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Perumal N, Wang D, Darling AM, Liu E, Wang M, Ahmed T, Christian P, Dewey KG, Kac G, Kennedy SH, Subramoney V, Briggs B, Fawzi WW. Suboptimal gestational weight gain and neonatal outcomes in low and middle income countries: individual participant data meta-analysis. BMJ 2023; 382:e072249. [PMID: 37734757 PMCID: PMC10512803 DOI: 10.1136/bmj-2022-072249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE To estimate the associations between gestational weight gain (GWG) during pregnancy and neonatal outcomes in low and middle income countries. DESIGN Individual participant data meta-analysis. SETTING Prospective pregnancy studies from 24 low and middle income countries. MAIN OUTCOME MEASURES Nine neonatal outcomes related to timing (preterm birth) and anthropometry (weight, length, and head circumference) at birth, stillbirths, and neonatal death. ANALYSIS METHODS A systematic search was conducted in PubMed, Embase, and Web of Science which identified 53 prospective pregnancy studies published after the year 2000 with data on GWG, timing and anthropometry at birth, and neonatal mortality. GWG adequacy was defined as the ratio of the observed maternal weight gain over the recommended weight gain based on the Institute of Medicine body mass index specific guidelines, which are derived from data in high income settings, and the INTERGROWTH-21st GWG standards. Study specific estimates, adjusted for confounders, were generated and then pooled using random effects meta-analysis models. Maternal age and body mass index before pregnancy were examined as potential modifiers of the associations between GWG adequacy and neonatal outcomes. RESULTS Overall, 55% of participants had severely inadequate (<70%) or moderately inadequate (70% to <90%) GWG, 22% had adequate GWG (90-125%), and 23% had excessive GWG (≥125%). Severely inadequate GWG was associated with a higher risk of low birthweight (adjusted relative risk 1.62, 95% confidence interval 1.51 to 1.72; 48 studies, 93 337 participants; τ2=0.006), small for gestational age (1.44, 1.36 to 1.54; 51 studies, 93 191 participants; τ2=0.016), short for gestational age (1.47, 1.29 to 1.69; 40 studies, 83 827 participants; τ2=0.074), and microcephaly (1.57, 1.31 to 1.88; 31 studies, 80 046 participants; τ2=0.145) compared with adequate GWG. Excessive GWG was associated with a higher risk of preterm birth (1.22, 1.13 to 1.31; 48 studies, 103 762 participants; τ2=0.008), large for gestational age (1.44, 1.33 to 1.57; 47 studies, 90 044 participants; τ2=0.009), and macrosomia (1.52, 1.33 to 1.73; 29 studies, 68 138 participants; τ2=0) compared with adequate GWG. The direction and magnitude of the associations between GWG adequacy and several neonatal outcomes were modified by maternal age and body mass index before pregnancy. CONCLUSIONS Inadequate and excessive GWG are associated with a higher risk of adverse neonatal outcomes across settings. Interventions to promote optimal GWG during pregnancy are likely to reduce the burden of adverse neonatal outcomes, however further research is needed to assess optimal ranges of GWG based on data from low and middle income countries.
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Affiliation(s)
- Nandita Perumal
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC, USA
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Dongqing Wang
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, VA, USA
| | - Anne Marie Darling
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Enju Liu
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Molin Wang
- Department of Epidemiology, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Biostatistics, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Tahmeed Ahmed
- Nutrition & Clinical Services, International Centre for Diarrheal Disease Research, Dhaka, Bangladesh
| | - Parul Christian
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kathryn G Dewey
- Department of Nutrition, University of California, Davis, CA, USA
| | - Gilberto Kac
- Nutritional Epidemiology Observatory, Josué de Castro Nutrition Institute, Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | - Stephen H Kennedy
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | | | - Brittany Briggs
- Certara USA, on behalf of the Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Epidemiology, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Nutrition, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
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Issarapu P, Arumalla M, Elliott HR, Nongmaithem SS, Sankareswaran A, Betts M, Sajjadi S, Kessler NJ, Bayyana S, Mansuri SR, Derakhshan M, Krishnaveni GV, Shrestha S, Kumaran K, Di Gravio C, Sahariah SA, Sanderson E, Relton CL, Ward KA, Moore SE, Prentice AM, Lillycrop KA, Fall CHD, Silver MJ, Chandak GR. DNA methylation at the suppressor of cytokine signaling 3 (SOCS3) gene influences height in childhood. Nat Commun 2023; 14:5200. [PMID: 37626025 PMCID: PMC10457295 DOI: 10.1038/s41467-023-40607-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 08/01/2023] [Indexed: 08/27/2023] Open
Abstract
Human height is strongly influenced by genetics but the contribution of modifiable epigenetic factors is under-explored, particularly in low and middle-income countries (LMIC). We investigate links between blood DNA methylation and child height in four LMIC cohorts (n = 1927) and identify a robust association at three CpGs in the suppressor of cytokine signaling 3 (SOCS3) gene which replicates in a high-income country cohort (n = 879). SOCS3 methylation (SOCS3m)-height associations are independent of genetic effects. Mendelian randomization analysis confirms a causal effect of SOCS3m on height. In longitudinal analysis, SOCS3m explains a maximum 9.5% of height variance in mid-childhood while the variance explained by height polygenic risk score increases from birth to 21 years. Children's SOCS3m is associated with prenatal maternal folate and socio-economic status. In-vitro characterization confirms a regulatory effect of SOCS3m on gene expression. Our findings suggest epigenetic modifications may play an important role in driving child height in LMIC.
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Affiliation(s)
- Prachand Issarapu
- Genomic Research on Complex Diseases (GRC-Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, Telangana, India
- MRC Unit The Gambia at The London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Manisha Arumalla
- Genomic Research on Complex Diseases (GRC-Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, Telangana, India
| | - Hannah R Elliott
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Suraj S Nongmaithem
- Genomic Research on Complex Diseases (GRC-Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, Telangana, India
| | - Alagu Sankareswaran
- Genomic Research on Complex Diseases (GRC-Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, Telangana, India
- Academy of Scientific and Innovative Research, AcSIR, Ghaziabad, India
| | - Modupeh Betts
- MRC Unit The Gambia at The London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Sara Sajjadi
- Genomic Research on Complex Diseases (GRC-Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, Telangana, India
- Academy of Scientific and Innovative Research, AcSIR, Ghaziabad, India
| | - Noah J Kessler
- Department of Genetics, University of Cambridge, Cambridge, UK
| | - Swati Bayyana
- Genomic Research on Complex Diseases (GRC-Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, Telangana, India
- Academy of Scientific and Innovative Research, AcSIR, Ghaziabad, India
| | - Sohail R Mansuri
- Genomic Research on Complex Diseases (GRC-Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, Telangana, India
- Academy of Scientific and Innovative Research, AcSIR, Ghaziabad, India
| | - Maria Derakhshan
- MRC Unit The Gambia at The London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - G V Krishnaveni
- Epidemiology Research Unit, CSI Holdsworth Memorial Hospital, Mysore, Karnataka, India
| | - Smeeta Shrestha
- Genomic Research on Complex Diseases (GRC-Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, Telangana, India
| | - Kalyanaraman Kumaran
- Epidemiology Research Unit, CSI Holdsworth Memorial Hospital, Mysore, Karnataka, India
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - Chiara Di Gravio
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Eleanor Sanderson
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Caroline L Relton
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kate A Ward
- MRC Unit The Gambia at The London School of Hygiene and Tropical Medicine (LSHTM), London, UK
- Department of Women & Children's Health, King's College London, London, UK
| | - Sophie E Moore
- MRC Unit The Gambia at The London School of Hygiene and Tropical Medicine (LSHTM), London, UK
- Department of Women & Children's Health, King's College London, London, UK
| | - Andrew M Prentice
- MRC Unit The Gambia at The London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Karen A Lillycrop
- School of Medicine, University of Southampton, Southampton, UK
- Biological Sciences, University of Southampton, Southampton, UK
| | - Caroline H D Fall
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - Matt J Silver
- MRC Unit The Gambia at The London School of Hygiene and Tropical Medicine (LSHTM), London, UK.
| | - Giriraj R Chandak
- Genomic Research on Complex Diseases (GRC-Group), CSIR-Centre for Cellular and Molecular Biology, Hyderabad, Telangana, India.
- Academy of Scientific and Innovative Research, AcSIR, Ghaziabad, India.
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Darling AM, Wang D, Perumal N, Liu E, Wang M, Ahmed T, Christian P, Dewey KG, Kac G, Kennedy SH, Subramoney V, Briggs B, Fawzi WW. Risk factors for inadequate and excessive gestational weight gain in 25 low- and middle-income countries: An individual-level participant meta-analysis. PLoS Med 2023; 20:e1004236. [PMID: 37486938 PMCID: PMC10406332 DOI: 10.1371/journal.pmed.1004236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/07/2023] [Accepted: 04/21/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Many women experience suboptimal gestational weight gain (GWG) in low- and middle-income countries (LMICs), but our understanding of risk factors associated with GWG in these settings is limited. We investigated the relationships between demographic, anthropometric, lifestyle, and clinical factors and GWG in prospectively collected data from LMICs. METHODS AND FINDINGS We conducted an individual participant-level meta-analysis of risk factors for GWG outcomes among 138,286 pregnant women with singleton pregnancies in 55 studies (27 randomized controlled trials and 28 prospective cohorts from 25 LMICs). Data sources were identified through PubMed, Embase, and Web of Science searches for articles published from January 2000 to March 2019. Titles and abstracts of articles identified in all databases were independently screened by 2 team members according to the following eligibility criteria: following inclusion criteria: (1) GWG data collection took place in an LMIC; (2) the study was a prospective cohort or randomized trial; (3) study participants were pregnant; and (4) the study was not conducted exclusively among human immunodeficiency virus (HIV)-infected women or women with other health conditions that could limit the generalizability of the results. The Institute of Medicine (IOM) body mass index (BMI)-specific guidelines were used to determine the adequacy of GWG, which we calculated as the ratio of the total observed weight gain over the mean recommended weight gain. Study outcomes included severely inadequate GWG (percent adequacy of GWG <70), inadequate GWG (percent adequacy of GWG <90, inclusive of severely inadequate), and excessive GWG (percent adequacy of GWG >125). Multivariable estimates from each study were pooled using fixed-effects meta-analysis. Study-specific regression models for each risk factor included all other demographic risk factors measured in a particular study as potential confounders, as well as BMI, maternal height, pre-pregnancy smoking, and chronic hypertension. Risk factors occurring during pregnancy were further adjusted for receipt of study intervention (if any) and 3-month calendar period. The INTERGROWTH-21st standard was used to define high and low GWG among normal weight women in a sensitivity analysis. The prevalence of inadequate GWG was 54%, while the prevalence of excessive weight gain was 22%. In multivariable models, factors that were associated with a higher risk of inadequate GWG included short maternal stature (<145 cm), tobacco smoking, and HIV infection. A mid-upper arm circumference (MUAC) of ≥28.1 cm was associated with the largest increase in risk for excessive GWG (risk ratio (RR) 3.02, 95% confidence interval (CI) [2.86, 3.19]). The estimated pooled difference in absolute risk between those with MUAC of ≥28.1 cm compared to those with a MUAC of 24 to 28.09 cm was 5.8% (95% CI 3.1% to 8.4%). Higher levels of education and age <20 years were also associated with an increased risk of excessive GWG. Results using the INTERGROWTH-21st standard among normal weight women were similar but attenuated compared to the results using the IOM guidelines among normal weight women. Limitations of the study's methodology include differences in the availability of risk factors and potential confounders measured in each individual dataset; not all risk factors or potential confounders of interest were available across datasets and data on potential confounders collected across studies. CONCLUSIONS Inadequate GWG is a significant public health concern in LMICs. We identified diverse nutritional, behavioral, and clinical risk factors for inadequate GWG, highlighting the need for integrated approaches to optimizing GWG in LMICs. The prevalence of excessive GWG suggests that attention to the emerging burden of excessive GWG in LMICs is also warranted.
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Affiliation(s)
- Anne Marie Darling
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Dongqing Wang
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, Virginia, United States of America
| | - Nandita Perumal
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Enju Liu
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Molin Wang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Tahmeed Ahmed
- Nutrition & Clinical Services, International Centre for Diarrheal Disease Research, Bangladesh
| | - Parul Christian
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Kathryn G. Dewey
- Department of Nutrition, University of California, Davis, Davis, California, United States of America
| | - Gilberto Kac
- Nutritional Epidemiology Observatory, Josué de Castro Nutrition Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Stephen H. Kennedy
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | | | - Brittany Briggs
- Certara USA, Inc. on behalf of the Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Wafaie W. Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
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Ciulei MA, Smith ER, Perumal N, Jakazi CS, Sudfeld CR, Gernand AD. Nutritious Supplemental Foods for Pregnant Women from Food Insecure Settings: Types, Nutritional Composition, and Relationships to Health Outcomes. Curr Dev Nutr 2023; 7:100094. [PMID: 37250388 PMCID: PMC10209485 DOI: 10.1016/j.cdnut.2023.100094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/21/2023] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
There is growing evidence that the provision of nutritious supplemental foods to undernourished pregnant women can improve maternal and infant outcomes. However, comparing and synthesizing the evidence base is complicated by differences in interventions and products and the use of ambiguous terminology. We aimed to define 2 common types of nutritious supplemental foods used in pregnancy, balanced energy-protein (BEP) supplements and lipid-based nutrient supplements (LNS), and to review the evidence supporting each via a narrative review of systematic reviews and meta-analyses (SRMAs). Information about the nutritional composition of the food supplements and their effects on maternal and infant outcomes was abstracted. Five SRMAs (n = 20 trials) evaluated the effect of BEP compared with no BEP/control (comparison group commonly received iron and folic acid [IFA]). BEP foods/products ranged in calories (118-1017 kcals), protein (3-50 g), fat (6-57 g), and micronutrient content. Overall, maternal BEP improved birth weight and reduced the risk of stillbirth and small for gestational age when compared with no BEP/control in pregnancy. Three SRMAs (n = 5 trials) evaluated the effect of LNS compared with IFA or multiple micronutrients (MMNs). The LNS interventions comprised small- and large-quantity LNS that ranged in calories (118-746 kcals), protein (3-21 g), fat (10-53 g), and micronutrient content. LNS compared with IFA increased pregnancy duration, birth weight, and birth length and reduced the risk of small for gestational age and infant stunting; however, no beneficial effect of LNS was identified when compared with MMN. Despite heterogeneity in the nutritional composition of BEP supplements, the evidence suggests that in nutritionally at-risk populations, these products may improve birth outcomes in pregnant women. The evidence is limited but promising when LNS is compared with IFA in improving maternal and infant outcomes. Overall, BEP, compared with MMN or LNS, are key areas that have not been studied and deserve attention.
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Affiliation(s)
- Mihaela A. Ciulei
- Department of Nutritional Sciences, the Pennsylvania State University, University Park, PA, United States
| | - Emily R. Smith
- Department of Global Health, George Washington University Milken Institute School of Public Health, Washington, DC, United States
- Department of Exercise and Nutrition Sciences, George Washington University Milken Institute School of Public Health, Washington, DC, United States
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, United States
| | - Nandita Perumal
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, United States
| | - Chioniso S. Jakazi
- Department of Global Health, George Washington University Milken Institute School of Public Health, Washington, DC, United States
| | - Christopher R. Sudfeld
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, United States
- Department of Nutrition, Harvard School of Public Health, Boston, MA, United States
| | - Alison D. Gernand
- Department of Nutritional Sciences, the Pennsylvania State University, University Park, PA, United States
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Woo JG, Melchior JT, Swertfeger DK, Remaley AT, Sise EA, Sosseh F, Welge JA, Prentice AM, Davidson WS, Moore SE, Woollett LA. Lipoprotein subfraction patterns throughout gestation in The Gambia: changes in subfraction composition and their relationships with infant birth weights. Lipids Health Dis 2023; 22:19. [PMID: 36737730 PMCID: PMC9896684 DOI: 10.1186/s12944-023-01776-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/16/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Lipoprotein subfraction concentrations have been shown to change as gestation progresses in resource-rich settings. The objective of the current study was to evaluate the impact of pregnancy on different-sized lipoprotein particle concentrations and compositions in a resource-poor setting. METHOD Samples were collected from pregnant women in rural Gambia at enrollment (8-20 weeks), 20 weeks, and 30 weeks of gestation. Concentrations of different-sized high-density, low-density, and triglyceride-rich lipoprotein particles (HDL, LDL, and TRL, respectively) were measured by nuclear magnetic resonance in 126 pooled plasma samples from a subset of women. HDL was isolated and the HDL proteome evaluated using mass spectroscopy. Subfraction concentrations from women in The Gambia were also compared to concentrations in women in the U.S. in mid gestation. RESULTS Total lipoprotein particles and all-sized TRL, LDL, and HDL particle concentrations increased during gestation, with the exception of medium-sized LDL and HDL particles which decreased. Subfraction concentrations were not associated with infant birth weights, though relationships were found between some lipoprotein subfraction concentrations in women with normal versus low birth weight infants (< 2500 kg). HDL's proteome also changed during gestation, showing enrichment in proteins associated with metal ion binding, hemostasis, lipid metabolism, protease inhibitors, proteolysis, and complement activation. Compared to women in the U.S., Gambian women had lower large- and small-sized LDL and HDL concentrations, but similar medium-sized LDL and HDL concentrations. CONCLUSIONS Most lipoprotein subfraction concentrations increase throughout pregnancy in Gambian women and are lower in Gambian vs U.S. women, the exception being medium-sized LDL and HDL particle concentrations which decrease during gestation and are similar in both cohorts of women. The proteomes of HDL also change in ways to support gestation. These changes warrant further study to determine how a lack of change or different changes could impact negative pregnancy outcomes.
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Affiliation(s)
- Jessica G Woo
- Departments of Pediatrics and Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - John T Melchior
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Biological Sciences Division, Pacific Northwest National Laboratory, WA, Richland, USA
| | - Debi K Swertfeger
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Alan T Remaley
- Lipoprotein Metabolism Section, Cardio-Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ebrima A Sise
- MRC Unit The Gambia, London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Fatou Sosseh
- MRC Unit The Gambia, London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Jeffrey A Welge
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew M Prentice
- MRC Unit The Gambia, London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - W Sean Davidson
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sophie E Moore
- MRC Unit The Gambia, London School of Hygiene and Tropical Medicine, Banjul, The Gambia
- Department of Women and Children's Health, King's College London, London, UK
| | - Laura A Woollett
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Liu E, Wang D, Darling AM, Perumal N, Wang M, Ahmed T, Christian P, Dewey KG, Kac G, Kennedy S, Subramoney V, Briggs B, Fawzi WW. Effects of prenatal nutritional supplements on gestational weight gain in low- and middle-income countries: a meta-analysis of individual participant data. Am J Clin Nutr 2022; 116:1864-1876. [PMID: 36130877 PMCID: PMC10843965 DOI: 10.1093/ajcn/nqac259] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/29/2022] [Accepted: 09/13/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Gestational weight gain (GWG) below or above the Institute of Medicine (IOM) recommendations has been associated with adverse perinatal outcomes. Few studies have examined the effect of prenatal nutrient supplementations on GWG in low- and middle-income countries (LMICs). OBJECTIVES We aimed to investigate the effects of multiple micronutrient supplements (MMSs) and small-quantity lipid-based nutrient supplements (LNSs) on GWG in LMICs. METHODS A 2-stage meta-analysis of individual participant data was conducted to examine the effects of MMSs (45,507 women from 14 trials) and small-quantity LNSs (6237 women from 4 trials) on GWG compared with iron and folic acid supplements only. Percentage adequacy of GWG and total weight gain at delivery were calculated according to the IOM 2009 guidelines. Binary outcomes included severely inadequate (percentage adequacy <70%), inadequate (<90%), and excessive (>125%) GWG. Results from individual trials were pooled using fixed-effects inverse-variance models. Heterogeneity was examined using I2, stratified analysis, and meta-regression. RESULTS MMSs resulted in a greater percentage adequacy of GWG [weighted mean difference (WMD): 0.86%; 95% CI: 0.28%, 1.44%; P < 0.01] and higher GWG at delivery (WMD: 209 g; 95% CI: 139, 280 g; P < 0.01) than among those in the control arm. Women who received MMSs had a 2.9% reduced risk of severely inadequate GWG (RR: 0.971; 95% CI: 0.956, 0.987; P < 0.01). No association was found between small-quantity LNSs and GWG percentage adequacy (WMD: 1.51%; 95% CI: -0.38%, 3.40%; P = 0.21). Neither MMSs nor small-quantity LNSs were associated with excessive GWG. CONCLUSIONS Maternal MMSs were associated with greater GWG percentage adequacy and total GWG at delivery than was iron and folic acid only. This finding is consistent with previous results on birth outcomes and will inform policy development and local recommendations of switching routine prenatal iron and folic acid supplements to MMSs.
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Affiliation(s)
- Enju Liu
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Dongqing Wang
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, VA, USA
| | - Anne M Darling
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Nandita Perumal
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Molin Wang
- Department of Epidemiology, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Biostatistics, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Tahmeed Ahmed
- Nutrition & Clinical Services, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Parul Christian
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kathryn G Dewey
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Gilberto Kac
- Nutritional Epidemiology Observatory, Josué de Castro Nutrition Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Stephen Kennedy
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | | | - Brittany Briggs
- Certara USA, Inc. on behalf of the Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Nutrition, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - members of the GWG Pooling Project Consortium
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, VA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Biostatistics, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
- Nutrition & Clinical Services, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Nutrition, University of California, Davis, Davis, CA, USA
- Nutritional Epidemiology Observatory, Josué de Castro Nutrition Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford, United Kingdom
- Certara Canada, Montreal, Quebec, Canada
- DVPL Tech
- Certara USA, Inc. on behalf of the Bill & Melinda Gates Foundation, Seattle, WA, USA
- Department of Nutrition, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
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7
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Perumal N, Ohuma EO, Prentice AM, Shah PS, Al Mahmud A, Moore SE, Roth DE. Implications for quantifying early life growth trajectories of term-born infants using INTERGROWTH-21st newborn size standards at birth in conjunction with World Health Organization child growth standards in the postnatal period. Paediatr Perinat Epidemiol 2022; 36:839-850. [PMID: 35570836 PMCID: PMC9790258 DOI: 10.1111/ppe.12880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 03/10/2022] [Accepted: 03/20/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The INTERGROWTH-21st sex and gestational age (GA) specific newborn size standards (IG-NS) are intended to complement the World Health Organization Child Growth Standards (WHO-GS), which are not GA-specific. We examined the implications of using IG-NS at birth and WHO-GS at postnatal ages in longitudinal epidemiologic studies. OBJECTIVES The aim of this study was to quantify the extent to which standardised measures of newborn size and growth are affected when using WHO-GS versus IG-NS at birth among term-born infants. METHODS Data from two prenatal trials in Bangladesh (n = 755) and The Gambia (n = 522) were used to estimate and compare size at birth and growth from birth to 3 months when using WHO-GS only ('WHO-GS') versus IG-NS at birth and WHO-GS postnatally ('IG-NS'). Mean length-for-age (LAZ), weight-for-age (WAZ) and head circumference-for-age (HCAZ), and the prevalence of undernutrition (stunting: LAZ < -2SD; underweight: WAZ < -2SD; and microcephaly: HCAZ < -2SD) were estimated overall and by GA strata [early-term (370/7 -386/7 ), full-term (390/7 -406/7 ) and late-term (410/7 -430/7 )]. We used Bland-Altman plots to compare continuous indices and Kappa statistic to compare categorical indicators. RESULTS At birth, mean LAZ, WAZ and HCAZ, and the prevalence of undernutrition were most similar among newborns between 39 and 40 weeks of GA when using WHO-GS versus IG-NS. However, anthropometric indices were systematically lower among early-term infants and higher among late-term infants when using WHO-GS versus IG-NS. Early-term and late-term infants demonstrated relatively faster and slower growth, respectively, when using WHO-GS versus IG-NS, with the direction and magnitude of differences varying between anthropometric indices. Individual-level differences in attained size and growth, when using WHO-GS versus IG-NS, were greater than 0.2 SD in magnitude for >60% of infants across all anthropometric indices. CONCLUSIONS Using IG-NS at birth with WHO-GS postnatally is acceptable for full-term infants but may give a misleading interpretation of growth trajectories among early- and late-term infants.
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Affiliation(s)
- Nandita Perumal
- Department of Global Health and PopulationHarvard TH Chan School of Public HealthBostonMassachusettsUSA
- Centre for Global Child HealthPeter Gilgan Centre for Research and LearningThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Eric O. Ohuma
- Centre for Global Child HealthPeter Gilgan Centre for Research and LearningThe Hospital for Sick ChildrenTorontoOntarioCanada
- Maternal, Adolescent, Reproductive and Child Health Centre, Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Andrew M. Prentice
- MRC Unit The Gambia at the London School of Hygiene and Tropical MedicineFajaraThe Gambia
| | - Prakesh S. Shah
- Department of PediatricsMount Sinai Hospital & the University of TorontoTorontoOntarioCanada
| | - Abdullah Al Mahmud
- International Centre for Diarrheal Disease Research, Bangladesh (icddr,b)DhakaBangladesh
| | - Sophie E. Moore
- MRC Unit The Gambia at the London School of Hygiene and Tropical MedicineFajaraThe Gambia
- Department of Women and Children’s HealthKing’s College LondonLondonUK
| | - Daniel E. Roth
- Centre for Global Child HealthPeter Gilgan Centre for Research and LearningThe Hospital for Sick ChildrenTorontoOntarioCanada
- Department of PediatricsHospital for Sick Children & the University of TorontoTorontoOntarioCanada
- Department of Nutritional SciencesUniversity of TorontoTorontoOntarioCanada
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8
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Silver MJ, Saffari A, Kessler NJ, Chandak GR, Fall CHD, Issarapu P, Dedaniya A, Betts M, Moore SE, Routledge MN, Herceg Z, Cuenin C, Derakhshan M, James PT, Monk D, Prentice AM. Environmentally sensitive hotspots in the methylome of the early human embryo. eLife 2022; 11:e72031. [PMID: 35188105 PMCID: PMC8912923 DOI: 10.7554/elife.72031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 02/18/2022] [Indexed: 11/26/2022] Open
Abstract
In humans, DNA methylation marks inherited from gametes are largely erased following fertilisation, prior to construction of the embryonic methylome. Exploiting a natural experiment of seasonal variation including changes in diet and nutritional status in rural Gambia, we analysed three datasets covering two independent child cohorts and identified 259 CpGs showing consistent associations between season of conception (SoC) and DNA methylation. SoC effects were most apparent in early infancy, with evidence of attenuation by mid-childhood. SoC-associated CpGs were enriched for metastable epialleles, parent-of-origin-specific methylation and germline differentially methylated regions, supporting a periconceptional environmental influence. Many SoC-associated CpGs overlapped enhancers or sites of active transcription in H1 embryonic stem cells and fetal tissues. Half were influenced but not determined by measured genetic variants that were independent of SoC. Environmental 'hotspots' providing a record of environmental influence at periconception constitute a valuable resource for investigating epigenetic mechanisms linking early exposures to lifelong health and disease.
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Affiliation(s)
- Matt J Silver
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical MedicineGambiaUnited Kingdom
| | - Ayden Saffari
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical MedicineGambiaUnited Kingdom
| | - Noah J Kessler
- Department of Genetics, University of CambridgeCambridgeUnited Kingdom
| | - Gririraj R Chandak
- Genomic Research on Complex Diseases, CSIR-Centre for Cellular and Molecular BiologyHyderabadIndia
| | - Caroline HD Fall
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General HospitalSouthamptonUnited Kingdom
| | - Prachand Issarapu
- Genomic Research on Complex Diseases, CSIR-Centre for Cellular and Molecular BiologyHyderabadIndia
| | - Akshay Dedaniya
- Genomic Research on Complex Diseases, CSIR-Centre for Cellular and Molecular BiologyHyderabadIndia
| | - Modupeh Betts
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical MedicineGambiaUnited Kingdom
| | - Sophie E Moore
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical MedicineGambiaUnited Kingdom
- Department of Women and Children's Health, King's College LondonLondonUnited Kingdom
| | - Michael N Routledge
- School of Medicine, University of LeedsLeedsUnited Kingdom
- School of Food and Biological Engineering, Jiangsu UniversityZhenjiangChina
| | - Zdenko Herceg
- Epigenomics and Mechanisms Branch, International Agency For Research On CancerLyonFrance
| | - Cyrille Cuenin
- Epigenomics and Mechanisms Branch, International Agency For Research On CancerLyonFrance
| | - Maria Derakhshan
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical MedicineGambiaUnited Kingdom
| | - Philip T James
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical MedicineGambiaUnited Kingdom
| | - David Monk
- Biomedical Research Centre, University of East AngliaNorwichUnited Kingdom
- Bellvitge Institute for Biomedical ResearchBarcelonaSpain
| | - Andrew M Prentice
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical MedicineGambiaUnited Kingdom
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9
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Candler T, Kessler N, Gunasekara C, Ward K, James P, Laritsky E, Baker M, Dyer R, Elango R, Jeffries D, Waterland R, Moore S, Ludgate M, Prentice A, Silver M. DNA methylation at a nutritionally sensitive region of the PAX8 gene is associated with thyroid volume and function in Gambian children. SCIENCE ADVANCES 2021; 7:eabj1561. [PMID: 34739318 PMCID: PMC8570597 DOI: 10.1126/sciadv.abj1561] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 09/16/2021] [Indexed: 05/13/2023]
Abstract
PAX8 is a key thyroid transcription factor implicated in thyroid gland differentiation and function, and PAX8 gene methylation is reported to be sensitive to the periconceptional environment. Using a novel recall-by-epigenotype study in Gambian children, we found that PAX8 hypomethylation at age 2 years is associated with a 21% increase in thyroid volume and an increase in free thyroxine (T4) at 5 to 8 years, the latter equivalent to 8.4% of the normal range. Free T4 was associated with a decrease in DXA-derived body fat and bone mineral density. Furthermore, offspring PAX8 methylation was associated with periconceptional maternal nutrition, and methylation variability was influenced by genotype, suggesting that sensitivity to environmental exposures may be under partial genetic control. Together, our results demonstrate a possible link between early environment, PAX8 gene methylation and thyroid gland development and function, with potential implications for early embryonic programming of thyroid-related health and disease.
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Affiliation(s)
- Toby Candler
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, UK
| | - Noah Kessler
- Department of Genetics, University of Cambridge, Cambridge, UK
| | - Chathura Gunasekara
- USDA/ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Kate Ward
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, UK
- MRC Lifecourse Epidemiology, University of Southampton, Southampton, UK
| | - Philip James
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Eleonora Laritsky
- USDA/ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Maria Baker
- USDA/ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Roger Dyer
- British Columbia Children’s Hospital Research Institute, Vancouver, BC, Canada
| | - Rajavel Elango
- British Columbia Children’s Hospital Research Institute, Vancouver, BC, Canada
| | - David Jeffries
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, UK
| | - Robert Waterland
- USDA/ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Sophie Moore
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, UK
- Department of Women and Children’s Health, King’s College London, London, UK
| | - Marian Ludgate
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK
| | - Andrew Prentice
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, UK
| | - Matt Silver
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, UK
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10
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Gonzales GB, Brals D, Sonko B, Sosseh F, Prentice AM, Moore SE, Koulman A. Plasma lipids and growth faltering: A longitudinal cohort study in rural Gambian children. SCIENCE ADVANCES 2021; 7:eabj1132. [PMID: 34533992 PMCID: PMC8448443 DOI: 10.1126/sciadv.abj1132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/28/2021] [Indexed: 06/13/2023]
Abstract
Growth faltering in children arises from metabolic and endocrine dysfunction driven by complex interactions between poor diet, persistent infections, and immunopathology. Here, we determined the progression of the plasma lipidome among Gambian children (n = 409) and assessed its association with growth faltering during the first 2 years of life using the panel vector autoregression method. We further investigated temporal associations among lipid clusters. We observed that measures of stunting, wasting, and underweight are dynamically associated with each other and that lipid groups containing polyunsaturated fatty acids (PUFAs) and phosphatidylcholines consistently predict future growth outcomes. Linear growth was dynamically associated with the majority of lipids, indicating a higher nutritional demand to improve height compared to weight among growth-restricted children. Our results indicate a critical role for PUFAs and choline in early life dietary interventions to combat the child growth faltering still so prevalent in low-income settings.
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Affiliation(s)
- Gerard Bryan Gonzales
- Nutrition, Metabolism, and Genomics Group, Division of Human Nutrition and Health, Wageningen University, Stippeneng 4, Wageningen, 6708 WE, Netherlands
- Laboratory of Gastroenterology, Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, 9000 Ghent, Belgium
- Core Metabolomics and Lipidomics Laboratory, Wellcome Trust-MRL Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Metabolic Disease Unit, Wellcome Trust-MRL Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Daniella Brals
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | - Bakary Sonko
- MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Banjul, Gambia
| | - Fatou Sosseh
- MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Banjul, Gambia
| | - Andrew M. Prentice
- MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Banjul, Gambia
| | - Sophie E. Moore
- MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Banjul, Gambia
- Women & Children’s Health, King’s College London, London, UK
| | - Albert Koulman
- Core Metabolomics and Lipidomics Laboratory, Wellcome Trust-MRL Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Metabolic Disease Unit, Wellcome Trust-MRL Institute of Metabolic Science, University of Cambridge, Cambridge, UK
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11
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Ghantous A, Novoloaca A, Bouaoun L, Cuenin C, Cros MP, Xu Y, Hernandez-Vargas H, Darboe MK, Prentice AM, Moore SE, Gong YY, Herceg Z, Routledge MN. Aflatoxin Exposure during Early Life Is Associated with Differential DNA Methylation in Two-Year-Old Gambian Children. Int J Mol Sci 2021; 22:8967. [PMID: 34445674 PMCID: PMC8396526 DOI: 10.3390/ijms22168967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/25/2021] [Accepted: 07/29/2021] [Indexed: 11/17/2022] Open
Abstract
Background: DNA methylation is an epigenetic control mechanism that may be altered by environmental exposures. We have previously reported that in utero exposure to the mycotoxin and liver carcinogen aflatoxin B1 from the maternal diet, as measured using biomarkers in the mothers' blood, was associated with differential DNA methylation in white blood cells of 6-month-old infants from The Gambia. Methods: Here we examined aflatoxin B1-associated differential DNA methylation in white blood cells of 24-month-old children from the same population (n = 244), in relation to the child's dietary exposure assessed using aflatoxin albumin biomarkers in blood samples collected at 6, 12 and 18 months of age. HM450 BeadChip arrays were used to assess DNA methylation, with data compared to aflatoxin albumin adduct levels using two approaches; a continuous model comparing aflatoxin adducts measured in samples collected at 18 months to DNA methylation at 24 months, and a categorical time-dose model that took into account aflatoxin adduct levels at 6, 12 and 18 months, for comparison to DNA methylation at 24 months. Results: Geometric mean (95% confidence intervals) for aflatoxin albumin levels were 3.78 (3.29, 4.34) at 6 months, 25.1 (21.67, 29.13) at 12 months and 49.48 (43.34, 56.49) at 18 months of age. A number of differentially methylated CpG positions and regions were associated with aflatoxin exposure, some of which affected gene expression. Pathway analysis highlighted effects on genes involved with with inflammatory, signalling and growth pathways. Conclusions: This study provides further evidence that exposure to aflatoxin in early childhood may impact on DNA methylation.
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Affiliation(s)
- Akram Ghantous
- International Agency for Research on Cancer, 150, Cours Albert Thomas, 69372 Lyon, France; (A.G.); (A.N.); (L.B.); (C.C.); (M.-P.C.); (H.H.-V.); (Z.H.)
| | - Alexei Novoloaca
- International Agency for Research on Cancer, 150, Cours Albert Thomas, 69372 Lyon, France; (A.G.); (A.N.); (L.B.); (C.C.); (M.-P.C.); (H.H.-V.); (Z.H.)
| | - Liacine Bouaoun
- International Agency for Research on Cancer, 150, Cours Albert Thomas, 69372 Lyon, France; (A.G.); (A.N.); (L.B.); (C.C.); (M.-P.C.); (H.H.-V.); (Z.H.)
| | - Cyrille Cuenin
- International Agency for Research on Cancer, 150, Cours Albert Thomas, 69372 Lyon, France; (A.G.); (A.N.); (L.B.); (C.C.); (M.-P.C.); (H.H.-V.); (Z.H.)
| | - Marie-Pierre Cros
- International Agency for Research on Cancer, 150, Cours Albert Thomas, 69372 Lyon, France; (A.G.); (A.N.); (L.B.); (C.C.); (M.-P.C.); (H.H.-V.); (Z.H.)
| | - Ya Xu
- School of Medicine, University of Leeds, Leeds LS2 9JT, UK;
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun-Yat Sen University, Guangzhou 510006, China
| | - Hector Hernandez-Vargas
- International Agency for Research on Cancer, 150, Cours Albert Thomas, 69372 Lyon, France; (A.G.); (A.N.); (L.B.); (C.C.); (M.-P.C.); (H.H.-V.); (Z.H.)
- Cancer Research Centre of Lyon (CRCL), Université de Lyon, 69008 Lyon, France
| | - Momodou K. Darboe
- MRC Unit the Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Boulevard, Fajara, Banjul P.O. Box 273, The Gambia; (M.K.D.); (A.M.P.); (S.E.M.)
| | - Andrew M. Prentice
- MRC Unit the Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Boulevard, Fajara, Banjul P.O. Box 273, The Gambia; (M.K.D.); (A.M.P.); (S.E.M.)
| | - Sophie E. Moore
- MRC Unit the Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Boulevard, Fajara, Banjul P.O. Box 273, The Gambia; (M.K.D.); (A.M.P.); (S.E.M.)
- Department of Women and Children’s Health, King’s College London, St Thomas’ Hospital, London SE1 7EH, UK
| | - Yun Yun Gong
- School of Food Science and Nutrition, University of Leeds, Leeds LS2 9JT, UK;
| | - Zdenko Herceg
- International Agency for Research on Cancer, 150, Cours Albert Thomas, 69372 Lyon, France; (A.G.); (A.N.); (L.B.); (C.C.); (M.-P.C.); (H.H.-V.); (Z.H.)
| | - Michael N. Routledge
- School of Medicine, University of Leeds, Leeds LS2 9JT, UK;
- School of Food and Biological Engineering, Jiangsu University, Zhenjiang 212013, China
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12
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Isanaka S, Garba S, Plikaytis B, Malone McNeal M, Guindo O, Langendorf C, Adehossi E, Ciglenecki I, Grais RF. Immunogenicity of an oral rotavirus vaccine administered with prenatal nutritional support in Niger: A cluster randomized clinical trial. PLoS Med 2021; 18:e1003720. [PMID: 34375336 PMCID: PMC8354620 DOI: 10.1371/journal.pmed.1003720] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 07/06/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Nutritional status may play a role in infant immune development. To identify potential boosters of immunogenicity in low-income countries where oral vaccine efficacy is low, we tested the effect of prenatal nutritional supplementation on immune response to 3 doses of a live oral rotavirus vaccine. METHODS AND FINDINGS We nested a cluster randomized trial within a double-blind, placebo-controlled randomized efficacy trial to assess the effect of 3 prenatal nutritional supplements (lipid-based nutrient supplement [LNS], multiple micronutrient supplement [MMS], or iron-folic acid [IFA]) on infant immune response (n = 53 villages and 1,525 infants with valid serology results: 794 in the vaccine group and 731 in the placebo group). From September 2015 to February 2017, participating women received prenatal nutrient supplement during pregnancy. Eligible infants were then randomized to receive 3 doses of an oral rotavirus vaccine or placebo at 6-8 weeks of age (mean age: 6.3 weeks, 50% female). Infant sera (pre-Dose 1 and 28 days post-Dose 3) were analyzed for anti-rotavirus immunoglobulin A (IgA) using enzyme-linked immunosorbent assay (ELISA). The primary immunogenicity end point, seroconversion defined as ≥3-fold increase in IgA, was compared in vaccinated infants among the 3 supplement groups and between vaccine/placebo groups using mixed model analysis of variance procedures. Seroconversion did not differ by supplementation group (41.1% (94/229) with LNS vs. 39.1% (102/261) with multiple micronutrients (MMN) vs. 38.8% (118/304) with IFA, p = 0.91). Overall, 39.6% (n = 314/794) of infants who received vaccine seroconverted, compared to 29.0% (n = 212/731) of infants who received placebo (relative risk [RR]: 1.36; 95% confidence interval [CI]: 1.18, 1.57, p < 0.001). This study was conducted in a high rotavirus transmission setting. Study limitations include the absence of an immune correlate of protection for rotavirus vaccines, with the implications of using serum anti-rotavirus IgA for the assessment of immunogenicity and efficacy in low-income countries unclear. CONCLUSIONS This study showed no effect of the type of prenatal nutrient supplementation on immune response in this setting. Immune response varied depending on previous exposure to rotavirus, suggesting that alternative delivery modalities and schedules may be considered to improve vaccine performance in high transmission settings. TRIAL REGISTRATION ClinicalTrials.gov NCT02145000.
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Affiliation(s)
- Sheila Isanaka
- Department of Research, Epicentre, Paris, France
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- * E-mail:
| | | | - Brian Plikaytis
- BioStat Consulting, LLC, Worthington, Ohio, United States of America
| | - Monica Malone McNeal
- Department of Pediatrics, University of Cincinnati, Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
| | | | | | | | - Iza Ciglenecki
- Médecins Sans Frontières—Operational Center Geneva, Geneva, Switzerland
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13
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Okala SG, Darboe MK, Sosseh F, Sonko B, Faye-Joof T, Prentice AM, Moore SE. Seasonal modulation of antibody response to diphtheria-tetanus-pertussis vaccination in infants: a cohort study in rural Gambia. BMC Public Health 2021; 21:1442. [PMID: 34294074 PMCID: PMC8296693 DOI: 10.1186/s12889-021-11383-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 06/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In rural Gambia, rates of malnutrition and infection are higher during the annual rainy/'hungry' season (June-October) in comparison to the dry/'harvest' season (November-May). The effects of this seasonal pattern on an infant's immune development and their capacity to respond to childhood vaccinations remain unclear. The aim of the current analysis was to determine whether antibody responses to diphtheria-tetanus-pertussis (DTP) vaccinations in infants differ between seasons. METHODS Infants received the DTP vaccine at 8, 12 and 16 weeks of age and antibody titres were measured in blood samples collected at 12 (n = 710) and 24 (n = 662) weeks of age. Mean DTP antibody titres, adjusted for maternal and infant confounders, were compared by t-tests and the effect sizes of the mean differences were calculated between seasons at mid-gestation (20 weeks gestation) and first vaccination (8 weeks of infant age). RESULTS A smaller number of infants received their first vaccination during the rainy/hungry season months compared to the dry/harvest season (n = 224 vs. n = 486). At 12 weeks, infants vaccinated during the rainy/hungry season had lower weight-for-length Z-scores (p = 0.01) and were more likely to be anaemic (p < 0.001). Their mothers, however, were pregnant mostly during the dry/harvest season, had higher weight gain (p < 0.001) and were less likely to be anaemic during pregnancy (p < 0.001). At 12 weeks, infants vaccinated during the rainy/hungry season had significantly higher mean diphtheria, tetanus and pertussis antibody titres; by 62.3, 16.9 and 19.7%, respectively (all, p < 0.001). However, at 24 weeks, they had lower mean anti-diphtheria titres (by 20.6%, p < 0.001) compared with infants vaccinated during the dry/harvest season, and no differences were observed in mean tetanus and pertussis antibody titres by vaccination season. CONCLUSIONS Infant antibody response to the primary dose of the DTP vaccine was influenced by both season of pregnancy and infancy, although effects were diminished following three doses. Environmental exposures, including nutrition, to both the mother and infant are hypothesised as likely drivers of these seasonal effects.
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Affiliation(s)
- Sandra G Okala
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, 10th Floor North Wing, London, SE1 7EH, UK
| | - Momodou K Darboe
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Fatou Sosseh
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Bakary Sonko
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Tisbeh Faye-Joof
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Andrew M Prentice
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Sophie E Moore
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, 10th Floor North Wing, London, SE1 7EH, UK.
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia.
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14
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Xu Y, Moore S, Chen G, Nshe P, Faye-Joof T, Prentice A, Gong YY, Routledge M. Impact of dietary aflatoxin on immune development in Gambian infants: a cohort study. BMJ Open 2021; 11:e048688. [PMID: 34285011 PMCID: PMC8292809 DOI: 10.1136/bmjopen-2021-048688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 07/02/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Chronic aflatoxin (AF) exposure has been shown to occur at high levels in children from sub-Saharan Africa (SSA), and has been associated with growth retardation and immune dysfunction. Our objective was to investigate the impact of AF exposure on immune development in early infancy using thymic size and antibody (Ab) response to vaccination as indicators of immune function. METHODS A total of 374 infants born between May 2011 and December 2012 were enrolled into the current study. These infants were recruited from a larger, randomised trial examining the impact of nutritional supplementation of mothers and infants on infant immune development (the Early Nutrition and Immune Development Trial). Thymic size (Thymic Index, TI) was measured by sonography at 1 week, 8 weeks, 24 weeks and 52 weeks of infant age. Infants were given the diphtheria-tetanus-pertussis (DTP) vaccine at 8 weeks, 12 weeks and 16 weeks of age, and Ab responses to each vaccine measured at 12 weeks and 24 weeks of age. AF-albumin (AF-alb) adduct levels in infant blood were measured by ELISA as the biomarker of AF exposure. RESULTS The geometric mean (GM) level of AF-alb increased with age. Only half of infants had detectable AF-alb with a GM of 3.52 pg/mg at 24 weeks, increasing to 25.39 pg/mg at 52 weeks, when 98% of infants had AF-alb >limit of detection. Significant negative association of AF-alb level with TI was seen in infants during the first 24 weeks, especially at 8 weeks of age (p<0.001), which is the time point of fastest thymus growth. There were no associations between AF exposure level and Ab response to pertussis and tetanus, but a significant positive correlation was observed between AF-alb level and Ab titre to diphtheria (p<0.005). CONCLUSIONS High levels of AF exposure during early infancy may impact on infant immune development. TRIAL REGISTRATION NUMBER ISRCTN49285450.
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Affiliation(s)
- Ya Xu
- School of Medicine, University of Leeds, Leeds, UK
| | - Sophie Moore
- Department of Women and Children's Health, King's College London, London, UK
| | | | | | | | | | - Yun Yun Gong
- School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Michael Routledge
- School of Medicine, University of Leeds, Leeds, UK
- School of Food and Biological Engineering, Jiangsu University, Zhenjiang, China
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15
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Ó Breasail M, Ward KA, Schoenbuchner SM, Ceesay M, Mendy M, Jarjou LM, Moore SE, Prentice A. Pregnancy-Related Change in pQCT and Bone Biochemistry in a Population With a Habitually Low Calcium Intake. J Bone Miner Res 2021; 36:1269-1280. [PMID: 33784438 DOI: 10.1002/jbmr.4295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 03/13/2021] [Accepted: 03/16/2021] [Indexed: 11/07/2022]
Abstract
In pregnancy, changes in maternal calcium (Ca) economy occur to satisfy fetal Ca demand. It is unclear whether maternal mineral reserves facilitate these requirements and no data exist from sub-Saharan Africa. The aim was to determine skeletal changes with peripheral quantitative computed tomography (pQCT) and bone biochemistry between early second and third trimesters. Pregnant rural Gambians aged 18 to 45 years (n = 467) participating in a trial of antenatal nutritional supplements (ISRCTN49285450) had pQCT scans and blood collections at mean (SD) 14 (3) and 31 (1) weeks' gestation. Outcomes were pQCT: radius/tibia 4% total volumetric bone mineral density (vBMD), trabecular vBMD, total cross-sectional area (CSA), 33%/38% radius/tibia cortical vBMD, bone mineral content (BMC), total CSA; biochemistry: collagen type 1 cross-linked β-C-telopeptide (β-CTX), type 1 procollagen N-terminal (P1NP), parathyroid hormone (PTH), and 1,25(OH)2 D. Independent t tests tested whether pooled or within-group changes differed from 0. Multiple regression was performed adjusting for age. Data for change are expressed as mean (confidence interval [CI] 2.5, 97.5%). Radius trabecular vBMD, cortical vBMD, and BMC increased by 1.15 (0.55, 1.75)%, 0.41 (0.24, 0.58)%, and 0.47 (0.25, 0.69)%. Tibia total and trabecular vBMD increased by 0.34 (0.15, 0.54)% and 0.46 (0.17, 0.74)%, while tibia cortical vBMD, BMC, and cortical CSA increased by 0.35 (0.26, 0.44)%, 0.55 (0.41, 0.68)% and 0.20 (0.09, 0.31)%, respectively. CTX, PTH, and 1,25(OH)2 D increased by 23.0 (15.09, 29.29)%, 13.2 (8.44, 19.34)%, and 21.0 (17.67, 24.29)%, while P1NP decreased by 32.4 (-37.19, -28.17)%. No evidence of mobilization was observed in the peripheral skeleton. Resorption, although higher in late versus early gestation, was lower throughout pregnancy compared with non-pregnant non-lactating (NPNL) in the same community. Formation was lower in late pregnancy than in early, and below NPNL levels. This suggests a shift in the ratio of resorption to formation. Despite some evidence of change in bone metabolism, in this population, with habitually low Ca intakes, the peripheral skeleton was not mobilized as a Ca source for the fetus. © 2021 crown copyright . Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR). The article published with the permission of the Controller of HMSO and the Queen's Printer of Scotland..
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Affiliation(s)
- Mícheál Ó Breasail
- MRC Nutrition and Bone Health Research Group, University of Cambridge, Cambridge, UK
| | - Kate A Ward
- MRC Nutrition and Bone Health Research Group, University of Cambridge, Cambridge, UK.,MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK.,MRC Unit, The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Simon M Schoenbuchner
- MRC Biostatistics Unit, University of Cambridge, Cambridge Institute of Public Health, Cambridge, UK
| | - Mustapha Ceesay
- MRC Unit, The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Michael Mendy
- MRC Unit, The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Landing M Jarjou
- MRC Unit, The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Sophie E Moore
- MRC Unit, The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia.,Department of Women and Children's Health, King's College London, London, UK
| | - Ann Prentice
- MRC Nutrition and Bone Health Research Group, University of Cambridge, Cambridge, UK.,MRC Unit, The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
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16
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Bone JN, Pickerill K, Woo Kinshella ML, Vidler M, Craik R, Poston L, Stones W, Sevene E, Temmerman M, Koech Etyang A, Roca A, Russell D, Tribe RM, von Dadelszen P, Magee LA. Pregnancy cohorts and biobanking in sub-Saharan Africa: a systematic review. BMJ Glob Health 2021; 5:bmjgh-2020-003716. [PMID: 33243854 PMCID: PMC7692823 DOI: 10.1136/bmjgh-2020-003716] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022] Open
Abstract
Background Technological advances and high throughput biological assays can facilitate discovery science in biobanks from population cohorts, including pregnant women. Biological pathways associated with health outcomes differ depending on geography, and high-income country data may not generalise to low-resource settings. We conducted a systematic review to identify prospective pregnancy cohorts in sub-Saharan Africa (SSA) that include biobanked samples with potential to enhance discovery science opportunity. Methods Inclusion criteria were prospective data collection during pregnancy, with associated biobanking in SSA. Data sources included: scientific databases (with comprehensive search terms), grey literature, hand searching applicable reference lists and expert input. Results were screened in a three-stage process based on title, abstract and full text by two independent reviewers. The review is registered on PROSPERO (CRD42019147483). Results Fourteen SSA studies met the inclusion criteria from database searches (n=8), reference list searches (n=2) and expert input (n=4). Three studies have ongoing data collection. The most represented countries were South Africa and Mozambique (Southern Africa) (n=3), Benin (Western Africa) (n=4) and Tanzania (Eastern Africa) (n=4); including an estimated 31 763 women. Samples commonly collected were blood, cord blood and placenta. Seven studies collected neonatal samples. Common clinical outcomes included maternal and perinatal mortality, malaria and preterm birth. Conclusions Increasingly numerous pregnancy cohorts in SSA that include biobanking are generating a uniquely valuable resource for collaborative discovery science, and improved understanding of the high regional risks of maternal, fetal and neonatal morbidity and mortality. Future studies should align protocols and consider their added value and distinct contributions.
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Affiliation(s)
- Jeffrey N Bone
- Department of Obstetrics and Gynaecology, The University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Kelly Pickerill
- Department of Obstetrics and Gynaecology, The University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, The University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, The University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Rachel Craik
- Department of Women and Children's Health, King's College London, School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, UK
| | - Lucilla Poston
- Department of Women and Children's Health, King's College London, School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, UK
| | - William Stones
- Centre for Reproductive Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Esperanca Sevene
- Centro de Investigação em Saúde de Manhiça, Manhiça, Maputo, Mozambique.,Department of Physiologic Sciences, Faculty of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Marleen Temmerman
- Department of Obstetrics and Gynaecology, Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Angela Koech Etyang
- Department of Obstetrics and Gynaecology, Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Anna Roca
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | | | - Rachel M Tribe
- Department of Women and Children's Health, King's College London, School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, UK
| | - Peter von Dadelszen
- Department of Women and Children's Health, King's College London, School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, UK
| | - Laura A Magee
- Department of Women and Children's Health, King's College London, School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, UK
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17
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Keats EC, Oh C, Chau T, Khalifa DS, Imdad A, Bhutta ZA. Effects of vitamin and mineral supplementation during pregnancy on maternal, birth, child health and development outcomes in low- and middle-income countries: A systematic review. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1127. [PMID: 37051178 PMCID: PMC8356361 DOI: 10.1002/cl2.1127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Almost two billion people who are deficient in vitamins and minerals are women and children in low- and middle-income countries (LMIC). These deficiencies are worsened during pregnancy due to increased energy and nutritional demands, causing adverse outcomes in mother and child. To reduce micronutrient deficiencies, several strategies have been implemented, including diet diversification, large-scale and targeted fortification, staple crop bio-fortification and micronutrient supplementation. Objectives To evaluate and summarize the available evidence on the effects of micronutrient supplementation during pregnancy in LMIC on maternal, fetal, child health and child development outcomes. This review will assess the impact of single micronutrient supplementation (calcium, vitamin A, iron, vitamin D, iodine, zinc, vitamin B12), iron-folic acid (IFA) supplementation, multiple micronutrient (MMN) supplementation, and lipid-based nutrient supplementation (LNS) during pregnancy. Search Methods We searched papers published from 1995 to 31 October 2019 (related programmes and good quality studies pre-1995 were limited) in CAB Abstracts, CINAHL, Cochrane Central Register of Controlled Trials, Embase, International Initiative for Impact Evaluations, LILACS, Medline, POPLINE, Web of Science, WHOLIS, ProQuest Dissertations & Theses Global, R4D, WHO International Clinical Trials Registry Platform. Non-indexed grey literature searches were conducted using Google, Google Scholar, and web pages of key international nutrition agencies. Selection Criteria We included randomized controlled trials (individual and cluster-randomized) and quasi-experimental studies that evaluated micronutrient supplementation in healthy, pregnant women of any age and parity living in a LMIC. LMIC were defined by the World Bank Group at the time of the search for this review. While the aim was to include healthy pregnant women, it is likely that these populations had one or more micronutrient deficiencies at baseline; women were not excluded on this basis. Data Collection and Analysis Two authors independently assessed studies for inclusion and risk of bias, and conducted data extraction. Data were matched to check for accuracy. Quality of evidence was assessed using the GRADE approach. Main Results A total of 314 papers across 72 studies (451,723 women) were eligible for inclusion, of which 64 studies (439,649 women) contributed to meta-analyses. Seven studies assessed iron-folic acid (IFA) supplementation versus folic acid; 34 studies assessed MMN vs. IFA; 4 studies assessed LNS vs. MMN; 13 evaluated iron; 13 assessed zinc; 9 evaluated vitamin A; 11 assessed vitamin D; and 6 assessed calcium. Several studies were eligible for inclusion in multiple types of supplementation. IFA compared to folic acid showed a large and significant (48%) reduction in the risk of maternal anaemia (average risk ratio (RR) 0.52, 95% CI 0.41 to 0.66; studies = 5; participants = 15,540; moderate-quality evidence). As well, IFA supplementation demonstrated a smaller but significant, 12% reduction in risk of low birthweight (LBW) babies (average RR 0.88, 95% CI 0.78 to 0.99; studies = 4; participants = 17,257; high-quality evidence). MMN supplementation was defined as any supplement that contained at least 3 micronutrients. Post-hoc analyses were conducted, where possible, comparing the differences in effect of MMN with 4+ components and MMN with 3 or 4 components. When compared to iron with or without FA, MMN supplementation reduced the risk of LBW by 15% (average RR 0.85, 95% CI 0.77 to 0.93; studies = 28; participants = 79,972); this effect was greater in MMN with >4 micronutrients (average RR 0.79, 95% CI 0.71 to 0.88; studies = 19; participants = 68,138 versus average RR 1.01, 95% CI 0.92 to 1.11; studies = 9; participants = 11,834). There was a small and significant reduction in the risk of stillbirths (average RR 0.91; 95% CI 0.86 to 0.98; studies = 22; participants = 96,772) and a small and significant effect on the risk of small-for-gestational age (SGA) (average RR 0.93; 95% CI 0.88 to 0.98; studies = 19; participants = 52,965). For stillbirths and SGA, the effects were greater among those provided MMN with 4+ micronutrients. Children whose mothers had been supplemented with MMN, compared to IFA, demonstrated a 16% reduced risk of diarrhea (average RR 0.84; 95% CI 0.76 to 0.92; studies = 4; participants = 3,142). LNS supplementation, compared to MMN, made no difference to any outcome; however, the evidence is limited. Iron supplementation, when compared to no iron or placebo, showed a large and significant effect on maternal anaemia, a reduction of 47% (average RR 0.53, 95% CI 0.43 to 0.65; studies = 6; participants = 15,737; moderate-quality evidence) and a small and significant effect on LBW (average RR 0.88, 95% CI 0.78 to 0.99; studies = 4; participants = 17,257; high-quality evidence). Zinc and vitamin A supplementation, each both compared to placebo, had no impact on any outcome examined with the exception of potentially improving serum/plasma zinc (mean difference (MD) 0.43 umol/L; 95% CI -0.04 to 0.89; studies = 5; participants = 1,202) and serum/plasma retinol (MD 0.13 umol/L; 95% CI -0.03 to 0.30; studies = 6; participants = 1,654), respectively. When compared to placebo, vitamin D supplementation may have reduced the risk of preterm births (average RR 0.64; 95% CI 0.40 to 1.04; studies = 7; participants = 1,262), though the upper CI just crosses the line of no effect. Similarly, calcium supplementation versus placebo may have improved rates of pre-eclampsia/eclampsia (average RR 0.45; 95% CI 0.19 to 1.06; studies = 4; participants = 9,616), though the upper CI just crosses 1. Authors' Conclusions The findings suggest that MMN and vitamin supplementation improve maternal and child health outcomes, including maternal anaemia, LBW, preterm birth, SGA, stillbirths, micronutrient deficiencies, and morbidities, including pre-eclampsia/eclampsia and diarrhea among children. MMN supplementation demonstrated a beneficial impact on the most number of outcomes. In addition, MMN with >4 micronutrients appeared to be more impactful than MMN with only 3 or 4 micronutrients included in the tablet. Very few studies conducted longitudinal analysis on longer-term health outcomes for the child, such as anthropometric measures and developmental outcomes; this may be an important area for future research. This review may provide some basis to guide continual discourse around replacing IFA supplementation with MMN along with the use of single micronutrient supplementation programs for specific outcomes.
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Affiliation(s)
- Emily C. Keats
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
| | - Christina Oh
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
| | - Tamara Chau
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
| | - Dina S. Khalifa
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
| | - Aamer Imdad
- PediatricsUpstate Medical University, SyracuseNew YorkUSA
| | - Zulfiqar A. Bhutta
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
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Kapila R, Kashyap M, Poddar S, Gangwal S, Prasad NGG. Evolution of pathogen-specific improved survivorship post-infection in populations of Drosophila melanogaster adapted to larval crowding. PLoS One 2021; 16:e0250055. [PMID: 33852596 PMCID: PMC8046209 DOI: 10.1371/journal.pone.0250055] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/31/2021] [Indexed: 01/04/2023] Open
Abstract
The environment experienced by individuals during their juvenile stages has an impact on their adult stages. In holometabolous insects like Drosophila melanogaster, most of the resource acquisition for adult stages happens during the larval stages. Larval-crowding is a stressful environment, which exposes the larvae to scarcity of food and accumulation of toxic waste. Since adult traits are contingent upon larval stages, in larval-crowding like conditions, adult traits are prone to get affected. While the effect of resource limited, poor-developmental environment on adult immune response has been widely studied, the effect of adaptation to resource-limited developmental environment has not been studied, therefore in this study we assayed the evolution of ability to survive infection in adult stages as a correlated response to adaptation to larval crowding environments. Using four populations of Drosophila melanogaster adapted to larval crowding for 240 generations and their respective control populations, we show that populations adapted to larval crowding show an improved and evolved post-infection survivorship against a gram-negative bacteria Pseudomonas entomophila. Whereas, against a gram-positive bacteria Enterococcus faecalis, no difference in post-infection survivorship was observed across control and selected populations. In this study, we report the co-related evolution of pathogen-specific increased survivorship post-infection in populations of Drosophila melanogaster as a result of adaptation to larval crowding environment.
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Affiliation(s)
- Rohit Kapila
- Department of Biological Sciences, Indian Institute of Science Education and Research Mohali, Mohali, India
| | - Mayank Kashyap
- Department of Biological Sciences, Indian Institute of Science Education and Research Mohali, Mohali, India
| | - Soumyadip Poddar
- Department of Biological Sciences, Indian Institute of Science Education and Research Mohali, Mohali, India
| | - Shreya Gangwal
- Department of Biological Sciences, Indian Institute of Science Education and Research Mohali, Mohali, India
| | - N. G. G. Prasad
- Department of Biological Sciences, Indian Institute of Science Education and Research Mohali, Mohali, India
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Ashorn P. Infant Growth After Maternal Dietary Supplementation Before and During Pregnancy. J Pediatr 2021; 229:14-16. [PMID: 33159913 DOI: 10.1016/j.jpeds.2020.10.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 10/29/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Per Ashorn
- Faculty of Medicine and Health Technology, Center for Child Health Research, Tampere University; Department of Paediatrics, Tampere University Hospital, Tampere, Finland
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20
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Pregnancy-related changes in bone turnover markers are not accompanied by mineral mobilisation in the appendicular skeleton in women with habitually low calcium intake. Proc Nutr Soc 2021. [DOI: 10.1017/s0029665121000239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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21
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Intrauterine growth restriction: Clinical consequences on health and disease at adulthood. Reprod Toxicol 2021; 99:168-176. [DOI: 10.1016/j.reprotox.2020.10.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/01/2020] [Accepted: 10/04/2020] [Indexed: 02/06/2023]
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22
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Eriksen KG, Andersson M, Hunziker S, Zimmermann MB, Moore SE. Effects of an Iodine-Containing Prenatal Multiple Micronutrient on Maternal and Infant Iodine Status and Thyroid Function: A Randomized Trial in The Gambia. Thyroid 2020; 30:1355-1365. [PMID: 32183608 PMCID: PMC7482118 DOI: 10.1089/thy.2019.0789] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: Iodine supplementation is recommended to pregnant women in iodine-deficient populations, but the impact in moderate iodine deficiency is uncertain. We assessed the effect of an iodine-containing prenatal multiple micronutrient (MMN) supplement in a rural Gambian population at risk of moderate iodine deficiency. Materials and Methods: This study uses data and samples collected as a part of the randomized controlled trial Early Nutrition and Immune Development (ENID; ISRCTN49285450) conducted in Keneba, The Gambia. Pregnant women (<20 weeks gestation) were randomized to either a daily supplement of MMNs containing 300 μg of iodine or an iron and folic acid (FeFol) supplement. Randomization was double blinded (participants and investigators). The coprimary outcomes were maternal urinary iodine concentration (UIC) and serum thyroglobulin (Tg), assessed at baseline and at 30 weeks' gestation. Secondary outcomes were maternal serum thyrotropin (TSH), total triiodothyronine (TT3), total thyroxine (TT4) (assessed at baseline and at 30 weeks' gestation), breast milk iodine concentration (BMIC) (assessed at 8, 12, and 24 weeks postpartum), infant serum Tg (assessed at birth [cord], 12, and 24 weeks postpartum), and serum TSH (assessed at birth [cord]). The effect of supplementation was evaluated using mixed effects models. Results: A total of 875 pregnant women were enrolled between April 2010 and February 2015. In this secondary analysis, we included women from the MMN (n = 219) and FeFol (n = 219) arm of the ENID trial. At baseline, median (interquartile range or IQR) maternal UIC and Tg was 51 μg/L (33-82) and 22 μg/L (12-39), respectively, indicating moderate iodine deficiency. Maternal MMN supplement increased maternal UIC (p < 0.001), decreased maternal Tg (p < 0.001), and cord blood Tg (p < 0.001) compared with FeFol. Maternal thyroid function tests (TSH, TT3, TT4, and TT3/TT4 ratio) and BMIC did not differ according to maternal supplement group over the course of the study. Median (IQR) BMIC, maternal UIC, and infant Tg in the MMN group were 51 μg/L (35-72), 39 μg/L (25-64), and 87 μg/L (59-127), respectively, at 12 weeks postpartum, and did not differ between supplement groups. Conclusions: Supplementing moderately iodine-deficient women during pregnancy improved maternal iodine status and reduced Tg concentration. However, the effects were not attained postpartum and maternal and infant iodine nutrition remained inadequate during the first six months after birth. Consideration should be given to ensuring adequate maternal status through pregnancy and lactation in populations with moderate deficiency.
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Affiliation(s)
- Kamilla G. Eriksen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Address correspondence to: Kamilla G. Eriksen, PhD, Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 26, 1958 Frederiksberg, Copenhagen, Denmark
| | - Maria Andersson
- Division of Gastroenterology and Nutrition, Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Sandra Hunziker
- Human Nutrition Laboratory, Institute of Food, Nutrition, and Health, ETH Zurich, Zurich, Switzerland
| | - Michael B. Zimmermann
- Human Nutrition Laboratory, Institute of Food, Nutrition, and Health, ETH Zurich, Zurich, Switzerland
| | - Sophie E. Moore
- Department of Women and Children's Health, King's College London, London, United Kingdom
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Periconceptional environment predicts leukocyte telomere length in a cross-sectional study of 7-9 year old rural Gambian children. Sci Rep 2020; 10:9675. [PMID: 32541825 PMCID: PMC7295801 DOI: 10.1038/s41598-020-66729-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 05/19/2020] [Indexed: 12/11/2022] Open
Abstract
Early life exposures are important predictors of adult disease risk. Although the underlying mechanisms are largely unknown, telomere maintenance may be involved. This study investigated the relationship between seasonal differences in parental exposures at time of conception and leukocyte telomere length (LTL) in their offspring. LTL was measured in two cohorts of children aged 2 yrs (N = 487) and 7–9 yrs (N = 218). The association between date of conception and LTL was examined using Fourier regression models, adjusted for age, sex, leukocyte cell composition, and other potential confounders. We observed an effect of season in the older children in all models [likelihood ratio test (LRT) χ²2 = 7.1, p = 0.03; fully adjusted model]. LTL was greatest in children conceived in September (in the rainy season), and smallest in those conceived in March (in the dry season), with an effect size (LTL peak–nadir) of 0.60 z-scores. No effect of season was evident in the younger children (LRT χ²2 = 0.87, p = 0.65). The different results obtained for the two cohorts may reflect a delayed effect of season of conception on postnatal telomere maintenance. Alternatively, they may be explained by unmeasured differences in early life exposures, or the increased telomere attrition rate during infancy.
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Okala SG, Sise EA, Sosseh F, Prentice AM, Woollett LA, Moore SE. Maternal plasma lipid levels across pregnancy and the risks of small-for-gestational age and low birth weight: a cohort study from rural Gambia. BMC Pregnancy Childbirth 2020; 20:153. [PMID: 32164563 PMCID: PMC7068879 DOI: 10.1186/s12884-020-2834-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 02/24/2020] [Indexed: 12/22/2022] Open
Abstract
Background Sub-optimal maternal lipid levels during pregnancy may be implicated in the pathophysiological mechanisms leading to low birth weight (LBW) and small-for-gestational-age (SGA). We aimed to determine whether maternal lipid levels across pregnancy were associated with birth weight and the risks of LBW and SGA in rural Gambia. Methods This secondary analysis of the ENID trial involved 573 pregnant women with term deliveries. Plasma levels of total cholesterol (TC), high-density lipoprotein cholesterol (HDL-c), low-density lipoprotein cholesterol (LDL-c), and triglycerides (TG) were analyzed at enrolment (mean (SD) = 13.9 (3.3) weeks gestation), 20 and 30 weeks gestation as continuous variables and percentile groups. Regression models with adjustment for confounders were used to examine associations between gestational lipid levels and birth weight and the risks of LBW (birth weight < 2500 g) and SGA (<10th percentile INTERGROWTH-21ST for birth weight). Results There were 7.9% LBW and 32.5% SGA infants. At enrolment, every unit increase in HDL-c was associated with a 2.7% (P = 0.011) reduction in relative risk of LBW. At 20 weeks gestation, every unit increase in TC levels was associated with a 1.3% reduction in relative risk of LBW (P = 0.002). Low (<10th percentile) HDL-c at enrolment or at 20 weeks gestation was associated with a 2.6 (P = 0.007) and 3.0 (P = 0.003) times greater risk of LBW, respectively, compared with referent (10th─90th) HDL-c. High (>90th percentile) LDL-c at 30 weeks gestation was associated with a 55% lower risk of SGA compared with referent LDL-c (P = 0.017). Increased levels of TC (β = 1.3, P = 0.027) at 20 weeks gestation and of TC (β = 1.2, P = 0.006) and LDL-c (β = 1.5, P = 0.002) at 30 weeks gestation were all associated with higher birth weight. Conclusions In rural Gambia, lipid levels during pregnancy were associated with infant birth weight and the risks of LBW and SGA. Associations varied by lipid class and changed across pregnancy, indicating an adaptive process by which maternal lipids may influence fetal growth and birth outcomes. Trial registration This trial was registered as ISRCTN49285450 on: 12/11/2009.
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Affiliation(s)
- Sandra G Okala
- Department of Women and Children's Health, King's College London, London, SE1 7EH, UK
| | - Ebrima A Sise
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Fatou Sosseh
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Andrew M Prentice
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Laura A Woollett
- Department of Pathology and Laboratory Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sophie E Moore
- Department of Women and Children's Health, King's College London, London, SE1 7EH, UK. .,MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia.
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Jones KS, Meadows SR, Schoenmakers I, Prentice A, Moore SE. Vitamin D Status Increases During Pregnancy and in Response to Vitamin D Supplementation in Rural Gambian Women. J Nutr 2020; 150:492-504. [PMID: 31834380 PMCID: PMC7056615 DOI: 10.1093/jn/nxz290] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/11/2019] [Accepted: 11/05/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Vitamin D is important to maternal, fetal, and infant health, but quality data on vitamin D status in low- and middle-income countries and response to cholecalciferol supplementation in pregnancy are sparse. OBJECTIVE We characterized vitamin D status and vitamin D metabolite change across pregnancy and in response to cholecalciferol supplementation in rural Gambia. METHODS This study was a secondary analysis of samples collected in a 4-arm trial of maternal nutritional supplementation [iron folic acid (FeFol); multiple micronutrients (MMN); protein energy (PE) as lipid-based supplement; PE + MMN]; MMN included 10 μg/d cholecalciferol. Plasma 25-hydroxycholecalciferol [25(OH)D3], 24,25-dihydroxycholecalciferol [24,25(OH)2D3], and C3-epimer-25-hydroxycholecalciferol [3-epi-25(OH)D3] were measured by LC-MS/MS in 863 women [aged 30 ± 7 y (mean ± SD)] in early pregnancy (presupplementation) and late pregnancy, (gestational age 14 ± 3 and 30 ± 1 wk). Changes in 25(OH)D3 and vitamin D metabolite concentrations and associations with pregnancy stage and maternal age and anthropometry were tested. RESULTS Early pregnancy 25(OH)D3 concentration was 70 ± 15 nmol/L and increased according to pregnancy stage (82 ± 18 and 87 ± 17 nmol/L in the FeFol and PE-arms) and to cholecalciferol supplementation (95 ± 19 and 90 ± 20 nmol/L in the MMN and PE + MMN-arms) (P < 0.0001). There was no difference between supplemented groups. Early pregnancy 25(OH)D3 was positively associated with maternal age and gestational age. Change in 25(OH)D3 was negatively associated with late pregnancy, but not early pregnancy, triceps skinfold thickness. The pattern of change of 24,25(OH)2D3 mirrored that of 25(OH)D3 and appeared to flatten as pregnancy progressed, whereas 3-epi-25(OH)D3 concentration increased across pregnancy. CONCLUSION This study provides important data on the vitamin D status of a large cohort of healthy pregnant women in rural Africa. Without supplementation, vitamin D status increased during pregnancy, demonstrating that pregnancy stage should be considered when assessing vitamin D status. Nutritionally relevant cholecalciferol supplementation further increased vitamin D status. These data are relevant to the development of fortification and supplementation policies in pregnant women in West Africa.
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Affiliation(s)
- Kerry S Jones
- MRC Nutrition and Bone Health Research Group, MRC Elsie Widdowson Laboratory, Cambridge, UK,NIHR Nutritional Biomarker Laboratory, MRC Epidemiology Unit, University of Cambridge, Cambridge, UK,Address correspondence to KSJ (e-mail: )
| | - Sarah R Meadows
- MRC Nutrition and Bone Health Research Group, MRC Elsie Widdowson Laboratory, Cambridge, UK,NIHR Nutritional Biomarker Laboratory, MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Inez Schoenmakers
- MRC Nutrition and Bone Health Research Group, MRC Elsie Widdowson Laboratory, Cambridge, UK,Norwich Medical School, University of East Anglia, Norwich, UK
| | - Ann Prentice
- MRC Nutrition and Bone Health Research Group, MRC Elsie Widdowson Laboratory, Cambridge, UK,MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Sophie E Moore
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia,Department of Women and Children's Health, King's College London, UK
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Bah A, Muhammad AK, Wegmuller R, Verhoef H, Goheen MM, Sanyang S, Danso E, Sise EA, Pasricha SR, Armitage AE, Drakesmith H, Cross JH, Moore SE, Cerami C, Prentice AM. Hepcidin-guided screen-and-treat interventions against iron-deficiency anaemia in pregnancy: a randomised controlled trial in The Gambia. Lancet Glob Health 2019; 7:e1564-e1574. [PMID: 31607468 PMCID: PMC7109523 DOI: 10.1016/s2214-109x(19)30393-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/31/2019] [Accepted: 09/06/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND WHO recommends daily iron supplementation for pregnant women, but adherence is poor because of side-effects, effectiveness is low, and there are concerns about possible harm. The iron-regulatory hormone hepcidin can signal when an individual is ready-and-safe to receive iron. We tested whether a hepcidin-guided screen-and-treat approach to combat iron-deficiency anaemia could achieve equivalent efficacy to universal administration, but with lower exposure to iron. METHODS We did a three-arm, randomised, double-blind, non-inferiority trial in 19 rural communities in the Jarra West and Kiang East districts of The Gambia. Eligible participants were pregnant women aged 18-45 years at between 14 weeks and 22 weeks of gestation. We randomly allocated women to either WHO's recommended regimen (ie, a daily UN University, UNICEF, and WHO international multiple-micronutrient preparation [UNIMMAP] containing 60 mg iron), a 60 mg screen-and-treat approach (ie, daily UNIMMAP containing 60 mg iron for 7 days if weekly hepcidin was <2·5 μg/L or UNIMMAP without iron if hepcidin was ≥2·5 μg/L), or a 30 mg screen-and-treat approach (ie, daily UNIMMAP containing 30 mg iron for 7 days if weekly hepcidin was <2·5 μg/L or UNIMMAP without iron if hepcidin was ≥2·5 μg/L). We used a block design stratified by amount of haemoglobin at enrolment (above and below the median amount of haemoglobin on every enrolment day) and stage of gestation (14-18 weeks vs 19-22 weeks). Participants and investigators were unaware of the random allocation. The primary outcome was the amount of haemoglobin at day 84 and was measured as the difference in haemoglobin in each screen-and-treat group compared with WHO's recommended regimen; the non-inferiority margin was set at -5·0 g/L. The primary outcome was assessed in the per-protocol population, which comprised all women who completed the study. This trial is registered with the ISRCTN registry, number ISRCTN21955180. FINDINGS Between June 16, 2014, and March 3, 2016, 498 participants were randomised, of whom 167 were allocated to WHO's recommended regimen, 166 were allocated to the 60 mg per day screen-and-treat approach, and 165 were allocated to the 30 mg per day screen-and-treat approach. 78 participants were withdrawn or lost to follow-up during the study; thus, the per-protocol population comprised 140 women assigned to WHO's recommended regimen, 133 allocated to the 60 mg screen-and-treat approach, and 147 allocated to the 30 mg screen-and-treat approach. The screen-and-treat approaches did not exceed the non-inferiority margin. Compared with WHO's recommended regimen, the difference in the amount of haemoglobin at day 84 was -2·2 g/L (95% CI -4·6 to 0·1) with the 60 mg screen-and-treat approach and -2·7 g/L (-5·0 to -0·5) with the 30 mg screen-and-treat approach. Adherence, reported side-effects, and adverse events were similar between the three groups. The most frequent side-effect was stomachache, which was similar in the 60 mg screen-and-treat group (82 cases per 1906 person-weeks) and with WHO's recommended regimen (81 cases per 1974 person-weeks; effect 1·0, 95% CI 0·7 to 1·6); in the 30 mg screen-and-treat group the frequency of stomachache was slightly lower than with WHO's recommended regimen (58 cases per 2009 person-weeks; effect 0·7, 95% CI 0·5 to 1·1). No participants died during the study. INTERPRETATION The hepcidin-guided screen-and-treat approaches had no advantages over WHO's recommended regimen in terms of adherence, side-effects, or safety outcomes. Our results suggest that the current WHO policy for iron administration to pregnant women should remain unchanged while more effective approaches continue to be sought. FUNDING Bill & Melinda Gates Foundation and the UK Medical Research Council.
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Affiliation(s)
- Amat Bah
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; LSHTM, London, UK
| | - Abdul Khalie Muhammad
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia
| | - Rita Wegmuller
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; GroundWork, Flaesch, Switzerland
| | - Hans Verhoef
- Division of Human Nutrition and Health, Wageningen University, Wageningen, Netherlands; LSHTM, London, UK
| | - Morgan M Goheen
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; University of North Carolina at Chapel Hill School of Medicine, Department of Microbiology and Immunology, Chapel Hill, NC, USA
| | - Saikou Sanyang
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia
| | - Ebrima Danso
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia
| | - Ebrima A Sise
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, and Department of Medical Biology, University of Melbourne, Melbourne, VIC, Australia
| | - Andrew E Armitage
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Hal Drakesmith
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - James H Cross
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; LSHTM, London, UK
| | - Sophie E Moore
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; Department of Women & Children's Health, King's College London, St Thomas' Hospital, London, UK
| | | | - Andrew M Prentice
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; LSHTM, London, UK.
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Okala SG, Darboe MK, Sosseh F, Sonko B, Faye-Joof T, Prentice AM, Moore SE. Impact of nutritional supplementation during pregnancy on antibody responses to diphtheria-tetanus-pertussis vaccination in infants: A randomised trial in The Gambia. PLoS Med 2019; 16:e1002854. [PMID: 31386660 PMCID: PMC6684039 DOI: 10.1371/journal.pmed.1002854] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 06/27/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Exposure to a nutritionally deficient environment during fetal life and early infancy may adversely alter the ontogeny of the immune system and affect an infant's ability to mount an optimal immune response to vaccination. We examined the effects of maternal nutritional supplementation during pregnancy on infants' antibody responses to the diphtheria-tetanus-pertussis (DTP) vaccine included in the Expanded Programme on Immunisation (EPI). METHODS AND FINDINGS The Early Nutrition and Immune Development (ENID) trial was a randomised, partially blinded trial conducted between April 2010 and February 2015 in the rural West Kiang region of The Gambia, a resource-poor region affected by chronic undernutrition. Pregnant women (<20 weeks' gestation) with a singleton pregnancy (n = 875) were randomised to receive one of four supplements: iron-folic acid (FeFol; standard of care), multiple micronutrient (MMN), protein-energy (PE), or PE + MMN daily from enrolment (mean [SD] 13.7 [3.3] weeks' gestation) until delivery. Infants were administered the DTP vaccine at 8, 12, and 16 weeks of age according to the Gambian Government protocol. Results for the primary outcome of the trial (infant thymic size) were described previously; here, we report on a secondary outcome, infant antibody response to vaccination. The effects of supplementation on mean DTP antibody titres measured in blood samples collected from infants at 12 weeks (n = 710) and 24 weeks (n = 662) were analysed with adjustment for confounders including maternal age, compliance to supplement, and infant sex and season. At 12 weeks, following a single dose of the vaccine, compared with FeFol (mean 95% confidence interval [CI]; 0.11 IU/mL, 0.09-0.12), antenatal supplementation with MMN or MMN + PE resulted in 42.4% (95% CI 20.1-64.6; p < 0.001) and 29.4% (6.4-52.5; p = 0.012) higher mean anti-diphtheria titres, respectively. Mean anti-tetanus titres were higher by 9.0% (5.5-12.5), 7.8% (4.3-11.4), and 7.3% (4.0-10.7) in MMN, PE, and PE + MMN groups (all, p < 0.001), respectively, than in the FeFol group (0.55 IU/mL, 0.52-0.58). Mean anti-pertussis titres were not significantly different in the FeFol, MMN, and PE + MNN groups but were all higher than in the PE group (all, p < 0.001). At 24 weeks, following all three doses, no significant differences in mean anti-diphtheria titres were detected across the supplement groups. Mean anti-tetanus titres were 3.4% (0.19-6.5; p = 0.038) higher in the PE + MMN group than in the FeFol group (3.47 IU/mL, 3.29-3.66). Mean anti-pertussis titres were higher by 9.4% (3.3-15.5; p = 0.004) and 15.4% (9.6-21.2; p < 0.001) in PE and PE + MMN groups, compared with the FeFol group (74.9 IU/mL, 67.8-82.8). Limitations of the study included the lack of maternal antibody status (breast milk or plasma) or prevaccination antibody measurements in the infants. CONCLUSION According to our results from rural Gambia, maternal supplementation with MMN combined with PE during pregnancy enhanced antibody responses to the DTP vaccine in early infancy. Provision of nutritional supplements to pregnant women in food insecure settings may improve infant immune development and responses to EPI vaccines. TRIAL REGISTRATION ISRCTN49285450.
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Affiliation(s)
- Sandra G. Okala
- Kings’ College London, Department of Women and Children’s Health, St Thomas’ Hospital, London, United Kingdom
| | - Momodou K. Darboe
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Fatou Sosseh
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Bakary Sonko
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Tisbeh Faye-Joof
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Andrew M. Prentice
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Sophie E. Moore
- Kings’ College London, Department of Women and Children’s Health, St Thomas’ Hospital, London, United Kingdom
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
- * E-mail:
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James PT, Jawla O, Mohammed NI, Ceesay K, Akemokwe FM, Sonko B, Sise EA, Prentice AM, Silver MJ. A novel nutritional supplement to reduce plasma homocysteine in nonpregnant women: A randomised controlled trial in The Gambia. PLoS Med 2019; 16:e1002870. [PMID: 31408467 PMCID: PMC6691988 DOI: 10.1371/journal.pmed.1002870] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 07/08/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Infant DNA methylation profiles are associated with their mother's periconceptional nutritional status. DNA methylation relies on nutritional inputs for one-carbon metabolic pathways, including the efficient recycling of homocysteine. This randomised controlled trial in nonpregnant women in rural Gambia tests the efficacy of a novel nutritional supplement designed to improve one-carbon-related nutrient status by reducing plasma homocysteine, and assesses its potential future use in preconception trials. METHODS AND FINDINGS We designed a novel drink powder based on determinants of plasma homocysteine in the target population and tested it in a three-arm, randomised, controlled trial. Nonpregnant women aged between 18 and 45 from the West Kiang region of The Gambia were randomised in a 1:1:1 allocation to 12 weeks daily supplementation of either (a) a novel drink powder (4 g betaine, 800 μg folic acid, 5.2 μg vitamin B12, and 2.8 mg vitamin B2), (b) a widely used multiple micronutrient tablet (United Nations Multiple Micronutrient Preparation [UNIMMAP]) containing 15 micronutrients, or (c) no intervention. The trial was conducted between March and July 2018. Supplementation was observed daily. Fasted venepuncture samples were collected at baseline, midline (week 5), and endline (week 12) to measure plasma homocysteine. We used linear regression models to determine the difference in homocysteine between pairs of trial arms at midline and endline, adjusted for baseline homocysteine, age, and body mass index (BMI). Blood pressure and pulse were measured as secondary outcomes. Two hundred and ninety-eight eligible women were enrolled and randomised. Compliance was >97.8% for both interventions. At endline (our primary endpoint), the drink powder and UNIMMAP reduced mean plasma homocysteine by 23.6% (-29.5 to -17.1) and 15.5% (-21.2 to -9.4), respectively (both p < 0.001), compared with the controls. Compared with UNIMMAP, the drink powder reduced mean homocysteine by 8.8% (-15.8 to -1.2; p = 0.025). The effects were stronger at midline. There was no effect of either intervention on blood pressure or pulse compared with the control at endline. Self-reported adverse events (AEs) were similar in both intervention arms. There were two serious AEs reported over the trial duration, both in the drink powder arm, but judged to be unrelated to the intervention. Limitations of the study include the use of a single targeted metabolic outcome, homocysteine. CONCLUSIONS The trial confirms that dietary supplements can influence metabolic pathways that we have shown in previous studies to predict offspring DNA methylation. Both supplements reduced homocysteine effectively and remain potential candidates for future epigenetic trials in pregnancy in rural Gambia. TRIAL REGISTRATION Clinicaltrials.gov Reference NCT03431597.
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Affiliation(s)
- Philip T. James
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Ousubie Jawla
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nuredin I. Mohammed
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kabiru Ceesay
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Fatai M. Akemokwe
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Bakary Sonko
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ebrima A. Sise
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Andrew M. Prentice
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Matt J. Silver
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, United Kingdom
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Küpers LK, Monnereau C, Sharp GC, Yousefi P, Salas LA, Ghantous A, Page CM, Reese SE, Wilcox AJ, Czamara D, Starling AP, Novoloaca A, Lent S, Roy R, Hoyo C, Breton CV, Allard C, Just AC, Bakulski KM, Holloway JW, Everson TM, Xu CJ, Huang RC, van der Plaat DA, Wielscher M, Merid SK, Ullemar V, Rezwan FI, Lahti J, van Dongen J, Langie SAS, Richardson TG, Magnus MC, Nohr EA, Xu Z, Duijts L, Zhao S, Zhang W, Plusquin M, DeMeo DL, Solomon O, Heimovaara JH, Jima DD, Gao L, Bustamante M, Perron P, Wright RO, Hertz-Picciotto I, Zhang H, Karagas MR, Gehring U, Marsit CJ, Beilin LJ, Vonk JM, Jarvelin MR, Bergström A, Örtqvist AK, Ewart S, Villa PM, Moore SE, Willemsen G, Standaert ARL, Håberg SE, Sørensen TIA, Taylor JA, Räikkönen K, Yang IV, Kechris K, Nawrot TS, Silver MJ, Gong YY, Richiardi L, Kogevinas M, Litonjua AA, Eskenazi B, Huen K, Mbarek H, Maguire RL, Dwyer T, Vrijheid M, Bouchard L, Baccarelli AA, Croen LA, Karmaus W, Anderson D, de Vries M, Sebert S, Kere J, Karlsson R, Arshad SH, Hämäläinen E, Routledge MN, Boomsma DI, Feinberg AP, Newschaffer CJ, Govarts E, Moisse M, Fallin MD, Melén E, Prentice AM, Kajantie E, Almqvist C, Oken E, Dabelea D, Boezen HM, Melton PE, Wright RJ, Koppelman GH, Trevisi L, Hivert MF, Sunyer J, Munthe-Kaas MC, Murphy SK, Corpeleijn E, Wiemels J, Holland N, Herceg Z, Binder EB, Davey Smith G, Jaddoe VWV, Lie RT, Nystad W, London SJ, Lawlor DA, Relton CL, Snieder H, Felix JF. Meta-analysis of epigenome-wide association studies in neonates reveals widespread differential DNA methylation associated with birthweight. Nat Commun 2019; 10:1893. [PMID: 31015461 PMCID: PMC6478731 DOI: 10.1038/s41467-019-09671-3] [Citation(s) in RCA: 113] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 02/18/2019] [Indexed: 12/16/2022] Open
Abstract
Birthweight is associated with health outcomes across the life course, DNA methylation may be an underlying mechanism. In this meta-analysis of epigenome-wide association studies of 8,825 neonates from 24 birth cohorts in the Pregnancy And Childhood Epigenetics Consortium, we find that DNA methylation in neonatal blood is associated with birthweight at 914 sites, with a difference in birthweight ranging from -183 to 178 grams per 10% increase in methylation (PBonferroni < 1.06 x 10-7). In additional analyses in 7,278 participants, <1.3% of birthweight-associated differential methylation is also observed in childhood and adolescence, but not adulthood. Birthweight-related CpGs overlap with some Bonferroni-significant CpGs that were previously reported to be related to maternal smoking (55/914, p = 6.12 x 10-74) and BMI in pregnancy (3/914, p = 1.13x10-3), but not with those related to folate levels in pregnancy. Whether the associations that we observe are causal or explained by confounding or fetal growth influencing DNA methylation (i.e. reverse causality) requires further research.
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Affiliation(s)
- Leanne K Küpers
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- University of Groningen, University Medical Center Groningen, Department of Epidemiology, Groningen, The Netherlands
- Division of Human Nutrition and Health, Wageningen University, Wageningen, The Netherlands
| | - Claire Monnereau
- The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Gemma C Sharp
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- School of Oral and Dental Sciences, University of Bristol, Bristol, UK
| | - Paul Yousefi
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Children's Environmental Health Laboratory, Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | - Lucas A Salas
- Department of Epidemiology, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
- ISGlobal, Bacelona Institute for Global Health, Barcelona, Spain
| | - Akram Ghantous
- Epigenetics Group, International Agency for Research on Cancer, Lyon, France
| | - Christian M Page
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
- Oslo Centre for Biostatisitcs and Epidemology, Oslo University Hospital, Oslo, Norway
| | - Sarah E Reese
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Service, Research Triangle Park, Durham, NC, USA
| | - Allen J Wilcox
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Service, Research Triangle Park, Durham, NC, USA
| | - Darina Czamara
- Department of Translational Research in Psychiatry, Max-Planck-Institute of Psychiatry, Munich, Germany
| | - Anne P Starling
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Alexei Novoloaca
- Epigenetics Group, International Agency for Research on Cancer, Lyon, France
| | - Samantha Lent
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Ritu Roy
- HDF Comprehensive Cancer Center, University of California, San Francisco, CA, USA
- Computational Biology and Informatics, UCSF, San Francisco, CA, USA
| | - Cathrine Hoyo
- Department of Biological Sciences, North Carolina State University, Raleigh, NC, USA
- Center for Human Health and the Environment, North Carolina State University, Raleigh, NC, USA
| | - Carrie V Breton
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, 90089, USA
| | - Catherine Allard
- Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Allan C Just
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kelly M Bakulski
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - John W Holloway
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Todd M Everson
- Department of Environmental Health, Rollins School of Public Health at Emory University, Atlanta, GA, USA
| | - Cheng-Jian Xu
- University of Groningen, University Medical Center Groningen, Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children's Hospital, Groningen Research Institute for Asthma and COPD, Groningen, The Netherlands
- University of Groningen, University Medical Center Groningen, Department of Genetics, Groningen, The Netherlands
| | - Rae-Chi Huang
- Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Diana A van der Plaat
- University of Groningen, University Medical Center Groningen, Department of Epidemiology and Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The Netherlands
| | - Matthias Wielscher
- Department of Epidemiology and Biostatistics, MRC-PHE Centre for Environment & Health, School of Public Health, Imperial College London, London, UK
| | - Simon Kebede Merid
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Vilhelmina Ullemar
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Faisal I Rezwan
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Jari Lahti
- Helsinki Collegium for Advanced Studies, University of Helsinki, Helsinki, Finland
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jenny van Dongen
- Department of Biological Psychology, Netherlands Twin Register, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Sabine A S Langie
- VITO - Health, Mol, Belgium
- Theoretical Physics, Faculty of Sciences, Hasselt University, Hasselt, Belgium
- Centre for Environmental Sciences, Hasselt University, Hasselt, Belgium
| | - Tom G Richardson
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Maria C Magnus
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Ellen A Nohr
- Research Unit for Gynaecology and Obstetrics, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Zongli Xu
- Department of Pediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Liesbeth Duijts
- Division of Human Nutrition and Health, Wageningen University, Wageningen, The Netherlands
- Department of Pediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Pediatrics, Division of Neonatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Shanshan Zhao
- Biostatistics and Computational Biology Branch, National Institute of Environmental Health Sciences, NIH, Research Triangle Park, Durham, NC, USA
| | - Weiming Zhang
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Michelle Plusquin
- Centre for Environmental Sciences, Hasselt University, Diepenbeek, Belgium
- MRC/PHE Centre for Environment and Health School of Public Health Imperial College London, St Mary's Campus, Norfolk Place, London, UK
| | - Dawn L DeMeo
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Olivia Solomon
- School of Oral and Dental Sciences, University of Bristol, Bristol, UK
| | - Joosje H Heimovaara
- University of Groningen, University Medical Center Groningen, Department of Epidemiology, Groningen, The Netherlands
| | - Dereje D Jima
- Center for Human Health and the Environment, North Carolina State University, Raleigh, NC, USA
- Bioinformatics Research Center, North Carolina State University, Raleigh, NC, USA
| | - Lu Gao
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, 90089, USA
| | - Mariona Bustamante
- ISGlobal, Bacelona Institute for Global Health, Barcelona, Spain
- Bioinformatics and Genomics Program, Centre for Genomic Regulation (CRG), Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Patrice Perron
- Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada
- Department of Medicine, Universite de Sherbrooke, Sherbrooke, QC, Canada
| | - Robert O Wright
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Irva Hertz-Picciotto
- Department of Public Health Sciences, School of Medicine, University of California Davis MIND Institute, Sacramento, CA, USA
| | - Hongmei Zhang
- Division of Epidemiology, Biostatistics and Environmental Health, School of Public Health, University of Memphis, Memphis, TN, USA
| | - Margaret R Karagas
- Department of Epidemiology, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
- Children's Environmental Health & Disease Prevention Research Center at Dartmouth, Hanover, NH, USA
| | - Ulrike Gehring
- Institute for Risk Assessment Sciences, Utrecht University, Utrecht, The Netherlands
| | - Carmen J Marsit
- Department of Environmental Health, Rollins School of Public Health at Emory University, Atlanta, GA, USA
| | | | - Judith M Vonk
- University of Groningen, University Medical Center Groningen, Department of Epidemiology and Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The Netherlands
| | - Marjo-Riitta Jarvelin
- Department of Epidemiology and Biostatistics, MRC-PHE Centre for Environment & Health, School of Public Health, Imperial College London, London, UK
- Center for Life Course Health Research, Faculty of Medicine, University of Oulu, 90014, Oulu, Finland
- Biocenter Oulu, University of Oulu, Oulu, Finland
- Unit of Primary Care, Oulu University Hospital, Oulu, Finland
| | - Anna Bergström
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Center for Occupational and Environmental Medicine, Stockholm County Council, Stockholm, Sweden
| | - Anne K Örtqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Susan Ewart
- College of Veterinary Medicine, Michigan State University, East Lansing, MI, USA
| | - Pia M Villa
- Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sophie E Moore
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, UK
- Department of Women and Children's Health, King's College London, London, UK
| | - Gonneke Willemsen
- Department of Biological Psychology, Netherlands Twin Register, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Siri E Håberg
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Thorkild I A Sørensen
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Novo Nordisk Foundation Center for Basic Metabolic Research, Section of Metabolic Genetics, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Public Health, Section of Epidemiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jack A Taylor
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Service, Research Triangle Park, Durham, NC, USA
| | - Katri Räikkönen
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Ivana V Yang
- Division of Biomedical Informatics and Personalized Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Katerina Kechris
- Department of Pediatrics, Division of Neonatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Tim S Nawrot
- Centre for Environmental Sciences, Hasselt University, Diepenbeek, Belgium
- Department of Public Health & Primary Care, Leuven University, Leuven, Belgium
| | - Matt J Silver
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, UK
| | - Yun Yun Gong
- School of Food Sciences and Nutrition, University of Leeds, Leeds, UK
| | - Lorenzo Richiardi
- Department of Medical Sciences, University of Turin, Turin, Italy
- AOU Citta della Salute e della Sceinza, CPO Piemonte, Turin, Italy
| | - Manolis Kogevinas
- ISGlobal, Bacelona Institute for Global Health, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Augusto A Litonjua
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brenda Eskenazi
- Children's Environmental Health Laboratory, Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
- Center for Environmental Research and Children's Health, School of Public Health, University of California, Berkeley, CA, USA
| | - Karen Huen
- Children's Environmental Health Laboratory, Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | - Hamdi Mbarek
- Department of Biological Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Rachel L Maguire
- Department of Biological Sciences, North Carolina State University, Raleigh, NC, USA
- Department of Community and Family Medicine, Duke University Medical Center, Raleigh, NC, USA
| | - Terence Dwyer
- The George Institute for Global Health, Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Martine Vrijheid
- ISGlobal, Bacelona Institute for Global Health, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Luigi Bouchard
- Department of Biochemistry, Université de Sherbrooke, Sherbrooke, QC, Canada
- ECOGENE-21 Biocluster, Chicoutimi Hospital, Saguenay, QC, Canada
| | - Andrea A Baccarelli
- Laboratory of Precision Environmental Biosciences, Columbia University Mailman School of Public Health, New York, NY, USA
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Lisa A Croen
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Wilfried Karmaus
- Division of Epidemiology, Biostatistics and Environmental Health, School of Public Health, University of Memphis, Memphis, TN, USA
| | - Denise Anderson
- Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Maaike de Vries
- University of Groningen, University Medical Center Groningen, Department of Epidemiology and Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The Netherlands
| | - Sylvain Sebert
- Center for Life Course Health Research, Faculty of Medicine, University of Oulu, 90014, Oulu, Finland
- Biocenter Oulu, University of Oulu, Oulu, Finland
- Department for Genomics of Common Diseases, School of Public Health, Imperial College London, London, UK
| | - Juha Kere
- Folkhälsan Institute of Genetics, Helsinki, and Research Programs Unit, Molecular Neurology, University of Helsinki, Helsinki, Finland
- Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, Sweden
- School of Basic and Medical Biosciences, King's College London, Guy's Hospital, London, UK
| | - Robert Karlsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Syed Hasan Arshad
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- David Hide Asthma and Allergy Research Centre, Isle of Wight, UK
| | - Esa Hämäläinen
- HUSLAB and the Department of Clinical Chemistry, University of Helsinki, Helsinki, Finland
| | | | - Dorret I Boomsma
- Department of Biological Psychology, Netherlands Twin Register, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Andrew P Feinberg
- Center for Epigenetics, Johns Hopkins University School of Medicine, Baltimore, MA, USA
| | | | | | - Matthieu Moisse
- KU Leuven - University of Leuven, Department of Neurosciences, Experimental Neurology and Leuven Institute for Neuroscience and Disease (LIND), Leuven, Belgium
- VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium
| | - M Daniele Fallin
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Erik Melén
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Sachs' Children's Hospital, Stockholm, Sweden
| | - Andrew M Prentice
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, UK
| | - Eero Kajantie
- National Institute for Health and Welfare, Helsinki and Oulu, Oulu, Finland
- Hospital for Children and Adolescents, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- PEDEGO Research Unit, MRC Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Emily Oken
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Dana Dabelea
- Department of Epidemiology, Colorado School of Public Health, and Department of Pediatrics, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - H Marike Boezen
- University of Groningen, University Medical Center Groningen, Department of Epidemiology and Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The Netherlands
| | - Phillip E Melton
- Centre for Genetic Origins of Health and Disease, School of Biomedical Sciences, University of Western Australia, Perth, Australia
- School of Pharmacy and Biomedical Sciences, Curtin University, Perth, Australia
| | - Rosalind J Wright
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gerard H Koppelman
- University of Groningen, University Medical Center Groningen, Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children's Hospital, Groningen Research Institute for Asthma and COPD, Groningen, The Netherlands
| | - Letizia Trevisi
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Marie-France Hivert
- Department of Medicine, Universite de Sherbrooke, Sherbrooke, QC, Canada
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Diabetes Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Jordi Sunyer
- ISGlobal, Bacelona Institute for Global Health, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Monica C Munthe-Kaas
- Norwegian Institute of Public Health, Oslo, Norway
- Department of Pediatric Oncology and Hematology, Oslo University Hospital, Oslo, Norway
| | - Susan K Murphy
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Eva Corpeleijn
- University of Groningen, University Medical Center Groningen, Department of Epidemiology, Groningen, The Netherlands
| | - Joseph Wiemels
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Nina Holland
- Children's Environmental Health Laboratory, Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | - Zdenko Herceg
- Epigenetics Group, International Agency for Research on Cancer, Lyon, France
| | - Elisabeth B Binder
- Department of Translational Research in Psychiatry, Max-Planck-Institute of Psychiatry, Munich, Germany
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Altanta, GA, USA
| | - George Davey Smith
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Vincent W V Jaddoe
- The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Rolv T Lie
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Wenche Nystad
- Department for Non-Communicable Diseases, Norwegian Institute for Public Health, Oslo, Norway
| | - Stephanie J London
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Service, Research Triangle Park, Durham, NC, USA
| | - Debbie A Lawlor
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK.
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Caroline L Relton
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK.
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Harold Snieder
- University of Groningen, University Medical Center Groningen, Department of Epidemiology, Groningen, The Netherlands.
| | - Janine F Felix
- The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
- Department of Pediatrics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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30
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Abstract
BACKGROUND Multiple-micronutrient (MMN) deficiencies often coexist among women of reproductive age in low- and middle-income countries. They are exacerbated in pregnancy due to the increased demands of the developing fetus, leading to potentially adverse effects on the mother and baby. A consensus is yet to be reached regarding the replacement of iron and folic acid supplementation with MMNs. Since the last update of this Cochrane Review in 2017, evidence from several trials has become available. The findings of this review will be critical to inform policy on micronutrient supplementation in pregnancy. OBJECTIVES To evaluate the benefits of oral multiple-micronutrient supplementation during pregnancy on maternal, fetal and infant health outcomes. SEARCH METHODS For this 2018 update, on 23 February 2018 we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies. We also contacted experts in the field for additional and ongoing trials. SELECTION CRITERIA All prospective randomised controlled trials evaluating MMN supplementation with iron and folic acid during pregnancy and its effects on pregnancy outcomes were eligible, irrespective of language or the publication status of the trials. We included cluster-randomised trials, but excluded quasi-randomised trials. Trial reports that were published as abstracts were eligible. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We identified 21 trials (involving 142,496 women) as eligible for inclusion in this review, but only 20 trials (involving 141,849 women) contributed data. Of these 20 trials, 19 were conducted in low- and middle-income countries and compared MMN supplements with iron and folic acid to iron, with or without folic acid. One trial conducted in the UK compared MMN supplementation with placebo. In total, eight trials were cluster-randomised.MMN with iron and folic acid versus iron, with or without folic acid (19 trials)MMN supplementation probably led to a slight reduction in preterm births (average risk ratio (RR) 0.95, 95% confidence interval (CI) 0.90 to 1.01; 18 trials, 91,425 participants; moderate-quality evidence), and babies considered small-for-gestational age (SGA) (average RR 0.92, 95% CI 0.88 to 0.97; 17 trials; 57,348 participants; moderate-quality evidence), though the CI for the pooled effect for preterm births just crossed the line of no effect. MMN reduced the number of newborn infants identified as low birthweight (LBW) (average RR 0.88, 95% CI 0.85 to 0.91; 18 trials, 68,801 participants; high-quality evidence). We did not observe any differences between groups for perinatal mortality (average RR 1.00, 95% CI 0.90 to 1.11; 15 trials, 63,922 participants; high-quality evidence). MMN supplementation led to slightly fewer stillbirths (average RR 0.95, 95% CI 0.86 to 1.04; 17 trials, 97,927 participants; high-quality evidence) but, again, the CI for the pooled effect just crossed the line of no effect. MMN supplementation did not have an important effect on neonatal mortality (average RR 1.00, 95% CI 0.89 to 1.12; 14 trials, 80,964 participants; high-quality evidence). We observed little or no difference between groups for the other maternal and pregnancy outcomes: maternal anaemia in the third trimester (average RR 1.04, 95% CI 0.94 to 1.15; 9 trials, 5912 participants), maternal mortality (average RR 1.06, 95% CI 0.72 to 1.54; 6 trials, 106,275 participants), miscarriage (average RR 0.99, 95% CI 0.94 to 1.04; 12 trials, 100,565 participants), delivery via a caesarean section (average RR 1.13, 95% CI 0.99 to 1.29; 5 trials, 12,836 participants), and congenital anomalies (average RR 1.34, 95% CI 0.25 to 7.12; 2 trials, 1958 participants). However, MMN supplementation probably led to a reduction in very preterm births (average RR 0.81, 95% CI 0.71 to 0.93; 4 trials, 37,701 participants). We were unable to assess a number of prespecified, clinically important outcomes due to insufficient or non-available data.When we assessed primary outcomes according to GRADE criteria, the quality of evidence for the review overall was moderate to high. We graded the following outcomes as high quality: LBW, perinatal mortality, stillbirth, and neonatal mortality. The outcomes of preterm birth and SGA we graded as moderate quality; both were downgraded for funnel plot asymmetry, indicating possible publication bias.We carried out sensitivity analyses excluding trials with high levels of sample attrition (> 20%). We found that results were consistent with the main analyses for all outcomes. We explored heterogeneity through subgroup analyses by maternal height, maternal body mass index (BMI), timing of supplementation, dose of iron, and MMN supplement formulation (UNIMMAP versus non-UNIMMAP). There was a greater reduction in preterm births for women with low BMI and among those who took non-UNIMMAP supplements. We also observed subgroup differences for maternal BMI and maternal height for SGA, indicating greater impact among women with greater BMI and height. Though we found that MMN supplementation made little or no difference to perinatal mortality, the analysis demonstrated substantial statistical heterogeneity. We explored this heterogeneity using subgroup analysis and found differences for timing of supplementation, whereby higher impact was observed with later initiation of supplementation. For all other subgroup analyses, the findings were inconclusive.MMN versus placebo (1 trial)A single trial in the UK found little or no important effect of MMN supplementation on preterm births, SGA, or LBW but did find a reduction in maternal anaemia in the third trimester (RR 0.66, 95% CI 0.51 to 0.85), when compared to placebo. This trial did not measure our other outcomes. AUTHORS' CONCLUSIONS Our findings suggest a positive impact of MMN supplementation with iron and folic acid on several birth outcomes. MMN supplementation in pregnancy led to a reduction in babies considered LBW, and probably led to a reduction in babies considered SGA. In addition, MMN probably reduced preterm births. No important benefits or harms of MMN supplementation were found for mortality outcomes (stillbirths, perinatal and neonatal mortality). These findings may provide some basis to guide the replacement of iron and folic acid supplements with MMN supplements for pregnant women residing in low- and middle-income countries.
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Affiliation(s)
- Emily C Keats
- The Hospital for Sick ChildrenCentre for Global Child HealthTorontoCanada
| | - Batool A Haider
- Alkermes, Inc.Department of Health Economics and Outcomes Research852 Winter StreetWalthamMAUSA02451
| | - Emily Tam
- The Hospital for Sick ChildrenCentre for Global Child HealthTorontoCanada
| | - Zulfiqar A Bhutta
- The Hospital for Sick ChildrenCentre for Global Child HealthTorontoCanada
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Milosavljevic B, Vellekoop P, Maris H, Halliday D, Drammeh S, Sanyang L, Darboe MK, Elwell C, Moore SE, Lloyd-Fox S. Adaptation of the Mullen Scales of Early Learning for use among infants aged 5- to 24-months in rural Gambia. Dev Sci 2019; 22:e12808. [PMID: 30739382 PMCID: PMC6767903 DOI: 10.1111/desc.12808] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 01/21/2019] [Accepted: 02/01/2019] [Indexed: 12/20/2022]
Abstract
Infants in low‐resource settings are at heightened risk for compromised cognitive development due to a multitude of environmental insults in their surroundings. However, the onset of adverse outcomes and trajectory of cognitive development in these settings is not well understood. The aims of the present study were to adapt the Mullen Scales of Early Learning (MSEL) for use with infants in a rural area of The Gambia, to examine cognitive development in the first 24‐months of life and to assess the association between cognitive performance and physical growth. In Phase 1 of this study, the adapted MSEL was tested on 52 infants aged 9‐ to 24‐months (some of whom were tested longitudinally at two time points). Further optimization and training were undertaken and Phase 2 of the study was conducted, where the original measures were administered to 119 newly recruited infants aged 5‐ to 24‐months. Infant length, weight and head circumference were measured concurrently in both phases. Participants from both phases were split into age categories of 5–9 m (N = 32), 10–14 m (N = 92), 15–19 m (N = 53) and 20–24 m (N = 43) and performance was compared across age groups. From the ages of 10–14 m, Gambian infants obtained lower MSEL scores than US norms. Performance decreased with age and was lowest in the 20–24 m old group. Differential onsets of reduced performance were observed in the individual MSEL domains, with declines in visual perception and motor performance detected as early as at 10–14 months, while reduced language scores became evident after 15–19 months of age. Performance on the MSEL was significantly associated with measures of growth.
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Affiliation(s)
| | - Perijne Vellekoop
- The Global Health and Tropical Medicine Training Institute, Amsterdam, The Netherlands
| | - Helen Maris
- Centre for Brain and Cognitive Development, Birkbeck, University of London, London, UK
| | - Drew Halliday
- Department of Psychology, University of Victoria, Victoria, BC, Canada
| | - Saikou Drammeh
- Medical Research Council, The Gambia, at The London School of Hygiene and Tropical Medicine, London, UK
| | - Lamin Sanyang
- Medical Research Council, The Gambia, at The London School of Hygiene and Tropical Medicine, London, UK
| | - Momodou K Darboe
- Medical Research Council, The Gambia, at The London School of Hygiene and Tropical Medicine, London, UK
| | - Clare Elwell
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Sophie E Moore
- Department of Women and Children's Health, King's College London, London, UK
| | - Sarah Lloyd-Fox
- Centre for Brain and Cognitive Development, Birkbeck, University of London, London, UK.,Department of Psychology, University of Cambridge, Cambridge, UK
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32
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Moore SE, Fulford AJC, Sosseh F, Nshe P, Darboe MK, Prentice AM. Thymic size is increased by infancy, but not pregnancy, nutritional supplementation in rural Gambian children: a randomized clinical trial. BMC Med 2019; 17:38. [PMID: 30773140 PMCID: PMC6378709 DOI: 10.1186/s12916-019-1264-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 01/21/2019] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Thymic size in early infancy predicts subsequent survival in low-income settings. The human thymus develops from early gestation, is most active in early life and is highly sensitive to malnutrition. Our objective was to test whether thymic size in infancy could be increased by maternal and/or infant nutritional supplementation. METHODS The Early Nutrition and Immune Development (ENID) Trial was a randomized 2 × 2 × 2 factorial, partially blinded trial of nutritional supplementation conducted in rural Gambia, West Africa. Pregnant women (N = 875) were randomized to four intervention groups (iron-folate (standard care), multiple micronutrients, protein energy or protein energy + multiple micronutrients at 'booking' (mean gestational age at enrolment = 13.6 weeks, range 8-20 weeks) until delivery. The iron-folate and multiple micronutrient arms were administered in tablet form and the protein energy arms as a lipid-based nutritional supplement. All intervention arms contained 60 mg iron and 400 μg folic acid per daily dose. From 24 to 52 weeks of age, infants from all groups were randomized to receive a daily lipid-based nutritional supplement, with or without additional micronutrients. Thymic size was assessed by ultrasonography at 1, 8, 24 and 52 weeks of infant age, and a volume-related thymic index calculated. Detailed data on infant growth, feeding status and morbidity were collected. RESULTS A total of 724 (82.7%) mother-infant pairs completed the trial to infant age 52 weeks. Thymic size in infancy was not significantly associated with maternal supplement group at any post-natal time point. Infants who received the daily LNS with additional micronutrients had a significantly larger thymic index at 52 weeks of age (equivalent to an 8.0% increase in thymic index [95% CI 2.89, 13.4], P = 0.002). No interaction was observed between maternal and infant supplement groups. CONCLUSIONS A micronutrient-fortified lipid-based supplement given in the latter half of infancy increased thymic size, a key mediator of immune function. Improving the micronutrient status of infants from populations with marginal micronutrient status may improve immune development and survival. TRIAL REGISTRATION ISRCTN registry (controlled-trials.com) Identifier: ISRCTN49285450.
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Affiliation(s)
- Sophie E Moore
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Boulevard, Fajara, PO Box 273, Banjul, The Gambia. .,Division of Women and Children's Health, King's College London, St Thomas' Hospital, 10th Floor North Wing, London, SE1 7EH, UK.
| | - Anthony J C Fulford
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Boulevard, Fajara, PO Box 273, Banjul, The Gambia
| | - Fatou Sosseh
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Boulevard, Fajara, PO Box 273, Banjul, The Gambia
| | - Patrick Nshe
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Boulevard, Fajara, PO Box 273, Banjul, The Gambia
| | - Momodou K Darboe
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Boulevard, Fajara, PO Box 273, Banjul, The Gambia
| | - Andrew M Prentice
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Boulevard, Fajara, PO Box 273, Banjul, The Gambia
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Watson S, Moore SE, Darboe MK, Chen G, Tu YK, Huang YT, Eriksen KG, Bernstein RM, Prentice AM, Wild CP, Xu Y, Routledge MN, Gong YY. Impaired growth in rural Gambian infants exposed to aflatoxin: a prospective cohort study. BMC Public Health 2018; 18:1247. [PMID: 30413157 PMCID: PMC6234772 DOI: 10.1186/s12889-018-6164-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 10/30/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Exposure to aflatoxin, a mycotoxin produced by fungi that commonly contaminates cereal crops across sub-Saharan Africa, has been associated with impaired child growth. We investigated the impact of aflatoxin exposure on the growth of Gambian infants from birth to two years of age, and the impact on insulin-like growth factor (IGF)-axis proteins. METHODS A subsample (N = 374) of infants from the Early Nutrition and Immune Development (ENID) trial (ISRCTN49285450) were included in this study. Aflatoxin-albumin adducts (AF-alb) were measured in blood collected from infants at 6, 12 and 18 months of age. IGF-1 and IGFBP-3 were measured in blood collected at 12 and 18 months. Anthropometric measurements taken at 6, 12, 18 and 24 months of age were converted to z-scores against the WHO reference. The relationship between aflatoxin exposure and growth was analysed using multi-level modelling. RESULTS Inverse relationships were observed between lnAF-alb and length-for-age (LAZ), weight-for-age (WAZ), and weight-for-length (WLZ) z-scores from 6 to 18 months of age (β = - 0·04, P = 0·015; β = - 0·05, P = 0.003; β = - 0·06, P = 0·007; respectively). There was an inverse relationship between lnAF-alb at 6 months and change in WLZ between 6 and 12 months (β = - 0·01; P = 0·013). LnAF-alb at 12 months was associated with changes in LAZ and infant length between 12 and 18 months of age (β = - 0·01, P = 0·003; β = - 0·003, P = 0·02; respectively). LnAF-alb at 6 months was associated with IGFBP-3 at 12 months (r = - 0·12; P = 0·043). CONCLUSIONS This study found a small but significant effect of aflatoxin exposure on the growth of Gambian infants. This relationship is not apparently explained by aflatoxin induced changes in the IGF-axis.
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Affiliation(s)
- Sinead Watson
- Institute for Global Food Security, School of Biological Sciences, Queen’s University Belfast, Belfast, UK
| | - Sophie E. Moore
- Division of Women’s Health, King’s College London, London, UK
- MRC Unit The Gambia, Serekunda, Gambia
| | | | - Gaoyun Chen
- Institute for Global Food Security, School of Biological Sciences, Queen’s University Belfast, Belfast, UK
| | - Yu-Kang Tu
- Institute of Epidemiology & Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yi-Ting Huang
- Institute of Epidemiology & Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Kamilla G. Eriksen
- MRC Elsie Widdowson Laboratory, Cambridge, UK
- University of Copenhagen, Copenhagen, Denmark
| | | | - Andrew M. Prentice
- MRC Unit The Gambia, Serekunda, Gambia
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Ya Xu
- School of Medicine, University of Leeds, Leeds, LS2 9JT UK
| | | | - Yun Yun Gong
- School of Food Science and Nutrition, University of Leeds, Leeds, UK
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James PT, Dominguez-Salas P, Hennig BJ, Moore SE, Prentice AM, Silver MJ. Maternal One-Carbon Metabolism and Infant DNA Methylation between Contrasting Seasonal Environments: A Case Study from The Gambia. Curr Dev Nutr 2018. [PMCID: PMC6351729 DOI: 10.1093/cdn/nzy082] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background The periconceptional period is a time in which environmentally induced changes to the epigenome could have significant consequences for offspring health. Metastable epialleles (MEs) are genomic loci demonstrating interindividual variation in DNA methylation with intraindividual crosstissue correlation, suggesting that methylation states are established in the very early embryo before gastrulation. In our previous Gambian studies, we have shown that ME methylation states in the offspring are predicted by maternal concentrations of certain nutritional biomarkers around the time of conception. Objective We aimed to assess whether the profile of maternal biomarker predictors of offspring methylation differs between rainy and dry seasons in a population of rural Gambians, using a larger set of 50 recently identified MEs. Methods We measured 1-carbon biomarkers in maternal plasma back-extrapolated to conception, and cytosine-phosphate-guanine (CpG) methylation at 50 ME loci in their infants’ blood at a mean age of 3.3 mo (n = 120 mother-child pairs). We tested for interactions between seasonality and effects of biomarker concentrations on mean ME methylation z score. We used backward stepwise linear regression to select the profile of nutritional predictors of methylation in each season and repeated this analysis with biomarker principal components (PCs) to capture biomarker covariation. Results We found preliminary evidence of seasonal differences in biomarker-methylation associations for folate, choline, and homocysteine (interaction P values ≤0.03). Furthermore, in stratified analyses, biomarker predictors of methylation changed between seasons. In the dry season, vitamin B-2 and methionine were positive predictors. In the rainy season, however, choline and vitamin B-6 were positive predictors, and folate and vitamin B-12 were negative predictors. PC1 captured covariation in the folate metabolism cycle and predicted methylation in dry season conceptions. PC2 represented the betaine remethylation pathway and predicted rainy season methylation. Conclusions Underlying nutritional status may modify the association between nutritional biomarkers and methylation, and should be considered in future studies.
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Affiliation(s)
- Philip T James
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, United Kingdom
- Address correspondence to PTJ (e-mail: )
| | - Paula Dominguez-Salas
- Department of Production and Population Health, Royal Veterinary College, London, United Kingdom
| | - Branwen J Hennig
- Population Health, Science Division, Wellcome Trust, London, United Kingdom
| | - Sophie E Moore
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Women and Children's Health, King's College London, London, United Kingdom
| | - Andrew M Prentice
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Matt J Silver
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London, United Kingdom
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Hennig BJ, Unger SA, Dondeh BL, Hassan J, Hawkesworth S, Jarjou L, Jones KS, Moore SE, Nabwera HM, Ngum M, Prentice A, Sonko B, Prentice AM, Fulford AJ. Cohort Profile: The Kiang West Longitudinal Population Study (KWLPS)-a platform for integrated research and health care provision in rural Gambia. Int J Epidemiol 2018; 46:e13. [PMID: 26559544 PMCID: PMC5837564 DOI: 10.1093/ije/dyv206] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2015] [Indexed: 11/12/2022] Open
Affiliation(s)
- Branwen J Hennig
- MRC International Nutrition Group at MRC Unit The Gambia, Banjul, The Gambia.,MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Stefan A Unger
- MRC International Nutrition Group at MRC Unit The Gambia, Banjul, The Gambia.,University of Edinburgh, Department of Child Life and Health, Edinburgh, UK
| | - Bai Lamin Dondeh
- MRC International Nutrition Group at MRC Unit The Gambia, Banjul, The Gambia
| | - Jahid Hassan
- MRC International Nutrition Group at MRC Unit The Gambia, Banjul, The Gambia
| | - Sophie Hawkesworth
- MRC International Nutrition Group at MRC Unit The Gambia, Banjul, The Gambia.,MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, UK.,MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK and
| | - Landing Jarjou
- MRC International Nutrition Group at MRC Unit The Gambia, Banjul, The Gambia
| | - Kerry S Jones
- MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK and
| | - Sophie E Moore
- MRC International Nutrition Group at MRC Unit The Gambia, Banjul, The Gambia.,MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, UK.,MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK and
| | - Helen M Nabwera
- MRC International Nutrition Group at MRC Unit The Gambia, Banjul, The Gambia
| | - Mohammed Ngum
- MRC International Nutrition Group at MRC Unit The Gambia, Banjul, The Gambia
| | - Ann Prentice
- MRC International Nutrition Group at MRC Unit The Gambia, Banjul, The Gambia.,MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK and
| | - Bakary Sonko
- MRC International Nutrition Group at MRC Unit The Gambia, Banjul, The Gambia
| | - Andrew M Prentice
- MRC International Nutrition Group at MRC Unit The Gambia, Banjul, The Gambia.,MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Anthony J Fulford
- MRC International Nutrition Group at MRC Unit The Gambia, Banjul, The Gambia.,MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, UK
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36
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Population DNA methylation studies in the Developmental Origins of Health and Disease (DOHaD) framework. J Dev Orig Health Dis 2018; 10:306-313. [PMID: 30101736 DOI: 10.1017/s2040174418000442] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Epigenetic changes represent a potential mechanism underlying associations of early-life exposures and later life health outcomes. Population-based cohort studies starting in early life are an attractive framework to study the role of such changes. DNA methylation is the most studied epigenetic mechanism in population research. We discuss the application of DNA methylation in early-life population studies, some recent findings, key challenges and recommendations for future research. Studies into DNA methylation within the Developmental Origins of Health and Disease framework generally either explore associations between prenatal exposures and offspring DNA methylation or associations between offspring DNA methylation in early life and later health outcomes. Only a few studies to date have integrated prospective exposure, epigenetic and phenotypic data in order to explicitly test the role of DNA methylation as a potential biological mediator of environmental effects on health outcomes. Population epigenetics is an emerging field which has challenges in terms of methodology and interpretation of the data. Key challenges include tissue specificity, cell type adjustment, issues of power and comparability of findings, genetic influences, and exploring causality and functional consequences. Ongoing studies are working on addressing these issues. Large collaborative efforts of prospective cohorts are emerging, with clear benefits in terms of optimizing power and use of resources, and in advancing methodology. In the future, multidisciplinary approaches, within and beyond longitudinal birth and preconception cohorts will advance this complex, but highly promising, the field of research.
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Xu Y, Gong YY, Routledge MN. Aflatoxin exposure assessed by aflatoxin albumin adduct biomarker in populations from six African countries: REVIEW ARTICLE. WORLD MYCOTOXIN J 2018; 11:411-419. [PMID: 33552312 PMCID: PMC7797627 DOI: 10.3920/wmj2017.2284] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 03/01/2018] [Indexed: 11/19/2022]
Abstract
Aflatoxins are a group of carcinogenic mycotoxins that have been implicated to have other adverse health impacts, including child growth impairment and immune function suppression. Aflatoxin B1 is the most toxic and most common of the aflatoxins. Contamination of various food crops is common in sub-Saharan Africa, particularly in staple crops such as maize and groundnuts, leading to chronic dietary exposure in many populations. For many years we have used the aflatoxin albumin adduct as a biomarker of aflatoxin exposure, assessed using a competitive inhibition enzyme linked immunosorbent assay (ELISA). Here, we review our recent studies of human exposure in six African countries; Gambia, Guinea, Kenya, Senegal, Tanzania and Uganda. This data shows the widespread exposure of vulnerable populations to aflatoxin. Geometric mean (95% confidence interval) levels of the biomarker ranged from 9.7 pg/mg (8.2, 11.5) in Ugandan children to 578.5 pg/mg (461.4, 717.6) in Kenyan adolescents during an acute aflatoxicosis outbreak year. We describe how various factors may have influenced the variation in aflatoxin exposure in our studies. Together, these studies highlight the urgent need for measures to reduce the burden of aflatoxin exposure in sub-Saharan Africa.
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Affiliation(s)
- Y Xu
- School of Medicine, University of Leeds, Leeds LS2 9JT, United Kingdom
| | - Y Y Gong
- School of Food Science & Nutrition, University of Leeds, Leeds LS2 9JT, United Kingdom
| | - M N Routledge
- School of Medicine, University of Leeds, Leeds LS2 9JT, United Kingdom
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Kessler NJ, Waterland RA, Prentice AM, Silver MJ. Establishment of environmentally sensitive DNA methylation states in the very early human embryo. SCIENCE ADVANCES 2018; 4:eaat2624. [PMID: 30009262 PMCID: PMC6040841 DOI: 10.1126/sciadv.aat2624] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 06/01/2018] [Indexed: 05/04/2023]
Abstract
The molecular mechanisms responsible for the developmental origins of later disease are currently unknown. We previously demonstrated that women's periconceptional nutrition predicts their offspring's DNA methylation at metastable epialleles (MEs). We present a genome-wide screen yielding 687 MEs and track their trajectories across nine developmental stages in human in vitro fertilization embryos. MEs exhibit highly unusual methylation dynamics across the implantation-gastrulation transition, producing a large excess of intermediate methylation states, suggesting the potential for differential programming in response to external signals. Using a natural experiment in rural Gambia, we show that genomic regions sensitive to season of conception are highly enriched for MEs and show similar atypical methylation patterns. MEs are enriched for proximal enhancers and transcription start sites and are influenced by genotype. Together, these observations position MEs as distinctive epigenomic features programmed in the early embryo, sensitive to genetic and periconceptional environment, and with the potential to influence phenotype.
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Affiliation(s)
- Noah J. Kessler
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Robert A. Waterland
- U.S. Department of Agriculture/Agricultural Research Service Children’s Nutrition Research Center, Departments of Pediatrics and Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Andrew M. Prentice
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Matt J. Silver
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
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39
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Van Baak TE, Coarfa C, Dugué PA, Fiorito G, Laritsky E, Baker MS, Kessler NJ, Dong J, Duryea JD, Silver MJ, Saffari A, Prentice AM, Moore SE, Ghantous A, Routledge MN, Gong YY, Herceg Z, Vineis P, Severi G, Hopper JL, Southey MC, Giles GG, Milne RL, Waterland RA. Epigenetic supersimilarity of monozygotic twin pairs. Genome Biol 2018; 19:2. [PMID: 29310692 PMCID: PMC5759268 DOI: 10.1186/s13059-017-1374-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 12/06/2017] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Monozygotic twins have long been studied to estimate heritability and explore epigenetic influences on phenotypic variation. The phenotypic and epigenetic similarities of monozygotic twins have been assumed to be largely due to their genetic identity. RESULTS Here, by analyzing data from a genome-scale study of DNA methylation in monozygotic and dizygotic twins, we identified genomic regions at which the epigenetic similarity of monozygotic twins is substantially greater than can be explained by their genetic identity. This "epigenetic supersimilarity" apparently results from locus-specific establishment of epigenotype prior to embryo cleavage during twinning. Epigenetically supersimilar loci exhibit systemic interindividual epigenetic variation and plasticity to periconceptional environment and are enriched in sub-telomeric regions. In case-control studies nested in a prospective cohort, blood DNA methylation at these loci years before diagnosis is associated with risk of developing several types of cancer. CONCLUSIONS These results establish a link between early embryonic epigenetic development and adult disease. More broadly, epigenetic supersimilarity is a previously unrecognized phenomenon that may contribute to the phenotypic similarity of monozygotic twins.
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Affiliation(s)
- Timothy E Van Baak
- USDA/ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Cristian Coarfa
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX, USA
| | - Pierre-Antoine Dugué
- Cancer Epidemiology and Intelligence Division, Cancer Council Victoria, Melbourne, VIC, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School for Global and Population Health, University of Melbourne, Melbourne, VIC, Australia
| | - Giovanni Fiorito
- Department of Medical Sciences, University of Torino and Italian Institute for Genomic Medicine, Torino, Italy
| | - Eleonora Laritsky
- USDA/ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Maria S Baker
- USDA/ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Noah J Kessler
- MRC Unit The Gambia, Keneba, Gambia
- MRC International Nutrition Group at LSHTM, London, UK
| | - Jianrong Dong
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX, USA
| | - Jack D Duryea
- USDA/ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Matt J Silver
- MRC Unit The Gambia, Keneba, Gambia
- MRC International Nutrition Group at LSHTM, London, UK
| | - Ayden Saffari
- MRC Unit The Gambia, Keneba, Gambia
- MRC International Nutrition Group at LSHTM, London, UK
| | - Andrew M Prentice
- MRC Unit The Gambia, Keneba, Gambia
- MRC International Nutrition Group at LSHTM, London, UK
| | - Sophie E Moore
- MRC Unit The Gambia, Keneba, Gambia
- Division of Women's Health, King's College London, London, UK
| | - Akram Ghantous
- Epigenetics Group, International Agency for Research on Cancer, Lyon, France
| | | | - Yun Yun Gong
- School of Food Science & Nutrition, University of Leeds, Leeds, UK
| | - Zdenko Herceg
- Epigenetics Group, International Agency for Research on Cancer, Lyon, France
| | - Paolo Vineis
- MRC-PHE Center for Environment and Health, School of Public Health, Imperial College London, London, UK
- Italian Institute for Genomic Medicine, Torino, Italy
| | - Gianluca Severi
- Centre for Epidemiology and Biostatistics, Melbourne School for Global and Population Health, University of Melbourne, Melbourne, VIC, Australia
- Italian Institute for Genomic Medicine, Torino, Italy
- CESP Inserm, Facultés de medicine Université Paris-Sud, Paris, France
| | - John L Hopper
- Centre for Epidemiology and Biostatistics, Melbourne School for Global and Population Health, University of Melbourne, Melbourne, VIC, Australia
| | - Melissa C Southey
- Genetic Epidemiology Laboratory, Department of Pathology, University of Melbourne, Melbourne, Victoria, Australia
| | - Graham G Giles
- Cancer Epidemiology and Intelligence Division, Cancer Council Victoria, Melbourne, VIC, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School for Global and Population Health, University of Melbourne, Melbourne, VIC, Australia
| | - Roger L Milne
- Cancer Epidemiology and Intelligence Division, Cancer Council Victoria, Melbourne, VIC, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School for Global and Population Health, University of Melbourne, Melbourne, VIC, Australia
| | - Robert A Waterland
- USDA/ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA.
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Nabwera HM, Moore SE, Mwangome MK, Molyneux SC, Darboe MK, Camara-Trawally N, Sonko B, Darboe A, Singhateh S, Fulford AJ, Prentice AM. The influence of maternal psychosocial circumstances and physical environment on the risk of severe wasting in rural Gambian infants: a mixed methods approach. BMC Public Health 2018; 18:109. [PMID: 29304780 PMCID: PMC5756408 DOI: 10.1186/s12889-017-4984-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 12/07/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Severe wasting affects 16 million under 5's and carries an immediate risk of death. Prevalence remains unacceptably high in sub-Saharan Africa and early infancy is a high-risk period. We aimed to explore risk factors for severe wasting in rural Gambian infants. METHODS We undertook a case-control study from November 2014 to June 2015, in rural Gambia. Cases had WHO standard weight-for-length z-scores (WLZ) < -3 on at least 1 occasion in infancy. Controls with a WLZ > -3 in the same interval, matched on age, gender, village size and distance from the clinic were selected. Standard questionnaires were used to assess maternal socioeconomic status, water sanitation and hygiene and maternal mental health. Conditional logistic regression using a multivariable model was used to determine the risk factors for severe wasting. Qualitative in depth interviews were conducted with mothers and fathers who were purposively sampled. A thematic framework was used to analyse the in-depth interviews. RESULTS Two hundred and eighty (77 cases and 203 controls) children were recruited. In-depth interviews were conducted with 16 mothers, 3 fathers and 4 research staff members. The mean age of introduction of complementary feeds was similar between cases and controls (5.2 [SD 1.2] vs 5.1 [SD 1.3] months). Increased odds of severe wasting were associated with increased frequency of complementary feeds (range 1-8) [adjusted OR 2.06 (95%: 1.17-3.62), p = 0.01]. Maternal adherence to the recommended infant care practices was influenced by her social support networks, most importantly her husband, by infant feeding difficulties and maternal psychosocial stressors that include death of a child or spouse, recurrent ill health of child and lack of autonomy in child spacing. CONCLUSION In rural Gambia, inappropriate infant feeding practices were associated with severe wasting in infants. Additionally, adverse psychosocial circumstances and infant feeding difficulties constrain mothers from practising the recommended child care practices. Interventions that promote maternal resilience through gender empowerment, prioritising maternal psychosocial support and encouraging the involvement of fathers in infant and child care promotion strategies, would help prevent severe wasting in these infants.
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Affiliation(s)
- Helen M Nabwera
- Medical Research Council Unit, The Gambia, P. O. Box 273, Banjul, The Gambia. .,Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel street, London, WC1E 7HT, UK.
| | - Sophie E Moore
- Medical Research Council Unit, The Gambia, P. O. Box 273, Banjul, The Gambia.,Division of Women's Health, King's College London, 10th floor North Wing, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Martha K Mwangome
- Kenya Medical Research Institute-Wellcome Trust Research Programme, P.O.Box 230-80108, Kilifi, Kenya
| | - Sassy C Molyneux
- Kenya Medical Research Institute-Wellcome Trust Research Programme, P.O.Box 230-80108, Kilifi, Kenya.,University of Oxford, Nuffield Department of Medicine, Henry Wellcome Building for Molecular Physiology, Old Road Campus, Headington, Oxford, OX3 7BN, UK
| | - Momodou K Darboe
- Medical Research Council Unit, The Gambia, P. O. Box 273, Banjul, The Gambia
| | | | - Bakary Sonko
- Medical Research Council Unit, The Gambia, P. O. Box 273, Banjul, The Gambia
| | - Alhagie Darboe
- Medical Research Council Unit, The Gambia, P. O. Box 273, Banjul, The Gambia
| | - Seedy Singhateh
- Medical Research Council Unit, The Gambia, P. O. Box 273, Banjul, The Gambia
| | - Anthony J Fulford
- Medical Research Council Unit, The Gambia, P. O. Box 273, Banjul, The Gambia.,Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel street, London, WC1E 7HT, UK
| | - Andrew M Prentice
- Medical Research Council Unit, The Gambia, P. O. Box 273, Banjul, The Gambia.,Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel street, London, WC1E 7HT, UK
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Prentice S. They Are What You Eat: Can Nutritional Factors during Gestation and Early Infancy Modulate the Neonatal Immune Response? Front Immunol 2017; 8:1641. [PMID: 29234319 PMCID: PMC5712338 DOI: 10.3389/fimmu.2017.01641] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 11/09/2017] [Indexed: 12/17/2022] Open
Abstract
The ontogeny of the human immune system is sensitive to nutrition even in the very early embryo, with both deficiency and excess of macro- and micronutrients being potentially detrimental. Neonates are particularly vulnerable to infectious disease due to the immaturity of the immune system and modulation of nutritional immunity may play a role in this sensitivity. This review examines whether nutrition around the time of conception, throughout pregnancy, and in early neonatal life may impact on the developing infant immune system.
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Affiliation(s)
- Sarah Prentice
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Johnson W, Elmrayed SA, Sosseh F, Prentice AM, Moore SE. Preconceptional and gestational weight trajectories and risk of delivering a small-for-gestational-age baby in rural Gambia. Am J Clin Nutr 2017; 105:1474-1482. [PMID: 28490512 PMCID: PMC5445671 DOI: 10.3945/ajcn.116.144196] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 03/29/2017] [Indexed: 12/18/2022] Open
Abstract
Background: Maternal nutritional status is a key determinant of small for gestational age (SGA), but some knowledge gaps remain, particularly regarding the role of the energy balance entering pregnancy.Objective: We investigated how preconceptional and gestational weight trajectories (summarized by individual-level traits) are associated with SGA risk in rural Gambia.Design: The sample comprised 670 women in a trial with serial weight data (7310 observations) that were available before and during pregnancy. Individual trajectories from 6 mo before conception to 30 wk of gestation were produced with the use of multilevel modeling. Summary traits were expressed as weight z scores [weight z score at 3 mo preconception (zwt-3 mo), weight z score at conception, weight z score at 3 mo postconception, weight z score at 7 mo postconception (zwt+7 mo), and conditional measures that represented the change from the preceding time] and were related to SGA risk with the use of Poisson regression with confounder adjustment; linear splines were used to account for nonlinearity.Results: Maternal weight at each time point had a consistent nonlinear relation with SGA risk. For example, the zwt-3 mo estimate was stronger in women with values ≤0.5 (RR: 0.736; 95% CI: 0.594, 0.910) than in women with values >0.5 (RR: 0.920; 95% CI: 0.682, 1.241). The former group had the highest observed SGA prevalence. Focusing on weight change, only conditional zwt+7 mo was associated with SGA and only in women with values >-0.5 (RR: 0.579; 95% CI: 0.463, 0.724).Conclusions: Protection against delivering an SGA neonate offered by greater preconceptional or gestational weight may be most pronounced in more undernourished and vulnerable women. Independent of this possibility, greater second- and third-trimester weight gain beyond a threshold may be protective. This trial was registered at http://www.isrctn.com/ as ISRCTN49285450.
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Affiliation(s)
- William Johnson
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom;
| | - Seham Aa Elmrayed
- Medical Research Council (MRC) Elsie Widdowson Laboratory, Cambridge, United Kingdom
| | - Fatou Sosseh
- Nutrition Theme, MRC Unit The Gambia, Banjul, Gambia
| | - Andrew M Prentice
- Nutrition Theme, MRC Unit The Gambia, Banjul, Gambia
- MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom; and
| | - Sophie E Moore
- Nutrition Theme, MRC Unit The Gambia, Banjul, Gambia
- Division of Women's Health, King's College London, London, United Kingdom
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Jobarteh ML, McArdle HJ, Holtrop G, Sise EA, Prentice AM, Moore SE. mRNA Levels of Placental Iron and Zinc Transporter Genes Are Upregulated in Gambian Women with Low Iron and Zinc Status. J Nutr 2017; 147:1401-1409. [PMID: 28515164 PMCID: PMC5483961 DOI: 10.3945/jn.116.244780] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 01/12/2017] [Accepted: 03/30/2017] [Indexed: 12/22/2022] Open
Abstract
Background: The role of the placenta in regulating micronutrient transport in response to maternal status is poorly understood. Objective: We investigated the effect of prenatal nutritional supplementation on the regulation of placental iron and zinc transport. Methods: In a randomized trial in rural Gambia [ENID (Early Nutrition and Immune Development)], pregnant women were allocated to 1 of 4 nutritional intervention arms: 1) iron and folic acid (FeFol) tablets (FeFol group); 2) multiple micronutrient (MMN) tablets (MMN group); 3) protein energy (PE) as a lipid-based nutrient supplement (LNS; PE group); and 4) PE and MMN (PE+MMN group) as LNS. All arms included iron (60 mg/d) and folic acid (400 μg/d). The MMN and PE+MMN arms included 30 mg supplemental Zn/d. In a subgroup of ∼300 mother-infant pairs, we measured maternal iron status, mRNA levels of genes encoding for placental iron and zinc transport proteins, and cord blood iron levels. Results: Maternal plasma iron concentration in late pregnancy was 45% and 78% lower in the PE and PE+MMN groups compared to the FeFol and MMN groups, respectively (P < 0.001). The mRNA levels of the placental iron uptake protein transferrin receptor 1 were 30–49% higher in the PE and PE+MMN arms than in the FeFol arm (P < 0.031), and also higher in the PE+MMN arm (29%; P = 0.042) than in the MMN arm. Ferritin in infant cord blood was 18–22% lower in the LNS groups (P < 0.024). Zinc supplementation in the MMN arm was associated with higher maternal plasma zinc concentrations (10% increase; P < 0.001) than in other intervention arms. mRNA levels for intracellular zinc-uptake proteins, in this case zrt, irt-like protein (ZIP) 4 and ZIP8, were 96–205% lower in the PE+MMN arm than in the intervention arms without added zinc (P < 0.025). Furthermore, mRNA expression of ZIP1 was 85% lower in the PE+MMN group than in the PE group (P = 0.003). Conclusion: In conditions of low maternal iron and in the absence of supplemental zinc, the placenta upregulates the gene expression of iron and zinc uptake proteins, presumably in order to meet fetal demands in the face of low maternal supply. The ENID trial was registered at www.controlled-trials.com as ISRCTN49285450.
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Affiliation(s)
- Modou Lamin Jobarteh
- Medical Research Council Unit The Gambia, Banjul, The Gambia.,Rowett Institute of Nutrition and Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Harry J McArdle
- Rowett Institute of Nutrition and Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Grietje Holtrop
- Biomathematics and Statistics Scotland (BioSS), Aberdeen, United Kingdom; and
| | - Ebrima A Sise
- Medical Research Council Unit The Gambia, Banjul, The Gambia
| | | | - Sophie E Moore
- Medical Research Council Unit The Gambia, Banjul, The Gambia; .,Division of Women's Health, King's College London, London, United Kingdom
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Bah A, Pasricha SR, Jallow MW, Sise EA, Wegmuller R, Armitage AE, Drakesmith H, Moore SE, Prentice AM. Serum Hepcidin Concentrations Decline during Pregnancy and May Identify Iron Deficiency: Analysis of a Longitudinal Pregnancy Cohort in The Gambia. J Nutr 2017; 147:1131-1137. [PMID: 28424258 PMCID: PMC5443464 DOI: 10.3945/jn.116.245373] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 02/06/2017] [Accepted: 03/20/2017] [Indexed: 01/01/2023] Open
Abstract
Background: Antenatal anemia is a risk factor for adverse maternal and fetal outcomes and is prevalent in sub-Saharan Africa. Less than half of antenatal anemia is considered responsive to iron; identifying women in need of iron may help target interventions. Iron absorption is governed by the iron-regulatory hormone hepcidin. Objective: We sought to characterize changes in hepcidin and its associations with indexes of iron stores, erythropoiesis, and inflammation at weeks 14, 20, and 30 of gestation and to assess hepcidin’s diagnostic potential as an index of iron deficiency. Methods: We measured hemoglobin and serum hepcidin, ferritin, soluble transferrin receptor (sTfR), and C-reactive protein (CRP) at 14, 20, and 30 wk of gestation in a cohort of 395 Gambian women recruited to a randomized controlled trial. Associations with hepcidin were measured by using linear regression, and hepcidin’s diagnostic test accuracy [area under the receiver operating characteristic curve (AUCROC), sensitivity, specificity, cutoffs] for iron deficiency at each time point was analyzed. Results: The prevalence of anemia increased from 34.6% at 14 wk of gestation to 50.0% at 20 wk. Hepcidin concentrations declined between study enrollment and 20 wk, whereas ferritin declined between 20 and 30 wk of gestation. The variations in hepcidin explained by ferritin, sTfR, and CRP declined over pregnancy. The AUCROC values for hepcidin to detect iron deficiency (defined as ferritin <15 μg/L) were 0.86, 0.83, and 0.84 at 14, 20, and 30 wk, respectively. Hepcidin was superior to hemoglobin and sTfR as an indicator of iron deficiency. Conclusions: In Gambian pregnant women, hepcidin appears to be a useful diagnostic test for iron deficiency and may enable the identification of cases for whom iron would be beneficial. Hepcidin suppression in the second trimester suggests a window for optimal timing for antenatal iron interventions. Hemoglobin does not effectively identify iron deficiency in pregnancy. This trial was registered at www.isrctn.com as ISRCTN49285450.
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Affiliation(s)
- Amat Bah
- Medical Research Council (MRC) Unit The Gambia-MRC International Nutrition Group, Banjul, Gambia;
| | - Sant-Rayn Pasricha
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Momodou W Jallow
- Medical Research Council (MRC) Unit The Gambia-MRC International Nutrition Group, Banjul, Gambia
| | - Ebrima A Sise
- Medical Research Council (MRC) Unit The Gambia-MRC International Nutrition Group, Banjul, Gambia
| | - Rita Wegmuller
- Medical Research Council (MRC) Unit The Gambia-MRC International Nutrition Group, Banjul, Gambia
| | - Andrew E Armitage
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Hal Drakesmith
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Sophie E Moore
- Division of Women's Health, King's College London, London, United Kingdom; and
| | - Andrew M Prentice
- MRC Unit The Gambia-MRC International Nutrition Group and London School of Hygiene and Tropical Medicine, London, United Kingdom
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Abstract
BACKGROUND Multiple-micronutrient (MMN) deficiencies often coexist among women of reproductive age in low- to middle-income countries. They are exacerbated in pregnancy due to the increased demands, leading to potentially adverse effects on the mother and developing fetus. Though supplementation with MMNs has been recommended earlier because of the evidence of impact on pregnancy outcomes, a consensus is yet to be reached regarding the replacement of iron and folic acid supplementation with MMNs. Since the last update of this Cochrane review, evidence from a few large trials has recently been made available, the inclusion of which is critical to inform policy. OBJECTIVES To evaluate the benefits of oral multiple-micronutrient supplementation during pregnancy on maternal, fetal and infant health outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (11 March 2015) and reference lists of retrieved articles and key reviews. We also contacted experts in the field for additional and ongoing trials. SELECTION CRITERIA All prospective randomised controlled trials evaluating MMN supplementation with iron and folic acid during pregnancy and its effects on the pregnancy outcome were eligible, irrespective of language or the publication status of the trials. We included cluster-randomised trials, but quasi-randomised trials were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach. MAIN RESULTS Nineteen trials (involving 138,538 women) were identified as eligible for inclusion in this review but only 17 trials (involving 137,791 women) contributed data to the review. Fifteen of these 17 trials were carried out in low and middle-income countries and compared MMN supplements with iron and folic acid versus iron with or without folic acid. Two trials carried out in the UK compared MMN with a placebo. MMN with iron and folic acid versus iron, with or without folic acid (15 trials): MMN resulted in a significant decrease in the number of newborn infants identified as low birthweight (LBW) (average risk ratio (RR) 0.88, 95% confidence interval (CI) 0.85 to 0.91; high-quality evidence) or small-for-gestational age (SGA) (average RR 0.92, 95% CI 0.86 to 0.98; moderate-quality evidence). No significant differences were shown for other maternal and pregnancy outcomes: preterm births (average RR 0.96, 95% CI 0.90 to 1.03; high-quality evidence), stillbirth (average RR 0.97, 95% CI 0.87, 1.09; high-quality evidence), maternal anaemia in the third trimester (average RR 1.03, 95% CI 0.85 to 1.24), miscarriage (average RR 0.91, 95% CI 0.80 to 1.03), maternal mortality (average RR 0.97, 95% CI 0.63 to 1.48), perinatal mortality (average RR 1.01, 95% CI 0.91 to 1.13; high-quality evidence), neonatal mortality (average RR 1.06, 95% CI 0.92 to 1.22; high-quality evidence), or risk of delivery via a caesarean section (average RR 1.04; 95% CI 0.74 to 1.46).A number of prespecified, clinically important outcomes could not be assessed due to insufficient or non-available data. Single trials reported results for: very preterm birth < 34 weeks, macrosomia, side-effects of supplements, nutritional status of children, and congenital anomalies including neural tube defects and neurodevelopmental outcome: Bayley Scales of Infant Development (BSID) scores. None of these trials reported pre-eclampsia, placental abruption, premature rupture of membranes, cost of supplementation, and maternal well-being or satisfaction.When assessed according to GRADE criteria, the quality of evidence for the review's primary outcomes overall was good. Pooled results for primary outcomes were based on multiple trials with large sample sizes and precise estimates. The following outcomes were graded to be as of high quality: preterm birth, LBW, perinatal mortality, stillbirth and neonatal mortality. The outcome of SGA was graded to be of moderate quality, with evidence downgraded by one for funnel plot asymmetry and potential publication bias.We carried out sensitivity analysis excluding trials with high levels of sample attrition (> 20%); results were consistent with the main analysis except for the findings for SGA (average RR 0.91, 95% CI 0.84 to 1.00). We explored heterogeneity through subgroup analyses by maternal height and body mass index (BMI), timing of supplementation and dose of iron. Subgroup differences were observed for maternal BMI for the outcome preterm birth, with significant findings among women with low BMI. Subgroup differences were also observed for maternal BMI and maternal height for the outcome SGA, indicating a significant impact among women with higher maternal BMI and height. The overall analysis of perinatal mortality, although showed a non-significant effect of MMN supplements versus iron with or without folic acid, was found to have substantial statistical heterogeneity. Subgroup differences were observed for timing of supplementation for this outcome, indicating a significantly higher impact with late initiation of supplementation. The findings between subgroups for other primary outcomes were inconclusive. MMN versus placebo (two trials): A single trial in the UK found no clear differences between groups for preterm birth, SGA, LBW or maternal anaemia in the third trimester. A second trial reported the number of women with pre-eclampsia; there was no evidence of a difference between groups. Other outcomes were not reported. AUTHORS' CONCLUSIONS Our findings support the effect of MMN supplements with iron and folic acid in improving some birth outcomes. Overall, pregnant women who received MMN supplementation had fewer low birthweight babies and small-for-gestational-age babies. The findings, consistently observed in several systematic evaluations of evidence, provide a basis to guide the replacement of iron and folic acid with MMN supplements containing iron and folic acid for pregnant women in low and middle-income countries where MMN deficiencies are common among women of reproductive age. Efforts could focus on the integration of this intervention in maternal nutrition and antenatal care programs in low and middle-income countries.
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Affiliation(s)
- Batool A Haider
- Harvard School of Public HealthDepartment of Global Health and Population677 Huntington AvenueBostonUSA02115
| | - Zulfiqar A Bhutta
- Hospital for Sick ChildrenCentre for Global Child HealthTorontoCanadaM5G A04
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Eriksen KG, Johnson W, Sonko B, Prentice AM, Darboe MK, Moore SE. Following the World Health Organization's Recommendation of Exclusive Breastfeeding to 6 Months of Age Does Not Impact the Growth of Rural Gambian Infants. J Nutr 2017; 147:248-255. [PMID: 28003540 PMCID: PMC5265696 DOI: 10.3945/jn.116.241737] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 10/23/2016] [Accepted: 11/29/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The WHO recommends exclusive breastfeeding (EBF) for the first 6 mo of life. OBJECTIVE The objective of this study was to assess the benefit of EBF to age 6 mo on growth in a large sample of rural Gambian infants at high risk of undernutrition. METHODS Infants with growth monitoring from birth to 2 y of age (n = 756) from the ENID (Early Nutrition and Immune Development) trial were categorized as exclusively breastfed if only breast milk and no other liquids or foods were given. EBF status was entered into confounder-adjusted multilevel models to test associations with growth trajectories by using >11,000 weight-for-age (WAZ), length-for-age (LAZ), and weight-for-length (WLZ) z score observations. RESULTS Thirty-two percent of infants were exclusively breastfed to age 6 mo. The mean age of discontinuation of EBF was 5.2 mo, and growth faltering started at ∼3.5 mo of age. Some evidence for a difference in WAZ and WHZ was found between infants who were exclusively breastfed to age 6 mo (EBF-6) and those who were not (nEBF-6), at 6 and 12 mo of age, with EBF-6 children having a higher mean z score. The differences in z scores between the 2 groups were small in magnitude (at 6 mo of age: 0.147 WAZ; 95% CI: -0.001, 0.293 WAZ; 0.189 WHZ; 95% CI: 0.038, 0.341 WHZ). No evidence for a difference between EBF-6 and nEBF-6 infants was observed for LAZ at any time point (6, 12, and 24 mo of age). Furthermore, a higher mean WLZ at 3 mo of age was associated with a subsequent higher mean age at discontinuation of EBF, which implied reverse causality in this setting (coefficient: 0.060; 95% CI: 0.008, 0.120). CONCLUSION This study suggests that EBF to age 6 mo has limited benefit to the growth of rural Gambian infants. This trial was registered at http://www.isrctn.com as ISRCTN49285450.
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Affiliation(s)
- Kamilla G Eriksen
- Medical Research Council (MRC) Elsie Widdowson Laboratory, Cambridge, United Kingdom;
| | - William Johnson
- Medical Research Council (MRC) Elsie Widdowson Laboratory, Cambridge, United Kingdom
| | | | - Andrew M Prentice
- MRC Unit The Gambia, Banjul, The Gambia;,MRC International Nutrition Group, London School of Hygiene and Tropical Medicine, London, United Kingdom; and
| | | | - Sophie E Moore
- MRC Unit The Gambia, Banjul, The Gambia;,Division of Women’s Health, King’s College London, London, United Kingdom
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Davis JCC, Lewis ZT, Krishnan S, Bernstein RM, Moore SE, Prentice AM, Mills DA, Lebrilla CB, Zivkovic AM. Growth and Morbidity of Gambian Infants are Influenced by Maternal Milk Oligosaccharides and Infant Gut Microbiota. Sci Rep 2017; 7:40466. [PMID: 28079170 PMCID: PMC5227965 DOI: 10.1038/srep40466] [Citation(s) in RCA: 137] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 12/06/2016] [Indexed: 12/25/2022] Open
Abstract
Human milk oligosaccharides (HMOs) play an important role in the health of an infant as substrate for beneficial gut bacteria. Little is known about the effects of HMO composition and its changes on the morbidity and growth outcomes of infants living in areas with high infection rates. Mother's HMO composition and infant gut microbiota from 33 Gambian mother/infant pairs at 4, 16, and 20 weeks postpartum were analyzed for relationships between HMOs, microbiota, and infant morbidity and growth. The data indicate that lacto-N-fucopentaose I was associated with decreased infant morbidity, and 3'-sialyllactose was found to be a good indicator of infant weight-for-age. Because HMOs, gut microbiota, and infant health are interrelated, the relationship between infant health and their microbiome were analyzed. While bifidobacteria were the dominant genus in the infant gut overall, Dialister and Prevotella were negatively correlated with morbidity, and Bacteroides was increased in infants with abnormal calprotectin. Mothers nursing in the wet season (July to October) produced significantly less oligosaccharides compared to those nursing in the dry season (November to June). These results suggest that specific types and structures of HMOs are sensitive to environmental conditions, protective of morbidity, predictive of growth, and correlated with specific microbiota.
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Affiliation(s)
- Jasmine C. C. Davis
- Department of Chemistry, University of California, Davis, CA 95616, United States
- Foods for Health Institute, University of California, Davis, CA 95616, United States
| | - Zachery T. Lewis
- Foods for Health Institute, University of California, Davis, CA 95616, United States
- Department of Food Science and Technology, University of California, Davis, CA 95616, United States
| | - Sridevi Krishnan
- Department of Nutrition, University of California, Davis, CA 95616, United States
| | - Robin M. Bernstein
- Department of Anthropology, University of Colorado, Boulder, CO 80309, United States
- Health and Society Program, Institute of Behavioral Science, University of Colorado, Boulder, CO 80309, United States
| | - Sophie E. Moore
- Medical Research Council (MRC) Human Nutrition Research, Cambridge, UK
- MRC Unit, The Gambia and MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrew M. Prentice
- MRC Unit, The Gambia and MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, UK
| | - David A. Mills
- Foods for Health Institute, University of California, Davis, CA 95616, United States
- Department of Food Science and Technology, University of California, Davis, CA 95616, United States
- Department of Viticulture and Enology, University of California, Davis, CA 95616, United States
| | - Carlito B. Lebrilla
- Department of Chemistry, University of California, Davis, CA 95616, United States
- Foods for Health Institute, University of California, Davis, CA 95616, United States
| | - Angela M. Zivkovic
- Foods for Health Institute, University of California, Davis, CA 95616, United States
- Department of Nutrition, University of California, Davis, CA 95616, United States
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48
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Maternal bone mineral changes during pregnancy as measured by peripheral QCT in rural Gambian women with a habitually low calcium intake. Proc Nutr Soc 2017. [DOI: 10.1017/s0029665117003391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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49
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Prentice AM, Mendoza YA, Pereira D, Cerami C, Wegmuller R, Constable A, Spieldenner J. Dietary strategies for improving iron status: balancing safety and efficacy. Nutr Rev 2017; 75:49-60. [PMID: 27974599 PMCID: PMC5155616 DOI: 10.1093/nutrit/nuw055] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
In light of evidence that high-dose iron supplements lead to a range of adverse events in low-income settings, the safety and efficacy of lower doses of iron provided through biological or industrial fortification of foodstuffs is reviewed. First, strategies for point-of-manufacture chemical fortification are compared with biofortification achieved through plant breeding. Recent insights into the mechanisms of human iron absorption and regulation, the mechanisms by which iron can promote malaria and bacterial infections, and the role of iron in modifying the gut microbiota are summarized. There is strong evidence that supplemental iron given in nonphysiological amounts can increase the risk of bacterial and protozoal infections (especially malaria), but the use of lower quantities of iron provided within a food matrix, ie, fortified food, should be safer in most cases and represents a more logical strategy for a sustained reduction of the risk of deficiency by providing the best balance of risk and benefits. Further research into iron compounds that would minimize the availability of unabsorbed iron to the gut microbiota is warranted.
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Affiliation(s)
- Andrew M Prentice
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
| | - Yery A Mendoza
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Dora Pereira
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Carla Cerami
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Rita Wegmuller
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Anne Constable
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Jörg Spieldenner
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Johnson W, Darboe MK, Sosseh F, Nshe P, Prentice AM, Moore SE. Association of prenatal lipid-based nutritional supplementation with fetal growth in rural Gambia. MATERNAL AND CHILD NUTRITION 2016; 13. [PMID: 27696720 PMCID: PMC5396370 DOI: 10.1111/mcn.12367] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 07/01/2016] [Accepted: 07/20/2016] [Indexed: 01/20/2023]
Abstract
Prenatal supplementation with protein-energy (PE) and/or multiple-micronutrients (MMNs) may improve fetal growth, but trials of lipid-based nutritional supplements (LNSs) have reported inconsistent results. We conducted a post-hoc analysis of non-primary outcomes in a trial in Gambia, with the aim to test the associations of LNS with fetal growth and explore how efficacy varies depending on nutritional status. The sample comprised 620 pregnant women in an individually randomized, partially blinded trial with four arms: (a) iron and folic acid (FeFol) tablet (usual care, referent group), (b) MMN tablet, (c) PE LNS, and (d) PE + MMN LNS. Analysis of variance examined unadjusted differences in fetal biometry z-scores at 20 and 30 weeks and neonatal anthropometry z-scores, while regression tested for modification of intervention-outcome associations by season and maternal height, body mass index, and weight gain. Despite evidence of between-arm differences in some fetal biometry, z-scores at birth were not greater in the intervention arms than the FeFol arm (e.g., birth weight z-scores: FeFol -0.71, MMN -0.63, PE -0.64, PE + MMN -0.62; group-wise p = .796). In regression analyses, intervention associations with birth weight and head circumference were modified by maternal weight gain between booking and 30 weeks gestation (e.g., PE + MMN associations with birth weight were +0.462 z-scores (95% CI [0.097, 0.826]) in the highest quartile of weight gain but -0.099 z-scores (-0.459, 0.260) in the lowest). In conclusion, we found no strong evidence that a prenatal LNS intervention was associated with better fetal growth in the whole sample.
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Affiliation(s)
| | - Momodou K Darboe
- MRC International Nutrition Group, MRC Unit The Gambia, Fajara, Banjul, The Gambia
| | - Fatou Sosseh
- MRC International Nutrition Group, MRC Unit The Gambia, Fajara, Banjul, The Gambia
| | - Patrick Nshe
- MRC International Nutrition Group, MRC Unit The Gambia, Fajara, Banjul, The Gambia
| | - Andrew M Prentice
- MRC International Nutrition Group, MRC Unit The Gambia, Fajara, Banjul, The Gambia
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