The NUTRIMENTHE EU Project:

Maternal dietary markers in pregnancyand the mental health of children

The Generation R Study

Henning Tiemeier

Child and Adolescent Psychiatry & Epidemiology, Erasmus MC

Madrid, October 28th, 2011

� Prospective cohort design

� From early foetal life

� 9.778 mothers and their children

� Urban, multi-ethnic population

Design Generation R

National origins of Generation R children

Dutch, other

European

58%

Others

9%Cape Verdian

4%

Dutch Antilles

4%

Turkish

9%

Moroccan

7%

Surinamese

8%

Based on classification according to the CBS, 2004; Missing: (12%);

Gestational age at measurement

Early preg.: 12 weeks

Mid-preg. : 20 weeks

Late preg. : 30 weeks

Measures:

• abdominal circumference

• head circumference, biparietal diameter

• femur length

• estimated foetal weight

BPD

HC

LVAW

Prenatal ultrasound measurements

MethodsMethods

Behaviour and Emotion: the Child Behavior Checklist 1½-5

� Measured at two time points (at 18 and 36 months) and by two

informants (mother and father)

� Internalizing & Externalizing score, plus syndrome scales

Early cognitive function

1. Nonverbal cognitive function:

� Parent Report of Children’s Abilities (PARCA) at 30 months

2. Verbal Cognitive function (Expressive language ):

� MacArthur Communicative Inventory (MCDI) at 18 months

� Language Development Survey (LDS) at 30 months

Cannabis use in early pregnancy and fetal growth trajectories

-180

-160

-140

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-80

-60

-40

-20

0

20

20 25 30 35 40

Weeks of gestation

Differences in foetal weight in grams

Cannabis users

Past cannabis users

Tobacco users

Non-users

Weeks of gestation El Marroun, J Am Acad

Child Adol Psychiat, 2009

Cannabis use in early pregnancy and fetal growth trajectories

-180

-160

-140

-120

-100

-80

-60

-40

-20

0

20

20 25 30 35 40

Weeks of gestation

Differences in foetal weight in grams

Cannabis users

Past cannabis users

Tobacco users

Non-users

Folate in pregnancy

- Folate demand is increased during pregnancy

- Folate , Homocysteine , MTHFR*, Folic acid supplementation

� neural tube defects

- After closure of the neural tube?

emotional and behavioural development?

* MTHFR = methylenetetrahydrofolate reductase

micronutrient involved in repair of the genome, regulation of gene expression, amino-acid metabolism, myelin formation, and neurotransmitter synthesis

Folate intake in the Netherlands

� Until 1996 it was against the law in the Netherlands to add substances,

including folate to food products

� In 1996 the EU law changed to allow for the addition of 100µg of folic

acid per 100kcal of food

� Still the Dutch tend to have a lower dietary folate intake

� The average daily intake of folate in the

� Netherlands 182 µg/day,

� Portugal 265 µg/day,

� Germany 246 µg/day,

� United Kingdom 213 µg/day

� United States 242 µg/day

� Folate intake in about half of all Dutch adults is inadequate

Objectives

Analyse effects of maternal folate concentrations in early

pregnancy on child behavioural development.

Hypotheses:

low maternal folate status in early pregnancy

- is associated with a higher risk of child emotional and

behavioural problems

- accounts for any effect of prenatal folic acid

supplementation as well as maternal MTHFR genotype

variation on child behaviour.

Methods

- Plasma folate and homocysteine concentrations

- (median 13.1 weeks of gestation)

- Folic acid use (questionnaire early pregnancy)

- MTHFR genotyping

- Child emotion and behavioural problems : CBCL at 1.5 and 3 years

Mothers with no folic acid supplementationduring pregnancy

Roza, Brit J Nutrition, 2009

Behavioural problems, 1.5 years

No Unadjusted Adjusted

OR (95% CI) p-value OR (95% CI) p-value

Supplement use(first 10 weeks of pregnancy)

3067 reference reference

No supplement use

1147 2·8 (2·2, 3·4) 0·001 1·4 (1·1, 1·9) 0·005

Adjusted forEthnicity, SES, maternal psychopathology, maternal age, smoking, birth weight,head circumference

Mothers with low folate plasmaconcentrations during pregnancy and child internalizing problems

No association homocysteine – child behaviour

No association homocysteine – child behaviour

Mothers with low folate plasma concentrations during pregnancy and child internalizing problems

Supplements - folate - child behaviour

- ORadequate – inadequate use: 1.45 (95% CI: 1.14, 1.84)

- Adding folate to the model: OR=1.38 (95% CI: 1.08, 1.78)

MTHFR genotype - child behaviour

No effect MTHFR genotype

Summary

- Low maternal folate status during early

pregnancy associated with higher risk of

internalizing problems in the offspring.

- Partly due to the lack of prenatal folic acid

supplement use, despite existing supplement

recommendations.

Thyroid hormones during pregnancy Thyroid hormones during pregnancy

� Maternal thyroid hormones: a crucial role in child’s brain

development; known since 1976 (Man et al).

� Thyroid hormones are involved in the formation hippocampus

and cytoarchitecure of somatosensory cortex (migration,

differentiation and demyelization).

� No fetal thyroid secretion before 12-14 weeks of gestation.

� The fetus continues to rely on maternal thyroid hormones

through the end of pregnancy.

� Thyroid function status in mothers: hypothyroidism,

hyperthyroidism, and hypothyroxinemia.

MethodsMethods

Thyroid sampling before 18th week of gestation in 4892 pregnant

women (TSH, free and total T4)

Normal reference range:

� TSH : 0.03-2.5 mU/l

� Free T4:11-15 pmol/l

� Total T4: 87-192 nmol/l

Hypothyroxinemia: A condition defined as normal TSH with low

levels of free T4

Levels of thyroid hormone deficits and fetal head size during pregnancy

Head circumference

early pregnancy

13.5 (5.7-18.0) weeks

midpregnancy

20.9 (18.3-24.9) weeks

late pregnancy

30.4 (25.1-39.2) weeks

n=4,683 n=4,501 n=4,491

reference 92.1 (91.8-92.4) 179.2 (179.1-179.3) 284.6 (284.3-284.9)

hypothyroxinemia 94.5 (92.6-95.4) p=0.01 178.9 (178.1-179.8) p=0.60 284.6 (283.4-285.8) p=0.99

hypothyroidism 95.7 (93.3-98.0) p=0.004 179.9 (178.5-181.3) p=0.31 284.5 (282.4-286.6) p=0.92

Biparietal diameter

N=4,966 n=4,789 n=4,774

reference 26.1 (26.0-26.1) 50.5 (50.4-50.6) 80.3 (80.2-80.4)

hypothyroxinemia 26.9 (26.3-26.8) p<0.000 50.3 (50.0-50.6) p=0.14 80.2 (79.7-80.7) p=0.67

hypothyroidism 27.8 (27.4-28.2) p<0.000 50.7 (50.2-51.2) p=0.42 80.8 (80.0-81.7) p=0.20

Thyroid status and relative fetal head growth

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0

1

2

3

4

15 0 25 50

gestational age postnatal age

(weeks)

dif

fere

nce

in

he

ad

cir

cu

mfe

ren

ce

(mm

)reference

hypothyroxenemia

hypothyroidismbirth

Early behavioral and emotional development

and thyroid hormones

0.12 (-0.06, 0.30), 0.1937290.09 (-0.04, 0.22), 0.193724Total T4 (per SD)

-0.02 (-0.16, 0.20), 0.8037120.01 (-0.13, 0.15), 0.913707Free T4 (per SD)

0.22 (0.04, 0.40), 0.02*36870.10 (-0.01, 0.21), 0.073682TSH (per SD)

B (95%CI), P valuenB (95%CI), P valuen

Externalizing ScoreInternalizing Score

Mother and Father report ( 18 and 36 months)

Ghassabian, Pediatric Res, 2011Across ages and informants

Early behavioral and emotional development:

� Maternal hypothyroxinemia is associated with head growth early

in pregnancy but not more internalizing and externalizing

problems

� Higher plasma levels of TSH was related to higher score on DSM-

oriented subscales of CBCL related to externalizing problems

1. Attention Deficit/Hyperactivity Problems

2. Oppositional Defiant Problems

Thyroid antibodies in pregnancy

Risk of problem behavior

Mother rating Father rating

Determinants in analyses: TPOAb, yes

in pregnancy

n OR (95%CI), p n OR (95%CI), p

Outcome measures:

Internalizing problems 3015 1.20 (0.78-1.85), 0.40 2648 1.17 (0.73-0.88), 0.50

DSM-oriented subscales

Affective Problems 0.96 (0.51-1.80), 0.90 1.31 (0.66-2.59), 0.44

Anxiety Problems 1.27 (0.74-2.17), 0.39 1.14 (0.61-2.13), 0.69

Externalizing problems 3139 1.60 (1.08-2.38), 0.02 2623 1.61 (1.04-2.49), 0.03a

DSM-oriented subscales

Attention Deficit/Hyperactivity 1.60 (0.90-2.87), 0.11 1.89 (1.16-3.07), 0.01b

Oppositional Deviant Problems 1.46 (0.91-2.34), 0.12 1.36 (0.73-2.52), 0.33c

Ghassabian, Thyroid, in press

Independent of TSH levels

Thyroid and language delay

Type of maternal thyroidfunction

n

Expressive language

Delay at age 18 months

OR (95% CI) pn

Expressive language

Delay at age 30 months

OR (95% CI) p

TSH, per SD

FT4, per SD

3384

3409

0.91 (0.81; 1.03) 0.13

0.95 (0.83; 1.09) 0.43

2757

2779

0.92 (0.81; 1.06) 0.25

0.84 (0.71; 0.99) 0.04

Mild maternalhypothyroxinaemia

Severe maternalhypothyroxinaemia

2736

2736

1.33 (0.91; 1.94) 0.14

1.77 (1.10; 2.84) 0.02

2225

2225

1.47 (1 .00; 2.17 ) 0.05

Henrichs et al; JCEM 2010

1.78 (1. 08; 2. 94) 0.02

SummarySummary

� A subtle change in a physiologic parameter may have considerable effect on

health of children.

� It is premature to speculate about possible intervention and their impact

before the relation is confirmed.

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Next stepsNext steps……

Iodine urine determination

� Can iodine levels in urine samples of mothers explain part of the association

between low thyroid functioning and behavior and cognitive development of

the children?

� Postnatal MRI Imaging

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Current directionsMock MRI Scanner

GE 3T MRI Scanner

� Thank you for your attention!

� The Generation R

� Psychiatric

� Epidemiology

� group

� Acknowledgement: the present study was supported by a research grant from the European Community’s 7th Framework Programme (FP7/2008 –2013) under grant agreement 212652 (NUTRIMENTHE project, “The Effect of Diet on the Mental Performance of Children”).