mean anti-diphtheria titres were detected across the supplement groups. Mean anti-tetanus titres were 3.4% (0.19-6.5; p = 0.038) higher in the PE + MMN group than in the FeFol group (3.47 IU/mL, 3.29-3.66). Mean anti-pertussis titres were higher by 9.4% (3.3-15.5; p = 0.004) and 15.4% (9.6-21.2; p < 0.001) in PE and PE + MMN groups, compared with the FeFol group (74.9 IU/mL, 67.8-82.8). Limitations of the study included the lack of maternal antibody status (breast milk or plasma) or prevaccination antibody measurements in the infants. CONCLUSION According to our results from rural Gambia, maternal supplementation with MMN combined with PE during pregnancy enhanced antibody responses to the DTP vaccine in early infancy. Provision of nutritional supplements to pregnant women in food insecure settings may improve infant immune development and responses to EPI vaccines. TRIAL REGISTRATION ISRCTN49285450.
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Affiliation(s)
- Sandra G. Okala
- Kings’ College London, Department of Women and Children’s Health, St Thomas’ Hospital, London, United Kingdom
| | - Momodou K. Darboe
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Fatou Sosseh
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Bakary Sonko
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Tisbeh Faye-Joof
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Andrew M. Prentice
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Sophie E. Moore
- Kings’ College London, Department of Women and Children’s Health, St Thomas’ Hospital, London, United Kingdom
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
- * E-mail:
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48
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Park JJH, Fang ML, Harari O, Dron L, Siden EG, Majzoub R, Jeziorska V, Thorlund K, Mills EJ, Bhutta ZA. Association of Early Interventions With Birth Outcomes and Child Linear Growth in Low-Income and Middle-Income Countries: Bayesian Network Meta-analyses of Randomized Clinical Trials. JAMA Netw Open 2019; 2:e197871. [PMID: 31348509 PMCID: PMC6661710 DOI: 10.1001/jamanetworkopen.2019.7871] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/29/2019] [Indexed: 12/24/2022] Open
Abstract
Importance The first 1000 days of life represent a critical window for child development. Pregnancy, exclusive breastfeeding (EBF) period (0-6 months), and complementary feeding (CF) period (6-24 months) have different growth requirements, so separate considerations for intervention strategies are needed. No synthesis to date has attempted to quantify the associations of interventions under multiple domains of micronutrient and balanced energy protein and food supplements, deworming, maternal education, water sanitation, and hygiene across these 3 life periods with birth and growth outcomes. Objective To determine the magnitude of association of interventions with birth and growth outcomes based on randomized clinical trials (RCTs) conducted in low-income and middle-income countries (LMICs) using Bayesian network meta-analyses. Data Sources MEDLINE, Embase, and Cochrane databases were searched from their inception up to August 14, 2018. Study Selection Included were LMIC-based RCTs of interventions provided to pregnant women, infants (0-6 months), and children (6-24 months). Data Extraction and Synthesis Two independent reviewers used a standardized data extraction and quality assessment form. Random-effects network meta-analyses were performed for each life period. Effect sizes are reported as odds ratios (ORs) and mean differences (MeanDiffs) for dichotomous and continuous outcomes, with 95% credible intervals (CrIs). This study calculated probabilities of interventions being superior to standard of care by at least a minimal clinically important difference. Main Outcomes and Measures The study compared ORs on preterm birth and MeanDiffs on birth weight for pregnancy, length for age (LAZ) for EBF, and height for age (HAZ) for CF. Results Among 302 061 participants in 169 randomized clinical trials, the network meta-analyses found several nutritional interventions that demonstrated greater association with improved birth and growth outcomes compared with standard of care. For instance, compared with standard of care, maternal supplements of multiple micronutrients showed reduced odds for preterm birth (OR, 0.54; 95% CrI, 0.27-0.97) and improved mean birth weight (MeanDiff, 0.08 kg; 95% CrI, 0.00-0.17 kg) but not LAZ during EBF (MeanDiff, -0.02; 95% CrI, -0.18 to 0.14). Supplementing infants and children with multiple micronutrients showed improved LAZ (MeanDiff, 0.20; 95% CrI, 0.03-0.35) and HAZ (MeanDiff, 0.14; 95% CrI, 0.02-0.25). The study found that pregnancy interventions generally had higher probabilities of a minimal clinically importance difference than the interventions for the EBF or CF in the first 1000 days of life. Conclusions and Relevance These analyses highlight the importance of intervening early for child development, during pregnancy if possible. Results of this study suggest that there is a need to combine interventions from multiple domains and test for their effectiveness as a package.
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Affiliation(s)
- Jay J. H. Park
- Experimental Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- MTEK Sciences, Vancouver, British Columbia, Canada
| | - Mei Lan Fang
- MTEK Sciences, Vancouver, British Columbia, Canada
- School of Nursing and Health Sciences, University of Dundee, Dundee, United Kingdom
| | - Ofir Harari
- MTEK Sciences, Vancouver, British Columbia, Canada
| | - Louis Dron
- MTEK Sciences, Vancouver, British Columbia, Canada
| | | | - Reham Majzoub
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Kristian Thorlund
- MTEK Sciences, Vancouver, British Columbia, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Edward J. Mills
- MTEK Sciences, Vancouver, British Columbia, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Zulfiqar A. Bhutta
- Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
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49
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Isanaka S, Kodish SR, Mamaty AA, Guindo O, Zeilani M, Grais RF. Acceptability and utilization of a lipid-based nutrient supplement formulated for pregnant women in rural Niger: a multi-methods study. BMC Nutr 2019; 5:34. [PMID: 32153947 PMCID: PMC7050705 DOI: 10.1186/s40795-019-0298-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 06/24/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND In food insecure settings, it may be difficult for pregnant women to meet increased nutritional needs through traditional diets. A promising new strategy to fill nutrient gaps in pregnancy involves the provision of lipid-based nutrient supplements (LNS). We aimed to assess the acceptability and utilization of a 40 g LNS formulation (Epi-E) with increased micronutrient content relative to the recommended daily allowance among pregnant women in rural Niger. METHODS We conducted a two-part, multi-methods study among pregnant women presenting to antenatal care in Madarounfa, Niger during two periods (Ramadan and non-Ramadan). Part 1 included two LNS test meals provided at the health center, and Part 2 included a 14-day home trial to simulate more realistic conditions outside of the health center. Open- and closed-ended questions were used to assess organoleptic properties of Epi-E using a 5-point hedonic scale after the test meals, as well as utilization and willingness to pay for Epi-E after the 14-day home trial. RESULTS Participants consumed more than 90% of the test meal in both periods. Epi-E was rated highly in terms of overall liking, color, taste and smell during test meals in both periods (median 5/5 for all); only time, mode and frequency of consumption varied between Ramadan and non-Ramadan periods in observance of daily fasting during the holy month. CONCLUSION Epi- E, a 40 g LNS formulation with increased micronutrient content, was highly acceptable among pregnant women in rural Niger, and utilization was guided by household and individual considerations that varied by time period. This formulation can be further tested as a potential strategy to improve the nutritional status of pregnant women in this context. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02145000. Registered 22 May 2014.
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Affiliation(s)
- Sheila Isanaka
- Epicentre, 8 rue Saint Sabin, 75011 Paris, France
- Harvard T.H. Chan School of Public Health, 665 Huntington Ave, Boston, MA 02115 USA
| | - Stephen R. Kodish
- Harvard T.H. Chan School of Public Health, 665 Huntington Ave, Boston, MA 02115 USA
| | - Abdoul Aziz Mamaty
- Epicentre Niger, Quartier Plateau, Bd Maurice Delens Porte 206, 13330 Niamey, Niger
| | - Ousmane Guindo
- Epicentre Niger, Quartier Plateau, Bd Maurice Delens Porte 206, 13330 Niamey, Niger
| | - Mamane Zeilani
- Nutriset SAS, Route du Bois Ricard, 76770 Malaunay, France
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50
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Bourassa MW, Osendarp SJM, 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 LÅ, 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] [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 Nutrition, Berkel & Rodenrijs, the Netherlands.,Division of Human Nutrition and Health, Wageningen University, Wageningen, the Netherlands
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Saima Ahmed
- The New York Academy of Sciences, New York, New York
| | - Clayton Ajello
- The Vitamin Angels Alliance, Inc., Santa Barbara, California
| | | | - Robert Black
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Parul Christian
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Bill & Melinda Gates Foundation, Seattle, Washington
| | - Simon Cousens
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Saskia de Pee
- Division of Human Nutrition and Health, Wageningen University, Wageningen, the Netherlands.,UN World Food Programme, Rome, Italy.,Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - Kathryn G Dewey
- Department of Nutrition, University of California, Davis, Davis, California
| | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Reina Engle-Stone
- Department of Nutrition, University of California, Davis, Davis, California
| | | | | | - John Hoddinott
- Division of Nutritional Sciences, Cornell University, Ithaca, New York
| | - Rolf Klemm
- The Vitamin Angels Alliance, Inc., Santa Barbara, California.,Helen Keller International, Baltimore, Maryland
| | | | | | | | - Sophie E Moore
- Department of Women and Children's Health, King's College London, London, United Kingdom
| | | | - Lars-Åke Persson
- London School of Hygiene and Tropical Medicine, Addis Ababa, Ethiopia
| | | | - Anuraj H Shankar
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Summit Institute of Development, Mataram, Indonesia
| | - Emily Smith
- Bill & Melinda Gates Foundation, Seattle, Washington.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Stephen A Vosti
- Department of Nutrition, University of California, Davis, Davis, California
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