Nutrition%20526%20-%209/29/2006%20A%20Public%20Health%20Approach%20to%20Maternal%20and%20Infant%20Health

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Nutrition 526 - 9/29/2006A Public Health
Approach to Maternal and Infant Health
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Topics

1. Who is having babies in the US? How many babies?
   What are the outcomes?
2. Why is nutrition important for pregnant women and
   babies?
3. What population based approaches to improve
   nutrition might improve outcomes?

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Topic 1

• How many babies?
• Who is having babies in the US?
• Race/ethnicity
• Age
• Marital status
• What are the nutrition-related outcomes we are
  concerned about for population health?

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Health, United States, 2005 www.cdc.gov/nchs/hus
.htm
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Percentage of Parents Who Were Married or
Cohabiting at Birth of First Child, by
Race/Ethnicity and Sex
MMWR September 15, 2006 / 55(36)998
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Infant Mortality

• Infant mortality rate Deaths of infants aged
  under 1 year per 1,000 or 100,000 live births.
  The infant mortality rate is the sum of the
  neonatal and postneonatal mortality rates.
• Neonatal mortality rate Deaths of infants aged
  0-27 days per 1,000 live births. The neonatal
  mortality rate is the sum of the early neonatal
  and late neonatal mortality rates
• Postneonatal mortality rate Deaths to infants
  aged 28 days-1 year per 1,000 live births.

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http//www.chipublib.org/004chicago/disasters/infa
nt_mortality.html
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Infant Deaths Per Thousand Live Births, by Race
and Hispanic Origin 1960-1995 
National Center for Health Statistics. Health,
United States, 1995
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Racial/Ethnic Disparities in Infant Mortality ---
United States, 1995--2002
MMWR June 10, 2005 / 54(22)553-556
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MMWR, April 19, 2002 / 51(15)329-332, 343
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Figure 2.  Rates of infant mortality, low
birthweight, and preterm birth, 1990-2002
Supplemental Analyses of Recent Trends in Infant
Mortality, CDC February 11, 2004
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Health Affairs, Vol 23, Issue 5, 2004
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Causes of Infant Death
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Health Affairs, Vol 23, Issue 5, 2004
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Rates of LBW () Rates of Premature Birth () Rates Infant Morality()
African Americans 13.4 17.7 13.5
Asians 7.8 10.4 4.6
Native Americans 7.2 13 9.7
Whites 6.9 11 5.7
Hispanics 6.5 11.6 5.4
NGA Center for Best Practices, June 2004
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Reported Stressful Life Events During Year
Before DeliveryKing County, 1999-2001Pregnancy
Risk Assessment Monitoring System (PRAMS)
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African Amer. Amer. Indian/AK Native White
Changed residence 44 53 33
Argued with partner more than usual 36 43 17
Had bills couldnt pay 31 42 14
Someone close died 24 25 15
Close family member hospitalized 24 22 24
Separated or divorced from partner 20 19 5
Someone close had drinking/drug problem 15 28 13
Partner said he didnt want pregnancy 15 21 8
Husband/partner lost job 14 20 8
Mom or partner went to jail 10 22 4
Involved in a physical fight 7 12 4
Homeless 11 15 1
Reported 5 or more stress events 12 23 4
stat. sig compared to whites
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Maternal Mortality
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African American and White Women Who Died of
Pregnancy Complications, United States
Annual number of deaths during pregnancy or
within 42 days after delivery, per 100,000 live
births. The apparent increase in the number of
maternal deaths between 1998 and 1999 is the
result of changes in how maternal deaths are
classified and coded. Source CDC, National
Center for Health Statistics.
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Risk of Maternal Death

• Race/ethnicity
• The risk of death for African American women is
  almost four times that for white women.
• The risk of death for Asian and Pacific Islander
  women who immigrated to the United States is two
  times that for Asian and Pacific Islander women
  born in the United States.
• Age
• The risk of death is nearly three times greater
  for women 3539 years old than for women 2024
  years old.
• The risk is five times greater for women over 40.
  

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The most common serious pregnancy complications

• Ectopic pregnancy
• Depression
• High blood pressure
• Infection
• Complicated delivery
• Diabetes
• Premature labor
• Hemorrhage

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Topic 2

• Why is nutrition important for pregnant women and
  babies?

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Poor Pregnancy Outcomes are Costly

• Medicaid finances 40 of annual births in the US
  and pays for 50 of hospital stays for premature
  and LBW.
• The care cost for children with one of 17 common
  birth defects is 8 billion per year in the US.

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Top Three Best Practices to Improve Birth
Outcomes and Reduce High Risk Births (NGA, June
2004)

• Improve access to medical care and health care
  services
• Encourage good nutrition and healthy lifestyles
• Eating healthy foods
• Taking folic acid
• Reduce use of harmful substances

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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

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Emerging Understandings about Nutrition in
Pregnancy

• Periods of critical development are key when
  considering effects of nutrition in pregnancy.
• Undernutrition has different effects at different
  times of life.
• 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.

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Effect of Womens own Intrauterine Nutritional
Experience her Offspring
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Two Studies of Effects of Maternal Birthweight on
Infant Birthweight
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Classic Definitions of Birth weight
Extremely low birth weight (ELBW) lt 1000 g
Very low birth weight (VLBW) lt1500 g
Moderately Low birth weight 1500 to lt2500 g
Low birth weight lt2500 g (HP2010)
Normal (NBW) 2500-lt4000 g
Ideal birth weight 3500- lt4000g
High birth weight (HBW) gt4000 g
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Godfrey KM, Barker DJP, Robinson S, Osmond C.
Mother's birthweight and diet in pregnancy in
relation to the baby's thinness at birth. Br J
Obstet Gynaecol 19971046637
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Illinois StudyCoutinho et al. Am J Epi, 1997
146804-809

• N15,287 Black and 117,708 white matched pairs of
  infants and mothers.
• Mothers were born between 1956-75, infants
  between 1989-1991

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Results

• Fathers birthweight had effect on infant
  birthweight but not as strong as mothers.
• In multiple linear regression for infants who
  weighed more than 2500 g, parental birthweight
  accounted for 5 of variance among black infants
  and 4 among white infants.
• (adjusted for parental age, years of schooling,
  marital status and adequacy of prenatal care)

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Results, cont.

• Each 100 g increase in maternal birthweight was
  associated with 24-27 g increase in infant
  birthweight

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Influence of Maternal Intrauterine Childhood
Nutrition on Outcomes of Pregnancy
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Reproductive performance and nutrition during
childhood

• Nutrition Reviews Washington Apr 1996
  Martorell, Reynaldo Ramakrishnan, Usha
  Schroeder, Dirk G Ruel, Marie

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Longitudinal Supplementation Trial (1969-1977)

• Guatemala, 4 Villages, one pair of villages had
  about 900 people each and the other about 500
  each.
• 2 each randomized to
• Atole (Incaparina, a vegetable protein mix
  developed by INCAP, dry skim milk, sugar, and
  flavoring, 163 kcal/cup, 11/5 g protein)
• Fresco (flavored drink with sugar, vitamins and
  minerals, 59 kcal/cup)

Institute of Nutrition of Central America and
Panama
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• Feeding center was open daily for over 7 years,
  from 1969 to 1977.
• Anyone in the village could attend, but careful
  recording of consumption, including of additional
  servings as well as of leftovers, was done only
  for women who were pregnant or breastfeeding and
  for children 7 years or younger.
• Supplements were available twice daily, in
  midmorning and midafternoon, so as not to
  interfere with meal times.

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Conceptual framework

• Malnutrition in early childhood constrains the
  future capacity of women to bear healthy newborns
  and their ability to feed and care for them, and
  through these mechanisms the growth and
  development of the next generation.

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Follow-Up data - 1990s

• The prevalence of low birthweight is currently
  12 in Atole villages (n 65) and 28 in Fresco
  villages (n 58) among women exposed to the
  supplements during the intrauterine period and
  the first 3 years of life.
• Mean birthweights are 2.90 kg in Atole villages
  and 2.73 in Fresco villages.

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Role of intergenerational effects on linear
growth

• U Ramakrishnan R Martorell D G
• Schroeder R Flores The Journal of Nutrition
  Bethesda Feb 1999

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Methods

• The sample was restricted to singleton, term (gt37
  wk of gestation) births that occurred in the four
  study villages between 1991 and 1996, to women
  who were born during the original longitudinal
  study (1969-1977)
• Complete data were available for 215 mother-child
  pairs, and 60 of the mothers (n 140)

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Results

• For every 100 g increase in maternal birth
  weight, her infant's birth weight increased by 29
  g after adjusting for the effects of maternal
  age, gestational age and sex of the infant. This
  relationship was highly significant (P lt 0.001)
• For every centimeter increase in maternal birth
  length, her child's birth weight increased by 53
  g.

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Influence of Maternal Nutrition in Pregnancy
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Dutch Famine StudiesSusser and Stein, Nutrition
Reviews, 1994

• Dutch famine winter lasted 6 months, from
  November 1944- when nazis imposed transport
  embargo on west Holland until-
• May 7, 1945 when Holland was liberated from the
  occupation
• Strong evidence for critical stages of
  development in several physiological systems

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Affects of Famine

• Fertility decreased
• Maternal weight fell during pregnancy with famine
  exposure
• Third trimester famine exposure had strong effect
  on birthweight
• Third trimester famine exposure was associated
  with infant mortality at 30-90 days

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Results for Infants Exposed to Famine

• Excess central nervous system disorders (such as
  NTD)
• Exposure early in gestation associated with
  excess obesity in young men (military records)
  and women
• Famine exposure late in pregancy associated with
  less obesity in young adulthood
• Famine exposure associated with twofold risk of
  schizophrenia in 50 year old women.

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Second Generation

• Modest association found in this cohort between
  birthweights of mothers and their offspring.

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Prenatal exposure to famine and brain morphology
in schizophrenia

• Hulshoff Pol HE Hoek HW Susser E Brown AS
  Dingemans A Schnack HG van Haren NE Pereira
  Ramos LM Gispen-de Wied CC Kahn RS American
  Journal of Psychiatry , Jul 2000

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Methods

• Nine schizophrenic patients and nine healthy
  comparison subjects exposed during the first
  trimester of gestation to the Dutch Hunger Winter
  were evaluated with magnetic resonance brain
  imaging, as were nine schizophrenic patients and
  nine healthy subjects who were not prenatally
  exposed to the famine.

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RESULTS

• Prenatal famine exposure in patients with
  schizophrenia was associated with decreased
  intracranial volume.
• Prenatal Hunger Winter exposure alone was related
  to an increase in brain abnormalities,
  predominantly white matter hyperintensities.

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Further evidence of relation between prenatal
famine and major affective disorder.

• Alan S Brown Jim van Os Corine Driessens Hans
  W Hoek et al The American Journal of
  Psychiatry Washington Feb 2000

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Methods

• Compared the risk of major affective disorder
  requiring hospitalization in birth cohorts who
  were and were not exposed, in each trimester of
  gestation, to famine during the Dutch Hunger
  Winter of 1944-1945.

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Results

• The risk of developing major affective disorder
  requiring hospitalization was increased for
  subjects with exposure to famine in the second
  trimester and was increased significantly for
  subjects with exposure in the third trimester,
  relative to unexposed subjects.

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Fetal Nutrition and Chronic Diseases of Adulthood
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Fetal Origins ConceptsBarker et al

• Nutrition in early life has permanent effects on
  structure, physiology and metabolism
• Undernutrition has different effects at different
  times of life (critical periods of development)
• Rapidly growing fetuses and neonates are
  vulnerable to undernutrition
• Undernutrition results from inadequate maternal
  intake, transport, or transfer of nutrients.

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Coronary heart disease death rates, expressed as
standardized mortality ratios, in 10,141 men and
5585 women born in Hertfordshire, United Kingdom,
from 1911 to 1930, according to birth weight.
(Osmond C, Barker DJP, Winter PD, Fall CHD,
Simmonds SJ. Early growth and death from
cardiovascular disease in women. BMJ
1993307151924)
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Catch-up growth in childhood and death from
coronary heart disease longitudinal study
(Eriksson et al, BMJ, 1999)

• Subjects 3641 men born in Helsinki between
  1924-1933
• Followed with school data for weight and height
• Deaths from coronary heart disease from 1971-95
  (standardized mortality ratios) were endpoints.

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Catch-up growth in childhood and death from
coronary heart disease longitudinalstudy
(Eriksson et al, BMJ, 1999

• Men who had low birth weight or were thin at
  birth have high death rates from coronary heart
  disease
• Death rates are even higher if weight "catches
  up" in early childhood
• Death from coronary heart disease may be a
  consequence of prenatal undernutrition followed
  by improved postnatal nutrition
• Programs to reduce obesity among boys may need to
  focus on those who had low birth weight or who
  were thin at birth

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Framework for understanding the maternal
regulation of fetal development and programming.
Keith M Godfrey and David JP Barker (Fetal
nutrition and adult disease Am J Clin Nutr 2000
71 1344-1352)
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Early Nutrition Chronic Disease in Adulthood
(Waterland Garza, Am J Clin Nutr, 199969179-97)

• Epi studies BMI, CVD, Htn, IGT
• Animal studies
• Potential mechanisms of metabolic imprinting

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Obesity in Young Men after Famine Exposure in
Utero and early Infancy(Ravelli et al NEJM, 1976)

• N300, 000 Dutch military inductees at age 19
• Famine exposure in first 2 trimesters lead to 80
  higher prevalence of overweight (plt0.0005)
• Famine exposure in last trimester or famine
  exposure in first 5 months of life associated
  with 40 lower prevalence of overweight (plt0.005)

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BMI

• The relationship between birth weight and BMI
  complicates studies of birth weight and chronic
  disease

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Preadult Influences on Cardiovascular Disease and
Cancer (Leon Ben-Shlomo in A Lifecourse
approach to chronic disease epidemiology, 1997)

• 5 large retrospective studies - 4 found inverse
  relationship between birth weight and adult CVD
• Confounding issues include SES and BMI

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CVD

• The preponderance of data suggest an inverse
  association between birth weight and adult CVD
  risk. (Waterland and Garza)

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Blood Pressure

• Retrospective studies in diverse populations
  have found that birth weight is inversely
  correlated with adult blood pressure. Although
  each of the studies has some weaknesses, together
  they support a biological link between
  intrauterine growth and adult blood pressure
  (Waterland and Garza)

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Impaired Glucose Tolerance

• Several large retrospective cohort studies in
  several countries have found relationship between
  bw and IGT.
• 266 men and women at age 50 odds ratio for ITG
  or type II diabetes were 3.5 for men and 12 for
  women with birth weights lt 2.5 compared to gt3.4
  (Phillips et al, Diabetologia, 1994)

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Impaired Glucose Tolerance, cont..

• In some populations (ex Pima Indians) both high
  and low birth weights are associated with IGT in
  adults.

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Animal Models (Waterland and Garza)

• Overall the data from animal models of metabolic
  imprinting support the observed epidemiological
  associations.

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Epigenetics

• Epigenetics the study of stable alterations in
  gene expression that arise during development and
  cell proliferation Epigenetic phenomena do NOT
  change the actual, primary genetic sequence
• Epigenetic phenomena are important because,
  together with promotor sequences and
  transcription factors, they modulate when and at
  what level genes are expressed
• The protein context of a cell can be understood
  as an epigenetic phenomena.
• Examples include DNA methylation, histone
  hypo-acetylation, chromatin modifications,
  X-inactivation, and imprinting.

http//cnx.rice.edu/content/m11532/latest/
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Metabolic Imprinting

• the basic biological phenomena that putatively
  underlie relations among nutritional experiences
  of early life and later diseases.

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Metabolic Imprinting Characteristics

• Susceptibility limited to a critical ontogenic
  window early in development
• Persistent effect lasting through adulthood
• Specific and measurable outcome
• Dose-response or threshold relation between
  exposure and outcome

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Metabolic Imprinting Potential Mechanisms

• Organ structure
• Cell number function
• Clonal selection
• Metabolic differentiation

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Organ Structure

• Organogenesis starts early by 5 weeks
  rudimentary organs are in place, by 8 weeks
  organogenesis is nearly complete
• Driven by inductive signals from adjacent cells
  and morphogen gradients (ex retinoic acid/vit.
  A)
• Local concentrations of nutrients and metabolites
  may modulate this process.

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Cell Number

• Tissues go through limited periods of
  hyperplastic and hypertrophic growth
• Rate of growth is dependent on nutrient
  availability
• Winnicks rat studies found severe malnutrition
  during critical periods limited brain cell number
  
• An organs metabolic activity is limited by cell
  number

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Cell Function

• Early nutrition may influence the cascade that
  establishes cell specific patterns.
• Ex hepatocyte polyploidization - in adults
  hepatocytes often have gt normal complement of
  chromosomes and increased metabolic activity.
  Lack of polyploidization could limit hepatic
  metabolic activity.

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Clonal Selection

• Each organ is based on a finite number of founder
  cells which may have slight differences
• Founder cells that divide the most rapidly may
  disproportionally make up a tissue
• Nutrient availability may select cells with
  certain characteristics
• Ex cells with more active lipogenic pathways
  could grow faster if access to fatty acids was
  limited

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Metabolic Differentiation

• Process cells develop stable patterns of basal
  and inducible gene expression
• Cells are characterized by the ability to express
  a limited number of genes.
• Mechanisms of control include
• chromatin structure (DNA packaging)
• transcription factors (maintained through cell
  divisions)
• DNA methylation

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Fall et al, 1988
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Gluckman et al. Biology of the Neonate, 2005
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Topic 3

• Public Health Approaches to Nutrition and
  Pregnancy
• Assessment
• Policy Development
• Assurance

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Assessment

• Planning for Pregnancy
• Risk Behaviors

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Effects of pregnancy planning status on birth
outcomes and infant care (Kost et al. Family
Planning Perspectives, 1998)

• Analysis of 1988 NMIHS (n9122) and NSFG (n2548)
  data.

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Effects of pregnancy planning status on birth
outcomes and infant care (Kost et al. Family
Planning Perspectives, 1998)
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Effects of pregnancy planning status on birth
outcomes and infant care (Kost et al. Family
Planning Perspectives, 1998)

• Knowing the planning status of a pregnancy can
  help identify women who may need support to
  engage in prenatal behaviors that are associated
  with healthy outcomes and appropriate infant
  care.

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Surveillance for Pregnancy

• PRAMS results Washington State

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Alcohol
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MMWR, December 24, 2004
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Multivitamin Use
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Multivitamin Use
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Breastfeeding Duration
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Breastfeeding Duration
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Smoking
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Unintended Pregnancy
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Post-Partum Depression PRAMS
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Washington State PRAMS
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WA State PRAMS
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Key Indicators of Perinatal Health for Washington
Residents August 2005

• The total number of live births has remained
  stable since 1998 at approximately 80,000 births
  per year.
• Medicaid-funded deliveries represented 45.6 of
  births in 2003.
• Birth rates and pregnancy rates decreased among
  teens 15-17 years and 18-19 years, especially
  from 1993 to 2003.
• Since the mid-1990s, total infant mortality,
  race-specific infant mortality and
  Medicaid-specific infant mortality have decreased
  slightly.

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Indicators, cont.

• SIDS rates have decreased substantially since
  1990, however changing reporting practices of
  coroners/medical examiners have played a role in
  this decline.
• Smoking during pregnancy, as reported on the
  birth certificate, has declined since 1992.
• In 2002, the percent of women initiating
  breastfeeding was high in Washington State at
  approximately 90.

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Areas of Concern in WA State

• Total low birth weight has increased steadily
  since 1990, in part due to the increase in
  multiple deliveries.
• In 2003, African American and Native American
  infant mortality rates continued to exceed infant
  mortality rates of other race and ethnic groups.
• In 2003, the highest singleton low birth weight
  (LBW) rate was for African Americans.

Key Indicators of Perinatal Health for Washington
Residents August 2005
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Concerns, cont.

• The singleton VLBW rate among African Americans
  remained over twice the rate of Whites between
  1990 and 2003.
• In 2003, women receiving Medicaid had lower rates
  of first trimester prenatal care and higher rates
  of late and no prenatal care than women who did
  not receive Medicaid.
• In 2003, smoking rates during pregnancy were
  significantly higher for women receiving Medicaid
  than for women who did not receive Medicaid.
• In 2002, the unintended pregnancy rate was
  approximately 54.

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Healthy People 2010 Goals Related to Maternal and
Infant Nutrition
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Reduce low birth weight (LBW) and very low birth
weight (VLBW).
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Reduce preterm births
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Reduce the occurrence of spina bifida and other
neural tube defects (NTDs)

• Target 3 new cases per 10,000 live births.
• Baseline 6 new cases of spina bifida or another
  NTD per 10,000 live births in 1996.

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Increase the proportion of pregnancies begun with
an optimum folic acid level.
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Increase abstinence from alcohol, cigarettes, and
illicit drugs among pregnant women
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Increase the proportion of mothers who breastfeed
their babies
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Increase smoking cessation during pregnancy

• Target 30 percent.
• Baseline 12 percent smoking cessation during the
  first trimester of pregnancy in 1991 (age
  adjusted to the year 2000 standard population).

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Reduce growth retardation among low income
children under age 5 years

• Target 5 percent.
• Baseline 8 percent of low-income children under
  age 5 years were growth retarded in 1997 (defined
  as height-for-age below the fifth percentile in
  the age-gender appropriate population using the
  1977 NCHS/CDC growth charts31 preliminary data
  not age adjusted).

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Reduce iron deficiency among young children and
females of childbearing age.
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Reduce anemia among low-income pregnant females
in their third trimester

• Target 20 percent.
• Baseline 29 percent of low-income pregnant
  females in their third trimester were anemic
  (defined as hemoglobin lt 11.0 g/dL) in 1996

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Anemia Rates - 1996

• African American, non-Hispanic 44
• American Indian/Alaska Native 31
• Asian/Pacific Islander 26
• Hispanic 25
• White, non-Hispanic 24