The "First 1,000 Days+" as Key Contributor to the Double Burden of Malnutrition.

Growth from conception through age 2 years, the "First 1,000 days," is important for long-term health of the growing fetus and child and is influenced by several factors including breastfeeding and complementary feeding. Low- and middle-income countries face a complicated array of factors that influence healthy growth, ranging from high food insecurity, poor sanitation, limited prenatal or neonatal care, and high levels of poverty that exacerbate the "vicious cycle" associated with intergenerational promotion of growth retardation. It is now well recognized that the period prior to conception, both maternal and paternal health and diet, play an important role in fetal development, giving rise to the concept of the "First 1,000 Days+". Breastfeeding and complementary feeding practices can be improved through a combination of interventions such as baby-friendly hospitals, regulations for marketing of foods and beverages to children, adequate counseling and support, and sound social and behavior change communication, but continued research is warranted to make such programs more universal and fully effective. Thus, improving the overall understanding of factors that influence growth, such as improved breastfeeding and age-appropriate and adequate complementary feeding, is critical to reducing the global prevalence of the double burden of malnutrition.

Regional Overview on the Double Burden of Malnutrition and Examples of Program and Policy Responses: African Region.

Sub-Saharan Africa is experiencing the double burden of malnutrition (DBM) with high levels of undernutrition and a growing burden of overweight/obesity and diet-related noncommunicable diseases (NCDs). Undernourishment in sub-Saharan Africa increased between 2010 and 2016. Although the prevalence of chronic undernutrition is decreasing, the number of stunted children under 5 years of age is increasing due to population growth. Meanwhile, overweight/obesity is increasing in all age groups, with girls and women being more affected than boys and men. It is increasingly recognized that the drivers of the DBM originate outside the health sector and operate across national and regional boundaries. Largely unregulated marketing of cheap processed foods and nonalcoholic beverages as well as lifestyle changes are driving consumption of unhealthy diets in the African region. Progress toward the goal of ending hunger and malnutrition by 2030 requires intensified efforts to reduce undernutrition and focused action on the reduction of obesity and diet-related NCDs. The World Health Organization is developing a strategic plan to guide governments and development partners in tackling all forms of malnutrition through strengthened policies, improved service delivery, and better use of data. It is only through coordinated and complementary efforts that strides can be made to reduce the DBM.

Regional Overview on the Double Burden of Malnutrition and Examples of Program and Policy Responses: Latin America and the Caribbean.

BACKGROUND: Hunger, food insecurity, stunting, anemia, overweight, and noncommunicable diseases (NCDs) may coexist in the same person, household, and community in Latin America and the Caribbean (LAC). The double burden of malnutrition (DBM) is an important cause of disability and premature death, which could be addressed with comprehensive policies such as the Plan of Action for the Prevention of Obesity in Children and Adolescents. This paper summarizes the main policies and actions aimed to prevent undernutrition and obesity. SUMMARY: Several countries are implementing the Plan of Action, Caribbean Public Health Agency is actively supporting Ministries of Health, Education, and Sport to develop school nutrition policies and strategies to create health-promoting environments at school and in their surrounding communities. Chile is implementing the comprehensive child protection system "Chile Crece Contigo" that integrates health, social development, and educational activities to optimize growth and childhood cognitive-motor development. Brazil is implementing policies and plans to commit to international targets regarding food and nutrition security, NCDs and their risk factors. Key Messages: The DBM exists in the Americas and contributes to disability and premature death. The Region is making progress implementing policies and actions addressing the DBM. However, stronger political will and leadership are needed to enact legislation and policies that create and support enabling -environments.

Projected future distribution of date palm and its potential use in alleviating micronutrient deficiency.

BACKGROUND: Micronutrient deficiency develops when nutrient intake does not match nutritional requirements for maintaining healthy tissue and organ functions which may have long-ranging effects on health, learning ability and productivity. Inadequacy of iron, zinc and vitamin A are the most important micronutrient deficiencies. Consumption of a 100 g portion of date flesh from date palm (Phoenix dactylifera L.) has been reported to meet approximately half the daily dietary recommended intake of these micronutrients. This study investigated the potential distribution of P. dactylifera under future climates to address its potential long-term use as a food commodity to tackle micronutrient deficiencies in some developing countries. RESULTS: Modelling outputs indicated large shifts in areas conducive to date palm cultivation, based on global-scale alteration over the next 60 years. Most of the regions suffering from micronutrient deficiencies were projected to become highly conducive for date palm cultivation. CONCLUSIONS: These results could inform strategic planning by government and agricultural organizations by identifying areas to cultivate this nutritionally important crop in the future to support the alleviation of micronutrient deficiencies.

[Epigenetics and Nutrition: maternal nutrition impacts on placental development and health of offspring]. / Epigénétique et Nutrition : impacts de l'alimentation maternelle sur le développement placentaire et la santé de la descendance.

The environment, defined broadly by all that is external to the individual, conditions the phenotype during development, particularly the susceptibility to develop non-communicable diseases. This notion, called Developmental Origins of Health and Disease (DOHaD), is based on numerous epidemiological studies as well as animal models. Thus, parental nutrition and obesity can predispose the offspring to develop metabolic and cardiovascular diseases in adulthood. The known underlying mechanisms include an altered development of tissues that adapt to maternal metabolic condition, and a placental dysfunction, which in turn impacts fetal growth and development. Epigenetic mechanisms modulate gene expression without affecting the DNA sequence itself. The main epigenetic marks are DNA methylation and histone post-translational modifications. These marks are erased and set-up during gametogenesis and development in order to ensure cellular identity. Therefore, they can lead to a memorisation of early environment and induce long-term alteration of cell and tissue functions, which will condition the susceptibility to non-communicable diseases. The placenta is a programming agent of adult disease. The environment, such as smoking or psychosocial stress, is able to modify epigenetic processes in placenta, such as small RNA expression and DNA methylation. We showed that placenta is sensitive to maternal obesity and maternal nutrition, in terms of histology, transcription and epigenetic marks. A clear sexual dimorphism is remarkable in the placental response to maternal environment. In adulthood, the phenotype is also different between males and females. Epigenetic mechanisms could underlie this differential response of males and females to the same environment. The DOHaD can no longer be ignored in Biology of Reproduction. The prevention of non-communicable diseases must take this new paradigm into account. Research will allow a better comprehension of the mechanisms of this early conditioning and the marked sexual dimorphism it is associated to.

The first 500 days of life: policies to support maternal nutrition.

BACKGROUND: From conception to 6 months of age, an infant is entirely dependent for its nutrition on the mother: via the placenta and then ideally via exclusive breastfeeding. This period of 15 months--about 500 days--is the most important and vulnerable in a child's life: it must be protected through policies supporting maternal nutrition and health. Those addressing nutritional status are discussed here. OBJECTIVE AND DESIGN: This paper aims to summarize research on policies and programs to protect women's nutrition in order to improve birth outcomes in low- and middle-income countries, based on studies of efficacy from the literature, and on effectiveness, globally and in selected countries involving in-depth data collection in communities in Ethiopia, India and Northern Nigeria. Results of this research have been published in the academic literature (more than 30 papers). The conclusions now need to be advocated to policy-makers. RESULTS: The priority problems addressed are: intrauterine growth restriction (IUGR), women's anemia, thinness, and stunting. The priority interventions that need to be widely expanded for women before and during pregnancy, are: supplementation with iron-folic acid or multiple micronutrients; expanding coverage of iodine fortification of salt particularly to remote areas and the poorest populations; targeted provision of balanced protein energy supplements when significant resources are available; reducing teenage pregnancies; increasing interpregnancy intervals through family planning programs; and building on conditional cash transfer programs, both to provide resources and as a platform for public education. All these have known efficacy but are of inadequate coverage and resourcing. The next steps are to overcome barriers to wide implementation, without which targets for maternal and child health and nutrition (e.g. by WHO) are unlikely to be met, especially in the poorest countries. CONCLUSIONS: This agenda requires policy decisions both at Ministry and donor levels, and throughout the administrative system. Evidence-based interventions are established as a basis for these decisions, there are clear advocacy messages, and there are no scientific reasons for delay.

Iron deficiency during pregnancy: the consequences for placental function and fetal outcome.

This review examines the importance of the placenta in iron metabolism during development and the effect of iron deficiency on maternal and fetal physiology. Iron is an essential micronutrient, required for a wide variety of biological processes. During pregnancy, the mother has to deplete her iron stores in order to provide the baby with adequate amounts. Trans-placental iron transfer involves binding transferrin (Tf)-bound iron to the Tf receptor, uptake into an endosome, acidification, release of iron through divalent metal transporter 1, efflux across the basolateral membrane through ferroportin and oxidation of Fe(II) by zyklopen. An additional haem transport system has been hypothesised, which may explain why certain gene knockouts are not lethal for the developing fetus. Iron deficiency is a common phenomenon during pregnancy, and the placenta adapts by up-regulating its transfer systems, maintaining iron at the expense of the mother. Despite these adaptations, deficiency cannot be completely prevented, and the offspring suffers both short- and long-term consequences. Some of these, at least, may arise from decreased expression of genes involved in the cell cycle and altered expression of transcription factors, such as c-myc, which in turn can produce, for example, kidneys with reduced numbers of nephrons. The mechanism whereby these changes are induced is not certain, but may simply be as a result of the reduced availability of iron resulting in decreased enzyme activity. Since these changes are so significant, and because some of the changes are irreversible, we believe that iron prophylaxis should be considered in all pregnancies.

Monitoring and effects of iodine deficiency in pregnancy: still an unsolved problem?

Iodine is required for the production of thyroid hormone. Thyroid hormone affects many metabolic processes in the body, including maturation of the central nervous system. In early pregnancy, the fetus is dependent on maternal thyroid hormone for normal brain development. If iodine deficiency leads to inadequate production of thyroid hormone during pregnancy, irreversible brain damage can result in the fetus. Therefore, achieving adequate iodine nutrition during pregnancy is an important public health objective. Although there have been tremendous gains over the last several decades in our understanding of the effects of iodine deficiency in pregnancy and how to combat them, a number of questions remain about how best to monitor the iodine status of pregnant populations, the effects of mild to moderate iodine deficiency on maternal and child outcomes, the safe upper limit of daily iodine intake in pregnant women and the risks and benefits of iodine supplementation for mildly iodine-deficient pregnant women.

Fetal and early childhood undernutrition, mortality, and lifelong health.

Child undernutrition is a major public health challenge, estimated to be responsible for 2.2 million annual deaths. Implementation of available interventions could prevent one-third of these deaths. Emerging evidence suggests that breast-feeding can lead to improvements in intelligence quotient in children and lower risks of noncommunicable diseases in mothers and children decades later. Nonetheless, breast-feeding and complementary feeding practices differ greatly from global recommendations. Although the World Health Organization recommends that infants receive solely breast milk for the first 6 months of life, only about one-third of infants in low-income countries meet this goal, just one-third of children 6 to 24 months old in low-income countries meet the minimum criteria for dietary diversity, and only one in five who are breast-fed receive a minimum acceptable diet. Although the potential effects of improved breast-feeding and complementary feeding appear large, funding for research and greater use of existing effective interventions seems low compared with other life-saving child health interventions.

Iron in pregnancy: How do we secure an appropriate iron status in the mother and child?

Iron deficiency and iron deficiency anemia (IDA) during pregnancy are risk factors for preterm delivery, prematurity, and small for gestational age birth weight. Iron deficiency has a negative effect on intelligence and behavioral development in the infant. It is essential to prevent iron deficiency in the fetus by preventing iron deficiency in the pregnant woman. The requirements for absorbed iron increase during pregnancy from ∼1.0 mg/day in the first trimester to 7.5 mg/day in the third trimester. More than 90% of Scandinavian women of reproductive age have a dietary iron intake below the recommended 15 mg/day. Among nonpregnant women of reproductive age, ∼40% have plasma ferritin ≤30 µg/l, i.e. an unfavorable iron status with respect to pregnancy. An adequate iron status during pregnancy implies body iron reserves ≥500 mg at conception, but only 15-20% of women have iron reserves of such a magnitude. Iron supplements during pregnancy reduce the prevalence of IDA. In Europe, IDA can be prevented by a general low-dose iron prophylaxis of 30-40 mg ferrous iron taken between meals from early pregnancy to delivery. In affluent societies, individual iron prophylaxis tailored by the ferritin concentration should be preferred to general prophylaxis. Suggested guidelines are: ferritin >70 µg/l, no iron supplements; ferritin 31-70 µg/l, 30-40 mg ferrous iron per day, and ferritin ≤30 µg/l, 60-80 mg ferrous iron per day. In women with ferritin <15 µg/l, i.e. depleted iron reserves and possible IDA, therapeutic doses of 100 mg ferrous iron per day should be advised.

Iodine deficiency in pregnancy, infancy and childhood and its consequences for brain development.

Iodine deficiency during foetal development and early childhood is associated with cognitive impairment. Randomised clinical studies in school-aged children encountered in the literature indicate that cognitive performance can be improved by iodine supplementation, but most studies suffer from methodological constraints. Tests to assess cognitive performance in the domains that are potentially affected by iodine deficiency need to be refined. Maternal iodine supplementation in areas of mild-to-moderate iodine deficiency may improve cognitive performance of the offspring, but randomised controlled studies with long-term outcomes are lacking. Studies in infants or young children have not been conducted. The best indicators for iodine deficiency in children are thyroid-stimulating hormone (TSH) in newborns and thyroglobulin (Tg) in older children. Urinary iodine may also be useful but only at the population level. Adequate salt iodisation will cover the requirements of infants and children as well as pregnant women. However, close monitoring remains essential.

Thioredoxin binding protein-2 inhibits excessive fetal hypoglycemia during maternal starvation by suppressing insulin secretion in mice.

Glucose is a major fuel for fetal development. Fetal blood glucose level is mainly dependent on maternal blood glucose concentration, though it is also regulated by fetal insulin level. Thioredoxin binding protein-2 (TBP-2), which is identical to vitamin D3 up-regulated protein (VDUP1) and thioredoxin interacting protein (Txnip), was recently reported to be a key transcriptional factor controlling glucose metabolism. Here, we elucidated the functions of TBP-2 in maintaining blood glucose homeostasis during the fetal period. TBP-2(+/-) female mice were mated with TBP-2(+/-) male mice; beginning 16.5-d post coitum, pregnant mice were fed or fasted for 24 h. Under conditions of maternal starvation, the blood glucose levels of TBP-2(-/-) fetuses were significantly lower than those of TBP-2(+/+) fetuses, corresponding to the elevated plasma insulin levels of TBP-2(-/-) fetuses compared with those of TBP-2(+/+) fetuses. There was no difference between TBP-2(+/+) and TBP-2(-/-) fetuses in terms of their pancreatic beta-cell masses or the expression of placental glucose transporters under conditions of either maternal feeding or fasting. Thus, during maternal fasting, fetal TBP-2 suppresses excessive insulin secretion to maintain the fetus's glucose levels, implying that TBP-2 is a critical molecule in mediating fetal glucose homeostasis depending on nutrient availability.

Micronutrient prenatal supplementation prevents the development of hypertension and vascular endothelial damage induced by intrauterine malnutrition.

AIMS: The premise that intrauterine malnutrition plays an important role in the development of cardiovascular and renal diseases implies that these disorders can be programmed during fetal life. Here, we analyzed the hypothesis that supplementation with mixed antioxidant vitamins and essential mineral in early life could prevent later elevation of blood pressure and vascular and renal dysfunction associated with intrauterine malnutrition. MAIN METHODS: For this, female Wistar rats were randomly divided into three groups on day 1 of pregnancy: control fed standard chow ad libitum; restricted group fed 50% of the ad libitum intake and a restricted plus micronutrient cocktail group treated daily with a combination of micronutrient (selenium, folate, vitamin C and vitamin E) by oral gavage. KEY FINDINGS: In adult offspring, renal function and glomerular number were impaired by intrauterine malnutrition, and the prenatal micronutrient treatment did not prevent it. However, increased blood pressure and reduced endothelium-dependent vasodilation were prevented by the micronutrient prenatal treatment. Intrauterine malnutrition also led to reduced NO production associated with increased superoxide generation, and these parameters were fully normalized by this prenatal treatment. SIGNIFICANCE: Our current findings indicate that programming alterations during fetal life can be prevented by interventions during the prenatal period, and that disturbance in availability of both antioxidant vitamins and mineral may play a crucial role in determining the occurrence of long-term cardiovascular injury.

Dietary aspects of pregnant women in rural areas of Northern India.

The aim of this article is to document the current dietary profile of pregnant women in rural areas of Delhi. In order to explore the diet the combination of quantitative (24-h recall method) and qualitative methods (food frequency method) were used. The mean intake of macronutrients and micronutrients, namely, iron, folic acid and Vitamin C which play an important role in the pathophysiology of nutritional anaemia during pregnancy was calculated from the foodstuffs, using Nutritive Value of Indian Foods. The preferences and avoidance of various foods by the pregnant women were also elicited. The data were analysed using Epi Info 3.4. The intake of calories, protein, iron, folic acid and Vitamin C was found to be less than the recommended dietary allowance in 100%, 91.2%, 98.2%, 99.1% and 65.8% of pregnant women respectively. Folic acid intakes were significantly lower in younger, primiparous and poorly educated women from low-income families. Vitamin C intake was lower among non-Hindus only. The overall data suggested the presence of food gap rather than isolated deficiency of any particular nutrient.

Fetal nutrition and adult hypertension, diabetes, obesity, and coronary artery disease.

The fetal-origins-of-adult-disease hypothesis describes an adaptive phenomenon of in utero reprogramming of the undernourished fetus that predisposes the infant to increased morbidity as an adult. Studies have identified a positive association between indicators of fetal undernutrition such as low birth weight and chronic adult diseases like hypertension, diabetes, obesity, and coronary artery disease. Current research is focusing on determining other factors that may contribute to these chronic adult diseases.

Role of trace elements zinc, copper and magnesium during pregnancy and its outcome.

Trace element deficiencies have been documented to play an important role in determination of the fetal outcome. Pregnant women in developing countries have been reported to consume diets with a lower density of minerals and vitamins. Deficiencies of trace elements like zinc, copper and magnesium have been implicated in various reproductive events like infertility, pregnancy wastage, congenital anomalies, pregnancy induced hypertension, placental abruption, premature rupture of membranes, still births and low birth weight. The present review article highlights the important of role played by zinc, copper and magnesium during pregnancy and its outcome. The role of individual trace elements and in combination with other trace elements has not been completely documented. There is a need to undertake further studies in this field.

Prevalence of multiple micronutrient deficiencies amongst pregnant women in a rural area of Haryana.

UNLABELLED: Deficiencies of micronutrients (zinc, iron, folic acid and iodine) during pregnancy are known causes of Low Birth Weight (LBW). Studies have documented status of one or two micronutrients amongst pregnant women (PW). However, no attempt has been made to concurrently assess the prevalence of multiple micronutrient deficiencies and the factors associated with them amongst PW. OBJECTIVE: The present study was undertaken to assess the prevalence of multiple micronutrient deficiencies amongst PW in a rural area. METHODS: A community based cross sectional survey was conducted in six villages of a rural area of district Faridabad in Haryana state, India during November 2000 and October 2001. All PW aged 18 years or more, with pregnancy duration of more than 28 weeks were enrolled. Data were collected on socio-economic status and other demographic parameters. Serum zinc, copper and magnesium levels were estimated by utilizing the Atomic absorption spectrophotometry (AAS); serum ferritin and folate was estimated by Enzyme Linked Immuno Sorbent Assay (ELISA) method and the Radio-Immuno Assay (RIA) method, respectively and serum thyroid stimulating hormone (TSH) level was estimated by the Abbot AxSYM System. Serum zinc, copper, magnesium, ferritin, and folate levels less than 70.0 microg/dl, 80.0 microg/dl, 1.80 mg/dl, 15 ng/ml, and 3 ng/ml, respectively were considered as indicative of deficiency for respective micronutrients. The TSH levels of 4.670 and more indicated iodine deficiency status. Dietary intake of micronutrients was assessed utilizing 1-day 24-hour dietary recall methodology. Food consumption pattern was assessed utilizing the food frequency questionnaire methodology. RESULTS: Nearly 73.5, 2.7, 43.6, 73.4, 26.3, and 6.4 percent PW were deficient in zinc, copper, magnesium, iron, folic acid and iodine, respectively. The highest concurrent prevalence of two, three, four and five micronutrient deficiency was of zinc and iron (54.9%); zinc, magnesium and iron (25.6%); zinc, magnesium, iron and folic acid (9.3%) and zinc, magnesium, iron, folic acid and iodine (0.8%), respectively. No pregnant woman was found to have concomitant deficiencies of all the six micronutrients. Dietary intake data revealed an inadequate nutrient intake. Over 19% PW were consuming less than 50% of the recommended calories. Similarly, 99, 86.2, 75.4, 23.6, 3.9 percent of the PW were consuming less than 50% of the recommended folic acid, zinc, iron, copper, and magnesium. The consumption of food groups rich in micronutrients (pulses, vegetables, fruits, nuts and oil seeds, animal foods) was infrequent. Univariate and Multivariate logistic regression analysis revealed that low dietary intake of nutrients, low frequency of consumption of food groups rich in micronutrients and increased reproductive cycles with short interpregnancy intervals were important factors leading to micronutrient deficiencies. CONCLUSION: There was a high prevalence of micronutrient deficiencies amongst the PW of the area, possibly due to the poor dietary intake of food and low frequency of consumption of food groups rich in micronutrients. The concurrent prevalence of two, three, four and five micronutrient deficiencies were common.