Outline: Background on birth outcomes and maternal nutrition MATERNAL NUTRITION OUTCOMES DIETARY INTAKES AND RELATED Micronutrient deficiencies Dietary intakes and assessments Dietary diversity and pregnancy outcomes Seminar on MIYCN ILSI SEA Region, Bangkok, Thailand July 24, 2017 Interventions: BCC, Parul Christian, SPONutrition Team Global Development supplementation, other 2014 Bill & Melinda Gates Foundation BORN TOO SMALL : 32 MILLION BABIES ARE BORN -FOR- THE FIRST 1000 DAYS OF LIFE : PREGNANCY - 2 Y OF AGE nd birthday offer a unique window of opportunity to shape healthier and more prosperous futures. The right nutrition during this 1,000 day window can have a profound www.thousanddays.org Anne CC et al; Lancet Global Health 2013 2014 Bill & Melinda Gates Foundation 2014 Bill & Melinda Gates Foundation
CONSEQUENCES OF SGA Annually, 6 m SGA births are associated with maternal short stature Increased (4-10 times) mortality in the neonatal period Impaired immune function through childhood leading to increased risk of diarrhea and pneumonia Neurocognitive effects: attention deficit, poor school performance Increased risk of childhood stunting Kozuki et al; J Nutr 2015 PREVALENCE OF SHORT STATURE IN WOMEN 15-49 Y MATERNAL BMI AND SGA BMI <18.5 kg/m2 8 cohorts; N=19,124 mothers Overall Adjusted RR 1.41 (1.24-1.60) Kozuki et al; J Nutr 2015
TRENDS IN LOW AND HIGH BMI PREVALENCE FOR WOMEN 20-49 Y Africa Other causes of SGA Asia Low weight gain during pregnancy (low energy/protein) Anemia, iron and other micronutrient deficiency Other nutrient deficiencies (n3 fatty acids, Ca) Non-nutritional causes: Teen pregnancy Americas/Caribbean Maternal infections (malaria, HIV, etc.) Life style (tobacco, others) Black et al, Lancet 2013 2014 Bill & Melinda Gates Foundation INTERGENERATIONAL CYCLE OF GROWTH FAILURE MICRONUTRIENT DEFICIENCIES Almost 2 billion individuals globally are estimated to have one or more micronutrient deficiencies Causes Poor quality diets Cultural factors Low bioavailability Illness, infection Seasonal variation in food availability Requirements are high during growth and in pregnancy Focus on pregnant women and young children : Deficiencies of micronutrients during pregnancy are associated with an increased risk of adverse birth outcomes and in young children with poor growth, health and development ACC/SCN 1992 2014 Bill & Melinda Gates Foundation
HIDDEN HUNGER INDEX AND CHANGE OVER TIME Ruel-Bergeron et al; PLosOne 2015 PREVALENCE OF ANEMIA IN PREGNANCY HIDDEN HUNGER IS LINKED TO THE HUMAN DEVELOPMENT INDEX AND GLOBAL HUNGER INDEX 13 14 PREVALENCE OF VITAMIN A DEFICIENCY IN PREGNANCY
PREVALENCE OF IODINE DEFICIENCY MICRONUTRIENTS DEFICIENCIES IN EARLY PREGNANCY IN NEPAL 61.1 60 40 40.3 39.8 40.2 37.4 31.8 32.8 28.3 20 11.1 13.9 0.7 0 (Jiang et al; J Nutr 2005) MICRONUTRIENT DEFICIENCIES IN EARLY PREGNANCY IN BANGLADESH DIETARY INTAKES OF PREGNANT WOMEN 60 47.8 40 35.1 37.5 30.6 23.3 21.7 20 2.9 4.6 2.4 0 Schulze et al; In preparation Lee et al; Pub Hlth Nutr 2012
Continued MEASURES OF DIETARY DIVERSITY FACTORS ASSOCIATED WITH DIETARY QUALITY AND IMPACT ON OUTCOMES Minimum Diet Diversity for Women (MDD-W) by FAO/FANTA: Dichotomous indicator of whether women consumed 5 out of 10 specified food groups the previous day or night. It reflects micronutrient adequacy and can be easily included in surveys ( 10 food groups: grains, white roots and tubers, and plantains; pulses (beans, peas and lentils); nuts and seeds; dairy; meat, poultry and fish; eggs; dark green leafy vegetables; other vitamin a-rich fruits and vegetables; other vegetables; other fruits) Nutrient Adequacy Ratio (intake as % of RDA), Mean Adequacy Ratio (mean NAR across nutrients) The Alternate Healthy Eating Index (AHEI) is used in the US 23
HOUSEHOLD FOOD INSECURITY REDUCES MATERNAL DIETARY DIVERSITY Na et al; J Nutr 2016 SEASON IS ASSOCIATED WITH DIETARY QUALITY Campbell et al. J Hlth Pop Nutr 2016 25 MATERNAL DIET DURING PREGNANCY : PUNE MATERNAL NUTRITION STUDY DIETARY QUALITY AND KNOWLEDGE AMONG PREGNANT WOMEN IN BANGLADESH Never <1/wk 1+/wk >Alternate days 2800 2750 2700 2650 2600 2550 2500 2450 GLV Fruits Milk Intake at 28 wk Adj p<0.005 for GLV, p<0.1 for fruits, p<0.1 for milk Shamim et al; FNB 2016 27 Fall et al; J Nutr 2003 26
MILK CONSUMPTION AND BIRTH WEIGHT AMONG THE DANISH Olsen et al, AJCN 2007 PROTEIN, NOT FAT CONTENT OF DAIRY IS ASSOCIATED WITH BIRTH WEIGHT DIETARY DIVERSITY/QUALITY AND BIRTH OUTCOMES Outcome Region Study type LBW Ethiopia Diet Indicator /Method Exposure Effect Reference RR: 2.06 Zerfu et al (2016) Outcomes out of 9 Region SGA China India cross-sectional FAO individual dietary OR:0.43 diversity score (IDDS) (95% CI: 0.22 0.85), p=0.014 green leafy vegetables cluster analysis OR: 0.43 varied diet identified Birth Spain weight India green leafy vegetables 0.06 kg (95% CI:0.05, 0.20), Zealand Saaka et al (2012) quintile Association Reference OR 0.77 Lu et al (2016) definition cluster analysis identified varied diet Spain principal components traditional diet analysis OR: 0.86 Thomson et al (2010) (95% CI: 0.75, 0.99) Alternate Healthy Eating fourth vs first OR: 0.24 (95% CI: 0.10, Rodriguez-Bernal et al Index (AHEI) quintile 0.55), p for trend = 0.001 (2010) factor analysis: vegetables, OR 0.74 Knudsen et al (2008) fruits, poultry and fish vs. red (95% CI 0.64 0.86) Rao et al (2001) Denmark Lu et al (2016) and processed meat and p < 0.05 Alternate Healthy Eating fourth vs first Index (AHEI) Exposure (95% CI:0.57, 1.04), p=0.08 (95% CI: 0.12 to 0.99) China Diet Indicator /Method 30 (95% CI: 1.03, 4.11) New Ghana Study type SGA AND PTB definition score (WDDS) Olsen et al, AJCN 2007 29 high-fat diary groups 126.3 g (95% CI: 38.5, 213.9 Rodriguez-Bernal et al g) (2010) 19 g (95% CI: 8-30) Rao et al (2001) Courtesy Isabel Madzorera, PhD Intern, HSPH PTB Ethiopia WDDS RR: 4.61 out of 9 Norway 31 Prudent dietary pattern Zerfu et al (2016) (95% CI: 2.31, 9.19) HR: 0.88 Englund - Ögge, L. et al (95% CI: 0.80 to 0.97) (2014) Courtesy Isabel Madzorera, PhD Intern, HSPH 32
Recommended Total Weight Gain Ranges for Pregnant Women IOM 2009 Recommended Total Rate of weight Gain, lb gain in 2nd or 3rd BMI Category trimester, lb/wk Underweight 28-40 1.0 (1.0-1.3) (<18.5) 25-35 1.0 (0.8-1.0) Normal (18.5-24.9) 15-25 0.6 (0.5-0.7) High (25.0-29.0) 11-20 0.5 (0.4-0.6) IOM, 2009 IOM, Nutrition during pregnancy. 1990 MATERNAL FACTORS ASSOCIATED WITH BIRTH OUTCOMES IN RURAL NEPAL Kozuki et al; J Matern Fetal Neonatal Med 2014 WHO ANC GUIDELINES
BCC DURING PREGNANCY NEED FOR GUIDING PRINCIPLES? NUTRITION BCC MIYCN diversification Need: Nutritional counseling strategy for pregnancy with proven benefit for pregnancy health and birth outcomes provided through a robust ANC platform Counseling based on food intake Monitoring and promoting optimal weight gain Reducing strenuous work Promoting supplement use Hb testing, urinary glucose and protein Source: http://www.unicef.org/nutrition/files /Brochure_maternal_nutrition.pdf Bill & Melinda Gates Foundation 2014 Bill & Melinda Gates Foundation 38 37 SUMMARY THANK YOU MATERNAL NUTRITION IS CRITICAL FOR IMPROVED BIRTH OUTCOMES; LOW HEIGHT, AND BMI AND INADEQUATE WEIGHT GAIN DURING PREGNANCY CONTINUE TO BE MAJOR FACTORS LEADING TO LOW BIRTH WEIGHT AND SGA MATERNAL MICRONUTRIENT DEFICIENCIES ARE COMMON IN MANY LMICS AND DIETARY QUALITY AND DIVERSITY ARE CHRONICALLY POOR; MAJOR DATA GAPS EXIST DIETARY QUALITY IS ASSOCIATED WITH POOR BIRTH OUTCOMES INCLUDING LBW AND SGA BUT CONFOUNDING CANNOT BE RULED OUT CAREFULLY DESIGNED BCC INTERVENTIONS DURING PREGNANCY TO IMPROVE WEIGHT GAIN AND INTAKE OF FOODS RICH IN MICRONUTRIENT NEEDS EVALUATING FOR THEIR IMPACT ON MATERNAL AND BIRTH OUTCOMES Bill & Melinda Gates Foundation 39