Stress and Nutrition During Pregnancy: Factors Defining Transgenerational Future Health Within the Family
A normal pregnancy is defined as the physiological state of a woman from fertilization to the birth of one or more living, healthy and full-term infants. Meanwhile, the term high-risk pregnancy refers to anomalous gestational conditions (e.g. eclampsia), which increase the possibility of pathophysiological states in the mother and/or the infant. There are several biological, gynaeco-obstetric and social risk factors for a high risk pregnancy. Conditions such as malnutrition, negative emotions, perceived stress and maternal anxiety are predictors of pathological conditions in both mother and child (e.g. obesity, diabetes, different types of cancer and some neurological and cardiovascular pathology). This scenario requires a modification of the concept of ‘high-risk pregnancy’, and advocates taking into account the monitoring of stress, anxiety, depression and food quality during pregnancy as potential risk factors not only for the baby, but also for subsequent generations.
KeywordsPregnancy Distress Malnutrition Negative emotions Transgenerational health
A normal pregnancy is defined as the physiological state of a woman from fertilization to the birth of one or more living, healthy and full-term infants (Guía de Práctica clínica para el Control Prenatal con enfoque de Riesgo 2008). Unfortunately, not all pregnancies are without complications; this is when the term high-risk pregnancy is used. It is important to highlight the fact that it is common during pregnancy for changes to be observed in women’s bodies that could be considered to be complications; for example, nausea, fatigue, drowsiness, liquid retention, swelling of the legs, mastodynia, frequent urination, gastroesophageal reflux, constipation and increased breathing rate are all common symptoms found in pregnant women (Cortez-Chavez 2006; Guyton/Hall 2005). These signs and symptoms, however, do not reflect real complications but rather how the body is adjusting to the pregnancy. As such, when we talk about truly high-risk pregnancies, we refer to anomalous gestational conditions (e.g., eclampsia), which increase the possibility of pathophysiological states in the mother and/or the infant, leading to the death of both or of one of the binominal parts of the mother-infant, or to permanent disabilities (e.g., psychomotor problems) in the full-term infant. The socio-medical gravity of high-risk pregnancies can be clearly seen in the fact that close to 800 women around the world die every day as a result of pregnancy-related complications, in addition to approximately three million new-born babies dying every year (World Health Organization [WHO] 2014). In Mexico, it is estimated that the leading cause of death among pregnant women is hypertensive disease (National Institute of Statistics and Geography [INEGI] 2013a), with a mortality rate for children under the age of one year old of 12.8 for every 1,000 live births (INEGI 2013).
In light of this situation, public health systems have proposed the implementation of pregnancy health programmes. For example, the campaign entitled ‘Reducing Pregnancy Risks’, launched by the WHO in the year 2000, recommends opportune clinical check-ups to detect risk factors in pregnant women. A risk factor is any circumstance that increases the probability of damage occurring as a result of personal, social and environmental situations that affect the individual (Mexican Department of Health 2001). As such, obstetric risk is understood to be ‘any external and/or intrinsic factor (or combination of factors) relating to women that could lead to some form of complication during pregnancy , labour, postpartum or that could, in any way, alter the normal development or survival of the product’ (Cortez-Chavez 2006: 3–4). In order to identify obstetric risk factors, the Mexican Department of Health implemented a multi-phase screening programme, entitled Prenatal Care, the goals of which are to identify, prevent and control factors that could put the life or health of the mother and the baby at risk during pregnancy (Ordoñez 2005). This programme classifies risk factors into three categories: biological, gyneco-obstetric and social; and it considers the presence of at least one of these factors to be sufficient cause for the doctor in question to categorise a pregnancy as high-risk:
Chronic or systemic diseases
Aged 35 or over
Haemorrhaging during the second half of pregnancy
Postpartum infection in previous pregnancy
Prior Caesarean section
Prior surgery in reproductive tract
Chronic urinary tract infection
Aged 20 or under
Less than two years after termination of last pregnancy
Having two or more caesareans
Having two or more abortions/miscarriages
Having five or more pregnancies
Rhesus isoimmunisation in current or previous pregnancies
Weight of last baby above 4,500 g
Obesity and malnutrition
Gynaecological age of less than two years.
Mother who is illiterate or has not finished elementary education
Occupational factor (exposure to toxic substances, chemicals or infectious diseases; working more than 36 h per week; lifting heavy objects; standing for more than four hours per shift; mental stress; working in a cold environment or one with intense noise levels)
History of sexual, physical and/or emotional abuse
Risk behaviours (self-medication, smoking, alcoholism and use of other hard drugs).
As such, prenatal care is a tool that helps the person charged with monitoring the health of the mother-child during pregnancy to opportunely identify risk factors during pregnancy, and thus implement the corresponding preventive and corrective measures. The following are important clinical signs that need to be monitored: vaginal bleeding during pregnancy, convulsions or blackouts accompanied by blood pressure readings higher than 90 mmHg, high temperature (>38°C), abdominal pain, ruptured membranes, severe pallor or cyanosis, marked decline or weakness, sensation of fainting, severe headaches, blurred vision, vomiting and/or respiratory difficulties. Furthermore, it is important to mention that pregnancy risk diagnoses should preferably be carried out prior to conception, continuing throughout the pregnancy, labour and postpartum (Aguilar-Moreno et al. 2001; Pérez-Rúa 2005).
During prenatal care, the doctor must inform the patient of all the physiological changes associated with pregnancy, in addition to explaining the warning signs that may present during pregnancy, labour and postpartum, emphasizing the importance of attending prenatal care sessions periodically and undertaking any laboratory and medical tests deemed necessary. He or she should also explain the importance of neonatal screening and breastfeeding, promote healthy lifestyles and encourage the mother to avoid smoking, drinking alcohol, self-medicating and consuming other substances that put the risk of her health and that of the child at risk (Aguilar-Moreno et al. 2001).
Even though prenatal care can help prevent high-risk pregnancies, this same care is notorious for not taking into account the monitoring of stress, anxiety, depression and food quality during pregnancy (Qiu et al. 2009; Winkel et al. 2015); however, it has been shown that these are potential risk factors not only for the foetus, but also for subsequent generations (Drake et al. 2011). As such, it is necessary to implement strategies that minimize the negative impact that poor nutrition and stress during pregnancy can have on the health of the mother and child.
2.2 Stress as a Risk Factor in Pregnancy and Its Impact on the Health of Different Generations
The magnitude of the response of a person to stress depends on the interaction with information from a range of different sources, both biological (e.g., genes) and psychosocial (e.g., past experiences, social support). These same interactions influence the response to stress developed by pregnant women; however, pregnant women face specific situations that the general public do not, and which are a source of information that can be stressful. These circumstances are associated with physical and hormonal changes (which are associated with mood swings) and the anxiety of the pregnancy itself, associated with concern regarding the health of the foetus and with the pain of labour (Huizink 2000, quoted by Mulder et al. 2002; Van den Bergh 1992). Additionally, it is known that age, deficient education, low socio-economic level, sexual abuse, unwanted pregnancy, an absent partner, lack of preparation for pregnancy and labour, and a history of depressive and psychiatric symptoms influence the perception of well-being and, as such, the stress levels of pregnant women (Paarlberg et al. 1996).
Furthermore, negative emotions, such as perceived stress and maternal anxiety, can predict depressive symptoms in both the mother and the baby (Milgrom et al. 2008), which is why stress has been recognized as an important etiological factor that can trigger mood disorders. This notion has been demonstrated in animal models, based on the supposition that the effects of stress on animals lead to a series of behavioural changes, some of which are reminiscent of symptoms that characterize depression and anxiety among human beings (van Dijken et al. 1992). Depression is particularly prevalent among pregnant women, affecting between 10 and 25% of them (Marcus et al. 2003; Nonacs/Cohen 2002). The greatest concern regarding these statistics lies in the fact that pregnant women with depression have a higher probability of premature labour (Orr et al. 2002); furthermore, other negative emotions, such as perceived stress and anxiety, have been associated with a reduction in the variability of foetal heartbeat (DiPietro et al. 1996), an increase in locomotor activity (DiPietro et al. 2002), and disruption to foetal habituation (Sandman et al. 1999), which, in conjunction, lead to miscarriages (Friebe/Arck 2008), low birthweight (Mutale et al. 1991) premature labour (Copper et al. 1996) and a wide variety of complications during pregnancy (Table 2.1).
Factors that trigger a high-risk pregnancy (own elaboration)
Gynaecological age of less than 2 years
Pre-eclampsia/eclampsia, prematurity and low birthweight
Aged 35 or over
Pre-eclampsia/eclampsia, low-lying placenta and uterine atony post labour
Less than 2 years between pregnancies
Prematurity and stunted intrauterine growth
Having had 5 or more pregnancies
Low-lying placenta and uterine atony post labour
Having had 2 or more abortions/miscarriages
Greater predisposition to abortion/miscarriage
History of pre-eclampsia/eclampsia
Predisposition to pre-eclampsia/eclampsia
Haemorrhaging during 2nd half of pregnancy
Predisposition to haemorrhaging
Having had 2 or more caesareans
Low-lying placenta, placenta accreta and rupture of the uterine scar during labour
Probability of repetition of foetal death
Probability of repetition
Pre-eclampsia/eclampsia, stunted uterine growth, foetal and maternal death
Pre-eclampsia/eclampsia, abortions/miscarriage, birth defects, stunted intrauterine growth or foetal microsomia
Pre-eclampsia, pre-term labour
Low birthweight, pre-term labour, miscarriage, pre-eclampsia, emotional problems in the life of the baby influence foetal programming, descendants of the mother are more susceptible to anxiety and depression
Buss et al. (2012), de Weerth et al. (2003), Diego et al. (2006), Grandia et al. (2008), Harville et al. (2009), Nepomnaschy et al. (2006), Paarlberg et al. (1999), Pawluski et al. (2011), Salacz et al. (2012), Sandman et al. (2006), van den Hove et al. (2005), Vianna et al. (2011), Wadhwa et al. (1993)
Imbalance of endocrine functions
Deregulation of placental clock
Deregulation of immunological tolerance
These situations lead to morbid states, such as pre-eclampsia, miscarriage, compromised foetal growth, pre-term induction of labour, low birthweight, delayed post-natal psychomotor development and a greater incidence of infections during pregnancy and postpartum, among other complications (Diego et al. 2006; Field/Diego 2008). The pathogenesis of pre-eclampsia and other hypertensive states during pregnancy is associated with exacerbated inflammatory processes and poor renal function (Sargent et al. 2007), which control not only blood pressure but also the secretion of hormones, such as cortisol and noradrenaline. Moreover, elevated concentrations of noradrenaline lead to decreased dopamine production, which can be seen in the manifestation of symptoms of depression (Field et al. 2004). Additionally, the secretion of angiogenic molecules by leukocyte cells can promote the development of hypertensive disease associated with gestational stress (Geara et al. 2009). Furthermore, neuro-immuno-endocrine alterations relating to gestational stress, be they psychosocial in nature or not, can lead to complications and ailments during pregnancy or labour, affecting the health of the child when it reaches adulthood, in the event it survives (Bastani et al. 2005; DiPietro et al. 2004; Huizink et al. 2004; Monk 2001; Wadhwa et al. 2001; Table 2.1).
It has recently been shown that exposure to stressful situations during embryonic and/or foetal life predisposes the adult to obesity, diabetes, different types of cancer and some neurological and cardiovascular pathologies, associated with epigenetic re-editing (Bastani et al. 2005; Bilbo/Schwarz 2012; Bresnahan et al. 2005; Brown et al. 2004; DiPietro et al. 2004; Ellman/Susser 2009; Huizink et al. 2004; Monk 2001; Mulder et al. 2002; Wadhwa et al. 2001). Furthermore, a number of lines of research have not only shown that stress affects the mother and the baby during pregnancy, but that the stress history of their ancestors and parents also conditions the evolution and result of the pregnancy, given that maternal glucocorticoids can regulate the transcription of a number of the product’s genes. These are not limited to individuals exposed to the stress of the mother, as they can also be transmitted to the descendants several generations into the future (Drake et al. 2011). As such, in 2013, Crudo et al., suggested that epigenetic re-editing, associated with the methylation of DNA, the acetylation of histones and the transcription stemming from different environments in the early lives of humans and rodents, is not limited to a small number of genes, but rather involves a range of genetic networks and functional genomic patterns.
2.3 Nutrient Consumption During High-Risk Pregnancy: The Transgenerational Impact
NOM-007-SSA2-1993, a standard focusing on the care offered to women during pregnancy, labour and postpartum and to newborns, states that the majority of obstetric damage and health risks facing the mother and the offspring can be prevented, detected and treated successfully. As such, it is important to consider that the nutritional conditions of the mother before and during pregnancy will create a favourable or adverse in utero environment that will predispose the foetus to disorders such as obesity, diabetes or metabolic syndrome (Barker 1995; Nathanielsz et al. 2007; Remacle et al. 2007; Reusens et al. 2007).
While foods greatly define health, growth and development from foetus to old age, it is important to consider that both undernutrition and overnutrition have a harmful influence on the development of diseases. This is why diet and nutrition during pregnancy and early postnatal life are important in ensuring health (Darnton-Hill 2013). There is a wide range of experimental evidence that highlights the impact that eating habits have on health. For example, studies in rodents have shown that consuming large quantities of fat during pregnancy can lead to symptoms of metabolic syndrome among offspring when they reach adulthood (Brown et al. 1990; Chechi/Cheema 2006; Guo/Jen 1995). It would seem that this is due to the fact that a maternal diet that is high in fats leads to the accumulation of lipids, inflammation and oxidative stress in the foetal liver (McCurdy et al. 2009), which, in turn, leads to the development of metabolic disorders, such as diabetes, dyslipidaemia and hypertension. Moreover, experiments on rats fed on a ‘cafeteria’ type diet during pregnancy showed that offspring acquire a preference for ‘junk’ food that is high in fats, sugars and energy density, combined with a lack of control over food intake as adults (Bayol et al. 2007).
It has also been shown that offspring whose mothers were submitted to a severe decrease in food intake during pregnancy presented with hyperphagia and decreased physical activity (Vickers et al. 2003). In both cases, it is clear that the subjects developed immediate adaptive metabolic responses that mean they are predisposed to developing metabolic diseases in adulthood (Langley-Evans 2006). Further studies, also on rodents, corroborated the fact that high-fat diets consumed by pregnant females ‘programme’ the hypothalamic pathways that regulate food intake (Bouret 2009). Although we do not know as much about the fine mechanisms that underlie the establishment of patterns of risk behaviour and metabolic states in human beings as we do in animal models, it is interesting that a large number of epidemiological studies on humans suggest that maternal obesity contributes to the incidence of obesity, type 2 diabetes and metabolic syndrome among their descendants (Levin 2006; Martin-Gronert/Ozanne 2005; Oken/Gillman 2003), not to mention that maternal malnutrition during pregnancy also increases the incidence of obesity among descendants (Levin 2009). In humans, as in animal models, the damaging effects associated with poor maternal nutrition during pregnancy are not only observed in the trends for metabolic disorders, they also have a neurological impact. Poor nutrition during pregnancy is associated with an elevated risk of depression (Rofey et al. 2009), attention deficit with or without hyperactivity (Waring/Lapane 2008), and anxiety (Kelley et al. 2005; Kiyohara/Yoshimasu 2009).
In summary, the type of nutrients consumed during pregnancy is an important factor to be taken into consideration in preventing high-risk pregnancy, as these nutrients lead to persistent changes in the body, changes that can also be transmitted from generation to generation. It has been postulated that these changes occur by means of epigenetic reprogramming (Sandovici et al. 2011), which makes neuroendocrine and metabolic conditioning possible so as to control food consumption, use and breakdown. The epigenetic mechanisms that condition hormonal and metabolic systems include the modification of DNA methylation levels and the modification of histone structure through methylation, acetylation and ubiquitination (Blewitt et al. 2006; Waterland et al. 2007).
Based on this, it is clear that nutritional problems lead to a series of epigenetic modifications that can have a negative impact on the mother-child dyad and on subsequent generations. However, it is important to remember that epigenetic marks and the phenotypical changes associated with them can be modified and even reversed by employing ‘positive’ factors, be they hormonal, psychological, nutritional, environmental, social and even cultural (Szyf et al. 2008), that function as translators for a ‘healthy’ environment (Gabory et al. 2009; Lelievre 2009).
The Secretary General of the United Nations, Ban Ki-moon (2009), referred to maternal health as ‘the mother of all health challenges … perhaps there is no other issue that better links safety, prosperity and progress as women’s health…’ (Castro-Santoro 2011, Par. 1)
In keeping with these views, we believe that, in order to tackle the problem of maternal and child morbi-mortality, it is important to start by redefining high-risk pregnancy. This new concept should not merely be considered an anomalous condition that increases the possibilities of developing pathological states or sequels that, in the short-, mid- and long-term, lead to the death of the mother and/or the offspring, but rather it should incorporate the risk that this implies for future generations, and, moreover, promote the message that pregnant women should avoid situations that generate stress, anxiety or depression, in addition to tackling poor nutrition, given that, as we have seen, these are factors that have a strong influence on the development of high-risk pregnancy.
Pregnancy is a crucial time, during which both a living being and the immediate and future health of subsequent generations is nurtured. As numerous studies have shown, the inadequate progress of the pregnancy conditions and/or promotes the development of psychiatric illnesses, such as schizophrenia, behavioural problems, such as attention deficit disorder or hyperactivity, emotional problems, such as depression, and even obesity, diabetes, different types of cancer, neurological pathologies and cardiovascular problems. This is why it is important to emphasize that proper stress management and a good diet can help reverse and/or prevent the incidence of these health problems among future generations.
Finally, it is important to recognize that stress and diet must be added to the list of factors that should be monitored in order to prevent high-risk pregnancy, and it is also important to modify the concept of prenatal care, focusing on monitoring pregnant women not only in terms of physical health, but also in mental and nutritional terms, through measures aimed at developing strategies that promote proper nutrition.
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