Dietary supplementation of rural Gambian women during pregnancy does not affect body composition in offspring at 11-17 years of age

Effects of nutritional interventions during pregnancy on birth, child health and development outcomes: A systematic review of evidence from low- and middle-income countries

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the reference lists of included studies and relevant reviews and contacted the authors of studies for any ongoing and unpublished studies.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.

Early-Life Nutrition Interventions and Associated Long-Term Cardiometabolic Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Early-life nutrition interventions can have lifelong cardiometabolic benefits. Most evidence on this topic is derived from observational studies. We evaluated the association of randomized controlled nutritional trials in early life and long-term cardiometabolic outcomes. Through literature search of PubMed, CABI Global Health, Embase, and Cochrane, with manual reference check and weekly alert from PubMed, we identified 8312 records, and included 53 records from 40 cohorts in 21 countries. The total number of participants was 33,551. Interventions were initiated as early as conception, and the longest until 7 y (except 1 study from infancy to 20 y). The cohorts were followed up for between 3 and 73 y. We identified 7 types of interventions (protein-energy supplements, long-chain PUFAs, single micronutrient, multiple micronutrients, infant and young child feeding, dietary counseling, and other) and 4 categories of cardiometabolic outcomes (biomarkers, cardiovascular, body size and composition, and subclinical/clinical outcomes). Most findings were null. Fasting glucose concentration was 0.04 mmol/L lower (95% CI: -0.05, -0.02 mmol/L; I2 = 0%) in the intervention groups than in the control groups (15 studies). BMI (kg/m2) was 0.20 higher (95% CI: 0.12, 0.28; I2 = 54%) in the intervention groups than control groups (14 studies). No significant effect was observed for total cholesterol (12 studies) or blood pressure (17 studies). Ongoing and personalized dietary counseling was associated with lower glucose and cholesterol, better endothelial function, and reduced risk of metabolic syndrome. The timing of intervention mattered, with earlier initiation conferring greater benefit (improved lipid profile and marginally lower glucose concentration) based on 2 studies. In sum, glucose concentration was lower following early-life nutrition interventions, but there is a risk of unintended consequences, including higher BMI. Maternal and child nutrition interventions must be evidence-based and tailored to each population to promote long-term cardiometabolic health.

Maternal and Infant Lipid-Based Nutritional Supplementation Increases Height of Ghanaian Children at 4-6 Years Only if the Mother Was Not Overweight Before Conception

BACKGROUND

Few studies have evaluated the long-term effects of nutritional supplementation during the first 1000 d of life. We previously reported that maternal and child lipid-based nutrient supplements (LNS) increased child length by 18 mo.

OBJECTIVE

The aim of this study was to examine the effects of LNS on later growth and body composition at 4-6 y of age.

DESIGN

This was a follow-up of children in the International Lipid-based Nutrient Supplements (iLiNS)-DYAD trial in Ghana. Women (n = 1320) at ≤20 weeks of gestation were randomly assigned to: 1) iron and folic acid during pregnancy and 200 mg calcium/d for 6 mo postpartum, 2) multiple micronutrients (1-2 RDA of 18 vitamins and minerals) during both periods, or 3) maternal LNS during both periods plus child LNS from 6 to 18 mo. At 4-6 y, we compared height, height-for-age z score (HAZ), and % body fat (deuterium dilution method) between the LNS group and the 2 non-LNS groups combined.

RESULTS

Data were available for 961 children (76.5% of live births). There were no significant differences between LNS compared with non-LNS groups in height [106.7 compared with 106.3 cm (mean difference, MD, 0.36; P = 0.226)], HAZ [-0.49 compared with -0.57 (MD = 0.08; P = 0.226)], stunting (< -2 SD) [6.5 compared with 6.3% (OR = 1.00; P = 0.993)], or % body fat [15.5 compared with 15.3% (MD = 0.16; P = 0.630)]. However, there was an interaction with maternal prepregnancy BMI (kg/m2) (P-interaction = 0.046 before correction for multiple testing): among children of women with BMI < 25 , LNS children were taller than non-LNS children (+1.1 cm, P = 0.017), whereas there was no difference among children of women with BMI ≥ 25 (+0.1 cm; P = 0.874).

CONCLUSIONS

There was no overall effect of LNS on height at 4-6 y in this cohort, which had a low stunting rate, but height was greater in the LNS group among children of nonoverweight/obese women. There was no adverse impact of LNS on body composition. This trial was registered at clinicaltrials.gov as NCT00970866.

Early life nutritional programming of health and disease in The Gambia

Exposures during the early life (periconceptional, prenatal and early postnatal) period are increasingly recognized as playing an important role in the aetiology of chronic non-communicable diseases (NCD), including coronary heart disease, stroke, hypertension, Type 2 diabetes and osteoporosis. The 'Developmental Origins of Health and Disease' (DOHaD) hypothesis states that these disorders originate through unbalanced nutrition early in life and risk is highest when there is a 'mismatch' between the early- and later-life environments. Thus, the DOHaD hypothesis would predict highest risk in countries where an excess of infants are born with low birth weight and where there is a rapid transition to nutritional adequacy or excess in adulthood. Here, I will review data from work conducted in rural Gambia, West Africa. Using demographic data dating back to the 1940s, the follow-up of randomized controlled trials of nutritional supplementation in pregnancy and the 'experiment of nature' that seasonality in this region provides, we have investigated the DOHaD hypothesis in a population with high rates of maternal and infant under-nutrition, a high burden from infectious disease, and an emerging risk of NCDs.

Antenatal dietary education and supplementation to increase energy and protein intake

BACKGROUND

Gestational weight gain is positively associated with fetal growth, and observational studies of food supplementation in pregnancy have reported increases in gestational weight gain and fetal growth.

OBJECTIVES

To assess the effects of education during pregnancy to increase energy and protein intake, or of actual energy and protein supplementation, on energy and protein intake, and the effect on maternal and infant health outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015), reference lists of retrieved studies and contacted researchers in the field.

SELECTION CRITERIA

Randomised controlled trials of dietary education to increase energy and protein intake, or of actual energy and protein supplementation, during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors independently extracted data and checked for accuracy. Extracted data were supplemented by additional information from the trialists we contacted.

MAIN RESULTS

We examined 149 reports corresponding to 65 trials. Of these trials, 17 were included, 46 were excluded, and two are ongoing. Overall, 17 trials involving 9030 women were included. For this update, we assessed methodological quality of the included trials using the standard Cochrane criteria (risk of bias) and the GRADE approach. The overall risk of bias was unclear. Nutritional education (five trials, 1090 women) Women given nutritional education had a lower relative risk of having a preterm birth (two trials, 449 women) (risk ratio (RR) 0.46, 95% CI 0.21 to 0.98, low-quality evidence), and low birthweight (one trial, 300 women) (RR 0.04, 95% CI 0.01 to 0.14). Head circumference at birth was increased in one trial (389 women) (mean difference (MD) 0.99 cm, 95% CI 0.43 to 1.55), while birthweight was significantly increased among undernourished women in two trials (320 women) (MD 489.76 g, 95% CI 427.93 to 551.59, low-quality evidence), but did not significantly increase for adequately nourished women (MD 15.00, 95% CI -76.30 to 106.30, one trial, 406 women). Protein intake increased significantly (three trials, 632 women) (protein intake: MD +6.99 g/day, 95% CI 3.02 to 10.97). No significant differences were observed on any other outcomes such as neonatal death (RR 1.28, 95% CI 0.35 to 4.72, one trial, 448 women, low-quality evidence), stillbirth (RR 0.37, 95% CI 0.07 to 1.90, one trial, 431 women, low-quality evidence), small-for-gestational age (RR 0.97, 95% CI 0.45 to 2.11, one trial, 404 women, low-quality evidence) and total gestational weight gain (MD -0.41, 95% CI -4.41 to 3.59, two trials, 233 women). There were no data on perinatal death. Balanced energy and protein supplementation (12 trials, 6705 women)Risk of stillbirth was significantly reduced for women given balanced energy and protein supplementation (RR 0.60, 95% CI 0.39 to 0.94, five trials, 3408 women, moderate-quality evidence), and the mean birthweight was significantly increased (random-effects MD +40.96 g, 95% CI 4.66 to 77.26, Tau² = 1744, I² = 44%, 11 trials, 5385 women, moderate-quality evidence). There was also a significant reduction in the risk of small-for-gestational age (RR 0.79, 95% CI 0.69 to 0.90, I² = 16%, seven trials, 4408 women, moderate-quality evidence). No significant effect was detected for preterm birth (RR 0.96, 95% CI 0.80 to 1.16, five trials, 3384 women, moderate-quality evidence) or neonatal death (RR 0.68, 95% CI 0.43 to 1.07, five trials, 3381 women, low-quality evidence). Weekly gestational weight gain was not significantly increased (MD 18.63, 95% CI -1.81 to 39.07, nine trials, 2391 women, very low quality evidence). There were no data reported on perinatal death and low birthweight. High-protein supplementation (one trial, 1051 women)High-protein supplementation (one trial, 505 women), was associated with a significantly increased risk of small-for-gestational age babies (RR 1.58, 95% CI 1.03 to 2.41, moderate-quality evidence). There was no significant effect for stillbirth (RR 0.81, 95% CI 0.31 to 2.15, one trial, 529 women), neonatal death (RR 2.78, 95% CI 0.75 to 10.36, one trial, 529 women), preterm birth (RR 1.14, 95% CI 0.83 to 1.56, one trial, 505 women), birthweight (MD -73.00, 95% CI -171.26 to 25.26, one trial, 504 women) and weekly gestational weight gain (MD 4.50, 95% CI -33.55 to 42.55, one trial, 486 women, low-quality evidence). No data were reported on perinatal death. Isocaloric protein supplementation (two trials, 184 women)Isocaloric protein supplementation (two trials, 184 women) had no significant effect on birthweight (MD 108.25, 95% CI -220.89 to 437.40) and weekly gestational weight gain (MD 110.45, 95% CI -82.87 to 303.76, very low-quality evidence). No data reported on perinatal mortality, stillbirth, neonatal death, small-for-gestational age, and preterm birth.

AUTHORS' CONCLUSIONS

This review provides encouraging evidence that antenatal nutritional education with the aim of increasing energy and protein intake in the general obstetric population appears to be effective in reducing the risk of preterm birth, low birthweight, increasing head circumference at birth, increasing birthweight among undernourished women, and increasing protein intake. There was no evidence of benefit or adverse effect for any other outcome reported.Balanced energy and protein supplementation seems to improve fetal growth, and may reduce the risk of stillbirth and infants born small-for-gestational age. High-protein supplementation does not seem to be beneficial and may be harmful to the fetus. Balanced-protein supplementation alone had no significant effects on perinatal outcomes.The results of this review should be interpreted with caution. The risk of bias was either unclear or high for at least one category examined in several of the included trials, and the quality of the evidence was low for several important outcomes. Also, as the anthropometric characteristics of the general obstetric population is changing, those developing interventions aimed at altering energy and protein intake should ensure that only those women likely to benefit are included. Large, well-designed randomised trials are needed to assess the effects of increasing energy and protein intake during pregnancy in women whose intake is below recommended levels.

Vitamin D binding protein genotype is associated with plasma 25OHD concentration in West African children

Vitamin D is well known for its role in promoting skeletal health. Vitamin D status is determined conventionally by circulating 25-dihydroxyvitamin D (25OHD) concentration. There is evidence indicating that circulating 25OHD concentration is affected by variation in Gc, the gene encoding the vitamin D binding protein (DBP). The composite genotype of two single nucleotide polymorphisms (rs7041 and rs4588) results in different DBP isotypes (Gc1f, Gc1s and Gc2). The protein configurational differences among DBP isotypes affect DBP substrate binding affinity. The aims of this study were to determine 1) Gc variant frequencies in a population from an isolated rural region of The Gambia, West Africa (n=3129) with year-round opportunity for cutaneous vitamin D synthesis and 2) the effects of Gc variants on 25OHD concentration (n=237) in a genetically representative sub-group of children (mean (SD) age: 11.9 (4.8) years). The distribution of Gc variants was Gc1f: 0.86, Gc1s: 0.11 and Gc2: 0.03. The mean (SD) concentration of 25OHD was 59.6 (12.9) nmol/L and was significantly higher in those homozygous for Gc1f compared to other Gc variants (60.7 (13.1) vs. 56.6 (12.1) nmol/L, P=0.03). Plasma 25OHD and 1,25(OH)2D concentration was significantly associated with parathyroid hormone in Gc1f-1f but not in the other Gc variants combined. This study demonstrates that different Gc variants are associated with different 25OHD concentrations in a rural Gambian population. Gc1f-1f, thought to have the highest affinity for 25OHD, had the highest 25OHD concentration compared with lower affinity Gc variants. The considerable difference in Gc1f frequency observed in Gambians compared with other non-West African populations and associated differences in plasma 25OHD concentration, may have implications for the way in which vitamin D status should be interpreted across different ancestral groups.

Nutritional influences over the life course on lean body mass of individuals in developing countries

The double burden of childhood undernutrition and adult-onset adiposity in transitioning societies poses a significant public health challenge. The development of suboptimal lean body mass (LBM) could partly explain the link between these two forms of malnutrition. This review examines the evidence on both the role of nutrition in “developmental programming” of LBM and the nutritional influences that affect LBM throughout the life course. Studies from developing countries assessing the relationship of early nutrition with later LBM provide important insights. Overall, the evidence is consistent in suggesting a positive association of early nutritional status (indicated by birth weight and growth during first 2 years) with LBM in later life. Evidence on the impact of maternal nutritional supplementation during pregnancy on later LBM is inconsistent. In addition, the role of nutrients (protein, zinc, calcium, vitamin D) that can affect LBM throughout the life course is described. Promoting optimal intakes of these important nutrients throughout the life course is important for reducing childhood undernutrition as well as for improving the LBM of adults.

The association of early life supplemental nutrition with lean body mass and grip strength in adulthood: evidence from APCAPS

In the present study, we examined the associations of early nutrition with adult lean body mass (LBM) and muscle strength in a birth cohort that was established to assess the long-term impact of a nutrition program. Participants (n = 1,446, 32% female) were born near Hyderabad, India, in 29 villages from 1987 to 1990, during which time only intervention villages (n = 15) had a government program that offered balanced protein-calorie supplementation to pregnant women and children. Participants’ LBM and appendicular skeletal muscle mass were measured using dual energy x-ray absorptiometry; grip strength and information on lifestyle indicators, including diet and physical activity level, were also obtained. Ages (mean = 20.3 years) and body mass indexes (weight (kg)/height (m)²; mean = 19.5) of participants in 2 groups were similar. Current dietary energy intake was higher in the intervention group. Unadjusted LBM and grip strength were similar in 2 groups. After adjustment for potential confounders, the intervention group had lower LBM (β = −0.75; P = 0.03), appendicular skeletal muscle mass, and grip strength than did controls, but these differences were small in magnitude (<0.1 standard deviation). Multivariable regression analyses showed that current socioeconomic position, energy intake, and physical activity level had a positive association with adult LBM and muscle strength. This study could not detect a “programming” effect of early nutrition supplementation on adult LBM and muscle strength.

Endocrine responses, weight change, and energy sparing mechanisms during Ramadan among Gambian adolescent women

OBJECTIVES

Ramadan fasting imposes a diurnal rather than a chronic energetic challenge. When Ramadan occurs during the agricultural season in subsistence populations, diurnal and chronic effects combine. The impact of layered energetic challenges on adolescent activity, metabolism, and body composition have not been quantified. This study compares the effects of a Ramadan (30 July-3 October 2009) and subsequent non-Ramadan (14 July-12 August 2010) agricultural season in 67 Gambian subsistence agriculturalist women between 14 and 20 years old.

METHODS

Researchers collected body composition, anthropometric, metabolic, and activity data. Metabolic hormones were measured in weekly urine (C-peptide of insulin) and serum (leptin). Energy expenditure was estimated from heart rate calibrated for oxygen consumption.

RESULTS

Participants lost more weight (Wald Chi-square 8.7, P < 0.01) and lean mass (Wald Chi-square 4.7, P < 0.05) in Ramadan than in the non-Ramadan agricultural season. Energy expenditure was lower (Wald Chi-square 11.2, P = 0.001) and there was a negative correlation between resting metabolic rate and energy expenditure in activity (R(2)  = 0.097, F = 5.366, P = 0.025) during Ramadan. Leptin and C-peptide were higher during Ramadan (Wald Chi-square 53.7, P < 0.001 and Wald Chi-square 15.0, P < 0.001).

CONCLUSIONS

Even using energy sparing behaviors, adolescent women enter negative energy balance when Ramadan and the agricultural season co-occur. Metabolic physiology shows a transient response to high glycemic index foods consumed at night. Older and larger individuals sustain greater losses during Ramadan.

Supplemental feeding during pregnancy compared with maternal supplementation during lactation does not affect schooling and cognitive development through late adolescence

BACKGROUND

The long-term impact of early malnutrition on human capital outcomes remains unclear, and existing evidence has come largely from observational studies.

OBJECTIVE

We compared the impact of a nutritional supplement given during pregnancy or lactation in rural Gambia on educational performance and cognitive ability in offspring at their maturity.

DESIGN

This study was a follow-up of a randomized trial of prenatal high protein and energy supplementation conducted between 1989 and 1994. Subjects were 16-22 y of age at follow-up, and information was collected on schooling achievement and cognitive ability by using the Raven's progressive matrices test, Mill Hill vocabulary test, and forward and backward digit-span tests.

RESULTS

A total of 1459 individuals were traced and interviewed and represented 71% of the original cohort and 81% of the surviving cohort. There was no difference in cognitive ability or educational attainment between treatment groups by using any of the methods of assessment.

CONCLUSION

We have shown little evidence to support a long-term effect of prenatal protein-energy supplementation compared with supplementation during lactation on cognitive development in rural Gambians. This trial was registered at http://www.controlled-trials.com as ISRCTN72582014.

Effects of pre- and postnatal nutrition interventions on child growth and body composition: the MINIMat trial in rural Bangladesh

BACKGROUND

Nutritional insults and conditions during fetal life and infancy influence subsequent growth and body composition of children.

OBJECTIVES

Effects of maternal food and micronutrient supplementation and exclusive breastfeeding counseling on growth of offspring aged 0-54 months and their body composition at 54 months of age were studied.

METHODS

In the MINIMat trial (ISRCTN16581394) in Matlab, Bangladesh, pregnant women were randomized to early (around 9 weeks) or usual invitation (around 20 weeks) to food supplementation and to one of the three daily micronutrient supplements: 30-mg Fe and 400-µg folic acid (Fe30F), 60-mg Fe and 400-µg folic acid (Fe60F), and multiple micronutrient supplements (MMS). The supplements were also randomized to exclusive breastfeeding (EBF) counseling or to usual health messages.

RESULTS

No differences in background characteristics were observed among the intervention groups. There was also no differential effect of prenatal interventions on birthweight or birthlength. Early food supplementation reduced the level of stunting from early infancy up to 54 months of age among boys (average difference - 6.5% units, 95% confidence interval [CI] 1.7-11.3, p=0.01) but not among girls (average difference - 2.4% units, 95% CI -2.2-7.0, p=0.31). MMS resulted in more stunting compared to standard Fe60F (average difference - 4.8% units, 95% CI 0.8-8.9, p=0.02). Breastfeeding counseling prolonged the duration of EBF (difference - 35 days, 95% CI 30.6-39.5, p<0.001). Neither pregnancy interventions nor breastfeeding counseling influenced the body composition of children at 54 months of age.

CONCLUSION

Early food supplementation during pregnancy reduced the occurrence of stunting among boys aged 0-54 months, while prenatal MMS increased the proportion of stunting. Food and micronutrient supplementation or EBF intervention did not affect body composition of offspring at 54 months of age. The effects of prenatal interventions on postnatal growth suggest programming effects in early fetal life.

Prediction of fat-free mass using bioelectrical impedance analysis in young adults from five populations of African origin

BACKGROUND/OBJECTIVES

Bioelectrical impedance analysis (BIA) is used in population and clinical studies as a technique for estimating body composition. Because of significant under-representation in existing literature, we sought to develop and validate predictive equation(s) for BIA for studies in populations of African origin.

SUBJECTS/METHODS

Among five cohorts of the Modeling the Epidemiologic Transition Study, height, weight, waist circumference and body composition, using isotope dilution, were measured in 362 adults, ages 25-45 with mean body mass indexes ranging from 24 to 32. BIA measures of resistance and reactance were measured using tetrapolar placement of electrodes and the same model of analyzer across sites (BIA 101Q, RJL Systems). Multiple linear regression analysis was used to develop equations for predicting fat-free mass (FFM), as measured by isotope dilution; covariates included sex, age, waist, reactance and height(2)/resistance, along with dummy variables for each site. Developed equations were then tested in a validation sample; FFM predicted by previously published equations were tested in the total sample.

RESULTS

A site-combined equation and site-specific equations were developed. The mean differences between FFM (reference) and FFM predicted by the study-derived equations were between 0.4 and 0.6 kg (that is, 1% difference between the actual and predicted FFM), and the measured and predicted values were highly correlated. The site-combined equation performed slightly better than the site-specific equations and the previously published equations.

CONCLUSIONS

Relatively small differences exist between BIA equations to estimate FFM, whether study-derived or published equations, although the site-combined equation performed slightly better than others. The study-derived equations provide an important tool for research in these understudied populations.

The adolescent transition under energetic stress: Body composition tradeoffs among adolescent women in The Gambia

BACKGROUND AND OBJECTIVES

Life history theory predicts a shift in energy allocation from growth to reproductive function as a consequence of puberty. During adolescence, linear growth tapers off and, in females, ovarian steroid production increases. In this model, acquisition of lean mass is associated with growth while investment in adiposity is associated with reproduction. This study examines the chronological and developmental predictors of energy allocation patterns among adolescent women under conditions of energy constraint.

METHODOLOGY

Fifty post-menarcheal adolescent women between 14 and 20 years old were sampled for weight and body composition at the beginning and end of 1 month in an energy-adequate season and 1 month in the subsequent energy-constrained season in a rural province of The Gambia.

RESULTS

Chronologically and developmentally younger adolescent girls gain weight in the form of lean mass in both energy-adequate and energy-constrained seasons, whereas older adolescents lose lean mass under conditions of energetic stress (generalized estimating equation (GEE) Wald chi-square comparing youngest tertile with older two tertiles 9.750, P = 0.002; GEE Wald chi-square comparing fast- with slow-growing individuals for growth rate 19.806, P < 0.001). When energy is limited, younger adolescents lose and older adolescents maintain fat (GEE Wald chi-square for interaction of age and season 6.568, P = 0.010; GEE Wald chi-square comparing fast- with slow-growing individuals for interaction of growth rate and season 7.807, P = 0.005).

CONCLUSIONS AND IMPLICATIONS

When energy is constrained, the physiology of younger adolescents invests in growth while that of older adolescent females privileges reproductively valuable adipose tissue.

Early invitation to food and/or multiple micronutrient supplementation in pregnancy does not affect body composition in offspring at 54 months: follow-up of the MINIMat randomised trial, Bangladesh

Growth patterns in early life are associated with later health. The effect of nutrition during in utero development on later body composition is unclear. We evaluated whether prenatal early invitation to food and/or multiple micronutrient supplementation (MMS) in pregnancy has an effect on offspring body composition at 54 months of age. In Maternal and Infant Nutrition Interventions in Matlab trial (ISRCTN16581394) in Bangladesh, 4436 pregnant women were randomised into six equally sized groups: double-masked supplementation with capsules of either 30 mg Fe and 400 μg folic acid, or 60 mg Fe and 400 μg folic acid, or MMS (15 micronutrients), was combined with a randomised early invitation (around 9 weeks) or a usual invitation (around 20 weeks) to start food supplementation (608 kcal 6 days per week). At 54 months, the body composition of the offspring was assessed by leg-to-leg bioelectrical impedance analysis. Of the 3267 live singletons with birth anthropometry, 2290 children were measured at 54 months, representing 70% of the live births. There was no interaction between the food and micronutrient supplementation on body composition outcomes. There were no significant differences in a range of anthropometric and body composition measurements, including weight, height, mid-upper arm circumference, head circumference, skinfold thickness, and fat mass and fat-free mass between the different prenatal food and micronutrient groups using an intention-to-treat analysis. This analysis shows that early invitation to food supplementation and MMS provided to rural Bangladeshi women during pregnancy did not affect offspring body composition at 54 months of age.

Antenatal dietary advice and supplementation to increase energy and protein intake

BACKGROUND

Gestational weight gain is positively associated with fetal growth, and observational studies of food supplementation in pregnancy have reported increases in gestational weight gain and fetal growth.

OBJECTIVES

To assess the effects of advice during pregnancy to increase energy and protein intake, or of actual energy and protein supplementation, on energy and protein intakes, and the effect on maternal and infant health outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (22 July 2011) and contacted researchers in the field. We updated the search on 12 July 2012 and added the results to the awaiting classification section of the review.

SELECTION CRITERIA

Randomised controlled trials of dietary advice to increase energy and protein intake, or of actual energy and protein supplementation, during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors independently extracted data and checked for accuracy. Extracted data were supplemented by additional information from the trialists we contacted.

MAIN RESULTS

We examined 110 reports corresponding to 46 trials. Of these trials, 15 were included, 30 were excluded, and one is ongoing. Overall, 15 trials involving 7410 women were included.Nutritional advice (four trials, 790 women)Women given nutritional advice had a lower relative risk of having a preterm birth (two trials, 449 women) (risk ratio (RR) 0.46, 95% CI 0.21 to 0.98 ), head circumference at birth was increased in one trial (389 women) (mean difference (MD) 0.99 cm, 95% CI 0.43 to 1.55) and protein intake increased (three trials, 632 women) (protein intake: MD +6.99 g/day, 95% CI 3.02 to 10.97). No significant differences were observed on any other outcomes.Balanced energy and protein supplementation (11 trials, 5385 women)Risk of stillbirth was significantly reduced for women given balanced energy and protein supplementation (RR 0.62, 95% CI 0.40 to 0.98, five trials, 3408 women), mean birthweight was significantly increased (random-effects MD +40.96 g, 95% CI 4.66 to 77.26 , Tau(2)= 1744, I(2) = 44%, 11 trials, 5385 women). There was also a significant reduction in the risk of small-for-gestational age (RR 0.79, 95% CI 0.69 to 0.90, I(2) = 16%, seven trials, 4408 women). No significant effect was detected for preterm birth or neonatal death.High-protein supplementation (one trial, 1051 women)High-protein supplementation (one trial, 505 women), was associated with a significantly increased risk of small-for-gestational age babies (RR 1.58, 95% CI 1.03 to 2.41).Isocaloric protein supplementation (two trials, 184 women)Isocaloric protein supplementation (two trials,184 women) had no significant effect on birthweight and weekly gestational weight gain.

AUTHORS' CONCLUSIONS

This review provides encouraging evidence that antenatal nutritional advice with the aim of increasing energy and protein intake in the general obstetric population appears to be effective in reducing the risk of preterm birth, increasing head circumference at birth and increasing protein intake, there was no evidence of benefit or adverse effect for any other outcome reported.Balanced energy and protein supplementation seems to improve fetal growth, and may reduce the risk of stillbirth and infants born small-for-gestational age. High-protein supplementation does not seem to be beneficial and may be harmful to the fetus. Balanced-protein supplementation alone had no significant effects on perinatal outcomes.The results of this review should be interpreted with caution, the risk of bias was either unclear or high for at least one category examined in several of the included trials and the quality of the evidence was low for several important outcomes. Also the anthropometric characteristics of the general obstetric population is changing, therefore, those developing interventions aimed at altering energy and protein intake should ensure that only those women likely to benefit are included. Large, well designed randomised trials are needed to assess the effects of increasing energy and protein intake during pregnancy in women whose intake is below recommended levels.

Nutritional supplementation during pregnancy and offspring cardiovascular disease risk in The Gambia

BACKGROUND

Maternal nutritional intake during pregnancy may have important consequences for long-term health in offspring.

OBJECTIVE

The objective was to follow up the offspring in 2 randomized trials of nutrient supplementation during pregnancy to investigate the effect on cardiovascular disease (CVD) risk in offspring.

DESIGN

We recruited offspring born during 2 trials in The Gambia, West Africa. One trial provided protein-energy-dense food supplements (1015 kcal and 22 g protein/d) to pregnant (intervention, from 20 wk gestation until delivery) or lactating (control, for 20 wk from birth) women and was randomized at the village level. The second was a double-blind, individually randomized, placebo-controlled trial of calcium supplementation (1.5 g/d), which was also provided from 20 wk gestation until delivery.

RESULTS

Sixty-two percent (n = 1267) of children (aged 11-17 y) born during the protein-energy trial were recruited and included in the analysis, and 64% (n = 350) of children (aged 5-10 y) born during the calcium trial were recruited and included in the analysis. Fasted plasma glucose was marginally lower in children born to mothers receiving protein-energy supplements during pregnancy than in those children of the lactating group (adjusted mean difference: -0.05 mmol/L; 95% CI: -0.10, -0.001 mmol/L). There were no other differences in CVD risk factors, including blood pressure, body composition, and cholesterol, between children born to intervention and control women from the protein-energy trial. Maternal calcium supplementation during pregnancy was unrelated to offspring blood pressure.

CONCLUSION

These data suggest that providing supplements to pregnant women in the second half of pregnancy may have little effect on the CVD risk of their offspring, at least in this setting and at the ages studied here. This trial was registered at www.controlled-trials.com as ISRCTN96502494.

Evidence for the intra-uterine programming of adiposity in later life

AIM

Research in animals has shown that altering foetal nutrition by under-nourishing or over-nourishing the mother or rendering her diabetic or foetal exposure to glucocorticoids and toxins can programme obesity in later life. The increased adiposity is mediated by permanent changes in appetite, food choices, physical activity and energy metabolism. In humans, increased adiposity has been shown in people who experienced foetal under-nutrition due to maternal famine or over-nutrition due to maternal diabetes. Lower birth weight (a proxy for foetal under-nutrition) is associated with a reduced adult lean mass and increased intra-abdominal fat. Higher birth-weight caused by maternal diabetes is associated with increased total fat mass and obesity in later life. There is growing evidence that maternal obesity, without diabetes, is also a risk factor for obesity in the child, due to foetal over-nutrition effects. Maternal smoking is associated with an increased risk of obesity in the children, although a causal link has not been proven. Other foetal exposures associated with increased adiposity in animals include glucocorticoids and endocrine disruptors.

CONCLUSIONS

Reversing the current obesity epidemic will require greater attention to, and better understanding of, these inter-generational (mother-offspring) factors that programme body composition during early development.

Effect of maternal calcium supplementation on offspring blood pressure in 5- to 10-y-old rural Gambian children

BACKGROUND

Evidence suggests that increased maternal calcium intake during pregnancy may result in lower offspring blood pressure, prompting calls for more robust data in this field, particularly in settings of habitually low calcium intake.

OBJECTIVE

The objective was to investigate the effect of maternal calcium supplementation on blood pressure in offspring by recruiting children born after a randomized, double-blind, placebo-controlled trial of calcium supplementation during pregnancy.

DESIGN

Children (n = 389) from a rural area of The Gambia (mean age: 7.4 ± 1.2 y; range: 5-10 y), whose mothers received a calcium supplement (1500 mg Ca/d from 20 wk of gestation until delivery) or placebo, were followed up in West Africa. Blood pressure was assessed under standardized conditions with use of the Omron 705IT automated oscillometric device (Morton Medical Ltd, London, United Kingdom), and anthropometric and body composition (bioelectrical impedance) measurements were also made.

RESULTS

The analysis was restricted to 350 children born at term, which represented 64% of original trial births. There was no difference in systolic (adjusted mean difference: -0.04 mm Hg; 95% CI: -1.78, 1.69 mm Hg) or diastolic (adjusted mean difference: 0.25 mm Hg; 95% CI: -1.27, 1.77 mm Hg) blood pressure between children whose mothers had received calcium and those who received placebo. No interaction between childhood body mass index (in kg/m(2); mean: 14.0) and maternal calcium supplementation was observed in this study.

CONCLUSION

Calcium supplementation in the second half of pregnancy in Gambian women with very low habitual calcium intakes may not result in lower offspring blood pressure at 5-10 y of age.

Conference on "Multidisciplinary approaches to nutritional problems". Postgraduate Symposium. Exploiting dietary supplementation trials to assess the impact of the prenatal environment on CVD risk

Animal studies have demonstrated that altering the maternal diet during pregnancy affects offspring disease risk. Data from human subjects on the early-life determinants of disease have been derived primarily from birth-weight associations; studies of the impact of the maternal diet are scarce and inconsistent. Investigating CVD risk factors in the offspring of women who have participated in maternal supplementation trials provides a useful resource in this research field, by virtue of employing an experimental design (as compared with observational studies). To date, follow-up studies have been published only for a small number of trials; these trials include the impact of maternal protein-energy, multiple-micronutrient and Ca supplementation on offspring disease risk. In Nepal maternal micronutrient supplementation has been shown to be associated with lower offspring systolic blood pressure at 2 years of age. Data from Guatemala on a pre- and postnatal protein-energy community intervention have suggested long-term improvements in fasting glucose and body composition but not in blood pressure. In The Gambia no association has been found between prenatal protein-energy supplementation and markers of CVD risk including body composition, blood pressure and fasting glucose and insulin in childhood and adolescence. Little evidence of an effect of maternal Ca supplementation on offspring blood pressure has been demonstrated in four trials, although the risk of high systolic blood pressure was found to be reduced in one trial. The present paper reviews the current evidence relating maternal nutritional supplementation during pregnancy to offspring CVD risk and explores the potential explanations for the lack of association.

Energy and protein intake in pregnancy

BACKGROUND

Gestational weight gain is positively associated with fetal growth, and observational studies of food supplementation in pregnancy have reported increases in gestational weight gain and fetal growth.

OBJECTIVES

To assess the effects of advice to increase or reduce energy or protein intake, or of actual energy or protein supplementation or restriction, during pregnancy on energy and protein intakes, gestational weight gain, and the outcome of pregnancy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (October 2002) and contacted researchers in the field.

SELECTION CRITERIA

Acceptably controlled trials of dietary advice to increase or reduce energy or protein intake, or of actual energy or protein supplementation or restriction, during pregnancy.

DATA COLLECTION AND ANALYSIS

Data were extracted by the authors from published reports, and supplemented by additional information from trialists contacted by the authors.

MAIN RESULTS

In five trials involving 1134 women, nutritional advice to increase energy and protein intakes was successful in achieving those goals, but no consistent benefit was observed on pregnancy outcomes. In 13 trials involving 4665 women, balanced energy/protein supplementation was associated with modest increases in maternal weight gain and in mean birth weight, and a substantial reduction in risk of small-for-gestational-age (SGA) birth. These effects did not appear greater in undernourished women. No significant effects were detected on preterm birth, but significantly reduced risks were observed for stillbirth and neonatal death. In two trials involving 1076 women, high-protein supplementation was associated with a small, nonsignificant increase in maternal weight gain but a nonsignificant reduction in mean birthweight, a significantly increased risk of SGA birth, and a nonsignificantly increased risk of neonatal death. In 3 trials involving 966 women, isocaloric protein supplementation was also associated with an increased risk of SGA birth. In three trials involving 384 women, energy/protein restriction of pregnant women who were overweight or exhibited high weight gain significantly reduced weekly maternal weight gain and mean birth weight but had no effect on pregnancy-induced hypertension or pre-eclampsia.

REVIEWER'S CONCLUSIONS

Dietary advice appears effective in increasing pregnant women's energy and protein intakes but is unlikely to confer major benefits on infant or maternal health. Balanced energy/protein supplementation improves fetal growth and may reduce the risk of fetal and neonatal death. High-protein or balanced protein supplementation alone is not beneficial and may be harmful to the infant.Protein/energy restriction of pregnant women who are overweight or exhibit high weight gain is unlikely to be beneficial and may be harmful to the infant.