Birth weight mediates the association of maternal undernutrition with child undernutrition prevalence in West Africa.

BACKGROUND: Maternal nutritional status before and during pregnancy is an important determinant of foetal health. In West Africa, maternal and child undernutrition remains a major public health problem and it is important to establish the mechanistic pathway linking the two disorders to help address the problem. We therefore assessed the mediating role of low birth weight (LBW) in the relationship of maternal undernutrition with child undernutrition in West Africa. METHODS: We included recent (2010-2019) DHS data from thirteen West African countries. Poisson regression model with robust standard errors was used to assess the relationship between maternal undernutrition (body mass index and anaemia) and child undernutrition (stunting, wasting, underweight, and anaemia). Structural equation modelling was used to conduct the mediation analysis. RESULTS: Prevalence of stunting, wasting, underweight, and anaemia among under-five children in West Africa was found to be 32.4%, 8.1%, 20.1%, and 71.5%, respectively. We found children of underweight mothers to be more likely to be undernourished (stunted, wasted, and underweight) and anaemic compared to children of normal-weight mothers. Also, children of anaemic mothers were more likely to be stunted and anaemic but not wasted compared with children of non-anaemic mothers. LBW mediated the observed relationships between maternal BMI and childhood stunting (22.6%), and maternal anaemia and childhood stunting (24.9%), wasting (11.7), and anaemia (6.6%). CONCLUSION: We found maternal undernutrition to be associated with child undernutrition in West Africa with LBW noted to be a mediator of the observed relationship. We recommend that, to address the child undernutrition problem in West Africa, governments and policymakers must integrate measures to address the burden of LBW.

Dietary Polycyclic Aromatic Hydrocarbon (PAH) Consumption and Risk of Adverse Birth Outcomes: A Systematic Review and Meta-Analysis.

BACKGROUND: There is suggestive epidemiological evidence that maternal dietary polycyclic aromatic hydrocarbons (PAH) may increase the risk of adverse birth outcomes. We sought to summarize the available evidence on the effect of dietary PAH exposure on birth outcomes. METHODS: PubMed and Scopus databases were systematically searched from inception up to November 2022. Studies were included if they were original articles, were conducted in a human population, assessed dietary PAH consumption, and investigated the relationship between dietary PAH consumption and any adverse birth outcomes. Risk of bias in the included studies was assessed qualitatively and quantitatively. A random effects model was used to compute summary effect estimates in the meta-analysis. RESULTS: Six observational studies (five prospective cohort studies, and one prevalence case-control study) were included. The included studies assessed dietary PAH exposure using dietary questionnaires. Information on the outcomes of interest was obtained from medical records. Three of the included studies were rated as good quality with the remaining three studies rated as fair quality. One study was considered as having low risk of bias for selection, information and confounding bias. Dietary PAH consumption was associated with 5.65g [95% confidence interval (CI): -16.36, 5.06] and 0.04cm (95% CI: -0.08, 0.01) reductions in birth weight and birth length, respectively, and an increase in head circumference [effect size (ES)=0.001; 95% CI: -0.003, 0.005]. The CI of all the summary effect estimates, however, included the null value. In the sensitivity analysis that included only studies that assessed dietary PAH exposure as the primary exposure of interest, dietary PAH consumption was associated with much higher reductions in birth weight (ES=-14.61; 95% CI: -21.07, -8.15) and birth length (ES=-0.06; 95% CI: -0.1, -0.03). High statistical heterogeneity was observed in the birth weight and birth length analysis and in the head circumference sensitivity analysis. DISCUSSION: The body of epidemiological evidence suggests that maternal dietary PAH exposure is associated with reduced fetal growth, measured as birth weight and length. There was considerable heterogeneity in the measurement of PAH exposure among the included studies. Also, nonstandardized and validated dietary questionnaires were employed by a majority of the included studies with potential exposure misclassification. These issues are likely to impact the summary effect estimates computed and underscores the need for high-quality epidemiological studies with improved exposure assessment and adequate confounding control to strengthen the evidence base. https://doi.org/10.1289/EHP12922.

Fruits and vegetables intake improves birth outcomes of women with gestational diabetes mellitus and hypertensive disorders of pregnancy.

BACKGROUND: Disorders of pregnancy such as hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) have been associated with adverse birth outcomes. However, the ameliorating role of maternal nutrition in the relationship between disorders of pregnancy and adverse birth outcomes has received very little attention. We investigated the relationship between HDP and GDM, and adverse birth outcomes in a Ghanaian population and evaluated the effect modifying role of fruits and vegetables consumption in the relationship. METHODS: We conducted a cross-sectional study among 799 mothers who had recently delivered singletons in the Cape Coast Metropolis, Ghana. Information on HDP, GDM and birth outcomes were retrieved from the maternal health book of the mothers. A food frequency questionnaire was used to assess fruits and vegetables intake during pregnancy. Modified Poisson regression was used to investigate the association between pregnancy disorders, and preterm birth (PTB) and low birth weight (LBW). Stratified analysis was used to assess the effect modifying role of fruits and vegetables consumption in the relationship. RESULTS: The proportion of mothers with HDP and GDM was 11.3% and 7.5%, respectively. The proportion of the mothers with both conditions was 0.9%. The prevalence of PTB and LBW in the population was 27.9 and 7.3%, respectively. These disorders of pregnancy were associated with increased risk of PTB (Adjusted Prevalence Ration [APR] = 3.02; 95% CI: 2.42, 3.77) and LBW (APR = 5.32; 95% CI: 3.19, 8.88). In the stratified analysis, risk of PTB was higher among mothers classified in tertile I compared to mothers classified in tertiles II and III. For LBW, the risk increased with increasing fruits and vegetables consumption. The interaction p values were 0.0043 and 0.1604 for PTB and LBW, respectively. CONCLUSIONS: We found mothers who were diagnosed with GDM and HDP to have increased risk of delivering a PTB and LBW baby. We also found fruits and vegetables consumption to modify the observed relationship. Mothers diagnosed with GDM and HDP should be advised during antenatal care visits to increase intake of fruits and vegetable consumption to help safeguard their health and that of the developing foetus.

Trends of risk factors associated with childhood stunting and anaemia in Ghana: evidence from the Demographic Health Survey and Multiple Indicator Cluster Survey (2003-2017).

OBJECTIVE: This study investigated the trend of effect estimates of the key risk factors of childhood stunting and anaemia between 2003 and 2017. DESIGN: A secondary analysis of the Demographic Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) data for the Ghanaian population between 2003 and 2017. Associations of selected socio-demographic (child age and gender; maternal age and education), economic (household wealth), environmental, dietary (minimum dietary diversity and iodine use) and health system (place of delivery and vaccination) factors were explored using the Poisson regression model. Trend analysis was explored using a fitted linear regression line on a time series plot. SETTING: Ghana. PARTICIPANTS: Children under 5 years. RESULTS: The results showed a reduction in the prevalence of stunting and anaemia over the 15-year duration. These health outcomes were found to be negatively associated with a wide array of socio-demographic (child age and gender, maternal age and education, residency), economic (household wealth), dietary (iodised salt use) and health service (place of delivery and vaccination) factors; however, the most consistent statistically significant association was observed between child's age and belonging to the poor wealth quintile. CONCLUSION: In order to prevent these indicators of child malnutrition, key consideration must be given to the early developmental stages of life. Child health policies must focus on addressing the key contextual factors of child malnutrition.

Intersectional inequalities in exclusive breastfeeding practices in India: analysis of national family health survey-4.

BACKGROUND: Exclusive breastfeeding in the initial six months of infancy plays a significant role in the physical and cognitive development of the child. One in two children below six months of age in India is not receiving exclusive breastfeeding, with the rates varying considerably between and within states. In this study, we investigated the effect of intersecting inequalities in exclusive breastfeeding practice amongst children below six months in India. METHODS: Data from the fourth National Family Health Survey (NFHS-4) was used for the study. The study used a weighed sample of 211,145 infants below six months. Exclusive breastfeeding practice was assessed based on the previous 24-hours feeding practice of the child. Intersecting social categories were created based on place of residence, religion, wealth index, and mothers' education. A binary logistic regression model was used to explore inequalities in the practice of exclusive breastfeeding based on the intersecting social categories. RESULTS: Exclusive breastfeeding practices varied significantly between the intersecting categories of religion, place of residence, wealth index, and education of the mother. Exclusive breastfeeding practice prevalence was the highest amongst children born in the Urban-Secondary-Poor-Others group (57.9%) and lowest amongst the Rural-Primary-Rich-Others category (34.5). In comparison to children in the most disadvantaged category (Rural-Primary-Poor-Others), children born in the Rural-Secondary-Poor-Others category had the highest odds [OR (odds ratio) 1.213; 95% CI 1.024, 1.437] of being exclusively breastfed, whilst children within the Rural-Primary-Rich-Others category had the lowest odds (OR 0.494; 95% CI 0.345, 0.708). Wide disparities were observed in the odds of engaging in exclusive breastfeeding practice amongst the middle groups than between the most advantaged and the most disadvantaged groups. The inequality indices show varied distribution of exclusive breastfeeding prevalence across the intersecting groups with higher exclusive breastfeeding prevalence noted amongst disadvantaged groups. CONCLUSIONS: The study found that intersecting inequalities in exclusive breastfeeding exist in India. In order to improve exclusive breastfeeding practice, targeted interventions must acknowledge and adopt a comprehensive approach that addresses inherent inequalities resulting from the intersection of various axes of social stratification.

Intraindividual double burden of malnutrition among women (15-49 years) in India, Myanmar, and Nepal: evidence from the recent Demographic and Health Surveys.

BACKGROUND: There is a concurrent increase in anaemia and overweight/obesity among women in the South and South East Asia regions. Despite these, studies on the co-existence of anaemia and overweight/obesity in these countries are abysmally limited. This secondary analysis sought to estimate the burden of the intraindividual double burden of malnutrition (IDBM), i.e., co-existence of anaemia and overweight/obesity among women of reproductive age (15-49 years) in India, Myanmar, and Nepal, and explore the impact of socio-demographic and economic factors on this health outcome. METHODS: A secondary analysis of the Demographic and Health Surveys (DHS) of India (2019-2021), Myanmar (2015-2016), and Nepal (2016) was conducted. A descriptive analysis of the health outcomes and the risk factors was done with frequencies and percentages. The association between selected socio-demographic (women's age, education status, number of children and place of residence) and economic (occupation status, and wealth quintile) variables with IDBM was found with binary logistic regression analysis. RESULTS: Around one in ten women of reproductive age group in India and Myanmar had IDBM. In Nepal, it occurs in one in nearly 15 women. Maternal age, education, household wealth, number of children, place of residence, and occupation were found to be significant predictors of IDBM. CONCLUSION: There is a high prevalence of IDBM in South Asian women and it varies substantially across different socio-demographic and economic predictors. Sufficient evidence from prospective studies is needed to establish causal association and also to implement need-based prevention and curative strategies.

Do dietary practices and household environmental quality mediate socio-economic inequalities in child undernutrition risk in West Africa?

OBJECTIVE: We investigated the relationship between socio-economic status and child undernutrition in West Africa (WA), and further examined the mediating role of dietary practices (measured as minimum dietary diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD)) and household environmental quality (HEQ) in the observed relationship. DESIGN: Thirteen countries were included in the study. We leveraged the most recent Demographic and Health Surveys datasets ranging from 2010 to 2019. Poisson regression model with robust standard errors was used to estimate prevalence ratios and their corresponding 95 % CI. Structural equation modelling was used to conduct the mediation analysis. SETTING: West Africa. PARTICIPANTS: 132 448 under-five children born within 5 years preceding the survey were included. RESULTS: Overall, 32·5 %, 8·2 %, 20·1 % and 71·7 % of WA children were stunted, wasted, underweight and anaemic, respectively. Prevalence of undernutrition decreased with increasing maternal education and household wealth (Trend P-values < 0·001). Secondary or higher maternal education and residence in rich households were associated with statistically significant decrease in the prevalence of stunting, wasting, underweight and anaemia among children in WA. MAD was found to mediate the association of low maternal education and poor household wealth with childhood stunting and underweight by 35·9 % to 44·5 %. MDD, MMF and HEQ did not mediate the observed relationship. CONCLUSIONS: The study findings enables an evaluation and improvement of existing intervention strategies through a socio-economic lens to help address the high burden of child undernutrition in WA and other developing regions.

Plasmodium falciparum coinfection is associated with improved IgE and IgG3 response against hookworm antigens.

Background: Plasmodium falciparum and Hookworm infections are prevalent in West Africa and they cause iron deficiency anemia and protein malnutrition in Children. Immune response of these parasites interact and their interactions could have repercussions on vaccine development and efficacy. The current goal of hookworm eradication lies on vaccination. We evaluated the effect of P. falciparum coinfection and albendazole treatment on naturally acquired antibody profile against hookworm L3 stage larvae antigen. Methods: In a longitudinal study, 40 individuals infected with Necator americanus only, 63 participants infected with N. americanus and P. falciparum, and 36 nonendemic controls (NECs) were recruited. The study was done in the Kintampo North Metropolis of Ghana. Stool and blood samples were taken for laboratory analyses. Serum samples were obtained before hookworm treatment and 3 weeks after treatment. Results: The malaria-hookworm (N. americanus and P. falciparum) coinfected subjects had significantly higher levels of IgE (ß = 0.30, 95% CI = [0.12, 0.48], p = 0.023) and IgG3 (ß = 0.15, 95% CI = [0.02, 0.52], p = 0.004) compared to those infected with hookworm only (N. americanus). The N. americanus groups had significantly higher levels of IgG3 (ß = 0.39, 95% CI = [0.14-0.62], p = 0.002) compared to the control group. Similarly, N. americanus and P. falciparum coinfected participants had significantly higher levels of IgE (ß = 0.35, 95% CI = [0.70-0.39], p = 0.002) and IgG3 (ß = 0.54, 95% CI = [0.22-0.76], p = 0.002). Moreover, albendazole treatment led to a significant reduction in IgE, IgA, IgM, and IgG3 antibodies against hookworm L3 stage larvae (p < 0.05). Conclusion: P. falciparum is associated with improved IgE and IgG response against hookworm L3 stage larvae. Treatment with single dose of albendazole led to reduction in naturally acquired immune response against hookworm infection. Thus, P. falciparum infection may have a boosting effect on hookworm vaccine effectiveness.

Secular trends in low birth weight and child undernutrition in West Africa: evidence from complex nationwide surveys, 1985-2019.

OBJECTIVE: We present prevalence estimates and secular trends of stunting, wasting, underweight, and anaemia among children under 5 years of age and low birth weight (LBW) over the period 1985-2019 in West Africa (WA). DESIGN: Analysis of Demographic and Health Survey (DHS) and World Bank data. DerSimonian-Laird random effect model with the Knapp-Hartung adjustment to the standard error was used to derive overall prevalence estimates. We used fixed effect ordinary least square regression models with cluster robust standard error to conduct time trends analyses. SETTING: West Africa. PARTICIPANTS: Children aged 0 to 59 months. RESULTS: Three distinct periods (1986-1990, 1993-1996 and 1997-2000) of sharp increases in prevalence of all outcomes was observed. After the year 2000, prevalence of all outcomes except LBW started to decline with some fluctuations. LBW prevalence showed a steady increase after 2000. We observed a decline in prevalence of stunting (ß = -0·20 %; 95 % CI -0·43 %, 0·03 %), log-wasting (ß = -0·02 %; 95 % CI -0·02 %, -0·01 %), log-underweight (ß = -0·02 %; 95 % CI -0·03 %, -0·01 %) anaemia (ß = -0·44; 95 % CI -0·55 %, -0·34 %), and an increase in LBW (ß = 0·06 %; 95 % CI -0·10 %, 0·22 %) in WA over the period. Pooled prevalence of stunting, wasting, underweight, anaemia and LBW in WA for the period 1985-2019 was 26·1 %, 16·4 %, 22·7 %, 76·2 % and 11·3 %, respectively. CONCLUSIONS: Child undernutrition prevalence varied greatly between countries and the year cohorts. We observed marginal reductions in prevalence of all outcomes except anaemia where the reductions were quite striking and LBW where an increase was noted. There is the need for more rigorous and sustained targeted interventions in WA.

Vitamin D intake modifies the association of household air pollution exposure with maternal disorders of pregnancy.

To date, only three studies have investigated the association of household air pollution (HAP) exposure with pregnancy disorders. The ameliorating role of diet and nutrition in the association has never been explored. We conducted a cross-sectional study among 799 mothers who had recently given singleton birth in the Cape Coast Metropolis, Ghana. Structured questionnaire and semi-quantitative food frequency questionnaire were used to assess HAP exposure (from use of biomass fuels for cooking and garbage burning at home) and vitamin D (vitD) intake, respectively. Multivariable binary logistic regression was used to investigate the association between HAP exposure and pregnancy disorders. HAP exposure due to cooking with biomass fuels and garbage burning at home was associated with two fold (AOR = 2.15; 95% confidence interval [CI]: 1.05, 4.43) and six fold (AOR = 6.35; 95% CI: 2.43, 16.58) increased odds of hypertensive disorders of pregnancy (HDP). For gestational diabetes (GDM), the increased odds were two folds for both exposures but the 95% CI included the null value. Stove stacking was also associated with two folds increased odds of GDM (AOR = 1.83; 95% CI: 0.91, 3.68). In stratified analysis, the odds of HDP and GDM associated with biomass fuels use decreased with increasing vitD intake. All the interaction p values were, however, greater than 0.05. We provide the first evidence on the ameliorating role of vitD intake on the effect of HAP exposure on pregnancy disorders. In LMICs where solid fuel use and garbage burning at home is widespread, health workers should advise mothers during antenatal care visits to increase intake of vitamin D rich foods.

Effect of hookworm infection and anthelmintic treatment on naturally acquired antibody responses against the GMZ2 malaria vaccine candidate and constituent antigens.

BACKGROUND: Malaria and helminths diseases are co-endemic in most parts of sub-Saharan Africa. Immune responses from each of these pathogens interact, and these interactions may have implications on vaccines. The GMZ2 malaria vaccine candidate is a fusion protein of Plasmodium falciparum merozoite surface protein 3 (MSP3) and glutamate rich protein (GLURP R0). GMZ2 has recently showed modest efficacy in a phase IIb multicenter trial. Here, we assessed the effect of hookworm (Necator americanus) infection and anthelmintic treatment on naturally acquired antibody responses against GMZ2 and constituent antigens. METHODS: This longitudinal cross-sectional study was conducted in the Kintampo North Municipality of Ghana. Blood and stool samples were taken from 158 individuals (4-88 years old) infected with either P. falciparum alone (n = 59) or both hookworm and P. falciparum (n = 63) and uninfected endemic controls (n = 36). Stool hookworm infection was detected by the Kato-Katz method and PCR. Malaria parasitaemia was detected by RDT, light microscopy and P. falciparum-specific 18S rRNA gene PCR. Serum samples were obtained prior to hookworm treatment with a single dose of albendazole (400 mg) and 3 weeks (21 days) after treatment. Levels of IgG1, IgG3 and IgM against GMZ2, MSP3 and GLURP R0 were measured by ELISA and compared among the groups, before and after treatment. RESULTS: Participants with P. falciparum and hookworm co-infection had significantly higher IgG3 levels to GMZ2 than those with only P. falciparum infection and negative control (p < 0.05) at baseline. Treatment with albendazole led to a significant reduction in IgG3 levels against both GMZ2 and GLURP R0. Similarly, IgM and IgG1 levels against MSP3 also decreased following deworming treatment. CONCLUSION: Individuals with co-infection had higher antibody responses to GMZ2 antigen. Treatment of hookworm/malaria co-infection resulted in a reduction in antibody responses against GMZ2 and constituent antigens after albendazole treatment. Thus, hookworm infection and treatment could have a potential implication on malaria vaccine efficacy.

Cadmium exposure and risk of adverse pregnancy and birth outcomes: a systematic review and dose-response meta-analysis of cohort and cohort-based case-control studies.

BACKGROUND: There are several inconsistencies in the epidemiological literature on the strength of the association between cadmium exposure and adverse pregnancy and birth outcomes, and the threshold dose of adverse effect. OBJECTIVES: We therefore conducted a systematic review and dose-response meta-analysis to evaluate the available evidence to influence clinical decision making and better tailor public health interventions. METHODS: PubMed and Scopus databases were searched up to January, 2019. Eighteen prospective studies satisfied the inclusion criteria. Random effects model was used to compute summary-effect estimates. RESULTS: Cadmium exposure resulted in 42.11 g (95% confidence interval [CI]: -69.03, -15.18) reduction in birth weight, and 0.105 cm (95% CI: -0.181, -0.029) reduction in head circumference per 1 µg/l increment in blood/urine cadmium levels. Cadmium exposure also resulted in 21% (RR = 1.21; 95% CI: 1.02, 1.43), 32% (RR = 1.32; 95% CI: 1.05, 1.67) and 10% (RR = 1.10; 95% CI: 0.96, 1.27) increased risk of low birth weight (LBW), preterm birth (PTB), and small-for-gestational age (SGA), respectively. Risk for all outcomes decreased with decreasing exposure. In fixed effects dose-response meta-regression analyses, we found no evidence of association of cadmium exposure with LBW and SGA. For PTB, a 1 µg/l increment in cadmium exposure corresponded to 0.5% (OR = 1.005, 95% CI: 1.003, 1.007) increase in PTB risk. CONCLUSIONS: Cadmium exposure was associated with risk of adverse birth outcomes. Regarding PTB, the formal dose-response meta-analyses suggests a causal association.