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Under- and Overnutrition in the First Thousand Days: The Importance of the Problem and Interventions
Z uXl Xf iXqXa X X r XA X. XB h u t t a a, b Zohra Lassib XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX a XXXXXXXXXXXXXXXXXXXXXXXXXXXX SickKids Center for Global Child Health, Toronto, Ont., Canada zulfi
[email protected] b
Center of Excellence in Women and Child Health, the Aga Khan University, Karachi, Pakistan
[email protected]
Key Messages
Both maternal undernutrition and obesity are huge public health problems associated with adverse outcomes. It is estimated that close to 27% of all births in low- and middle-income countries may be small for gestational age and associated with maternal malnutrition. Maternal obesity is associated with a high risk of adverse maternal outcomes and an excess risk of macrosomic babies, birth asphyxia or trauma and newborn mortality. Improving birth weight and accelerating linear growth from birth to 2 years of age is associated with large gains in human capital with no excess of adult cardiovascular risks. Although the boundaries for effective interventions have been suggested as the first 1,000 days (i.e. the period of pregnancy and the first 2 years of age), there may be benefits from interventions beyond these boundaries, better gains from interventions delivered preconceptionally and also continued gains in health and cognitive development even after 24 months of age.
The recent Lancet series on maternal and child nutrition [1, 2] highlights the importance of undernutrition as well as obesity to short- and long-term health and nutrition outcomes. There are also clear associations of maternal undernutrition with fetal growth retardation [3]. It is estimated that in 2010 there were 32,4 million babies born small for gestational age or approximately 27% of all births in low- and middle-income countries. This may very well be an underestimate. There are also notable gains in our knowledge of the consequences of maternal obesity on risks of complications and adverse outcomes. Obese pregnant women (pre-pregnant BMI 30 kg/m2) have a 4-fold higher risk of developing gestational diabetes mellitus and double the risk of developing preeclampsia compared with normalweight women. During labor and delivery, maternal obesity is associated with maternal death, hemorrhage, caesarean section or infection. There is a clear excess risk of macrosomic babies, birth asphyxia or trauma and newborn mortality. In addition, there may excess risks of subsequent child-
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hood and adolescent obesity associated with maternal overweight and obesity during pregnancy. The early intrauterine environment plays a role in ‘programming’ the phenotype affecting health in later life. Maternal overweight and obesity at the time of pregnancy increase the risk for childhood obesity that continues into adolescence and early adulthood, potentiating the transgenerational transmission of obesity. A recent analysis of data from the COHORTS consortium, a collaboration of scientists evaluating 5 birth cohorts from lowand middle-income countries (India, the Philippines, South Africa, Guatemala and Brazil), allows for a better understanding of the long-term relationships between early determinants and long-term outcomes. Previous findings from meta-analyses of these 5 birth cohorts suggested that small size at birth and at 2 years of age (particularly height) were associated with reduced human capital: shorter adult height, less schooling, reduced economic productivity and – for women – lower offspring birth weight [4]. On the other hand, larger child size at 24 months of age and rapid weight gain after infancy were risk factors for high glucose concentrations, blood pressure and harmful lipid levels. A more recent analysis suggests that larger birth weight and faster linear growth from 0 to 2 years lead to large gains in human capital, but has little association with adult cardiovascular risk factors [5].
Mothers (from ‘‘– 9’’ months to 0 – birth) • Adequate diet and rest • Tetanus toxoid immunization • Antenatal checkup and counseling • Supplementation (folic acid, iron folic acid, calcium, iodine, micronutrient) • Food • Tobacco cessation • Deworming • Malaria prevention and intermittent preventive treatment • Obesity prevention
–9 months
–6 months
–3 months
Infants (from 6 months to 24 months) • Breast-feeding • Complementary feeding • Supplementation/fortification (vitamin A, zinc, iron, jode • Full immunization • Growth monitoring • Deworming • Diarrhea management, feeding, zinc supplement • Clean environment, water, sanitation and hygiene • Malaria prevention and treatment • Obesity prevention
0
6 months
Mothers (period between 0 and 6 months) • Adequate diet and rest • Iron • Vitamin A • Support for breast-feeding at home and workplace
12 months
18 months
24 months
Infants (from 0 and 6 months) Early initiation of breast-feeding • Exclusive breast-feeding • Essential newborn care • Immunization • Growth monitoring • Malaria prevention • Care seeking for fever •
Other Indirect Interventions: Agriculture, Social Protection, Water Sanitation and Hygiene
While the focus on the first 1,000 days makes operational sense, it is important to recognize that the concept assumes that the boundaries for effective interventions remain the period of pregnancy and the first 2 years of age. This may not be true operationally or physiologically as some of the more effective interventions may be in the preconceptional period [6], and, while interventions to impact stunting may be maximally effective in the first 24 months after birth [2, 7], there may be significant gains in cognitive development even thereafter. This finding underscores the importance of considering the first 1,000 days as illustrative and not absolute limits for action (fig. 1).
References 1. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, Ezzati M, GranthamMcGregor S, Katz J, Martorell R, Uauy R; Maternal and Child Nutrition Study Group: Maternal and child undernutrition and overweight in low-income and middleincome countries. Lancet 2013;382:427–451. 2. Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HP, Shekar M; Maternal and Child Undernutrition Study Group: What works? Interventions for maternal and child undernutrition and survival. Lancet 2008;371:417–440. 3. Katz J, Lee AC, Kozuki N, Lawn JE, Cousens S, Blencowe H, Ezzati M, Bhutta ZA, Marchant T, Willey BA, Adair L, Barros F, Baqui AH, Christian P, Fawzi W, Gonzalez R, Humphrey J, Huybregts L, Kolsteren P, Mongkolchati A, Mullany LC, Ndyomugyenyi R, Nien JK, Osrin D, Roberfroid D, Sania A, Schmiegelow C, Silveira MF, Tielsch J, Vaidya A, Velaphi SC, Victora CG, WatsonJones D, Black RE; CHERG Small-for-Gestational-Age-Preterm Birth Working Group: Mortality risk in preterm and small-for-gestational-age infants in low-income and middle-income countries: a pooled country analysis. Lancet 2013;382:417–425.
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4. Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, Sachdev HS; Maternal and Child Undernutrition Study Group: Maternal and child undernutrition: consequences for adult health and human capital. Lancet 2008;371:340–357. 5. Adair LS, Fall CH, Osmond C, Stein AD, Martorell R, Ramirez-Zea M, Sachdev HS, Dahly DL, Bas I, Norris SA, Micklesfi eld L, Hallal P, Victora CG; COHORTS group: Associations of linear growth and relative weight gain during early life with adult health and human capital in countries of low and middle income: fi ndings from fi ve birth cohort studies. Lancet 2013;382:525–534. 6. Dean SH, Imam AM, Lassi ZS, Bhutta ZA: Importance of intervening in the preconception period to impact pregnancy outcomes; in Bhatia J, Bhutta ZA, Kalhan SC (eds): Maternal and Child Nutrition: The First 1,000 Days. Nestlé Nutr Inst Workshop Ser. Basel, Karger, 2013, vol 174, pp 65–75. 7. Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, Webb P, Lartey A, Black RE; Lancet Nutrition Interventions Review Group; Maternal and Child Nutrition Study Group: Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet 2013;382:452–477.
