Preconception Nutrition

Baithesda
Outline
• Latar belakang
• Definisi Preconception
• Preconception risk factors in perspective
• Current strategies for preconception nutrition intervention
Introduction

Hanson et al, 2015

Nutrition: Why
Introduction
is it important?

Hanson et al, 2015

 Preconception definition
• The three months before
conception (Potter, 1964; Gnoth,
2003) – 3 bulan sebelum konsepsi
• A minimum of one year prior to the
initiation of any unprotected sexual
intercourse that could possibly
result in a pregnancy (Dean, 2013)
– Minimal 1 tahun dimulainya
hubungan sexual tanpa kontrasepsi
Tiga definisi atau perspektif baru tentang masa

1. Perspektif biologi
• Periode kritis pada rentang beberapa minggu sekitar
konsepsi yg meliputi pematangan gametes, fertilisasi, dan
perkembangan embrio
• Sangat sensitive terhadap factor lingkungan, misalkan
ketersediaan macro- and micronutrients atau paparan rokok,
alcohol, obat2an atau zat2 beracun lainnya
2. Terkait tindakan individu
• Masa prekonsepsi dimulai ketika
perempuan atau pasangan mengambil
keputusan untuk memiliki anak, namun
waktu konsepsi tidak diketahui
• Masa prekonsepsi dapat waktu yang
dibutuhkan oleh individu/pasangan
untuk mencapai kesehatan yang
diinginkan sebagai persiapan untuk
kehamilan
3. Perspektif kesehatan masyarakat
Masa prekonsepsi merupakan fase sensitive pada siklus kehidupan
manusia, contohnya, perilaku di usia remaja seperti pola makan,
latihan, kegemukan, merokok dan minum alcohol, biasanya terjadi
sebelum kehamilan
Preconception risk factors in perspective
Komposisi tubuh dan gizi WUS
BMI
• Baik BB kurang maupun lebih berhubungan dengan risiko utama kesehatan
ibu dan anak
• Secara global, angka kejadian BB kurang/underweight pada wanita (BMI
<18.5 kg/m2) turun dari 15% menjadi 10%;
• Negara2 di Asia Selatan tertinggi angka wanita dg BB kurang/underweight
dg perkiraan 24% di tahun2014
• Di saat angka underweight mengalami penurunan, angka kejadian obesitas
(BMI ≥30 kg/m2) pada wanita secara global justru meningkathas dari 6%
menjadi 15%
NCD Risk Factor Collaboration (2016)
• Di banyak HIC and LMIC, lebih dari 50% wanita akan mengalami kelebihan
BB/overweight atau obese ketika hamil [Ng et al, 2013; Poston et al, 2016)].
• Dampak obesitas pada WUS →ketidakmampuan untuk hamil sampai
pada terjadinya komplikasi kehamilan (pre-eclampsia, gestational
diabetes) and delivery (macrosomia), congenital anomalies, stillbirth,
BBLR, ASI kurang dan bahkan kematian [Gesink, Maclehose, & Longnecker, 2007;
Marchi et al, 2015; Poston et al, 2016; Turcsin et al, 2014].
• Secara global juga terjadi peningkatan obesitas pada laki2, dari 3%
menjadi 11% antara 1975 dan 2014; paternal obesity memiliki
hubungan yg erat dengan terganggunya fertilitas dengan
mempengaruhi kualitas dan kuantitas sperma [Kort et al, 2006], dan
berhunungan dengan peningkatan risiko penyakit kronik pada
generasi selanjutnya [Kaati, Bvgren & Edvinsson, 2002].
• Orangtua obesitas akan berdampak pada risiko obesitas pada
generasi [Godfrey, 2017]
Manfaat penurnan BB pada masa prekonsepsi pada kehamilan
• Penurunan BB sebanyak 10% sangat berarti pada penurunan risiko
pre-eclampsia, gestational diabetes, preterm delivery, macrosomia,
dan stillbirth [Schummers, et al, 2015].
• Perempuan yg telah melakukan prosedur bedah bariatric paling
kurang dua tahun sebelum konsepsi memiliki risiko yang rendah
terhadap gestational diabetes, hypertensive disorders and large-for-
gestational age neonates dibandingkan dengan wanita dg BMI yg
sama yg tdk melakukan prosedur bedah bariatric [Galazis et al, 2014;
Johansson et al, 2015, Tobias et al, 2011]
Manfaat penurnan BB pada masa prekonsepsi pada kehamilan
(Con’t)
• Tingkat aktivitas fisik yg tinggi di masa prekonsepsi
berhubungan erat dengan rendahnya risiko terhadap
gestational [Tobias et al, 2011] dan pre-eclampsia [Aune et
al, 2014].
• Jalan cepat selama 4 jam/lebih dalam seminggu sebelum
hamil juga berhubungan dengan rendahnya risiko terhadap
gestational diabetes [Zhang et al, 2006].
Nutrisi Prekonsepsi dan Faktor risiko gaya hidup/lifestyle
• Konsekuensi dari ibu kurang meliputi terhambatnya perkembangan fetal,
stunting, wasting, kekurangan vitamin A dan atau zinc, bersama dengan tdk
optimalnya ASI, diperkirakan mengakibatkan 3.1 juta kematian anak/tahun,
atau 45% dari total kematian anak pada 2011 [Black et al, 2013].
• Hasil review mendapati bahwa meskipun terjadi penurunan kejadian BB
rendah/underweight, namun disimpulkan adanya kurang gizi/undernutrition
pada remaja putri dan WUS di LMICs meliputi iron, vitamin A, iodine, zinc,
and calcium yang seharusnya bisa dicegah [Caulfield & Arlington, 2015 ].
• Jenis diet pada HICs, lebih tinggi masukan daging merah (red meat), olahan
kacang2an (refined grains), refined sugars, dan susu tinggi lemak, dan juga
kurangnya masukan beberapa nutrisi penting seperti magnesium, iodine,
calcium and vitamin D [Bath et al, 2013; Cordain et al, 2005].
• Banyak WUS tidak mempersiapkan nutrisi sebelum kehamilan, pada
perempuan usia 18-25 years didapati 77% rendah masukan iodine
dan 96% rendah iron dan folate yang sangat direkomendasikan untuk
kehamilan (Stephenson et al, 2018
• Wanita yg diberikan suplemen Folic acid tiga bulan sebelum
kehamilan berhubungan secara signifikan dengan rendahnya risiko
terhadap BBLR, miscarriage, stillbirth, kematian bayi dibandingkan
dengan wanita yang tdk mengkonsumsi folic acid sebelum
kehamilan(He et al, 2016), menurunkan kejadian neural tube defects
(Mastroiacovo & Leoncini, 2011
Spina bifida Anencephaly
• 9 dari 10 perempuan berusia 18-25 tahun di UK dan Australia,
dilaporkan mengkonsumsi kurang dari lima buah dan porsi sayuran
setiap hari (Stephenson et al , 2018)
• Pola makanan lebih dr 3 tahun sebelum kehamilan, tinggi masukan
buah, sayuran, kacang2an, dan ikan, dan rendah masukan daging
merah dan olahannya, menurnkan risiko gestational diabetes [Bao et al,
2014; Schoenaker et al,2015; Tobias et al, 2012; Zhang et al 2006]
Smoking, alcohol and caffeine
• Dampak merokok: pregnancy loss, intrauterine growth restriction dan
BBLR [Reeves & Bernstein, 2008; US CDC, 201452, 53].
• Reducing smoking before conception improves these outcomes and in
preterm births (Been et al, 2014)
• Maternal alcohol consumption can result in a range of fetal alcohol
spectrum disorders resulting in physical, behavioral and learning
difficulties [British Medical Association, 2007]
• Caffeine consumption during pregnancy has been associated with a
reduction in birth weight of a similar size to that caused by alcohol,
and a significant trend for greater reduction in birth weight with
higher caffeine intake [Care study, 2008]. This relationship was consistent
across all three trimesters, suggesting that cutting back on caffeine
before conception could be beneficial.
Current strategies for preconception nutrition
intervention

supplementation/
Incentives Behavior change
fortification
Supplementation and food fortification

• Fortifying foods (ketahanan pangan) seperti tepung maupun beras

menjadi mandat 87 negara (Food Fortification Initiative, 2016)
• WHO: pedoman pemberian garam beryodium, untuk mencegah
irreversible mental impairment of the fetus (WHO, 2014)
• Fortification folic acid menjadi mandat di USA, Canada, Chile, Costa
Rica and South Africa untuk menurunkan NTD (Crider, Bailey, & Berry, 2011;
Mastroiacovo & Leoncini, 2011)

• Indonesia (summary)
Cash transfers/incentives

• Di LICs, cash transfers efektif dlm meningkatkan i) pendaftaran dan

kehadiran di sekolah pada remaja perempuan, ii) akses ke layanan
kesehatan and iii) konsumsi makanan keluarga (Fenn et al, 2015; 2017; Manley,
Gitter, & Slavchevska, 2012)

• All risk factors for poor birth and nutritional outcomes, preconception
cash transfers may be useful (Rawling & Rubio, 2005; Ruel & Alderman, 2013)
Behavior change interventions

• Low resource households cannot simply change their behavior if food

is unavailable and so strategies must combine behavior change with
food access (Nair et al, 2015, 2017)
• Participatory learning and action through women’s groups of a
healthcare approach has successfully engaged women and reduced
maternal and neonatal mortality in rural, low-resource settings (Prost et
al, 2013)

• Interventions in high resource contexts can focus on individual choice

but evidence suggests that multi-level interventions may be more
effective (Compernolle et al, 2014)
(Barker et al, 2018)
 References
• Potter RG, P M. Predicting the time required to conceive. Population Studies. 1964; 18(1):99–116.
• Gnoth C, et al. Time to pregnancy: results of the German prospective study and impact on the
management of infertility. Hum Reprod. 2003; 18(9):1959–66. [PubMed: 12923157]
• Dean S, et al. Setting research priorities for preconception care in low- and middle-income
countries: aiming to reduce maternal and child mortality and morbidity. PLoS Med. 2013;
10(9):e1001508. [PubMed: 24019762]
• NCD Risk Factor Collaboration. Worldwide trends in diabetes since 1980: a pooled analysis of 751
population-based studies with 4.4 million participants. Lancet. 2016; 387(10027):1513–30.
[PubMed: 27061677]
• Ng M, et al. Global, regional, and national prevalence of overweight and obesity in children and
adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013.
Lancet. 2014; 384(9945):766–81. [PubMed: 24880830]
• Poston L, et al. Preconceptional and maternal obesity: epidemiology and health consequences.
Lancet Diabetes Endocrinol. 2016; 4(12):1025–1036. [PubMed: 27743975]
• Gesink Law DC, Maclehose RF, Longnecker M. Obesity and time to pregnancy. Hum
Reprod. 2007; 22(2):414–20. [PubMed: 17095518]
• Marchi J, et al. Risks associated with obesity in pregnancy, for the mother and baby: a
systematic review of reviews. Obes Rev. 2015; 16(8):621–38. [PubMed: 26016557]
• Turcksin R, et al. Maternal obesity and breastfeeding intention, initiation, intensity and
duration: a systematic review. Matern Child Nutr. 2014; 10(2):166–83. [PubMed:
22905677]
• Kort HI, et al. Impact of body mass index values on sperm quantity and quality. J Androl.
2006; 27(3):450–2. [PubMed: 16339454]
• Kaati G, Bygren LO, Edvinsson S. Cardiovascular and diabetes mortality determined by
nutrition during parents' and grandparents' slow growth period. Eur J Hum Genet. 2002;
10(11):682–8. [PubMed: 12404098]
• Godfrey KM, et al. Influence of maternal obesity on the long-term health of offspring.
Lancet Diabetes Endocrinol. 2017; 5(1):53–64. [PubMed: 27743978]
• 37. WHO. Guidelines on Food Fortification with Micronutrients. World Health Organization; 2000.
• 38. Black RE, et al. Maternal and child undernutrition and overweight in low-income and middle-
income countries. Lancet. 2013; 382(9890):427–51. [PubMed: 23746772]
• 39. Caulfield L, E V, Arlington VA. Strengthening Partnerships, Results, and Innovations in Nutrition
Globally (SPRING) project. Nutrition of Adolescent Girls and Women of Reproductive Age in Low-
and Middle-Income Countries: Current Context and Scientific Basis for Moving Forward. 2015
• 40. Bath SC, et al. Effect of inadequate iodine status in UK pregnant women on cognitive
outcomes in their children: results from the Avon Longitudinal Study of Parents and Children
(ALSPAC). Lancet. 2013; 382(9889):331–7. [PubMed: 23706508]
• 41. Cordain L, et al. Origins and evolution of the Western diet: health implications for the 21st
century. Am J Clin Nutr. 2005; 81(2):341–54. [PubMed: 15699220]
• He Y, et al. Folic acid supplementation, birth defects, and adverse pregnancy outcomes in Chinese
women: a population-based mega-cohort study. The Lancet. 2016; 388:S91.
• Mastroiacovo P, Leoncini E. More folic acid, the five questions: why, who, when, how much, and
how. Biofactors. 2011; 37(4):272–9. [PubMed: 21674648]
• Bao W, et al. Prepregnancy low-carbohydrate dietary pattern and risk of
gestational diabetes mellitus: a prospective cohort study. Am J Clin Nutr.
2014; 99(6):1378–84. [PubMed: 24717341]
• Tobias DK, et al. Prepregnancy adherence to dietary patterns and lower risk
of gestational diabetes mellitus. Am J Clin Nutr. 2012; 96(2):289–95.
[PubMed: 22760563]
• Zhang C, et al. A prospective study of dietary patterns, meat intake and the
risk of gestational diabetes mellitus. Diabetologia. 2006; 49(11):2604–13.
[PubMed: 16957814]
• Schoenaker DA, et al. Pre-pregnancy dietary patterns and risk of gestational
diabetes mellitus: results from an Australian population-based prospective
cohort study. Diabetologia. 2015; 58(12):2726–35. [PubMed: 26358582]