Dr. Narendra Malhotra gave the POGS oration on fetal origins of adult diseases. He has had an illustrious career as an obstetrician and gynecologist in India, holding many leadership positions and publishing extensively. His research has shown that adverse conditions in the womb and early life can program the fetus's development and permanently increase risks for diseases like diabetes, hypertension, and heart disease later in adulthood. Maternal nutrition, infections, and other environmental factors during pregnancy can influence the fetus through hormonal and epigenetic changes leading to effects on organs like the pancreas, kidneys and blood vessels that manifest as disease in later life.
Lecture held at the 4th Evidence-Based Neonatology conference, Nov 12 2017, in Hyderabad, India.
The lecture gives a short overview of the "fetal programming" theory, also referred to as the Developmental Origin of Health and Disease (DOHaD).
the lecture will explain the benefits of using omega 3 in pediatric neurology cases including the use for normal brain functions development in normal babies, premature babies, GDD , cases with cortical visual defect , ADHD, Autism , and anxiety
omega 3 might be of benefits for children with epilepsy , migraine and stroke
Lecture held at the 4th Evidence-Based Neonatology conference, Nov 12 2017, in Hyderabad, India.
The lecture gives a short overview of the "fetal programming" theory, also referred to as the Developmental Origin of Health and Disease (DOHaD).
the lecture will explain the benefits of using omega 3 in pediatric neurology cases including the use for normal brain functions development in normal babies, premature babies, GDD , cases with cortical visual defect , ADHD, Autism , and anxiety
omega 3 might be of benefits for children with epilepsy , migraine and stroke
Identifying women with GDM is important because appropriate therapy can decrease maternal and fetal morbidity .
Can prevent two generations from developing diabetes in the future.
Nutritional Management of Premature InfantsMCH-org-ua
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)
Role of antioxidants in female infertility Dr. Jyoti AgarwalLifecare Centre
Role of antioxidants in female infertility Dr. Jyoti Agarwal
3 Concepts
Oxygen toxicity is an inherent challenge to aerobic life
Oxygen is essential for life.
Excess oxygen can have harmful effects.
When oxygen is metabolised in the body , it produces substances called FREE RADICALS which damage our cells.
Polycystic ovary syndrome (PCOS) is a common hormonal disorder, thought to affect between 4%–8% of women of reproductive age. Due to a lack of awareness, and the dramatic variation in the signs and symptoms between individuals, a large number of women may have PCOS without being at all aware of it. Unless help is sought for common symptoms (including oily skin and recurring acne; irregular, infrequent or absent periods; excess facial and body hair growth; head hair loss or thinning; weight gain) a formal diagnosis may never be made and issues can persist unmanaged until menopause. PCOS is most commonly diagnosed in women hoping to become pregnant, but who experience fertility issues as a result of irregular ovulation or miscarriage. In this webinar, Dr Nina Bailey PhD outlines the key mechanisms in the pathophysiology of PCOS, the signs and symptoms that should trigger further investigation, and the key nutritional strategies that can be adopted to help women manage the condition.
Nutrition during pregnancy
Nutrition before pregnancy
unhealthy eating trends
Nutrition during pregnancy
important of good Nutrition during pregnancy
Key Nutrition during pregnancy
Optimal weight gain during pregnancy
1st trimester
2nd trimester
3rd trimester
Nutrition during lactation
protein
Sources of vitamins
The presentation has three parts: UNITE for Diabetes Philippines CPG recommendations on medical nutrition therapy (MNT), improving adherence to MNT and use of SMS.
Eat and drink two to four servings of dairy products and calcium-rich foods a day. Calcium is found in dairy products, fish with bones (such as sardines and canned salmon), broccoli, and legumes. Aim to get 1,200 milligrams per day. Pump up your iron
The intense fetal growth and development during pregnancy requires maternal physiologic adaptation and a change in nutritional needs.
Adequate maternal intake of macronutrients and micronutrients promotes normal embryonic and fetal development.
Importantly, maternal nutritional status is a modifiable risk factor that can be evaluated, monitored, and, when appropriate, improved.
Beginning this process before conception is important since addressing diet during pregnancy can impact some outcomes (eg, gestational weight gain), but may not be sufficiently early to affect others, such as the occurrence of gestational diabetes related to obesity .
Identifying women with GDM is important because appropriate therapy can decrease maternal and fetal morbidity .
Can prevent two generations from developing diabetes in the future.
Nutritional Management of Premature InfantsMCH-org-ua
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)
Role of antioxidants in female infertility Dr. Jyoti AgarwalLifecare Centre
Role of antioxidants in female infertility Dr. Jyoti Agarwal
3 Concepts
Oxygen toxicity is an inherent challenge to aerobic life
Oxygen is essential for life.
Excess oxygen can have harmful effects.
When oxygen is metabolised in the body , it produces substances called FREE RADICALS which damage our cells.
Polycystic ovary syndrome (PCOS) is a common hormonal disorder, thought to affect between 4%–8% of women of reproductive age. Due to a lack of awareness, and the dramatic variation in the signs and symptoms between individuals, a large number of women may have PCOS without being at all aware of it. Unless help is sought for common symptoms (including oily skin and recurring acne; irregular, infrequent or absent periods; excess facial and body hair growth; head hair loss or thinning; weight gain) a formal diagnosis may never be made and issues can persist unmanaged until menopause. PCOS is most commonly diagnosed in women hoping to become pregnant, but who experience fertility issues as a result of irregular ovulation or miscarriage. In this webinar, Dr Nina Bailey PhD outlines the key mechanisms in the pathophysiology of PCOS, the signs and symptoms that should trigger further investigation, and the key nutritional strategies that can be adopted to help women manage the condition.
Nutrition during pregnancy
Nutrition before pregnancy
unhealthy eating trends
Nutrition during pregnancy
important of good Nutrition during pregnancy
Key Nutrition during pregnancy
Optimal weight gain during pregnancy
1st trimester
2nd trimester
3rd trimester
Nutrition during lactation
protein
Sources of vitamins
The presentation has three parts: UNITE for Diabetes Philippines CPG recommendations on medical nutrition therapy (MNT), improving adherence to MNT and use of SMS.
Eat and drink two to four servings of dairy products and calcium-rich foods a day. Calcium is found in dairy products, fish with bones (such as sardines and canned salmon), broccoli, and legumes. Aim to get 1,200 milligrams per day. Pump up your iron
The intense fetal growth and development during pregnancy requires maternal physiologic adaptation and a change in nutritional needs.
Adequate maternal intake of macronutrients and micronutrients promotes normal embryonic and fetal development.
Importantly, maternal nutritional status is a modifiable risk factor that can be evaluated, monitored, and, when appropriate, improved.
Beginning this process before conception is important since addressing diet during pregnancy can impact some outcomes (eg, gestational weight gain), but may not be sufficiently early to affect others, such as the occurrence of gestational diabetes related to obesity .
Prevalence of Congenital Malformations in Newborns Delivered in a Rural Medic...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
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International Journal of Pharmaceutical Science Invention (IJPSI) is an international journal intended for professionals and researchers in all fields of Pahrmaceutical Science. IJPSI publishes research articles and reviews within the whole field Pharmacy and Pharmaceutical Science, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online.
Corona is here to stay and it is predicted that over 70% of population will get the infection (fortunately not all will fall sick or very sick). (Recovery rate of over 74% & Death rate around 2%).
A lot of confusion exists regarding testing for covid and what test to do, when and how to interpret these tests.
Compiled by Dr. Narendra Malhotra
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
2. NARENDRA MALHOTRA
M.D., F.I.C.O.G., F.I.C.M.C.H
President FOGSI (2008), Dean of I.C.M.U. (2008)
Director Ian Donald School of Ultrasound
National Tech. Advisor for FOGSI-G.O.I.—Mc Arthur Foundation EOC Course
Editor SAFOG journal,chair AOFOG publication & YGAA committee
Hon Prof Ob Gyn at DMIMS,Sawangi,Advisor ART unit at MAMC & SMS Jaipur
Practicing Obstetrician Gynecologist at Agra. Special Interest in High Risk Obs., Ultrasound,
Laparoscopy and Infertility, ART & Genetics
Member and Fellow of many Indian and international organisations
FOGSI Imaging Science Chairman (1996-2000)
Awarded best paper and best poster at FOGSI : 5 times, Ethicon fellowship, AOFOG young gyn.
award, Corion award, Man of the year award, Best Citizens of India award
Over 30 published and 100 presented papers
Over 50 guest lectures given in India & Abroad.Presented 13 orations.
Organised many workshops, training programmes, travel seminars and conferences
Editor 8 books, many chapters, on editorial board of many journals
Editor of series of STEP by STEP books
Revising editor for Jeatcoate’s Textbook of Gynaecology (2007)
Very active Sports man, Rotarian and Social worker
MALHOTRA HOSPITALS
84, M.G. Road, Agra-282 010
Phone : (O) 0562-2260275/2260276/2260277, (R) 0562-2260279, (M) 98370-33335; Fax : 0562-2265194
E-mail : mnmhagra10@dataone.in / mnmhagra3@gmail.com
Website : www.malhotrahospitals.com
Consultant for IVF at jalandhar,ludhiana,ambala,bhiwani,gwalior,allahabad,gorakhpur,udaipur,bariely,jaipur,delhi
Neapal & Bangladesh
4. Early life origins of human helath and disease
Compelling evidence that many of the risks leading to chronic
adulthood diseases,originate in the earliest stages of life
Adverse intrauterine enviornment and infancy leads to
negative health effects in adulthood
There is evidence on the developmental origins of
diabetes,cancers and obesity
Genetic and epigentic pathways of development are affected
by nutrition and pollution
Enviornmental insult not only affects the individual ,but also
the future generations
Preventive intrauterine nutritional measures can be applied.
7. It is now widely accepted that the
risks of a number of chronic diseases
in adulthood such as diabetes
mellitus, hypertension and coronary
heart disease may have their origins
before birth
Fetal origins of adult diseases
Ref:Effect of In Utero and Early-Life Conditions on Adult Health and Disease; Peter D. Gluckman et.al; N Engl J Med 2008;359:61-73.
The early life origins of asthma and related allergic disorders
J O Warner
Correspondence to:
Prof. J O Warner
Professor of Child Health, Allergy & Inflammation Sciences, Division of Infection, Inflammation & Repair, School of
Medicine, University of Southampton, UK; jow@soton.ac.uk
8. Early Programming and Fetal origins of adult
diseases
Developmental plasticity: Ability of an organism to develop in
various ways, depending on the particular environment or
setting
Developmental programming is defined as the response by the
developing mammalian organism to a specific challenge during a
critical time window that alters the trajectory of development
with resulting persistent effects on phenotype
Ref: Prenatal origins of adult disease; Current Opinion in Obstetrics and Gynecology 2008, 20:132–138
Peter D. Gluckman, et.al, N Engl J Med 2008;359:61-73
9. History of Early Programming
Barker’s in 1980’s reveals:
High correlation between infant and adult mortality
Association between low birth weight and adult
ischemic heart disease
This lead to his ‘fetal Origin of Adult Diseases’ and to
the
Early programming hypothesis.
Ref: Ravelli GP et al N Eng J Med 1976, 12;295(7) 349-53;
Lucas A, Adv Exp Med. Biol 2005, 569:13-5: PMID 934222, 1613710
10. Science of early programming
Numerous examples of early programming in animals and
humans
Some trails have prospective follow-up well into adult life
Ref: Fall C. Indian J Med Res 2009;130:593-599
11. Effects of programming
Programming involves structural
changes in
Important organs, altered cell number,
imbalance in distribution of different
cell types within the organ, and
altered blood supply or receptor
numbers.
Ref: Mark J. Nijland et.al; Current Opinion in Obstetrics and Gynecology 2008, 20:132–138
12. Fetal Origins of Adult Disease
Responses to adverse environments:
1. Accelerated maturation
( G- corticoid level)
1. Keeps nutrients
( growth & nutrition)
3. Pregnancy termination
(abortion, prematurity)
MATERIAL
ENVIRONMENT
+
MATERIAL &
PLACENTAL
PHYSIOLOGY
fetal
Environment
IntrauterineEnv
U –Placental
Unity
+ GENOME
Alterations:
•fetal growth
•Interaction pre-and-
post natal environments
FETAL ORIGIN OF DISEASE
13.
14. Sadler TW Lagman’s Medical Embryology 1990
Umbilical
vessels Chorionic
vessels
Chorionic
plate Amnion
Spiral
artery
Placental
septum
Basal
plate
Uteroplacental
veins
Normal Placental Development
15. Cuningham FG, MacDonald PC, Leveno K, Gant NF, Gilstrap LC II Williams
Obstetrics 1993
The Supply Line to the Human Fetus
16. Fetal Origins of Adult Disease
How does the fetus respond an adverse
environment – e.g.: nutritional? By making
irreversible changes in its development
Abnormal insulin
secretion/action
Reduced vascularity
Reduced nephron number
Type II Diabetes
Hypertension
CV Disease
17. Maternal size
Metabolism
Nutrition
fetal Nutrition and
Growth
Birth Size and
Body Composition
Childhood Environment
And
Growth
Risk factors
Morbidity
Mortality
Yajnik CS, Deshmukh U, 2009
Pregnancy – a critical window of opportunity
Ref: Dr.Niva Shapira,Women’s Health,2008;4(6)-639-656
19. Effects of undernutrition
Ref: Maternal nutrition: Effects on health in the next generation Caroline Fall; Indian J Med Res 130, November 2009, pp 593-599
Cortisol
Maternal
diet
Uteroplacentral
blood flow
Placentral
transfer
Fetal
genome
Nutrient demand exceeds supply
FETAL UNDERNUTRITION
Brain sparing Down regulation
of growth
Early
Maturation
Altered
body
composition
Impaired development:
bloodvessels,liver,
kidneys,pancreas.
↓ Insulin/IGF-1
Secretion and
sensitivity
Central
obesity
Insulin
resistance
Hyperlipidaemia
Hypertension
Type 2 diabetes and CHD
Muscle ↓
20. Conceptual frameworks for how maternal diet and
micronutrients status may affect the development of chronic
disease in the offspring
Ref: Stewart CP, J Nutr 2010 140(10): 437-445 PMID 20071652
Hormonal adaptations
Fe,Zn,Ca
•Increased stress hormones
•Decreased somatotrophic
hormones(GF,Insulin)
Epigenetic gene
regulation
Folate ,Vitamin B-12
Restricted foetal growth and
development
Maternal micronutrient deficiency
Renal function
Fe, Zn,Vitami n A foalte
•Impaired
nephrogenesis/
Reduced
nephronendowment
•Reduced GFR
•Increased sodium
sensitivity
Cardiovascular function
Fe,Zn,Viatmin A folate
•Impaired
vascularization
•Malformations
•Cardiac hpertrophy
Pancreas / β –cell
function
Fe,Zn,folate,Vitamin
B-12
•Reduction in
number and area of
β - cell
Body composition
Mg,Zn,folate,Vitamin
B-12
•Reduced lean body
mass
•Altered fat deposition
or metabolism
•Sedentary behaviour
•Altered appetite
•regulation
Primary Function
Vitamin A,Vitamin D
•Reduced bronchial
branching & alveoli
•Reduced elastin
•Reduced VEGF
•Chronic respiratory
infections
•Reduced lung
capacity
Hypertension
Insulin resistance
and β – cell
dysfunction
Cardio metabolic
risk
22. Perinatal period is a “Brain
Time”:
A window of opportunity for
Nutritional optimization of
brain development and
future health and performance
23. Maternal Nutrition and Cognition in offspring
Permanent, large
cognitive and
motor
effects of early
nutrition – with
structural changes
in
the brain
24. MRI Brain mapping
Suggests cognitive effects of
early nutrition related to
multiple effects on brain
structure
Ref: Edmonds CJ et al. Pediatrics 2010;126:e1095–e1101
26. For each 1kg
reduction in birth weight
(compared to other
twin) there was a 13
Point loss in verbal IQ
Ref: Edmonds CJ et al. Pediatrics 2010;126:e1095–e1101
27. Maternal immune activation alters foetal brain
development through interleukin-6
Birth in winter/spring is an accepted risk factor for
schizophrenia, mostly associated with influenza
(Tochigi et al, 2004)
Second-trimester respiratory infection increases
the risk for schizophrenia in the offsprings by 3-7
fold.
14-21% of schizophrenia cases are assumed to have
been caused by maternal infection.
Cytokines that drive that innate immune response,
i.e Interleukin (IL-6), assumed to affect brain health.
Ref: Stephen E.P Smith, The Journal of Neuroscience, 3 October 2007, 27(40): 10695-10702
28. the
period of prior to full
term is a very sensitive
one for Nutritional
Programming of the
brain
37. Pune Maternal Nutrition Study:
Conclusions
First demonstration that maternal
micronutrient nutrition influences risk of
diabetes in the offspring
Vegetarianism determines the B12 and folate
status of Indians.
39. Maternal obesity and perinatal risks
“Maternal obesity is associated with
increased risk of almost all pregnancy
complications: GDM, PIH, LGA, congenital
defects”.
“A child of an obese mother suffer from
suboptimal in utero environment may extend
the risk to adulthood”.
Optimizing pre-pregnancy weight could
prevent upto 40% of childhood overweight
(11y)
40. Primary prevention
fetal and / or early postnatal over
nutrition
fetal and / or early postnatal
hyperinsunilism
Maternal Diabetes
mellitus during
pregnancy
Permanent malprogramming of the ‘neuro-endocrine-immune-system’
(particularly of hypothalamic regulatory centers of food intake, body
weight & metabolism)
Perinatally acquired disposition to
obesity, diabetes mellitus, and the
metabolic Syndrome X
Intrauterine
growth retardation
(‘low birth weight’)
Maternal phenotype of female offspring
during their pregnancy : overweight and
impaired glucose tolerance
41. Recommended total weight gain
Weight gain per
week after 12 weeks
First 12 weeks [88] 0.9 – 1.8 Kg (2-4 lb)
After 12 weeks [88]
BMI < 19.8 12.5 to 18 Kg (28 – 40 lb) o.5 Kg (-1 lb)
BMI of 19.8 to 26.0 11.5 to 16 Kg (25 – 35 lb) 0.4 Kg (- 1 lb)
BMI > 26.0 TO 29.0 7 to 11.5 Kg (15 – 25 lb) 0.3 Kg (0.7 lb)
BMI >29.0 7 to 11.4 Kg ( 15 – 25 lb)
Multiple pregnancy [92]
BMI < 19.8 22.7- 28.1 Kg ( 50 – 62 lb)
BMI of 19.8 to 26.0 18.1 – 24.5 Kg (40 – 54 lb)
BMI > 26.0 TO 29.0 17.2-21.3 Kg (38- 47 lb)
BMI >29.0 13.2 – 17.2 Kg (29-38 lb)
Twin pregnancy[88] 15.9 – 20.4 Kg (34 – 45 lb) 0.7 Kg (3lb)
Twin pregnancy[88] >16.2 Kg at 24 weeks [91]
22.7 Kg (50 lb) overall
Adolescent Pregnancy[93]
≤ 16 years old Upper end of recommendations
Upper end of
recommendations
> 16 – 19 years old Similar to adult women
Similar to adult
women
Recommended weight during pregnancy
42. Perinatal diabetogenic risks
Maternal GDM increases T2DM risk upto 70%
within 10y
Even borderline Glycemia increases risk of
LGA, earlier adiposity rebound, MetS,
Increased energy intake, BMI, and BF% and
reduced EE
Rapid growth (foetal and post-natal)
contribute to hyper-insulinism high BP, BMI
and MetS
Ref: Davey, 2005;Wang et al, 2007;Boney et al, 2005
43. Diet Analysis and lipid profiel in urban Asian Indian
adolescents- young adults- I
Subjects: n-1236 (607 M, 629 F) aged 17.6 y 193-25
y), BMI- 198.8
RESULTS: carbohydrates 53% Kcal, protein 11%,
total fat 34%, SFAs 11%, MUFA 10%, PUFA 9% (n-
31%, n-6.8%), trans-fat 0.3%
Fat intake 84+/-29 g/d M, 72+/- g/d F-4-fold DRI of
Asian Indian (20-22 g/d)
CONCLUSIONS: High total fat and SFA with
low n-3 PUFA could contribute to increasing
obesity and insulin resistance in urban
Indians.
Ref: Gulati S, et al. J Am Coll Nutr 2010 Apr, 29(2): 81-9 PMID 20679142
53. Personalized Medicine Paradigm
“It will be possible to ascertain the genetic
predisposition to disease of a given individual or
population and then implement behavioral and/or
pharmacological interventions to delay or prevent
disease or to improve treatment”
Collins F and Guttmacheer AE. JAMA 2001;286:2332.
57. Current scenario in India
18% of pregnant women consumed
< 50% of calories
34% of pregnant women consumed <50%
of protein
85% of pregnant women consumed <50%
iron
57% of pregnant women consumed <50%
b-caroten - relative to their
RDA(recommended dietary allowance)
Ref: Indian Pediatrics 1999; 36: 991-998
58. Calcium and Vitamin D Status in India
Indian RDA for non-pregnant women- 600 mg/day.
Over 50% of women, are not meeting this number
There is evidence of calcium depletion, measured by bone
mineral density, particularly in women after repeated
pregnancy and lactation
Vitamin D deficiency exists in Indian adults
-based on 25 hydroxy Vitamin D2
Vit D status of children - very low in both urban and rural
populations
Pregnant women and their new born had low vitamin D status
Dietary calcium supplementation had positive effect on
25(OH)D levels
Ref: JAPI, 2009; (57):40-48
59. Pregnancy – importance of nutrients
There are periods before and during
pregnancy in which specific nutrients are
required for optimal development.
There is growing evidence that adequate
intake of nutrients, like iodine,
docosahexaenoic acid (DHA), choline, and
folate, is necessary during pregnancy and
lactation
Ref: Am J Clin Nutr 2009;89(suppl):685S–7S
61. Diet
Starting a healthy diet before pregnancy
Diet - Quantity and quality
Basic and extra nutrients for
• Maintenance of maternal health
• Needs of growing fetus
• Strength and vitality required during labour
• Successful lactation
Ref: http://www.acog.org/publications/patient_education/bp001.cfmDutta D.C. Text book of obs, 2004
62. Planning healthy meals
Include all food groups in diet
• Vegetables & fruits
• Milk and dairy foods
• Cereals & Grains
• Meat, beans, and eggs
• Fats and oils
63. Supplementary nutrition
Personal food preferences, lifestyle habits and
special needs may affect the intake of nutrients
Essential vitamins lacking in diet or destroyed during
cooking
Nutritional supplements are one of the ways to fill
the nutritional gap that may be arising due to
improper diet
It fills the gap by providing the vitamins, minerals,
and other substances that may be missing out
64. Maternal supplementation affects both the
mother and newborn
Ref: Resmussen KM, J Nutr 2010,Feb140(2): 402—6; Epub 2009 Dec 23 PMID 20032480
66. Vital nutrients in breast milk
Breast milk provides all the nutrients a baby needs to
grow well for the first six months of life. The key
nutrients in breast milk support the optimal growth
and development of the baby and all organs and
systems.
Breast milk contains:
• DHA and AA - building blocks of brain & eye
development
• Taurine & choline - support overall mental
development & functioning.
• Calcium and vitamin D for bone development
• Many protective factors that protect the infant
from infections
• Fat, protein and carbohydrate, which are easily
digested and absorbed
67. Mother’s nutrition influences the composition and
quality of breast milk
The nutritional needs of a
breastfeeding mother is high -
increased demand for Energy, Vitamins
C, B12
• Nutrients consumed by mother is
transferred to the growing baby to
support its growth and
development.
• Nutritional deficiencies may
develop during this period and
affect both mothers and infants
Maintaining a diet of fruits, vegetables,
whole grains, lean meats, and dairy
products regularly will help to meet
nutritional needs
68. Gestation is a critical opportunity for future health
Gestation is a most critical period for future
maternal and infant health, wellbeing, performance
and diseases.
Maternal undernutrition/obesity increases risk for
pregnancy complications, and future health.
Transitional diets (i.e westernization) add risk of
imbalance and deficiencies, especially vs. increased
calorie-dense foods and the obesity epidemic.
Multiparous women represent especially relevant
target population for nutritional support.
69. Gestation is a critical opportunity for future health
fetal “programming” affect also immunity, brain
health and development, future taste and eating
habits.
A variety of local, seasonal, low calorie, and high
nutrient dense foods and well planned meals are
important for satisfying increased perinatal
requirements, for metabolic balance and for health
protection.
Healthy eating in pregnancy, together with food
modification, fortification and supplementation as
required.
Speaker Notes: Prof.David Barker conducted studies in animals as early as the 1980’s to show that health during infancy has very high correlation to diseases that individuals developed as adults. This led him to develop the hypothesis of Early Programming and Foetal Origins of Adult diseases. This theory was given some weightage by the findings from the Dutch Famine Study. During the last 6 months of World War 2, an acute famine affected the western Netherlands. At the beginning of the famine the average daily ration was about 1800 calories until September 1944. This fell to about 1200 Calories in November and by the end of the year this was >800 Calories. By February this had become 580 Calories. This study showed that individuals that were exposed to famine in the last trimester of Pregnancy and the first 3-5 months of life had significantly lower obesity rate than that amongst unexposed controls. Incidence of obesity was a lot higher in individuals exposed to famine during the first and second trimesters of intratuterine life.
Speaker Notes: A number of studies have been done to test this hypothesis and many of these trials are prospective with follow up in adults. A classic example of this kind of study is the Pune Maternal nutrition Study conducted by Dr. Yajnik and his group in villages near Pune. We will discuss these in detail later in the presentation.
Speaker Notes: Evolution of non communicable disease in adult age start very early in life as early as pregnancy. Pregnancy is a critical window of opportunity where factors such as maternal size, metabolism, and nutrition affect fetal nutrition and growth which in turn affect the size at birth of the baby and his body composition. Post pregnancy the environmental factors that influence a child’s growth modify the risk that lead to development of adult risk factors, some morbidity and eventually premature mortality. In this whole sequence of events, maternal factors are the most important factors since a female child’s programming in utero, programs future generations resulting in intergenerational system of programming that results in epigenetic changes. Therefore, maternal nutrition is one of the most important environmental factors that influences fetal programming.
Speaker Notes: This chart has been taken from a review paper written by Dr. Caroline Fall and is a short summary of the effects of maternal undernutrition on her child. Maternal nutrition predisposes her child to developing diabetes and CVD early in life. What this theory implicitly states is that improving the status of girls and women could prevent common chronic diseases in future generation. The nutrients arriving at the placenta, and how they are transferred to the foetus, depend on maternal metabolism: her endocrine status, her partitioning of nutrients between storage, utilization or circulation, and her cardiovascular adaptations to pregnancy, such as plasma volume expansion which increases uterine blood flow. These are influenced by maternal nutrition in ways that are poorly understood. The link between maternal and foetal nutrition is thus indirect and explains why the full impact of maternal diet on foetal growth remains unclear
Speaker Notes: This slides elaborates on how the deficiency of many micronutrients such as Iron, Zinc, Vitamin A, Manganese, Calcium , folate etc results in epigenetic changes in gene regulation that restrict fetal growth and development. Hales and Barker (7) proposed that maternal or fetal malnutrition could affect fetal growth, metabolism, and vascular development.These changes could, in turn, affect the development of the kidneys; pancreatic b-cells; muscle, liver, or adipose tissue; or the hypothalamic-pituitary-adrenal (HPA) axis. This conceptual framework has been expanded to describe associations betweenmaternal micronutrient status, the role and mechanism for organ systems development, and the consequent functional outcomes in the offspring based on available evidence
Speaker Notes: We have discussed in detail the role that maternal nutrition plays in causing life style related disorders in her offspring. However that is not the only thing that is influenced by maternal nutritional status. Maternal undernutrition also affects the cognitive development since perinatal time is the biggest window of opportunity for nutritional optimization of brain development
Speaker Notes: However data from preterm births has shown that there are structural changes in the brain which results in significant cognitive and motor development – all of them were the result of early nutrition. For e.g. an inadequate supply of iodine during gestation results in damage to the fetal brain that is irreversible by mid-pregnancy. Animal studies have demonstrated that even mild to moderate maternal hypothyroxinemia may result in suboptimal neurodevelopment, and increase the risk for neurological disabilities in offspring.
Speaker Notes: Even data from MRI dones on children show that early nutrition has a significant role to play in the cognitive development of the child as it has multiple effects on the structure of the brain. In animals, documented effects of early undernutrition on brain structure include changes incell number, growth of the cerebral cortex, and dendriticarborization. In humans there are marked changes in cortical folding, myelination, and gray-matter distribution. Consistent with these findings, it has been demonstrated that nutritional interventions that lasted only a few weeks had large, long-term, and likely permanent effects on cognitive function in infants who were born preterm and in whom interventions took place ex utero but before the equivalence of term. It has been shown that shown that nutritional interventions affect brain macrostructure.
Speaker Notes: Studies done on monozygotic twins show that there was a relationship between a within-pair difference in birth weight and a subsequent within pair-difference in VIQ scores. This relationship differed according to the degree of discrepancy in birth weight. However, the mean advantage for the heavier twin can be as large as half an SD in verbal IQ scores.
Speaker Notes: Studies in twins have further added to this body of evidence. In twins, for each 1 kg reduction in birth weight there was a 13 point loss in verbal IQ
Speaker Notes: Maternal undernutrition has also indirect effects on the brain development of the fetus. Poor nutrient intake may affect the immune system of the mother making her susceptible to infections. Maternal infections such as influenza or respiratory infections are associated with increased risk of schizophrenia in the children. This information is based on data collected from over 12,000 mothers and these findings are supported by an association between elevated cytokines or anti-influenza antibodies in maternal serum and Schizophrenia in the offspring.
Speaker Notes: Based on his study in Pune, Dr. Yagnik proposed the theory of the “Indian Thin-Fat Baby”. This chart on the left compares the anthropometric data from Indian babies with anthropometric data from caucasian babies. The 0 line represents the weight of the caucasian baby. As you can see from the chart the Indian babies are 2.5 SD lighter than the caucasian baby. However, the subscapular measurement was very similar in the two babies indicating that the amount of fat is much higher in the Indian baby even though it is much lighter in weight. This showed that the thin fat phenotype is present at birth. The picture on the right shows the levels of insulin, leptin and adiponectin in the cord blood of Indian babies at much higher levels than in the blood of caucasian babies. 3 endocrine abnormalities associated with a future risk of diabetes
Speaker Notes: After demonstrating that Indian babies have a body composition and endocrine profile at birth that predisposes them to diabetes later in life. Dr. Yajnik started to look for determinants of this phenotype. They looked at maternal nutrition and found that conventional measurements such as calories, protein and fat were not very strongly predictive of birth size. In fact the maternal frequency of intake of fruits, green leafy vegetables and milk-foods that are powerhouses of micronutrients are more accurately predictive of birth size. The more often the mother ate these foods the higher the birthweight of her baby. They measured the red blood cell folate level and found that it was strongly predictive of birthsize.
Speaker Notes: Dr. Yagnik then embarked on the evaluation of the biochemical parameters that might contribute to this phenotype of Indian babies. Indians have high levels of homocysteine.A 40 year old Indian has twice as much homocysteine as that of the Caucasian. However high levels of homocysteine in Caucasians is due to a low intake of folate whereas in Indians high homocysteine levels are due to low intake of vitamin B12. Low Vitamin B12 intakes may be due to high degree of vegetarianism in India. They compared the levels of homocysteine in the preserved blood of mother to the size of her baby and found that high levels of homocysteine were strongly correlated with SGA at birth.
Speaker Notes: When they measured these children at 6 years of age they saw that Maternal nutrition and nutrient intake was strongly correlated with the body composition of their children even at 6 years of age. Children born to mothers with higher B12 had lower BMI. Mothers with higher levels of folate had children with more adiposity and higher levels of insulin at 6 years of age. This was particularly true for mothers with low B12 concentrations. This is the first prospective study where maternal nutritional status during pregnancy has been linked risk of diabetes in the children.
Speaker Notes: Gestational diabetes in the mother exposes the fetus to a state of hyperinsulinemia in-utero. This programs the fetus to develop a disposition towards obesity, diabetes Mellitus and Metabolic Syndrome. In the case of the female offspring it changes the phenotype such that the fetus when grows to adulthood and becomes pregnant is also predisposed to obesity and IGT during pregnancy.
Speaker Notes: Thus the epigenetic susceptibility, combined in precipitating factors that are lifestyle related accelerated by glucotoxicity and lipotoxicity that arises out of the small rise in the levels of these nutrients results in Multiphasic Malnutrition related diabetes Mellitus.
Speaker Notes: Programming for CVD risk in later life continues to happen even after birth. Dr. Lucas and Dr. Singhal have conducted a number of studies in both animals and humans and their findings suggest that a high-nutrient diet in infancy adversely programmes the principal components of the metabolic syndrome by promoting growth acceleration(upward centile crossing). This suggestion raises the concept that relative undernutrition and slower infant growth benefits later CVD and its risk factors. Breastfed infants show slower growth than those fed formula (especially in the early weeks when breastfeeding is not fully established), and subsequently have lower risk of CVD, hypercholesterolaemia,obesity, NIDDM, and high blood pressure. Reduced early growth due to a lower nutrient intake is the potential link between breastfeeding and reduced CVD later in life.
Speaker Notes: There has been a lot of evidence for this body of research
Speaker Notes: The pregnancy diet needs to be such that is it meets the nutrient needs for adequate brain development and growth of the baby, supports mother’s immunity and healthy digestion since pregnancy may be accompanied with constipation.
Speaker Notes: Where pregnancy has generally been approached as a maternal stage with temporal additional nutritional requirements, evidence in the post-genome medical arena increasingly suggests that the prenatal period may constitute a critical time for postgestational short- and long-term maternal health and well-being, and that nutrition provides essential design factors for the lifelong health and functioning of mother and child.