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Nutrition in early life and food security. HEALTH PROMOTION FORUM IN THE AMERICAS SANTIAGO, CHILE. OCTOBER 20 - 24, 2002. CENTRO LATINOAMERICANO DE PERINATOLOGIA Y DESARROLLO HUMANO (CLAP - OPS/OMS). Eduardo Bergel [email protected] CLAP AIM AND STRATEGIES.

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Nutrition in early life and food security l.jpg

Nutrition in early life and food security.

HEALTH PROMOTION FORUM IN THE AMERICAS

SANTIAGO, CHILE. OCTOBER 20 - 24, 2002

CENTRO LATINOAMERICANO DE

PERINATOLOGIA Y DESARROLLO

HUMANO (CLAP - OPS/OMS)

Eduardo Bergel

[email protected]


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CLAP AIM AND STRATEGIES

The aim of CLAP is to contribute to improve maternal, perinatal and infant health in Latin America and The Caribbean, through direct technical cooperation with the countries, research, and training of human resources.


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CLAP AIM AND STRATEGIES

  • Determine priorities in the region through efficient information systems and epidemiological surveillance.

  • Advocacy to promote quality of care through the implementation of effective, evidence based interventions.

  • Clinical research to Investigate original solutions for unsolved problems.

  • Train professionals to improve their capacities to perform these activities.

  • Inform and empower women to allow them to request the best care for them and their children.


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Definition of Food Security

  • Access by all people at all times to enough food for an active, healthy life. Food security includes:

    • The ready availability of nutritionally adequate and safe foods, and

    • An assured ability to acquire acceptable foods in socially acceptable ways (e.g., without resorting to emergency food supplies, scavenging, stealing or other coping strategies).

Life Sciences Research Organization. Core indicators of nutritional status for difficult-to-sample populations. J Nutr. 1990; 120 (suppl):1559-1600.


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Food Security and Age*

*Population based survey (n=9194) Iowa Dept. of Public Health (2000)


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Term

11.0

Symmetric

Term

2.0

Asymmetric

Preterm

Preterm

INCIDENCE AND COMPOSITION

OF LOW BIRTH WEIGHT (<2.500 g)

NEWBORNS IN DEVELOPED

AND DEVELOPING COUNTRIES

(1992-1995)

LBW (%)

Developed

Countries

Developing

Countries


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IUGR

1,100,000 per year

3170

Perinatal AIDS

206 newborns per year

0.6

South America

AIDS Incidence

7,640 cases per year

22

Infant deaths

215,000 per year

619

Perinatal deaths

293,000 per year

843

500

1500

2000

2500

3000

3500

1000

0

Rates per 1 million habitants


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Low birthweight in two generations by income in 1982


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10

8

6

4

2

0

3-12

12-24

24-36

36-48

48-60

60-72

72-84

Targeting nutrition interventions to young children: the window of opportunity for prevention

mm

Ht Δ per 100 Kcal of supplement

Window of opportunity

for actions to prevent

undernutrition

Age interval (month)

*Adjusted for : initial weight, morbidity, SES, sex and dietary intake

Source: Schroeder, Martorell, Rivera, et al , J. Nutr. 125: 1051S - 1059S, 1995


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In the 1980s a group of epidemiologists

from Southampton began investigating

why there was an extremely high incidence

of these “Western” diseases in areas of

relative social disadvantage (Northern

England)

The first thing that they noticed was that

the areas with high incidence of death from

cardiac disease were areas where there was

a high perinatal mortality rate ~50-70 years

ago.


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Their next “stroke of luck” was that in

some of these areas there were extremely

thorough records kept by midwives and

health visitors

These included:

birth weight, length and head circumference

placental weight

weight and height at 1 year


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RR

1.0

Hertfordshire

Sheffield

USA

Uppsala

0.8

0.6

0.4

< 2500 3000 3500 4000 4500

grams

Birth weight and risk of cardiac disease


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The “fetal origins’ hypothesis

“Coronary heart disease is associated with

specific patterns of disproportionate fetal

growth that result from fetal undernutrition

in middle to late gestation”


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Adult mortality according to season at birth

Gambia (n = 3162)


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Birth weight and blood pressure, by age at assessment.

Systematic review


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Nutrient deprivation

Radiation

Heavy alcohol use

Heavy metals

Cigarette smoke

Note also that nutrition in the immediate post-partum has profound effects on long-term health

Breastfeeding:

Cognitive function

Obesity

Cardiovascular dx

Birthweight has now been associated with:

Cardiovascular disease

Heart disease

Hypertension

Stroke

Mental health

Anti-social personality disorder

Cognitive/behavioral problems

Reproductive health

Infertility

Marriage

Diabetes

Birthweight of next generation

Fetal exposures with long-term effects


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Thrifty Phenotype Hypothesis

Hales and Barker, Diabetologia 35: 595 (1992)

Phillips, Diabetes Care 21 (2S): 150B (1998)

This hypothesis argues that in response to

“hard times”, the fetus makes a series of

metabolic adaptations to survive. These

adaptations, or their effects, persist into

adult life and result in insulin resistance,

hypertension etc. when other environmental

factors (obesity, inactivity) come into play.


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Experimental evidence

  • Not really been tested-difficult to do

Fetal

Growth/

metabolism

Nutrition

intervention

In pregnancy

Long-term

growth monitoring

and follow-up for

disease

Randomize

pregnant

women

Usual

care


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Does birthweight measure fetal nutrition?

  • Birthweight represents both fetal growth and length of gestation

  • Fetal growth seems to be protected under quite adverse circumstances

  • Role of micronutrients may be quite different from that of macronutrients


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Micronutrient deficiencies

  • Iron

  • Zinc

  • Vitamin A

  • Folic acid


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Guatemala

High prevalence of known risk factors for pre-eclampsia

Low incidence of the disease.

High dietary calcium intake.

Belizán JM, Villar J. The relationship between calcium intake and edema-proteinuria and hypertension-gestosis: a hypotheses. Am J Clin Nutr. 1980; 33:2202-2210.


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REGION

CALCIO (mg)

Daily dietary calcium intake, by region(FAO, 1990)

World

472

Developed countries

860

Developing countries

346

Africa

363

Latin America

499

Asia

498

Others

402


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Daily dietary calcium intake, pregnant women attending public hospitals, Rosario, Argentina.

Calcium intake %

mg/day Frequency Cumulative

------------------------------------------

0 121 30.9

10 a 90 36 40.1

100 a 190 74 58.9

200 a 290 54 72.7

300 a 390 39 82.7

400 a 490 19 87.5

500 a 590 14 91.1

600 a 690 13 94.4

700 a 790 4 95.4

800 a 890 1 95.7

900 a 990 4 96.7

1000 a 1100 5 98.0

1100 a 1190 1 98.2

>1200 7 100.0


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In this population, 98 % of women attending antenatal care in the public sector do not reach the recommended amount of dietary calcium intake (>1200 mg/day)

*Optimal Calcium Intake. NIH Consensus Statement12,1 (1994).


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A

SORTEO

B

  • Embarazadas:

  • Primíparas

  • Control prenatal antes de las 20 semanas de gestación

  • Sin Patologías

2000 mg de Calcio

por dia

Placebo


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MADRE

Niño

(5-9 años)

Preclampsia

Salud bucal

(% con caries)

Calcio

2.5 %

63.6 %

11 %

34 %

27 %

51 %

4.0%

86.6 %

19 %

Placebo

Niño

(12-13 años)

Hipetension

arterial


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Calcium supplementation during pregnancy

Outcome: Pre-eclampsia

Risk

Reduction

%

Calcium

n/N

Placebo

n/N

Peto OR

(95% CI Fixed)

Peto OR

(95%CI Fixed)

Study

Adequate calcium diet(900 mg/d)

CPEP 1997

Villar 1987

Villar 1990

Subtotal (95%CI)

158 / 2163

1 / 25

0 / 90

159 / 2278

168 / 2173

3 / 27

3 / 88

174 / 2288

6

63

87

9

0.94 (0.75, 1.18)

0.37 (0.05, 2.38)

0.13 (0.01, 1.26)

0.91 (0.73, 1.14)

Low calcium diet(<900 mg/day)

15 / 579

2 / 55

0 / 22

4 / 125

2 / 97

4 / 29

27 / 907

23 / 588

12 / 51

8 / 34

21 / 135

11 / 93

15 / 34

90 / 935

34

82

85

76

78

76

68

0.66 (0.34, 1.26)

0.18 (0.06, 0.55)

0.15 (0.03, 0.69)

0.24 (0.11, 0.55)

0.22 (0.07, 0.67)

0.24 (0.08, 0.71)

0.32 (0.22, 0.47)

Belizán 1991

L-Jaramillo 1989

L-Jaramillo 1990

L-Jaramillo 1997

Purwar 1996

S-Ramos 1994

Subtotal (95% CI)

Total /95%CI)

186 / 3185

264 / 32223

30

0.70 (0.58, 0.85)

.5

.7

1

1.5

2


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Differential

calcium diet

Normal

calcium diet

Double (n= 32)

2 pups for each rat

n= 40

98 virgin rats

Normal (n= 33)

n= 37

n= 42

Low (n= 32)

52

weeks

4

weeks

Pregnancy

Lactation

Monthy blood pressure measurements

20 weeks

of age

Weaning

Mating

Birth


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mm Hg

+1 SE

124

Maternal low

calcium diet

122

-1 SE

120

12.1 mmHg

(8.8 to 15.4)

p< 0.0001

118

116

114

112

+1 SE

Maternal normal

calcium diet

110

-1 SE

108

106

0

4

8

12

16

20

24

28

32

36

40

44

48

52

56

Age (Weeks)


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Experimental evidence

Fetal

Growth/

metabolism

Nutrition

Intervention

In pregnancy

Long-term

growth monitoring

and follow-up for

disease

Randomize

pregnant

women

Usual

care


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Emerging Understandings about Nutrition in Pregnancy:

  • Fetal nutritional status is affected by the intrauterine and childhood nutritional experiences of the mother

  • Maternal nutritional status at time of conception is an important determinant of outcomes

  • Intrauterine nutritional environment affects health and development of the fetus throughout life


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Emerging Understandings about Nutrition in Pregnancy

  • Societies transitioning from chronic malnutrition to access to high calorie foods are at high risk of chronic disease due to lasting effects of early nutritional status


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Implications

  • Increased attention to maternal nutrition.

  • Increased attention to smoking during pregnancy, breastfeeding.

  • Increased support for evidenced based, nutrition-related programs during pregnancy.

  • More research to evaluate the impact of nutritional intervention.


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