Transcript Nutrition in early life and food security.

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
[email protected]
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.
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.
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.
Food Security and Age*
Less than 20
20 to 29
30 to 39
40 or more
70
60
50
(%)
Food
Insecure
40
30
20
10
0
I am worried about whether The food that I bought just I ran out of foods I needed We eat the same thing for
my food will run out...
didn't last…
to put together a meal….
several days in a row…
*Population based survey (n=9194) Iowa Dept. of Public Health (2000)
INCIDENCE AND COMPOSITION
OF LOW BIRTH WEIGHT (< 2.500 g)
NEWBORNS IN DEVELOPED
AND DEVELOPING COUNTRIES
(1992-1995)
7.7
Symmetric
LBW (%)
3.3
Term
2.0
Preterm
0.6
1.4
Asymmetric
4.2
Preterm
Developed
Countries
5.4
Developing
Countries
Term
11.0
South America
South
America
AIDS Incidence
22 7,640 cases per year
Perinatal AIDS
0.6
206 newborns per year
IUGR
1,100,000 per year
3170
Infant deaths
215,000 per year
619
Perinatal deaths
293,000 per year
843
0
500
1500
2000
2500
1000
Rates per 1 million habitants
3000
3500
Low birthweight in two
generations by income in
1982
% < 2500 g
15
Mother
10
5
0
<50
50-
150-
MONTHLY INCOME (US$)
Child
Targeting nutrition interventions to young children: the window
of opportunity for prevention
Ht Δ per 100
Kcal of
supplement
mm
10
8
6
4
2
Window of
opportunity
for actions to
prevent
undernutrition
0
3-12
12-24
24-36
36-48
48-60
60-72
72-84
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
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.
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
Birth weight and risk of cardiac
disease
Hertfordshire
RR
1.0
Sheffield
USA
Uppsala
0.8
0.6
0.4
< 2500
3000
3500
grams
4000
4500
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”
Adult mortality according to season at birth
Gambia (n = 3162)
Birth weight and blood
pressure, by age at
assessment.
Systematic review
Fetal exposures with long-term effects
•
•
•
•
•
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
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.
Experimental evidence
• Not really been tested-difficult to do
Randomize
pregnant
women
Nutrition
intervention
In pregnancy
Usual
care
Fetal
Growth/
metabolism
Long-term
growth monitoring
and follow-up for
disease
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
Micronutrient deficiencies
–Iron
–Zinc
–Vitamin A
–Folic acid
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.
Daily dietary calcium intake, by region (FAO, 1990)
REGION
World
Developed countries
Developing countries
Africa
Latin America
Asia
Others
CALCIO (mg)
472
860
346
363
499
498
402
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
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 Statement 12,1 (1994).
Embarazadas:
•Primíparas
•Control prenatal antes de las 20 semanas de gestación
•Sin Patologías
A
2000 mg de Calcio
por dia
B
Placebo
SORTEO
MADRE
Preclampsia
Calcio
2.5 %
34 %
4.0%
Placebo
Niño
(5-9 años)
Hipetension
arterial
Niño
(12-13 años)
Salud bucal
(% con caries)
11 %
51 %
63.6 %
27 %
19 %
86.6 %
Calcium supplementation during pregnancy
Outcome: Pre-eclampsia
Calcium
n/N
Study
Adequate calcium diet (900 mg/d)
CPEP 1997
Villar 1987
Villar 1990
Subtotal (95%CI)
Placebo
n/N
Risk
Reduction Peto OR
%
(95%CI Fixed)
Peto OR
(95% CI Fixed)
158 / 2163 168 / 2173
1 / 25
3 / 27
0 / 90
3 / 88
159 / 2278 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)
Belizán 1991
L-Jaramillo 1989
L-Jaramillo 1990
L-Jaramillo 1997
Purwar 1996
S-Ramos 1994
Subtotal (95% CI)
Total /95%CI)
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
186 / 3185 264 / 32223
.5
.7
1
1.5
2
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)
30
0.70 (0.58, 0.85)
Differential
calcium diet
Normal
calcium diet
Double (n= 32)
2 pups for each rat
98 virgin rats
n= 40
Normal (n= 33)
n= 37
n= 42
Low (n= 32)
4
weeks
20 weeks
of age
Pregnancy
Lactation
Weaning
Mating
Birth
52
weeks
Monthy blood pressure measurements
mm Hg
124
+1 SE
122
Maternal low
calcium diet
-1 SE
120
118
12.1 mmHg
(8.8 to 15.4)
p< 0.0001
116
114
112
+1 SE
110
-1 SE
108
106
0
4
8
12 16 20 24 28 32 36 40 44 48 52 56
Age (Weeks)
Maternal normal
calcium diet
Experimental evidence
Randomize
pregnant
women
Nutrition
Intervention
In pregnancy
Usual
care
Fetal
Growth/
metabolism
Long-term
growth monitoring
and follow-up for
disease
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
• 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
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.