Undernutrition and malaria in pregnancy - a dangerous dyad?

Abstract

Background: In 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.

Discussion: This 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.

Conclusion: We call for more collaboration between researchers studying malaria and nutrition in pregnancy, and propose a research agenda to address this important twin health problem.

Keywords: Fetal growth restriction; Low birthweight; Malaria; Nutrition; Pregnancy.

Fig. 1

Interactions between macronutrient undernutrition and malaria. 1) Undernutrition is common in areas where malaria prevalence is high, and rural and economically disadvantaged communities are often most affected. 2) Pregnant women are more likely to be bitten by malaria-infected mosquitoes, and are more susceptible to malaria infection. 3) Undernutrition is common in pregnant women, and short inter-pregnancy intervals may lead to nutritional depletion. 4) Undernutrition may impair antimalarial treatment efficacy. 5) Nutritional status and nutrient supplementation may affect antimalarial immunity. 6) Malaria and undernutrition may interact to worsen pregnancy outcomes. 7) Both malaria and undernutrition are important causes of low birthweight. 8) Malaria and undernutrition may affect growth and immunocompetence in the offspring. 9) These combined effects of malaria and undernutrition may have long-term health and socioeconomic consequences extending into adult life and passed on transgenerationally