The deleterious effects of maternal malnutrition
Reshma Patil and Avinash Patil write on the substantial health and economic consequences of poor maternal nutrition.
The United Nations’ (UN) Millennium Development Goals aim to halve the proportion of people suffering from hunger between 1990 and 2015. (1) Currently, 11% of the total global disease burden has been attributed to undernutrition. (2) While the sequelae of child malnutrition have been well studied, the longitudinal effects of fetal growth restriction and perinatal nutrient deficiencies are gaining increasing attention. (2) Intrauterine growth restriction followed by rapid weight gain in childhood is associated with increased risk of cardiovascular and metabolic disease. (3,4) Additionally, the UN has reported that the effects of chronic malnutrition are long lasting, often leading to recurrent illnesses, decreased educational attainment, and a lower level of skills and lifetime earnings. (1)
Intrauterine growth restriction (IUGR) is defined by the American College of Obstetrics & Gynecology (ACOG) as a weight-for-gestational age less than the 10th percentile in a fetus. (5) Despite this classification, adverse perinatal outcomes are generally confined to fetuses below the 5th percentile. (5) While many risk factors exist for IUGR, they can be broadly organized as maternal, fetal, or placental. Notable risk factors for IUGR include low pre-pregnancy weight, poor maternal weight gain, maternal hypertension or diabetes, extremes of reproductive age (<16 years or >35 years), low socioeconomic status, and fetal chromosomal anomalies (anencephaly, Trisomy 13). Historical studies of the Siege of Leningrad and the Dutch famine (World War II period) suggest that maternal caloric intake must be below 1500 kCal per day before effects on birth weight are evident. Perinatal morbidity and mortality is significantly increased, with evidence that 26% of all stillbirths were the result of IUGR.
Maternal nutrient intake during pregnancy has been identified as a modifiable factor affecting birth weight. Studies of dietary patterns among pregnant women have correlated a “Western diet” of red meat and high-fat dairy with decreased birth weight. (6) Furthermore, this dietary pattern has been associated with decreasing education and age, increasing parity, smoking, and community housing. (7) Vitamin D, which uses sunlight as part of its synthetic process, can be deficient in women living in populations where “sunshine deprivation” is common. Typically, diet provides less than 10% of the body’s vitamin D requirements. In many countries, time spent outdoors is limited either due to cultural/religious reasons or a shifting lifestyle. The resultant effect is decreased vitamin D production affecting calcium and bone homeostasis. (8)
The implications of maternal malnutrition reach far beyond the perinatal period. The developmental-origins hypothesis posits that long-term risk of disease is initially induced through adaptive responses of the fetus to maternal cues regarding her health or physical state. (4) This developmental plasticity is due to the interactions of the genome and epigenome influencing the mature phenotype and affecting sensitivity to later environmental factors, thus modifying risk of disease (even as an adult). For example, a fetus with intrauterine growth restriction followed by improved nutrition later in development has a greater risk of developing coronary artery disease, hypertension, or type 2 diabetes mellitus. (3,4) Similarly, studies have linked single nutrient deficiencies with long-latency diseases — the implication is that each affects many organ systems. Maternal deficiency of vitamin D during pregnancy affects fetal innate immunity, increasing susceptibility to autoimmune diseases, multiple sclerosis, systemic lupus erythematosis, rheumatoid arthritis, and type 2 diabetes. (8) Similar concerns are present with perinatal deficiencies of vitamin A, zinc, iron, vitamin B12, and iodine. (2)
The consequences of maternal malnutrition can be staggering economically. Worldwide, IUGR is responsible for 13.5 million disability-adjusted life-years, or DALYs (roughly 1 lost year of healthy life per DALY). (2) ACOG recommends delivery of fetuses with IUGR when risks of continued in utero development outweigh the benefits. This contributes to an increased number of cesarean sections for delivery, and often a stay in the neonatal ICU for the newborn. In 2005 the number of c-sections jumped 62 percent within a decade; approximately 1.3 million women gave birth by this method. (9) These increased numbers are accompanied by rising costs as well. Similarly, the costs of medical care for a premature infant continue to rise. A study conducted in 25 hospitals from January 1993 to September 1994 shows that the total cost for all 3,288 infants admitted into the NICU was $49,457; the cost per day for all the infants was $1,115. (10) The effect of maternal undernutrition has been suggested to span at least three generations, adding an intergenerational dimension to this problem. According to Meera Shekar, a World Bank nutrition specialist, “If we miss this window [of opportunity...between conception through the first two years of life], we miss a whole generation…[Nutrition] is something that can drive economic growth rather than riding on the coat-tails of economic growth, because children who are well-nourished have been shown to have much higher income potential as adults.” (11)
Although the task is formidable, efforts are underway to address the issue of malnutrition and its impact upon society. Uganda, which has been hailed as the first country to state that food is a basic human right, (1) implemented a Food and Nutrition Policy to combat malnutrition caused by ignorance and poverty. (12) Nongovernmental organizations such as Doctors Without Borders have created food substitutes to ensure that the poverty stricken can obtain at least their minimal nutrition. “Plumpynut” has been released in Niger to much acclaim; several other nations have now expressed interest in utilizing this product in their fight against malnutrition. (13) The common theme between these approaches is that a modest investment can yield great dividends to both individuals and the country as a whole. Improved nutritional status during the childbearing years leads to healthier and more productive offspring. These same individuals are better prepared to contribute to their economy and break the cycle of poverty and disease.
Avinash S. Patil MD, resident physician in Obstetrics and Gynecology (3rd year post graduate) at the University of Tennessee Health Science Centre, Memphis, Tennessee, U.S.A.
apatil@utmem.edu
and
Reshma S. Patil, AB, recently graduated in international relations, Mount Holyoke College, South Hadley, Massachusetts, USA.
patil.rs@gmail.com
References
1. United Nations System Standing Committee on Nutrition Reports on the World Nutrition Situation. [Online]. [cited 2008 Jul 21] http://www.unsystem.org/scn/Publications/html/RWNS.html
2. Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, Mathers C, Rivera J. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008;371:243-60.
3. Victoria CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, Sachdev HS. Maternal and child undernutrition: consequences for adult health and human capital. Lancet. 2008;371:340-57.
4. Gluckman PD, Hanson MA, Cooper C, Thornburg K. Effect of In Utero and Early-Life Conditions on Adult Health and Disease. NEJM. 2008;359:61-73.
5. Cox SM. Intrauterine Growth Restriction. [Online]. In: ACOG Practice Bulletin. Num 12. Available from: PubMed. [cited 2008 Sep 6].
6. Knudsen VK, Orozova-Bekkevold IM, Mikkelsen TB, Wolff S, Olsen SF. Major dietary patterns in pregnancy and fetal growth. EJCN. 2008;62:463-70.
7. Northstone K, Emmett P, Rogers I. Dietary patterns in pregnancy and associations with socio-demographic and lifestyle factors. EJCN. 2008;62:471-9.
8. Dawodu A, Wagner CL. Mother-child vitamin D deficiency: an international perspective. Arch Dis Child. 2007;92:737-40.
9. Agency for Healthcare Research and Quality. [Online]. 2008 Feb [cited 2008 Jul 22]; http://www.ahrq.gov/
10. Rogowski J. Measuring the Cost of Neonatal and Perinatal Care. Pediatrics 1999 Jan;103(1):329-335.
11. Nutrition: What Is Malnutrition? [Online]. [cited 2008 Jul 20]; http://youthink.worldbank.org/issues/health/nutrition/malnutrition.php
12. The Uganda Food and Nutrition Policy. [Online]. 2003 [cited 2008 Jul 22]; pma.go.ug/pdfs/food%20and%20nutrition%20policy.pdf
13. CBS News 60 Minutes A Life Saver Called “Plumpynut”. [Online]. 2008 Jun 22 [cited 2008 Jul 22]; http://www.cbsnews.com/stories/2007/10/19/60minutes/main3386661.shtml