Topics • Pregnancy Data • Intergenerational Nutritional Effects • Fetal Growth and Chronic Disease • Public Health Approaches to Nutrition and Pregnancy
Health, United States, 2002: www.cdc.gov/nchs/hus.htm • What does the pregnant/parenting population look like? • What have the trends been? • Who’s not having babies?
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
Emerging Understandings about Nutrition in Pregnancy • Periods of critical development are key when considering effects of nutrition in pregnancy. Undernutrition has different effects at different times of life. • 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
Emerging Understandings about Nutrition in Pregnancy (Coming Attractions….) • Pregnancy is a period of increased flexibility in metabolism and absorption of energy and nutrients.
Godfrey KM, Barker DJP, Robinson S, Osmond C. Mother's birthweight and diet in pregnancy in relation to the baby's thinness at birth. Br J Obstet Gynaecol 1997;104:663–7
Illinois StudyCoutinho et al. Am J Epi, 1997 146:804-809 • N=15,287 Black and 117,708 white matched pairs of infants and mothers. • Mothers were born between 1956-75, infants between 1989-1991
Results • Father’s birthweight had effect on infant birthweight but not as strong as mothers. • In multiple linear regression for infants who weighed more than 2500 g, parental birthweight accounted for 5% of variance among black infants and 4% among white infants. • (included parental age, years of schooling, matiral status and adequacy of prenatal care)
Results, cont. • Each 100 g increase in maternal birthweight was associated with 24-27 g increase in infant birthweight
Influence of Maternal Intrauterine & Childhood Nutrition on Outcomes of Pregnancy
Reproductive performance and nutrition during childhood Nutrition Reviews; Washington; Apr 1996; Martorell, Reynaldo; Ramakrishnan, Usha; Schroeder, Dirk G; Ruel, Marie;
Longitudinal Supplementation Trial (1969-1977) • Guatemala, 4 Villages, one pair of villages had about 900 people each and the other about 500 each. • 2 each randomized to: • Atole (Incaparina, a vegetable protein mix developed by INCAP*, dry skim milk, sugar, and flavoring, 163 kcal/cup, 11/5 g protein) • Fresco (flavored drink with sugar, vitamins and minerals, 59 kcal/cup) *Institute of Nutrition of Central America and Panama
Feeding center was open daily for over 7 years, from 1969 to 1977. • Anyone in the village could attend, but careful recording of consumption, including of additional servings as well as of leftovers, was done only for women who were pregnant or breastfeeding and for children 7 years or younger. • Supplements were available twice daily, in midmorning and midafternoon, so as not to interfere with meal times.
Conceptual framework “Malnutrition in early childhood constrains the future capacity of women to bear healthy newborns and their ability to feed and care for them, and through these mechanisms the growth and development of the next generation.”
Follow-Up data - 1990s • The prevalence of low birthweight is currently 12% in Atole villages (n = 65) and 28% in Fresco villages (n = 58) among women exposed to the supplements during the intrauterine period and the first 3 years of life. • Mean birthweights are 2.90 kg in Atole villages and 2.73 in Fresco villages.
Role of intergenerational effects on linear growth U Ramakrishnan; R Martorell; D G Schroeder; R Flores; The Journal of Nutrition; Bethesda; Feb 1999;
Methods • The sample was restricted to singleton, term (>37 wk of gestation) births that occurred in the four study villages between 1991 and 1996, to women who were born during the original longitudinal study (1969-1977) • Complete data were available for 215 mother-child pairs, and 60% of the mothers (n = 140)
Results • For every 100 g increase in maternal birth weight, her infant's birth weight increased by 29 g after adjusting for the effects of maternal age, gestational age and sex of the infant. This relationship was highly significant (P < 0.001) • For every centimeter increase in maternal birth length, her child's birth weight increased by 53 g.
Dutch Famine StudiesSusser and Stein, Nutrition Reviews, 1994 • Dutch famine winter lasted 6 months, from November 1944- when nazis imposed transport embargo on west Holland until- • May 7, 1945 when Holland was liberated from the occupation • Strong evidence for critical stages of development in several physiological systems
Affects of Famine • Fertility decreased • Maternal weight fell during pregnancy with famine exposure • Third trimester famine exposure had strong effect on birthweight • Third trimester famine exposure was associated with infant mortality at 30-90 days
Results for Infants Exposed to Famine • Excess central nervous system disorders (such as NTD) • Exposure early in gestation associated with excess obesity in young men (military records) and women • Famine exposure late in pregancy associated with less obesity in young adulthood • Famine exposure associated with twofold risk of schizophrenia in 50 year old women.
Second Generation • Modest association found in this cohort between birthweights of mothers and their offspring.
Prenatal exposure to famine and brain morphology in schizophrenia Hulshoff Pol HE; Hoek HW; Susser E; Brown AS; Dingemans A; Schnack HG; van Haren NE; Pereira Ramos LM; Gispen-de Wied CC; Kahn RS; American Journal of Psychiatry , Jul 2000;
Methods • Nine schizophrenic patients and nine healthy comparison subjects exposed during the first trimester of gestation to the Dutch Hunger Winter were evaluated with magnetic resonance brain imaging, as were nine schizophrenic patients and nine healthy subjects who were not prenatally exposed to the famine.
RESULTS: • Prenatal famine exposure in patients with schizophrenia was associated with decreased intracranial volume. • Prenatal Hunger Winter exposure alone was related to an increase in brain abnormalities, predominantly white matter hyperintensities.
Further evidence of relation between prenatal famine and major affective disorder. Alan S Brown; Jim van Os; Corine Driessens; Hans W Hoek; et al; The American Journal of Psychiatry; Washington; Feb 2000;
Methods • Compared the risk of major affective disorder requiring hospitalization in birth cohorts who were and were not exposed, in each trimester of gestation, to famine during the Dutch Hunger Winter of 1944-1945.
Results • The risk of developing major affective disorder requiring hospitalization was increased for subjects with exposure to famine in the second trimester and was increased significantly for subjects with exposure in the third trimester, relative to unexposed subjects.
Fetal Origins ConceptsBarker et al • Nutrition in early life has permanent effects • Undernutrition has different effects at different times of life. • Rapidly growing fetuses and neonates are vulnerable to undernutrition • Undernutrition results from inadequate maternal intake, transport, or transfer of nutrients.
Coronary heart disease death rates, expressed as standardized mortality ratios, in 10,141 men and 5585 women born in Hertfordshire, United Kingdom, from 1911 to 1930, according to birth weight. (Osmond C, Barker DJP, Winter PD, Fall CHD, Simmonds SJ. Early growth and death from cardiovascular disease in women. BMJ 1993;307:1519–24)
Catch-up growth in childhood and death from coronary heart disease: longitudinal study(Eriksson et al, BMJ, 1999) • Subjects: 3641 men born in Helsinki between 1924-1933 • Followed with school data for weight and height • Deaths from coronary heart disease from 1971-95 (standardized mortality ratios) were endpoints.
Catch-up growth in childhood and death from coronary heart disease: longitudinalstudy(Eriksson et al, BMJ, 1999 • Men who had low birth weight or were thin at birth have high death rates from coronary heart disease • Death rates are even higher if weight "catches up" in early childhood • Death from coronary heart disease may be a consequence of prenatal undernutrition followed by improved postnatal nutrition • Programs to reduce obesity among boys may need to focus on those who had low birth weight or who were thin at birth
Framework for understanding the maternal regulation of fetal development and programming. Keith M Godfrey and David JP Barker • (Fetal nutrition and adult diseaseAm J Clin Nutr 2000 71: 1344-1352)
Early Nutrition & Chronic Disease in Adulthood(Waterland& Garza, Am J Clin Nutr, 1999;69:179-97) • Epi studies: BMI, CVD, Htn, IGT • Animal studies • Potential mechanisms of metabolic imprinting
Obesity in Young Men after Famine Exposure in Utero and early Infancy(Ravelli et al NEJM, 1976) • N=300, 000 Dutch military inductees at age 19 • Famine exposure in first 2 trimesters lead to 80% higher prevalence of overweight (p<0.0005) • Famine exposure in last trimester or famine exposure in first 5 months of life associated with 40% lower prevalence of overweight (p<0.005)
BMI • The relationship between birth weight and BMI complicates studies of birth weight and chronic disease