Nutrition in early life and food security.

1. 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 bergeled@clap.ops-oms.org

2. 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.

3. 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.

4. 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.

5. Food Security and Age* *Population based survey (n=9194) Iowa Dept. of Public Health (2000)

6. 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

7. 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

8. Low birthweight in two generations by income in 1982

9. 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

11. 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.

12. 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

13. 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

14. 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”

15. Adult mortality according to season at birth Gambia (n = 3162)

16. Birth weight and blood pressure, by age at assessment. Systematic review

17. 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

18. 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.

19. 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

21. 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

22. Micronutrient deficiencies • Iron • Zinc • Vitamin A • Folic acid

25. 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.

26. 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

27. 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

28. 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).

29. A SORTEO B • Embarazadas: • Primíparas • Control prenatal antes de las 20 semanas de gestación • Sin Patologías 2000 mg de Calcio por dia Placebo

30. 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

31. 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

32. 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

33. 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)

34. Experimental evidence Fetal Growth/ metabolism Nutrition Intervention In pregnancy Long-term growth monitoring and follow-up for disease Randomize pregnant women Usual care

35. 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

36. 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

37. 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.