Mother and infant

Maternal diet during pregnancy is thought to be one of the most influential factors on child health and development. However, dietary interventions during this period may miss a critical window to improve health during childhood, as well as adult life.

In a recent series of articles in The Lancet, researchers address the significance of nutrition in the preconception period, or the time before a woman becomes pregnant. The series of three articles challenges the current perspective of the preconception period. Currently defined as 3 months before conception, the authors suggest preconception should also include any time a woman is at child bearing age. This revision is based on an understanding of the biological events occurring during the periconceptional period, or the time immediately surrounding conception. In addition, it addresses a lack of nutritional preparedness for pregnancy in women of reproductive age and the failure of dietary interventions during pregnancy in preventing adverse health outcomes.

How does pre-pregnancy nutrition affect child health?

The periconceptional period begins before fertilization occurs, with maturation of sperm and oocytes, and extends until implantation of the fertilized egg. From the time of fertilization, this process occurs relatively quickly (up to 9 days in humans) but is characterized by drastic changes developmentally, genetically, and metabolically. The embryonic genome undergoes epigenetic modifications, or alterations to the DNA that do not change the genetic code but rather affect how a gene is expressed by turning expression on or off. These modifications are responsive to environmental conditions and nutrient availability, and likely adapt to promote optimal survival under existing conditions. However, the established gene expression pattern may be detrimental in environmental conditions outside of the uterus, promoting disease development later in life.

Although epigenetic changes can occur throughout one’s lifetime, the periconceptional period is unique in that a small number of cells are present. Full exposure to the environment allows this founder population of cells to establish the genetic program that persists throughout development.

How does this change current practice?

The influence of maternal nutrition during the periconceptional period on disease and development in offspring is not a new concept. Both maternal overnutrition and obesity, as well as undernutrition have been known to adversely affect metabolic regulation in offspring and increase the risk for metabolic disease development.

More recently, analysis from the UK National Diet and Nutrition Survey suggest that less than 10% of women of reproductive age meet the recommended daily intakes during pregnancy for several key micronutrients including zinc, vitamin A, folate, and calcium. Only 30% of women meet the daily intake recommendations for iron. A lack of success of multiple micronutrient supplementation during pregnancy in improving child health outcomes, including survival, growth, body composition, and blood pressure, indicate the importance of correcting such nutritional deficiencies well before pregnancy.

These findings suggest that preconception intervention strategies should include population targeted interventions for women of reproductive age, in addition to those targeting the 3 months before conception. This will allow adequate time to correct for nutritional deficiencies before pregnancy.

Sarah Reyes, Ph.D. Candidate in Nutritional Sciences at Cornell University and NIH Predoctoral Trainee in Translational Research in Nutrition

Sarah Reyes received her B.A. in Interdisciplinary Studies – International Studies and Human Nutrition and her M.S. in Animal Science from the University of Idaho and is completing her Ph.D. studies in the Human Nutrition Program at Cornell University’s Division of Nutritional Sciences. Sarah is an NIH predoctoral trainee on a translational research in nutrition training grant of which, until recently, former ASN president Patrick Stover was the PI. Sarah has been an ASN member since 2009 and holds the position of Secretary for the International Society for Research in Human Milk and Lactation’s Trainee Interest Group, an ASN partner organization.

1. How did you first get involved in nutrition science and research?

I come from Idaho, a rural state with high rates of chronic diseases such as diabetes and hypertension. I originally wanted to become a physician because access to quality medical care in Idaho is relatively limited for poor and rural populations. I chose to study International Studies and Human Nutrition to give me breadth of knowledge that I thought would position me competitively for acceptance into medical school. However, the more I learned about the cycles of poverty and oppression in my International Studies courses and the power of nutrition and exercise to prevent and even treat chronic disease, I realized quickly that my passion was to empower people like me—the daughter of a mixed-race couple from a blue-collar family in poor, rural America—to prevent chronic disease. I became passionate about public health and how to disrupt the systems in place that sustain cycles of poverty and oppression. I recognized that my overlapping interests in basic science and public health could be a powerful tool to create evidence-based recommendations to empower disadvantaged and marginalized members of our society achieve better health outcomes. (At the time I wasn’t aware of the term translational research, but ultimately that’s what I pursued). My interest in nutrition, specifically, was inspired by my undergraduate courses which taught me that my grandmother’s type II diabetes and neuropathy were consequence of years of subsisting on a diet nearly void of fresh fruits and vegetables and eating too much white bread, white sugar, and white potatoes (I mean it was rural Idaho—yes, the stereotype applies).

2. Tell us about your current position and the research activities in which you are involved.

I’m a PhD candidate in the Division of Nutritional Sciences at Cornell University. Kathleen Rasmussen, ScD, RD is the Chair of my doctoral committee, and I collaborate with the laboratories of Anthony Hay, PhD, at Cornell University, Mark McGuire, PhD, at the University of Idaho, and Shelley McGuire, PhD at Washington State University. In the spirit of translational research, I was intent on using basic science to advance a public health initiative for my doctoral research. I was able to leverage my Chair’s interest in women’s real-life experiences with pumping and feeding expressed breast milk with the combined expertise in microbiology and lactation physiology of my collaborators. I was particularly interested in the discordance between the way expressed milk was collected in studies cited in current recommendations for handling and storage of expressed milk at home and the way expressed milk is collected in real-life. Specifically, most studies collect milk aseptically whereas real-life is messy. Women often have to pump their milk in less than ideal conditions such as in restrooms, vehicles, and other public spaces. Plus, expressed milk is often stored at multiple temperatures and poured into several different containers. My doctoral research has focused on characterizing and comparing the human milk microbiome in real-life conditions v. aseptic collection and identifying sources of and factors associated with bacterial contamination in expressed milk. We conducted a randomized trial to do this research and I’m just finishing up the analyses of this work. Our results not only fill a critical gap needed to improve existing recommendations for handling and storage of expressed milk at home, but it also opens up questions about how differential exposure to microbes from breast milk influence the infant gastrointestinal microbiome and health outcomes. I’m excited to share some of our results for the first time at Nutrition 2018!

3. You are a student at a prestigious university, a mother of two, and pregnant?! How do you do it?

I get that question a lot! In fact, I made a YouTube video of a day in my life to give others a glimpse of how I make it work. First, I have a fully supportive and loving husband, Paul Reyes. His commitment to helping me achieve this goal is undoubtedly a huge reason why I have been able to pull off school and kids simultaneously. My hat goes off to all the single, working moms out there. I don’t know how they do it! Second, having kids has pushed me to become more intentional about my goals, to prioritize my daily, weekly, monthly, and yearly tasks needed to accomplish those goals, and to manage my time so I can maintain the energy and enthusiasm needed to be productive over extended periods of time while still being present at home.

4. What do you feel are the biggest challenges facing nutrition researchers today? 

My biggest concern for nutrition researchers is public trust. Without trust, individuals will not heed recommendations. Especially where I’m from, many are leery of dietary recommendations because some have changed drastically over time (think cholesterol and eggs). Drastic changes in recommendations are perceived as “scientists don’t know what they’re doing.” Plus, policies enacted to ensure healthy eating is equitable (e.g., trans-fat bans, soda size restrictions in NYC, school lunch policies limiting access to sugary and salty foods) are seen as attacks on individual rights and freedoms, which fuels distrust in recommendations. I think a combination of the use of rigorous study methods to produce quality science along with nutrition scientists being more vocal on social and other media platforms can help improve public trust.

5. Is there anything else you’d like to tell ASN members, especially students?

Know what your objectives are and be intentional on dedicating time to those. Expose yourself to as many learning opportunities as you can to gain breadth of knowledge and experience. For example, take a short-course on equity either online, at your university, or at another university. Become involved in things that matter to you both professionally and personally! This will keep you enthusiastic and motivated about your research and help you live a healthier life. Stay open-minded and remain objective in your pursuit of science. Finally, find a good mentor and a good advocate. A good mentor will help you learn how to conduct rigorous science and sharpen the skills you need to meet your own personal objectives. An advocate is someone who is respected in your field that can help you find and avail on opportunities that will help you achieve your goals.

[Learn more about ASN student membership here]

Sarah Reyes’ primary interests are the developmental origins of health and disease and finding equitable solutions to empower disadvantaged and marginalized populations achieve better health outcomes. Sarah’s interests are focused on the mother-infant dyad and, in particular, the breastfeeding relationship. Most recently, Sarah’s work has focused on characterizing the bacterial communities in breast milk pumped in real-life conditions. Sarah has conducted research in mammalian and bacterial cell culture, biochemical analyses, epidemiology, and microbiome research. In addition to her research interests, Sarah is interested in opportunities to use her knowledge to serve others. She recently attended the Make the Breast Pump Not Suck Hackathon where she helped design a study to evaluate the efficacy of hand expression on milk volume for incarcerated women in New Mexico. Visit her video, A Day in the Life of a PhD Mom | Ivy League, Kids, and Pregnancy.

These days you can hardly watch a T.V. program without being bombarded by the newest diet craze. Maybe it’s the time of year, January, when everyone is hoping to make 2018 their year, but more likely it is because dieting has become a multi-billion-dollar industry in the United States.

 

As a new-ish mother I’ve been carrying around the last 5, 10, okay 15 pounds for the last 7 months and decided in a sleep deprived haze to attempt a weight loss intervention for 2018. I was immediately overwhelmed by the number of programs, quick fixes, and suspicious non-FDA approved ‘supplements’ floating around on the market.

 

While all of these diets certainly have their individual gimmicks, they center around the core idea of calories in vs calories out. This core tenant of weight loss has been recognized as the hallmark of successful lifestyle change, that is, to lose weight one must intake less energy than they expend. While there are multiple ways to achieve this negative energy balance (i.e. diet, exercise, weight loss surgery, pharmaceuticals, etc.) I was interested in how to achieve negative balance while retaining a healthy breastmilk supply.

 

Breastmilk is composed of the 3 major macronutrients: fat, protein, and carbohydrate. Of these, mature breastmilk (that produced around day 6), contains 3.5 g of fat, 7 g of carbohydrate, and 0.9 g protein per 100ml. It also contains a whole host of other vitamins, minerals, immunoglobulins, and bioactive factors (1).  Most of the papers examining breastmilk composition in well controlled studies focus on diversity and amount of specific Fatty Acids, total protein profile, and total energy content (2). Multiple studies have also focused on the amount of DHA passed in breastmilk and linked it to maternal consumption of fatty fish (2).

 

While the outcomes of these studies showed associations of maternal diet with breastmilk composition only one well controlled study has been done to address the effects of following a diet (low carbohydrate or low fat) on the composition and supply of breastmilk. This study found that under moderate caloric restriction women on a ‘low’ (~31%) carbohydrate diets (vs low fat diets ~26% fat) had higher levels of fat in their breastmilk with higher levels of energy expenditure. Neither diet impacted breastmilk production as both were only moderately hypocaloric (3).

So where does that leave us?

 

We know women are likely to gain and retain weight during a first pregnancy putting them at higher risk for complications should a second pregnancy be desired. It appears that the most important time for weight loss interventions is the first 18 months post-partum after which weight loss tends to plateau (4). With the importance of exclusively breastfeeding up to a year we need more studies that focus on effective weight loss techniques for post-partum women who wish to maintain milk supply.

 

As for me? I think I’ll cut out the bread and leave the butter.

 

 

 

 

1) World Health Organization. “Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals.” (2009).

 

2) Bravi, Francesca, et al. “Impact of maternal nutrition on breast-milk composition: a systematic review, 2.” The American journal of clinical nutrition 104.3 (2016): 646-662.

 

3) Mohammad, Mahmoud A., Agneta L. Sunehag, and Morey W. Haymond. “Effect of dietary macronutrient composition under moderate hypocaloric intake on maternal adaptation during lactation–.” The American journal of clinical nutrition 89.6 (2009): 1821-1827.

 

4) Gunderson, Erica P. “Childbearing and obesity in women: weight before, during, and after pregnancy.” Obstetrics and Gynecology Clinics 36.2 (2009): 317-332.

Potential mothers, new mothers and mothers of multiples often worry about how their nutrition will affect their children. With the high rates of childhood obesity, some mothers worry more than ever about what they are putting in their bodies. Although this could be a discussion that includes pesticides on food, chemicals in cleaners and even air pollution, let’s just focus on nutrition.

 

It has been shown that a strong predictor of a child’s future BMI is the mother’s pre-pregnancy BMI (Schou-Anderson et al, 2012). This prediction comes from two sources, environment (how parents eat directly influences how children eat) and genetics (especially epigenetics). Epigenetics is how our cells control gene expression without changing the core DNA sequence and can include both DNA methylation and histone modification. It is consistently reported that maternal diet can directly alter DNA binding sites (Aagaard-Tillery et al, 2008) and DNA methylation (Dudley et al, 2011) in the offspring of mothers fed high fat diets. High fat diets contain energy dense foods consisting of >45% of total calories from fat, essentially mirroring the typical Western diet, which is full of highly palatable, highly processed energy dense foods. While this is certainly not a comprehensive list of publications on this topic, it is safe to say that maternal diet can influence an offspring’s risk of developing obesity through epigenetics (a nice review here). Hence the idea that whatever you eat, your baby also experiences.

 

While this may not be a novel concept, it is more important than ever to educate mothers (and fathers!) about the influence their diet could have on their future children’s body composition and their overall risk for obesity-associated diseases. While this information may initially leave parents anxiously asking questions like “Is there anything I can do?!”; “Is the damage already done?”; or “What could I have done differently?”, our goal is to provide information that is both reassuring and accurate knowing that with the right nutritional decisions, your child will be just fine!

 

Multiple studies have shown interventions in eating patterns and exercise work for reducing obesity and risk for associated diseases (reviewed here, here, here, here, here etc.).

 

The trick? Implementing these changes in your families diet and exercise routines to change the trajectory that epigenetics may have imposed when your little one was no larger than a grain of rice.

 

As a new parent you can go no longer than 24 hours without hearing the phrase “Breast is Best.” I know this to be true because I became a parent in June of this year. In the hospital we were offered consults with lactation and had no less than six posters in our room touting the benefits of breastfeeding. As a PhD student I was intrigued by the literature behind these recommendations and eagerly spent multiple late night nursing sessions on my iPad reading the latest research. What I found were some studies finding associations with reduced risk of obesity, and others failing to find this same association (literature). Overall, it was concluded in the previous review that breastfeeding was associated with a reduced risk of obesity.

While this was great news, I could not help but question; was this association because of breastmilk or mode of delivery? Bottle feeding is typically associated with formula feeding but a growing number of women have begun pumping their breastmilk after returning to work or in cases of pre-term birth and latch issues.

Could bottle feeding breastmilk still ameliorate the risk of obesity later in life?

I was not the first person to raise this question which has been addressed here, here, here, and here. Overall the consensus seems to be that early bottle feeding, of breastmilk or formula, is associated with an increased risk for excess weight gain and poor self regulation. Exclusively feeding expressed milk is also associated with early cessation of breast-milk feeding.

So this leads to the inevitable question; what is a mother to do?

While the literature is still unclear if bottled breastmilk can fight obesity risk, it is clear the breastmilk has multiple other benefits according to the American Academy of Pediatrics and should be offered when possible. So to those mothers who pump a little, a lot, or all the time, I say pump on ladies!

For many generations parenting books and gurus alike have heralded the importance of routine. Beginning in infancy, children are scheduled to eat, sleep and play, and busy moms often follow this schedule to assure their youngest children are happy, healthy and well socialized. But, as is always the case, children grow older and become involved in more activities making it difficult to stick with rigid schedules established in infancy.

Recent evidence however has shown that regular mealtimes, bedtimes and limits on television at age 3 were all linked to children having better emotional self-regulation later in life. Self-regulation has two distinct domains, emotional and cognitive. Together, these domains help children control their attention. While these two domains have traditionally been studied together it is important to examine them independently as emotional self-regulation is tied to subcortical structures in the brain while cognitive self-regulation is based in the prefrontal cortex. The prefrontal cortex is known to mature later in development continuing its maturity until the early 20’s so outcomes based on these two domains must be distinct.

Anderson and colleagues (2017) tackled these questions in their recent publication accepted in the Journal of Obesity. Using a prospective study they examined how both domains of self-regulation and routine can impact obesity later in childhood (although only until age 11). The Millennium Cohort Study gathered data from 19,244 families recruited in the UK from 2000-2002. Data was collected beginning at 9 months with follow-ups at ages 3, 5, 7 and 11. Child Social Behavior Questionnaires were used at age 3 to determine self-regulation, while height/weight was used at age 11 to determine BMI and obesity status. A series of logistic regressions were used to understand how self-regulation and routine related to risk for obesity at age 11.

Results showed that having a “sometimes-regular bedtime” or “inconsistent bedtimes” were both associated with elevated risk for obesity at age 11. High television/video viewing time was initially associated with higher obesity rates but the result was not significant after controlling for other routines, a result that could be explained by the imprecise measurements used to quantify time spent. Surprisingly, children with mealtimes that varied considerably were found to be less likely to be obese at age 11. While this study agrees with previous literature in terms of bedtime, the results for mealtime were unexpected and need to be considered in the context of the study which was observational and based on parent self-report. Overall, emotional self-regulation and household routines were independent predictors of obesity at age 11 and those children with regular bedtimes, mealtimes, and limits on television/video displayed enhanced emotional self-regulation.

While this study demonstrates the importance of routine, it is important to understand that many factors could not be controlled for, leaving the study with multiple limitations. Still, if putting the kids to bed at the same time could be protective, maybe those rigid schedules shouldn’t be abandoned just yet.

 

References:

Anderson, S. E., et al. “Self-regulation and household routines at age three and obesity at age eleven: Longitudinal analysis of the UK Millennium cohort study.” International journal of obesity (2005) (2017).

Sowell, Elizabeth R., et al. “Mapping cortical change across the human life span.” Nature neuroscience 6.3 (2003): 309-315.

 

Does Breastfeeding Make You Smarter?

Good nutrition has been shown to help with survival, growth, mental development, health, and well-being across one’s lifespan. Unearthing precisely what to eat to help achieve maximal benefit has been the subject of many research studies and debates, especially regarding childhood nutrition starting at an early age.

Breastfeeding has been recognized for its ability to provide infants with essential nutrients to help with growth and development. Research has shown there are many benefits associated with breastfeeding, such as building a healthy gut microbiota and increasing the bond between mother and child. The child benefits from the nutrients found in breast milk, such as docosahexaenoic acid (DHA) and arachidonic acid, omega-3 and -6 fatty acids essential for cognitive development. Somewhere down the line the notion that breastfeeding can make your baby smarter has been perpetuated. However, this has not yet been proven.

Researchers from the University College Dublin in Ireland conducted a study to investigate the impact of breastfeeding on children’s cognitive development. Around 8,000 families from the Growing Up in Ireland longitudinal infant cohort were randomly selected to participate. Data was collected when the child was 9 months old, 3 years old, and 5 years old. Questionnaires were used to measure children’s cognitive abilities, expressive vocabulary, and problem behaviors, and breastfeeding data was collected as retrospective self-report from the mothers. Propensity score matching, instrument variables, and sibling pair models were used for the analysis. The “breastfed” and “never breastfed” groups were matched based on infant, mother, and family-level factors, such as birth weight and maternal age.

Children who were breastfed scored higher on the problem-solving scale. However, after adjusting for potential confounders, this result was found to be no longer significant. This means other factors, such as socioeconomic status, could better explain the variability here. Breastfed children had lower parent-rated hyperactivity compared with controls after the adjustment, but this effect was only seen at 3 years of age. This may mean that breastfeeding helps reduce hyperactivity in the short term, but this effect was not maintained. Although the researchers found no evidence to support that breastfeeding helps improve cognitive abilities, they did note that their study did not contradict any of the medical benefits of breastfeeding. Research on breastfeeding will continue to be done and hopefully we will see more positive findings emerge in this area. For now, the current World Health Organization recommendation for breastfeeding is to exclusively breastfeed for the first 6 months of a child’s life, if you are able.

 

References:

Girard L, Doyle O, Tremblay RE. Breastfeeding, Cognitive and Noncognitive Development in Early Childhood: A Population Study. Pediatrics. 2017;139(4):e20161848. doi:10.1542/peds.2016-1848

Student Blogger for Global Nutrition Council at ASN’s Scientific Sessions and Annual Meeting at EB 2016

By: Sheela Sinharoy, MPH

A symposium called Biology of Linear Growth on Tuesday examined linear growth from the molecular to the population level, bringing perspectives from biology, physical anthropology, nutrition, and epidemiology

Are you familiar with the process of endochondral ossification? Julian Lui, MD PhD explained that this is the process that results in linear growth. It takes place in the growth plates, at the end of long bones such as the femur, and is subject to systemic regulation by endocrine, nutritional, and inflammatory cytokine factors as well as local regulation by paracrine factors and other cellular mechanisms. Malnourished children have lower levels of hormones like insulin-like growth factor 1 (IGF-1) and estrogen, as well as increased levels of glucocorticoids, leading to decreased linear growth. Dr. Liu explained that this allows the body to conserve resources and that, in situations of food insecurity, “Growth is something of a luxury that can be postponed until better times.”

Rather than growing continuously, children grow in saltations, meaning that – as many a parent has observed – a child may grow substantially overnight and then not at all for a number of days afterwards. Michelle Lampl, MD PhD stated that as children age, these saltations become less and less frequent, with older children growing much less often than infants. The amount and frequency of these growth saltations can be affected by environmental factors, which can interact with cellular effects. Maternal smoking, for example, has a well-documented inhibitory effect on growth, as does maternal alcohol consumption and stress.

Since linear growth happens most rapidly in early life, the first 1,000 days from conception to two years of age are considered a critical period. Parul Christian, DrPH presented results from a meta-analysis analyzing various maternal and child nutrition interventions targeting this 1,000-day window. Starting during pregnancy, balanced protein-energy, iron-folic acid, and multiple micronutrient supplementation were all found to increase birth weight. However, maternal supplementation during pregnancy was not associated with any long-term linear growth in children under five years old. For infants and young children, nutrition promotion and food supplementation showed promise as interventions with positive impacts on child height.

In the final talk of the symposium, Aryeh Stein, PhD addressed the question of linear catch-up growth: for those children whose growth has been suppressed by malnutrition, is it possible to catch up on missed growth, even after the first 1,000 days? A number of studies have provided different nutrients and foods to children ages two and older. Dr. Stein presented results from studies of protein, zinc, iron, iodine, calcium, multiple micronutrients, and food. Protein and some of the micronutrients may have promise, but several of the calcium studies reported negative effects, while food had no association with growth.

The symposium made it clear that nutrition has an important role to play in stimulating or inhibiting linear growth. However, a great deal remains to be learned about these complex biological processes and the most effective interventions to promote children’s optimal growth.

Student Blogger for Global Nutrition Council at ASN’s Scientific Sessions and Annual Meeting at EB 2016

By: Sheela Sinharoy, MPH

A symposium titled Program Effectiveness for Addressing Undernutrition during the First 1,000 Days provided attendees with examples of programs in Bangladesh, Guatemala, and Burundi.

In Bangladesh, the Rang-Din Nutrition Study tested lipid-based nutrient supplements (LNS) in a community-based program. According to presenter Kay Dewey, the study found that giving LNS to mothers prenatally reduced the prevalence of stunting and increased the birth weight, head circumference, and body mass index (BMI) in infants at birth. LNS and multiple micronutrient powders (MNP) for children were also associated with better developmental and cognitive outcomes. Dr. Dewey noted that the impact on child anthropometry was much larger in food insecure households, so future programs may want to target based on this and other criteria.

Moving from Asia to Africa, Marie Ruel presented results from an impact evaluation of a food-assisted integrated health and nutrition program in Burundi. The program gave food rations to mothers and children and also provided behavior change communication. Interestingly, the nutrition situation in Burundi deteriorated sharply during the program period, but decreases were less severe in the treatment groups. For example, while the prevalence of stunting increased dramatically in the control group, the prevalence in the treatment group remained essentially flat. Thus, although the treatment group did not improve, the results suggest that the intervention protected families who otherwise would have been vulnerable to economic shocks.

Guatemala is another country with a very high prevalence of chronic undernutrition, and Deanna Olney presented results from a study of a similar food assistance program. The impact of the program was greatest among those who received a full family food ration plus an individual ration of corn-soy blend. In these households, mothers had significantly higher mean BMIs, children had a lower prevalence of stunting, and both mothers and children had a lower prevalence of anemia. However, there were no significant impacts on child underweight, wasting, or language or motor development.

The differing impacts of various programs was the impetus for a talk by Per Ashorn, who discussed pathways of impact for fetal growth, linear growth, and cognitive function. He explained that the pathways for linear, ponderal, and head growth are partially different, and there are possibly partially different pathways to childhood length gain and brain function. This suggests a need for multipronged interventions targeting pathways including infection, nutrition, and inflammation, as well as a variety of outcome measures to assess the interventions’ impact.

Of course, cost is an important – and often challenging – issue when planning interventions. The final talk of the symposium was given by Steve Vosti, who explained that programs must balance need, acceptability, use, and both short-term and persistent demand in order to achieve impact. These and many other factors, such as the costs of manufacturing supplements in country and the proportion of locally available ingredients being used, can affect the cost of an intervention. In addition to deciding on the most appropriate intervention to meet a need, practitioners must take these factors into account when planning their programs.

By: Sheela Sinharoy, MPH

Sunday began with a symposium titled, Delivering Nutrition Interventions to Women during Pregnancy: Beyond Individual Interventions to Comprehensive Antenatal Guidelines and Care. A series of speakers made clear that as antenatal care (ANC) models continue to evolve, there is plenty of room for improvement to provide a positive pregnancy experience for women and their families.

ANC is not meeting its potential. This was the conclusion of the first speaker, Erica Phillips. She discussed the model of focused ANC (FANC) recommended by the World Health Organization (WHO), which involves 75-80 tasks for an intake visit and 60-65 tasks for each follow-up. She explained that following these recommendations would require an estimated 30-40 minutes for a first visit and 20 minutes for a follow-up. Even when recommended tasks are completed, quality of care may still be low. Ms. Phillips stated that “where FANC has been adopted, success has been limited.”

Still, ANC can be an effective platform for breastfeeding promotion, according to the next speaker, Mduduzi Mbuya. He presented a case study from the Sanitation, Hygiene, Infant Nutrition Efficacy (SHINE) trial in Zimbabwe. The country faces a critical shortage of health workers, with only 9.8 skilled health workers per 10,000 people (as compared to a ratio of 117:10,000 in the USA). SHINE therefore engaged community-based village health workers and found that the prevalence of exclusive breastfeeding at six months of age increased from 23% to 68%. Dr. Mbuya attributed this result primarily to strong fidelity of implementation by village health workers.

Micronutrient supplementation is another important component of ANC, and Kate Dickin spoke about a trial of calcium supplementation in Kenya and Ethiopia. There, researchers found that women were motivated and willing to take calcium supplements as recommended and that most women sustained their adherence to the supplements through the six-week study period and said they would continue through the end of their pregnancies. Dr. Dickin attributed this largely to the intervention’s behavior change communication strategy, which was based on extensive formative research and addressed context-specific motivators and barriers.

Next, Catharine Taylor spoke about the way forward and the need for integrated, women-centered models of care. She said that ANC models should take the local context into account; have all goods and personnel in same physical space; provide clear and consistent guidelines, training and supervision to health workers; provide demonstrations and encourage active engagement and discussion; provide incentives and support; and implement women-held records and integrated health registers. As examples, she described the Centering Pregnancy model and women’s support groups, which have shown promise in a number of developing country settings.

Finally, Rebecca Stoltzfus closed the session, emphasizing the need for more community-based evidence, especially looking at “packages of ANC that are contextually adapted to be delivered in the most effective ways.” Thus, symposium attendees walked away with a substantial research agenda for the strengthening of antenatal guidelines and care.