Women's Nutrition And Reproductive Health - Cornell University

The story of LilaWomen’s Nutrition andReproductive HealthKathleen M. Rasmussen, ScDProfessorDivision of Nutritional SciencesCornell UniversityOctober 4, 2011Lila’s mother was undernourished, and Lila was born small.She grew up into an undernourished woman, and her daughter was LBW, and undernourished as a child.Lila’s daughter is likely to grow into an undernourished woman, and to have LBW babies.From: King FS, Burgess A. Nutrition for Developing Countries. Oxford: OxfordMedical Publications, 1993.Nutrition during a woman’s lifeNutrition during a woman’s lifeFrom: ACC/SCN and IFPRI. 4th Report on the World Nutrition Situation:Nutrition Throughout the Life Cycle. Geneva: WHO, 2000.From: ACC/SCN and IFPRI. 4th Report on the World Nutrition Situation:Nutrition Throughout the Life Cycle. Geneva: WHO, 2000.Nutrition during a woman’s lifeNutrition during a woman’s lifeFrom: ACC/SCN and IFPRI. 4th Report on the World Nutrition Situation:Nutrition Throughout the Life Cycle. Geneva: WHO, 2000.From: ACC/SCN and IFPRI. 4th Report on the World Nutrition Situation:Nutrition Throughout the Life Cycle. Geneva: WHO, 2000.1

Nutrition during a woman’s lifeNutrition during a woman’s lifeFrom: ACC/SCN and IFPRI. 4th Report on the World Nutrition Situation:Nutrition Throughout the Life Cycle. Geneva: WHO, 2000.From: ACC/SCN and IFPRI. 4th Report on the World Nutrition Situation:Nutrition Throughout the Life Cycle. Geneva: WHO, 2000.Photo: BI Strassmann.Menarche and menstruationAssociation of height and fatness withage at menarche (n 213)54321Height (cm) 1515-1616-1717-1818-19 190 113 301114 400150 150Relative risk ( 95% CI) of menarchebeforee age 12.5 yFrom: Strassmann BI. Evolutionary Anthropology 1996;5:157.Quetelet's index (kg/m2)From: Maclure M, et al. Am J Clin Nutr 1991;54:649.2

Maternal growthin knee height isassociated withlower birthweightamong multiparous,but not primiparous,adolescentsAssociation of maternal age with measures ofiron status, folate status and anemia: Bangladesh,nulliparous married womenConsequences of early pregnancy forthe girl herself Unprepared for motherhood in terms of socialdevelopment– Leads to poor mothering behavior Unprepared for motherhood in terms of physicaldevelopment– Leads to impaired growth (particularly in pelvic size)or progressive malnutrition– May lead to “maternal depletion” during or after herchildbearing years– Increased risk of prolonged labor leading to obstetricinjury or deathConsequences of early pregnancy forsociety If the girls survives, she may contribute less tosociety– Lack of completed education– Physical disability from obstetric injury– Higher population growth than if childbearingstarts later If she dies, her productivity is lost and she mayalso leave orphaned childrenFrom: Prentice AM, Prentice A. NNew Scientist 1988;118(1608):42.From: Khambalia A, et al. J Nutr 2009;139:1179.Pregnancy3

How do we know how much of anutrient is needed?How do we know how much of anutrient is needed? Experimental animals– Feed an “open‐formula” diet with the specificnutrient deleted– See if evidence of deficiency developsCan we do this in people? Human subjects– Feed them more of what might be missing– See if their health improves in some perceptibleand (better yet) measurable wayMRC study ok/geos/ga.htmlFrom: Prentice AM, Prentice A. New Scientist 988;118(1608):42.4

Seasonal pattern of birthweight in control and interventionvillages in GambiaEffect of maternal food supplementationduring pregnancy on birthweight: GambiaFrom: Ceesay S., et al. Br Med J 1997;315:786.Adjusted** birthweight (g)3500PresupplementationΔ 89 62PostsupplementationΔ 11 58Δ 99 44DryAll year3000250020000WetSeason*Adjusted for sex, month, parity and gestational ageFrom: Prentice AM, et al. Am J Clin Nutr 1987;46:912.Effect of prenatal supplementation onperinatal and neonatal death ratesamong 2,092 births over 5 y in rural GambiaNutritional costs of reproductionFrom: Otten JJ, et al. Dietary Reference Intakes. Washington, DC:National Academy Press, 2006.Life StageLBW--all yearNon‐pregnant(19‐30 y old)LBW--hungryLBW--harvestStillbi thStillbirthsNeonatal deathsPostneonatal deathsPerinatal deaths0.00.20.40.60.81.01.21.41.61.8Odds ratioFrom: Ceesay SM et al. Br Med J itamin A(μg/d)Formula based onage, height, weightand physical activity*461870071277707191300Pregnancygy1st trimesternd2 trimester3rd trimester 0** 340 452Lactation0‐6 mo7‐12 mo 330† 400‡*EER 354 – (6.91*age [y]) PA [(9.36*weight[kg]) 726*height[m])]**Pregnancy energy deposition†Milk energy output – weight loss‡Milk energy outputEffect of iron/folic acid or multiple micronutrientsupplements v. folic acid alone among pregnant womenby household wealth index: China, n 5828 (clustered)Relative risk (95% CI) v.folic acidd alone1.6Iron/folic acidMultiple lthierLBW ( 2500 g)PoorestWealthiergPreterm ( 37 wk)From: Zeng L, et al. Int J Epidemiol 2011;40:350.From: UNICEF/WHO/UNU. 1999.5

Effect of multiple micronutrient supplements on infant deaths (top)and fetal loss and maternal death (bottom): Indonesia, n 31,290Early infant mortalityNeonatal mortalityEarly neonatal mortalityLate neonatal mortalityPostneonatal mortalityFetal lossAbortionsStillbirthsFetal loss and neonatal mortalityPerinatal mortalityMaternal mortality (to 12 wk)0.0Lombok0.20.40.60.81.01.21.41.61.8Relative risk (95% CI)From: http://www.cia.govFrom: SUMMIT Study Group. Lancet 2008;371:215.Early infant, birth to 90 d; early neonatal, birth to 7 d; late neonatal, 8 to 28 d; postneonatal 28 to 90 d;fetal loss, abortions stillbirths; fetal loss and neonatal, abortions stillbirths neonatal deaths;perinatal, stillbirth early neonatalConclusions Some women need protein/energy, somemicronutrients and some both Undernourished pregnant women may benefitppbyy havinggfrom nutritional supplementationlarger infants and, in some cases, by gainingweight themselves– The increase in birthweight is modest– Some interventions also reduce stillbirths and/orcomponents of infant mortalityFrom: SUMMIT Study Group. Lancet 2008;371:215.Nutritional costs of reproductionFrom: Otten JJ, et al. Dietary Reference Intakes. Washington, DC:National Academy Press, 2006.LactationLife StageNon‐pregnant(19‐30 y old)From: Rowland MGM, Whitehead RG.The Epidemiology of Protein‐EnergyMalnutrition in Children in a WestAfrican Village Community.Cambridge: Dunn Nutrition d)Vitamin A(μg/d)Formula based onage, height, weightand physical activity*461870071277707191300Pregnancygy1st trimesternd2 trimester3rd trimester 0** 340 452Lactation0‐6 mo7‐12 mo 330† 400‡*EER 354 – (6.91*age [y]) PA [(9.36*weight[kg]) 726*height[m])]**Pregnancy energy deposition†Milk energy output – weight loss‡Milk energy output6

From: Prentice AM, Prentice A. New Scientist ations/factbook/geos/gt.html7

Effect of maternal supplementation from 5-25 weekspostpartum on maternal body weightamong undernourished Guatemalan womenMaternal wweight (kg)46444240HESLESAbove median CCBelow median CC38510152025Duration of lactation (wk)From: Gonzalez-Cossio T. PhD dissertation. Ithaca, NY:Cornell University, 1994.Effect of maternal supplementation from 5-25 weekspostpartum on exclusive breastfeeding (EBF)among undernourished Guatemalan womenEffect of maternal supplementation from 5-25 weekspostpartum on infant milk intakeamong undernourished Guatemalan women100Proportionn of EBF (%)Infant milk iintake (g/d)800750700Complete SampleHESLES*959085Complete sample80HESLES7570656505051015202530Duration of lactation (wk)152025From: Gonzalez-Cossio T. PhD dissertation. Ithaca, NY:Cornell University, 1992.Photos: K.M. Rasmussen.From: Gonzalez-Cossio T. PhD dissertation. Ithaca, NY:Cornell University, geos/id.html10Duration of lactation (wk)8

Effect of high-dose vitamin A supplementationof the mother on infant vitamin A statusat 6 mo of ageEffect of high‐dose maternal supplementation with vitamin Aon maternal serum and milk retinol concentrationsP 0.008P 0.01Proportion (%%) of subjects10080Vitamin A (n 68)Placebo (n 70)P 0.0056040200From: Stoltzfus RJ. Unpublished PhD dissertation, Cornell Univ., 1992. 0.052 0.052Serum retinol category (μmol/L)From: Stoltzfus RJ, et al. J Nutr 1992;123:666.ConclusionsNutrition during a woman’s life In studies with strong designs, bothprotein/energy and micronutrientsupplements improve lactation performance(e.g. exclusive breastfeeding, nutrientstransferred to the baby) Maintenance of exclusive breastfeeding isimportant for the reduction of infection aswell as for birth spacing, which promotes bothmaternal and child healthFrom: ACC/SCN and IFPRI. 4th Report on the World Nutrition Situation:Nutrition Throughout the Life Cycle. Geneva: WHO, 2000.Millenium Development Goals Reduce by three‐quartersthree quarters the maternalmortality ratio Achieve, by 2015, universal access toreproductive health9

Nutrition during a woman's life From: ACC/SCN and IFPRI. 4th Report on the World Nutrition Situation: Nutrition Throughout the Life Cycle. Geneva: WHO, 2000. Nutrition during a woman's life From: ACC/SCN and IFPRI. 4th Report on the World Nutrition Situation: Nutrition Throughout the Life Cycle. Geneva: WHO, 2000.