Undernutrition and malaria in pregnancy – a dangerous dyad?

Abstract

BackgroundIn low-resource settings, malaria and macronutrient undernutrition are major health problems in pregnancy, contributing significantly to adverse pregnancy outcomes such as preterm birth and fetal growth restriction. Affected pregnancies may result in stillbirth and neonatal death, and surviving children are at risk of poor growth and infection in infancy, and of non-communicable diseases in adulthood. Populations exposed to macronutrient undernutrition frequently reside in malaria-endemic areas, and seasonal peaks of low food supply and malaria transmission tend to coincide. Despite these geographic and temporal overlaps, integrated approaches to these twin challenges are infrequent.DiscussionThis opinion article examines the current evidence for malaria-macronutrition interactions and discusses possible mechanisms whereby macronutrient undernutrition and malaria may interact to worsen pregnancy outcomes. Macronutrient undernutrition dysregulates the immune response. In pregnant women, undernutrition may worsen the already increased susceptibility to malarial infection and could impair development of protective immunity to malaria, and is likely to exacerbate the impact of placental malaria on fetal growth. Malarial infection, in turn, can drive nutritional depletion; poor gestational weight gain and weight loss in pregnancy increases the risk of adverse pregnancy outcomes. Despite a commendable number of studies and trials that, in isolation, attempt to address the challenges of malaria and undernutrition in pregnancy, few dare to venture beyond the ‘single disease – single solution’ paradigm. We believe that this may be a lost opportunity: researching malaria–nutrition interactions, and designing and implementing integrated interventions to prevent and treat these commonly co-existing and intertwining conditions, may markedly reduce the high burden of preterm birth and fetal growth restriction in affected areas.ConclusionWe call for more collaboration between researchers studying malaria and nutrition in pregnancy, and propose a research agenda to address this important twin health problem.

Burden and determinants of undernutrition among young pregnant women in Ethiopia

“…The presence of these conditions during pregnancy increases the risk of undernutrition through affecting dietary intake and absorption of nutrients (Barker, Kirkham, Ng, & Jensen, ; Chhoun et al, ; Hurley, Caulfield, Sacco, Costigan, & Dipietro, ; Nguyen et al, ; Teegarden & Bale, ). Malaria, tuberculosis, diarrheal diseases, and other infections highly impact nutritional status of pregnant women in impoverished settings (Papathakis & Rollins, ; Strunz et al, ; Unger, Ashorn, Cates, Dewey, & Rogerson, ; World Health Organization, ). These disease processes increase energy expenditure and protein catabolism, draining nutritional reserves (Unger et al, ).…”

“…Malaria, tuberculosis, diarrheal diseases, and other infections highly impact nutritional status of pregnant women in impoverished settings (Papathakis & Rollins, ; Strunz et al, ; Unger, Ashorn, Cates, Dewey, & Rogerson, ; World Health Organization, ). These disease processes increase energy expenditure and protein catabolism, draining nutritional reserves (Unger et al, ). Similarly, depression during pregnancy may also result in maternal undernutrition through engagement in unhealthy behavioural and antenatal practices such as unhealthy eating patterns (Barker et al, ; Teegarden & Bale, ).…”

Coverage and effectiveness of intermittent preventive treatment in pregnancy with sulfadoxine–pyrimethamine (IPTp-SP) on adverse pregnancy outcomes in the Mount Cameroon area, South West Cameroon

“…Despite recent decline in malaria transmission in Africa, the burden of malaria in pregnancy (MiP) in the absence of adequate prevention remains substantial [3]. In geographical areas with high transmission, the impact of malaria on maternal health depends on age, gravidity, trimester of pregnancy, coinfection [1,4] nutritional status [5] the intensity of malaria transmission (increased in rural populations), season, and use of malaria prevention [6].…”

Malaria, malnutrition, and birthweight: A meta-analysis using individual participant data

“…Recent evidence indicates that the relationship between malaria infection and LBW may depend upon the mother’s nutritional status [ 8 ]. Studies in Papua New Guinea (PNG) and Benin found inconsistent evidence of modification of the malaria infection–LBW relationship by maternal anthropometric status, but studies from Kenya and the Democratic Republic of the Congo (DRC) reported significant modification [ 9 – 12 ].…”